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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ M presents for evaluation of abdominal pain, distension, nausea, and emesis. BIBEMS from assisted living. Pt is poor historian ___ neurocognitive impairment ___ prior mycotic brain aneurysm complicated by intracranial bleed in ___. States that he has been experiencing abdominal discomfort for some time, unsure when he most recently has had flatus or bowel function. Believes that he has had multiple episodes of emesis. Per review of EMS and ED records, pt having poor PO intake, increasing distension, and emesis prior to presentation. Underwent CT A/P in ED that shows concern for SBO vs ileus with extensive fecalization of luminal contents. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the study of ___, there is an placement of a left subclavian PICC line that extends to the lower portion of the SVC. Otherwise, little change in the appearance of the heart and lungs. Radiology showed 1. Interval progression of enteric contrast administered orally on ___, now seen in the right hemicolon and cecum. 2. Re-demonstration of dilated loops of proximal air and fluid-filled small bowel, possibly representing low-grade obstruction or a component of ileus given interval progression of contrast and persistent air and fluid within the distal small bowel and colon. 3. Unchanged moderate bilateral layering nonhemorrhagic pleural effusions. 4. Unchanged mildly enlarged mesenteric lymph nodes measuring up to 13 mm, possibly reactive in nature. 5. Unchanged bilateral renal cysts. 6. Unchanged fatty pancreatic atrophy and accessory tissue splenic tissue. Other incidental findings, as above. Radiology showed 1. The enteric tube terminates in the proximal stomach. 2. No radiographic evidence of obstruction. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently ___. Concurrent pulmonary edema and right upper lobe pneumonia developed between ___ and ___. Severe left lower lobe pneumonia has been stable throughout. Component of pulmonary edema has improved slightly since ___ but large scale pneumonia in the right lung has remained relatively stable, left lower lobe is collapsed, perhaps obscuring previous consolidation, cardiomegaly is severe and moderate bilateral pleural effusions are stable. There is no pneumothorax. Transvenous right ventricular pacer lead follows its expected course. Left PIC line ends in the low SVC. Patient has had median sternotomy for at least an aortic valve replacement. Radiology showed 1. Loculated left lower quadrant fluid with layering internal debris, likely blood products, with evidence of peripheral/marginal enhancement at its superior aspect. Medially at the superior aspect of this loculated fluid, there is a 4.3 x 2.5 cm interloop collection with a thin enhancing rim. While rim enhancement of these collections may simply represent inflammation given recent surgery, infection cannot be excluded by CT. Correlate with physical exam. 2. Prominent proximal small bowel loops primarily involve the enteroenteric anastomosis, possibly with a small component of proximal small-bowel ileus. No evidence of bowel obstruction. 3. Unchanged multiple pancreatic cystic foci. Unchanged multiple bilateral renal cysts, some which are likely hemorrhagic/proteinaceous. Diffuse subcutaneous soft tissue edema. Other incidental findings, as above. 4. Please see separate report for intrathoracic findings from same-day CT chest. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:34 ___, 15 minutes after discovery of the findings. CT CHEST W/CONTRAST showed 1. Right upper lobe consolidation compatible with pneumonia. Left upper lobe consolidation may represent an additional focus of pneumonia versus pulmonary edema. 2. Large bilateral pleural effusions and adjacent atelectasis, with near complete collapse of the left lower lobe. RECOMMENDATION(S): Continued followup with conventional chest radiograph. Ultrasound-guided abscess drain. showed Successful US-guided placement of ___ pigtail catheter into the collection. A sample was sent for microbiology evaluation. Chest radiograph showed 1.Ill-defined opacities overlying the right upper and right middle lobes are mildly improved as compared to chest radiograph ___. 2. Small bilateral pleural effusions and bibasilar atelectasis. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed Enteric tube tip in mid stomach. Chest radiograph showed No significant changes compared chest radiograph ___ 10:45. Chest radiograph showed No significant change in chest radiograph ___. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed Compared to chest radiographs ___ through ___. Moderate pulmonary edema and moderate right pleural effusion are unchanged. Severe left lower lobe atelectasis has worsened, accompanied by moderate left pleural effusion. Moderate enlargement of the cardiomediastinal silhouette is unchanged since at least ___. No pneumothorax. Left PIC line ends in the low SVC. Right trans subclavian right ventricular pacer lead in standard placement unchanged. Radiology showed Successful post-pyloric advancement of a Dobbhoff feeding tube. The tube is ready to use. Radiology showed Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. The catheter should not be used for 24 hours. CHEST (PORTABLE AP) showed In comparison with the study of ___, the Dobhoff tube has been removed. Continued enlargement of the cardiac silhouette with only mild elevation of pulmonary venous pressure. Retrocardiac opacification is consistent with pleural fluid and some volume loss in the lower lobe. Radiology showed Successful exchange of a gastrojejunostomy tube for a new 16 ___ MIC gastrojejunostomy tube. The tube is ready to use. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed 1. An enteric tube terminates in the stomach. 2. Bibasilar consolidations, left greater than right, similar to recent CT, may represent aspiration or pneumonia. 3. Trace left pleural effusion. Radiology showed No evidence of the radiopaque foreign body in the intra-abdominal cavity not accounted for in the instrument count . Radiology showed Contrast administered through the NG tube does not advance past the jejunojejunostomy in the left upper quadrant. In the setting of high NG tube output, this finding suggests that there may be recurrent obstruction at this level. However, there is a large volume of air within the more distal small bowel suggesting that the obstruction is early, partial, or an insufficient volume of nasogastric contrast was administered. NOTIFICATION: The findings were discussed with Dr ___. by ___ ___, M.D. in person on ___ at 3:40 ___, 1 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Comparison to ___. Increasing atelectasis. Increasing opacity in the right upper perihilar lung areas. The feeding tube is in the middle parts of the stomach. Moderate cardiomegaly persists. No complications. The patient was diagnosed with Unspecified intestinal obstruction. The patient was treated with ___: Exploratory Laparotomy with Extensive Lysis of Adhesions, Stricturoplasty of R-Y Anastomosis ___: ___ Drain placement ___: ___ Placement of GJ Tube ___: Successful exchange of a gastrojejunostomy tube for a new 16 ___ MIC gastrojejunostomy tube. The patient was given written instructions concerning 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. ___ admitted to the ___ service from the Emergency Department on ___ following his original workup that was most concerning for a small bowel obstruction. Initial CT imaging was complicated given the uncertainty surrounding his previous abdominal surgeries in the 1980s. Conservative management was first started and the patient was made NPO, received IVF and had a NGT placed for bowel decompression. Nasogastric decompression originally put out 1.5 L of feculent appearing liquid upon placement. A Foley catheter was placed to monitor his urine output in order to optimize his hydration status. Given Mr. ___ complicated neuropsychiatric history, he was unable to provide any information about his past medical history but remained pleasant throughout his stay. On HD#2, Mr. ___ was brought back to the OR and underwent an Exploratory Laparotomy, an extensive 2.5 hour Lysis of Adhesions, a Stricturoplasty of what was expected to be his R-Y Duodenojejunostomy and removal of an impacted bezoar just proximal to the DJ anastomosis. For further information regarding the procedure, please refer to the operative note by Dr. ___ in the ___. Post-operatively, Mr. ___ did well; his NGT was removed on POD#2 and he was started on sips. However, on POD#4, he experienced increased abdominal distension and large volume bilious emesis requiring replacement of his NGT. On POD#5 and #6, Mr. ___ continued to have large volume bilious emesis and underwent CT Scans of his abdomen and pelvis on both days. CT imaging on POD#6 demonstrated contrast from the previous exam moving through to his colon. Over the next several days, Mr. ___ demonstrated intermittent return of bowel function with large bowel movements, despite continued episodes of bilious emesis requiring continued NGT decompression. He self-removed several NG Tubes over the course of his stay. On POD#6, he was diagnosed with a large, RUL Pneumonia and he was started on a 7 day course of Vancomycin and Meropenem (considering his antibiotic allergies) via a Left Sided PICC Line. Imaging on POD#6 also demonstrated a large, partially rim enhancing fluid collection in his LLQ which was subsequently drained by ___ on ___ following logistic and sedation issues required for drain placement. Cultures and gram stains demonstrated no bacterial etiology. Mr. ___ remained on his antibiotics for his pneumonia and serial CXR demonstrated improvement. Despite repeated episodes of bilious emesis and self-discontinuation of NG tubes, Mr. ___ also continued to have bowel movements 1 week out from his surgery. There were no additional radiologic findings to support a continued mechanical obstruction and it was thought that Mr. ___ partial obstructive symptoms were secondary to severe gastroparesis. Due to his history of ___ Disease and his additional neuropsychiatric complications, conventional dopaminergic prokinetic agents like Reglan were unable to be used, and he was started on IV Azithromycin in an attempt to stimulate foregut peristalsis. TPN was started for his moderate nutritional deficiency. On ___, a Dobbhoff Nasojejunal Tube was placed under fluoroscopy and Osmolite Tube Feeds were started shortly thereafter. Tube feeds were eventually switched to Jevity 1.5 as the patient had loose bowel movements with osmolite. Mr. ___ tolerated the tube feeds at goal but accidentally pulled out his Dobbhoff. His abdominal clinical exams continued to slowly improve. ___ was consulted who placed a GJ Feeding Tube under moderate sedation on ___ and he was started on tube feeds again on ___. The GJ tube later clogged and was replaced by ___ on ___. The patient's TPN was discontinued and his PICC line was removed. On ___, Neurology was consulted for recommendations regarding restarting the patient's home management of AEDs. Neurology recommended starting Ativan 0.5mg q8h standing as bridge while NPO, resuming gabapentin once able to take enteral medications (started at 800mg TID, then after 3 days, go up to 1200mg TID for 3 days, then up to 1800-1200-1800mg TID (home dose)). The patient received scheduled Ativan, but it was held due to patient somnolence, and Neurology said it was ok to discontinue on ___. After holding Ativan, the patient's mental status returned to baseline. Psychiatry was also consulted and recommended that the patient discontinue home clozapine due to his recent bowel obstruction. Psychiatry recommended he receive seroquil 12.5mg prn agitation. During the patient's stay, he received subcutaneous heparin to prevent blood clots. Once tolerating a diet, home warfarin was resumed for atrial fibrillation. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating tube feeds, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions.</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 PMHx significant for chronic abdominal pain narcotic dependence gastoparesis s/p G-tube placement, atypical chest pain, osteoporosis, depression/anxiety and chronic open R buttock abscess with recent I&D on ___ and VAC placement who now presents with fever of 103. Radiology showed No acute cardiopulmonary process. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute process within the abdomen or pelvis. 2. Right sacral decubitus ulcer with a wound VAC in place. US EXTREMITY LIMITED SOFT TISSUE LEFT showed No evidence of fluid collection in the left anterior chest wall. The patient was diagnosed with Infection following a procedure, initial encounter, Cellulitis of buttock, Oth surgical procedures cause abn react/compl, w/o misadvnt. The patient was treated with ___: L port-a-cath removal Multiple bedside debridements of right buttock wound. At the time of discharge, the patient had PRIMARY: Enterococcus bacteremia Right buttock abscess Narcotic dependence Chronic pain SECONADRY: Osteoporosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o female with chronic abdominal pain, narcotic dependence, benzodiazepine use, gastoparesis s/p G-tube placement, atypical chest pain, osteoporosis, depression/anxiety and chronic open R buttock abscess s/p multiple I&D and VAC placement who presents with fever to 103, found to have enterococcus bacteremia. # Bacteremia: The patient presented with fevers to ___ at home with chills. Vital signs on presentation were notable for a temp of 100.9 and HR 123. ___ blood cell count initially normal at 7.8. Pt was initially started on empiric cefepime and gentamicin in the ED. The patient's R buttock abscess was considered a possible source of infection, however only mild redness was noted on exam and was felt unlikely to be the cause of fevers per surgery team. On presentation she had a left-sided port-a-cath (in place for many years), which was concerning for line infection, especially as the patient's husband accesses the port at home. ROS with no localizing signs of other infection. Patient was continued on cefepime and started on clindamycin initially on the floor. Blood cultures drawn in the ED grew enterococcus, which was felt to be due to port infection. ID was consulted. CT abdomen and LUE ultrasound did not reveal any obvious source of infection. The patient's had a documented history of red man syndrome to vancomycin, however chart review revealed the patient had received vancomycin during a recent hospitalization without issue. She was started on a slow infusion of vanc, but developed an allergic reaction with hives. The vanc was discontinued and she was treated with Benadryl. Her symptoms resolved. ID recommended starting daptomycin with daptomycin-heparin locks for her port-a-cath. TTE to rule-out endocarditis was negative. The surgery team recommended not removing the port, given her history of poor peripheral access and need for continued IV antibiotics. Surveillance blood cultures were drawn daily. Her blood cultures cleared on day 4 (___). She was continued on daptomycin for a 14-day course. With her history of inappropriate access of the port-a-cath at home for intravenous administration of a medication prescribed IM by a non-trained individual (the patient's husband), there were no alternative IV access options for discharge home or to another facility to receive antibiotic treatments. The patient therefore remained in the hospital to complete her antibiotic course. She remained hemodynamically stable and afebrile throughout this period. Her left port-a-cath was removed on ___ due to patient preference and risk for future infection. # Chronic Pain/Narcotic abuse: She has a ___ year history of multiple abdominal surgeries, several bowel obstructions, ischemic colitis, cholecystectomy, appendectomy, hemorrhoidectomy, TAH/BSO, and colostomy. She has also previously been on TPN as well as tube feeds and still has a gastric tube in place, although this is specifically used for venting now. Her narcotic tolerance has increased to the point of high doses of both benzodiazepines and narcotics have been prescribed on an outpatient regimen. At home, the patient self-administers a significant amount of Demerol via her port-a-cath (equating to approx. 30mg IV morphine Q2H). This was prescribed to her as an IM medication by her previous PCP (Dr. ___. On admission, the patient was placed on IV dilaudid 2mg Q2H on the floor given her significant opioid requirement at home and initiation of this dosing regimen in the ED per a protocol from ___. She was also continued on Ativan 2mg Q2H (home dose of ___ Q6H), which was also started in the ED. She was then tapered to Q4H without signs of withdrawal, and in the final days of her hospital stay was taking only 2 doses of lorazepam per day, in addition to clonazepam 0.5mg BID. Chronic pain was consulted and recommended continuing IV Dilaudid initially on admission. Psychiatry was consulted regarding Ativan dosing and recommended not exceeding home dose of 16mg daily. A detox program was strongly recommended to the patient on several occasions, however the patient consistently refused this option. After multiple discussions with the patient, she agreed to transition to an entirely PO pain medication and benzodiazepine regimen with a long-acting benzo with plan to taper off both medications at discharge. This decision was reached in consideration of the fact that a new primary care physician would not continue prescribing IM Demerol. The patient was started on Cymbalta 30mg daily, however this was discontinued after the patient developed a headache she attributed to this medication. She was then started on Bupropion XL 150mg daily. On ___, the patient's Ativan was changed from IV to PO at the same dose and frequency. The following day, she was started on PO Klonopin 0.5mg BID and her Ativan was changed to 2mg Q6H per psychiatry. On ___, She was transitioned to PO dilaudid 10mg Q3H:PRN with IM 2mg for breakthrough per chronic pain recommendations. The patient reported stomach upset with the PO dilaudid, which she has experienced in the past. Several options of managing this were trialed including co-administering with food, anti-emetics, and tums, however the patient refused most PO dilaudid doses. She also refused all other options for oral pain medications and/or patches. She was made aware that she would not receive a prescription for IM dilaudid at discharge. We also discussed our concern for opiate withdrawal if the patient refuses PO at home. As the patient stated she has a "6 month supply of Demerol at home" she was instructed NOT to continue taking this medication and was advised of the risks of taking PO dilaudid in addition to Demerol. She acknowledged understanding of these risks. A taper for Klonopin of 0.5mg BID for 2 weeks, followed by 0.25mg BID for 2 weeks was agreed upon. A Dilaudid taper was as follows: 8mg PO Q4H x 3 days, then 8mg PO Q6H x 3 days, then 8mg PO Q8H x 21 days, for total 30 days. She accepted prescriptions of PO Dilaudid, Wellbutrin, and Klonopin at discharge. The risks of stopping benzodiazepines abruptly were discussed with patient and she acknowledged her understanding. # Psychosocial Issues: During the patient's previous hospitalization in ___, the patient's husband brought meperidine into the hospital and was found at her bedside appearing to be in the process of injecting into her port. He was asked to leave the premises and was not permitted to return. The patient's PCP, ___, terminated his care due to this event. He prescribed the patient a 1 month supply of medications while she sought out a new PCP. Several multidisciplinary meetings were held during the present hospitalization to discuss the visitation rights of the patient's husband. As the steps taken in ___ were carried out with appropriate measures in order to preserve the safety of the patient, the case was not reviewed per the husband's request. It was decided that he would be allowed one 30 minute visit daily, on weekdays only, supervised by security. He did not take advantage of this opportunity during this admission. Please see documentation by Dr. ___ in ___ on ___ for full details. # Primary Care follow-up: The patient's former PCP, ___ ___, terminated his care of the patient as of ___ due to the events described above. He provided her with a 1 month supply of Demerol and Ativan while she found a new PCP. During the present hospitalization, the patient disclosed that she had not yet found a new PCP. She did allude to a possible new physician at ___, but refused to provide the physician's name. We reached out to leadership at ___ ___ in order to secure a new PCP for the patient, however since the patient reported a 6-month supply of Demerol at home, no physician would be comfortable taking on this patient and continuing to provide opiates. This issue was discussed with the patient and she agreed to follow-up with a PCP at ___. # Abscess: The patient was s/p bedside I&D on ___ with VAC placement. Pt evaluated by surgery in the ED. She was maintained on a VAC to suction, which was changed by surgery every 3 days. Her wound was debrided at the bedside on ___. Plastic surgery was consulted for possible wound closure. The patient opted to maintain the wound VAC and follow-up in plastic surgery clinic as an outpatient. Dr. ___ agreed to act as "primary physician" in order to obtain home ___ services for wound VAC maintenance. # Hx of potassium disturbances: Patient with history of both hypokalemia and hyperkalemia during previous admissions. Last admission with normal K and K of 3.7 on current presentation. Electrolytes were monitored daily without need for repletion. # Osteoporosis: The patient was continued on home calcium supplements. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of chronic left upper quadrant abdominal pain after lap gastric band ___ s/p removal ___ complicated by abdominal infections (along the greater curvature of his stomach, since resolved on recent imaging post IV antibiotics). The patient reports that prior to ___ he had been doing well, and his pain had been much improved. ___ evening through ___ he noted sharp LUQ pain, intermittent in nature, with associated fever to 101.9 (most recently this morning). He denies chills, nausea, vomiting, or change in bowel habits (he last had a normal BM this mroning). Review of systems is positive as above, otherwise negative. Radiology showed 1. Mild stranding surrounding soft tissue thickening subjacent to the left abdominal wall, extending to the greater curvature of the stomach, minimally changed since ___. Infection in this area cannot be excluded, but the overall appearance is improved since ___. A previously-seen abscess along the greater curvature of the stomach on the ___ CT is no longer visualized. 2. 3 mm nonobstructing calculus within the lower pole of the left kidney. The patient was diagnosed with ABDOMINAL PAIN LUQ, HYPERTENSION NOS, DIABETES UNCOMPL ADULT, BARIATRIC SURGERY STATUS . At the time of discharge, the patient had Intra-abdominal infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the ___ surgical service on ___ with complaints of left upper quadrant abdominal pain beginning last week with associated fever to 101.9; WBC 12.2 on admission. The patient denied chills, nausea, vomiting or change in bowel habits. An Abd/Pelvic CT was obtained in the ED suggesting 'mild stranding surrounding soft tissue thickening subjacent to the left abdominal wall, extending to the greater curvature of the stomach, minimally changed since ___ with resolution of previous abscess seen along greater curvature of stomach. While in house, he was inititally given intravenous levofloxacin and metronidazole, which was transitioned to an oral regimen on hospital day 2. His pain improved , white blood cell count decreased to 8.1 and Tmax was 100.9 during his admission. Additionally, the patient's blood sugars were elevated during admission to 280s on HD1. ___ was consulted with recommendations for increasing the patient's sliding scale while in-house and upon discharge and keeping his glargine at 32 units q HS; pt had not received his glargine the night of admission accounting for some elevation in blood sugar, however, he did remain in the 200s the following day after receiving his usual dose. Also, metformin had been held for 48 hours following Abd CT and was resumed upon discharge; he was maintained on a diabetic/ consistent ___ diet upon discharge. He was discharged on HD3 with a 2 week course of antibiotics and follow-up scheduled with Dr. ___ next week. Following discharge, his urine culture was finalized with yeast 10,000-100,000 organisms/mL. Pt was without complaints of urinary symptoms, however, the patient was contacted and asked to follow-up with his PCP ___ ___ days of discharge for a repeat U/A and also any further management of blood sugars, which he agreed. Additionally, the patient was encouraged to follow-up with the ___ clinic within ___ weeks. ___ was contacted to request appointment; pt was encouraged to call scheduling contact number if he had not received a phone call within 24 hours, which he agreed.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old male with who normally receives his medical care at ___ but presented for evaluation of new onset abdominal pain (after changes in insurance coverage). Radiology showed Findings concerning for distal colonic obstruction. Radiology showed Small bowel obstruction with transition point in the right lower quadrant adjacent to a Richter type hernia. No evidence of bowel ischemia. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. At the time of discharge, the patient had Small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the ACS service for a small bowel obstruction. He initially was admitted to the surgical floor with a nasogastric tube in place, on IV fluids, and given IV forms of his essential home medications, except for coumadin, which was held. He expressed significant improvement in pain and passed flatus as well as had a bowel movement by HD#2. His NGT was removed, and his diet was slowly advanced. He tolerated this very well. He continued to pass flatus and have bowel movements, and expressed having no abdominal pain. At the time of discharge, he was tolerating a regular diet, having no pain, and passing flatus. He expressed feeling well to complete his recovery outside the hospital. He was discharged in good condition with instructions to follow-up with Dr. ___ in 2 weeks. He was also set up with an appointment to have his INR drawn at his usual Vanguard ___ clinic on ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male here with periumbilical pain starting around midnight, gradual onset increasing in intensity over the course of the day today. Still located around the umbilicus. Nausea without vomiting. Reported he felt he tried to urinate this morning to decrease the pain but was unable to do so. A few years ago he had an admission to a hospital for similar abdominal pain with unclear cause US APPENDIX showed Dilated, noncompressible appendix, up to 14 mm in diameter, with surrounding free fluid. Findings are concerning for acute appendicitis, given the clinical history. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 10:42 on ___. The patient was diagnosed with ACUTE APPENDICITIS NOS. The patient was treated with ___ lapstoroscopic appendectomy. At the time of discharge, the patient had acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a a ___ who presented ___ with a 12hr history of abd pain initially epigastric localizing to RLQ. Associated with nausea, chills, anorexia. ___ any vomiting. Has been passing flatus. Did have some urinary hesitancy this am but otherwise ___ any dysuria, hematuria. ___ any diarrhea, bloody stools, or recent weight loss. Last meal was dinner the preceding night. Abd ultrasound done at admission showed a dilated, noncompressible appendix, up to 14 mm in diameter, with surrounding free fluid, highly suggestive of acute appendicitis. After informed consent was obtained, the patient was taken to the OR for laparoscopic appendectomy. Surgery and postoperative course were uncomplicated. Following surgery the patient was admitted to the floor overnight for observation. His diet was advanced and he tolerated this well. He was able to void without issue, ambulate normally, and tolerate diet. On ___ when he met appropriate criteria he was discharged home with instructions to follow up in clinic postopertatively in ___ weeks.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Ms. ___ is a ___ woman with history of DVT/PE not on anticoagulation due to bleeding, history of lupus anticoagulant positivity, celiac artery stenosis, iron deficiency anemia, previous admissions for upper GIB now presenting with hematemesis and abdominal pain. Chest radiograph, portable AP upright view. showed No evidence for acute cardiopulmonary process. No free air. Recently placed port terminating in the right atrium. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with EGD- ___. At the time of discharge, the patient had Hematemesis Iron deficiency anemia Abdominal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with history of DVT/PE not on anticoagulation due to bleeding, history of lupus anticoagulant positivity, celiac artery stenosis, iron deficiency anemia, previous admissions for upper GIB now presenting with hematemesis and abdominal pain.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a history of vertically transmitted HBV cirrhosis, listed with last MELD 18, portal vein thrombosis, and CKD who presents with acutely confused state. He has had two previous hospitalizations for hepatic encephalopathy, ___ years previous and then 1 month previous while in ___ when he had forgotten to bring his lactulose. He had returned to the ___ two weeks previous, and reports that over the past few days his baseline difficulty falling asleep was worse than usual, with daytime sleepiness, and he initially attributed this to his recent travel. This AM he was difficult to arouse, and was found pacing around the house, unresponsive to most questions or answering with unintelligible responses, complaining that he was unable to sleep. His family reports that he often has a similar confused state early in the morning which clears through the day, but that this was both worse and more persistent and so brought him to the ED. He denies any melena or history of GI bleeding, EGD in ___ showed 3 cords of esophageal varices with no high risk signs, guaiac negative in the ED. He reports he has been taking all his medications including lactulose and rifaximin, last BM yesterday AM and normal. He denies any dysuria, cough, shortness of breath, fever, chills, or other localizing symptoms. Metabolic panel not significantly off from baseline, no new medications. In the ED, Vital signs were: 98.2 79 131/80 18 100% Infectious workup included a CXR without acute findings, a u/a with glycosuria but not suspicious for UTI, and pending urine/blood cultures. RUQ U/S did not visualize the portal vein, which has been chronically thrombosed. Other important labs include a lactate of 2.3 and ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria Radiology showed No acute cardiopulmonary process. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Nonvisualization of the main portal vein, possibly related to chronic thrombosis. 2. Cirrhosis with stable splenomegaly. The patient was diagnosed with HEPATIC ENCEPHALOPATHY. At the time of discharge, the patient had Primary Diagnoses =============== Hepatic encephalopathy HBV cirrhosis Secondary Diagnoses ================== Obstructive Sleep Apnea Chronic Kidney Disease Pancytopenia Portal Vein Thrombosis 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>Mr. ___ is a ___ year old male with a history of HBV cirrhosis, listed with MELD 18, portal vein thrombosis, and CKD who presented with a confusional state consistent with past episodes of hepatic encephalopathy. With lactulose and bowel movements, his mental status cleared and returned to baseline. # HEPATIC ENCEPHALOPATHY: Acute on chronic confusional state associated with inattentiveness and altered sleep/wake cycle was most consistent with hepatic encephalopathy, similar to his two previous hospitalizations for encephalopathy. He was given his lactulose and improved after having more bowel movements, both by mental status exam and per his family's assessment. Testing for acute triggers such as GI bleed, metabolic aberrations, acute change in his chronic portal en thrombosis, or concurrent infection were all negative. He had not had a bowel movement in 24 hours prior to admission, he should take enough lactulose to have 3 BMs/day. Continued home rifaximin. # Cirrhosis: Secondary to chronic HBV, on entecavir, recent viral loads have been undetectable. MELD score 18, is transplant listed. Portal vein chronically thrombosed. No ascites by exam/ultrasound or history of SBP, no history of HRS. Home entecavir was continued. Last EGD ___ showed 3 cords of esophageal varices in the lower third of the esophagus, with evidence of portal gastropathy. Home omeprazole and propanolol were continued. CKD secondary to damage from HBV glomerulonephritis with no evidence of ___. Pancytopenia secondary to HBV marrow suppression as well as hypersplenism, pneumoboots were used in lieu of heparin prophylaxis. #Glycosuria: Glucose to 1000 on U/A, with serum glucose elevated but only at 249. This was thought to be residual from tenofovir induced Fanconi syndrome with disrupted proximal glucose absorption, though tenofovir has been discontinued for ___ years. Phosphate, bicarbonate, potassium all normal. His A1c was elevated at 6.8, the highest it has been in years. He should follow up as an outpatient to consider initiating treatment. Transitional Issues =========================== -It is important that he continue his rifaximin, and continue to take adequate lactulose to have 3 bowel movements per day. -A1c was 6.8, he should follow up with his PCP to consider management of his -follow up with liver and PCP #CODE: Full #CONTACT: No HCP, pt phone ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo male on ASA 81 with a PMHx of Epilepsy who was transferred from OSH with 3 weeks of headache, now unrelieved by Tylenol over the past ___ hours. Imaging at the OSH demonstrated R acute on chronic SDH. The patient denied any recent trauma or falls. Neurosurgery was consulted for further recommendations and evaluation. Radiology showed No radiographic evidence of acute cardiopulmonary disease. CT HEAD W/O CONTRAST showed 1. Motion limited exam. 2. Small hyperdense epidural hematoma deep to the right parietal craniotomy flap. 3. Large right subdural collection of air, fluid, and dependent hyperdense blood demonstrates the same maximal width at the level of the frontal lobe as the subdural hematoma prior to the evacuation, though it is smaller posteriorly. 4. Unchanged right-sided mass effect with right to left subfalcine herniation, partial effacement of the right lateral ventricle, and 6 mm leftward shift of midline structures. Radiology showed Mild fluid overload. No focal consolidation to suggest pneumonia on the AP view. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Status post right parietal craniotomy with evacuation of the layering mixed density subdural hematoma. Stable appearance of the pneumocephalus and layering hyperdensity. No new hemorrhage. Stable leftward midline shift. 2. No new territorial infarct or intra-axial hemorrhage. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Evolving postoperative changes related to patient's known right frontoparietal craniotomy and right parietal burr hole, and right hemisphere subdural hemorrhage evacuation. 2. Grossly stable right hemisphere acute on subacute subdural hemorrhage with pneumocephalus, as described. 3. Grossly stable approximately 7 mm right to left midline shift with continued mass effect on right lateral ventricle. The patient was diagnosed with Nontraumatic acute subdural hemorrhage. The patient was treated with ___ -R Craniotomy for Evac SDH on the Right. At the time of discharge, the patient had ___ Delirium. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#___: Mr. ___ was evaluated in the ED after transfer for an outside hospital with a right acute on chronic subdural hematoma. His aspirin was held and he was admitted to the neuro floor for monitoring. His PTT was elevated and closely monitored; he remained off subcutaneous heparin. On ___, the patient was placed on EEG monitoring which was negative for seizure activity and the leads were removed. On ___, the patient was taken to the operating room and underwent a right craniotomy for evacuation of a subdural hematoma. Post-operatively, he recovered in the PACU and was later transferred to the ___ for close monitoring. On ___, the patient remained neurologically stable on examination. He underwent a scheduled head CT which showed expected post-operative changes with a small hyperdense right EDH in the parietal region. The subdural drain remained in place. On ___ the patient was transfused 1 unit of platelets as his platelet count was 95, his subdural drain was then removed. A post pull NCHCT was stable, and did not show any residual drain left in place. On ___ the patient was noted to be confused and was not following commands and had LUE weakness. He was ordered for EEG. His infectious workup continued to be pending. Discussion held with family regarding goals of care as they refused EEG. The patient was monitored closely and a formal family meeting was scheduled for ___. Family was denying neurological assessment of the patient and his meds were changed to IV. EEG D/C'd. Repeat CT Head completed on ___ showing stable subdural collection. During the family meeting the ___ hospital course was reviewed and options moving forward were discussed with family. Ethics was consulted to assist with management and social work was consulted for family support and coping. After long discussion with the family the patient was made DNR/DNI. On ___ he was having L arm twitching concerning for seizures. He was given his am Keppra early and noted to have twitching after the dose. His Keppra was increased and he was given IV Ativan with good results. After another discussion with the family the patient was transitioned to CMO and palliative care was consulted to assist with management. He was transitioned to Morphine and Ativan for comfort. On POD 7 the incision was assessed and the sutures appeared ready to be removed however the family requested the sutures remain in place to keep the patient comfortable. On discharge palliative, social work, and the neurosurgery team spoke with family regarding discontinuing keppra and increasing frequency of scheduled Ativan with PRN Valium PR for seizures. His prescriptions were sent to the receiving facility by ___ to expedite the lapse between doses during transport. The patient appeared comfortable at discharge and he was pre-medicated prior to transport. # DELIRUM The patient was having issues with delirium as well as an elevated WBC count. His steroids were discontinued. A UA, CXR and blood cultures were sent for infectious workup. He was later transitioned to CMO. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ with h/o TBI (___), SDH (___) s/p bilateral craniotomies, EtOH abuse, EtOH withdrawal seizures, and seizure disorder on home keppra, Dilantin, lamictal and tegretol who presents to OSH ___ status epilepticus. Patient was last seen normal ___ at 1645 when moving a lawn. He was witnessed by a neighbor to collapse and have seizure activity characterized by expressive aphasia, fixed gaze to right and jerking movements ___ extremities. EMS was called. Blood sugar ___ field was 65. He was taken to ___ where he was nonverbal, concern was for a stroke. He then had acute tonic clonic seizure activity. He was intubated for airway protection, given 1000mg Keppra and 8mg Ativan. Head CT showed no acute finding. He was started on a propofol drip and sent to ___ for further management. At ___ he continued to have GTCs. He was given 2mg of IV Ativan x2 and loaded with 20mg/kg of phenytoin with cessation ___ seizures. R femoral line was placed at ___ ED. He was also started on a midazolam drip. He had no fever or leukocytosis. His urine and serum tox screen were negative. He is admitted to Neuro ICU for further management. Chest radiograph showed 1. The tip of the ETT is seen approximately 3.8 cm above the carina. 2. Hypoinflated lungs with retrocardiac opacities, likely atelectasis. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is been placement of a nasogastric tube that extends to the upper body of the stomach, with the side port just distal to the esophagogastric junction. The tube should be pushed forward another 5-8 cm for more optimal positioning. The tip of the endotracheal tube remains in good position, approximately 3.5 cm above the carina. Continued opacification at the left base most likely represents atelectasis and small effusion. However, in the appropriate clinical setting, superimposed aspiration/pneumonia would be difficult to exclude, especially in the absence of a lateral view. CHEST PORT. LINE PLACEMENT showed 1. The right IJ central venous catheter tip ends in the superior cavoatrial junction. All other support lines and tubes are in unchanged position. 2. Left lower lobe opacity likely reflects a small pleural effusion with associated atelectasis, unchanged from the prior study. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. Study is limited secondary to patient compliance, as patient was unable to complete the exam. Within these limitations there is no evidence of infarct or mass effect. There is diffuse brain, medial temporal, and cerebellar atrophy . Radiology showed No unexplained metallic foreign bodies. LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE showed 1. Lumbar puncture at L3-4 without complication. I, Dr. ___ supervised the trainee during the key components of the above procedure and I reviewed and agree with the trainee's findings and dictation. The patient was diagnosed with Epilepsy, unsp, not intractable, with status epilepticus. At the time of discharge, the patient had Epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o TBI, SDH s/p bilateral craniotomies and seizure disorder reportedly on home keppra, lamictal, Dilantin, and tegretol who presented with generalized convulsive status epilepticus. #Generalized Convulsive Status Epilepticus He was witnessed to have jerking movements and gaze deviation while mowing the lawn at his group home. He was taken to ___ ___ where he was nonverbal and then had acute tonic clonic seizure. He was intubated for airway protection, given 1000mg Keppra and 8mg Ativan. Head CT showed no acute finding. He was started on a propofol drip and sent to ___ for further management. At ___ he continued to have generalized convulsive seizures. He was given 2mg of IV Ativan x2 and loaded with 20mg/kg of phenytoin with cessation ___ seizures. He had no fever or leukocytosis. Digoxin level and ___ level were undetectable (rec'd as part of seizure w/u). His urine and serum tox screen were negative. Unfortunately, AED levels were not sent at ___ ___. He was admitted to Neuro ICU for further management. On arrival to ICU he was actively seizing (GTC) on midaz 4mg/h and prop 60. He was given 5mg of midaz bolus with immediate cessation of tremors and increased rate of midaz from 4 to 5mg/hr. His home medications were started and uptitrated. He was loaded w/ phenytoin as above and started on fosphenytoin 100mg Q8H (home dose phenytoin 300mg qhs); however doses were held d/t supratherapeutic INR. He was started on carbamazepine 400mg bid as well as Keppra 1500mg BID (home dose 1g bid), Lorazepam 0.5mg AM, 2mg q pm (home dose) and Lamictal 200mg bid (home dose). His EEG continue to show discharges ___ left frontal region up to ___ Hz. He underwent an Atival trial, which did not change his clinical status or EEG. Because his EEG was felt to be acive, lamictal was increased to 250 mg BID and carbamazepine was increased to 600 mg BID. On on ___ he was transferred to the ___ for further management. ___ terms of etiology, he certainly has risk factors for status given his prior history of TBI, SDH w/ craniotomies and prior history of status epilepticus and there was some concern he was not taking his medications appropriately (although, his group home reports he is administered his meds). Additionally, there was some concern he may have an infectious process and he was initially placed on empiric meningitis treatment (vancomycin, cefepime, ampicillin, acyclovir); however, CSF studies unrevealing. He did have secretions but no overt consolidation on CXR. Given this, all antibiotics were stopped. He underwent on MRI on ___ which showed ************** # Acute Toxic Metabolic Encephalopathy He was intubated for airway protection ___ the setting of status epilepticus. Post intubation he was delirious, inattentive, perseverative and unable to follow commands. He was pulling at his lines and was given Haldol ___ this setting. His encephalopathy could be attributed to post-ictal state, infection or AEDs. He was transitioned to Seroquel 25mg QHS PRN # History of Alcohol Abuse Disorder EtOH level undetectable on admission and he reportedly has not been drinking (per his sister, people from his home). He did receive thiamine 500 mg TID x 3 days and folate initially. # Possible COPD Likely undiagnosed COPD. Given albuterol nebs ___ ICU. ============================================================== NEUROLOGY FLOOR HOSPITAL COURSE Mr. ___ is a ___ yo man with history of TBI, s/p bilateral craniotomies, alcohol abuse, and seizure disorder managed on multiple AEDs (phenytoin, lamotrigine, levetircetam, and carbamazepine). He was initially admitted to the Neuro ICU with convulsive status epilepticus and is now s/p medical management and extubation. He's had significant clinical improvement and no subsequent seizures. Neurologic exam notable for mild disorientation, perseveration, and inattention but otherwise non focal. EEG abnormal at baseline but stable without subsequent seizures. MRI brain limited as patient unable to tolerate but notable for significant atrophy of the cerebellum and temporal lobes. His AEDs were increased to the following doses: - carbamazepine 800 mg BID - lamotrigene 300 mg BID - levetiracetam 1500 mg BID - phenytoin 200 mg QHS - seroquel 12.5 mg BID Transitional issues: # His outpatient neurologist Dr. ___. Please call for an appointment. # Follow up with PCP within one week of discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CC: ___ Chest: Frontal and lateral views showed No significant change from ___. No acute cardiopulmonary process seen. The patient was diagnosed with Adult failure to thrive. At the time of discharge, the patient had Primary: Failure to thrive Dehydration Weight loss Secondary: Hyponatremia CKD stage III COPD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with history of CAD s/p DES, dCHF, CKD stage III, DM, HTN, HLD, COPD presenting with failure to thrive and hyponatremia. # Weight loss: # Failure to thrive: Mr. ___ presented with failure to thrive over months, more acute in the last few days with weakness and poor PO intake in the setting of recent diarrhea following laxative use. His presentation seemed most consistent with dehydration, and he improved dramatically with IVFs alone (received approximately 1.2L IVFs in total). WBC on admission was 9.7 ->10.3 on discharge, not thought to represent infection in the absence of fevers, negative UA/UCx, clear CXR, and BCx without growth. Mr. ___ reported ~30 lbs weight loss over a 4-month period, concerning for a possible undiagnosed malignancy, with no dysphagia to suggest esophageal pathology. TSH WNL. I discussed the possibility of a malignancy with Mr. ___, who stated that he would not want treatment for cancer even if it were discovered and declined further evaluation. Further discussion around testing for possible occult malignancy was deferred to the patient's PCP ___ ___ years (Dr. ___ at the patient's request. I spoke with Dr. ___ felt that Mr. ___ may be appropriate for home hospice, but referral was deferred to Dr. ___ in the absence of a clear terminal diagnosis. Mr. ___ will be discharged home with home ___. He was tolerating a regular diet at discharge. Dr. ___ will contact Mr. ___ with a f/u appointment within the next week. # Hyponatremia: # CKD stage III: # Non-gap metabolic acidosis: Patient presented with Na 127 and Cr 1.5 (from b/l 1.4-1.5). Na improved to 135 and Cr to 1.4 with IVFs (total of 1.2L), suggestive of pre-renal etiology. Mr. ___ was tolerating a regular diet at discharge. HCO3 at discharge was 21; consideration of sodium bicarb initiation was deferred to his PCP. # Constipation: Likely secondary to poor PO intake and absence of bowel regimen. TSH WNL. A bowel regimen was initiated, which included two enemas. Mr. ___ had a formed bowel movement prior to discharge, without melena/hematochezia and guaiac negative. He was discharged on standing Colace and Senna (with instructions to hold for diarrhea) with Miralax PRN. # Dyspnea on exertion: # Hypoxia: PCP reports transient hypoxia to 75% in clinic prior to referral to the ED. On arrival to the ED, patient was saturating 100% on RA, reporting only baseline dyspnea on exertion. CXR was clear, with no evidence of PNA or pulmonary edema. Low suspicion for PE (and V/Q scan done ___ in setting of similar and chronic DOE low likelihood for PE). Unclear whether pulse oximetry in clinic accurate, as patient was monitored with no recurrence of hypoxia. Ambulatory saturation was 92% prior to discharge, with resting saturation of 97% RA. # HFpEF: EF 55%. Appeared dry to euvolemic on exam initially and received IVFs as above. Patient reports that he was previously on Lasix, discontinued weeks ago after a recent hospitalization for pre-syncope. Given ongoing weight loss and poor PO intake, Lasix had not been re-initiated as an outpatient and was not resumed this admission. He was encouraged to monitor his weight and contact Dr. ___ with weight gain. Standing weight at discharge was 209.7 lbs. # Diabetes mellitus: A1c 7.1%. He was continued on his home 70/30 insulin 30u BID with sliding scale coverage. # Hypothyroidism: TSH WNL. Continued home levothyroxine. # Hypertension: Normotensive on his home lisinoipril. Patient was previously on metoprolol, which he reports was discontinued recently (possibly at ___ admission) in setting of pre-syncope and was not re-initiated. # Dysuria: Patient reported dysuria with initiation of his urinary stream, as well as poor urinary flow. Likely secondary to BPH. UA negative for UTI. Deferred initiation of BPH therapy to PCP as outpatient. PSA was not checked, given that patient would not want treatment for cancer (see above). # Hyperlipidemia: Patient previously prescribed simvastatin 80mg daily, which he has not been taking as he thinks it interferes with his sleep. Simvastatin was not administered in house. It was kept on his medication list at discharge, and patient was encouraged to discuss with his PCP at his next appointment. # CAD s/p DES: Continued home ASA 81mg daily. Statin management as above. # COPD: No evidence of acute exacerbation. Advair was substituted for home symbicort while hospitalized, with symbicort resumed on discharge. # OSA: Patient declined CPAP while hospitalized. Plan to resume as outpatient. ** TRANSITIONAL ** [ ] trend weights; may need resumption of Lasix [ ] consider sodium bicarbonate for CKD [ ] readdress simvastatin with patient if within GOC; consider downtitration to 40mg daily [ ] consider initiation of therapy for BPH [ ] consider testing for occult malignancy, but likely not within patient's GOC</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a history of BPH, HTN, and glaucoma who presented with weakness. The patient was minimally verbal on presentation but able to answer simple questions. The history was obtained from his son, who was present, with some review of systems asked to the patient. Earlier the evening presentation ___, the patient was going up the stairs and got to the third stair and "froze." He was unable to go up the stairs anymore and his son had him sit down and then called EMS. Per EMS report, the patient was alert and oriented and had no complaints. On arrival, he denied chest pain and said he felt comfortable. No pain at all. He was oriented to hospital setting, but per his son does not know the date. He did not report trouble breathing, choking on food, complaints about urination, or recent fevers or chills. He has chronic stomach pain for years and is always bringing up phlegm. Nothing out of the ordinary in days prior to admission, though several weeks ago had dizziness and vomiting which only lasted a day or two and then resolved. At baseline, his son explains that it is good when he answers questions, which he does not always do. He can be very repetitive. In the ED, initial vitals were: 97.9 (Tm 103), 90, 132/50, 16, 96% RA Labs notable for: UA with 5 WBCs, 1 RBC, few bacteria. Lactate 2.0. WBC 16.1 with 90% PMNs. Hgb 9.2 (8.5 in ___. Plt 527 (433 in ___. BUN/Cr 40/1.1. Phos 2.2. Imaging notable for: CXR with low lung volumes and bibasilar atelectasis. Patient was given: ___ 19:27 IVF 1000 mL NS 500 mL ___ 19:57 IV Acetaminophen IV 1000 mg ___ 21:19 IV CeftriaXONE 1 gm CHEST (AP AND LAT) showed Low lung volumes and bibasilar atelectasis. CT abdomen pelvis with oral contrast. showed 1. No evidence of infection in the abdomen or pelvis given limitations of the noncontrast study. 2. Large stool burden throughout the colon. 3. Prostatomegaly with evidence of chronic bladder outlet obstruction and bladder diverticuli. 4. Please refer to chest CT performed concurrently for intrathoracic findings. CT CHEST W/O CONTRAST showed Findings concerning for multifocal pneumonia, involving the right middle and both lower lobes. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had PRIMARY: Community Acquired Pneumonia SECONDARY: Essential thrombocytosis Chronic abdominal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#Multifocal pneumonia: Patient presented with weakness. However, the HPI and initial exam was not consistent with acute neurologic event. Given elevated WBC to 16.1 and 90% PMN, presentation was thought to be likely infection. Patient appeared somewhat dehydrated based on his initial labs (elevated BUN, all cell counts above baseline) and received 500 cc's of NS in the ED. Mild UTI as on UA was thought unlikely to cause such significant WBC response, but patient was treated with ceftriaxone 1gm q24h pending other source. In setting of increasing white count ___ AM to 18.1 and scattered rhonchi on lung exam, we obtained thorax CT to rule out pneumonia and GI process. CT abdomen was reassuring. ___ evening chest CT was concerning for multifocal pneumonia, so patient was broadened with 500mg azithromycin at 0030 on ___. He received 2 doses of ceftriaxone (___) before eventual discharge. White blood count improved to 10.7 as of ___. Patient remained asymptomatic (no dyspnea, subjective fevers or chills, or any pain) throughout hospitalization. He was discharged with a 7 day course of levofloxacin (3 doses given q48hour, dose#1 given in-hospital on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs ___ is a ___ yo RH HF with PMH of HTN, HLD, CAD, spinal stenosis, who had a witnessed onset of dysarthria, R gaze preference, L weakness whilst being a passenger in her daughter's car at around 2:30 pm. Pt was in her usual state of health yesterday, but this morning woke up feeling tired and unwell, with some increased difficulty walking. However, she was able to go about her morning activities. Whilst driving, pt's daughter suddenly noticed her mom slumping over. She asked her if there was anything wrong but the patient would not respond immediately and would not look at her. She reported that when she spoke, her speech was slurred and she would keep looking only to the right side. Pt was brought to the ED, where R arm & leg weakness was first noticed. Radiology showed Prior right frontal infarct demonstrating matched perfusion abnormality with increased mean transit time, decreased blood volume, and decreased blood flow. Cannot rule out acute on chronic ischemia in this area. If there is no contraindication, correlation with MRI is advised if concern for acute ischemia. Radiology showed Multiple areas of acute infarct involving the right frontal, parieto-occipital, and temporal lobes. MRA shows a short segment of severe narrowing of the right M1 with minimal flow signal intensity. There is also occlusion of a right M2 branch. There are severe short segment focal areas of narrowing within the left M1 and M2 segments. Findings likely relate to atherosclerotic disease. T1 hyperintensity in the gyriform of right temporal and occipital lobe. Differenital would include cortical necrosis or microhemorrhage. Nonspecific white matter abnormalities, likely a sequelae of chronic small vessel ischemic disease. Chronic infarction involving the right frontal lobe with associated volume loss and gliosis. Heterogenously enlarged left thyroid gland. Recommend a follow ultrasound as clinically warranted. Case discussed with Dr. ___ at 11:00am on ___ via phone by Dr. ___, at the time the findings were made. Radiology showed 1. No evidence of hemorrhagic conversion or mass effect. 2. Low attenuation within the right temporal lobe corresponds to area of ischemia on MR, unchanged from yesterday's CT. 3. Encephalomalacia of the right frontal lobe consistent with prior infarct, unchanged. Radiology showed Normal chest radiograph without radiographic evidence of tuberculosis. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, OTHER SPEECH DISTURBANCE. At the time of discharge, the patient had Cerebral embolism with infarction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs ___ is a ___ yo RH HF with PMH of HTN, HLD, CAD, spinal stenosis, who had a witnessed onset of dysarthria, R gaze preference, L weakness whilst being a passenger in her daughter's car. She was found to have multiple lesions in the right MCA distribution concerning for embolic infarcts. ACTIVE ISSUES # STROKE: Mrs ___ is a ___ yo RH HF with PMH of HTN, HLD, CAD, spinal stenosis, who had a witnessed onset of dysarthria, R gaze preference, L weakness whilst being a passenger in her daughter's. On exam, she was no longer dysarthric but had R gaze preference, L tactile and visual neglect and very mild L weakness. Overall, presentation was consistent with hyperacute R cortical ischemia, in inferior division of R MCA territory. The sudden onset suggests embolic etiology. As her initial presentation was more severe than her current presentation, it is possible that an embolus initially obstructed the R MCA more proximally and then broke up. Based on her persistent deficits and NIHSS 6, decision was made to give tPA in ED. Mrs. ___ was admitted to the neurological ICU for post-tPA monitoring. Her exam was stable the next morning. A repeat head CT 24 hours post-tPA was negative for bleed; aspirin 81mg and sub-cutaneous heparin were started. MRI showed multiple areas of acute infarct involving the right frontal, parieto-occipital, and temporal lobes. MRA showed a short segment of severe narrowing of the right M1 with minimal flow signal intensity. There is also occlusion of a right M2 branch. TTE with bubble showed no PFO or ASD. Tele showed sinus rhythm. In terms of reisk factors assessment: LDL 96. She was started on simvastatin 10 daily. A1c was 5.4%. # Hypertension: Given her acute stroke, we allowed patient's blood pressure to autoregulate for the first few days. Her Toprol XL dose was halved. Then, we put her back to full home dose of her Toprol XL which is 100mg daily. Then, we added amlodipine 5mg daily to help control her BP as her sBP runs as high as 190's at times but ranges mostly 150's-180's. We did not use ACE-I because of her reported allergy to enalapril. # h/o positive PPD: - CXR showed not evidence of TB . # Heterogenous thyroid gland: Noted on MRI. Follow up as outpatient. # Agitation: Patient had an episode of agitation/paranoia at night time likely secondary to delirium/sundowning given recent stroke, being in a strange environment with language barrier. She then became attentive and orientated in the morning. Physical restraint was required for about 12 hours. Seroquel was ordered prn for agitation. Patient has not need physical restraint for 3 days prior to discharge. Her mental status is back to baseline on discharge. TRANSITIONAL ISSUES - consider thyroid ultrasound as an outpatient for further evaluation of heterogenous thyroid gland. - Please continue to work on blood pressure control. Goal is normotension.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male PMH A. fib on warfarin, HFrEF (LVEF 40-45%), CAD s/p POBA x1, HTN, HLD, and T2DM who presented with presyncope. He is being admitted for work-up of suspected UGIB given Hgb drop and melenic stools. CHEST (PA AND LAT) showed 1. Stable moderate to severe enlargement of the cardiomediastinal silhouette. 2. No focal consolidation to suggest pneumonia or mass evident by plain radiography. The patient was diagnosed with Anemia, unspecified. The patient was treated with EGD with cautery. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ gentleman with a significant past medical history of Afib on warfarin with PPM, HFrEF (LVEF 40-45%), CAD s/p POBA, HTN, T2DM, and duodenal Dieulafoy lesion in ___, who presented with fatigue and black stools with drop in hgb to 6.7 from 10 in ___, found to have multiple AVMs on EGD now cauterized. During this admission, the patient's CBC was closely monitored. His hgb and hct have remained stable at around 7.7 post 2 unit pRBCs. He symptomatically improved with increased energy. Patient also underwent an EGD and push enteroscopy to evaluate for upper GI bleed. Multiple AVMs were found and cauterized although they were not actively bleeding at the time of the scope. There may have been other causes of bleed that were not visualized. Patient was restarted on a regular diet and his home warfarin and aspirin after the procedure and has tolerated diet and medications well. Patient also presented with an ___, likely prerenal in the setting of active GI bleed, now resolved at discharge. His home diuretics and blood pressure medications were held this admission in the setting of possible active GI bleed. His home diuretics and diltiazem were restarted at the time of discharge. His carvedilol and losartan were held in the setting of normal pressures while in the hospital. Given symptomatic improvement and no sign of active bleeding, Mr. ___ was deemed ready to go home. TRANSITIONAL ISSUES: [ ] f/u cbc within one week as there may be an additional source of bleeding (AVMs were not bleeding at the time of EGD) necessitating pill endoscopy or colonoscopy [ ] Home carvedilol and losartan were held in the setting of normal blood pressures while inpatient. Patient advised to check blood pressures at home and restart losartan if SBP>140. Please follow-up blood pressure and adjust medications as appropriate. ACUTE ISSUES: ============= # Acute blood loss anemia: # Concern for UGIB: Patient presented with dark stools and fatigue for 2 months duration, seen in past for dark stools and fatigue outpatient. Found to have drop of hemoglobin from 10 in ___ to 6.7 on admission. Transfused 2 units with appropriate response. Home warfarin held until EGD then resumed without complication post-procedure. Patient found to have multiple AVMs that were not bleeding on EGD, which were cauterized. Given Pantoprazole 40mg PO BID to be continued outpatient. # HFrEF: LVEF 40-45% (___). Arrival proBNP ~2200 (2700 ___. Vitals stable, on room air. Denies any shortness of breath or chest pain. Home diuretics and blood pressure medications were held given concern for potential re-blead. Diuretics and diltiazem were restarted on discharge. Continued to hold carvedilol and losartan at discharge. # ___ on CKD: Cr 1.5 on admission from baseline 1.1-1.2. Possibly pre-renal in setting of blood loss anemia. Improved following transfusion, back at 1.2 on discharge. # A. fib: # SSS s/p PPM in ___: CHADS-VASc 5. Restarted home warfarin and aspirin following EGD. Patient tolerated well. CHRONIC ISSUES: =============== # CAD s/p POBAx1: Patient was continued on home atorvastatin. Aspirin was held until post procedure. Home carvedilol held as per above. #HTN: Home medications were held this admission in the setting of GI bleed. Losartan and diltiazem were restarted at time of discharge. #HLD: Patient continued ___ Atorvastatin. #T2DM: Patient continued on home glargine regime with appropriate adjustments when NPO. Patient was also on sliding scale insulin. #Gout: Home allopurinol was decreased to 50mg PO daily given ___. Allopurinol dose was resumed to 100mg PO daily at discharge given resolution of ___. # CODE: full (presumed) # CONTACT: ___, daughter, Phone: ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ================================== HMED ADMISSION NOTE ___ ================================== PCP: ___ Radiology showed Right lower lobe opacity may correspond to patient's known lung cancer. Correlate with prior imaging. The patient was diagnosed with COUGH. At the time of discharge, the patient had COPD exacerbation Right lung mass. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with history of COPD on home oxygen with multiple admissions for COPD exacerbations at ___, with recent diagnosis of lung cancer (RLL), who presents with one week of cough, fatigue, and shortness of breath consistent with a COPD exacerbation. ACTIVE ISSUES ------------- # COPD: She had a CXR that did not demonstrate pneumonia. She was treated for a COPD exacerbation with azithromycin (completed 5 days), prednisone (40mg x4 days, 20mg x2 days), and albuterol/ipratropium nebulizers. Her symptoms improved. She was continued on advair. She was given tessalon and guaifenesin for cough. She was continued on supplemental oxygen at ___ liters nasal cannula. She was discharged with two days of prednisone 20mg daily and will follow up with her oncologist on day #3 to determine if therapy needs to be continued. # Non-small cell Lung cancer: She was seen by radiation Oncology during her admission and underwent simulation treatment to Lung field on ___. She will follow up with her oncologist on ___. She will follow up with radiation oncology on ___. MRI brain performed on ___ at ___ demonstrated small vessel ischemic disease without evidence of metastasis. #Diabetes: The Januvia was held during the hospitalization but was restarted at discharge. She was maintained on an insulin sliding scale during the hospitalization. Blood sugars were in the 100s-200s while on prednisone 20mg. She will continue to monitor blood sugars at home while on prednisone. INACTIVE ISSUES --------------- # Anemia, normocytic: Most likely anemia of chronic disease. Her hematocrit was trended during her admission and remained stable ___. Would consider iron studies as an outpatient. # Hypertension: patient was continued on her home amlodipine # Depression: patient was continued on her home citalopram and bupropion. # Arthritis: patient was continued on her hydroxychloroquine and leflunomide. Patient is unsure of what type of arthritis she has. TRANSITIONS OF CARE ------------------- [ ] follow up with oncology ___ ---[ ] consider more prolonged steroid taper at that time [ ] follow up with radiation oncology ___ [ ] consider iron studies to further evaluate anemia</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who is otherwise healthy who was going down a flight of stairs this afternoon when he tripped and fell, he felt that his left leg underwent a twisting moment, and he fell down several stairs. He noticed immediate pain and deformity of the left leg and inability to bear weight. Denies any other injury. Denies head strike/LOC Radiology showed Severely comminuted distal tibial fracture with intra-articular extension, intra-articular extension better seen on the prior study. Laterally displaced oblique fracture of the distal fibular shaft. TIB/FIB (AP AND LAT) LEFT IN O.R. showed Severely comminuted distal tibial fracture with intra articular extension is re- demonstrated. Minimal change compared to the previous study obtained at 19:05 on the same day demonstrated Lateral a displaced oblique fracture of the distal fibula is re- demonstrated with better opposition Radiology showed Severely comminuted intra-articular distal tibia fracture with multiple fracture fragments, including a fragment which comes in very close proximity to the skin. The posterior tibial and extensor digitorum longus tendons traverse through the fracture site and are partially surrounded by fragments of bone. . Comminuted fracture of the distal fibula shaft. s NOTIFICATION: The findings were discussed with ___ M.D. by ___ ___, M.D. on the telephone on ___ at 11:42 AM, 5 minutes after discovery of the findings. TIB/FIB (AP AND LAT) IN O.R. LEFT showed Correlation with real-time findings and, when appropriate, conventional radiographs is recommended for further assessment. DX TIB/FIB AND ANKLE showed Tibial and fibular fractures with external fixator in-situ. Evaluation of tibial fracture somewhat limited by overlapping hardware. There is displacement and mild angulation of the fibular fracture. The patient was diagnosed with Displaced pilon fx left tibia, init for opn fx type I/2, Oth fx upper and low end l fibula, init for opn fx type I/2, Fall (on) (from) unspecified stairs and steps, init encntr. The patient was treated with ___ - Ex-fix L Pilon (___) ___ - Hybrid frame L pilon (___). At the time of discharge, the patient had Left pilon fracture Left fibula fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a L pilon and fibula fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for closed reduction of left pilon and fibula fracture with application of multiplanar external fixator, which the patient tolerated well. He was taken back to the operating room on ___ for application of hybrid external fixator to his left lower extremity. For full details of the procedure please see the separately dictated operative report. After both surgeries, the patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1 of both surgeries. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non-weightbearing in external fixator to the left lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o necrotizing pancreatitis (likely alcoholic) and pseudocyst resected in ___ and stenting/stent removal in ___ w/ ERCP at ___ presents with abdominal pain and nausea x 1 day. At 8am on day of admission, reported sudden-onset sharp intermittent epigastric pain and nausea simultaneously similar to but not quite as severe as prior episode of pancreatitis. Has had recurrent episodes since ___, last was ___ year ago, but never severe enough to go to hospital. Drank ___ beers the night before episode. No associated vomiting, fevers, chills, dyspnea, or chest pain. Went to OSH, received dilaudid and zofran, and was transferred to ___ for further management. Radiology showed 1. Stranding and fluid surrounding the pancreatic head and uncinate process, findings consistent with acute pancreatitis. No pseudocyst. No evidence of necrosis at this time. Complete atrophy of the pancreatic body and tail. 2. Fatty liver. Steatohepatitis cannot be excluded. 3. Moderate pericardial effusion. 4. Prominence of the left ureter and diffuse bladder wall thickening, unchanged from ___. Latter findings suggest chronic outlet obstruction. The patient was diagnosed with ACUTE PANCREATITIS. At the time of discharge, the patient had pancreatitis, acute. The patient was given written instructions concerning 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 necrotizing pancreatitis (likely alcoholic) and pseudocyst resected in ___ and stenting/stent removal in ___ w/ ERCP at ___ presents with abdominal pain and nausea x 1 day, consistent with recurrent pancreatitis. # Pancreatitis: There was no evidence of pseudocyst on CT scan. ___ score 1 at admission, indicating 0-3% probability of mortality. He was NPO on admission, and needed several doses of morphine and zofran along with gentle IV fluids (given his reportedly severe aortic stenosis). He felt no symptoms the following day, when we advanced his diet to clears, then the following day to regular, without recurrence of symptoms. He was encouraged to abstain from alcohol completely and to avoid fatty foods as much as possible to minimize probability of pancreatitis recurrence. # Aortic stenosis: We have no recent echocardiogram records in our computer system, though ___ TTE shows 1.3cm3 aortic valve area. Patient reports plans of valve replacement surgery in ___ months. IV fluids were given gently on the first night of admission but discontinued when taking PO, and he never developed symptoms related to aortic stenosis. # Pericardial effusion: incidentally found on CT scan, interpreted as moderate size. We did not perform an echocardiogram given the lack of thoracic symptoms in-house.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ legally blind man with IDDM, Stage 5 CKD, HTN who presents with hip pain after falling in his house on ___. Radiology showed No acute cardiopulmonary process. FEMUR (AP AND LAT) showed Images obtained for surgical purposes CHEST (PORTABLE AP) showed 1. Compared to ___, probable collapse of the lateral segment of the right middle lobe, likely secondary to a mucous plug. However, pneumonia is also a possibility in the appropriate clinical setting. 2. Endotracheal tube positioned approximately 5 cm above the carina. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:41 am, 10 minutes after discovery of the findings. RENAL U.S. showed No evidence of hydronephrosis or stones. Radiology showed New airspace opacities within the right lung but most pronounced in the right lower lung zone may reflect aspiration/pneumonia. The patient was diagnosed with Displaced subtrochanteric fracture of left femur, init, Other fall on same level, initial encounter. The patient was treated with Intubation (___) Left long trochanteric fixation nail (___). At the time of discharge, the patient had PRIMARY DIAGNOSIS Displaced fracture of proximal femur SECONDARY DIAGNOSES Repeated falls Chronic kidney disease, Stage V Type 2 diabetes mellitus, insulin-dependent Respiratory failure Anemia Metabolic acidosis Hypertension Diabetic retinopathy Glaucoma Hyperkalemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ legally blind gentleman with IDDM, HTN, CKD Stage 5 not on HD suffering from a displaced fractured proximal femur s/p fall ___, admitted for medical optimization prior to TFN on ___. Pre-op course complicated by worsening renal function, metabolic acidosis, electrolyte abnormalities, and acute-on-chronic anemia. Patient transferred to ICU on ___ after TFN procedure due to inability to extubate, likely secondary to medical sedation in the setting of renal failure. Extubated successfully on ___, and transitioned to the floor. Treated for HAP given CXR infiltrate, fever, and leukocytosis. Should have close follow-up after DC with nephrology for initiation of dialysis. ****************MICU COURSE****************** ___ legally blind gentleman with IDDM, HTN, CKD Stage 5 not on HD s/p fall with displaced fractured proximal femur s/p trochanteric fixation nail on ___ with difficulty extubating post-surgery related to the use of sedating medications in the setting of renal failure. He was briefly on phenylephrine for MAPs <60 while in the PACU, noted to be minimally responsive. During the case, his estimated EBL was 100cc, his Hgb was 6.5, and he was transfused 1 unit PRBCs. #Hypoxemic Resp Failure Given that the patient remained intubated and requiring pressor support, transfer to MICU for further management was requested. On arrival to the MICU overnight on ___, patient opened his eyes to voice and follows commands, he was intubated and required AC with minimal vent settings due to low tidal volumes. Morning of ___, patient was more response, switched to pressure support ___ with good minute ventilation and passed spontaneous breathing trial with RISBI 32, he was extubated around 1400 on ___ maintained on shovel mask 35% with SaO2 >95%. # ___ on CKD: In terms of his renal failure, UCx was sent, patient made ___ cc/hr of dark yellow urine. K+ remained ___ with bicarb ___, VBG with pH 7.27 and remained euvolemic. Renal was consulted, no urgent need for dialysis. Per renal, he received a total of 4 g calcium gluconate for hypocalcemia, was started on calcium acetate phos binder for hyperphosphotemia and 1300 mg BID sodium bicarbonate. # Pneumonia # Leukocytosis # Fever CXR demonstrated a consolidation and collapse of the right lateral middle lobe concerning for aspiration with rising white count of 20K concerning for HAP vs. CAP. Patient received 1g vanco on ___ at 10 AM and 500 mg ceftazidime for treatment. BCx were sent. MEDICINE SERVICE COURSE ========================== #Hypoxic Respiratory Failure: #Concern for Aspiration PNA: Febrile in ICU with rising WBC count and w/ RLL opacity on ___ CXR, likely RLL atelectasis ___ mucous plugging but aspiration PNA / aspiration pneumonitis possible, so started on vanc/ceftazadime. CXR ___ showed marked improvement with radiology suggesting RLL edema from re-expansion vs. RLL infiltrate. MRSA screen, blood cx, and urine cx x2 negative. Transitioned to renally-dosed levofloxacin to end on ___. # Proximal Left femur fracture: After fall at home, evaluated by orthopedic surgery and planned for TFN after medical evaluation. Pain initially managed with IV dilaudid, which likely contributed to acidosis. TFN ___ complicated by difficult extubation and MICU stay ___ for respiratory failure. Followed by orthopedic surgery throughout admission. # Acute on chronic normocytic anemia: Hgb nadir 6.6 on ___, from 9.0 on admission. Etiology likely acute blood loss after femur fracture with subsequent slow oozing around operative site, exacerbating chronic anemia from renal failure. Hemolysis unlikely with normal LDH, haptoglobin, and Tbili. Patient received total 4U pRBC during admission. # Metabolic acidosis: # CKD Stage 5: # Hyperkalemia: Pre-operative labs notable for hyperkalemia, mixed respiratory and metabolic acidosis, hypocalcemia, and hyperphosphatemia, consistent with chronic renal failure exacerbated by respiratory suppression and volume depletion. Hyperkalemia improved with insulin, hydration, and diuresis. Acidosis improved with decreasing narcotics. Renal team evaluated patient during admission and determined no indication for acute initiation of dialysis. # Insulin dependent T2DM: HgbA1c ___ home lantus recently decreased from 10u to 5u qhs for concern for hypoglycemia I/s/o good glycemic control. Home lantus held initially; restarted after surgery in the setting of hyperglycemia, likely from enhanced insulin clearance with improved renal function. # Fall: Pt reports fall near kitchen counter ___ w/o headstrike or LOC. Most likely mechanical fall ___ visual impairment and diabetic neuropathy or orthostatic I/s/o autonomic neuropathy; less likely CNS cause given lack of focal symptoms, or arrhythmia given stable ECG and tele without evens. Other etiologies to consider include vasovagal, ACS (TropT 0.03 x2; no STEMI), hypoglycemia. Pt and family report h/o multiple falls and fall hazards in house where pt lives alone; preventing future falls will necessitate adequate home services and ideally 24hr care. # Hypertension: Home nifedipine and metoprolol held post-operatively in the setting of hypotension but restarted when patient became hypertensive prior to discharge. Home lisinopril held in the setting of worsened renal function and hyperkalemia. TRANSITIONAL ISSUES ========================== [] Please draw repeat CBC and Chem10 by ___ to follow-up anemia and renal function [] Patient will need close nephrology follow-up. Discussion should continue with the patient and his family about initiation of dialysis. [] Consider starting erythropoeitin for anemia in CKD. [] Per renal, started on calcium acetate and sodium bicarbonate during admission. [] Lisinopril stopped given low GFR and possible contribution to hyperkalemia. [] Social work and case management should continue to follow with patient at rehab, as he could likely benefit from a home safety evaluation [] Post-op wound care: Please change dressing with gauze and tegaderm every ___ days or when saturated [] Please help patient make follow-up appointment with Dr. ___ ___ (Orthopedics) on or around ___ (2 weeks post-operation) [] Would consider bisphosphonate therapy after optimization of calcium and vitamin D by nephrology given likely fragility fracture CODE STATUS: Full Code CONTACT: ___ (Son ___ ___ (daughter) at same number</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Per admitting resident: ___ s/p laparoscopic left inguinal hernia on ___ ___, Dr. ___ who presents with two days of fevers, chills, cough and abdominal pain. The patient underwent elective repair, uncomplicated procedure, and was discharged home from the ___. He states that the first week post-operatively he felt well and was continuing to improve: pain was resolving, he was resuming regular activities and tolerating a regular diet. However, approximately one week ago, he had recurrent worsening left lower quadrant pain, fevers and chills, and decreased appetite. He reports developing a non-productive cough but denies rhinorrhea. He also reports one syncopal episode associated with coughing, in which he was standing and a few minutes later awoke on the floor. He denies nausea/emesis or constipation. He has had daily, watery bowel movements and denies BRBPR or melena. His last colonoscopy was within the last year and notable only for polyps. He reports urinary urge and urinary frequency but voiding small amounts; denies dysuria. His wife recommended that he present to the ED for evaluation when the fevers persisted through the weekend. At time of presentation to the ED, he was noted to be febrile and tachycardic with a lactate at time of admission of 4.1. He responded well to 4L IVF, with normalizing lactate and vital signs. At time of surgical evaluation, he is well-appearing and hemodynamically stable. CHEST (PORTABLE AP) showed No focal consolidations to suggest pneumonia. CT ABD AND PELVIS W/O CONTRAST showed Large perisigmoid abscess with an inverted U shape, containing fluid, gas, a presumed fecalith, and a small focus of enteric contrast. Findings are most suggestive of perforated diverticulitis with abscess formation, though given history of recent left inguinal hernia surgery, complications from a bowel injury is difficult to exclude. Of note, the lateral component of this collection abuts the superior aspect of the left inguinal canal and the anteromedial component of the collection extends into the left rectus abdominus muscle. Evaluation is slightly limited without IV contrast. CT-guided pelvic drainage showed Successful CT-guided placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. Radiology showed Lungs are low volume with bibasilar atelectasis. Right-sided PICC line projects to the cavoatrial junction. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen The patient was diagnosed with Fever, unspecified. The patient was treated with ___: CT-guided placement of an ___ pigtail catheter. At the time of discharge, the patient had Perforated diverticulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to pre-op/Emergency Department on ___. Upon arrival to ED patient had acute kidney injury, tachycardia, fever, hypotension and abdominal pain. Given findings, the patient received a CT scan that demonstrated a pelvic abscess. Interventional radiology placed a percutaneous drain that expelled purulent fluid. The fluid was cultured and found to be polymicrobial. Blood cultures drawn at admission demonstrated streptococcus anginosus (milleri). Infectious disease was consulted who recommended ceftriaxone and metronidazole to cover for bacteremia secondary to intra-abdominal abscess. A peripherally inserted central catheter was placed and the patient was discharged on two weeks of antibiotics. His acute kidney injury returned to baseline (0.9-1.0) with hydration and treatment of his infection. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with intravenous pain medication and then transitioned to oral oxycodoneonce tolerating a diet. CV: The patient's fever, tachycardia and hypotension resolved with antibiotics. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO. Post placement of percutaneous drain his diet was advanced as tolerated to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection. His fever deffervesced with antibiotics. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. He was maintained on subcutaneous heparin for deep vein thrombosis prophylaxis while hospitalized. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with severe RUE pain with C6-7 disc herniation. s/p C7 corpectomy and C6-T1 fusion. Social History: ___ Family History: Noncontributory Physical Exam: On discharge, patient was in no acute distress. Motor examination was ___ throughout bilateral lower extremities. Sensation was intact in all distributions bilaterally Normal reflexes. No hyperreflexic signs. Gait is normal. Dressing is intact with incision clean and dry. Radiology showed On the swimmer's lateral view, C1 through C7 are seen, with C7 partially obscured. T1 is subtly seen, but not well seen. Given this, no radiographic evidence of acute fracture or dislocation. However, clinical concern for cervical spine injury persists, CT or MRI is more sensitive and should be considered. CT scan pending. CT C-SPINE W/O CONTRAST showed No acute fracture or dislocation. Degenerative changes C5/C6 and C6/C7. Posterior disc osteophyte at C5/C6 mildly to moderately narrows the central canal. Disc bulge at C6/C7 mildly narrows the central canal. C5/C6, C6/C7 disc protrusion/ disc bulge better assessed on recent prior MRI. Chest: Frontal and lateral views showed No acute cardiopulmonary process. CERVICAL SINGLE VIEW IN OR showed Intraoperative radiographs of the cervical spine. Further details please refer to the operative report in the ___ medical record. C-SPINE NON-TRAUMA ___ VIEWS showed 1. Status post C7 corpectomy with spine stabilization hardware in place, without complication. 2. No fracture or dislocation. HAND (PA,LAT AND OBLIQUE) RIGHT showed No fracture, lytic or blastic bone lesions or radiopaque foreign body identified The patient was diagnosed with Weakness. The patient was treated with C7 corpectomy C6-T1 anterior fusion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable ___ were used for postoperative DVT prophylaxis.Intravenous antibiotics were continued for 24hrs postop per standard protocol.Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's.Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ F w/ PMH b/l SDH, afib on ASA, DLBCL s/p RCHOP, embolic infarcts, epilepsy who presents with 1 month of progressive R sided weakness. CT HEAD W/O CONTRAST showed No acute intracranial process. No evidence of intracranial hemorrhage. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed No significant interval change compared to prior MR imaging. No acute intracranial infarct, mass or hemorrhage. No abnormal enhancing lesions. Chronic small bilateral occipital lobe infarcts appear similar compared to prior imaging. Mild white matter microangiopathic changes are fairly stable. Generalized cerebral atrophy with ex vacuo dilatation of ventricular system. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed No evidence of compromise of the cervical cord in the spinal canal. No abnormal cord signal intensity. No acute vertebral body fractures or dislocations. Degenerative changes result in multilevel neural foraminal narrowing most marked on the right at the C3-4 and left C6-7 levels as described above. The patient was diagnosed with Weakness. At the time of discharge, the patient had Right sided weakness 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>Ms. ___ is a pleasant ___ F w/ PMH b/l SDH, afib on ASA, DLBCL s/p RCHOP, embolic infarcts, epilepsy who presents with 1 month of progressive R sided weakness and 10 days of worsening R sided tingling. The tingling has been happening off and on for the last ___ years, but this time it is tingling for longer than usual. On exam, she has a mild UMN pattern weakness in the 4+ range in both her arm and her leg. There are no sensory changes on formal testing with pin. Given her stroke risk factors (ie having afib but only being on ASA given her bleeding risk in the setting of bilateral SDH), she had an MRI of her brain looking for a stroke that could have led to her right sided weakness. There was no change on her MRI from her prior MRI in ___. Chronic small bilateral occipital lobe infarcts were noted and similar to that seen in ___ ___s chronic small vessel changes. She also had an MRI of her cervical spine, which did not show any abnormal cord signal intensity. She has some degenerative changes resulting in multilevel neural foraminal narrowing worse at R C3-C4. Overall, it is unclear what caused her right sided weakness and neuropathy. Given that the weakness has been going on for the last week to 4 weeks, it may have been that she had a small left sided stroke resulting in a mild right hemiparesis. This would not be picked up on DWI/ADC if it happened >14 days ago, so perhaps that could be one explanation. Regardless, she is not someone who could be safely anticoagulated given her age and risk of falling in the setting of a history of bilateral subdural hemorrhages. She will remain on aspirin for the time being and follow up with outpatient neurology. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Note contains an addendum. See bottom. UNILAT UP EXT VEINS US LEFT showed 1. Nonocclusive thrombus in the left internal jugular vein. 2. Two brachial veins are noted with occlusive thrombus in one and nonocclusive thrombus in the other. 3. Patent visualized left subclavian vein with loss of respiratory variation, suggestive of upstream thrombus/occlusion/stenosis. 4. The remaining left upper extremity veins are patent. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality. 2. Evaluation of the major venous vasculature is limited due to suboptimal contrast timing. No definite thrombus seen in the left innominate or subclavian veins. Nonocclusive thrombus in the left internal jugular vein noted on prior ultrasound study is not well seen. 3. Large hiatus hernia. 4. Additional chronic findings, as above. The patient was diagnosed with Acute embolism and thrombosis of left internal jugular vein, Acute embolism and thrombosis of deep veins of l up extrem, Acute embolism and thrombosis of left subclavian vein, Shortness of breath. The patient was treated with LHC/RHC ___. At the time of discharge, the patient had ================= PRIMARY DIAGNOSIS ================= Deep Vein thrombosis =================== SECONDARY DIAGNOSIS =================== Heart Failure with Reduced Ejection Fraction Acute Kidney Injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>================== SUMMARY STATEMENT ================== Ms. ___ is a ___ female with history of radiation to the left breast and PPM placement in the left subclavian vein presenting with LUE swelling and found to have thrombus in LIJ, left subclavian vein, and two left brachial veins, now therapeutic on coumadain. Found to have a new wall motion abnormality on TTE with newly reduced EF, RHC w/ elevated filling pressures (PCW 24) s/p IV diuresis with improvement in dyspnea on exertion. ===================== TRANSITIONAL ISSUES ===================== [ ] Dr. ___ to manage INR as outpt via ___ clinic [ ] Please draw next INR and Chem-7 + Mg on ___ and fax results to ___ [ ] Consider repeat chem-7 at follow up appointment with Dr. ___ to ensure ___ stable [ ] Low dose BB started this admission, pt w/ soft BPs (SBPs ___ but asymptomatic, continue to titrate as outpatient [ ] Consider restarting ACEi as outpatient. Pt had mild improving ___ at discharge ___ diuresis in addition to softer blood pressures, and thus was not started on ___ despite new HFrEF [ ] F/u BMP closely given furosemide started this admission [ ] Ferritin 53 this admission w/ stable anemia, will likely benefit from IV Fe repletion as outpatient given new HFrEF, deferred this admission given hx of previous Fe infusions [ ] Consider further workup for new onset cardiomyopathy, possible cardiac MRI, as an outpatient [ ] Follow up with vascular surgery as outpatient given history of multiple provoked DVT [ ] Will likely require anticoagulation for at least ___ months given that this is provoked, and consider evaluation for further anticoagulation as an outpatient given that this is her second DVT Discharge Diuretic - Lasix 20mg Daily Discharge Weight - 226 lbs Discharge Cr - 1.2 NEW MEDICATIONS Warfarin 5mg daily Furosemide 20mg daily Metoprolol XL 12.5 daily =========================== HOSPITAL COURSE BY PROBLEM =========================== ACUTE ISSUES: ============= #Heart Failure with Reduced Ejection Fraction Patient complaining of dyspnea on exertion for the past several weeks prompting TTE that showed newly depressed EF of 39% (EF >55% in ___ with regional wall motion abnormalities. Troponins were negative. Had LHC/RHC without coronary artery disease, but elevated filling pressures w/ PCW 24. Pacemaker interrogated w/o acute events. Etiology of heart failure may be secondary to adriamycin toxicity or a stress cardiomyopathy in light of her acute clot burden as below. Successful IV diuresis, switched to PO ___. - Preload: Continue Lasix 20mg PO - Afterload: None, holding home ACEi in setting of ___, consider re-starting as outpatient - NHBK: Started on metoprolol succinate 12.5mg #LIJ, left subclavian, left brachial DVT Presented with sudden onset LUE swelling and LUE U/S showed extensive thrombus in LIJ, L subclavian vein, and two left brachial veins. Thought to be precipitated by recent PPM placement. No concern for compartment syndrome this admission. Was bridged initially w/ lovenox and then hep gtt given borderline kidney function. Discharged on warfarin with therapeutic INR. - Discharge INR 2.4 - Anticoagulation will be managed by ___ clinic and Dr. ___ # ___ on CKD, resolved: History of CKD stage III. Cr 1.2 in ___ with intermittent ___ to 1.5 this admission while diuresing. Discharge Cr 1.2.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ left-handed white man w/PMH of CAD on ASA 81mg, dyslipidemia, HTN (on no meds), who presents today after waking up with nausea, slurred speech, diplopia, ataxia and R-sided weakness. Last known normal at 1030 ___ when he went to bed to have sleepover with grandson. Pt was not seen by daughter overnight and denies getting up at night. Daughter was woken up around 5 am by grandson saying that pt was not doing well and calling for help. He was sitting up in bed, "wobbling", unable to stand up or walk upon awaking and yelling for help, dysarthric, complaining of double vision, gagging & complaining of nausea. Noticed that R arm was "limp". 911 was called and patient brought to ED ___. Neurological exam in ED notable for dysconjugate gaze, multi-directional nystagmus, vomiting x 1, truncal ataxia, dysmetria, moving all extremities. Stat non-contrast head CT negative at ___ for acute bleed. ECG NSR. Blood work normal (BMP, coags, LFTs, trop) except lactate 2.9. STAT transfer to ___ for further evaluation. CTA HEAD AND CTA NECK showed Basilar artery and left posterior cerebral artery thrombosis with intraluminal filling defects in the basilar artery and in the proximal right posterior cerebral artery. Occlusion of the left vertebral artery from its origin to C3. Atheromatous changes without other evidence of significant arterial stenosis. CHEST (PORTABLE AP) showed The patient is intubated. The tip of the endotracheal tube projects approximately 3.5 cm above the carinal. The patient also has a nasogastric tube, the course of the tube is unremarkable, the tip of the tube is not visualized on the image. Borderline size of the cardiac silhouette with mild fluid overload but no overt pulmonary edema. Areas of atelectasis at both the left and the right lung bases. No pneumothorax. No pleural effusions. No pneumonia. Radiology showed No evidence of infarction. However, the presence of contrast material may obscure the signs of earlyinfarction. MRI would be more sensitive for acute infarction. Radiology showed Acute infarcts involving the left cerebral peduncle, bilateral pons, and left cerebellar hemisphere. There is loss of normal flow void within the posterior circulation in keeping with patient's history of thrombus. There is no hemorrhage. Nonspecific white matter abnormalities, likely sequela of chronic small vessel ischemic disease. Case discussed with Dr. ___ telephone by Dr. ___ at 9 a.m. on ___, immediately after the findings were made. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the nasogastric tube. And the endotracheal tube have been removed. The left internal jugular vein catheter is in unchanged position. Bilateral platelike atelectasis at the left lung bases are minimally more severe than on the previous image. No other change. Radiology showed 1. No acute hemorrhage. 2. Small evolving infarcts in the midbrain and left cerebellum. 3. No CT evidence of a new acute major vascular territorial infarct; MRI could be considered for further evaluation if clinically warranted. 4. Persistent hyperdensity in the basilar artery, compatible with thrombus. Radiology showed Dobbhoff tube with the tip in the midesophagus. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 4:27 ___, 2 minutes after discovery of the findings. Radiology showed Final image showing the Dobbhoff tube within the stomach. Radiology showed 1. No acute hemorrhage. 2. Evolving infarcts in the left midbrain, left cerebellum, and bilateral pons. 3. Persistent hyperdensity in the basilar artery extending to and likely into the left posterior circulation, compatible with thrombus. CHEST (SINGLE VIEW)CHEST (SINGLE VIEW)i showed Mild interstitial pulmonary edema and pulmonary vascular congestion of clearly worsened since ___. Normal cardiomediastinal silhouette. No appreciable pleural abnormality. Left skin fold should not be mistaken for pneumothorax. Left internal jugular line ends at the origin of the SVC. CTA HEAD AND CTA NECK showed There are evolving infarcts involving the left cerebellar hemisphere, left mid brain and bilateral pons. There is no hemorrhage. There is stable complete occlusion of the midportion of the basilar artery with a filling defect more distally. There is also occlusion of the left posterior cerebral artery. There is persistent occlusion of the left vertebral artery from its origin to the C3 level. There are new reticular opacities within the right upper lobe which may reflect an infectious or an inflammatory process. Radiology showed The feeding tube continues to have its tip projecting over the stomach. The left internal jugular central line continues to terminate in the proximal SVC. There is no evidence of pulmonary edema. Patchy opacities at both bases most likely reflect atelectasis, although a bibasilar pneumonia could not be entirely excluded. No pleural effusions. No pneumothorax. Overall cardiac and mediastinal contours are stable. Radiology showed Dobbhoff tube extends below the diaphragm with the tip in the body of the stomach. CHEST PORT. LINE PLACEMENT showed New PICC line CHEST (PORTABLE AP) showed NG tube in stomach. CHEST (PORTABLE AP) showed NG tube in the stomach. New NG tube placement. AP radiograph of the chest was reviewed in comparison to ___ obtained at 2:55 p.m. The NG tube tip is in the stomach. The right PICC line tip is at the level of cavoatrial junction. Heart size and mediastinum are grossly stable. Lungs are essentially clear except for potential minimal atelectasis at the left lung base. was done. PORTABLE HEAD CT W/O CONTRAST showed 1. The fourth ventricle appears smaller than on ___. This exam is motion limited, particularly at the level of the posterior fossa, and evaluation for a new cerebellar infarct or edema is limited. Lateral and third ventricles are stable in size. Recommend short interval follow-up CT for reassessment. 2. Stable appearance of bilateral midbrain infarcts. NOTIFICATION: The findings and recommendations were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 5:12 ___. Radiology showed 1. The fourth ventricle appears improved compared to the prior exam and may have been likely secondary to artifact or patient motion. No new hemorrhage is identified. Evaluation for new cerebellar infarct or edema is limited. 2. Stable appearance of the bilateral midbrain infarcts. Radiology showed NG tube within the stomach on the final image. PORTABLE HEAD CT W/O CONTRAST showed 1. No new acute intracranial process. Stable ventricles from prior exam. 2. Continued evolution of infarcts involving the left cerebellar hemisphere, the left midbrain, and the bilateral pons. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Heart size top- normal. Lungs clear. No pleural abnormality. Nasogastric tube ends in the distal portion of the nondistended stomach. Right PIC line ends in the region of the superior cavoatrial junction. Evaluation of the patient with cough, suspected pneumonia. AP radiograph of the chest was reviewed in comparison to ___. The right PICC line tip is at the level of low SVC/cavoatrial junction. Heart size and mediastinum are stable. Bibasal linear opacities are noted, most likely representing atelectasis with slight progression as compared to the prior study, thus infectious process in the lung bases is a possibility. There is no pneumothorax. No appreciable pleural effusion is seen. NG tube tip is most likely in the stomach. was done. PORTABLE ABDOMEN showed Normal bowel gas pattern with no evidence of obstruction. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. The patient was treated with PEG placement. At the time of discharge, the patient had Posterior circulation infarcts Basilar artery thrombosis Vertebral artery occlusion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ICU Course: Mr. ___ was admitted to the neurology ICU with basilar artery occlusion that was thought to be due to embolization from the left vertebral artery origin or from in situ thrombosis of the basilar artery. He had frequent pressure and posture dependent changes in his exam. At his best he was awake and alert and oriented x3 with some mild LUE and LLE weakness and ataxia. With drops in blood pressure and sitting up his exam worsened with increase somnolence and worsening left sided plegia. In the setting of worsening exams, he had serial NCHCTs which did not show signs of edema or hemorrhage. For this reason he was continued on norepinephrine for blood pressure support and the HOB was kept flat. He was started on midodrine in attempt to wean off IV pressors. He slowly improved. Blood pressure goals were weaned down slowly and HOB was gradually increased as tolerated by his neurologic exam. By ___ he was able to get out of bed to the chair and tolerate SBP as low as 120. Mr. ___ was evaluated multiple times by speech and swallow therapy and was unfortunately unable to tolerate a PO diet safely. Therefore a PEG tube was placed on ___. Following PEG placement he was started on coumadin. On ___, he was found to have a UTI and was started on ceftriaxone for a planned ___ultures grew E.Coli.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with pmhx of dm, htn, afib on coumadin, ___ who presents with diffuse facial swelling worsening over 3 days. Pt states prior of onset of facial swelilng, he had 5 days of itchy eyes, and went to the eye doctor and received eye drops. He noted that after taking the drops he began having diffuse itching and swelling of his face. He stopped taking the drops and went to the emergency room 1 day prior to presentation and was given antibiotics. He states that he has also tried using vaseline and rubbing alcohol after which developed periorbital edema, watery eyes, erythema and continued puritis. Radiology showed No post-septal cellulitis. Swelling in the preseptal soft tissues consistent with preseptal cellulitis. There is soft tissue stranding located in the soft tissues lateral to the orbits. Findings discussed with Dr. ___ by ___ at the time of discovery. The patient was diagnosed with CELLULITIS OF FACE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT. The patient was treated with Heat CT. At the time of discharge, the patient had Primary Diagnoses: Cellulitis Secondary Diagnoses: Atrial Fibrillation Diastolic Congestive Heart Failure Diabetes mellitus Coronary Artery Disease Gout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ year old Male with a past medical history of DM, hypertension, atrial fibrillation on coumadin, ___ admitted for diffuse facial swelling worsening over 3 days. ACUTE ISSUES ============ #Cellulitis: Patient presented with diffuse facial swelling that began 3 days prior to admission after 5 days of itchy eyes and use of new eye drops. CT showed preseptal cellulitis with no postseptal involvement. He was started on IV antibiotics then transitioned to PO clindamycin to complete a 10 day course - follow up with dermatologist Dr. ___. CHRONIC ISSUES ============== #Atrial fibrillation- Stable during admission. Patient has history of A fib with chads score of 3, currently rhythm controlled. Continued home amiodarone and warfarin. #DM- Stable during admission, not on medication regimen, continued diet control #dCHF- No clinical signs or symptoms of heart failure. Continued home torsemide. #CAD: History of CAD -continued valsartan, lipitor, amlodipine, #Gout: Continued home allopurinol. TRANSITIONAL ISSUES ===================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History from records, daughter, and conversation with PCP. Pt has no recollection of today's events. Radiology showed Mild interstitial pulmonary edema. Radiology showed No acute intracranial process. Radiology showed 1. No acute cervical fracture. Multilevel moderate degenerative changes. 2. Thyroid nodules and calcifications for which thryoid ultrasound can be performed on a non emergent basis for further evaluation. 3. Mild pulmonary edema. Additional findings discussed with Dr. ___ by ___ via telephone on ___ at 7:22 ___. Radiology showed No acute fracture or dislocation. The patient was diagnosed with HEAD INJURY UNSPECIFIED, OPEN WOUND ARM MULT/NOS, ABRASION HIP & LEG, UNSPECIFIED FALL, URIN TRACT INFECTION NOS, ALZHEIMER'S DISEASE, DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIROAL DISTURBANCE, HYPERTENSION NOS. At the time of discharge, the patient had # s/p fall # urinary tract infection # urinary retention Secondary diagnoses: # advanced dementia # hypertension # anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># s/p unwitnessed fall: details unknown but pt deconditioned, possible mild delirium secondary to UTI. Wound care was provided for knees and LUE skin tears, and she was started on vitamin D 1000U to decrease risk of falls. ___ evaluated pt and recommended rehab. # recurrent UTI: likely secondary to intermittent urinary retention, plus some fecal incontinence. Started empirically on vancomycin, as current infection occurred through ciprofloxacin, and last UTI in OMR was pansensitive enterococcus. She is allergic to PCN, Keflex, and Sulfa. Urine cx from ED grew mixed flora, so urine cx was repeated. Urine culture was negative and antibiotics stopped prior to discharge. # urinary retention: She consistently had high PVR on bladder scan, so ___ was placed. She will keep ___ until f/u with her uro-gynecologist Dr ___. # fecal incontinence: stool softeners were discontinued, and she was given Metamucil to add bulk. Consider probiotics as well.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ male w/PMHx including severe aortic stenosis s/p ___ ___, CAD w/systolic CHF, afib on warfarin, diabetes with complications, smoldering multiple myeloma, stage III CKD, anemia and thrombocytopenia, peptic ulcer disease s/p Billroth II anastomosis with known lymphangiectasia with gastric remnant (with bleeding in the past associated with aspirin), history of colon cancer ___ Duke's B2 with right colectomy, last colonoscopy in ___, s/p recent GJ tube placement on ___. He is now presenting with bleeding after he pulled out his GJ-tube on ___. . Per report, the patient was doing well at ___ when he pulled it out. Why he pulled it out, and the timing of when it came out are not clear, regardless, there was significant bleeding afterwards. Our most recent evaluation of his mental status was on discharge, ___, when there is no documentation of confusion or delirium. Radiology showed Successful placement of a 14 ___ ___ gastrojejunostomy tube with its tip in the jejunum. CHEST (PORTABLE AP) showed Cardiomegaly is accompanied by moderate to marked pulmonary edema with both alveolar and interstitial components. Moderate bilateral pleural effusions are also present, increased from the prior study, and associated with adjacent basilar atelectasis CHEST (PORTABLE AP) showed Compared to the previous radiograph, there is a mild increase in extent of a pre-existing right pleural effusion. Also increased are the signs indicative of pulmonary edema that is now moderate in severity. Massive cardiomegaly persists. Status post aortic valve replacement. Bilateral areas of atelectasis are unchanged. The patient was diagnosed with MECHANICAL COMPLIC OF GASTROSTOMY, ABN REACT-EXTERNAL STOMA. At the time of discharge, the patient had GJ-tube dislodgement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT ================================ ___ male w/PMHx including severe aortic stenosis s/p ___ ___, CAD w/systolic CHF, afib on warfarin, diabetes with complications, smoldering multiple myeloma, stage III CKD, anemia and thrombocytopenia, peptic ulcer disease s/p Billroth II anastomosis with known lymphangiectasia with gastric remnant (with bleeding in the past associated with aspirin), history of colon cancer ___ ___'s B2 with right colectomy, last colonoscopy in ___, s/p recent GJ tube placement on ___. He is now presenting with bleeding after he pulled out his GJ-tube on ___. Now s/p replacement of his GJ tube by ___ on ___. . PLAN by PROBLEMS ================================ # Diarrhea He was noted to have diarrhea, but per his son, this has happened in the past and has been attributed to tube feeds. Banana flakes were added with some improvement in his diarrhea. Stool C. diff was sent and was NEGATIVE. . # Rash Patient was noted to have a rash on his trunk, that spared his limbs, palms / soles and mucosal surfaces. He had DFA for HSV and VZV, both which were negative. He had a wound swab with a negative Gram stain and no growth on culture to date. He also had a fungal culture, with no growth to date. Blood cultures also with no growth (FINAL). Most likely this is a fungal folliculitis. He was started on a steroid ointment and an anti-fungal ointment with improvement. Of note, his son-in-law, Dr. ___, is a local dermat___ and examined pt on a frequent basis. . # Traumatic removal of GJ tube in the setting of dysphagia and significant aspiration risk, with acute blood loss anemia, stable ___ was able to replace the GJ tube on ___ successfully. He was able to tolerate TF's at goal. He did require 3 units PRBC transfusion before stabilization of his Hct. . # Anemia, acute blood loss Most likely related to dislodging GJ-tube and replacing GJ-tube. He is s/p 3 unit PRBC transfusion with stable post-transfusion Hct check. He had no evidence of active bleeding after blood transfusion . # Severe aortic stenosis s/p ___ ___, CAD w/systolic CHF, afib on warfarin, HTN, HL He was continued on home ASA, atorvastatin, furosemide. His Coumadin had been held prior to admission due to anticipated need for replacement of GJ tube. On admission, he was placed on heparin GTT. After replacement of his GJ tube, he was restarted on Coumadin. He is on anticoagulation for his Atrial fibrillation. Per his Cardiologist, Dr. ___ his ___, he does not require Coumadin. ASA is adequate for his ___. He is currently with therapeutic INR. Most recent Coumadin dose has been 3mg daily for the past few days. Will need INR check on ___. . # Diabetes mellitus, c/b retinopathy, neuropathy BS in good range, he was on gentle HISS . # Stage III CKD - avoid nephrotoxins, monitor Cr/UOP/lytes while here, with stable Cr. . # Smoldering multiple myeloma, monoclonal gammopathy, anemia and thrombocytopenia He received 3 units PRBC for acute blood loss anemia, otherwise his count remained low but stable. . # Peptic ulcer disease s/p Billroth II anastomosis with known lymphangiectasia with gastric remnant (with bleeding in the past associated with aspirin) When his GJ tube was out, he was placed on IV Protonix. He was resumed on lansoprazole once GJ tube replaced. . # Hypothyroidism Continued home levothyroxine via GJ-tube . # Possible history of depression Continued home sertraline via GJ-tube . # Possible history of bronchospasm vs. COPD Was previously discharged with PRN albuterol and ipratropium for unclear reasons. These were continued but he did not require frequent treatments. . # FEN Continued TF's at goal. He is strict NPO . # Code Status: FULL CODE # CONTACT INFORMATION: HCP ___ (daughter) ___ Alternate ___ (wife) ___ Alternate Dr. ___ (son) ___ .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o dementia, HTN, and HLD presents from a nursing home with syncope. It was an witnessed event in a bathroom at the nursing home where the patient has been residing. Patient was sitting down, and did not fall or hit her head. Abnormal movement was observed by nursing home staff. Patient reported feeling dizzy this AM. No headache, chest pain, palpitation, nausea, vomiting, or diarrhea. She denies fever or chills. Chest: Frontal and lateral views showed Low lung volumes. Somewhat under penetrated due to body habitus. Given the above, subtle medial right base opacity most likely reflects overlap of vascular structures or possibly atelectasis, with aspiration or infection felt less likely. CT HEAD W/O CONTRAST showed No acute intracranial process. The patient was diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS . At the time of discharge, the patient had PRIMARY DIAGNOSES: ------------------ Syncope UTI SECONDARY DIAGNOSES: ------------------- Orthostatic hypotension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o dementia, HTN, and HLD presented from a nursing home with syncope. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with ESRD ___ to DM, s/p living donor renal transplant in ___ presents with a 3 weeks history of LLQ pain. The patient is accompanied by his son and grandson who interpret for him. Pt states that the pain started approximately one week after undergoing a prostate biopsy when he was lifting a case of water bottles. The pain has remained fairly constant in quality and location, no alleviating factors. It is worse with movement/straining. Pt also reports a recent (approx. 2 weeks) change in bowel habits with alternating watery and formed stool. Denies nausea, vomiting, obstipation, fevers or chills. The patient takes oral iron supplements and says his stool always looks dark but has noted no frank blood. Last colonoscopy in ___, wnl. The patient has a h/o metastatic SCC of the scalp, s/p local excision and radiotherapy with metastases to lung. Of note, the patient has had increasing leukocytosis, thrombocytosis and anemia since last ___. Radiology showed 1. Irregular thickening and abnormal enhancing nodularity of an approximately 6 cm loop of small bowel in the left lower quadrant highly worrisome for malignancy most likely metastasis given patient's history of metastatic melanoma. 2. Nonspecific 4.7 x 5.3 cm area of mild subcutaneous fat stranding in the left anterior abdomen at the level of the umbilicus. Findings could reflect cellulitis. CHEST (PRE-OP PA AND LAT) showed Comparison to ___. No relevant change. Normal lung volumes. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. No pneumonia, no pleural effusions. No pulmonary edema. Chest CT showed Interval increase in size field currently micro loculated right upper lobe nodule as described in details. Unchanged appearance of the left upper lobe nodule, bronchial wall thickening and appearance of the post wedge resection in the right lower lobe. The airway infection/ inflammation is extensive and more pronounced than on the previous examination. Coronary calcifications. For pre size assessment of the upper abdomen please see CT abdomen obtained on ___ and the corresponding report NOTIFICATION: Findings discussed with Dr. ___ telephone at 18:58 on ___ at time study was reviewed. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed The nasogastric tube is coiled in the distal esophagus above the level of the diaphragm, recommend repositioning. A subsequent chest radiograph demonstrating a repositioned tube was available at the time of the report. CHEST (PORTABLE AP) showed The nasogastric tube terminates in the stomach. Radiology showed The enteric tube terminates in the distal stomach. No evidence of ileus or obstruction. The patient was diagnosed with Noninfective gastroenteritis and colitis, unspecified, Left lower quadrant pain. The patient was treated with ___ Small-bowel resection.. At the time of discharge, the patient had Small bowel mass s/p small bowel resection DM. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o male s/p kidney transplant ___ presented with left lower quadrant pain and change in bowel habits, new anemia and melena. He was scanned and CT demonstrated a mass in the small bowel in the left lower quadrant at the site of the patient's pain. Given h/o metastatic squamous cell carcinoma it was suspected that mass was likely a metastatis and the plan was to take him to the OR. Prior to OR, he was given PRBC for anemia (hct 22%) with increase. GI was consulted for EGD to rule out upper GI causes of blood loss. EGD was performed on ___ showing: atypical appearing erosion of the mucosa in the distal gastric body. Cold forceps biopsies were performed for histology. Duodenum appeared normal. Biopsy was consistent with iron stained gastritis. On ___, he underwent small bowel resection for tumor. Surgeon was Dr. ___. Please refer to operative note for complete details. He did well and there were no complications. NG needed to be replaced and then he didn't do well with clamping due to nausea. NG was replaced to suction. Clamp trials were then tried and residuals were low (15cc). NG was removed on ___. Clear diet was started. He was passing flatus and had BMs on ___. Diet was advanced and tolerated. Abdomen was non-distended. Incision was intact and without redness or drainage. Pain was initially managed with PCA. Once diet was started, he was transitioned to po pain medication -ultram and Tylenol. He did get a few doses of oxycodone as well. ___ Clinic was consulted for hyperglycemia. He was started on Lantus (home insulin was Levemir/Humalog SS) with improved control. Metformin was resumed. ___ evaluated and found that he had no acute ___ needs. ___ was not indicated. He was discharged to home in stable condition. Of note, Rapamune was stopped preop in anticipation of surgery (potential to impair wound healing). Tacrolimus was started and dose adjusted to 3mg bid with troughs in the 4.9 range. Tacrolimus was ordered and filled by ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ ___ woman with PMH significant for HTN, HLD, DM, pancreatitis, AAA, DVT and right parietal ___ gyrus) stroke who presents with slurred speech. She says she believes that her slurred speech began yesterday evening and was acute in onset. She says it was also noted by the facility where she lives. She has had brief episodes, lasting seconds, of slurred speech in the past, but this has now persisted since onset last yesterday evening. She does not note any associated neurologic defecits with the dysarhtria, including no visual changes, weakness, or numbness (she noted right forearm and ___ and ___ digit numbness but says this is chronic). She says that for almost the past year, she has had difficulty thinking of words she wants to say, but no acute changes with this either. Of note, she was admitted to ___ last week with abdominal pain and was found to have acute on chronic pancreatitis. She was discharged on Morphine and says she was taking a half tablet of this after discharge, but has not taken the last few days. Neuro ROS: Positive for slurred speech as per HPI. Also notable for chronic numbness of right forearm and ___ and ___ digit and longstanding gait difficulties. No headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. She notes almost one year history of ___ difficulties. No focal weakness or numbness aside from what was previously mentioned. No bowel or bladder incontinence or retention. General ROS: no fevers. She notes frequent abdominal pain and nausea with occasional vomiting as well as alternating diarrhea and constipation. She also noted cough productive of white sputum. No shortness of breath, chest pain or tightness, palpitations, dysuria or rash. Radiology showed No acute cardiopulmonary process. Radiology showed No acute intracranial process. Radiology showed 1. A small area of restricted diffusion in right posterior frontal lobe (series 10, image 16), which appears hyperintense on FLAIR images and likely represents an acute/early subacute infarct. 2. Unchanged areas of susceptibility artifact in bilateral parieto-occipital lobes. 3. Stable changes of chronic small vessel ischemic disease. 4. Small chronic infarct/contusion in the left parieto-occipital region and chronic right cerebellar infarct, unchanged. 4. Stable saccular aneurysm measuring 2 x 4 mm from the left cavernous internal carotid artery. 5. No evidence of flow limiting stenosis or occlusion in arteries of head and neck. These findings were discussed with Dr ___ by Dr ___ telephone at 9:05 AM on ___. The patient was diagnosed with OTHER SPEECH DISTURBANCE, OTHER MALAISE AND FATIGUE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Occlusion of cerebral arteries, cerebral embolism, with cerebral infarction (middle cerebral artery) SECONDARY DIAGNOSIS: Hypertension, Hyperlipidemia, Tobacco 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>___ h/o ischemic stroke, L cavernous ICA saccular aneurysm, HTN, HL, DM, AAA, DVT, R ulnar neuropathy, cervical and lumbar polyradiculopathy, polyneuropathy now p/w slurred speech for three days in the setting of oral morphine therapy for pancreatitis, here for evaluation for possible cerebral ischemia. Found to have a small tiny R frontal cortical stroke while noncompliant with clopidogrel therapy. Her slurred speech was not apparent on reexamination and is likely due to her new alprazolam therapy. She was restarted on Clopidogrel and her risk factors were reassessed. Her Atorvastatin was increased to 40 mg from 10 mg when her LDL was found to be 101 (goal < 70). Given the embolic appearance of her small stroke, a TEE was performed (in the setting of a negative TTE) which shows a simple atheroma in the descending thoracic aorta but no other major abnormalities (this atheroma is distal to the R brachiocephalic/carotid artery takeoff, so it is not the explanation for her symptoms). She was assessed by ___ who recommended acute rehab given a mild gait instability. . PENDING STUDIES: None .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH of HCV (last viral load ___ HCV 896,000), IVDU (last use 4 months ago), anxiety, depression presents with rash on R hand and streaks up his arm. Describes rash as itchy, burning rash which first began in his fingers and he was diagnosed with bed bug bites on ___. Yesterday, he noticed a red streak going up from his fingers to his bicep and as a result he came in to the ED. He lives in a group home and one of his roomate has bed bugs, but no red streaks. He works as a ___ and has been wearing rubber gloves and workign with bleach at work. No gardening, no trauma. He states that his room and clothes have been treated for bed bugs. Denies fevers, chills, SOB, URI like symptoms. Last IVDU was years ago. In ED, initial vitals are 100.2 79 144/93 16 99% RA. Exam was notable for multiple lesions on dorsum of R hand in various stages of healing, red streaks from hand to axilla on R side. Labs were notable for lactate 0.8, normal chem 7, WBC 12.6. Patient was given 650mg po tylenol, started on IV vanc and zozyn. Admitted to medicine for IV antibiotics. Vitals prior to transfer were: 97.7 70 126/73 16 97% RA On the floor, he denies any pain or loss of sesation/strength in his right hand. FOREARM (AP AND LAT) RIGHT showed No subcutaneous gas. The patient was diagnosed with NONSPECIF SKIN ERUPT NEC. At the time of discharge, the patient had Lymphangitis. The patient was given written instructions concerning 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 HCV (last viral load ___ HCV 896,000), IVDU (last use 4 months ago), anxiety, depression presents with rash on R hand and streaks up his arm. # Lymphangitis: Patient relays history of minor trauma in distal skin area (bed bugs leading to exoriations and open lesions in fingers and dorsum area of hand) and characteristic streaks leading to proximal lymph nodes, which was suspicious for lymphangitis. Patient had a low grade fever and leukocytosis but was hemodynamically stable. Contact dermatitis from gloves less likely as rash is only unilateral and not in distribution of gloves. Necrotizing fasciitis in differential but has no signs of tissue gas formation on x-ray and no pain. He received two doses of vancomycin with quick resolution of erythema and streaking. He was discharged on Clindamycin 300mg PO TID, plan for 7 day course (d1 = ___. Tylenol was used as needed for pain. # Rash: from bed bugs lesions. Was on hydrocortisone cream as outpatient. Hydrocortisone 1% BID PRN was continued for symptomatic relief. He has had his room evaluated and treated by an exterminator. # Hepatitis C: genotype 1, has not responded to Rebetron or Ribavirin in the past. He has a scheduled appointment with liver in ___ for retreatment with the newer drugs. # History of Substance Abuse: including cocaine, heroine, methadone, and benzodiazepines. Reports last use of illicit drugs was ___. # Depression: continued home celexa and doxepin # GERD: continued home famotidine TRANSITIONAL ISSUES - Complete course of clindamycin</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx down syndrome, DM2, recurrent PNA c/b effusions requiring drainage, hypothyroidism, gout, and HLD, who presents from a group home after complaining of dyspnea, cough, subjective fevers and fatigue x 1 week. Patient is a limited historian so history is limited and largely obtained from ___ admission exam. Patient has had 1 week cough, subjective fevers, decreased energy levels. He went for a visit with his mother over the weekend and returned with increased WOB; noted to be desatting to 79. Appears to be on supplemental O2 at night as needed but this was increased from baseline and persistent in the morning so sent to the ED. The patient presented to ___ was found to have a WBC of 33.5 at an OSH w/neutrophilia of 88%. At the outside hospital, patient noted to be 79% on RA. Was also found to have left sided empyema with smaller loculated components. Patient received Zosyn 4.5 grams and 750 mg Levoquin PTA to ___. He had a ___ done at ___ with 21cc of the empyema drained and sent for studies/cultures. Based on previous outside hospital records, he has previously had pneumonias with loculated pleural effusions that necessitated chest tubes before. Was transferred to ___ for further evaluation. In the ED, initial vitals were: 99.1 93 124/69 26 96% Nasal Cannula Labs notable for: WBC 31.6 N 88.8% INR 1.4 ___ 15.4 ___ pH 7.45, pCO2 45 HCO3 32 Imaging was notable for: CT chest w/contrast 1. Large loculated left-sided empyema with other smaller components loculatedalong the posterior left apex. There is left upper lobe and left lower lobe collapse with rightward shift of mediastinal structures. 2. A locule of gas is seen in the inferior aspect of the left-sided empyema with adjacent subcutaneous emphysema and a focus of higher attenuating density within the empyema, which may represent sequela of recent intervention with small amount of hemorrhage. Clinical correlation is needed. 3. Collapsed left lower lobe demonstrates slight heterogeneity with focal low-attenuation rim enhancing areas concerning for necrotizing pneumonia and/or abscesses. 4. Age-indeterminate compression deformities are seen in the T12 and L1 vertebrae. Thoracics and IP were consulted: Thoracics deferred to IP for eval and drainage. - Patient was given: ___ 18:53 IV Piperacillin-Tazobactam ___ 19:44 IV Vancomycin ___ 00:15 IV Piperacillin-Tazobactam ___ 01:30 IVF NS ( 500 mL ordered) Upon arrival to the floor, patient denies pain, reports some SOB, and says he needs to go to the bathroom. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI CHEST (PORTABLE AP) showed 1. Status post placement of left chest tube with decreasing opacification of left hemithorax. Improving left upper lobe parenchymal opacities. 2. Stable mild cardiomegaly. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. Left basal thoracostomy tube is sharply folded as it crosses into the chest. To position is not confirmed on this single frontal view. Nevertheless the volume of left pleural fluid has decreased, now there is a uniform thickened pleural margin along the lateral costal surface. No pneumothorax. Left basal atelectasis is still severe. Interstitial edema is mild. Moderate cardiomegaly unchanged. Video swallow showed No gross aspiration. Minimal flash penetration with thin liquids. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. CHEST (PORTABLE AP) showed Allowing for significant differences in positioning, the overall appearance is similar to ___. Less well-defined appearance of old left heart border is probably predominantly related to differences in positioning. Left-sided chest tube is difficult to trace beyond the plane of the lateral left chest wall. If clinically indicated, an additional view with increased penetration an edge enhancement could help for further assessment. CHEST (PORTABLE AP) showed Comparison to ___. The extent of pleural fluid on the left has minimally increased. Subsequent increase of the associated left basilar atelectasis. Normal appearance of the heart and of the right lung. CHEST (PORTABLE AP) was done. CT CHEST W/O CONTRAST showed Substantial interval improvement after drainage of loculated left empyema. Improvement in the left basal consolidation Subcutaneous air within the left chest wall, attention to exclude the possibility of air leak The patient was diagnosed with Pneumonia, unspecified organism, Hypoxemia. The patient was treated with Chest Tube Placement ___, removed ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS: - Empyema - Sepsis - Hypoxemia SECONDARY DIAGNOSIS: - Elevated INR (coagulopathy) - Gout - Peripheral edema. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMHx down syndrome, dementia, PNA (in ___ c/b effusions requiring drainage, presented with 1 week of fevers, chills, SOB, admitted for strep viridians empyema requiring chest tube placement. # EMPYEMA # SEPSIS Patient presented to ___ with malaise, cough, dyspnea and subjective fever x 1 week. He was hypoxemic w/ SpO2 to low ___, WBC count > 30. Imaging showed left-sided empyema with loculations. Received Zosyn and Levoquin and was transferred to ___. Patient was continued on vancomycin/Zosyn on arrival to ___. He had a chest tube placed on ___ with > 1.4L purulent drainage. Cultures grew Strep Viridans so his abx coverage was narrowed to ceftriaxone on ___. Patient clinically improved. His white cell count decreased (11 on discharge from 30 on admission). His chest tube was removed on ___. Patient was discharged on a course of augmentin for 14 days. He will follow-up with interventional pulmonology in two weeks after discharge. [ ] Continue augmentin for 14 days, consider extending to 4 to 6 weeks [ ] Follow-up WBC count # HYPOXEMIA: Patient presented with SpO2 in the low 80%s secondary to his empyema. He initially required 4L nasal cannula which was able to be reduced to 2L nasal cannula after chest tube placement. Patient remained on 2L O2 during remainder of hospitalization and discharged with home oxygen. [ ] Follow-up oxygen saturation and wean oxygen supplementation as tolerated for goal O2>92% # Increased INR: INR was 1.4 on admission. It was thought to be related to his acute infection. INR downtrended with treatment of infection to 1.2 at time of discharge. [ ] Follow-up INR as outpatient CHRONIC ISSUES: # Gout: continued allopurinol # Hypothyroidism: continued synthroid # Down syndrome: Continued Aricept # Peripheral edema: held furosemide ISO infection ====================== TRANSITIONAL ISSUES: ====================== NEW MEDICATIONS: [ ] Amoxicillin-Clavulanic Acid ___ mg PO Q12H for 14 days, consider extending to 4 to 6 weeks MEDICATION CHANGES: [ ] Furosemide HELD due to infection and low blood pressures, re-start as outpatient ITEMS FOR FOLLOW-UP: [ ] Follow-up WBC count as outpatient (11 on discharge) [ ] Follow-up INR as outpatient (1.2 on discharge) [ ] Follow-up oxygen saturation and wean oxygen supplementation as tolerated # CODE: full (presumed) # CONTACT: ___ - house ___ of ___ - ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CT ABD AND PELVIS W/O CONTRAST showed 1. Nodular liver consistent with provided history of cirrhosis with left lobe hypertrophic changes. No splenomegaly or ascites. 2. Subtle ground-glass opacity in the lower lungs could reflect hypoventilatory changes, difficult to exclude a component of edema. Please correlate clinically. 3. Non-obstructing nephrolithiasis without ureteral stone or hydronephrosis. 4. No findings to account for bright red blood per rectum on this unenhanced CT exam. 5. Abnormal sclerotic appearance of T10 vertebral body is unchanged of unclear etiology. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent hepatic vasculature. 2. Cirrhotic liver with suspected sequela of portal hypertension including mild splenomegaly and trace ascites in the right lower quadrant. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified, Weakness. The patient was treated with EGD attach Pertinent Results: ___ 11:10AM BLOOD WBC-8.7 RBC-2.25* Hgb-6.7* Hct-22.7* MCV-101* MCH-29.8 MCHC-29.5* RDW-17.1* RDWSD-61.1* Plt ___ ___ 07:45AM BLOOD WBC-7.0 RBC-2.99* Hgb-8.8* Hct-27.2* MCV-91 MCH-29.4 MCHC-32.4 RDW-16.7* RDWSD-53.0* Plt ___ ___ 11:10AM BLOOD Plt ___ ___ 07:45AM BLOOD Plt ___ ___ 11:10AM BLOOD Glucose-102* UreaN-50* Creat-3.1* Na-135 K-5.0 Cl-101 HCO3-17* AnGap-17 ___ 07:45AM BLOOD Glucose-150* UreaN-21* Creat-2.0* Na-139 K-4.6 Cl-109* HCO3-17* AnGap-13 ___ 11:10AM BLOOD ALT-29 AST-74* AlkPhos-302* TotBili-0.6 ___ 06:35AM BLOOD ALT-28 AST-53* AlkPhos-266* TotBili-0.5 ___ 06:44AM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.5 Mg-1.9 ___ 06:40AM BLOOD Iron-33* ___ 06:40AM BLOOD calTIBC-404 Ferritn-49 TRF-311 ___ 06:35AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* ___ 11:10AM BLOOD CRP-2.7 ___ 06:35AM BLOOD HCV Ab-NEG. At the time of discharge, the patient had GI bleed Acute on chronic renal failure Cirrhosis Atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#GIB #Acute blood loss anemia on anemia of chronic disease (originally w/ melena and hematochezia): In the setting of C. difficile infection. EGD was preformed which did not find a source of bleeding. No biopsy taken of duodenal nodularity so as not to confound bleeding situation. Stool H. pylori was negative (though patient on PPI). As the bleeding has stopped, anticoagulation was restarted and the patient monitored. No further bleeding was seen. He will continue high dose omeprazole for 8 weeks before resuming his home dose. He received 3 U pRBC total. #EtOH cirrhosis: Decompensated by grade I EV and GAVE ___. With ongoing EtOH use. Has not kept outpt hepatology appointments. RUQ US shows cirrhotic liver with suspected sequela of portal hypertension including mild splenomegaly and trace ascites in the right lower quadrant. V: trace ascites on US I: no known prior hx SBP B: Small and moderate varices, started coreg, currently 6.25 mg BID E: no current or known prior hx HE S: US for ___ screening as above (noncon CT done ___ insensitive) - Hep A/B immune #Recurrent C. difficile enterocolitis: Previously treated w/ Vanc in ___. Back on Vanc 125 mg PO QID for 14- day course. Bowel movements have improved. CT AP w/out any acute finding. #Acute on chronic renal failure III: ___ due to volume loss. Cr now back to baseline. Avoid nephrotoxins. # Chr. thrombocytopenia: Secondary to splenomegaly and use. # A.fib/ flutter: Changed to coreg as above given varices. Anticoagulation changed to apixaban 5 mg BID as patient was not adherent to warfarin and INR testing (presented with supratherapeutic INR) # DM II: Adjusted Lantus and meal-time Humalog to 12 U and 4 U, respectively. # Chronic systolic CHF: Resuming torsemide given improvement in bowel movements. Metoprolol changed to Coreg as above. Also on isosorbde and hydral. Patient has not been on ACE-I/ ___ per cardiology notes # Hx CAD: Continue statin. Okay to resume ASA per hepatology. Patient no longer on ticagrelor per last ___ discharge summary # Alcohol abuse: Counselled. On acamprosate as outpatient # Tobacco abuse: Counselled. Declines nicotine patch Mr. ___. was seen and examined on the day of discharge and 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: Ms. ___ is a lovely ___ year old Farsi speaking female with a history of HFpEF, AS, MR, multifactorial gait disorder, and hypothyroidism presenting with lethargy and dyspnea from ___. CHEST (PA AND LAT) showed Low lung volumes limits evaluation. Moderate pulmonary edema. Left lower lobe consolidation may reflect atelectasis and pleural effusion, although pneumonia can not be excluded in the appropriate clinical setting. Probable small to moderate left pleural effusion and possible trace right or small pleural effusion. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Study degraded by motion and dental artifact. 2. Within limits of study, no definite evidence of acute intracranial hemorrhage or acute large territorial infarct. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___. Moderate cardiomegaly and mild to moderate pulmonary edema unchanged. Lung volumes are low and therefore left basal consolidation could be either atelectasis or pneumonia. Likely small pleural effusions unchanged. No pneumothorax. The patient was diagnosed with Heart failure, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old Farsi speaking female with a history of HFpEF, AS, MR, multifactorial gait disorder, and hypothyroidism presenting with ethargy and dyspnea from ___ being admitted to ___ for HFpEF exacerbation. Being treated for aspiration pneumonia vs HFpEF exacerbation. ACUTE ISSUE ============ # HFpEF Exacerbation # Possible Aspiration PNA # Altered mental status Patient with history of HFpEF (last EF 55% in ___ found to be dyspneic at her nursing home with new oxygen requirement. CXR significant for moderate edema and possible left lower lobe consolidation. Bibasilar crackles present on exam with a new oxygen requirement likely representing CHF exacerbation. Could also be PNA in setting of aspiration given fluctuating mental status. She was noted to be hypercarbic as well. A CXR was performed which did not show any new process aside from known edema. A NCHCT was negative for any acute changes. Troponins and BNP were elevated, likely in the setting of demand ischemia. A bumex drip was initiated, with boluses in addition to help with diuresis, and over the 24 hours that she was here, her mental status did slightly improve however she became progressively hypercarbic. Her HCP was notified of the situation, and did NOT want the patient to receive supplemental positive pressure ventilation. She was therefore diuresed as aggressively as possible to aid in her oxygenation. We did continue broad treatment for aspiration PNA vs CAP as the patient was noted to be continuously aspirating while here, and after further conversation from the living facility, she has been aspirating for some time. The patients HCP requested a transfer back to ___ with hospice services as she expressed that the patient would not want to be in the hospital at all, even if we were to be able to remove additional volume with IV diuresis as the hypercarbia needs positive pressure ventilation and this is not within her goals of care, and that she wanted the patient to be transferred back to ___ as expeditiously as possible. IV access was lost overnight in the hospital as the patient was and was not replaced in keeping with her goals of care. A careful and thoughtful review of her medications was done with the pharmacist, patient's daughter and the hospice agency in order to maximize the smoothest transition. ================ CHRONIC ISSUES: =============== #Coronary artery disease #Hyperlipidemia Discontinue home aspirin and statin #Hypothyroid - Continue home levothyroxine #GERD Discontinue home famotidine (dose reduced given CrCl) #B12 deficiency/nutrition Hold Cyanocobalamin 1000 mcg IM/SC QMONTHLY Discontinue Multivitamins W/minerals 1 TAB PO DAILY CODE: DNR/DNI/NO TRANSFER TO THE ICU. NO ESCALATION OF CARE CONTACT: Daughter ___ ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: ___ (___) Radiology showed 1. Splenomegaly with pelvic lymphadenopathy. Findings in the setting of markedly elevated white count raise concern for leukemia. 2. Renal hypodensities, too small to characterize, likely cysts. 3. Hepatic hypodensities, likely cysts or hamartoma. Radiology showed Right lung nodule, probably old granuloma but comparison with prior chest x-ray is necessary with none available CT should be performed. The patient was diagnosed with LEUKOCYTOSIS, UNSPECIFIED , SPLENOMEGALY. At the time of discharge, the patient had Possible CLL Splenomegaly Leukocytosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yoM with h/o TMJ who presents with leukocytosis to 173K, splenomegaly, and pelvic adenopathy. # Leukocytosis: Most likely CLL given constellation of leukocytosis that is lymphocyte-predominant, splenomegaly and adenopathy. Heme/onc reviewed peripheral smear and is c/w this. Other potential diagnoses are hairy cell leukemia, mantle cell lymphoma, lymphoplasmacytic lymphoma. No current signs of leukostasis or tumor lysis. ___ have aggressive disease given likely short doubling time given near normal CBC ___ year ago. Uric acid, LDH, LFTs normal. SPEP and flow cytometry pending. ___ heme/onc was consulted and recommended sending DAT, HCV and HBV serologies, peripheral cytogenetics and FISH, and HIV. If diagnosis is uncertain as ___ be considered for bone marrow biopsy. # TM: Home Vicodin, gabapentin # FEN: No IVF, replete electrolytes, regular diet # PPX: Subcutaneous heparin, senna/colace, pain meds # ACCESS: Peripherals # CODE: Full code # CONTACT: ___ is friend ___ in ___ ___ # DISPO: Home</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ ___ - ___ speaking woman with Alzheimer's disease, hypertension, diastolic heart failure, type A aortic dissection s/p repair now on daily aspirin 81 mg who presented with 1 week of fatigue and confusion with vomiting since last night. She is currently being treated for a UTI diagnosed by her PCP ___ ___. MRI AND MRA BRAIN PT12 MR HEAD showed 1. 5 cm right temporal lobe subacute parenchymal hematoma, similar. No evidence of mass or vascular malformation. 2. Stable small volume intraventricular hemorrhage, no hydrocephalus. 3. Probable subarachnoid hemorrhage. 4. Possible mild leptomeningeal or surface enhancement at the cerebellum, post gadolinium images are motion degraded, follow-up brain MRI without contrast recommended to document resolution. 5. Extensive chronic infarcts, as above. 6. 2 mm infundibulum versus aneurysm lateral wall cavernous segment right ICA. 7. Findings consistent with high cervical ICA bilateral fibromuscular dysplasia. The patient was diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified. At the time of discharge, the patient had Acute hemorrhagic stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ woman with Alzheimer's disease, hypertension, diastolic heart failure, type A aortic dissection s/p endovascular stent graft c/b popliteal artery occlusion, lumbar spinal stenosis and osteoarthritis presenting with one week of altered mental status and found to have a right lobar intraparenchymal hemorrhage. #Right temporoparietal IPH Patient presented with one week of altered mental status and was found to have right lobar intraparenchymal hemorrhage. Given history of Alzheimer's, there was concern for amyloid angiopathy though MRI did not show any evidence of microbleeds. Suspect hypertensive bleed given SBP 190s on admission to ED. CT also with chronic microvascular angiopathy and encephalomalacia in the left parietal and occipital lobes. Continued on home antihypertensives for goal SBP<150. Hold ASA, NSAIDs, other anti-platelet agents -Her statin was also held and should not be re-started until 3 months post bleed. #Alzheimer's Dementia Physical examination notable for waxing and waning mental status. She was continued on donepezil 5mg daily and gabapentin 100mg qHS. She was also given quietapine 6.25mg PRN for agitation. She was given a one time dose of 12.5mg Seroquel which caused too much sedation. #Lumbar stenosis Physical examination notable for lower extremity hyperreflexia likely secondary to severe lumbar spinal stenosis. Concern for deconditioning secondary to pain, age and generalized weakness on exam. Will need rehabilitation for physical therapy. #Hypertension SBP 190s on admission briefly requiring nicarpine gtt. SBPs have been 100s on home medications of carvedilol 25mg BID, furosemide 40mg daily and losartan 100mg daily. His furosemide was stopped while she was refusing PO. Resume when patient is taking adequate fluids. #Type A Aortic dissection s/p endovascular repair - Continue afterload reduction with carvedilol. Holding pravastatin given her hemorrhage #ID UA dirty without leuks; urine culture ___ negative. Discontinued nitrofurantoin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is ___ with a complex history including gastric bypass in ___, chronic pancreatitis, and bile peritonitis in ___, recently admitted to ___ for intraabdominal abscess ___ who was referred from clinic today for failure to thrive. Radiology showed 1. Right Port-A-Cath unchanged with tip in the upper atrium. If placement in the low SVC is desired, the catheter could be retracted 2.5 cm. 2. Small bilateral pleural effusions with bibasilar atelectasis on the left greater than the right. Radiology showed 1. Limited visualization of the sigmoid colon. Otherwise normal-appearing colon and cecum with no evidence of colonic polyp or mass. Sensitivity of CT colonography for lesions greater than 1 cm is ___ percent. Sensitivity for polyps 6-9 mm is approximately 60-70 percent. Flat lesions may be not visualized on CT colonography. 2. The previously noted extraluminal collection posterior to the gastrojejunal anastomosis is no longer well visualized, however evaluation is limited due to lack of oral or IV contrast. The patient was diagnosed with ABDOMINAL PAIN GENERALIZED. The patient was treated with ___: EGD and colonoscopy under MAC. At the time of discharge, the patient had Primary diagnosis: Failure to thrive Secondary diagnoses: esophageal and anastomotic ulcers anxiety depression COPD Iron deficiency 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>___ hx of gastric bypass ___ with recent intraabdominal fluid collect s/p IV abx and recent tachycardia, weight loss, dizziness, and weakness consistent with failure to thrive. # Failure to thrive, nausea: Pt reports severe nausea w/ PO intake and reports loss of 10lb over the last ___ weeks. General surgery saw Pt in ED and felt that she was stable and did not require surgical intervention. They felt that CT abdomen was not necessary. Also, her pain seems be in a similar location to her prior fluid collection. GI was consulted and an ___ was performed which showed clean-based ulcer in esophagus and at anastomosis. Recommendations following procedure include twice daily PPI and sucralfate. Nutrition consult was placed and recommended Ensure TID with meals. The patient's symptoms gradually improved with hydration and bowel rest. She will follow up with Dr. ___ as an outpatient. # Suboxone therapy/h/o addiction: Pt states that she is taking her suboxone 4x daily rather than the 1x daily that she is recorded as having been prescribed, although this is prescribed by a ___ practitioner, Dr. ___ at ___. If she is indeed taking 4x her prescribed dose of suboxone, opiate toxicity could potentially be an exacerbant of her nausea. Her dose was clarified with outpatient provider ___ at ___ to be 8mg q6 hours and the patient was continued on this dose while inpatient. # Palpitations: unclear etiology, but Pt was tachycardic on presentation and on the floor. She was monitored on telemetry # gastric wall edema/esophageal thickening: EGD and colonoscopy were performed, results described above. # normocytic anemia: Hct currently at 32.9; recent baseline ___, low ___ for much of ___. Pt's Hct may be hemoconcentrated given dehydrated appearance. Recent iron studies w/ low iron at 11, low normal ferritin at 16, low TRF 110, suggestive of iron deficiency / malnutrition. The patient's hematocrit was monitored during admission and she was given an Fe transfusion prior to discharge. # smoking history / COPD: home albuterol and fluticasone-salmeterol. She was given a nicotine patch while inpatient # GERD: home pantoprazole, increased to BID dosing with findings on EGD. # muscles cramps: home methocarbamol # depression: home buspirone, duloxetine, quetiapine # anxiety: home haloperidol prn, although Pt's tremulousness may be a reflection of extrapyramidal side-effects of long-term antipsychotic use. # insomnia: home trazodone TRANSITIONAL ISSUES: -will need biopsies followed up with Dr. ___ need to continue outpatient iron transfusions</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o Male w/ PMH of HTN who presented to the ___ after onset of an episode in which he experienced chest pressure, b/l UE numbness and tingling, shortness of breath, and diaphoresis while in the car with his son. The ___ report states that he syncopized. However, the patient denies LOC and states that he was unable to move in the setting of this event. It resolved ~ 10 minutes after it began. He denies palpitation, prior cardiac history, pleuritic cp. His upper extremities were tight and clenched. THere was no bowel/bladder incontence, lip biting, palpitations, stress. A CODE BLUE was called in the ___ lobby. On evaluation, the patient was tired appearing, conscious with strong pulse. . In the ___, VS were 97.9 84 141/76 20 100% and EKG was with no signs of acute arrhythmia or ischemia. CTA was negative for PE. CEs were negative x 2. On the floor, the patient is free of symptoms and his review of systems is otherwise negative. Radiology showed 1. No evidence of acute intra-thoracic process. 2. No aortic dissection. No central, lobar, or segmental pulmonary embolism. Evaluation of subsegmental right lower lobe pulmonary arteries is limited due to motion. The patient was diagnosed with SYNCOPE AND COLLAPSE, CHEST PAIN NOS, SKIN SENSATION DISTURB, HYPERTENSION NOS. At the time of discharge, the patient had chest pain not otherwise 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>[] BRIEF CLINICAL COURSE: ___ y/o Male w/ PMH of HTN who presented to the ___ after onset of an episode in which he experienced chest pressure, bilateral upper extremity numbness and tingling, shortness of breath, and diaphoresis while in the car with his son. CTA chest was negative for PE, and stress echo was normal. . #Chest Pain NOS: unclear etiology of event. ___ represent episode of angina, but patient has no history of such episodes. Hypertension is his only CAD risk factor ___ his normal HgA1C and normal lipid panel and no history of tobacco use. As such there was no indication for heparin gtt in setting of negative cardiac enzymes. No evidence of pulmonary embolism on CTA of the chest. Alternatively could represent anxiety vs other neurologic process, although the history is not consistent with complex seizure ___ lack of post ictal period. The patient was prophylactically placed on ASA 325mg daily while hospitalized. Stress Echo testing on the day of discharge was normal. Thus, the patient was discharged home in good condition, asymptomatic, with PCP follow ___. ___ his lack of cardiac risk factors, he was not started on prophylactic ASA or other anticoagulation . #HTN: We continued the patient on his home dose of 25mg PO HCTZ daily. During this admission, the patient remained normotensive on floor with SBPs in the range of 110-135. . []TRANSITIONAL ISSUES: NONE</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo man with IDDM, recent MI ___ s/p stent, multiple foot infections including Left ___ toe amputation ___ ___ and right ___ toe amputation ___ ___ with recent MRSA foot infection ___ right foot several months ago requiring debridement and drainage presents with worsening of right foot with redness and swelling over foot and especially toe. VENOUS DUP EXT UNI (MAP/DVT) RIGHT showed 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. 3.6 x 1.2 x 4.9 cm hypoechoic right groin lymph node. Finding finding may be reactive in etiology given provided history of right lower extremity cellulitis. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 4:00 ___, 100 minutes after discovery of the findings. Radiology showed No radiographic evidence of osteomyelitis. The patient was diagnosed with CHRONIC SKIN ULCER NEC. The patient was treated with Abscess drainage by podiatry. At the time of discharge, the patient had RLE Cellulitis and abscess IDDM. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo man with IDDM, CAD s/p stent, with recurrent bilateral foot infections presents with at cellulitis of right foot extending up leg and abscess s/p drainage on ___. # Diabetic Foot Cellulitis with abscess, growing out MRSA and pseudomonas: Presents with marked cellulitis and fluid collection near right hallux. S/p abscess drainage of right foot by podiatry on ___. ESR only mildly elevated to 31. Xray shows no acute osteo. Podiatry thinks that MRI not necessary. No probe to bone on exam. Started on vanco and unasyn with marked improvement of cellulitis. Cultures returned with MRSA sensitive to bactrim and pseudomonas sensitive to cipro. Switched on ___ to bactrim and cipro. Bactrim to take through ___. Cipro to take through ___. - ___ off loading shoe - Outpt follow up with podiatry # IDDM w/ complications: Very uncontrolled ___ setting of dietary noncompliance, frequent snacking, and infection. Pt followed by ___ as outpt and seen by ___ here. Pt was switched to lantus BID, and increased to more aggressive carb counting and correction factor ratios. Glucoses very much improved # CAD s/p MI and stent: - Plavix and aspirin - Metoprolol - Lisinopril - Statin # HX GI bleed: Continue PPI # Psoriasis: Continue home creams # BPH: Continue flomax # Anemia: Chronic. # CKD: Baseline is 1.6 Transitional: Follow up of right groin enlarged LN, most likely due to infection FEN: Diabetic diet Prophy: Heparin SQ Code: Full confirmed Dispo: Screening for placement tomorrow ___ ___</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 CAD, RA on Enbril and prednisone who initially presented to an OSH with cough and chest pain. Patient states that about ___ days prior to presentation, he began having a productive cough. Cough was productive of brown sputum with some bright red blood. He saw his PCP who started him initially ___ Azithromycin and then switched him to Levaquin. However, he was not improving, so his wife ___ took him to an OSH. He also complains of subjective fevers and chills. No sick contacts or travel. No abd pain, diarrhea/constipation. At the OSH, imaging suggested cavitary PNA and R-sided PE. PPD was reportedly negative on ___. He was then started on Vanc, Zosyn, heparin gtt and transferred to ___ for further management. ___ the ED initial vitals were: 98.2 110 130/77 20 98% 2L Nasal Cannula - Labs were significant for PTT 57.9, INR 1.4, WBC 10.5, H/H 9.___/30.1, BNP 134, trop-T negative x 1, chem-10 and lactate WNL. Patient was given heparin gtt and ondansetron. Reportedly received Vanc and Zosyn prior to arrival. Vitals prior to transfer were: 95 135/76 22 99% Nasal Cannula On the floor, 99.2 135/80 82 20 94% on 4L He complains of his right sided chest pain. Radiology showed 1. Pulmonary embolism within the right main pulmonary artery extending into segmental branches. 2. Large right upper lobe cavitary lesion measuring 6.3 x 5.3 cm, diffuse patchy ground-glass opacities in the bilateral lobes and multiple enlarged mediastinal lymph nodes. Constellation of findings is suspicious for infectious process including tuberculosis though malignancy such as squamous cell carcinoma is not fully excluded. Esophagram showed Mild spasm in the distal esophagus. No esophageal stricture or mass. Radiology showed Penetration with thin liquids. No evidence of gross aspiration. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. The patient was diagnosed with PULM EMBOLISM/INFARCT, PNEUMONIA,ORGANISM UNSPECIFIED. The patient was treated with There were no major surgical or invasive procedures during hospitalization.. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================= RIGHT SIDED PULMONARY EMBOLUS CAVITARY LUNG LESION DYSPHAGIA SECONDARY DIAGNOSIS =================== RHEUMATOID ARTHRITIS CORONARY ARTERY DISEASE CHRONIC PAIN GASTROESOPHAGEAL REFLUX DISEASE OBSTRUCTIVE SLEEP APNEA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman with a hx of CAD, RA on Enbril, presenting from an outside hospital found to have PE and cavitary pneumonia. # RIGHT SIDED PULMONARY EMBOLUS: Mr. ___ had a CT imaging consistent with pulmonary embolus. This PE was on the right side. ___ order to treat the PE, he was started on a heparin drip with subsequent bridging to warfarin. At the time of discharge his INR was 3.2, with greater than 24 hours of therapeutic range INR. At the time of discharge he was transitioned to lovenox given that we expected that he would need to return for IP procedure ___ a few weeks and we felt that it would be easier to bridge with lovenox than warfarin. He received lovenox teaching ___ the hospital, and was discharged on lovenox for anticoagulation ___ the setting of the pulmonary embolus. He was told not to stop anticoagulation without speaking to a physician and also told that he would be switched to oral anticoagulation after the procedure. Of note, he did undergo duplex ultrasound of the lower extremities which did not reveal any thrombus present. No heart strain on ECG. # CAVITARY LESION: Patient's CT and CXR showed cavitary lesion ___ the right lung. Initially thought to be due to cavitary pneumonia superinfected after lung necrosis from the pulmonary embolus. However there is also concern for malignancy. CT findings indicated "Pulmonary embolism within the right main pulmonary artery extending intosegmental branches. Large right upper lobe cavitary lesion measuring 6.3 x 5.3 cm, diffuse patchy ground-glass opacities ___ the bilateral lobes and multiple enlargedmediastinal lymph nodes. Constellation of findings is suspicious forinfectious process including tuberculosis though malignancy such as squamouscell carcinoma is not fully excluded." He was started on vancomycin and piperacillin-tazobactam. Given his rheumatoid arthritis therapy with enbrel and prednisone, risk for fungal infection was present. Both interventional pulmonology and general pulmonology were consulted. Sputum smears were negative for acid fast bacilli. Quantiferon gold was indeterminate. Cryptococcal antigen was negative. Aspergillus galactomannan antigen negative. Beta glucan was positive although patient was on a beta lactam (piperacillin-tazobactam), which could lead to false positive result. Histoplasma antigen was pending. Sputum culture showed sparse growth commensal respiratory flora. Blood cultures showed no fungus or mycobacterium present. CMV IgG and IgM were negative. Sputum ___ showed budding yeast with pseudohyphae with preliminary fungal culture growing yeast. Preliminary nocardia culture showed no nocardia isolated. MTB direct amplification was sent to state lab for further identification. Acid fast smear was negative. Interventional pulmonary was consulted and recommended a repeat CT image of the chest (scheduled for ___ to determine if the cavitary lesion improved with antibiotics. At that time, consideration for a bronchoscopy with biopsy of the lesion/lymph nodes will be critical to determine etiology of the cavitary lesion and mediastinal lymphadenopathy. Additionally obtaining sputum cytology may be critical ___ the future to determine the cause of the lesion. Decision was made not to do bronchoscopy with lymph node biopsy ___ the hospital setting given the acute pulmonary embolus and risk for progression while holding anticoagulation for the procedure. Infectious disease was consulted who recommended transition from vancomycin/piperacillin-tazobactam to Augmentin 875 mg PO BID for a total antibiotic course of 14 days (end date ___. Follow-up on this cavitary lesion will be critical, as there is still concern for malignancy given his smoking history and CT findings concerning for squamous cell cancer. # Odynophagia/Dysphagia: Patient reported significant substernal discomfort after eating as well as significant weight loss over the past four months. Concern for malignancy was present given the CT findings and dysphagia with weight loss.We obtained video swallow and barium esophagram which only showed distal esophageal spasm without obstruction or stricture. His PCPs office was called and noted that he had a EGD one month prior that did not show obstruction or mass. # RHEUMATOID ARTHRITIS: Patient was on enbrel and prednisone for rheumatoid arthritis. Initially he was continued on these medications, however, given the possibility of infection, they were stopped. The prednisone was restarted on discharge (pt was called and asked to restart the med, although not listed on dc med list). # CORONARY ARTERY DISEASE: patient has history of CAD with 2 previous MIs with stent placements. These occurred ___ ___ and ___. Continued home dose aspirin, metoprolol, and atorvastatin. # CHRONIC PAIN: continued with his home dose gabapentin 800 mg Q8H as well as his home oxycodone-acetaminophen. # GASTROESOPHAGEAL REFLUX DISEASE: continued home omeprazole 20 mg PO daily. # OBSTRUCTIVE SLEEP APNEA: Uses CPAP at home. Continued with CPAP during hospitalization. TRANSITIONAL ============ #Please follow-up with appointment for your CT scan of your chest which will be scheduled by the Interventional Pulmonology team (___). Please also follow up with the Interventional Pulmonary team ___ clinic. They will help schedule all of these appointments for your within the next three weeks. It will be critical to follow-up with these appointments as malignancy is still on the differential of this cavitary lung lesion. #There are numerous oustanding laboratory data as noted above. Please follow-up the results of the Quantiferon-TB Gold, Histoplasma antigen, Sputum fungal culture; nocardia culture, MTB direct amplification, Acid Fast Smear, Acid Fast Culture, Blood CMV AB, CMV IgG antibody, CMV IgM antibody, sputum acid fast cultures, as well as blood cultures. #INTERVENTIONAL PULMONARY: When biopsy is done, please ensure gram stain, aerobic + anaerobic cultures, fungal culture, acid-fast bacilli smear and culture, MTB PCR, Nocardia smear and culture. #FOLLOW-UP RESULTS: Please follow-up results of the fungal culture as was growing budding yeast with pseudohyphae. #HYPERCOAGULABLE WORKUP: please consider hypercoagulable workup given the lack of inciting factor for the pulmonary embolus. #ANTICOAGULATION: pt will need to be transitioned from lovenox to coumadin after biopsy. #CODE STATUS: FULL CODE #CONTACT: ___ (wife) ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ (EU Crit ___ - MRN ___ is a ___ year old right-handed man with developmental delay, remote history of brain abscess s/p surgical drainage, epilepsy on lamotrigine 200mg BID and topomax 100mg BID, bipolar disorder, drug-induced parkinsonism, who presents from his group home for new onset left facial droop, left-sided weakness. History obtained by family and as per chart review. Cerebral diagnostic angiography and mechanical thrombectomy for large vessel occlusion stroke. This exam the following steps were performed: 1. Retrograde access of the right femoral artery 2. Right femoral artery arteriogram 3. Right internal carotid artery arteriogram 4. Mechanical thrombectomy of the occluded right middle cerebral artery 5. Closure of arteriotomy with Perclose showed Correlation with real-time findings and, when appropriate, correlative radiographs is recommended for full assessment. CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK showed 1. Occlusion of the distal M1 segment of the right middle cerebral artery and mismatched corresponding perfusion deficit as detailed above, with core volume 9 mL and mismatch volume of 114 mL on RAPID perfusion analysis. 2. Possibly early ischemic changes along the right insula and basal ganglia. No hemorrhage. 3. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Acute to subacute infarcts in the right basal ganglia, and right parietal lobe. No hemorrhagic conversion. 2. Subtle foci of diffusion abnormality in the left inferior frontal lobe could be artifactual or additional foci of infarcts. 3. Postsurgical changes with encephalomalacia of the right frontal lobe and a pseudomeningocele along the craniotomy defect . 4. Mild bilateral proptosis, nonspecific. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. New punctate focus of air centered within the right frontal lobe in the region of stroke with associated intraparenchymal hyperdense foci. Findings may reflect trace fori of intraparenchymal hemorrhage versus contrast in the setting of recent thrombectomy procedure. 2. Evolving right anterior middle cerebral artery infarction, more conspicuous as compared to the prior exam. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:55 pm, 5 minutes after discovery of the findings. Chest radiographs, 2 portable AP upright views. showed Status post endotracheal intubation. Orogastric tube in the stomach. Minor atelectasis. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial hemorrhage. 2. Old right frontal encephalomalacia and post craniotomy changes. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. CT PELVIS WANDW/O C showed 1. No central venous thrombus. 2. Punctate, nonobstructing left renal stone. No hydronephrosis. 3. Partially imaged enteric tube, coiled within the third portion of the duodenum, with the tip terminating at the level of the pylorus. Repositioning is recommended. 4. Mild, right greater than left, bibasilar atelectasis. CHEST (PORTABLE AP) showed New pulmonary edema as well as layering bilateral pleural effusions. CHEST (PORTABLE AP) showed ET tube tip is 4 cm above the carina. NG tube tip is in the stomach. Right PICC line tip is at the level of cavoatrial junction. Heart size and mediastinum are unchanged including mild mediastinal widening. There is interval improvement in bibasal consolidations but still present vascular congestion. Small bilateral pleural effusion is unchanged. No pneumothorax CHEST (PORTABLE AP) showed Comparison to ___. Lung volumes have slightly increased, likely reflecting improved ventilation or increase in ventilatory pressure. There continues to be a platelike atelectasis at the left lung bases moreover, there is a stable retrocardiac atelectasis the tip of the endotracheal tube continues to be low. No change in appearance of the right lung. CHEST (PORTABLE AP) showed In comparison with the study of ___, the nasogastric tube has been removed. The right subclavian PICC line extends to the lower SVC. There are improved lung volumes, most likely accounting for the decreased atelectatic changes, most prominent at the left base. No evidence of appreciable vascular congestion.. CHEST (PORTABLE AP) showed The nasogastric tube extends below the level the diaphragm but beyond the field of view of this radiograph. The endotracheal tube has been removed. Unchanged cardiopulmonary findings. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed Dobbhoff tube placement ending at the stomach fundus. Mildly increased bibasal opacity, especially at right base. Could possibly represent elevated pulmonary venous pressure related to neurogenic edema or developing aspiration. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed In comparison with the earlier study of this date, the tip of the Dobhoff tube is been pulled back slightly and now faces the lateral wall of the mid body of the stomach. Otherwise, little change. The patient was diagnosed with Cerebral infarction, unspecified. The patient was treated with TEE. At the time of discharge, the patient had Acute Ischemic Stroke Seizures. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old man with history of developmental delay and lasting cognitive impairment, prior brain abscess, epilepsy, bipolar disorder, and drug-induced parkinsonism who presented to the hospital with left facial and left-sided weakness. Imaging on arrival showed right M1 thrombus and he underwent mechanical thrombectomy with subsequent TICI IIB reperfusion. His motor deficit improved after the procedure. etiology of stroke unclear, likely cardio-embolic given clear carotids. # Right M1 Thrombus s/p thrombectomy at ___ at 1249PM His deficit significantly improved following thrombectomy. He was intubated for seizure control following the procedure and neurological exam after extubation showed improvement compared to previous. He had residual left upper extremity proximal greater than distal weakness and left facial droop, mild dysarthria. He was started on aspirin, Plavix and atorvastatin. Stroke work-up showed HgbA1c -5.4%, LDL 114, TTE showed atrial septal defect with right-to-left shunt, no visible thrombus. Normal EF and PA pressures. lower extremity Dopplers ultrasound and pelvic CTV did not show any evidence of DVT. TEE was obtained which showed large ASD-atrial septal aneurysm with large PFO, measurements taken. We will refer to structural heart disease clinic for follow-up as outpatient. No evidence of atrial fibrillation on telemetry monitoring, ZIO Patch ordered at discharge. ___ OT and speech therapy were consulted, he participated well. Initially he was on a modified diet, later advanced to regular consistency with thin liquids, one-to-one supervision and meds crushed per speech therapy recommendation. He is being transferred to inpatient rehab for continuation of ___ OT. He will continue on ASA and Plavix. #Seizure disorder with breakthrough seizure Post-procedure he developed breakthrough seizures, likely etiology related to stroke and lower seizure threshold given missed AM seizure medications. He developed a cluster of focal seizures with left facial and left arm twitching, received multiple doses of IV Ativan and was intubated for further control of seizures. His home medications lamotrigine and Topamax were resumed per NG tube and he was started on IV Keppra with good seizure control and ultimately was switched to PO (see medications). Continuing all 3 antiepileptics at discharge. #Respiratory failure -Needed intubation for seizure control but also developed acute pulmonary edema and vent associated pneumonia prolonging vent requirement. He received PRN Lasix with improvement, did not require any further doses after extubation. He was initially on broad-spectrum antibiotics and sputum/BAL cultures grew MSSA. Antibiotics tailored to cefazolin and completed a total 7-day course during his stay in the hospital. He was asymptomatic, breathing comfortably at room air at discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with Alzheimers and old fracture to right distal ___ ___ ago presents s/p mechanical fall today at 3pm with subsequent right ___ pain and superficial scrape to right patella. Patient brought to ___ ED with only injury to right leg. Neurovasc intact. Xrays demonstrate right ___ ___ fracture and Ortho consulted Radiology showed Minimally displaced comminuted fracture of the right proximal tibia involving the medial tibial plateau. Radiology showed 1. Comminuted tibial plateau fracture with fracture line seen in both the medial and lateral proximal tibia. No significant displacement or depression detected. 2. No other fracture identified, though a nondisplaced proximal fibular fracture could be occult given the degree of osteopenia. 3. Chondrocalcinosis in the medial and lateral menisci. Exam dated ___ presented now for official interpretation. Radiology showed Low lung volumes with bibasilar atelectasis. The patient was diagnosed with FX UPPER END TIBIA-CLOSE, FALL ON STAIR/STEP NEC. The patient was treated with ORIF right tibia. At the time of discharge, the patient had right tibial plateau and proximal femur 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 tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF right femur, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TDWB in unlocked ___ in the RLE extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ right handed woman with a history of HTN and hep C cirrhosis presented with acute onset expressive aphasia. She was playing cards between ___ and had some language problems that resolved after around 2 hours. At ~4:00pm had recurrence of language problems and was brought to an OSH ED. There, she was noted to have an expressive aphasia. BP initially was 208/98 and she was treated with labetalol. She also got Zofran for nausea. A tele stroke was called. She had an NIHSS of 1 for aphasia. She was given IV tPA (bolus time 19:17) and transferred to ___ via med flight. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No acute intracranial abnormality. 2. Mild intracranial and cervical vasculature atherosclerosis without any high-grade stenosis. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. No evidence of hemorrhage or infarction. 2. Age-related involutional changes and findings of small vessel ischemic disease. The patient was diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac, Essential (primary) hypertension. At the time of discharge, the patient had Primary diagnosis: TIA Secondary diagnosis: Hepatitis C cirrhosis Hypertension GERD with ___ esophagus Gastric bypass surgery. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with a past medical history of hepatitis C and hypertension who presented ___ with acute onset aphasia (vs. speech apraxia) and received tPA at an outside hospital (see HPI for further details). She was then transferred to ___ for further management. In the ED, pt had a STAT CTA/H/N which showed mild plaque at aortic arch and ICA bifurcation bilaterally but no high-grade stenosis or clot. Pt was then admitted to the neurologic ICU for post-tPA care. Overnight, pt clinically improved. On hospital day #2 (___), pt's speech difficulties had resolved entirely and she had a non-focal neurological examination. MRI did not reveal an acute infarct and only showed small vessel ischemic disease. At the time of discharge, it was felt that pt likely had a TIA. Her TIA was felt to be possibly due to an athero-embolus given her plaque on CTA. Her echo was unremarkable and telemetry did not show atrial fibrillation. She was discharged with ___ of Hearts monitor to assess for paroxysmal atrial fibrillation. At the time of discharge, for secondary stroke prevention, she was started on aspirin 81mg daily. Both her hepatologist and PCP were notified of this medication addition given her history of cirrhosis (LFTs, coags, and platelets were normal). She was not started on a statin due to her history of liver disease and her LDL being only ___. = = = = = = = = = = ================================================================ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack = = = = = = = = = = ================================================================ 1. Dysphagia screening before any PO intake? (X) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented? (X) Yes (LDL = 88) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (X) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No 9. Discharged on statin therapy? () Yes - (X) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (X) Yes [Type: (X) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (X) N/A ========================= TRANSITIONS OF CARE ========================= -Mrs. ___ presented with symptoms of speech difficulty (expressive aphasia vs. speech apraxia). She received tPA and symptoms notably improved. MRI did not reveal an acute infarct. -She was presumed to have a TIA and was started on aspirin 81mg at discharge for secondary stroke prevention. This information was provided to Ms. ___ hepatologist, as Ms. ___ stated she had not been on aspirin in the past due to hepatitis C cirrhosis. Liver function tests and CBC were normal while in the hospital. -Source of her stroke was felt to be an embolus from either atherosclerosis (there was mild plaque on her CTA head and neck) or a cardiac source. Ms. ___ was discharged with ___ of ___ monitor to evaluate for paroxysmal arrhythmias; echo was unremarkable and there was no arrhythmia on telemetry during her hospitalization. LDL was 88; Ms. ___ was not started on a statin due to her LDL not being significantly elevated and her concurrent liver disease.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ yo. RHM w/PMH of NIDDM, HTN, HL, Bell's palsy, now presenting with a dual chief complaint of binocular diplopia and R arm pain. Pt really began to notice double vision after waking up on ___. However, the previous day his vision was already not quite right "as if my glasses were dirty". Double vision worsens on right gaze. There is also a slight droop of his left eyelid, which his wife only noticed today. Pt saw his ophthalmologist for this yesterday, who "couldn't find anything wrong" but suggested that he probably had a diabetic cranial nerve palsy, and should go to the ED for further evaluation. Also on ___ morning, pt woke up with severe right-sided neck pain radiating to the posterior shoulder and dorsolateral aspect of his arm, to his lateral forearm just below the elbow. This is ___ severity, and pt has been unable to get comfortable in any position (although putting his hand up and resting against his occiput with the arm abducted and externally rotated seems to help a little bit). He has been taking Advil at home for this. No history of neck trauma. Pt went to ___ for this complaint, where he was suspected to have a right ___ nerve palsy. Vitals were T97.7 p81, BP 166/88, RR 16, O2 100%. CT head showed no acute process. An MRI could not be done because of pt's severe claustrophobia. Radiology showed Right proximal internal carotid artery stenosis (approximately 40-50%) appearing to be related primarily to non-calcified atherosclerotic plaque. Radiology showed Minimal plaque with a right less than 40% carotid stenosis. On the left, there is no stenosis. On the right, in the area of soft plaque, there may be a component of thrombus but that cannot be determined conclusively by this study. The patient was diagnosed with VISUAL DISTURBANCES NEC, OCCLUS CAROTID ART NO INFARCT, DIABETES UNCOMPL ADULT, HYPERTENSION NOS DIPLOPIA, OCCLUS CAROTID ART NO INFARCT, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. At the time of discharge, the patient had 1. Right ICA thrombus 2. Diabetic amyotrophy 3. Right sixth nerve palsy Secondary diagnosis: 1. Uncontrolled DM. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ yo RHM w/PMH of obesity (250 pounds), NIDDM, HTN, HL, Bell's palsy (not sure anymore which side of his face was affected), now presenting with a dual chief complaint of binocular diplopia (subjectively getting worse when he looks at something in the distance) and R arm pain (in a stripe like fashion from his neck over his shoulder into the back of his upper arm), and incidentally discovered thrombus or soft plaque in the R ICA, starting just prior to the bifurcation, followed by a loop distally. He also has an anomaly in his posterior circulation with having two connections between the right vertebral artery and basilar artery. These three processes appear to be independent from each other. 1. Regarding the ICA thrombus we wanted to perform MRI of the head and MRA of the neck, but as he could not stay flat , it was attemped, but he was not able to complete the MRI. Instead, we performed carotid US which showed: soft plaque vs. thrombus in the right internal carotid artery. He was started on Coumadin and needs to continue that for 3 months with INR goal of ___ which will be managed by PCP. 2. Double vision: after evaluating the patient we found that he has RIGHT ___ nerve palsy, most likely due to DM. He will also be seen in ___ clinic after discharge to see if he requires any additional management for this. 3. Right shoulder pain and proximal weakness: after he was evaluated for other cause, we think it is due to diabetic amyotrophy. He was started on Gabapentin and Percocet for pain control.He may need EMG/NCV as an outpatient if his pain does not improve and if he develops weakness. 4. DM: HbA1C: 10.6 which showed that his DM is poorly controlled, we controlled his DM in hospital with insulin. He needs to be followed in Justlin as an outpatient. 5. HTN: we continued home medications to control the BP and ASA </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with DM2, HTN, CAD s/p NSTEMI, depression with suicidal gesture 1 week ago, h/o narcotic pain med abuse who was transferred from an OSH for hypertensive urgency. He was recently admitted ___ for hypertensive emergency with blurry vision, chest pressure and headache. Upon discharge, he says his SBP was 140. On his way home he had worsened headache that radiated up from his neck to the top of his head; pain was ___. The next day (___) he checked his BP at home and it was 228/100. He went to ___, where he head a negative head CT and he is now transferred to ___ for further management. In the ___ ED, initial VS: pain ___, T 98.3, HR 63, BP 164/100, RR 16, POx 100% 2L NC. Labs were significant for Cr at baseline and WBC 12.9. EKG unchanged from prior. The ED Radiologists read the OSH head CT as showing no acute process. He received his oral meds (Labetalol 200mg PO, Lisinopril 20mg PO, and Amlodipine 10mg) but when he was persistently hypertensive he was given Labetalol 10mg IV and 1 inch notropaste. He was admitted for HTN urgency and VS prior to transfer were: T98.3, BP 197/87, HR 62, POx 100%RA, RR 13. Radiology showed 1. No acute intracranial process. 2. Subtle small area of hypoattenuation in the inferior right frontal lobe which is unchanged from prior examination and may be related to streak artifact. Radiology showed 1. Right adrenal adenoma measuring 11 x 9 x 9 mm. 2. Left nephrolithiasis. The patient was diagnosed with HYPERTENSION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT. At the time of discharge, the patient had Primary Diagnosis: Hypertensive emergency Right adrenal adenoma Secondary Diagnosis: Resistant hypertension Chronic kidney disease Anxiety Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman with HTN, DM2, CAD, recent admission for HTN urgency who presents again in hypertensive urgency. # Hypertensive crisis: The pt was admitted with sbp's in 200s. He had no new evidence of end organ damage. The pt had no EKG changes, though he has CAD history and admited to chest pain prior to admission. He was ruled out by cardiac enzymes. He did complain of headache on admission but his neuro exam showed no focal deficits and a head CT was negative for any acute process. His creatinine on admission was at his baseline of 1.3-1.4. On recent admission, he underwent work up for secondary causes of hypertension. MRI/MRA of kidneys were preformed and showed renal artery stenosis but Nephrology did not think the amount of stenosis was clinically significant. He also underwent workup for hyperaldosteronism due to hypokalemia and resistant hypertension, which showed supppressed plasma renin activity. Normal cosyntropin stimulated cortisol and aldosterone levels in the serum, however, selective adrenal vein blood sampling revealed massively elevated baseline and stimulated levels on the right side, concerning for adrenal tumor. An CT of Ab/pelvis showed a right adrenal adenoma measuring 11 x 9 x 9 mm. During this admission his blood pressure was difficult to control. Initially he was restarted on home dose labetalol 400 mg TID, Lisinopril 20 mg BID (max dose), Amlodipine 10 mg QHS (max dose), and Spironolactone 100 mg daily without adequate control with BP continuing to be in 190/90s. Renal was consulted and recommended increasing spironolactone to 200mg BID and we added clonidine 0.1mg BID as well. Endocrine was consulted and recommended we send out a plasma metanephrine to rule out a pheochromocytoma. Surgery was also consulted and decided to perform the surgery on an outpatient basis after pheochromocytoma has been ruled out. Dr. ___ will be arranging follow up for surgery. # Coronary Artery Disease, native vessel: Initially the pt was complaining of chest pain. He was ruled out for having an MI with negative cardiac enzymes and EKG. We continued him on Lisinopril 20mg BID, Labetalol 400mg q8, Simvastatin 20mg and ASA 81mg. His chest pain resolved once his blood pressure was better controlled. # Psych: Pt recently was admitted to psych hospital for suicide attempt. During this hospitalization he denied any suicidal intentions. We continued citalopram 30mg, trazodone 300mg qhs. # DM2, uncontrolled, with complications: His glucose levels were controlled using a Humalog insulin sliding scale during this hospital admission. # Anemia: Hct stably in mid ___ during this admission. MCV 85, normal iron studies. # Transitional issues: A plasma metanephrine level was ordered during this admission and will need to be followed up after discharge to rule out pheochromocytoma prior to surgery. He has follow up appointments with endocrine and nephrology. Dr. ___ will contact pt on ___ following discharge to arrange office appt for surgical scheduling and also will arrange for cardiology pre-op as well. His office number is ___. ***Would recommend follow-up of anemia (Hct 34.1 on discharge) and creatinine (1.7 on discharge) in outpatient setting.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENTING ILLNESS: ___ is a ___ year old male with a history of chronic C4 glomerulonephritis and proteinuria presenting after a recent trip to ___ with swelling and pain in his left foot. Patient states that he returned from ___ on ___ at which point some swelling on the distal portion of his left plantar foot. He states that he then developed swelling and pain in his left ankle. Over the weekend, the pain increased to the point where he was unable to tolerate much activity at all. He took a dose of ibuprofen for pain relief. He states that he was unable to ambulate on the ankle. Pt reports developing similar swelling in his ankles roughly a year ago that prevented him from getting off the couch for a few days. He states that over roughly 10 days, his symptoms improved spontaneously. For this episode, he was able to go to a PCP visit today where labs demonstrated a WBC of 16 and D-dimer of 1646 prompting concern for an infectious process vs. VTE. MRI of his left foot and ultrasound of his LLE were also obtained and pt received CTX 1g IV x 1. Of note, pt's MRI foot did not show evidence of OM, but did show possible tibiotalar joint effusion and MTP joint effusion with findings possible consistent with gout. In addition, the LLE U/S was negative for DVT. Pt was referred to the ED for further evaluation. In the ED, initial vital signs were: 98.3 94 137/75 17 100% RA UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. ANKLE (AP, MORTISE AND LAT) LEFT showed No fracture or dislocation. Degenerative changes, as noted above with areas of spurring and small fragments at the tibiotalar joint, possibly related to prior injury. The patient was diagnosed with Gout, unspecified. The patient was treated with Joint arthrocentesis. At the time of discharge, the patient had Primary Diagnosis Gout Secondary Diagnosis C3 glomerulopathy and proteinuria 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>___ year old with chronic C4 glomerulopathy and proteinuria presenting with a polyarticular inflammatory arthritis, also found to have ___. ACTIVE ISSUES ============= # Acute Gouty Polyrthritis: Left foot swelling with isolated tenderness to left MTP and also right MTP joints was most consistent with gout. He was evaluated by orthopedics and vascular surgery in the ED, given elevated D dimer on outpatient labs. Left lower extremity dopplers were negative for DVT. There was low suspicion for septic joint. Rheumatology was consulted. Arthrocenteis was performed with negative ___, <50,000 WBC, and needle Monosodium Urate Crystals with negative birefrig consistent with gout flare. He was given 60mg PO Prednisone with improvement in his swelling and pain. He was discharged on a PO prednisone taper, with initiation of colchicine and allopurinol daily for gout prophylaxis. He will have follow up with a rheumatologist at ___ as an outpatient. CCP was negative (<16), RF was 20 and Urine GC/Chlamydia was negative. Joint fluid culture results were pending at the time of discharge but were preliminarily no growth. # ___ on CKD, C3 GN: Pt presented with Cr 1.6 from baseline 1.3 in the setting of recent NSAID use and inflammatory arthritis. Cr returned to baseline s/p IVF and holding NSAIDS. Home lisinopril was restarted and he was set up to see a nephrologist in the outpatient setting on ___. Protein/Cr ratio was elevated at 12.3 on admission, to be follow up on the day after discharge in Nephrology as an outpatient. CHRONIC ISSUES ============== # Hypertension: Continued home lisinopril # Nasal congestion: Continued home Flonase TRANSITIONAL ISSUES =================== # Gout/Rheumatology - Final joint fluid culture pending at discharge - Patient will need Rheumatology follow up upon discharge, to be arranged by PCP through ___. - Started on daily colchicine 0.6mg and allopurinol ___ for prophylaxis. To be continued daily unless otherwise directed in Rheumatology follow up. - Recommend eating red meat and drinking alcohol in moderation to avoid precipitating gout attacks. - Prednisone taper ___: 50mg ___: 40mg ___: 30mg ___: 20mg ___: 10mg ___: 5mg ___: Stop # C3 glomerulopathy and proteinuria - Patient with scheduled Nephrology follow up on ___ - Holing NSAIDs on discharge # CONTACT: ___ (partner) ___ # CODE STATUS: Full code </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with history significant for scleroderma as well as chronic abdominal pain who presents to ___ with ___ day history of severe abdominal pain as well as constipation. He takes dilaudid as needed and uses a fentanyl patch for his pain management. He was in his usual state of health until ___ (6 days ago) when he started having diarrhea, attributed to use of miralax, and he stopped the miralax. On ___ (4 days ago) he began feeling worsening of his abdominal pain and stopped passing gas and having BM's. The pain progressed to the point where he could not manage at home and he came to the ED for assistance. Usually he gets his care at ___. Radiology showed No definite pneumoperitoneum identified. Radiology showed 1. No acute process in the abdomen or pelvis. 2. Stable pending thoracic aortic aneurysm. When compared to ___, the proximal abdominal aortic aneurysm appears slightly increased in size. Distal abdominal aorta aneurysm and bilateral common iliac artery aneurysm are stable. Continued imaging follow-up is recommended. 3. Unchaged bilaterally lower lobe ground-glass opacities when compared to ___, likely due to chronic fibrotic process. RECOMMENDATION(S): Follow-up CT in 6 months of the abdominal aortic aneurysm Radiology showed Normal bowel gas pattern. No evidence of abnormally dilated loops of large or small bowel to suggest obstruction or ileus. The patient was diagnosed with Acute kidney failure, unspecified, Unspecified abdominal pain. At the time of discharge, the patient had Acute on chronic abdominal pain Constipation Acute on chronic testicular pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Summary: ___ hx scleroderma, hypertension, hyperlipidemia, gout, chronic back pain, chronic abdominal pain p/w acute abdominal pain also found to have acute kidney injury. #Abdominal pain - Patient presented with more severe abdominal pain than baseline in the setting of stopping his home stool softeners. CT A/P with no evidence of rupture of his known abdominal aneurysms. He reported his pain as chronic and episodic. He was given an aggressive bowel regimen that included magnesium citrate, enemas (soap ___ and tap water) and methylnaltrexone. He had soft bowel movements and resolution of his abdominal distension on the morning of ___. His distension increased but then improved on ___ after more bowel movements. While constipated, patient was put on standing IVF. His pain was controlled with his home Dilaudid and Fentanyl patch. His back spasms were controlled with his home Flexeril. #Testicular discomfort: On ___, patient developed sharp, sudden testicular pain that radiated to his abdomen and back. He reports that this pain is also chronic and intermittent and feels as "if someone is kicking him in the testes." UA/Urine gonorrhea/chlamydia were sent and were negative. Pain was managed with his home medications, and pain receded by the end of the day. No masses palpated, no testicular swelling. #Scleroderma: Continued patient on home Plaquenil 200 mg PO daily. #Acute kidney injury - Paient's creatinine was 2.3 at admission up from his baseline of 0.9. His creatinine improved with fluids, patient counseled on staying hydrated during pain episodes. UA was negative and blood pressure was within normal limits so was not initially concerning for a scleroderma renal crisis. Lisinopril was held in the setting of kidney injury. #Eosinophilia - ABS eosinophil count >1000. Not clear etiology, possibly related to scleroderma. Patient denies allergies, unlikely parasitic infection. Eosinophlia resolved. #Leukocytosis - no clear signs or symp of infection or acute intra-abdominal process. CXR and UA clear. Likely reactive in the setting of pain and constipation, and has trended down with IVF likely was dry/concentrated initially. #Anemia - Hg now down to 10.5 (which appears to be patient's baseline). As above likely was dry on admit, notably he is anemic. Last c-scope was about ___ years ago. No signs or symptoms of bleeding. -continue ferrous sulfate 325 mg PO daily -continue folic acid 1 mg daily #Hyperlipidemia - c/w pravastatin 20 mg qpm #Hypertension - Patient initially with low blood pressures and some of his home medications were held. By discharge he was restarted on all of his home medications including: -c/w clonidine 0.1 mg PO BID -continue labetalol 600 mg TID -continue torsemide 20 mg daily -continue lisinopril 40 mg daily #Gout -allopurinol ___ mg daily #Chronic back and abdominal pain - as above c/w fentanyl, dilaudid 4 mg PO q6h PRN, flexeril prn, venlafaxine 112.5 mg PO daily,gabapentin 300 mg PO BID #GERD - c/w omeprazole 20 mg daily #Tobacco use -continue nicotine patch 21 mg daily #BPH -continue tamsulosin 0.4 mg PO qhs TRANSITIONAL ISSUES -continued control of elevated blood pressure -outpatient workup for anemia (likely ___ chronic inflammation with scleroderma) -repeat CBC w/differential to monitor eosinophil count (currently wnl at discharge) CONTINUE TAKING Allopurinol ___ mg daily Clonidine 0.1 mg PO BID Cyclobenzaprine 20 mg TID PRN pain/back spasm Fentanyl patch 100 mcg/hour every 72 hours Folic Acid 1 mg daily Gabapentin 300 mg BID Dilaudid 4 mg every 6 hours PRN severe pain Plaquenil 200 mg daily Labetalol 600 mg TID Lisinopril 40 mg daily Nicotine Patch 21 mg daily Omeprazole 20 mg daily Miralax daily Pravastatin 20 mg daily Tamsulosin 0.4 mg at bedtime Venlafazine XR 112.5 mg PO daily CHANGED MEDICATIONS Ferrous Sulfate 325 mg daily (not twice a day) Restasis every 12 hours Torsemide 20 mg daily NEW MEDICATIONS Senna Bisacodyl PR HOLD MEDICATIONS Spironolactone 100 mg daily - in setting of hyperkalemia More than 30 minutes were spent on discharge planning for this page</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ with history of obesity s/p roux-n-y- gastric bypass in ___ that was complicated by marginal ulcer requiring reversal in ___. She presents today with epigastric pain and associated nausea/emesis. After her reversal, she was seen in the ER in ___ with epigastric pain and nausea/dysphagia. She underwent EGD that showed no ulcer and UGI that only showed mild esophageal dysmotility. Her symptoms improved. Starting ___, however, she developed recurrent epigastric pain that she states is reminiscent of her pain when she had the initial marginal ulcer. She describes it is as stabbing and initially intermittent but now constant. Reports associated nausea and non-bilious emesis with slight blood-tinge. No hematochezia or melena. Reports normal bowel movements and passing flatus. No fevers or chills. Reports taking 2 doses of NSAIDs four weeks ago when she had a UTI; otherwise no NSAIDs and no smoking. She takes once daily omeprazole and Carafate as need but not recently. CT ABDOMEN PELVIS WITH CONTRAST showed 1. A small umbilical hernia and a small supraumbilical Richter hernia are new from ___. 2. No bowel obstruction, extraluminal oral contrast or free intra-abdominal fluid or air. Radiology showed Subtle retrocardiac opacity could be seen in the setting of an infectious process. Otherwise stable appearance of mild pulmonary vascular congestion. The patient was diagnosed with Epigastric pain. The patient was treated with Incisional Hernia repair w mesh ___. At the time of discharge, the patient had abdominal pain, hernia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the ED on ___ for epigastric pain and associated nausea/emesis. The patient was known to have multiple incisional hernias and was seen by Dr. ___. She was scheduled for the incisional hernia repair on ___. She stay in the hospital until the day of the procedure for conservative management of her epigastric pain and nausea/emesis. The patient presented to pre-op on ___. Patient was evaluated by anaesthesia. She was given a thoracic epidural prior to the procedure for pain control. The patient was taken to the operating room for a incisional hernia repair with mesh underlay. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the ward for observation. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a PCA and epidural. Pain was well controlled. The patient was then transitioned to a regular diet once she was able to tolerate it. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO. Afterwards, the patient was started on a stage 3 bariatric diet, which the patient tolerated well. Subsequently, the patient was advanced to regular diet which the patient was tolerating on day of discharge. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The epidural was removed on ___ and patient was able to tolerate her pain on PO medications. 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: ___ PMH of MDS ___ 2 cycles of Decitabine, while awaiting possible allogeneic transplant), ___ right IJ port (___), who was seen in ED yesterday for new right anterior jugular clot, returns with worsening fever and neck pain. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed Right internal jugular vein occlusive thrombus extending from the level of the thyroid to the right brachiocephalic vein associated with significant peripheral inflammation and reactive lymph nodes, concerning for thrombophlebitis. Radiology showed Successful removal of a right upper chest port. The tip of the catheter was sent for culture. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. No evidence of cholelithiasis or acute cholecystitis. 2. No evidence of biliary dilatation. Normal hepatic echotexture. CHEST PORT. LINE PLACEMENT showed Comparison to ___. The patient has received a left-sided PICC line. The course of the line is unremarkable, the tip of the line projects over the lower SVC. No complications, notably no pneumothorax. The previously seen right pectoral Port-A-Cath was removed. Stable appearance of the lung parenchyma and the cardiac silhouette. The patient was diagnosed with Fever, unspecified, Cervicalgia, Occlusion and stenosis of right carotid artery, Urinary tract infection, site not specified. The patient was treated with ___ - Port Removal. At the time of discharge, the patient had Primary Diagnosis: - Right Internal Jugular Thrombus - Port Infection - Myelodysplastic Syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMH of MDS ___ 2 cycles of Decitabine, while awaiting possible allogeneic transplant) ___ right IJ port (___) and very recent diagnosis of right jugular vein thrombosis who was admitted with fever, neck pain, and thrombophlebitis of the right jugular vein. Imaging found extension of clot with significant peripheral inflammation and reactive lymph nodes. She was started on IV heparin and antibiotics. She had her port removed on ___. After port removal she had significant improvement in her symptoms. She was transitioned back to lovenox. Culture from port tip grew coag neg staph >15 colonies, indicating line was colonized with staph, oxacillin sensitive. Treating for 4 weeks from removal of port on ___ (Day ___, to be completed ___ with IV daptomycin for ease of administration and team preference. # Neck Pain secondary to Acute IJ Thrombus: # Port Infection: She was started on Vanc/CTX/Flagyl given concern for clot superinfection. Port removed on ___ with improvement in symptoms. Port catheter tip now growing coag negative Staph. She was discharged to complete 4-week course of daptomycin. # RUQ Pain: Developed mild RUQ pain with normal LFT's and negative RUQ US. Continue to monitor. # Constipation: Bowel regimen. # HLD: Continued statin. # Hypothyroidism: Continued synthroid. # MDS: # Anemia in Malignancy: On decitabine ___ 2 cycles. Awaiting possible upcoming allogeneic transplant in ___. She should follow up with her ___ oncologists and with the ___ transplant team at ___. # Billing: 45 minutes spent coordinating and executing this discharge plan. ====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of right hip replacement with recent liner exchange with Dr. ___ due to recurrent hip dislocations. The patient was bending over when she felt a pop in her hip, she stood up and felt a second pop. Since that time, she has been unable to walk. Denies numbness or paresthesias. Has required OR reduction for her previous dislocations. Denies any fall. HIP UNILAT MIN 2 VIEWS RIGHT showed Interval reduction in the dislocation of the right hip arthroplasty. No evidence of additional hardware complication. The patient was diagnosed with Dislocation of internal right hip prosthesis, init encntr, Exposure to other specified factors, initial encounter. At the time of discharge, the patient had Recurrent right prosthetic hip dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a recurrent right prosthetic hip dislocation. A reduction was attempted and successful overnight in the ED. The patient was admitted to the orthopedic surgery service for fitting of an abduction brace. The patient was given anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated with strict instructions to remain in the abduction brace at all times when ambulating, in 30 degrees of abduction and ___ degrees of flexion in the right lower extremity. Abduction pillow when laying down or sleeping The patient will follow up with Dr. ___ in ___ weeks. 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: HISTORY OF PRESENT ILLNESS: Mrs. ___ is a pleasant ___ year old woman with HTN, HPL, CAD (hx of MI), hx of CVA, and PAD who was transferred via MedFlight from ___ tonight for concern for descending thoracic aortic dissection. Radiology showed 1. Interval increase of bilateral hemorrhagic pleural effusions with adjacent increased collapse of the lower lobes, only partially aerated anteriorly. 2. A new stent has been placed, but persistent periaortic hematoma with moderate hemomediastinum. 3. There are signs of fluid overload with anasarca, ascites and mild pulmonary edema. Findings were reported to Dr. ___ at 12:13 p.m. by Dr. ___. Radiology showed Marked interval improvement in now interstitial pulmonary edema. Evaluation of the patient after TEVAR after placement of bilateral chest tubes to drain hemothorax, currently on waterseal. Portable AP radiograph of the chest was reviewed in comparison to a prior study obtained the same day earlier. The right chest tube is in place. There is a right apical pneumothorax demonstrated, small but slightly increased as compared to prior examination. The left chest tube is in place with no apparent left pneumothorax. The mediastinal and cardiac contours are unchanged including the aortic stent. was done. Assessment of the patient after chest tube has been placed after suction. Portable AP radiograph of the chest was compared to prior study obtained the same day earlier. The current examination demonstrates minimal residual right apical pneumothorax, substantially decreased since the prior study. No left pneumothorax is seen. Rest of the image is stable. was done. Radiology showed 1. Small right basilar pneumothorax, improved over the past day. 2. Small bilateral pleural effusions. 3. Small amount left lower lobe atelectasis, unchanged in the past day. Evaluation of the patient after TEVAR. Portable AP radiograph of the chest was reviewed in comparison to ___. Heart size and mediastinum are stable. The descending aortic stent is stable. Lungs are essentially clear. No interval increase in pleural effusion is seen. No pneumothorax is seen. was done. The patient was diagnosed with ABDOM AORTIC ANEURYSM, ATRIAL FIBRILLATION, PERSONAL HISTORY OF TIA, AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS. The patient was treated with ___: Endovascular repair of thoracic aneurysm ___: Bilateral chest tube placement. At the time of discharge, the patient had Penetrating aortic ulcer with intrathoracic rupture. Non ST elevation myocardial infarction Pulmonary Edema. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>After reviewing the OSH CT findings, it was recommended the patient go urgently to the OR for repair of her ruptured thoracic aorta by an endovascular approach. The patient's family was notified and the patient herself gave informed consent. She underwent TEVAR on ___. Please refer to the dictated operative report for further details. The patient tolerated the procedure well and there were no complications. Postoperatively, she was brought intubated to the CVICU for continued resuscitation. The remainder of her hospital stay is as follows, by systems: NEURO: Preoperatively, it was decided against placing a lumbar drain due to the length of time it would require to place one. Postop, while intubated, the patient was sedated with propofol and her pain was treated with a fentanyl drip. Immediately upon transfer to the CVICU postop, she was noted to be moving all four extremities spontaneously and she never developed any neurologic sequelae as a result of the TEVAR. The patient did develop delirium/sundowning on POD#3, insisting that she was at home and trying to climb out of bed and walk out of her room while still attached to all her lines and drains. This improved over the hospital course but she continues to be confused/slightly agitated especially at night but easily reoriented. ___: The patient was transferred to ___ on an esmolol gtt. This was continued intra- and postop for BP control, with an SBP goal range between 120-140. The patient developed tachycardia with HRs into the 130-140s on POD1. She complained only of vague chest/epigastric soreness and pain that radiated into her back. Cardiac enzymes were found to be elevated and cycled. Because they continued to climb (trop eventually peaking at 2.13), cardiology was called, who recommended full anticoagulation. They felt that her perioperative MI with transient lateral ST-T changes and increase troponin was secondary to her critical illness and need for multiple pressors. She was started on a heparin drip which we transitioned to plavix when she stabilized. A TTE was obtained on POD2, which showed an LVEF 50-55% and dyskinetic apical cap. Comparison with her old echos at ___ revealed these findings to be pre-existing. She was eventually transitioned to PO metoprolol. She was restarted on her home coumadin dose on POD 7. PULM: A non-con CT of the chest was obtained on POD1 to evaluate the extent of hemothorax and hemomediastinum present. Initially, it was decided against placing chest tubes. However, in the late afternoon of POD1, the patient developed acute desaturations and respiratory distress consistent with flash pulmonary edema. Therefore chest tubes were placed bilaterally and lasix was given with subsequent resolution of symptoms and improved oxygenation. The chest tubes initially drained close to a liter each the first 24 hours but the output dropped off thereafter. They were placed to water seal POD#3 and subsequent CXRs showed markedly improved aeration of the lung. They were both discontinued by POD#6. FEN/GI: The patient was allowed to have clear liquids POD#2. This was advanced to a regular diet on POD#3 and tolerated well. GU: The patient had a Foley catheter for UOP monitoring. She had preserved renal function and her UOP was appropriate. HEME: The patient's EBL was 500cc and she received 4U pRBC in the OR. Postop, her hcts remained stable. She did not require any further transfusions thereafter. She was started on a heparin gtt on POD#1 for her acute coronary syndrome, which was continued for 48 hours. She was then transitioned to plavix. DISPO:She worked with ___ who recommended rehab prior to returning home secondary to deconditioning and unsteady gait. She is instructed to follow up her cardiologist, Dr. ___ discharge from rehab and with Dr. ___ in one month with CTA of the torso. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with ___ Danlos syndrome, multiple orthopedic joint surgeries, asthma, recent ovarian hyperstimulation who presented with new onset L thigh pain and swelling. Pain was sudden in onset while driving ___, worse with leg extension, feels swelling in knee and going up and down in leg, No trauma, long car rides, change in color in feet. Denies any similar symptoms in the past. Denies fevers, chills, SOB, CP, HA, n/v/d/c. Full 10 point ROS otherwise negative. Radiology showed Minimal incidental degenerative changes at the pubic symphysis. Otherwise normal examination. No evidence of deep space infection. The patient was diagnosed with PAIN IN LIMB. At the time of discharge, the patient had Ligamentous Injury to the left thigh and knee ___ Syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F with ___ Danlos syndrome, multiple orthopedic joint surgeries, asthma, recent ovarian hyperstimulation (now resolved) who presented with new onset L thigh pain and subjective swelling. . # Leg extremity pain and swelling: Throughough workup in ED including doppler u/s, knee films and CT showed no evidence of clots, bleeds, infection or other etiology for her swelling. -orthopedics was consulted and thought this could be a ligamentous injury. A ___ brace was prescribed and she was started on Ibuprofen. She was also seen by Physical therapy. -pain initially requiring IV dilaudid, and then tolerable with oxycodone prn -she will f/u with orthopedics -given omeprazole for GERD and especially while taking Ibuprofen, colace for narcotic induced constipation . # Chronic muscle pain: continued on flexeril . # Insomnia: continued on trazodone . # Low grade temperature: with h/o UTI, U/A was checked and was negative, no fever</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ R BKA ___ presents with low grade fevers x 4 days, worsening pain, drainage from R BKA stump. She reports noticing intermittent drainage (small amounts of blood) one month ago but this was not associated with pain. It started to hurt approximately a week ago prompting a visit to ___ where she was discharged with pain medication. Over the weekend, for the past ___ days she reports low-grade temperatures which were noticed at dialysis and persistent pain. She returned to the OSH and was transferred here for further assessment Radiology showed 1. Mild interstitial pulmonary edema. 2. Mild-to-moderate cardiomegaly, not significantly changed. 3. Findings compatible with renal osteodystrophy. The patient was diagnosed with AMPUTAT STUMP COMPL, INFEC, ACCIDENT NOS. The patient was treated with ___: Above the knee amputation. The patient was given written instructions concerning 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 ___ on ___ with an infected BKA stump (performed on ___. The decision was made to perform an AKA. On ___, the patient was taken to the OR for an AKA. Please see operative report for further details. After a brief stay in the PACU, the patient was transferred to the vascular floor for further management. Neuro: The patient received IV pain medications for pain control while NPO and was advanced to an oral regimen once taking a diet. She was complaining of immense pain on POD1 but continued titration of pain meds and time improved her symptoms. She was discharged with good pain relief. CV: The patient had no cardiac issues during her hospitalization Pulm: The patient had no pulmonary issues during her hospitalization GI: The patient was given a bowel regimen and was regularly passing stools during her hospitalization. GU: The patient received hemodialysis on ___, and ___ while she was in house. Kayexalate was held while in house but was restarted at discharge to manage potassium levels when patient resumes her normal diet. She will have potassium levels drawn in the coming days. Heme: The patient was monitored for anemia and blood loss. On POD3 the patient had a hematocrit drop of 5 from 28 to 23 and was given 1U of PRBC. ID: The patient was initially on vancomycin, ciprofloxacin, and flagyl for her infected BKA stump though she did not have an elevated white count. After her AKA, her new stump did not show any erythema or signs of infection and antibiotics were stopped. Endocrine: The patient was admitted on a regimen of sliding scale and 70/30 insulin. She was kept on this regimen and was given half doses post-operatively due to reduced PO intake. She will be discharged on her regular regimen and will titrate as an outpatient as necessary. On ___, the patient was tolerating a regular diet, pain was controlled, she was voiding independently and passing bowel movements. She will return to rehab for further physical therapy after her AKA. Discharge plans were communicated to the patient and she was in agreement. She will follow up with Dr. ___ in the clinic in ___ weeks. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of DMII, HTN, HCV and macrophage activation syndrome now coming from home after discharge from ___ ___ on ___ with persistent fevers. Patient was seen in the ED 1 week ago with fever and HA and found to have a UTI by UA. Her fever and HA resolved in the ED and she was discharged on Ciprofloxacin. She presented to the ED in ___ two days later because she was unable to tolerate PO abx and was having continued fevers. She apparently had an episode of SOB and vomiting after getting out of the shower. She also had a diffuse rash on her trunk and extremities that had developed. While at ___, she was initially started on broad specturj antibiotics,; hwoever, it was felt her presentation could represent an MAS flare, so she was started on prednisone 60 mg PO. She was dischagred on prednisone and tylenol, as no source could be found for her fevers and it was felt she was having recurrent MAS. At home she was unable to tolerate PO, was c/o severe throat pain, and her mental status was determined by her daughter to be well below baseline so she was brought to ___ ED for further evaluation. Her family says that this presentation is very similar to what occurred back in ___. Radiology showed Prominence of bronchovascular structures in the setting of low lung volumes could be due to an atypical infection or small airway disease in the proper clinical setting. No lobar consolidation. Radiology showed No acute intracranial abnormality. Radiology showed 1. Bilateral bony demineralization. 2. Hypoplastic right ulnar styloid process versus an erosion. 3. Otherwise, no erosions bilaterally. Radiology showed AP chest compared to ___. Previous parenchymal abnormality in the left mid lung has cleared. It was probably asymmetric pulmonary edema, which has also resolved. Moderate-to-severe cardiomegaly and generalized enlargement of the aorta are chronic. Pleural effusions are minimal. No pneumothorax. Radiology showed No evidence of acute intracranial process. Radiology showed 1. Mild pulmonary edema is worse. 2. Moderate cardiomegaly is unchanged. Radiology showed 1. Single 1.3 cm gallstone and sludge without evidence of cholecystitis. 2. Stable hepatic cyst; otherwise normal liver. 3. Small left pleural effusion. PICC line placement. Portable AP radiograph of the chest was reviewed in comparison to ___. The right PICC line has been placed with its tip being in the right atrium and should be pulled back approximately 2.5 cm. Cardiomegaly and mediastinal contours are stable as well as marked interstitial pulmonary edema. Basal atelectasis in the left lower lobe is noted, unchanged in association with left pleural effusion. Minimal right atelectasis and pleural effusion are better appreciated on the chest CT from ___. was done. Radiology showed 1. Chest CT is unchanged from 5 days earlier performed for the same indication. 2. Moderate subcutaneous edema with a small amount of presacral fluid, of indeterminate etiology, possibly related to anasarca. Findings were discussed with Dr. ___ by ___ by telephone at 7:19 p.m. on ___ at the time of initial review of the study. Radiology showed No evidence of bilateral lower extremity DVT. Radiology showed 1. Normal brachial plexus. 2. Bilateral symmetrical muscle edema involving the muscles of both shoulder girdles and the masseter muscles bilaterally. 3. Moderate-sized left pleural effusion with associated left lower lobe atelectasis. 4. Cardiomegaly. As this was not a dedicated shoulder MRI, if further assessment of the left shoulder is required a dedicated shoulder MRI is recommended. Radiology showed Moderate cardiomegaly and pulmonary and mediastinal vascular engorgement have worsened relative to ___, consistent with cardiac decompensation. Consolidation in the left lower lobe has worsened, could be pneumonia or atelectasis. Small accompanying left pleural effusion is unchanged. Tip of the right PIC line projects over the upper right atrium and would need to be withdrawn 3 cm to position it in the low SVC. No pneumothorax. Radiology showed 1. New moderate sized simple pericardial effusion. 2. Bilateral small pleural effusions with bibasal atelectasis, left greater than right and mild pulmonary edema are stable since ___. Radiology showed No evidence of lower extremity deep venous thrombosis bilaterally. Radiology showed 1. Prominent CBD measuring 9 mm, previously 6 mm, with no intrahepatic biliary dilatation. 2. Cholelithiasis, stable, without cholecystitis. 3. Small left pleural effusion. 4. Stable left hepatic cyst, but no suspicious focal lesions. Radiology showed No new infiltrates. Radiology showed 1. Decrease in size of pericardial and pleural effusions with bilateral atelectasis but no findings of fungal infection. 2. 4mm right lower lobe pulmonary nodule for which ___ month follow up can be obtained once clinical symptoms have resolved. The patient was diagnosed with FEVER, UNSPECIFIED, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Bone marrow biopsy.. At the time of discharge, the patient had Hemophagocytic lymphohistiocytosis Macrophage Activating Syndrome Secondary diagnoses: Type 2 Diabetes mellitus Paroxysmal atrial fibrillation CMV viremia Enterococcal bacteremia Hepatitis B Hepatitis C. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with DMII, HTN, insulinoma, HBV, HCV presented with fevers, altered mental status after a urinary tract infection found to have recurrence of hemophagocytic lymphohistiocytosis (HLH). Course complicated by Afib with RVR requiring MICU stay, enterococcus bacteremia, CMV viremia. # Macrophage Activating Syndrome/HLH Hematology/Oncology was consulted by general medicine admitting team, and the patient was deemed to meet criteria for hemophagocytic lymphohistiocytosis (HLH), and she was transferred to the bone marrow transplant service to start the HLH94 protocol (etoposide and dexamethasone). Day 1 of the HLH94 protocol was ___. After her first dose of etoposide, the fever broke, vancomycin was stopped on ___, and she was maintained on cefepime. Judged likely an infection driving HLH. No obvious malignancy; CEA was elevated, team did consider obtaining breast MRI and/or colonoscopy, deferred for now. Currently CT showed no obvious masses. Pt unlikely to have genetic cause for her disease at her advanced age. Hep B VL undetectable, HCV VL has been very high likely bc of immunosuppression, but ID and Hepatology felt HCV unlikely trigger of HLH. EBV and Hep B undetectable on most recent viral loads. EBV, however, initially detected, cleared quickly. Pt received several courses of etoposide and was maintained on PO dexamethasone. Ferritin was trended, initially downtrending but then variable as treatment progressed. Had doxycycline PO for ___mpirically as appeared to help patient on initial presentation. Pt started on several prophylactic medications while immunosuppressed: atovaquone (reportedly had fever with bactrim in past), acyclovir, nystatin swish & swallow, lansoprazole for GI prophylaxis while on corticosteroids, Fluconazole 200 mg QD and Tamiflu 75 QD (several patients on service w/ flu). She was continued on dexamethasone 5mg throughout the rest of her stay and received 8 cycles of etoposide. She was started on cyclosporine on ___ for additional immunosuppresion, which she tolerated well. Her fevers finally subsided and she felt subjectively better after each cycle. # VRE bacteremia: Blood cultures for febrile neutropenia showed VRE sensitive to daptomycin on ___. She was started on daptomycin which was continued through ___ with no subsequent fevers. # CMV viremia: CMV virema noted on ___, ID was consulted, treatment started with ganciclovir on ___. Her CMV VL decreased nicely over several weeks. She was transitioned to PO valganciclovir prior to discharge. She will follow up with Dr. ___ in ___ clinic as an outpatient. # Hepatitis B and C. H/o hepatitis B, but neg viral load, so it not appear that reactivation of disease triggering HLH. She was continued on LaMIVudine 100 mg PO DAILY for h/o Hep B. Some case reports of Hep C as trigger. Pt is Hep C genotype 2 but cannot take interferon, as IFN could potentially exacerbate HLH. ID saw pt, and reminded team that while increasing viral load is likely ___ neutropenia, VL is not relevant marker of this disease. Her HCV VL was trended weekly and stayed >69K per lab results. # Upper Odynophagia and dysphagia: Patient c/o pain with swallowing on admission. Likely yeast esophagitis given long term high dose steroids. Symptoms improved on miracle mouthwash and Nystatin swish and swallow, and PPI. # Rash: patient with petechaiae from thrombocytopenia, excoriations from pruritis and flushing of the skin likely from histamine release during an inflammatory process. Relieved with sarna lotion. Rash improved with etoposide. # Afib with RVR: The patient developed afib with RVR on ___ in the setting of fever, was transferred to the MICU, rate controlled with IV metop/dilt, then converted to sinus rhythm. On ___, went back into afib with RVR, which persisted for 48 hours despite fevers resolving, so we started anticoagulation with lovenox, suspended while thrombocytopenic. # Chest pain / SOB: Patient had several episodes of chest discomfort / shortness of breath ruled out for MI several times, and ruled out for PE. It is thought that she had fluid overload from afib with RVR, hypoalbuminemia, mitral regurg. Imaging revealed pleural effusion and required lasix daily. TTE ___ showed larger effusion, but no tamponade. Pericarditis was considered; not a candidate for NSAIDs, on steroids already. Maintained euvolemia on 20mg PO lasix daily during admission. # UTI: Patient with + urine culture on ___ grew out pansensitive E. coli. Had been on broad spectrum antibiotics at OSH x 5 days. U/A mildly positive on admission, urine culture negative. Further abx were held until the patient started to decompensate on HD 5 as above. # Diabetes: Held metformin and started insulin, ___ consulted followed as sugars were difficult to control on steroids. She was discharged on an insulin regimen with NPH and Humalog SS. She received diabetes teaching by ___ prior to discharge. She has been instructed to f/u with ___ after d/c.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of CRI, mental retardation, anemia, who was recently admitted for difficulty walking and started on treatment for prostatitis with cipro, now readmitted with acute on chronic kidney injury, cr 3.6-->6.0. The pt was recently admitted from ___ for inability to walk. He was found to have a boggy/?tender prostate on admission, and +u/a (ucx c/w contamination). Given some concern for prostatitis, the pt was empirically treated with ciprofloxacin (renally dosed at 250mg q24h) for a goal 4wks. Last cr ___. The pt is unclear about exactly what led to his coming to the hospital, but purportedly his labs were checked and he was found to have a cr 6.0 and sent to the ED. In the ED, the pt's vs 98.3 67 140/65 18 98% ra. BUN/Cr 93/6.0, Hct 28 (baseline), K 4.6. u/a with traces blood and trace protein. ulytes demonstrating FeUrea 44%. Prot/cr 0.2. PVR reportedly 155. 1L NS was given. Pt was admitted for workup of acute on chronic kidney injury. On the floor, the pt was 98.1 123/64 66 18 98%RA. He denies any dysuria, frequency, abdominal pain. ___ pain and swelling L>R which is chronic. He stated he was tired and did not want to talk any more. eval for obstruction, hydronephrosis COMPARISON: Renal ultrasound ___ FINDINGS: The right kidney measures 10.8 cm in length, again seen is a relatively simple appearing bilobed upper pole cortical cyst measuring 4.5 x 2.5 x 1.8 cm, without flow, not significantly changed. Second simple appearing cyst in the right lower pole cortex measuring 1.6 x 1.5 x 2.0 cm is without flow, not visualized on prior. Left kidney measures 8.9 cm in length. There is minimal fullness of the bilateral renal pelves, without frank hydronephrosis. Decompressed urinary bladder containing a Foley catheter is not well visualized. IMPRESSION: Minimal fullness of the bilateral renal pelves, without frank hydronephrosis. Simple appearing right renal cortical cysts. showed Minimal fullness of the bilateral renal pelves, without frank hydronephrosis. Simple appearing right renal cortical cysts. The patient was diagnosed with RENAL & URETERAL DIS NOS. At the time of discharge, the patient had Primary: - Acute on chronic kidney injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of CRI, mental retardation, anemia, who was recently admitted for difficulty walking and started on treatment for prostatitis with cipro, now readmitted with acute on chronic kidney injury, cr 3.6-->6.0. # Acute on chronic kidney injury: Pt with baseline cr 3.6, found to have asymptomatic increase to 6.0 at ___ following being discharged from the previous hospital admission (___). ___ likely prerenal due to recent decrease PO intake and diarrhea with labs suggestive of intrinsic renal injury as well. Urine sediment was negative for ATN. Renal u/s was negative for hydronephrosis. The patient's furosemide was held throughout the hospitalization and started at a lower dose prior to discharge. With fluids, creatinine improved and at discharge was 4.1. # CKD: The inpatient renal team representing his outpatient nephrologist Dr. ___ recommendations and followed closely throughout the hospitalization. Patient continued on calcitrol and sodium bicarbonate. He will follow up with Chem 10 and albumin lab draws the upcoming ___ and next ___ for surveillance at ___. These labs should be sent to his PCP as well as faxed to Dr. ___ at ___. # Prostatitis: Pt started on cipro x28d in his previous hospitalization for prostatitis. Given that he was asymptomatic, a u/a here in ___ that was normal and concern for potential kidney injury, ciprofloxacin was discontinued at admission and will not be continued at discharge. # Venous stasis ulcers: Chronic. Wound care followed. # HTN: continued home metoprolol. # Anemia: chronic. continued home iron # Transitional issues - Patient's HCP ___ need to make appointment with Dr. ___, by phone at ___ - Patient's HCP ___ also need to call to make an appointment with PCP -___ check daily weights, Chemistry 10 panel with albumin on ___ and ___. Will need these labs drawn qweekly after this. Please fax results to the PCP as well as Dr. ___ at ___ -If albumin still low, please obtain nutrition consult</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o opioid use disorder w/history of injection drug use, currently in remission since ___, with complex history of TV endocarditis, presenting with c/o chest pain, SOB (?fever) 2 days after leaving ___, where she was being treated for recurrent TV endocarditis. Chest radiograph showed No acute cardiopulmonary process CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormalities on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. 2. No acute displaced calvarial fracture. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute fracture or traumatic malalignment. 2. Prominent supraclavicular lymph nodes bilaterally with associated mild inflammatory fatty stranding on the right. This could be related to the patient's ongoing endocarditis, however clinical correlation is recommended. Repeat examination to document resolution following appropriate treatment is also recommended. NOTIFICATION: The additional findings detailed in impression 2 was discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 3:38 pm, 10 minutes after discovery of the findings. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Several foci of peripheral parenchymal opacities are noted in the right lower lobe and left lower lobe, with subtle lucent focus adjacent to the right lower lobe consolidation, which may represent early cavitation and given recent history of endocarditis, favor septic emboli, though nonspecific infectious or inflammatory conditions remain differential possibilities. 3. Patient is status post tricuspid valve replacement. The patient was diagnosed with Syncope and collapse, Chest pain, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Tricuspid valve endocarditis complicated by septic emboli SECONDARY DIAGNOSES: Septic pulmonary emboli, improved Asymptomatic bacteriuria Opioid use disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F w/ h/o IVDU, hepatitis C, infective endocarditis c/b R hip septic arthritis s/p washout and s/p TV replacement (stented bioprosthetic Epic; ___ at ___ c/b reinfection of new bioprosthetic valve who presented with pleuritic chest pain and SOB 2 days after leaving AMA from ___, where she was being treated for recurrent TV endocarditis. She presented to ___ with hopes of being evaluated for candidacy for a TV replacement. During this hospitalization, we obtained a CTA and Echo to evaluate possibly worsening pulmonary emboli or worsening tricuspid vegetations compared to her findings at ___. We determined that both the emboli and vegetations were stable, and determined that she completed an appropriate antibiotic course and no longer needs further antibiotic suppression. Our CT surgery team agreed with the operative plan established at ___ by Dr. ___ (6 months of abstinence from drugs prior to re-evaluation for TV replacement). She was discharged with plans to follow-up with primary care and CT surgery at ___, and with plans to follow-up with a ___ clinic.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMHx of Afib on Coumadin s/p mechanical fall onto her left side. No HS or LOC. Sustained a left FNFx for which ortho was consulted. No numbness or paresthesias. Unable to walk. Community ambulatory with a cane at baseline. PELVIS (AP ONLY) showed Status post left hip prosthesis in overall anatomic alignment. The patient was diagnosed with Unsp intracapsular fracture of left femur, init for clos fx, Fall on same level, unspecified, initial encounter. The patient was treated with Left hip hemiarthroplasty. At the time of discharge, the patient had Left femoral neck fracture now s/p left hip hemiarthroplasty. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left hip fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left hip hemiarthroplasty, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity with anterior hip precautions, and will be discharged on her home coumadin 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: ___, otherwise healthy, presented to ED for evaluation of severe pharyngitis who presented to the ED for evaluation of severe pharyngitis and odynophagia. CT obtained in ED was concerning for supraglottic edema. ORL consulted for airway evaluation and management recommendations. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Thickened and edematous epiglottis with pronounced aryepiglottic fold edema and thickening, right greater than left, is most consistent with supraglottitis. No drainable fluid collection seen. No definite retropharyngeal edema. 2. Multiple enlarged bilateral cervical lymph nodes are likely reactive. 3. Small 3 mm right thyroid lobe nodule. No follow-up is recommended at this time. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or older. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:43 am, 5 minutes after discovery of the findings. The patient was diagnosed with Acute pharyngitis, unspecified, Elevated white blood cell count, unspecified, Tachycardia, unspecified. At the time of discharge, the patient had supraglottitis/pharyngitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#supraglottitis/pharyngitis Following ENT evaluation, she was admitted to the ICU for airway observation. She was started on IV antibiotics and steroids. The patient was initially placed on droplet precautions for c/f viral infection; however multiple exams were notable for right tonsillar pillar with erythema and exudative plaque, more concerning for bacterial infection. Pain improving markedly by time of discharge, tolerating adequate PO, ambulating independently and making adequate urine. . . #hypothyroidism: continued home-dose levothyroxine . . #anxiety: continued home Wellbutrin . . #HTN: anti-hypertensives held in ICU, SBP consistently 120-140, restarted day of discharge . .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ w/ Hx of tracheobronchomalacea on 3L home ___ s/p multiple IP interventions including silicone Y-stent and recurrent bronchoscopies for mucous plugging, CHF (EF 40%), adrenal insufficiency on chronic prednisone and other issues who presents from rehab with productive cough and SOB for the past 3 days. He was hospitalized at ___ from ___ for removal of his tracheal stent on ___ post-op course complicated by continued intubation for mucus secretion. He was extubated without complication and transferred to the floor. He was evaluated for tracheoplasty, and the plan was made for IP to perform this in ___ . He was discharged to a rehab facility on ___ on a 28-day course of Levaquin for HCAP and a Prednisone taper for adrenal insufficiency. On the day of admission, he noted an increase in SOB and cough with change in sputum color from white to white/yellow over the past week. He also required 4L O2 NC (baseline 3L). He has not had fever or chills, though he does note night sweats for the past 2 nights. In the ED initial vitals were: 98.5 98 122/73 20 100% 10L NRB. Labs were significant for WBC 10.3 w/ 85% PMNs, Hgb 10.1, proBNP 197, HCO3 41, BUN/Cr ___, lactate 0.9, UA unremarkable. CXR revealed chronic changes with no overt pulmonary edema or PNA. IP evaluated him in the ED and felt his Sx were more likely due to HCAP than tracheobronchomalacea, and recommended admission for IV ABx, steroids, and nebs. He was started on vanc/cefepime, morphine, and methylprednisolone 80 mg IV. Vitals prior to transfer were: 98.2 80 119/81 18 99% Nasal Cannula On the floor, patient reports that his breathing was comfortable, and that currently his most bothersome symptom was his chronic back pain. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OTHER DISEASES OF TRACHEA AND BRONCHUS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ w/ Hx of tracheobronchomalacea on 3L home ___ s/p multiple IP interventions including silicone Y-stent and recurrent bronchoscopies for mucous plugging, CHF (EF 40%), adrenal insufficiency on chronic prednisone and other issues who presents from rehab with productive cough and SOB concerning for HCAP. He was started on vancomycin/cefepime, increased his prednisone, he clinically improved, and he was discharged to ___ rehab pending tracheobronchoplasty in the future. # Cough/SOB/Tracheobronchomalacea: This patient likely has many contributors to his respiratory distress: tracheobronchomalacia, HCAP, mucous plugging, airway reactivity, and possibly volume overload given CHF and peripheral edema. Ultimately felt to be secondary to HCAP in the setting of TBM with lower of steroids. Interventional Pulmonology was following him throughout his hospital course and recommended IV antibiotics for 8 days, amoxicillin-clavulanate PO until the surgery, and a future IP appointment to discuss the exact timing of the surgery. He was continued on home nocturnal BiPAP, benzonatate, guaifenasin, montelukast, and was given albuterol/ipratropium nebulizer treatments. # HCAP: IP evaluated pt in ED and felt his Sx were more likely due to infection than TBM. Respiratory status currently stable on 4L NC. No culture data from previous admission to guide antibiotic selection (only yeast grew from bronchial washings). Per IP, no known MDR organisms and minimal past microbiology data. LDH in 200s. Sputum cultures x2 were heavily contaminated with oropharyngeal flora. He was discharged on vancomycin/cefepime on an 8 day total course (last day ___. # Adrenal Insufficiency on chronic corticosteroids: Patient with long history of steroid dependence for adrenal insufficiency. Received Methylprednisolone 80 mg IV in ED. In the setting of acute stress, prednisone was increased to 60mg x2 days then put to 40mg daily on a taper (course 30 mg x1 day, then 20mg thereafter). He was also placed on PCP prophylaxis with ___ DS 3x/week on ___. # CHF: Patient with peripheral edema that per him is around his baseline. There are no crackles on exam, no significant pulm edema on CXR, and no overt JVD. Mr. ___ was continued on his home dose of furosemide 40mg PO BID. Discharge weight 92.7 kg. # Chronic Pain: Patient has chronic back and abdominal pain secondary to various injuries. He was maintained on home fentanyl patch and morphine sulfate ___ PO ___ q6 hours while in hospital and then switched back to his home regimen on discharge. # CAD: Chronic stable issue on home carvedilol, simvastatin, and aspirin. # DM2: Chronic stable issue on home insulin glargine 35 units and insulin sliding scale. FSBG was between 130 and 260 during this hospital stay. # BPH: Chronic stable issue continued on home terazosin. # ___ Esophagus: Continuing home pantoprazole but sucralfate discontinued for medication interactions. # Depression/Anxiety: Chronic stable issue continued on home mirtazapine and diazepam # Hypogonadism: Chronic stable issue continued on home Androgel® # Constipation: Chronic stable issue continue on home polyethylene glycol PO daily # Code Status: Full Code confirmed with patient. Emergency contact is his wife ___ at ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male coming in after assault by roommate who hit him repeatedly in R eye waking him up. He says that he fell on his left side during the altercation. He endorses pain in his left chest and his left back as well as spinal tenderness. He was sent to ___ and a CT head was done with no acute abnormality intracranially. There was periorbital swelling as well. CT CHEST W/O CONTRAST showed 1. Acute nondisplaced fracture to the anterior left third rib with no evidence of pneumothorax. 2. Heterogeneously fatty and cirrhotic appearing liver with sequelae of portal hypertension. Gynecomastia. The patient was diagnosed with Fracture of one rib, left side, init for clos fx, Unspecified injury of right eye and orbit, initial encounter, Assault by other bodily force, initial encounter. At the time of discharge, the patient had left 3rd rib fracture right orbital swelling. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male who was admitted to the hospital after being assaulted by his roommate. He reported that he was repeatedly struck in the right eye waking him up. The patient reportedly fell on his left side during the altercation. Upon admission, the patient reported left chest and left back pain as well as spinal tenderness. He was evaluated at an OSH where a cat scan of the head was done which showed no acute intracranial abnormality. He was reported to have right ___ swelling. Because of swelling, he was reportedly evaluated by the Ophthalmology service who recommended non-operative intervention. The patient was reportedly prescribed eye drops. There was no globe injury or acute fracture. The patient remained hemo-dynamically stable. A cat scan of the chest showed one acute non-displaced 3rd rib fracture. The patient's pain was controlled with oral analgesia. He was instructed in the use of the incentive spirometer. He was tolerating a regular diet and voiding without difficulty. He did not experience any visual changes. Prior to discharge, the patient was evaluated by the Social worker, who after discussion with the patient, felt safe returning home. The patient was discharged home on HD #1 with stable vital signs. The patient was informed of the need for follow-up with the Ophthalmology service in 1 week and he was prescribed eye drops until his follow-up visit. He also has an appointment scheduled with his primary care provider. Discharge instructions were reviewed and questions answered. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ with history of PTSD, anxiety, and depression, presents with altered mental status after an intentional overdose. Per EMS, roommates noticed patient was acting abnormally and so they called EMS. Patient admitted to taking 750 mg of Adderall and some Zoloft. Initially patient stated that she took these medications at 7:30 AM. However, later on she stated she took the medications last night. History very limited due to patient's altered mental status. She did admit to taking the medications as a suicide attempt. Yesterday was the anniversary of her father's death which is what prompted her to take these medications. She does not know how the Zoloft she took and is unable to verbalize if she took other medications. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process. The patient was diagnosed with Poisoning by amphetamines, intentional self-harm, init, Altered mental status, unspecified, Oth places as the place of occurrence of the external cause. At the time of discharge, the patient had Suicide attempt Drug overdose Tachycardia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of PTSD, anxiety, and depression, presents with altered mental status after an intentional overdose. Tylenol level positive and received 21hr of NAC now medically stable for inpatient psychiatric care</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with no significant past medical history, who went to lay down after telling his wife he was not feeling well after painting. He asked his wife for a glass of water then became unresponsive. EMS was called and he was taken to OSH where he was intubated. He was transferred to ___ for further care. Radiology showed ET tube in appropriate position. Radiology showed 1. Unchanged left frontal intraparenchymal hemorrhage and left subdural hematoma as described in detail above, causing mass effect and shifting of the normally midline structures towards the right with mild effacement of the right quadrigeminal cistern and effacement of the sulci. 2. Left frontal arteriovenous vascular malformation with prominent draining veins. A preliminary report was provided by Dr. ___ on ___. Radiology showed 1. Interval evacuation of a left-sided subdural hemorrhage with resulting pneumocephalus and only minimal amount of bloods at the evacuation bed. Rightward subfalcine herniation is significantly improved from pre-operative exam. 2. Left frontal intraparenchymal hemorrhage is not significantly changed in size or appearance compared with pre-operative exam. Embolization material noted in the region left frontal of AVM malformation. Radiology showed Status post left frontal craniotomy with left frontal intraparenchymal hemorrhage, and a small left subdural hemorrhage, resulting in 4 mm of midline shift. Radiology showed 1. No evidence of new intracranial hemorrhage. 2. Status post left frontal craniotomy with left frontal intraparenchymal hemorrhage and small left subdural hematoma with associated midline shift, unchanged from ___. Radiology showed 1. Mild increase in midline shift to the right. Medial displacement of the left uncus not clearly seen on prior CT studies. 2. No evidence of new hemorrhage. Findings were given by Dr. ___ to Dr. ___ by telephone on ___ @ 300PM, 40 minutes after they were made. Radiology showed 1. No evidence of new intracranial hemorrhage. 2. Status post left frontal craniotomy with stable left frontal intraparenchymal hemorrhage and surrounding edema and resolution of postsurgical pneumocephalus. Midline shift is essentially unchanged from ___. Radiology showed 1. Status post left frontal craniotomy and embolization of AVM with no significant interval change in large left frontal intraparenchymal hemorrhage and surrounding edema. Midline shift is unchanged. The patient was diagnosed with SUBARACHNOID HEMORRHAGE, SUBDURAL HEMORRHAGE. The patient was treated with ___ Cerebral angiogram with Onyx embolization ___ Left craniotomy for ___ evacuation. At the time of discharge, the patient had L frontal AVM L frontal IPH L ___ Cerebral edema. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to neurosurgery on ___. He was found to have a left IPH and SDH with 11mm of midline shift. He found to have a left frontal AVM on CTA. He was taken to angio for embolization of the AVM. He was then taken to the OR for left craniotomy for ___ evacuation. Subgaleal JP drain was placed. The patient was taken to SICU post op. Post op head CT showed evacuation of SDH with stable frontal IPH, embolization material was seen in left frontal region of AVM malformation. The patient remained intubated overnight. On ___ NCHCT was stable. JP drain was removed. Keppra was increased to 1,000 mg BID. Systolic blood pressure was kept strict less than 140. On ___ the patient was febrile to 100.9F. Sputum gram stain showed GNR, GPC culture was still pending. The patient was not started on antibiotics while awaiting culture results. WBC was 9.3. He was extubated successfully. He was preoped for angio on ___. On ___ his exam was slightly improved as he was able to lift his RUE antigravity. He underwent a portable head CT which was stable and after review it was determined that he would undergo cerebral angiogram for embolization. On ___, the patient's exam remained stable. He underwent a cerebral angiogram with embolization without complication. On the morning of ___, Mr. ___ was found to be more somnolent on exam and intermittently following commands. A portable CT head was ordered, which was stable. On the same day, his bilateral femoral sheaths were discontinued. On ___ he was brighter on exam, and was mobilized with ___. On ___ patient had a decline in his mental status, on examination in the morning, he was unable to answer questions about place and date, a CT was performed that showed a larger left frontal hemorrhage. Patient was transferred to the ICU. On ___ patient remained in the ICU. EEG was placed. Systolic blood pressure was liberalized to less than 160. He continued to work with physical therapy. speech and swallow evaluated the patient and cleared him for a soft solid nectar thick liquid diet. A multipodus boot was also applied to his RLE for foot drop. On ___ patient was slightly brighter on exam. EEG results showed no seizure or epileptiform activity. The EEG leads were removed. His Keppra was continued to 1 gram BID. On ___, the patient continued to do well. His motor exam remained stable, but notable for ___ strength in his anterior tibialis, gastrocnemius, and extensor hallus longus. He was seen by speech and swallow and due to continued improvement, his diet was advanced to regular solids and thin liquids. He was transferred to the inpatient ward that afternoon. On ___ Speech upgrade to thin liquids, regular solids. Patient transferred to floor. On ___ Dr. ___ was stable, ___ showed no interval changes, Anesthesia performed pre-op tests and the patient was consented by both Neurosurgery and Anesthesia. On ___ No events for Dr. ___ the day. At the time of discharge on ___ he is tolerating a regular diet, afebrile with stable vital signs. He will return on ___ for surgical resection of the AVM.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH BRCA (dx with relapse ___ yr ago pt refuse surgery or tx), HTN, Dementia who presents from her nursing home with symptoms of rigors and fever to 101.3, which her family and nursing home staff report are typical UTI symptoms for this patient. She was in her usual state of health until this morning when, after breakfast her nurse noticed her rigoring. She was subsequently transferred via EMS to ___ ER. When I question the patient, she reports she feels fine. She denies any respiratory or GI symptoms and both family and rehab staff confirm this. Her O2 sat was only 92%, however, and the rehab staff was concerned that her lung sounds were concerning at the bases. Radiology showed Reticular interstitial prominence could reflect an atypical infectious process. The patient was diagnosed with FEVER, UNSPECIFIED, TACHYCARDIA NOS. At the time of discharge, the patient had Primary Diagnosis: Urinary Tract Infection Secondary Diagnosis: HTN, 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>ASSESSMENT/PLAN ___ with PMH BRCA (dx with relapse ___ yr ago pt refuse surgery or tx), HTN, Dementia who presents from her nursing home with symptoms of rigors and fever to 101.3 with large leuks in urine c/f UTI.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is an ___ year old man with history of dementia (lives in assisted living facility, A&Ox1-2 at baseline, essentially dependent on others for all ADLs), prior seizure in the setting of receiving ertapenem, history of prior ischemic stroke (unknown timing or circumstances, seen at ___, who presents with an episode of minimal responsiveness in setting of a 1 day history of generalized malaise. History provided by records and collateral from nursing at the ___ facility. CHEST (PORTABLE AP) showed No prior chest radiographs available for review. Lungs are reasonably well expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are unremarkable though assessment is difficult because of patient rotation. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Brief episodes of unresponsiveness not due to seizures. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>1. Episodes of unresponsiveness, low likelihood of seizures: Patient's episode of unresponsiveness at his ALF was noted to resolve shortly after administration of fluids at ___, with non-contrast head CT negative at that time. Patient was transferred to ___ to investigate possible underlying seizure activity; continuous video EEG monitoring for 24 hours preliminarily did not reveal active seizures. Although patient was noted to have an episode of somnolence and decreased responsiveness to questions and commands one day prior to discharge, no seizure activity was noted at that time; these symptoms resolved in a few hours without intervention. No infectious process was identified on laboratory testing or chest imaging. Based on the absence of a clear worsening of underlying seizure disorder, antiepileptic regimen was not changed. Symptoms may have been related to symptomatic hypovolemia given poor oral intake at baseline and response to IV fluids.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presents with history of L PTX x2 presents with left shoulder pain starting earlier today. He notes that it feels similar to his prior PTXs, so he came to the ED. His first spontaneous PTX was in early ___ and managed conservatively. He then had a recurrent PTX in ___, which was also managed conservatively. He has never required a chest tube. Surgery was discussed with him last admission, but he declined. On presentation today, he reports left shoulder pain, but was stable on room air on admission and continues to be breathing well on supplemental O2. CHEST (PORTABLE AP) showed Small left apical pneumothorax, new compared to prior chest radiograph from ___. No evidence for tension. Radiology showed Small left apical pneumothorax, which is slightly enlarged compared to chest radiograph from ___. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:31 am, 10 minutes after discovery of the findings. CR - CHEST PA LATERAL showed Unchanged small left apical pneumothorax. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had Left spontaneous pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the hospital and was placed on oxygen at 5 LPM to attempt to resolve the small left pneumothorax. His left shoulder pain resolved and a repeat chest xray was done on ___ which showed a small left apical pneumothorax, maybe slightly larger than the prior film on ___. He had minimal pain and his room air ambulatory saturations were 96%. A repeat chest xray was done 7 hours later and there remained a stable left apical pneumothorax. As he wishes to postpone any surgical treatment until he has a break from college, he was discharged on ___ and will follow up with Dr. ___ in 2 weeks with another chest xray. If he has any increased chest/shoulder pain or shortness of breath he will return to the Emergency Room.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with history of ETOH cirrhosis (c/b GAVE, ascites, Hepatic Encephalopathy, SMV thrombosis -- resolved), alcohol abuse, and HTN, recently admitted for abdominal pain, vomiting, and diarrhea on ___, now representing with same complaints. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent portal vein with hepatopetal flow. Cirrhotic liver with moderate ascites and splenomegaly. No focal hepatic lesions. 2. Cholelithiasis without cholecystitis. CHEST (PORTABLE AP) showed Cardiomediastinal contours are normal. Lung volumes are low and note is made of patchy and linear bibasilar opacities with appearance suggestive of atelectasis. Possible small left pleural effusion. Radiology showed Successful ultrasound-guided diagnostic and therapeutic paracentesis with removal to 2 L serosanguineous fluid. Samples were sent to the lab for cell count and culture as requested. CT scan of the abdomen and pelvis showed 1. 2.3 x 5.1 x 7.9 cm structure of heterogenous density with few gas bubbles just deep to the umbilicus, either related to hematoma or phlegmon/early abscess. It does not appear drainable at the current time. 2. Heterogenous liver, at least partially due to some steatotic changes. There are a few nodular hypodense areas seen in the posterior aspects of segments 6 and 7, which could be due to the overlying heterogeneity of the liver parenchyma, although given the underlying cirrhotic change dedicated cross-sectional imaging of the liver (either by CT or MRI) is recommended to exclude underlying lesion. 3. Diffuse mild dilation of the small bowel loops, compatible with ileus. RECOMMENDATION(S): Dedicated liver protocol CT or MRI, after the acute episode has resolved. The patient was diagnosed with UMBILICAL HERNIA W OBSTR. The patient was treated with Hernia repair. At the time of discharge, the patient had Primary: Umbilical Hernia s/p repair Cellulitis Secondary: EtOH abuse EtOH cirrhosis ___ LVPs as outpatient, negative for SBP ___ MRI abdomen with cholelithiasis, sclerosed hemangioma segment VIII ___ 3 admissions with decompensation due to ascites At least two visits to ___ in ___ with paracenteses ___ EGD with biopsies of esophagus and stomach reportedly negative, no comment on presence or absence of varices HCV negative ___ HBV non-immune ___ Autoimmune hep negative ___ 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 ___ year old woman with history of ETOH cirrhosis (complicated by GAVE, ascites, Hepatic Encephalopathy, SMV thrombosis subsequently resolved), alcohol abuse, and HTN, presenting with abdominal pain, vomiting, and diarrhea and umbilical hernia, s/p hernia repair on ___. #Abdominal pain: Likely secondary to umbilical hernia and distention initially secondary to ascites. Patient admitted with 1 wk hx of abdominal pain associated with nausea, vomiting, and diarrhea. Spontaneous bacterial peritonitis ruled out in ED with diagnostic paracentesis. Patient taken to OR by transplant surgery ___ for repair of umbilical hernia. Also received paracentesis in OR removing 4L fluid, was given 25% albumin. On day 1 post-op, patient developed fever to 101.5 which resolved. Patient subsequently developed erythema surrounding the surgical site concerning for cellulitis vs secondary bacterial peritonitis. Was started on empiric vanc/zosyn and underwent diagnostic/therapeutic ___ paracentesis ___ removing 2L, was negative for bacterial peritonitis. Patient transitioned briefly to PO Bactrim given negative para but then rebroadened to IV vanc/zosyn due to worsening induration at surgical site. CT abdomen ___ consistent with phlegmon vs hematoma. Per discussion with surgery there was no indication for further surgical management and area noted on CT was not drainable. Patient was transitioned to PO augmentin on ___ for a 10 day course. Patient's pain was managed initially with IV dilaudid and gradually transitioned to PO oxycodone. Patient was provided with short term course of PO oxycodone until follow up with PCP. Should consider pain clinic referral if ongoing pain. #ETOH Cirrhosis: Child's class B, MELD 14 on admission. Patient has history of hepatic encephalopathy but there was no evidence of encephalopathy during hospital course. INR and TBili stable during hospital course, and patient was on home regimen of Lasix, spironlactone, rifaxamin, and lactulose. #ETOH Abuse: Given patient's active drinking status, she was placed on CIWA protocol with lorazepam. CIWA protocol was discharged after 5 days, and patient received 0.5mg lorazepam Q12H PRN anxiety given continued anxiety. Patient should follow up alcohol abuse and treatment with PCP as outpatient. TRANSITIONAL ISSUES ======================== -Patient discharged with 10 day course of Augmentin to be completed on ___ -please follow up surgical site and ensure it is improving -patient should follow up with transplant surgery in clinic for monitoring as well (appointment listed) -Continue to discuss alcohol abuse and rehabilitation -patient discharged with short term supply of oxycodone and Ativan. Need for these medications should be re-evaluated at follow up appointment. -consider referral to pain clinic -IMPRESSION: 1. 2.3 x 5.1 x 7.9 cm structure of heterogenous density with few gas bubbles just deep to the umbilicus, either related to hematoma or phlegmon/early abscess. It does not appear drainable at the current time. 2. Heterogenous liver, at least partially due to some steatotic changes. There are a few nodular hypodense areas seen in the posterior aspects of segments 6 and 7, which could be due to the overlying heterogeneity of the liver parenchyma, although given the underlying cirrhotic change dedicated cross-sectional imaging of the liver (either by CT or MRI) is recommended to exclude underlying lesion. 3. Diffuse mild dilation of the small bowel loops, compatible with ileus. RECOMMENDATION(S): Dedicated liver protocol CT or MRI, after the acute episode has resolved. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH sigmoid diverticulosis, hypothyroidism and remote h/o metastatic sarcoma who is presenting with 2 weeks spasmodic abdominal pain worsening over the last day and a half with new onset nausea. Pt reports unexpected onset of waves of abd pain. Pt denies any association of pain with eating, movement, or specific activity. She report having to sit down and stop doing activities with pain onset. Pain is diffuse in location and lasts for minutes. Pt has also had poorer PO intake ___ to abd pain for past 2 weeks. She denies any change in BMs until after coming to hospital at which time she has had 3 episodes of diarrhea, unknown bloody or other characteristics. Pt denies dysuria, and flank pain. Radiology showed No evidence of acute cardiopulmonary process. Radiology showed 1. Approximately 10 cm segment of the distal ileum/cecum, which demonstrates marked bowel wall thickening. There is no significant fat stranding or fluid adjacent to this bowel loop. The differential considerations include infection, inflammation or ischemia of subacute/chronic nature. Underlying mass lesion is also considered due to lack of associated stranding and acute inflammatory changes. 2. Large hiatal hernia. 3. Extensive calcified atherosclerotic disease of the aorta and its branches without associated aneurysmal changes. 4. Compression deformities of L5 and L1 vertebral bodies with associated sclerosis, likely chronic. 5. Fibroid uterus. 6. Intermediate density renal lesions, which can be further assessed with renal ultrasound on non-emergent basis. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE. The patient was given written instructions concerning 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 sigmoid diverticulosis, hypothryoidism presents with 2 weeks of abd pain, new onset diarrhea, and transient nausea with elevated WBC ct, concentrated urine, and imaging colitis in ileal-cecal area c/f infectious vs. ischemic colitis.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with hyperlipidemia presenting from ___ with 2 days of slurred speech and left sided weakness. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. No evidence for an acute infarction. 2. Incidental note of a 5 mm colloid cyst near the foramen of ___. 3. Probable mild chronic small vessel disease. 4. Additional findings described above. The patient was diagnosed with Weakness. At the time of discharge, the patient had TIA Prediabetes Hyperlipidemia Obesity. The patient was given written instructions concerning 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 many with hyperlipidemia who presented with left leg weakness and dysarthria who was admitted to the Neurology stroke service. Fortunately, his symptoms improved and by the time that he was examined on rounds, he had returned to his baseline. Thus, this is most likely a TIA secondary to vascular risk factors. He does have significant vascular risk factors and received detailed education about his risk factors and what the appropriate treatment for each of his risk factors is. His LDL was significantly elevated to 173. We started ___ 10 mg for this, considering that he had previously proximal muscle pain when he was on a low dose of Atorvastatin . HbA1c 6.3. TSH slightly elevated at 7.4, T3 and free T4 were normal. Emphasized the importance of healthy diet, daily exercise, preventative health care and routine primary care follow up. His stroke risk factors include the following: 1) DM: A1c 6.3% 2) Hyperlipidemia: LDL 173, ___ started 3) Obesity BMI 32.5 4) Snoring with suspected sleep apnea Transitional issues: [ ] Hg A1c 6.3% [ ] PCP to ___ as tolerated, goal LDL <70 [ ] no follow up is needed for incidentally found colloid cyst seen on MR brain [ ] needs sleep study to evaluate for sleep apnea AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? () Yes - (x) No 4. LDL documented? (x) Yes (LDL = 173 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL] 6. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed 1. Left basal opacity may represent atelectasis but cannot exclude superimposed pneumonia. 2. Tortuous thoracic aorta. CT HEAD W/O CONTRAST showed No acute intracranial process. CHEST (PORTABLE AP) showed Low lung volumes. No evidence of acute intrathoracic process. Mild bibasilar atelectasis. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute findings in the abdomen or pelvis. 2. Areas of crescentic intraluminal filling defects in the abdominal aorta likely represent chronic intraluminal thrombi related to severe atherosclerotic disease. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Acute metabolic encephalopathy Dementia Rhabdomyolysis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ ___ speaking man with hx diabetes mellitus, dementia, blindness and hearing loss, recent admission ___ for UTI and otitis externa presenting with encephalopathy and visual/tactile hallucinations x 3 weeks, found to have elevated lactate of unclear etiology and mild rhabdomyolysis for which he was initially monitored in the FICU, transferred to the floor on ___. # Toxic metabolic encephalopathy: # Visual/tactile hallucinations: # Dementia: Presented with worsening confusion and visual/tactile hallucinations over 3 weeks. There was initial c/f sepsis given presenting tachycardia and elevated lactate (see below), although he remained afebrile, without a leukocytosis, and with no obvious infectious source (no e/o otitis media/externa, CXR without clear PNA, UA positive but UCx subsequently negative, BCx NGTD, HIV negative, and CT A/P without intra-abdominal pathology). NCHCT was negative, and there was no headache or meningismus to suggest CNS infection. Treponemal Ab pending at the time of discharge. B12, TSH WNL. No clear medication culprits, and no history of intoxication or e/o withdrawal syndrome. Initially treated with empiric CTX (___), cefepmine (___), and azithromycin (___) - ultimately discontinued in the absence of clear infectious source. Etiology for his presenting encephalopathy and hallucinations ultimately unclear, possibly delirium in setting of underlying dementia, but both had resolved by the time of discharge; confirmed to be back to baseline by son/HCP at the bedside (AOx1-2, pleasant and minimally conversant in setting of blindness and deafness). Seen by ___, who found him to be at his mobility baseline and recommended home without services (has ___ family caregivers and supervision). Home risperidone 2mg QHS continued in hospital and on discharge. # Elevated lactate: Lactate peaked at 6.4 on admission. In setting of encephalopathy and sinus tachycardia, initially concerning for sepsis, but infectious w/u was ultimately negative as above and empiric antibiotics were discontinued. CT A/P without evidence of bowel ischemia. ___ have been secondary to dehydration in setting of encephalopathy vs metformin effect and resolved with IVFs and holding home metformin. Given A1c of 6.0%, home metformin held on discharge pending PCP ___. # Mild rhabdomyolysis: CK 380 on admission and peaked at 1100 on ___. No e/o renal/liver dysfunction or cardiac ischemia. ___ have been secondary to dehydration/immobility vs drug effect (possibly home simvastatin) and resolved with IVFs. Home simvastatin was held in hospital and on discharge pending PCP ___. # Type 2 diabetes mellitus: A1c 6.0%, with fingersticks well-controlled this admission. In setting of elevated lactate, home metformin held in hospital and on discharge pending PCP ___. # Constipation: No e/o ileus or obstruction. Initiated bowel regimen with senna daily and miralax PRN on discharge. # GERD: Continued home omeprazole. # BPH Continued home Tamsulosin. # Microscopic hematuria: Repeat UA as outpatient to document resolution if within GOC. # Contacts/HCP/Surrogate and Communication: ___ (son) ___ # Code Status/ACP: DNR/ok to intubate ** TRANSITIONAL ** [ ] ___ Trep Ab, pending at discharge [ ] ___ BCx, pending at discharge [ ] metformin held on discharge in setting of elevated lactate and well-controlled diabetes; ___ diabetes mellitus off this medication [ ] simvastatin held on discharge in setting of mild rhabdomyolysis; defer resumption to PCP [ ] ___ constipation; discharged on bowel regimen [ ] repeat UA as outpatient to document resolution of microscopic hematuria, if within ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ RHD woman with PMH of seizures ___ traumatic brain injury and prior IVDU who presents with a 2 day history of left wrist and arm/hand swelling and pain. 2 days ago she started noticing swelling in her left wrist. She thought it might be ___ a spider bite as she recently moved into a wooded area and took Benadryl to no affect. Yesterday the swelling became tender and she went to ___ for evaluation during which time a hand x-ray showed no fracture dislocation or foreign body. Ultrasound showed "2 cm x 7 mm thick complex subcutaneous collection at the site of swelling with characteristics consistent with probable phlegmon or very thick fluid. No clearly defined drainable abscess was identified". She received 1 dose of vancomycin and was discharged on Keflex and Bactrim. She was scheduled for follow-up reevaluation today. At that time she had continued swelling and pain in her wrist and the swelling had spread to her proximal forearm and hand. Orthopedics was consulted at ___ recommended a hand surgery evaluation but would not be able to provide such evaluation until ___. She was transferred here for further care. She reports she feels "unwell" but otherwise denies fevers/chills. No numbness or weakness in hand, just pain. US EXTREMITY LIMITED SOFT TISSUE LEFT showed -Findings concerning for abscess with debris measuring 2.6 x 4.8 x 2.8 cm. Skin thickening and edema of the surrounding tissue. -Wall thickening of a traversing vein, likely representing phlebitis, which otherwise remains patent. The patient was diagnosed with Cutaneous abscess of left upper limb. The patient was treated with bedside I&D of R dorsal wrist abscess. At the time of discharge, the patient had R dorsal wrist abscess. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Pt was admitted to the hospital for the above diagnosis, dorsal hand abscess. She underwent bedside I&D and washout on ___ and the wound was packed and dressed with dry sterile gauze. Cultures from that wound eventually grew out Strep Anginosis and her antibiotics which were initially Vancomycin (trough 12) and Cipro were switched to PO erythromycin which she tolerated well. On HD2 the packing was removed and the pt was instructed on how to rinse her wound with soap and water for 20 min, three times per day. After each rinse, the wound was repacked by nursing care. By HD3 the patient's pain was well controlled on her home suboxone, she was tolerating dressing changes, and she was ambulating and voiding independently and tolerating a regular diet. She expressed her readiness for home and she was discharged in a healthy condition. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old female with history of restrictive lung disease, and unspecified degenerative neuromuscular disease, and baseline collapsed RLL with one week of URI symptoms and chest congestion. She went to ___ yesterday with shortness of breath and was found to have an O2 sat of 75%RA which improved to 95%/2L. The patient describes one week of URI symptoms with productive cough, nasal congestion, and intermittent SOB. She also reports orthopnea. Patient reports sick contacts at home. She received the influenza vaccine this year. . In the ER, initial vital signs demonstrated tachycardia to 114, stable BP, and O2 sat of 95%/2L. A CXR was performed which demonstrated a left basilar and retrocardiac opacity, suggestive of atelectasis, but infection could not be ruled out. Initial labs demonstrated a WBC count of 8.1, BNP of 354 and were remarkable for a bicarb of 37. She was given levofloxacin 750mg for concern for pneumonia and albuterol/ipratropium nebs. Radiology showed Retrocardiac and left basilar opacity suggestive of atelectasis noting infection cannot be excluded. No prior available to assess for interval change. The patient was diagnosed with HYPOXEMIA, RESPIRATORY ABNORM NEC, OTHER LUNG DISEASE NEC, IDIOPATHIC SCOLIOSIS. At the time of discharge, the patient had Primary diagnosis: Hypoxia Viral syndrome . Secondary diagnoses: Neuromuscular disorder Restrictive lung disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ with history of restrictive lung disease, unknown degenerative neuromuscular disease, and baseline collapsed RLL presenting with one week of chest congestion and cough, found to be hypoxic at clinic, with opacities on CXR, likely viral URI. . ACUTE ISSUES #Hypercarbic respiratory failure: Patient with history of pulmonary disease (restrictive [secondary to neuromuscular disease?] and decreased diffusion capacity), presented with hypoxia in setting of recent URI. The patient did not have leukocytosis or fever upon admission. There were opacities on CXR thought to be atelectasis, though pneumonia could not be excluded. Her bicarb was elevated to 37, though this is thought to be chronic. Her O2 sat remains lower than baseline of high-80's to low-90's on RA. Not thought to be PE given negative d-dimer and no ___ findings. Patient was treated for CAP with levofloxacin given hypoxemia and history of lung disease. She was also started on a regimen of albuterol/ipratropium and acetylcysteine nebs, and was given intensive chest ___. The patient was transferred to the MICU after being found lethargic one morning, with a CO2 of 115. She was immediately placed on BiPAP and continued throughout the day with a steady downtrending of her CO2. BiPAP was removed the following morning and she was able to tolerate nasal cannula while awake. She required BiPAP during naps and overnight. Settings were initially titrated by vent, then transferred to a home machine. The patient was evaluated by both Pulmonology and Sleep Medicine who recommended bipap for sleep with settings of ___ H2O with 4L O2 with SpO2 maintained >88% and <95%. She was intermittantly requiring NCO2 during the day; this can also be titrated to 88%<O2 sat<95%. An appointment has been made for outpatient Sleep Medicine follow-up. The patient will require follow-up with her outpatient pulmonologist. Patient received pneumococcal vaccine prior to discharge. . #Conjunctivitis Patient with injection of right eye since initiation of nightly Bipap. This was thought to be related to her Bipap mask irritating her eye at night. Patient without symptoms other than mild foreign-body sensation. She was given artificial tears, as needed. . CHRONIC ISSUES # GERD: The patient has a history of GERD, she was continued on her home-dose omeprazole. . # Depression: The patient has a history of depression. She was not reporting sign or symptoms of depression during her hospitalization. She was continued on her home-dose sertraline. . TRANSITIONAL ISSUES #Patient had a marginally abnormal UA during hospitalization. This should be repeated by PCP. #Patient will require outpatient follow-up with Sleep Medicine for evaluation of home BiPap services. An initial inpatient evaluation made recommendeds for interim home BiPap. #Patient is at high risk for complications of influenza. Prophylaxis should be considered at acute rehab should active cases of influenza or ILI be at facility. #A TSH is pending at the time of discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old male with history of quadriplegia after diving accident in ___ s/p spinal surgery and prior DVTs while on warfarin who presents with bilateral DVTs. Mr. ___ states his mom and PCA noticed swelling in his right leg on ___. They put on compression stockings and it minimally improved by ___ but became suddenly worse on day of presentation so went to ___. At ___, they did bilateral LENIS showing DVT in left common femoral to the left popliteal, and right common femoral to the mid common femoral. CTA chest was negative for PE. He was started on a Heparin drip with bolus and sent to ___ for further management. ROS negative for chest pain, dyspnea, hemoptysis, fever, cough, nausea, vomiting. In the ED, initial vital signs were: T 98.0 HR 110 BP 130/98 RR 18 SaO2 99% RA - Exam notable for: 1+ edema in bilateral ___, dopplerable pulses bilaterally, no evidence of ___ phlegmasia - Labs were notable for: Hgb 11.6, Hct 35.9, ___ 13.7, PTT 150, INR 1.3 - Studies performed included: CTA Chest from OSH, Bilateral LENIS from OSH per report showed DVT in left common femoral to the left popliteal, and right common femoral to the mid common femoral - Patient was given: IV Heparin @ 1600 units/hr - Vitals on transfer: T , HR 89, BP 119/61, RR 16, SaO2 97% RA Radiology showed An inferior vena cava filter appears unchanged in position since ___, projecting lateral to the right aspect of the L3 vertebral body. Radiology showed Infrarenal IVC filter in place with non opacification of the IVC below the IVC filter, common iliac, external iliac, common femoral and partially imaged superficial femoral and deep femoral veins compatible with occlusive thrombus. Faint opacification of the common internal iliac arteries may be from retrograde flow. The patient was diagnosed with Acute embolism and thombos unsp deep veins of low extrm, bi. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================= Bilateral DVTs SECONDARY DIAGNOSES: ==================== Quadriplegia UTI. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with history of quadriplegia after diving accident in ___ and prior PE (s/p IVC filter ___ and 6mon course warfarin) who was found at ___ to have b/l DVTs and started on a heparin drip. A CTA showed no evidence of PE. He was then transferred to the ___ for further management. At ___, he was continued on the heparin drip and placement of his IVC filter was confirmed by ___. Vascular surgery was consulted, who recommended a CTV which showed filling defects in IVC from level of IVC filter to distal femoral veins. No surgical interventions were warranted at the time. He was then started on apixaban. Throughout the hospitalization, he was hemodynamically stable and did not show any signs of bleeding. # Bilateral DVT: Patient with history of b/l DVTs s/p IVC filter placement and 6mon course Coumadin in ___. IVC filter still in place as seen on KUB. DVTs likely ___ IVC filter, which increased venous stasis in lower extremities and therefore risk of DVTs. CTA negative for PE. No family history of clotting disorder. Vascular surgery was consulted, who recommended a CTV which showed filling defects in IVC from level of IVC filter to distal femoral veins. No surgical interventions were warranted at the time. Patient was switched to apixaban and heparin gtt was discontinued. He was discharged home with vascular surgery follow-up. # UTI: patient with suprapubic catheter, with recurrent UTIs. Diagnosed with UTI by urologist on ___ and being treated with 7-day course of Cephalexin. Caphalexin was continued during course of admission. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx myotonic dystrophy (w/ baseline hypoxia and difficulty swallowing), Afib w/ AV nodal disease s/p demand A/sequential V pacemaker on sotolol and pradaxa p/w hypotension and AMS. Her husband reports she was feeling well today but at a party this evening drank small amt EtOH, smoked MJ (others drank and smoked same), became somnolent. EMS called and noted SBPs 50 and HR 52. In the ED, pt received 3L NS without improvement and was started on peripheral norepi with stable SBP 100 on .27 mcg/kg/min. Intubation was preferred given labile mental status and O2 requirement (mid ___ on RA, 100% on 6L) but pt refused this. Pt refused CVL, aware of the risks. Glucagon was deferred. Pt has capacity to refused CVL and intubation per ED. CHEST (PORTABLE AP) showed Low lung volumes with probable bibasilar atelectasis and mild pulmonary vascular congestion. CHEST (PORTABLE AP) showed In comparison with the study of ___, there are improved lung volumes. Continued enlargement of the cardiac silhouette with some tortuosity of the distal aorta and no change in the well-positioned leads of a pacer device. No evidence of vascular congestion or acute focal pneumonia at this time. The patient was diagnosed with Hypotension, unspecified. At the time of discharge, the patient had # Hypotension # Atrial fibrillation # Transaminitis # Hypothyroidism # GERD # HLD # Complex sleep apnea # Muscular dystrophy # Hypertension # Bladder spasm. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old female with past medical history of atrial fibrillation on sotalol and pradaxa who was admitted ___ to the ICU with hypotension following alcohol and marijuana use, initially requiring peripheral vasopressors, complicated by LFT abnormalities attributed to hypotension, subsequently improving with supportive measures, able to be discharged home #Hypotension: Patient presented with SBP 50mmHg with elevated lactate, initially requiring peripheral pressors in the ICU, subsequently improved with IV fluid boluses and supportive care. No infection, bleeding or acute cardiac event identified. There was initial question of sotalol toxicity by the ICU team, but per toxicology evaluation clinical picture was not consistent with this toxidrome. EP interrogation of pacer was unrevealing. TTE without obvious new wall motion defect or valvulopathy. Symptoms were likely secondary to excess alcohol and marijuana use complicated by her underlying comorbidities. Blood pressure normalized as above, and patient was montiored x 24 hours without event. Ramipril held at discharge, to be reassessed at PCP ___. # Atrial fibrillation - Patient on chronic sotalol with pacemaker. As above, initially concern for sotalol toxicity but this was exonerated. Per discussion with EP and outpatient cardiologist, sotalol was restarted at prior dose with repeat EKG 2 hours later without significant change. Continued pradaxa. # Transaminitis - secondary to mild shock liver in setting of hypotension. Peaked at ALT 114, AST 130, AP 71, Tbili 0.9. Improving to ALT 50, AST 27, AP 58, Tbili 0.8 at discharge. Would repeat at ___ # Hypothyroidism - continued levothyroxine # GERD - continued pantoprazole # HLD - continued rosuvastatin # Complex sleep apnea ___ muscular dystrophy - continued CPAP # Hypertension - held ramipril # Bladder spasm - continued oxybutynin Transitional Issues - Would consider recheck of LFTs to ensure continue normalization (LFTs at discharge were ALT 50, AST 27, AP 58, Tbili 0.8) - Ramipril held in setting of hypotension; could consider restarting at ___ > 30 minutes spent on this discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with DM2, OSA, recent left knee PJI, s/p explant and placement of antibiotic spacer with Dr. ___ on ___ (on vanc/cipro), recent pAF diagnosis (on apixaban), presenting from rehab with hypotension and tachycardia. CHEST (PORTABLE AP) showed No acute intrathoracic process. Chronic deformity of the left humeral head and neck. Radiology showed Worsening soft tissue edema surrounding the left knee with moderate sized joint effusion. Septic joint difficult to exclude. The patient was diagnosed with Unspecified atrial fibrillation, Palpitations. At the time of discharge, the patient had prosthetic joint 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 ___ year old male with DM2, OSA, recent left knee PJI, s/p explant and placement of antibiotic spacer with Dr. ___ on ___ (on vanc/cipro), recent pAF diagnosis (on apixaban), presenting from rehab with rapid AF, now in sinus, admitted for w/u of mild leukocytosis and elevated CRP. #Prosthetic joint infection #Leukocytosis #CRP elevation from baseline Mr ___ currently has an antibiotic spacer in his left knee after his prosthetic joint had to be removed for infection. He has been on vancomycin and ciprofloxacin managed by ID in rehab. He presented with a slight uptrend in CRP from prior (84 from 70.5 on ___ and leukocytosis with WBC 11 from 6.8 on ___. Aside from knee pain, he had no localizing symptoms/exam/lab findings. CXR without pneumonia, UA without evidence of UTI. No evidence of PICC-associated infection. Given no culture data, difficult to know if antibiotics have appropriate coverage--possible that switch from CTX to ciprofloxacin is responsible for presentation, although this switch happened on ___ and he was clinically stable for ~2 weeks on this regimen. Without any change to the antibiotics, his CRP trended down to 54 and his white count to 7.3. #Paroxysmal atrial fibrillation: CHADS2VASC: 2 (Age, HTN). Mr ___ presented with rates to 170s and spontaneously cardioverted while on diltiazem gtt. His metoprolol was increased from 25 daily to 50 daily (fractionated into Q6 dosing). He will be discharged on this higher dose of metoprolol. He has remained in the ___ HR. Apixaban held for possible procedure. Restarted upon discharge. CHRONIC ISSUES ================ #DM2: -Held home metformin, insulin sliding scale while in the hospital #GERD: Continued home omeprazole #Anxiety/depression: Continued home escitalopram, alprazolam #BPH: Continued home Flomax #HLD: Increased simvastatin to 40mg given ASCVD risk of 20.9%</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o poorly controlled DM2 and right ankle osteomyelitis ___ fracture in ___, currently on dapto/flagyl/cipro who presents with right ankle pain, "redness around and drainage" from the ___ area, new leukocytosis and left shift. . Recently, the patient was admitted to the ___ on ___ for right ankle osteo, and discharged home with a planned 6 week course of IV daptomycin and PO ciprofloxacin. He was seen on ___ by post discharge follow up at which point he was compliant with his medications, preforming wound changes QOD, and still had severe pain but overall felt improved. He was seen in the ___ and then the ___ ___ on ___ with fever, but discharged when they noted a normal ___ count and no other signs of infection besides his chronic osteo. On ___, he re-presented to ___ with increasing right ankle pain and fever to 102 where he was found to have an elevated WBC with left shift. Right ankle xray was unchanged. He had an MRI which showed improvement in osteo without mention of invovlement of tibia. During his stay, he was offered BKA (the only definitive treatment for his disease) but he declined. Flagyl was added, his leukocytosis resolved, and he was discharged home with plans for ongoing outpatient follow-up. . ___ placed last ___, saw clear fluid draining from his arm on ___. ___ came on sat am to change the dressing and thought it didnt look right. He had rigors and sweats this morning at 6am. Pain in his right ankle worsened so he presented to ___ again today. He was found with a FSBS in the 400's and was started on a insulin gtt. They transferred back to ___ for further workup. . In the ___, initial VS were: 97.6 90 110/62 18 98% 2L. Elevated lactate with borderline BP's so warranted ICU admission. Insulin drip was stopped. Received 1 gram of tylenol, 4grams of IV morphine, and 2.5L of IVF. CVL was placed. Most recent vitals prior to transfer were 100.1 87 92/59 12 96% on RA. . On arrival to the MICU, he reports right ankle pain and feeling sad. Septic shock, new right central venous line placement. Portable AP radiograph of the chest was reviewed in comparison to ___. Right internal jugular line has been inserted with its tip at the level of mid SVC. Heart size and mediastinum are unremarkable. There is substantial increase in the diameter of the vasculature, consistent with vascular engorgement/interstitial pulmonary edema. No focal consolidations to suggest infectious process noted. There is no pneumothorax. No sizeable pleural effusion is seen. was done. Radiology showed 1. PICC ends in low SVC. 2. New left basilar atelectasis. The patient was diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, LONG-TERM (CURRENT) USE OF INSULIN, HYPERLIPIDEMIA NEC/NOS. At the time of discharge, the patient had Primary Diagnosis: ___ site infection Secondary Diagnosis: Chronic Calcaneal Osteomyelitis 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>Primary Reason for Admission: Mr ___ is a ___ with h/o poorly controlled DM2 and right ankle osteomyelitis ___ fracture in ___, sternum osteomyelitis ___ CPR, currently on dapto/flagyl/cipro, who presents with right ankle pain, "redness around and drainage" from the PICC area, and +SIRS criteria. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female s/p trip and fall over a wire today. The patient reports she landed face down and pushed her life alert button for help. She was taken to ___ where imaging was consistent with a type 2 DENS fracture and a C1 posterior Arch fracture. She was transferred to ___ for further care and evaluation. Upon arrival Neurosurgery was consulted. The patient denied chest pain, SOB, diplopia, fevers or chills. Radiology showed No acute sequelae of trauma. Please refer to subsequent CT torso for further details. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Dental amalgam streak artifact limits study. 2. Left vertebral artery 7 mm segment inferolateral to the foramen magnum fails to opacify with IV contrast, which may reflect vascular injury. 3. Heavy atherosclerotic calcification at the right internal carotid origin causes 40% stenosis. 4. Acute type 2 dens fracture and C1 anterior arch fracture are better evaluated on prior C-spine CT. 5. Centrilobular emphysema and multiple nonspecific opacities, better evaluated on CT torso performed on same day. NOTIFICATION: The findings regarding possible vascular injury at left V3 were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:51 ___, 5 minutes after discovery of the findings. CT TORSO showed No acute sequelae of trauma in the torso. Incidental findings as described above. NOTIFICATION: No acute sequelae of trauma in the torso. KNEE (AP, LAT AND OBLIQUE) LEFT showed 1. No acute fracture or dislocation. 2. Moderate to severe tricompartmental degenerative change. 3. Chondrocalcinosis. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed 1. Minimally displaced type 2 dens fracture as well as C1 fractures are better visualized on prior CT examination. 2. There is no definitive evidence for ligamentous injury. 3. Prevertebral soft tissue swelling from the C1-C2 level to C6-C7 is identified. 4. No cord signal abnormality. No diffusion-weighted signal abnormality of the cord. 5. Multilevel degenerative changes as described above. The patient was diagnosed with Cervicalgia. At the time of discharge, the patient had Type II dens fracture. C1 anterior arch fractures. Left skull base 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. ___ was admitted to the neurosurgical service on ___ after suffering a trip and fall while at home. She was transferred from ___ with a Type II dens fracture. She underwent a CTA of the head which showed a possible V3 segment injury. The imaging was reviewed by Dr. ___ she was started on a full strength Aspirin daily. She was placed in a hard cervical collar to be worn at all times. On ___, the patient remained neurologically intact on examination. She underwent a MRI of the cervical spine which was negative for ligamentous injury. On ___, the patient remained neurologically stable on examination. Prophylactic subcutaneous Heparin was held as she was ambulatory per Dr. ___. She was re-evaluated by physical and occupational therapy and it was determined she would be discharged to a skilled nursing facility with a plan to follow-up with Drs. ___ of ___ Neurosurgery in 1-month. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a PMH notable for cavernous hemangiomas of brain, SDHs s/p TBI, aspiration pneumonias and recent hyponatremia presenting with cough and fevers from a rehab facility. The patient's wife noticed a new cough and warmth on the day of admission. The patient also experienced a single episode of emesis; reportedly of tube feeds. The wife requested he be evaluated by EMS. On EMS arrival the patient was found to have a temperature of ___. He was taken to ___ where an infectious workup was performed. Vitals on presentation to ___ were: T: 101.4 F Pulse: 133 RR: 30 BP: 142/90. Oxygen Saturation: 100%; 15L/min. Labs were significant for WBC 13.7 and lactate 1.5, chem 10 was within normal limits. Blood cultures were performed. The patient received vancomycin and Zosyn and was transferred to ___ for further care. Radiology showed Left lower lobe pneumonia, alternatively this may represent atlectasis. Likely small left pleural effusion. Radiology showed 1. Small left pleural effusion with compressive atelectasis. 2. Right mid and lower lung atelectasis. No focal consolidation. Radiology showed 1. Stable ventricular size and ventriculostomy catheter position. 2. Stable large bilateral mixed-density subdural collections. 3. Grossly stable appearance of numerous cavernous malformations, without evidence of new hemorrhage or edema. Radiology showed Atelectasis and consolidation of the right lung base. Persist left lower lobe atelectasis with concomitant small pleural effusion. Radiology showed Resolution of right middle lobe and left lower lobe pneumonia with improvement in right lower lobe atelectasis. The patient was diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, FEVER, 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>___ male with a past medical history notable for cavernous hemangiomas of brain, SDHs s/p TBI, and aspiration pneumonias presenting with cough and fevers from a rehab facility. #Sepsis: Attributed to aspiration pneumonia given the patient's cough, hypoxemia, history of aspiration and CXR/CT abnormalities. Blood cultures and urine cultures were negative. Patient improved with supplemental oxygen, aggressive suctioning and broad spectrum antibiotic coverage not requiring pressor support. Initially started on Vancomycin and Zosyn with eventual narrowing to Zosyn alone. Completed 8 day course of zosyn on ___. Last febrile on ___. On discharge, blood cultures from ___ were still pending. #Altered mental status: The patient's mental status is severely compromised at baseline secondary to prior strokes, SDH, and ICHs. Head CT on last admission ___ after ___ showed a small increase in chronic bilateral SDHs with mixed attenuation and new hemorrhage in the posterior horn of the left lateral ventricle. Prior to this admission he was speaking words and physically interactive with family. His presentation was most consistent with hypoactive delirium secondary to concurrent infection. His mental status gradually improved over the course of the hospital stay. At the time of discharge, he is more physically interactive with his wife and the medical team, though was not verbal, but when compared to the physical exam during the admission, this appears to be new baseline. #Hypoxemia, oxygen requirement: On admission, was requiring 10L supplemental oxygen. Oxygen requirement improved throughout admission with treatment of PNA, chest ___, aspiration precautions, and frequent nasotracheal and orotracheal suctioning. Saturating well on room air, with occasional ___ requirement likely due to infiltrate from resolving PNA, micro-aspirations, atelectasis, and small left pleural effusion. Occasional micro-aspirations due to chronic neurological impairment causing inability to protect airway, causing occasional short periods of tachypnea, however resolved quickly with deep suctioning and decreased in frequency with regular oral suctioning. On day of discharge, patient was on room air using shovel mask overnight with humidifed oxygen. Unfortunately, patient will continue to have micro-aspiration events. #Hematuria: Developed hematuria on day of discharge. UA with no e/o infection. Hematuria likely due to foley trauma. #Tachycardia: Heart rate up to 120s during admission, likely due to infection and hypovolemia. HRs returned to his baseline 95-105 on discharge with treatment of his infection and volume repletion with tube feeds and free water flushes through his PEG. #Seizure disorder: Last known seizure ___. He is currently on lamotrigine and phenytoin. Dosages recently changed at rehab; change does not appear to have been approved by outpatient neurologist (Dr. ___. Returned patient to home doses of phenytoin and lamictal, however remained subtherapeutic (phenytoin level 6.6 on ___. Per outpatient neurologist, on ___, patient given 500mg phenytoin x1 and increased dose to 200mg QAM and 250mg QPM. Patient will follow-up with outpatient neurology. Throughout admission, patient had slight muscle twitches at rest, no overt seizure activity, and no evidence of non-convulsive seizure activity on EEG during this admission. #Cavernous hemangiomas of brain/SDH/ICH: Most recent bleed after fall in ___. No signs of bleed at present, and no evidence of bleed on head CT ___. Held all ASA, NSAIDS and anticoagulation (including DVT PPX) during hospitalization. #Hyponatremia: Patient has a history of hyponatremia. Per wife, the patient has been having weekly sodium checks. Plan to resume weekly sodium checks and send results to rehab MD for review. TRANSITIONAL ISSUES # Code: ___ -___ rehab draw phenytoin level prior to AM dose on ___ and fax results to Dr. ___ (fax ___ -Follow up appointment with outpatient neurologist (Dr. ___ ___ for management of partial complex epilepsy and AED dosage titration. -Follow up final results of ___ blood cultures -Voiding trial and discontinuation of Foley catheter. Montoring urine output for continued hematuria. -Chest ___, oral suction TID. -Weekly serum sodium checks, please send reports to rehab MD. -___ up imaging findings with PCP: 1. Expansile lucent lesion in T7 with mild wedge compression fracture, possibly complicated vertebral hemangioma. MRI may be considered for further assessment, if not already done. 2. Incompletely imaged suspected pathologically enlarged left axillary lymph node.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ h/o CKD III (Cr baseline 1.8), DM (on insulin), paroxysmal atrial fibrillation, HLD (not on statin ___ rhabdo), and stable AAA presents to the ER for fatigue, low back pain and subjective leg weakness. He initially presented to ___ with with subjective leg weakness for 2 days w/out numbness or tingling. Patient denies any chest pain, cough, abdominal pain, black or bloody stools. CT was negative for abdominal/renal or lumbar process but did show 10x6.2x5.7cm AAA and RML PNA. Temperature at ___ was 100.6F and creatinine elevated to 2.4. Patient was transferred to ___ for vascular consult and possible neuro consult for c/o BLE weakness, fatigue, low back pain, and difficulty w/ ambulation and standing. His daughter notes confusion. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. Moderate to severe spinal canal stenosis at the L3-4 level. 2. Multilevel significant neural foraminal narrowing as described above. 3. Mild degenerative change of the thoracic spine. 4. Normal cord. 5. Abdominal aortic aneurysm, measuring approximately 5.3 cm. 6. Right basilar consolidation is only partially seen. Recommend chest PA and lateral to evaluate extent of pleural plaques, right lung consolidation, and exclude small likelihood of small pneumothorax. RECOMMENDATION(S): Chest PA and lateral. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:03 am, 10 minutes after discovery of the findings. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. Mucosal thickening as described above. CT torso with contrast. showed 1. Compared to the prior CT, the infrarenal abdominal aortic aneurysm is unchanged in size, and measures approximately 6.4 cm x 5.3 cm x 9.8 cm (AP x TR x CC). No evidence of rupture or dissection. Please note that preoperative measurements of the aneurysm are pending 3-D reconstructions. 2. Unchanged left internal iliac artery aneurysm, measuring approximately 3 cm x 2.4 cm. 3. A consolidation of the right middle lobe is compatible with pneumonia. 4. Small right pleural effusion. 5. Bilateral pleural calcifications, suggestive of prior asbestos exposure. 6. Adenoma of the left adrenal gland. 7. Right renal cyst. 8. Sigmoid diverticulosis, without evidence of diverticulitis. 9. Small hiatal hernia. 10. Coronary artery atherosclerosis. RECOMMENDATION(S): The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 5:03 pm, 10 minutes after discovery of the findings. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Primary: Abdominal aortic aneurysm Lumbar stenosis Community acquired pneumonia Hyponatremia Toxic metabolic encephalopathy Urinary retention. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH CKD III (Cr baseline 1.8), DM (on insulin), paroxysmal atrial fibrillation, HLD (not on statin ___ rhabdo), stable AAA last checked ___ presents to the ER for fatigue, low back pain and subjective leg weakness, found to have stable but 5.7cm AAA, spinal stenosis causing weakness, treated for community-acquired pneumonia. #Leg weakness: #Lumbar stenosis: Patient with transient leg weakness on admission. Neurosurgery and neurology consulted. MRI showed "spinal canal stenosis at the L3-4 level" and "Multilevel significant neural foraminal narrowing" and there was no indication for urgent surgical intervention as not consistent with cord compression. His exam showed ___ strength except for 4+ plantar/dorsiflexion suggestive of lower motor neuron deficit consistent with imaging level. His weakness resolved. He worked with physical therapy and was discharged with neurosurgery follow up. #AAA: Prior to transfer, imaging showed possible expansion of known AAA. 4.6 cm ___ -> 4.8 cm ___ -> 5cm ___ Was to have outpatient vascular work up. Surgery was advised for >5.5 cm or increase of >0.5 cm in 6 months. On CT non-con at OSH was 5.7. Although different modalities (ultrasound, CT) there was concern for acute change in size and he was transferred to ___ for vascular surgery evaluation, who recommended CTA for assessment and surgical planning. Underwent CTA, vascular surgery evaluation and will follow-up with vascular surgery at scheduled clinic appointment. #Toxic metabolic encephalopathy: #MCI: Concern for TME vs. TIA/stroke on initial presentation due to confusion. NCHCT without acute findings. Neurological exam largely non-specific but did show some frontal (changes in behavior) and cerebellar (tremor.) Delirium resolved morning after admission, most likely due to metabolic(hyponatremia to 129), infectious causes(untreated pneumonia,) urinary retention, with aspect of sundowning. TSH, B12, folate within normal limits. Further work up of possible mild cognitive impairment deferred to outpatient. #Urinary retention: #Likely BPH: Patient with post void residuals 700-1000ml. No cord compression, suspected element of overflow incontinence. He was straight catherized in hospital but indwelling was placed as it was felt patient could not reliably straight cath at home. Tamsulosin started, uptitrate as tolerated as outpatient. Please discontinue foley and perform voiding trial in 1 week at rehab. If fails would recommend intermittent straight cath and arrange urology evaluation. #Pneumonia, bacterial: Patient with RML pneumonia on OSH CT scan. Patient asymptomatic, but did have fever to 103 at OSH. Completed 5 day course for CAP: azithromycin (___) and ___ #Hyponatremia: Patient's baseline Na is 135 from prior ___ records. Admitted with Na 129 on ___. Improved to 135 with out specific intervention.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ with a history of HIV (on HAART, no detectable viral load), chronic low back pain (on opiates), depression, anxiety, and hypertension, recent admit in ___ for DVT/PNA p/w AMS. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process. Chest radiograph showed Bibasilar opacities are concerning for multifocal pneumonia, possibly lower lobes. Radiology showed 1. Diffuse ascites and edema throughout the abdomen and pelvis. This results in poor contrast of the abdominopelvic structures on this unenhanced exam, limiting evaluation for a cute pathology. 2. Diffusely increased attenuation of the liver, new since ___, may be secondary to iron overload or medication. 3. Within the limitations of the study, no other evidence of acute abnormality is identified. CT CHEST W/O CONTRAST showed 1. Tiny nodular and ground-glass opacities noted within the right middle lobe, lingula and left lower lobe are consistent with an infectious process. Typical and atypical etiologies in an immunocompromised patient should be considered. 2. Small simple bilateral pleural effusions. 3. Hypodense blood pool within the heart is suggestive of anemia. 4. Enlargement of the main pulmonary artery is suggestive of pulmonary arterial hypertension. The patient was diagnosed with Pneumonia, unspecified organism, Disorientation, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS Hospital Acquired Pneumonia Toxic Metabolic Encephalopathy Chronic Back Pain Atrial fibrillation Transaminitis Hypertension Type II Non- ST Elevation MI SECONDARY DIAGNOSIS Deep Vein Thrombosis Malnutrition Depression/Anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with a history of HIV (on ART, no detectable viral load ___, chronic low back pain (on opiates) recently admitted for DVT/PNA (___) who presented with AMS likely ___ toxic metabolic encephalopathy iso infection and sepsis attributed to PNA. Pt was initially transferred to the ICU iso severe agitation requiring precede but agitation has resolved and pt was transferred back to the floor. Pt received IV antibiotics for presumed PNA and encephalopathy improved. # Encephalopathy. Pt initially p/w toxic metabolic encephalopathy iso sepsis from PNA described below. Delirium was notable for severe agitation requiring MICU admission for precede administration. Delirium improved significantly with IV antibiotics and upon readmission to the floor pt was AOx3 and generally calm. At time of discharge pt demonstrated persistent confusion/inattention (AOx3 but unable to state president ___ backwards). Pt likely has persistent delirium. He possibly pt has underlying dementia or less likely is persistently altered ___ underlying psychiatric conditions. Pt received Depakote 500 mg BID while inpatient and was re-started on zyprexa 5 mg upon discharge given QTC ___ of 397. Per psychiatry evaluate, home fetzima should be restarted as an outpatient. Psychiatry advised that benzos should be avoided. They suggested starting ramelteon to regulate sleep/wake cycle. # Pneumonia: Pt p/w AMS, leukocytosis and sepsis with CT Chest c/f PNA. Pt was treated for 8D course of HAP with vanc/cefepime, transitioned to zosyn/azithromycin. Pt will require repeat CT chest in ___ weeks. # Chronic pain. Hx of chronic back pain on Percocet (5 mg-325 mg) TID, MS contin 100 mg BID and gabapentin 800 mg QID:PRN. Home pain medications were initially held iso AMS and then restarted gradually. Pt was discharged on home regimen with exception of gabapentin, discharge dose 300 mg TID. # Afib: Noted to have Afib on ___ with RVR up to 170s-180s which resolved with IV metoprolol 5 mg x1. No prior history of afib, however CHADS Vasc of ___oes not require long term anticoagulation for atrial fibrillation. Pt was continued on metoprolol for history of NSVT/HTN and anticoagulation for DVT, described below. # Weight loss: 30 lb documented weight loss in our records. Unprovoked DVT last year, cachectic on exam. Concerning for underlying malignancy. Outpatient providers should discuss with patient/HCP cancer screening. RESOLVED/CHRONIC # Transaminitis: (resolved). Elevated transaminases noted on admission likely ___ sepsis, ascites/edema of abdomen and increased attenuation of the liver noted on CT abd ___. Transaminitis resolved during admission. # Type II NSTEMI: Pt w/new TWI on EKG on admission. Had NSTEMI II w/trop elevation on last admission. Trops slightly elevated at 0.06, stable upon recheck. Likely demand ischemia in setting of sepsis. # CAD: Continue ASA 81 mg, atorvastatin 80 mg QPM # Deep vein thrombosis: Of note, during admission ___ pt was found to have presumed unprovoked bilateral DVTs (non-occlusive in R common femoral extending to the popliteal, L superficial femoral). Per PCP, ___ for 6 month AC with warfarin (ending ___ per anticoagulation tab note, however 6 months from initiation would be ___, however pt has been sub-therapeutic on admission and in outpatient clinic for approximately 50% of course. Pt was discharged to rehab on Enoxaparin 60 mg SC Q12H as it was difficult to achieve therapeutic INR and titration will be affected by restarting ART. # HIV: Diagnosed ___, VL ___ undetectable. Previously on combivir and nevirapine. Stopped taking medications for one month prior to admission. Low c/f ___ given CD4 330s. HIV VL 3.1 (log10 value). ART will be restarted in outpatient ___ clinic, once it can be confirmed that pt will reliably take home medications. # Malnutrition: Albumin 2.8 on admit. Per family, pt has difficulty feeding himself at home. Pt received daily MVA and ensure TID with meals. # HTN: SBPs elevated up to 170s during admission. Pt was restarted on home metoprolol succinate 100 mg PO QD and home lisinopril 5 mg PO QD which was up-titrated to 10 mg QD during admission. SBP 100-110s on discharge so pt was discharged on 5 mg lisinopril. # Depression/Anxiety. Psychiatry recommended that pt restart home fetzima as an outpatient. They also recommended Depakote as discussed above. # Thyroid Nodule. H/o thyroid nodule status post hemithyroidectomy in ___ with benign pathology. TSH mildly elevated at 4.3 however Free T4 1.1 wnl. TRANSITIONAL ISSUES [] Restart home fetzima [] Consider utility of ramelteon, started to regulate sleep/wake cycle [] Repeat CT in ___ weeks after discharge [] Discharged on lovenox 60 mg SC BID. End date ___ per anticoagulation tab in OMR (Of note 6 months from initiation would be ___. Decision about whether to restart warfarin should be considered at time of discharge from rehab as pt may complete planned course of AC at rehab [] Titrate back gabapentin (home 800 mg QID:PRN) [] F/u with outpatient HIV provider ___: restarting ART. Pt will need appointment set up in infectious disease clinic at ___. [] Continue ensure TID as pt p/w malnutrition [] Monitor QTC as zyprexa was restarted on discharge (QTC 397 on ___ # CODE: full # CONTACT: Brother: ___. ___ Niece: ___ ___ (HCP)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old man with a history of hypertension who presents with a sense of abnormal chewing motions as well as a tongue which does not protrude all the way to the left. CTA HEAD AND CTA NECK showed 1. No evidence of acute intracranial hemorrhage. 2. No evidence of hemodynamically significant stenosis or evidence of pathologic large vessel occlusion within the vasculature of the head or neck 3. Enlarged cervical and prominent upper mediastinal lymph nodes of uncertain significance. 4. Paranasal sinus disease. CHEST (PA AND LAT) showed No acute intrathoracic process. MR HEAD W/O CONTRAST showed 1. No evidence of acute intracranial hemorrhage or acute ischemia. The patient was diagnosed with OTHER SPEECH DISTURBANCE. At the time of discharge, the patient had Right hypoglossal nerve palsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old man with a past medical history including hypertension who presented to the ___ ED ___ with tongue weakness. CT/CTA conducted in the ED did not demonstrate any acute intracranial hemorrhage or hemodynamically significant stenosis or large vessel occlusion. Mr. ___ was admitted to the stroke neurology service for further management. # NEUROLOOGY Symptoms persisted while in the hospital. Mr. ___ was admitted to the stroke service as there was concern for stroke. He was initially placed on telemetry, fall precautions and aspiration precautions. He had a bedside swallow assessment prior to eating. Fortunately, his head MRI was negative for any acute ischemia or intracranial hemorrhage. Following this result, multiple labs were checked to assess for the etiology of his peripheral cranial nerve XII palsy. Labs were negative or pending at time of discharge. There was not a clear etiology to his cranial nerve XII palsy. Mr. ___ will follow-up with his primary care doctor at his previously scheduled appointment. # CARDIOVASCULAR As there was initial concern for stroke, a fasting lipid panel was checked. This showed elevated triglycerides to 383 and elevated total cholesterol to 230. Mr. ___ should follow-up with his primary care doctor regarding these findings. # GLOBAL Mr. ___ was placed on heparin SQ for DVT prophylaxis while in the hospital. ============================== TRANSITIONS OF CARE ============================== - Mr. ___ was diagnosed with a CN XII (hypoglossal) nerve palsy during hospital stay. MRI and CTA head and neck did not show any abnormalities. Etiology of this nerve palsy was unclear at time of discharge. Mr. ___ declined a lumbar puncture. Please follow-up the pending labs at time of discharge to further clarify the etiology of this nerve palsy. - Mr. ___ was also found to have elevated total cholesterol to 230 and triglycerides to 383 on fasting lipid panel. He may need additional medications as an outpatient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M w/ hx of ESRD (dialysis MWF) HTN, DM, recent vascular surgery revision of LUE bracheocephalic fistula on ___ who presented from ___ after complications with hemodialysis. During the second canulation attempt he noted severe pain going down to the left thumb. He said that they were then unable to proceed because that dialysis line became filled with clot and they "sucked out a large clot". At that point, he was sent to ___. He last had dialysis on ___ was uneventful despite the newly revised fistula. He denies any other complaints, no CP, no SOB, no abd pain, no N/v, no bleeding from other sites. Initial VS in the ED: 97.8 66 142/69 18 98%. Labs notable for K 4.9 and elevated creatinine and phos (ESRD). Transplant surgery was consulted in the ED but they did not feel there was an indication for surgery at that time.Patient was given percocet for pain. Radiology showed Limited study demonstrates patent AV fistula with overlying edema. Further characterization may be obtained via a dedicated vascular study. The patient was diagnosed with END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT. The patient was treated with Hemodialysis. At the time of discharge, the patient had Complications from fistula. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with ESRD who presented from hemodialysis center after an unsuccessful attempt to use AVF.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of HTN, PE (Xarelto), Borderline resectable pancreatic cancer (s/p ___ neoadjuvant cycles FOLFOX), presented with ___ c/b biliary obstruction CT ABD AND PELVIS WITH CONTRAST ___ showed 1. Findings suggest cystitis. 2. Short-term worsening of biliary dilatation consistent with worsening distal obstruction associated with suspected neoplastic disease in the pancreatic head. PELVIS, NON-OBSTETRIC showed 1. Status post hysterectomy. Bilateral ovaries not visualized. 2. No focal fluid collections identified. Previously seen subcentimeter fluid collection in the area of the vaginal cuff is not visualized by ultrasound due to small size, better assessed on prior CTA from ___ and CT abdomen/pelvis from ___. Retrospectively, findings could represent a colovaginal sinus tract, either sequelae of prior surgery or inflammation if there has been a history sigmoid diverticulitis. 3. Small amount of free fluid in the cul-de-sac. The patient was diagnosed with Nonspec elev of levels of transamns & lactic acid dehydrgnse. The patient was treated with Endoscopic retrograde cholangiopancreatography ___ with stent placement. At the time of discharge, the patient had Primary: Biliary obstruction s/p ERCP UTI Pancreatic cancer Secondary: PE Vaginal bleeding. The patient was given written instructions concerning 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 PMH of HTN, PE, Borderline resectable pancreatic cancer (s/p ___ neoadjuvant cycles FOLFOX), who presented with ___ c/b biliary obstruction. She underwent a CT scan which showed biliary duct dilitation ___ obstruction near pancreatic head. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F 5 months post partum presents with 5 month history of whooshing sound in L ear. She states that the sound began as intermittent and has progressively become louder and more constant in nature. She only hears the sound in the left ear. Lately, it has been accompanied with bilateral temporal headaches that are not relieved with tylenol. She was seen by ___ for evaluation of sound and was ordered for an outpatient MRI/A, but told to call if symptoms worsened. Patient reported that last night she began to feel lightheaded and the headaches represented. The whooshing sound also became more apparent and she felt palpitations in her chest. Concerned, she called the ___ office who told her that she should come to the ED to have an urgent MRI/A scan done. Radiology showed ___ underwent cerebral angiography which revealed dural AV fistula involving the left transverse sigmoid junction. This is primarily fed by branches of the left external carotid artery and the tentorial branch of the left internal carotid artery. The patient tolerated the procedure well. There were no complications. Radiology showed 1. Early asymmetric filling of the left transverse and sigmoid sinuses and early filling of the left internal jugular vein with asymmetric prominence of the left sub occipital venous access and asymmetric enlargement of the left external carotid artery branches suggests a left dural arteriovenous fistula. 2. No evidence of dural venous sinus thrombosis, infarct, hemorrhage, or aneurysm. No acute intracranial abnormality. A wet read with these findings was placed by Dr. ___ discussed with Dr. ___ at ___ on ___. The patient was diagnosed with HEADACHE, ACQ ARTERIOVEN FISTULA. The patient was treated with Angiogram ___. At the time of discharge, the patient had L dural AV fistula. The patient was given written instructions concerning 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 whooshing sound in L ear since delivering her baby, MRI/A shows concern for L dural AVF. Patient was admitted to neurosurgery for a diagnostic angiogram. Patient was neuro intact on examination. On ___, patient was taken to angiogram with no intraoperative complications. She was diagnosed with a L dural AV fistula. Once angiogram was completed, patient was transferred to the floor with flat bedrest for 2 hours. Patient reported blurried vision for approximately 2 minutes which resolved on it's own. Post angio exam was stable and no further episodes of changes in vision. On ___, patient was discharged home with directions to pump her breast milk and discard it for 48 hours. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ T2DM, Asthma, HTN and a history of multiple perirectal abscesses & fistulas requiring multiple operative drainages, fistulotomies, ___ placements & LIFT procedure, recent ED visit for abscess, p/w abscess MRI of the Pelvis showed Compared to the prior pelvic MRI from ___, Setons have been removed from all the fistulous tracts which look stable. However the branch that courses posteriorly through the left gluteal fold (branch 3) is more prominent and now filled with fluid. The patient was diagnosed with Rectal abscess, Other specified diseases of anus and rectum. At the time of discharge, the patient had ___ abscess Multiple complex fistulas. The patient was given written instructions concerning 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 ___ ED at ___ on ___ with ___ anal pain. He was admitted and observed. His pain was controlled, and the abscess/fistula output was observed. He had an MRI (see separate report) and no further intervention was needed Neuro: Pain was well controlled on Tylenol and Dilaudid for breakthrough pain. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. GI: The patient was initially kept NPO in case he'd need to be taken to the OR, but was then advanced to a regular diet. Patient's intake and output were closely monitored. GU: The patient was voiding without difficulty. Urine output was monitored as indicated. ID: The patient was closely monitored for signs and symptoms of infection and fever, of which there was none. Heme: The patient received enoxaparin and ___ dyne boots during this stay. He was encouraged to get up and ambulate as early as possible. On ___, the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, voiding, and ambulating independently, the pain was controlled. He will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Trauma: MVC: Radiology showed 1. Multiple left-sided segmental rib fractures with small amount of subcutaneous emphysema in the left chest wall and small left pleural effusion. 2. Bibasilar atelectasis. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process. 2. Metallic foreign bodies projecting over right frontal bone may be due to prior surgery but correlation with surgical history is recommended. 3. 2 right frontoparietal burr holes are seen. Please correlate with surgical history. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute fracture or traumatic malalignment. 2. Small left pneumothorax and left chest and neck subcutaneous emphysema. CT CHEST/ABD/PELVIS W/ CONTRAST showed 1. Small left hemopneumothorax without evidence of tension. 2. Grade 2 splenic injury with laceration, subcapsular hematoma, and small volume hemoperitoneum overlying the liver and spleen. No active contrast extravasation. 3. Mild left hydronephrosis and hydroureter with diffuse urothelial thickening and hyper enhancement which may relate to inflammatory or infectious etiologies. Clinical correlation with urinalysis is recommended. 4. Flail chest with segmental fractures of left ribs 5 through 10. Additional fractures involving the left third and fourth ribs. Associated left chest wall subcutaneous emphysema. 5. Renal cysts are seen bilaterally, several of which are complex, findings which can be further assessed with renal ultrasound when the patient is stable. 6. Suprapubic catheter in place with mild bladder wall thickening. RECOMMENDATION(S): 1. Renal cysts can be further assessed on ultrasound when the patient's condition stabilizes. 2. Left-sided urothelial thickening and hyper enhancement for which correlation with urinalysis is recommended. Radiology showed 4 mm radiopaque foreign body medial to the midshaft of the left humerus. No acute fracture or dislocation otherwise identified. Radiology showed Slightly limited assessment of the ring finger. Otherwise, no acute fracture or dislocation. CHEST (PORTABLE AP) showed Multiple left-sided posterior lateral displaced rib fractures at least involving the left fifth through eighth ribs are again seen. There are streaky linear opacities at both bases likely reflecting atelectasis. In addition, there is a layering left effusion. Overall cardiac and mediastinal contours are stable. No pulmonary edema. No obvious pneumothorax. Left humeral series showed No evidence of displaced fracture or dislocation of the left humerus. No radiopaque foreign bodies. The patient was diagnosed with SPLEEN PARENCHYMA LACER, FX MULT RIBS NOS-CLOSED, MV COLLISION NOS-DRIVER. At the time of discharge, the patient had Trauma: MVC Left ___ rib fx grade II splenic laceration subcapsular splenic hematoma small left hemo-pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the hospital after he was involved in a motor vehicle accident. Upon admission, he was made NPO, given intravenous fluids, and and underwent imaging. He sustained left sided fractured ribs ___, a splenic laceration, and a small left hemo-pneumothorax. He was admitted to the intensive care unit for pulmonary toilet and pain managment. Because of his multiple fractured ribs, the Pain service was consulted and the patient underwent placement of an epidural catheter. He was monitored in the intensive care unit for 24 hours where he remained stable. He was transferred to the surgical floor on HD #3. The patient's vital signs remained stable. The epidural catheter was removed and the patient was started on oral analgesia. His pulmonary status remained stable and he maintained adequate saturation. He was passing clear urine out of his supra-pubic tube. His hematocrit remained stable at 36 with a normal white blood cell count. Prior to discharge, he was evaluated by Physical therapy and recommendations were made for discharge to a rehabilation center where the patient could regain his strength and mobility. The patient was discharged on HD # 6 in stable condition. An appointment to follow-up in the acute care clinic will be arranged at a later date by the clinic. ******review u/a results at follow-up </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with chronic back pain (on narctoics and monthly injections), duodenitis (EGD ___ with erythematous duodenopathy with negaiv biopsies), presenting acute on chronic abdominal pain. Pt states he was at a friends house last night after consuming "a few shots", the pain got worse and he called EMS. He said this was pain was his typical. The patient has been seen at several hospitals recently. He also notes several months of intermittent episodes of diffuse abdominal pain, nausea, vomiting and diarrhea. He vomitted 15 times last night and noted specks of blood in his emesis afterwards. He denied chest pain, SOB. . In the ED, initial vs were: Denies passing gas or having bowel movements. Says he is vomiting, but only has spit up in the bag beside him. Drank 2 shots today, did not take percocet. Has not used marijuana in ___ days per his report. . 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. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Radiology showed No evidence of acute intra-abdominal process. No change since ___. The patient was diagnosed with ABDOMINAL PAIN GENERALIZED. At the time of discharge, the patient had Primary Diagnosis - Hematemsis - Chronic RUQ 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 chronic abdominal pain, admitted with hematemesis in the setting of abdominal pain and vomiting. . ACTIVE ISSUES # Mild Hematemesis secondary to ___: Specks of blood in vomiting x15. DDx include ___, less likely large acute GIB secondary to borhaves, dulefoys, AVMs, mass. The pt was treated supportively with IV PPI, 2 large bore PIVs, but there were no further episodes in house. - NPO . # Chronic Abdominal Pain: Unclear etiology. Has been evaluated at ___ on multiple occasions. Case discussed with PCP today and confirms history. Working diagnosis for now is gastris and duodenitis. Gastropersis is possible although not typically associated with abdominal pain. Biliary colic in differential. No evidence for pancreatitis, peritonitis, mesenteric ischemia, SBO, LBO, appendicitis, cholecystitis, diverticulitis, peptic ulcer disesae, colitis, hypercalcemia, AAA, adrenal insufficiency, toxins (lead, iron), vasculitis (per PCP ___ WNL), FMF (no fevers), constipation, UTI. No evidence for mass or abdominal lymphaenopathy. The patients diet was advanced, he was treated with GI cocktail and PPI as well as low dose narcotics for chronic pain, and was discharged the next day. . CHRONIC ISSUES # Back Pain: Chronic in nature. Hold meds. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with recently diagnosed metastatic rectal cancer as well as comorbid SVT who was discharged yesterday following a ablation for SVT. He recently completed XRT and ___ short course to reduce his rectal mass and palliate his pain and partial obstuction. He presents today to the ED with worsening lower abdominal pain. He was discharged yesterday from the Cardiac service where he was treated for SVT. In the ED his initial vital signs were 97.4 69 191/161 20 96%. He spiked a fever to 101.6. WBC was 5.4. UA showed evidence of UTI. Of note, he has an indwelling foley ___ for urinary retention believed to be related to his cancer. He was given a dose of Ceftriaxone in the ED along with 5mg IV Morphine for pain. Bld Cx X2, UCx were sent and are pending. Patient reports that he has had worsening lower abdominal, suprapubic pain since ___. He continues to have lumbar back pain, but this is unchanged in quality and unclear if it is worsened. He has had several small bowel movements today, but had only one large bowel movement in the ED which he was unable to control. No N/V. No sweats, rigors. No HA, no URI sx, no cough, no rash. His major complaint is ___ pain when seen. CHEST (PORTABLE AP) showed Left-sided Port-A-Cath is unchanged in position. Lungs are without evidence of focal airspace consolidation to suggest pneumonia. No pneumothorax or pulmonary edema. No pleural effusions. 3mm nodular opacity in the left peripheral lower lung corresponds to a calcified nodule on recent chest CT ___ and therefore is consistent with a granuloma. Stable cardiac and mediastinal contours. The patient was diagnosed with DIARRHEA, URIN TRACT INFECTION NOS. The patient was treated with Foley replaced. At the time of discharge, the patient had Urinary Tract Infection Non-infectious diarrhea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with rectal cancer stage IV and SVT admitted with fevers, worsening lower abdominal pain and evidence of a urinary tract infection. Active Issue # Urinary tract infection: patient complained of abdominal pain and fevers on admission. He was found to have mixed flora on urine culture. He was started on ceftriaxone and his foley was changed. He was converted to PO bactrim and continued to be afebrile during the course of his stay. Patient previously declined offer of suprapubic catheter. # Stage IV Rectal adenocarcinoma: patient recently completed ___ and radiation treatment. His port was accessed and found to have clotted. 24hr alteplase was placed and was flushed successfuly therafter. Port documents were solicited from the hospital in PR in which it was placed, but were unsuccessful at the time of discharge. Chronic Issues # AVNRT s/p ablation: patient was recently ablated for multipleo episodes of AVNRT despite beta blockade. Patient was initiated thereafter on sotalol and continued on 80mg sotalol BID while admitted Transitional Issues - Please obtain records regarding port placed in ___ - Please follow up on blood cultures, pending at time of discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ CLL, stage 3 lung cancer, prior breast cancer, in USOH until 2 weeks ago when she developed increasing anasarca and fatigue. Got blood tranfusion for pancytopenia after bendamustine. Lasix 20mg X 5 days but still not having great uop. Took home BP today 86/50, so asked to come in to ED. ROS -ve for infectious symptoms. Last BM earlier today. CXR, UA, lactate, trop wnl. Cr stable. BNP elevated (3458), EKG showed SR, NANI, anterior TWI, V3-4 new and PVCs. ANC 508. Bedside echo wnl. Getting unit of blood since concern for possible demand. BP 95-110 in the ED. Admitted for further workup. CHEST (PA AND LAT) showed As above. No evidence of pneumonia. CHEST PORT. LINE PLACEMENT showed Tip of the new left PIC line is at the superior cavoatrial junction. ___ be a new small left perihilar nodule. Right lower lobe nodular opacity present in ___ is either smaller or obscured by the right hilus. . Heart size normal. No pleural abnormality. ABDOMEN US (COMPLETE STUDY) showed Extensive adenopathy. No focal lesion in the liver. No abnormality in relation to the portal or hepatic veins. No ascites. Small echogenic focus in the spleen most consistent with a hemangioma. Bilateral renal cysts, 1 at the upper pole of the right kidney measures 4.2 x 3.6 cm in size as seen on previous CT scan. BILAT LOWER EXT VEINS showed DVT involving the right peroneal vein only. No thrombus in the left lower extremity deep veins. Bilateral inguinal adenopathy. CHEST (PORTABLE AP) showed As compared to ___ chest radiograph, cardiomediastinal contours are stable with known multifocal lymphadenopathy as characterized on recent CT of ___. A subtle diffuse interstitial pattern is new compared the prior study, and could reflect interstitial edema or an atypical pneumonia in the setting of neutropenic fever. CT may be considered for more complete characterization if warranted clinically. Radiology showed Successful placement of a left 50 cm basilic approach single lumen PowerPICC with tip in the distal SVC. The line is ready to use. The patient was diagnosed with HYPOTENSION NOS, NEUTROPENIA, UNSPECIFIED , OTHER ISCHEMIC HEART DISEASE, ABNORM ELECTROCARDIOGRAM. The patient was treated with ___ placement ___ ___ #2 placement ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS: 1. Breast Cancer: pT1bN0Mx ER+/PR+/Her 2 neg, LVI (-) 2. CLL/SLL (unfavorable cytogenetics) 3. NSCLC, adenocarcinoma (T1aN2Mx, at least stage IIIa) NEW DIAGNOSIS: 1. MRSA Central Line Associated Blood Stream Infection 2. Chronic Lower Extremity Edema 3. Distal 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>___ w/ CLL/SLL (unfavorable cytogenetics), breast cancer in remission, and recent diagnosis of NSCLC IIIa admitted w/ improving rash but worsening anasarca after outpt blood transfusion, which has improved but now w/ MRSA bacteremia. # Anasarca/lower extremity edema - Pt reports chronic ___ for almost ___ but admitted w/ worsening ___ with blood transfusion. Etiology most likely seems related to volume overload. Weight stable at 151.3 lb. She did not require Lasix during the last week of her hospitalization. She notes that her ___ is chronic and despite many interventions, never has ever fully resolved. # CLASBI Developed F ___ and growing GPCs in ___ bottles on ___. PICC was originally placed ___ was removed ___. TTE and TEE neg for endocarditis. She was seen by ID team. Vancomycin was started ___. She needs total of 2 weeks of abx since ___ negative culture through ___. ALl cultures subsequent to initiation of vancomycin were negative. Vanco trough was persistently slightly high just above 20 so dose decreased to 750mg day of discharge. Repeat trough should be checked on am ___. # Anemia/Pancytopenia She has hypoproliferative anemia, no evidence of hemolysis or bleeding. Last transfusion ___ then again ___, Likely ___ CLL compounded by cytotoxic effect of prior bendamustine. While DAT is positive, LDH/haptoglobin/smear not suggestive of hemolysis. Low retic count supports anemia of underprodcution likely ___ CLL and chemotherapy. # Distal DVT Found in R peroneal vein, a distal vein. Given high risk of propagation in context of host, outpatient team decided to proceed with anticoagulation. Risks and benefits discussed. Due to pancytopenia, it was felt that BID Lovenox would be best medication for her. - cont Lovenox BID. Plt have been stable # Lung Ca: Currently not chemo-rads candidate given pancytopenia, per Dr. ___ would have severe bone marrow suppressive effect and radiation alone not likely to alter quality of life and would have severe toxicities. Pt herself shying away from wishing to pursue any aggressive options as well. # CLL She has profound cytopenia limiting therapy per oncologist Pt's sister in law and brother discussed raising the idea of hospice and feel like this would be in line with the patient's goals. Pt is in agreement though would still like treatment for infections, etc, not fully CMO. She will need to f/u with her primary oncology team. # Hypertension/Hypotension BP stable, low to normal range. Here ACEI and CCB were d/ced. Since ___, outpatient SBPs have been ___. Prior to that SBPs in 140s-160s range. Likely due to vascular insufficiency. Cortisol stimulation test did not suggest adrenal insufficiency. # Constipation Chronic and per her report, due to our food. +flatus - cont senna/colace/duloclax/MOM # ___: Improving. Does not require neutropenic precautions # Breast Cancer: continue anastrozole # Depression: sw consult given passive SI as outpt but she denied this inpatient # Seizure disorder: continue valproic acid, keppra, lamictal # Rash: per derm, most likely ___ blood transfusion. Almost completely resolved. We continued her home claritin # COPD: stable, continue home inhalers</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with severe anxiety, cancer of the R breast s/p lumpectomy x 2 in ___ and in ___ with local recurrence in ___ for which she was recommended to undergo mastectomy but has not done. Pt with pain in the L hip and see in orthopedics in ___ with lytic lesions in the L acetabulum for which bone biopsy was recommended but pt did not follow up. DX PELVIS AND FEMUR showed Innumerable new lytic lesions throughout the pelvis particularly pronounced around the left acetabulum and right femoral head/neck concerning for progression of known metastatic breast cancer. The lesion in the right femoral neck is at high risk for pathologic fracture. No definite fracture seen. CT abdomen and pelvis showed 1. New numerous hepatic and widespread osseus metastatic disease compared to ___. Of note, left iliac and L5 vertebral body lesions have associated soft tissue component and right femoral neck lesion has an associated acute pathologic fracture. NOTIFICATION: The findings and impression were discussed via telephone by ___ with Dr. ___ on ___ at 5:12 pm, 5 minutes after discovery of the findings. CT CHEST W/CONTRAST showed 3.2 x 4 cm infiltrative mass in the right breast multiple small right subpectoral and right axillary lymph nodes. Extensive lytic and sclerotic osseous metastasis. Hepatic metastasis. Please refer to dedicated report on abdomen which has been dictated separately. CT HEAD W/ AND W/O CONTRAST Q1212 CT HEAD showed 1. No findings to suggest intracranial metastatic disease within confines of contrast enhanced CT examination. No acute large territory infarct or intracranial mass effect. No evidence of abnormal postcontrast intracranial enhancement. 2. Multiple lytic osseous lesions throughout the calvarium, with the a dominant left parietal calvarial lesion measuring approximately 3.2 cm in AP dimension. This mass lesion demonstrates marked could thinning of the inner and outer table with soft tissue density extending into the subgaleal and epidural regions. The dominant right parietal lesion measures approximately 5.4 cm in AP dimension, but is much less confluent. 3. There appears to be an osseous lesion involving the right aspect of the clivus, which could potentially affect cranial nerve 6. 4. The visualized orbits are unremarkable. The orbital apices appear unremarkable. 5. If there are no contraindications, MRI of the head and orbits, with Fiesta sequence through the internal auditory canals, would be much more sensitive for intracranial metastatic disease. Ultrasound-guided targeted liver biopsy showed Uncomplicated 18-gauge targeted liver biopsy x 4, with specimen sent to pathology. RECOMMENDATION(S): Post-procedure orders in OMR and communicated to Dr. ___. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 4:47 pm, 3 minutes after discovery of the findings. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed No brain metastatic lesions. No intracranial mass, hemorrhage or acute infarct. Fairly diffuse pachymeningeal thickening is nonspecific and may be seen in the setting post LP, dural metastasis, infection/inflammation or idiopathic pachymeningitis. However, presence of skull metastasis suggest the dural thickening is could likely be due to infiltration from metastatic disease. Extensive skull and cervical spine metastasis are again noted. Reference is made to CT brain report of ___ for a description of the calvarial metastasis. The patient was diagnosed with Pain in left hip, Secondary malignant neoplasm of bone marrow. The patient was treated with ___ liver mass biopsy. At the time of discharge, the patient had Metastatic breast cancer Right femoral neck fracture, pathologic. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F w/ untreated, slow-growing breast cancer since ___ p/w right hip/thigh pain due to bone mets and pathologic right femoral neck fracture. Extremely challenging hospitalization in which she has essentially refused all efforts to palliate her hip pain other than oral pain medications. # Right femoral neck fracture (pathologic) # Right hip/thigh pain: Consulted RadOnc, Onc, Ortho, Palliative. -Gave Pamidronate 90 mg IV x1 on ___ per Onc recs. -Ortho-Trauma saw her on admission. Patient delayed decision on surgery. So was maintained NWB RLE on bedrest pending her decision. She ultimately declined palliative right hemi-arthroplasty for reasons including not wanting a male surgeon, wanting to talk to an ___ MD first, and wanting more time to consider her options. Ortho-Trauma advised NWB RLE, and ROM as tolerated (no longer on bedrest). -Radiation Oncology evaluated and recommended palliative radiation therapy. She was initially in agreement with this, and went for the planning session on ___, but when they called for her to go down for the first treatment session on ___, she refused. She said she didn't want to be rushed into it, and would prefer to do it as an outpatient. She said she wanted to be seen by ___ and be seen by ___ prior to undergoing any radiation therapy. We had ___ evaluate her and a female surgeon from ___ also met with her. -___ saw her on ___: she declined palliative surgical tx offered by them. Said that she understood from their discussion that there was a chance that the hip could heal on its own over the next 6 weeks, so she did not want to pursue surgery at this time. She said she was not "in a psychological state" to have surgery and described herself as "a very indecsive person." ___ upgraded her weight-bearing restrictions to touch down weight bearing of the RLE, so that she could more easily manage transfers and other aspects of mobility. They cautioned her that there is a substantial chance that the fracture does not heal on its own and instead progresses/worsens. -She worked with ___, who advised rehab given her significant need for assistance with transfers and any mobility. The patient refused rehab and said she would want to go home. She refused home services. -On arrival to the hospital, she was extremely uncomfortable and highly resistant to any ROM of the right hip. She would lay on her left side and keep the hip flexed. Any attempted movement prompted severe anxiety, panic, and pain. The pain would resolve rapidly, but attempted transfers and/or bed repositioning maneuvers were very challenging due to her anxiety. She was initiated on a pain regimen of standing Tylenol, PRN toradol (prior to liver met biopsy, stopped after that), standing & PRN oxycodone, and IV morphine pre-procedurally/prior to planned transfers. The pain regimen seemed to work well, and the IV morphine was discontinued. In the last ___ days of hospital course, she was mostly pain free at rest, only seemed to have pain during actual movement of the right hip, which itself seemed to resolve very quickly. Her pain regimen was adjusted during the course of her hospitalization with the help of the palliative care team. See reported that the pain with hip aROM had improved from ___ initially to ___ on the day she left AMA. # Metastatic breast carcinoma: Known prior breast Ca, which is now a large and ulcerating right breast mass, so this was the presumed primary. CT c/a/p done showed widely metastatic disease to liver and bones. ___ did biopsy of liver met (___). Path confirmed the dx of metastatic breast carcinoma. Oncology discussed treatment options with her and they advised anastrazole 1 mg PO daily, which she said she would be willing to take, and was initiated prior to the patient leaving AMA on ___. An appointment was made for her in ___ clinic with Dr. ___ for ___, should she choose to attend. # Dural enhancement: on MRI. Evaluated by Neuro-Oncology (Dr. ___, who felt this was most consistent with metastatic carcinomatosis. The treatment of diffuse dural metastasis is systemic chemotherapy, which the patient was not interested in initiating during this hospitalization, but which she can discuss with her primary Oncologist at her upcoming ___ appointment. # Blurry vision w/ right lateral rectus muscle paresis and facial asymmetry: CT head without ICH or large stroke, but many skull mets one of which might be the culprit (may be pressing on CN 6). MRI brain without any brain mets. Consulted Neuro-Oncology at the recommendation of the Oncology team. # Blindness: due to longstanding cataracts/glaucoma that she did not seek ___ for. She has a large magnifying glass and flashlight that she uses to read things. # Goals of care: It was very challenging to fully understand and help Ms ___ to achieve her goals. She initially indicated that she wanted palliative interventions for her severe right hip pain, however aside from pain medications,with their relatively immediate effects on the pain, she ultimately turned down all of the palliative interventions we could offer that required a greater degree or process of decision-making. She seems to have a combination of strongly avoidant and obsessive personality traits. She is extremely anxious and, in her own words "paralyzed with indecision" at times, but refused both talk therapy and psychopharmacotherapy for anxiety when evaluated by the Psychiatry consult & liason service. She is intensely private, won't share any information about friends/family with us, and won't allow us to reach out to anyone on her behalf. She is also distrusting of both her condition and our motives. She requested at times that we print out all of her imaging studies, labs, and DNR/DNI order. On ___, I did this, highlighted all the key parts (name of study, findings, etc.), and gave them to her to help alleviate some of her anxiety/distrust. When I asked her today (___) if she had read any of these, she said no, because she has been interrupted so much in the past 24 hours, which is fair, but I have also gone in and found her sitting by herself, doing nothing, on multiple occasions today. Unclear to me if she is actually able to read the reports, even with her magnifying glass/light/etc. She demonstrated circular reasoning at times, was often non-linear in her thinking, and at times demonstrated poor recall. However, with frequent repetition, she gradually integrated new information, and was able to demonstrate understanding of the risks of refusing palliative interventions (e.g. palliative hip hemi-arthroplasty, palliative radiation therapy), as well as additional diagnostic evaluations (e.g. CTPA to evaluate for PE) or medical interventions (e.g. possible anticoagulation for PE, if found). Palliative care, SW, and I all talked with her extensively and did our best to understand her goals of care and help her achieve them. Her long history of avoiding medical interventions and allowing her medical conditions (breast cancer, left hip metastatic lesions, and cataracts/glaucoma) to follow their natural course was considered by our multi-disciplinary team, to be an integral part of her personality, and so we did our best to work within this conceptual framework to offer her palliative interventions that would limit the potential side effects that she seemed to be much more afraid of than the disease processes themselves. # Disposition: patient left AMA on ___. Earlier that day she told us that she felt like she was being imprisoned and wanted to go home. We reviewed our concerns about her safety at home in her current condition with limited personal mobility (evaluated by ___ & OT), and she was dismissive of our concerns. She expressed that she would be just fine at home, but also requested that we provide her with a wheelchair. We explained that although we would absolutely not keep her against her will, we were at the same time not under an obligation to facilitate putting her in an unsafe situation. Along those same lines, I explained that I did not feel comfortable prescribing her narcotic pain medications for unsupervised home use due to the combination of her severe vision impairment and her high risk of falling without assistance. I asked her if she would consider staying to continue working with ___ in the hospital to get stronger & more capable of safe transfers on her own, so she could go home safely. She declined. She said she would call a friend to pick her up. Ultimately someone did come to pick her up from the hospital at around 10 ___, and the patient refused to allow the night team to reveal any details of her condition/illness with this person. We provided her with a prescription for anastrazole on discharge. # Code status: DNR/DNI (confirmed with patient).</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ with PMH ESRD with multiple failed/infected accesses(failure of L radiocephalic AVF, thrombosis L brachiocephalic AVG, failure R radiocephalic & brachiocephalic AVF w/ persistent pos BCx from tunneled line), with multiple hospitalizations for recurrent vanc sensitive enterococcus. He presents from prison to the ED today after developing fevers associated with shaking chills and dry heaves. He completed HD yesterday without complications. Today, he developed fevers and shaking chills as well as a new nonproductive cough. He has had no tenderness at his tunneled catheter site or the site of his new AV graft. The patient was given motrin before arrival. Per ED note, pt has a new nonproductive cough though the patient denies this. The patient denies any CP, SOB, abdominal pain, changes in bowel movements, or n/v. The patient is anuric. In the ED, initial vital signs were 100.6 139 104/54 19 98%. Patient was given 2L NS, 1g vancomycin and 1 g tylenol. Blood cultures x 3 were drawn. WBC was 9.8 and lactate 1.9. CXR was negative for any acute cardiopulmonary process. Patient was VS on transfer: 98.2 106 100/49 20 100%. On the floor, T 98.1 BP 121/74 HR 97 O2sat 96% on RA. Patient was stable w/no additional complaints. Radiology showed No acute cardiopulmonary process. Radiology showed Successful removal of a left internal jugular venous approach tunneled hemodialysis catheter. The patient was diagnosed with DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT, ACCIDENT NOS. The patient was treated with Removal of Tunneled HD line by interventional radiology (___). At the time of discharge, the patient had Primary: Sepsis Secondary: End stage renal disease on hemodialysis Anemia 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>PLAN AND ASSESSMENT: Pt is a ___ with PMH ESRD on HD with multiple failed/infected accesses, multiple hospitalizations for recurrent vanc sensitive enterococcal line infections, now presenting with fevers and chills concerning for cath-associated blood stream infection. ACTIVE ISSUES # Serratia/Enterococci Septicemia. Pt was septic ___ Serratia bacteremia likely due to CRBSI. Line pulled by ___ on ___. The patient was evaluated by Nephrology and Infectious Disease and the pt was started on IV Cefepime with significant clinical improvement. Patient also had a single blood culture from ___ grow enterococcus (became positive on ___. Pt's amlodipine and metoprolol were held given his recent sepsis and SBPs in the low 100s-120s. TTE on ___ showed no sign of vegetations; however, the pt received TEE for worsening TR noted compared to prior echo in ___. TEE on ___ showed no sign of vegetation. For this reason, pt was d/c'ed on 2 week course of PO Cipro and IV vancomycin. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with a history of stage IIIc ovarian cancer with metastatic recurrence status post multiple lines of chemotherapy currently on rucaparib and Avastin who presented to ___ with complaints of abdominal pain and emesis that started on ___. She was ultimately transferred to ___ for further evaluation and care. SECOND OPINION CT ABDOMEN AND PELVIS showed 1. High-grade small bowel obstruction with a transition point in the right lower quadrant, likely related to adhesions. No obstructing mass identified. There is fecalization of loops of dilated small bowel, with mesenteric hyperemia and edema, and possibly mild wall thickening. No pneumatosis or portal venous gas noted. 2. Unchanged bilateral lower lobe pulmonary metastases, hepatic metastases, peritoneal nodules and right external iliac lymphadenopathy. 3. Stable L3, left iliac and sacral sclerotic lesions. 4. Increasing small pericardial effusion. CHEST (PORTABLE AP) showed Enteric tube terminates in the expected location of the stomach. The patient was diagnosed with Other intestnl obst unsp as to partial versus complete obst. At the time of discharge, the patient had Small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is ___ year with a history of stage IIIc ovarian cancer with metastatic recurrence who underwent multiple treatments of chemotherapy with progression of disease, currently on rucaparib with plan to start Avastin who was transferred from an outside hospital for treatment of small bowel obstruction. A CT abdomen and pelvis from the outside hospital demonstrated a high-grade small bowel obstruction with a transition point in the right lower quadrant, likely related to adhesions. No obstructing mass was noted on CT. There were also unchanged pulmonary metastasis, hepatic metastasis, and peritoneal nodes as well as an increasing small pericardial effusion. Upon arrival to the ED,gynecology oncology was consulted and, given the patient's overall well appearance and after reviewing the imaging, the decision was made to manage the small bowel obstruction conservatively. An nasogastric tube was placed in the ED and the patient was made NPO with IV fluids. General surgery was consulted and the patient was monitored with serial abdominal exams. On hospital day 2, patient's abdominal exam showed no peritoneal signs during her stay and she remained afebrile with a normal white blood cell counts. At that time, patient passed flatus and her NG tube output decreased. An NG tube clamping trial was performed and there was minimal residual after four hours. Her NGT was thus removed and patient was kept NPO overnight. On hospital day 3, patient was advanced to clears in the morning without issue. At noon, patient tolerated crackers and toast. She continued to pass flatus and had a bowel movement. Her abdominal exam was normal. She was subsequently discharged home in stable condition on hospital day 3. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with history of encopresis, asthma and anxiety who presents with 4 days of abdominal pain and vomiting. He reports he started feeling poorly 4 days prior to admission with development of left sided abdominal pain. He presented to the ED and had a CT scan which was unremarkable and was discharged home. He then returned to the hospital with persistent abdominal pain. He reports pain is severe and on the left side of his abdomen. He is able to sleep but when awake, the pain is unbearable. He also has a number of episodes of non-bloody, bilious vomiting. Denies nausea. ABDOMEN (SUPINE AND ERECT) showed Unremarkable bowel gas pattern. No radiopaque calculi. No abnormal fecal loading. Supine and upright abdominal plain film showed Unremarkable bowel gas pattern. No evidence of bowel obstruction or free air. MR HEAD W AND W/O CONTRAST showed 1. No acute intracranial hemorrhage, mass effect, or acute infarct. 2. Partially empty sella and low-lying cerebellar tonsils though with normal rounded configuration. The findings are nonspecific though can be seen with pseudotumor cerebri -- clincial correlation is recommended. RECOMMENDATION(S): The findings were discussed by Dr. ___ with Dr. ___ by telephone on ___ at 11:40 AM, minutes after discovery of the findings. Esophagram showed No evidence of esophageal spasm. Barium passes readily into the stomach. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, VOMITING. The patient was treated with EGD. At the time of discharge, the patient had Abdominal pain Vomiting Anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of asthma, recent admission for suspected alcoholic gastrits presents with LUQ abdominal pain and vomiting. #Abdominal pain, LUQ #Vomiting Unclear etiology of pain. Alcoholic gastritis seems unlikely given patient has recently stopped drinking. Recurrent nature makes viral gastroenteritis less likely. While lipase is elevated, doubt this is pancreatitis given normal CT findings. Functional dyspepsia and impaired motility also on differential. Seen by gastroenterology who recommended bowel regimen. The patient was treated symptomatically with improvement in symptoms. The GI service was consulted and performed an EGD which revealed antral gastritis and esophageal candidiasis. He was discharged on treatment with fluconazole and omeprazole for a planned 3 week and 2 month course respectively. Brain MRI done given hypertension/bradycardia which showed findings that could be consistent with pseudotumor though he was experiencing no symptoms suggestive of such. He should follow up with his gastroenterologist for consideration of gastric emptying study after discharge. A barium swallow was negative for esophageal spasm. TSH, cortisol unrevealing. It was recommended that he seek treatment for his anxiety as a contributing factor in his nausea/vomiting. # MRI findsings Brain MRI ordered and without significant findings that would cause his symptoms. Given the absence of symptoms of increased ICP and lack of headache, visual changes, or palsy, and that nausea only happens with food intake, will not assess further. Should be evaluated by ophtho as an outpatient. #Asthma Noncompliant with medications at home and currently stable #Anemia Iron studies were normal. #Anxiety Recommend close outpatient follow up. Pt seen by social work. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with DM2, vascular dementia s/p multiple CVA's with residual aphasia, recurrent UTI's with chronic Foley, limited mobility s/p L hip fx (essentially bedbound), and on chronic Coumadin for history of DVT who presents with fever from nursing facility. Pt had decreased mental status and temperature to 100.7. No documentation of localizing symptoms. CXR was obtained based on abnormal pulmonary exam which was concerning for PNA and mild vascular congestion. Pt given IM CTX and sent to the ED for evaluation. . In the ED, pt afebrile, WBC elevated to 15K. Noted to be altered. CXR obtained, which shows bibasilar atelectasis. Urinalysis shows >150wbc and many bacteria. INR elevated at 5.4. Pt given azithromycin, vancomycin, 1L of NS and admitted. CT HEAD W/O CONTRAST showed No acute intracranial hemorrhage or mass effect. Encephalomalacic changes in the right MCA territory, as before. Correlate clinically to decide on the need for further workup or followup. Mucosal thickening with fluid in the ethmoid in the right side of the sphenoid and right maxillary sinuses, partially included. CHEST PORT. LINE PLACEMENT showed Right sided PICC line tip is at the cavoatrial junction. 2 lead pacemaker is in similar position compared to prior. Lung volumes are slightly low. There is no focal infiltrate or effusion The patient was diagnosed with FEVER, UNSPECIFIED, ALTERED MENTAL STATUS . At the time of discharge, the patient had UTI Supratherapeutic INR. The patient was given written instructions concerning 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 F with vascular dementia, on chronic Coumadin for prior DVT, chronic Foley recurrent UTI's here with fever and altered mental status. Likely infectious source is urine given normal CXR and lack of pulmonary symptoms. AMS likely ___ infection given fever and WBC. Elevated INR, does warrant CT head though, suprisingly not done in ED. 1. Fever/Leukocytosis/somnolence ---> complicated UTI (ESBL and chronic Foley) She had received IM CTX at her nursing home. She initially received IV CTX and Azithromycin in the ED for presumed PNA. However, her CXR did not show clear infiltrate and she lacked pulmonary symptoms. Her urine was very suspicious for UTI, especially given chronic Foley and previous UTI's. She was started on Vancomycin and Ceftriaxone to cover for GNR's and possible enterococcus. Her Foley catheter was exchanged. She did not have further fevers and her mental status improved to baseline. Her WBC returned to normal limits. Her urine culture returned positive for >100K CFU ESBL E. coli and ___ enterococcus. Her antibiotics were changed to Meropenem, with plan for 10 day course for complicated UTI. She will complete her antibiotic course at home via a PICC line. Interestingly, her symptoms resolved prior to administration of the correct antibiotic regimen. Given the lower colony count for the enterococcus, did not choose to treat as true pathogen, more likely colonization in setting of Foley catheter. She changed to ertapenem 1g daily on the day of discharge, ___, and will finish antibiotics on ___. 2. AMS Most likely toxic-metabolic encephalopathy from underlying infection/UTI. However, given elevated INR on admission and AMS, head imaging is warranted. - obtain CT head - NEGATIVE for bleed - treat infection as above - improved with treatment of infection 3. Supratherapeutuic INR - hold coumadin - check Head CT for bleed - no reversal given no active bleeding or high-risk of bleeding - she was discharged on 2mg daily, with INR of 2.0 on the day of discharge 4. DM2 - SSI with home lantus 5units - fingersticks q6 while altered, revert to meal time sliding scale once she starts eating 5. ___ Elevated BUN/Cr on admission, with Cr of 1.1, baseline <1. Resolved with IVF. Most c/w pre-renal ___ from hypovolemia in the setting of acute infection. 6. Hypernatremia Pt had elevated Na of 149. She was given some free H2O via IV while NPO. This improved her Na level. Encouraged free H2O intake, and Na levels returned to normal. She is at risk for limited access to free H20 given her baseline status and is at risk for developing hypernatremia. Encourage access to free H2O at nursing home to permit drinking to thirst. FEN - NPO, LR at 100 PPX - INR > 2 Code - DNR /DNI per documentation from ECF</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ with prior history of ruptured appendicitis c/b abscess ___ ___ at ___ treated with antibiotics and percutaneous drain who presented on ___ with RLQ discomfort associated with leukocytosis (WBC 17.3). Patient had not undergone an interval appendectomy. Since that episode, patient has had intermittent GI discomfort but starting 2 weeks ago has had a persistent dull ache ___ her RLQ. She had one episode of nausea and vomiting but no fever or chills. She underwent a CT scan at ___ ___ which showed "a conglomerate and tethered appearance of distal ileal bowel loops ___ the right lower quadrant may reflect the sequela of a prior inflammatory process without visualization with the appendix and a possible 2.8 cm right adnexal cystic lesion." At that time, she had a WBC of 11. She re-presented to urgent care ___ not feeling better and found to have a WBC of 15. She was started on cipro/flagyl and directed to the ED ___. ___ addition to pain, she also reports dysuria. She has been able to eat and has had no changes ___ her bowel habits. She underwent a colonoscopy ___ ___ that was reportedly normal. PELVIS, NON-OBSTETRIC showed 1. Findings worrisome for pelvic abscess, better characterized on same day CT abdomen/ pelvis. 2. Nonvisualization of ovaries. 3. Fibroid uterus. CT-guided right lower quadrant abscess drainage. showed Successful CT-guided placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. CT Abdomen and Pelvis showed Findings consistent with perforated appendicitis with right lower quadrant multilobulated abscess measuring approximately 7.0 x 4.3 x 5.9 cm. Secondary thickening of the urinary bladder and cecum. RECOMMENDATION(S): Surgical consultation. Percutaneous drainage may be considered. The patient was diagnosed with Acute appendicitis with generalized peritonitis. The patient was treated with ___: CT-guided placement of an ___ pigtail catheter into right lower quadrant collection. At the time of discharge, the patient had perforated appendicitis with abscess. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with history of perforated appendicitis who present on ___ with persistent RLQ pain found on imaging to have (recurrent) perforated appendicitis with abscess, leukocytosis of 17, but otherwise hemodynamically stable. Patient was admitted to the general surgery service for abscess drainage and IV antibiotics (cipro/flagyl). #SURGICAL COURSE: Interventional Radiology was consulted for drain placement at abscess. ___ did a CT-guided placement of an ___ pigtail catheter into the collection with a JP bulb placed. Patient tolerated the procedure well symptoms improved there-after. Initially exudative light brown appearing material drained was collected and sent for culture. Patient received daily catheter flushes by nursing. On discharge, drain continued to drain some minimal serosanguinous material. #NEURO: The patient was alert and oriented throughout hospitalization; pain was initially managed with Tylenol. Pain was very well controlled. #CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. #PULMONARY: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. #GI/GU/FEN: Initially patient presented with some dysuria. Her UA/UC were negative. Pelvic ultrasound was significant for fibroid uterus with notice of a lower abdominal abscess. CT findings consistent with perforated appendicitis with right lower quadrant multi-lobulated abscess measuring approximately 7.0 x 4.3 x 5.9 cm. There was also note of secondary thickening of the urinary bladder and cecum, likely inflammatory due to the nearby abscess. Her abdominal pain improved significantly after starting IV antibiotics, taking Tylenol, and getting the drain placed. The patient was NPO prior to her ___ procedure; there-after patient was advanced to a regular diet which she tolerated well. She had several loose bowel movements after starting IV antibiotics, which was likely a side effect consider she had no further leukocytosis or other infectious symptoms prompting workup. #ID: The patient's fever curves were closely watched for signs of infection, of which there were none. Patient was started on IV ciprofloxacin and flagyl on admission. Her WBC on discharge was normal at 5.8. She was discharged on PO Ciprofloxacin and Flagyl. #HEME: Patient received BID SQH for DVT prophylaxis, ___ addition to encouraging early ambulation and Venodyne compression devices. #OTHER: Case management helped set up ___ services for the patient to go home with for her abscess drain care. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH diverticulosis, stage I papillary serous endometrial Ca s/p robotic TAH-BSO, on cycle 5 Carboplatin (received Taxol w/Cycle 1). Per ED notes, L flank pain began y'day, intermittent ___. She endorses nausea & vomiting. She denies dyusia, frequency, chest pain, shortness of breath, constipation, distention, diarrhea. Radiology showed 1. Diverticulitis affecting the descending colon. No evidence of an abscess or perforation. 2. Slight interval increase in the size of the pancreatic cyst, now measuring 1.4 cm x 2 cm. This can be assessed with MRCP on a non-urgent basis. 3. Left pelvic side wall hypodense lesion, possibly a lymphocele or seroma, but further assessment with MRI is recommended given the patient's history of gynecologic malignancy. This was discussed with Dr. ___ at 4:20 pm, ___. The patient was diagnosed with DIVERTICULITIS OF COLON, MALIG NEO CORPUS UTERI, HYPERTENSION NOS. At the time of discharge, the patient had Primary: Diverticulitis Secondary: Endometrial Cancer on chemotherapy. The patient was given written instructions concerning 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 ___ woman with a history of endometrial cancer, s/p robotic TAH-BSO and undergoing chemotherapy with carboplatin (due to begin cycle 5 on ___, received Taxol with cycle 1). She presented with left flank pain and her clinical exam, lab results, and radiologic findings were consistent with diverticulitis.</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 T2DM ___ A1C 9.3), HTN, Afib on warfarin, and CAD w/ drug-eluting stent who presented with nausea, vomiting, abdominal pain, and BRBPR. CT ABDOMEN PELVIS WITH CONTRAST showed 1. Colonic wall thickening with adjacent fat stranding from the splenic flexure to the junction of the descending and sigmoid colon is compatible with colitis. Given the location, an ischemic etiology is favored, however infectious/inflammatory etiologies are also possible. 2. Endometrial thickening. Recommend nonemergent pelvic ultrasound for further evaluation. 3. Cholelithiasis and moderate hiatus hernia. RECOMMENDATION(S): Nonemergent pelvic ultrasound for impression point 2. NOTIFICATION: The updated findings and impression were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 9:36 am. The patient was diagnosed with Dizziness and giddiness, Nausea, Right upper quadrant pain, Right lower quadrant pain. At the time of discharge, the patient had Ischemic colitis Type 2 DM Diabetic ketoacidosis Afib HTN Hypothyroid Peripheral neuropathy HLD Mood Post-menopausal bleeding. The patient was given written instructions concerning 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 =============== ___ year-old woman with T2DM ___ A1C 9.3), HTN, Afib on warfarin, and CAD w/ drug-eluting stent who presented with nausea, vomiting, abdominal pain, and BRBPR. Acute Issues ============ # Ischemic colitis: Developed gradual onset abdominal pain and BRBPR in the ED. Admission CTAP demonstrating colonic wall thickening and fat stranding most compatible with colitis. This most likely represents ischemic colitis as the distribution is consistent with watershed reasons. Cause of ischemic colitis is likely from poor PO intake and DKA. Patient was made NPO for bowel rest for 24 hours and then started on diet. She had a second small episode of BRBPR on ___ AM (24 hours after the first episode), which likely is residual from the first episode. She was started on ceftriaxone/flagyl for empiric antibiotics. She should continue antibiotic therapy with cefpodoxime 400 mg PO q12h and metronidazole 500 mg PO q8h for a one-week course (___). Warfarin was held on admission but resumed prior to discharge. Last colonoscopy in ___ showed normal colon, and as hemoglobin and hemodynamics remained stable, we did not feel inpatient colonoscopy would add further value. She was educated on return precautions. # Type 2 DM # DKA: Patient with longstanding diabetes, last A1C 9.3. Has had end organ damage with autonomic neuropathy and diabetic retinopathy. Had anion gap and glucose levels in 300s in the ED concerning for DKA, which was treated with 4L IVFs. Anion gap resolved in the ED. The patient should continue her home insulin regimen: Lantus 35U qAM and qHS + HISS. Chronic Issues ============== # Afib: History of ___ in ___. CHADS2 score of 2, does not meet criteria for bridging as per bridge trial. Last warfarin dose on ___. The patient was continued on her home sotalol 100 mg BID. Her home warfarin was held for one day given BRBPR and resumed at a reduced dose of 3mg daily on ___. She should have her INR checked on ___ with her PCP with warfarin dose re-evaluated at that time. # HTN: The patient was continued on her home losartan 100 mg daily with holding parameters. # Hypothyroid: The patient was continued on her home levothyroxine 100 mcg daily. # Peripheral neuropathy: The patient was continued on her home duloxetine 60 mg daily. # HLD: The patient was continued on her home rosuvastatin 20 mg daily and home aspirin 81 mg daily. # Mood: The patient was continued on her home buproprion 300 mg daily. # Other: The patient was continued on her home vitamin D 5000U daily and home pantoprazole 20 mg daily. Transitional Issues =================== # Post-menopausal bleeding: CT on admission showed endometrial thickening. This is already being worked up as an outpatient. Patient will need endometrial biopsy, which has been scheduled. - CONTINUE cefpodoxime 400 mg PO q12h and metronidazole 500 mg PO q8h for 1 week (___). - CONTINUE warfarin at 3mg PO daily (reduced dose due to being on metronidazole). Next INR check on ___ at ___ ___, confirmed by phone. - Discharge INR 1.7.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/chronic pancreatitis, recently started on TPN presents for ___ evaluation. ___ saw her today and noted brownish discharge from ___ site and suggested she come to ER. Denies pain at site or fever. Also reports 3 days of cough productive of yellow sputum, sore throat, nasal congestion and worsening epigastric pain typical of pancreatitis exacerbations. States she is only taking ice chips and all other nutrition is via TPN. In ED ___ evaluated no concerns. Pt given 2mg IV dilaudid, 1mg IV ativan, zofran and 1Lns. Chest: Frontal and lateral views showed Patchy right middle lobe opacity, raising concern for pneumonia. Recommend followup to resolution. Right-sided PICC again extends deep into the right atrium; if the desire position of the tip is at or just above the cavoatrial junction, the catheter could be pulled back by approximately 5.5-6 cm. Radiology showed 1. Right PICC now terminating in the proximal right atrium. 2. Persistent right middle lobe opacity, consistent with pneumonia. RECOMMENDATION(S): Retraction of the PICC by 2 cm is advised for repositioning of tip in the low SVC. NOTIFICATION: The findings were discussed by Dr. ___ with ___ from the IV team on the telephone on ___ at 12:19 ___. The patient was diagnosed with CHRONIC PANCREATITIS, FEVER, UNSPECIFIED. At the time of discharge, the patient had ___ line drainage ? 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>ASSESSMENT AND PLAN: ___ w/chronic pancreatitis recently started on TPN presents for ___ eval and found to have PNA. # PNA: no fever or hypoxia: levaquin x5 days although suspicion for pneumonia was relatively low. # Concern for PICC Infection: she was eval by ___ team in ED and determined there was no evidence of infection. It was repositioned and dressed to ensure adequate placement and consistency # Chronic Pancreatitis: pt reports increased pain but denies any PO intake. If this is true there is no reason for her to have a flare of pancreatitis. All labs wnl. No signs of dehydration. Multiple documented concerns for medication ___ in the past. Of note, PCP is in the process of tapering home oral dilaudid. She was given dilaudid IV overnight, although there was no clear evidence of significant exacerbation. She did not get a prescription for dilaudid at discharge, she has appointment with PCP ___ ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo righthanded, ___-speaking woman who presents with episodic dizziness. She works as a patient assistant in a nursing home, 11pm-7am shift. At work ___ night at 3am, she suddenly became dizzy and lightheaded. She felt generalized weakness all over, not worse on L vs. R, and felt shaky in arms and legs. She was unable to do any more work, she rested for a couple of hours then since she was not getting better, called her son to pick her up because she could not drive. The dizziness lasted for ___ hours, no changes with her position, nothing made it better or worse. She describes the dizzy feeling as spinning inside her head, with no actual spinning or movement of the world around her. She did not feel nauseated. She also c/o blurry vision during this episode. She did not try covering one eye. It resolved after a couple hours also. The patient was driven home by her son. She was able to get up from the car and walk into the house without stumbling. Her gait looked steady per her son. She rested for the day and felt fine. Radiology showed No significant abnormalities on MRI of the brain with and without gadolinium. MRA NECK: The fat-suppressed axial images as well as MRA of the neck demonstrate no evidence of dissection, stenosis or occlusion. Both carotid and vertebral arteries are patent. The distal left vertebral artery appears small in size, a variation. IMPRESSION: No significant abnormalities on MRA of the neck. The patient was diagnosed with MUSCSKEL SYMPT LIMB NEC, VERTIGO/DIZZINESS. At the time of discharge, the patient had Primary Diagnosis: Vertigo 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>She was admitted for further evaluation of vertigo, transient facial sensory symptoms, and left leg weakness. Her symptoms resolved overnight. She received an MRI Brain and MRA Neck which were unrevealing of acute ischemia or structural lesions/abnormalities that could explain her symptoms. Her cardiac telemetry did not reveal any arrythmias. She was discharged home with a recommendation to followup with Neurology should her symptoms recur or persist. PENDING STUDIES: None</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man with history notable for ischemic cardiomyopathy with chronic systolic heart failure (LVEF 10% in ___ s/p ___ ICD for primary prevention, prior LV thrombus on warfarin, CAD s/p DES to LCx (___), HTN, HLD, insulin-dependent diabetes, CKD, and hypothyroidism presenting for worsening lower extremity edema and weight gain. CHEST (PA AND LAT) showed Low lung volumes. No acute cardiopulmonary abnormality. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change. Again there is huge enlargement of the cardiac silhouette. Curvilinear calcification in the region of the left ventricle is concerning for an aneurysm. No evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Single lead pacer extends to the apex of the right ventricle. The patient was diagnosed with Shortness of breath, Heart failure, unspecified, Dyspnea, unspecified, Type 1 diabetes mellitus with hyperglycemia, Long term (current) use of insulin. At the time of discharge, the patient had PRIMARY ======= Acute HFrEF Exacerbation SECONDARY ========= LV Thrombus Acute on Chronic Kidney Injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with iCM with chronic systolic heart failure (LVEF 10% in ___ s/p ___ ICD, prior LV thrombus on warfarin, CAD s/p DES to LCx (___), presenting now for CHF exacerbation. TRANSITIONAL ISSUES =================== [] Patient is not on a beta blocker outpatient. It may be beneficial to have further discussions regarding the benefits of attempting to reinitiate therapy versus the risks of decreasing heart function given his low ejection fraction at baseline. [] While inpatient, there were initial discussions regarding whether CardioMEMS would be of benefit for this patient. He was agreeable to this, and thus it should be followed up at his next cardiology appointment. [] Patient has reported history of hyperkalemia with spironolactone. However, he also has reported history of hyperkalemia with Lisinopril, but seemed to tolerate this well inpatient. It may be of benefit to trial spironolactone again, and consider potassium reducing agents if he becomes hyperkalemic again. [] Patient's Imdur was decreased to 30mg daily in the setting of introducing lisinopril. Please continue to monitor his blood pressures to ensure this is an adequate dose. [] Please follow up INR and Chem10 from ___ ACUTE ISSUES ============ # ACUTE ON CHRONIC SYSTOLIC HEART FAILURE Patient presented with home with history of signs and symptoms concerning for volume overload. After review of his HPI, it was thought his symptoms were likely secondary to dietary indiscretion as well as an inadequate medication regimen in the setting of as needed torsemide. Patient was started on IV diuretics, and responded well. Once he was thought to be euvolemic, he was transitioned to oral Torsemide and was able to maintain euvolemia on this dose. For afterload reduction, patient's nitrate was decreased, and he had an increase in dose of hydralazine as his blood pressures appeared to be able to tolerate this. He was also newly started on lisinopril, and monitored closely for hyperkalemia, which he did not have. Patient was continued on home acetazolamide and digoxin. [] Consider beta-blocker if blood pressures can tolerate [] Consider CardioMEMS [] Patient has reported history of hyperkalemia with spironolactone. However, he also has reported history of hyperkalemia with Lisinopril, but seemed to tolerate this well inpatient. It may be of benefit to trial spironolactone again, and consider potassium reducing agents if he becomes hyperkalemic again. [] Patient's Imdur was decreased to 30mg daily in the setting of introducing lisinopril. Please continue to monitor his blood pressures to ensure this is an adequate dose. CHRONIC / STABLE ISSUES ======================= # LV THROMBUS Previously noted on echo from ___, and started on warfarin. Again redemonstrated on echo from ___. Patient presented with subtherapeutic INR, and thus given his active thrombus, he was initiated on heparin while awaiting INR to become therapeutic. Heparin was discontinued once INR was in therapeutic range, so patient was continued on his doses of warfarin. # CORONARY ARTERY DISEASE Most recent cath ___ with DES to LCx. No recent chest pain or other ischemic symptoms. Patient was on triple therapy with Plavix, aspirin, and warfarin, however based on the WOEST trial and that the patient was more than ___ year out since stent placement, Plavix was discontinued in favor of simply continuing dual therapy with aspirin and warfarin. He was continued on home rosuvastatin. # Chronic Kidney Disease Baseline appears to be around 1.6. Slightly elevated at time of admission, suspect secondary to cardio-renal disease vs progression of his underlying kidney disease. ___ also appear worse during hospitalization due to initiation of lisinopril. Stabilized at time of discharge. # DIABETES Continued Lantus 44u bedtime with mealtime sliding scale # HYPOTHYROIDISM Continued levothyroxine Sodium 112 mcg PO/NG DAILY # GOUT Continued allopurinol ___ mg PO/NG DAILY</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with h/o dementia, ___, BPH, Afib on coumadin, MV repair, with recent complicated course including CVA ___, recurrent UTIs and recurrent C.diff presents with gluteal hematoma after fall and hypotension. Radiology showed No acute fracture or dislocation. Radiology showed 1. Large intramuscular hematoma extending from the right gluteus into the right posterior thigh, measuring 6.4 x 12.9 x 45 cm is relatively size stable compared to the ___ Hospital CT performed 7 hours prior. Two foci of active extravasation noted - posterior to the right femoral neck and in the posterior compartment of the thigh. 2. Incidental findings include diverticulosis without diverticulitis, minimal ectasia of the distal aorta and calcification of the distal aorta and iliac arteries. Radiology showed AP chest compared to ___ and ___. Moderate left pleural effusion is stable, small right pleural effusion has increased. Severe cardiomegaly and mediastinal vascular engorgement are unchanged. I doubt there is pulmonary edema. The visible portions of the lungs are clear. Lung bases are not fully aerated, usually due to atelectasis but not excluding pneumonia. Left PIC line ends in the axilla, as before. Radiology showed Layering left pleural effusion, which is also seen on ___ but difficult to compare due to differences in patient positioning. The patient was diagnosed with CONTUSION OF THIGH, UNSPECIFIED FALL, ANEMIA NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE. At the time of discharge, the patient had Primary: Right gluteal hematoma Dementia Atrial fibrillation 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>___ with h/o dementia, dCHF, BPH, Afib on coumadin, MV repair, with recent complicated course including CVA ___, recurrent UTIs, and recurrent C.diff who presents with gluteal hematoma after a mechanical fall on systemic anticoagulation and hypotension.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Note Date: ___ Signed by ___ on ___ at 10:20 pm Affiliation: ___ Cosigned by ___, MD on ___ at 5:01 pm ORTHOPAEDIC SPINE SURGERY CONSULT NOTE Radiology showed No acute intracranial abnormality. Radiology showed 1. Bilateral articular pillar/laminar and right pedicle fractures of C7 with associated widening of the anterior interspace at C7-T1 and 7 mm anterolisthesis with impingement of the spinal cord at this level. 2. Lucencies through the anterior osteophytes from DISH spine at the level of C3, C4/C5 and C7/T1 do not morphologically appear acute however there is prevertebral soft tissue swelling and this should be evaluated on subsequent MR. 3. Prominent associated prevertebral hematoma, which extends inferiorly with bilateral upper mediastinal hematoma, which extends inferiorly to surround the great vessels and aortic arch, though does not appear centered around the arch. Vascular injury cannot be excluded and CTA of the neck including the arch should be considered. Results were discussed over the telephone with Dr. ___ at 8:00 p.m. on ___, five minutes after review. Radiology showed 1. Widening of the upper mediastinum, better characterized by CT scan as hematoma within the mediastinum. 2. Acute-appearing left lateral ninth rib fracture. Radiology showed 1. No thoracic spine fracture or malalignment. 2. Inferior continuation of prevertebral hematoma extending into the mediastinum bilaterally around the thoracic aorta and great vessels. Vascular injury is not excluded and CTA of the neck may be helpful for further characterization. Results were discussed over the telephone to Dr. ___ by Dr. ___ ___ at 8 p.m. on ___, five minutes after discovery. Radiology showed No lumbar spine fracture or malalignment. Degenerative changes as noted above. Radiology showed Interval posterior fusion from C3 down to the proximal thoracic spine. Please refer to intraoperative report for further details. Radiology showed 1. Large left-sided basilar pneumothorax with possible rightward shift of the mediastinum raising concern for tension pneumothorax. 2. Gaseous distension of the stomach; consider placement of a NG tube for decompression. COMMENTS: These findings were discussed with Dr. ___ team) by Dr. ___ telephone at 1:26 p.m. on ___, five minutes after these findings were discovered. Radiology showed 1. Endotracheal tube ends 4.9 cm from the carina. 2. Interval placement of left-sided chest tube with only minimal persistent left basilar pneumothorax and interval decrease in rightward shift of the mediastinum. 3. Persistent gaseous distension of the stomach. Chest tube on waterseal. AP radiograph of chest was reviewed in comparison to ___. The left pigtail catheter is in place. No evidence of pneumothorax is seen. There is interval improvement in the right basal aeration with still present opacity. Cardiomediastinal silhouette is stable. The cervical spine hardware is overall unremarkable. was done. Radiology showed AP chest compared to ___, 3:04 p.m. Right middle and lower lobe collapse have worsened. Right upper lobe is clear. Peribronchial opacification at the left lung base could be due to aspiration. Upper enteric drainage tube ends in the upper stomach and should be advanced 5 cm to move all the side ports beyond the GE junction. Left pleural drain still in place. No appreciable left pleural effusion or pneumothorax. Some right pleural effusion is presumed, but not as significant as the atelectasis. I discussed these findings by telephone with the house officer caring for this patient at 10:00AM after a page at 9:50 a.m. as soon as the findings were recognized. Radiology showed AP chest compared to ___, 7:59 p.m.: ET tube is in standard placement, nasogastric tube passes into the stomach and out of view. Left pleural pigtail catheter unchanged in location at the base of the left lung. Right middle and lower lobe are no longer uniformly collapsed, but there is a severe consolidation in the entire right lower lung concerning for developing pneumonia. The left lower lobe shows a small amount of new consolidation. There is no pulmonary edema. Heart is mildly enlarged, increased since ___. A very small left pleural effusion may be present. No pneumothorax. Dr. ___ was paged at 11:05 a.m. when the findings were recognized. Radiology showed Increase in consolidation and lesser volume in the right middle lobe and right lower lobes. ET tube in appropriate position. Radiology showed Right-sided PIC line enters a vein in the neck and ends out of the field of view of the radiograph. COMMENTS: These findings were discussed with Dr. ___ by Dr. ___ telephone at 10:41am on ___, 5 minutes after discovery. Unstable C7 fracture, re-intubation, re-assessment. AP radiograph of the chest was reviewed in comparison to prior study obtained on ___ obtained at 5:50 p.m. Current examination demonstrates right central venous line tip being at the level of mid SVC. The ET tube tip is not clearly seen, obscured by the spinal hardware. The NG tube tip is in the stomach. Left pigtail catheter is in place. As compared to prior examination, there is interval increase in right basal opacity as well as the left basal opacity most likely consistent with increasing pleural effusion. No definitive pneumothorax is seen. was done. Evaluation of the patient after tracheostomy. AP radiograph of the chest was reviewed in comparison to prior study obtained the same day earlier. Tracheostomy is in place with its tip partially obscured by the spinal hardware thus cannot be precisely determined. The Dobbhoff tube tip is in the stomach. Heart size and mediastinum are stable. Bibasal atelectasis and left pigtail catheter are unchanged in appearance. The right lower lung atelectasis is noted, improved as compared to prior examination. was done. Chest tube on waterseal. Portable AP radiograph of the chest was reviewed in comparison to ___ obtained at 05:29 a.m. Left pigtail catheter is in place. There is no interval development of pneumothorax. There is on the other hand increase in the right pleural effusion, that potentially can be due to positional differences, although true increase cannot be excluded. The NG tube tip is in the stomach. was done. Radiology showed AP chest compared to ___: Left lower lobe collapse has not improved since ___. Less severe atelectasis in the right lower lobe may not have improved, partially obscured by persistent moderate right pleural effusion. On both sides, the upper lobes are compensatorily overinflated. There is no pneumothorax. The heart is top normal size. Tracheostomy tube is midline. Right PIC line ends low in the SVC, and an upper enteric drainage tube passes into a non-distended stomach and out of view. Radiology showed AP chest compared to ___: Moderate bilateral pleural effusions have increased, and pulmonary and mediastinal veins are not dilated, suggesting volume overload or cardiac decompensation. Heart size is difficult to assess due to the adjacent atelectasis and increasing pleural effusion, but is not severely dilated. Tracheostomy tube midline. Right PICC line ends low in the SVC. Upper enteric drainage tube passes into the stomach and out of view. Bibasilar atelectasis is severe, but may have improved slightly on the right. Radiology showed AP chest compared to ___, 5:42 a.m.: Previous mild pulmonary edema has resolved since 5:00 a.m., but bilateral lower lobe and possible middle lobe collapse and moderate bilateral pleural effusions are unchanged, explaining hypoxia. Heart size normal. Tracheostomy tube in standard placement. Central venous catheter ends in the mid-to-low SVC. No pneumothorax. Radiology showed AP chest compared to ___ through ___, 10:17 p.m.: Right middle and lower lobe collapse, and accompanying moderate right pleural effusion have been present without appreciable improvement for the past several days. Previous cardiac decompensation reflected in pulmonary edema and vascular congestion has resolved. Left lower lobe has been collapsed as well, though there may be slight improvement in the degree of atelectasis. Alternatively, the left lower lobe is still collapsed and there is new consolidation at its upper margin in the lingula or apicoposterior segment of the left upper lobe. Bronchopulmonary toilet is probably the underlying problem. I cannot say whether aspiration is contributory. Radiology showed New NG tube has been placed with tip ending in distal gastric cavity. Right PICC is unchanged with tip ending in upper SVC. Tracheostomy tube is unchanged and in standard position. Unchanged appearance of the cervical spinal fixation hardware. Persists bibasilar atelectasis, larger to the right than to the left, with small right pleural effusion. Cardiomediastinal silhouette is unchanged. There is no pneumothorax. Radiology showed AP chest compared to ___: Feeding tube with a wire stylet in place ends in the upper portion of a moderately distended stomach. Tracheostomy tube is still in place. Right PICC line ends in the mid-to-low SVC. There is still substantial bibasilar atelectasis as well as small pleural effusions. Heart size is normal. Radiology showed AP chest compared to ___: Right lower lobe collapse has been present almost consistently since ___. Middle lobe pneumonia has recurred since it cleared on ___. Moderate left pleural effusion is larger today than ___, and the extent of left lower lobe atelectasis, difficult to assess, probably has not changed. There is no pulmonary edema. The heart is not enlarged. Tracheostomy tube is in standard position. The leads of new transvenous right atrioventricular pacer device follow their expected courses. Right PIC line still ends in the mid SVC. No pneumothorax. Persistent mucus plugging after bronchoscopy. Portable AP radiograph of the chest was reviewed in comparison to ___. There is interval development of right lower lobe atelectasis and progression of the left lower lobe atelectasis, findings that potentially may be related to mucus plugging as suggested. Cardiomediastinal silhouette is unchanged. There is no pneumothorax. Hardware and central venous line are unchanged in position. was done. Radiology showed Gastric bubble projecting over the left upper quadrant, overlapping with the splenic flexure. Radiology showed 1. Increased right lower opacities, could be due to increasing atelectasis or reexpansion pulmonary edema. 2. Decreased left lower lung atelectasis. Radiology showed 1. Status post laminectomy and fusion from C3 through T2 in the upper thoracic spine. No hardware loosening or failure is detected at this time. 2. Asymmetric disc space narrowing posteriorly and grade 2/borderline grade 3 anterolisthesis at C7/T1, possibly more pronounced than on the ___ CT. Attention to this area on followup films is recommended. The patient was diagnosed with FX C7 VERTEBRA-CLOSED, UNSPECIFIED FALL. The patient was treated with ___ PROCEDURE IN DETAIL: 1. Open treatment, posterior, C7 and T1 fractures. 2. Posterior fusion C3 through T3. 3. Posterior instrumentation C3 through T3. 4. Autograft, local, for fusion. 5. Allograft, for fusion. 6. Far lateral decompression, T1. 7. C7 laminectomy. 8. Repair traumatic CSF leak. IMPLANTS: 1. Globus ellipse posterior spinal instrumentation. 2. Corticocancellous allograft. ___: PROCEDURES: 1. Bronchoscopy. 2. Percutaneous tracheostomy. ___ Dual chamber PPM placed by EP. At the time of discharge, the patient had 1. C7 fracture dislocation. 2. T1 fracture dislocation. 3. Spinal cord injury. 4. Ankylosing spondylitis.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. In PACU, pt. developed hypoxia was re-intubated and subsequently taken to the trauma ICU for close monitoring. Pt. had a complicated hospital course detailed below. He remained in the ICU until discharge and was discharged directly to rehab from the ICU.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old woman with a PMH significant for NASH cirrhosis (c/b grade I EV, EGD ___, and HE), who presents with ___ days of confusion, as well as a fall 2 days prior to admission (___). Chest: Frontal and lateral views showed 1. No acute cardiopulmonary process. 2. Known right upper lobe nodule with central areas of cavitation is not significantly changed. CT HEAD W/O CONTRAST showed No acute intracranial process. CT C-SPINE W/O CONTRAST showed No acute fracture or traumatic dislocation. DX KNEE AND ANKLE showed No acute fracture or dislocation. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver, without evidence of focal lesion, splenomegaly or ascites. Limited Doppler evaluation due to technical factors shows gross patency of the main portal vein and left portal vein as well as the splenic vein. The right portal veins were not well visualized. Splenorenal shunt is re- demonstrated. 2. Gallstones and adenomyomatosis of the gallbladder. Stable ectasia of the common bile duct. Fluoroscopy showed Intraoperative images were obtained during transbronchial biopsy. Please refer to the operative note for details of the procedure. Radiology showed Status post right upper lobe lesion biopsy. No pneumothorax identified. The patient was diagnosed with Hepatic failure, unspecified without coma. The patient was treated with ___ Endobronchial biopsy of lung. At the time of discharge, the patient had PRIMARY DIANGOSES ================= HEPATIC ENCEPHALOPATHY LATENT TUBERCULOSIS INFECTION SECONDARY DIAGNOSES ================== ___ 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>This is a ___ year old woman with a PMH significant for NASH cirrhosis (c/b grade I EV, EGD ___, and HE), MELD-Na of 9, who presents with ___ days of confusion concerning for hepatic encephalopathy, resolved with lactulose & rifaximin, as well as known cavitating lesion in lung undergoing workup for lung cancer. ACTIVE ISSUES # HEPATIC ENCEPHALOPATHY: No leukocytosis or fevers; bland UA; CXR without obvious infection; blood cultures pending. Suspect encephalopathy was likely due to insufficient lactulose. No evidence of PVT on ultrasound. Resolved with increased lactulose. Discharged with lactulose TID (goal ___ BM) as well as rifaximin 550 mg BID. #LUNG MASS: With cavities vs. dilated bronchi, on ___ CT chest. Concerning for TB vs. fungal process vs. possible lung cancer, given radiographic description as spiculated and involving the pleura. She is of ___ origin, with regular travel to ___. QuantGold positive, with negative AFB smear x3 from induced sputum. Galactomannan negative. Beta-glucan positive, at 162 (threshold >80). - Will need to follow up biopsy - Consider treatment for latent tuberculosis CHRONIC ISSUES # CIRRHOSIS: secondary to NASH. Grade I EVs identified on EVD in ___ given small size, not on nadolol. No prior history of ascites or SBP. Encephalopathy in the past and on admission, resolved within a few days of admission. # COAGULOPATHY, and # THROMBOCYTOPENIA : INR mildly elevated to 1.2. No signs of bleeding. Secondary to cirrhosis. # DIABETES MELLITUS: diet-controlled. Hb A1C 5%, ___. # HYPOTHYROIDISM: continued him home levothyroxine. ============================================== TRANSITIONAL ISSUES ============================================== - Positive Quantiferon Gold (IGRA) test; consider latent tuberculosis treatment - Positive beta-glucan; follow up lung mass biopsy - Lung mass: follow up biopsy. Preliminary read: positive for adenocarcinoma. </s>