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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with h/o HTN, HLD, diabetes, moderate aortic stenosis and ___ who presented with dizziness and an episode where he lost consciousness. DUPLEX DOPP ABD/PEL showed No hemodynamically significant stenosis in either the superior mesenteric artery or celiac artery. There is likely evidence of a prior dissection in the superior mesenteric artery approximately 2-3 cm from the origin of the aorta with demonstration of bidirectional flow. Flow is normal distally to this area and there is no increase in velocity. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:01 ___, 10 minutes after discovery of the findings. The patient was diagnosed with Epigastric pain. At the time of discharge, the patient had Primary Diagnoses ================= Orthostatic/vasovagal syncope SMA dissection Secondary Diagnoses ====================== Severe aortic stenosis Hypertension Diabetes ___ Hypothyroidism Benign prostatic hyperplasia Hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with h/o hypertension, hyperlipidemia, T2DM, ___ and known aortic stenosis who presented with episode of lightheadedness followed by brief LOC/muscle twitching most consistent with syncope caused by hypovolemia with incidental SMA dissection found on imaging.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HIV on HAART who presents with low back pain and left leg pain. Radiology showed As above. The patient was diagnosed with LUMBAR DISC DISPLACEMENT. The patient was treated with Left L4-5 hemilaminectomy with facetectomy & discectomy. At the time of discharge, the patient had Lower back pain secondary herniated disc. The patient was given written instructions concerning 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. ___ initially presented with 2 weeks of LBP radiating down the left leg with difficulty walking, found to have large disc extrusion at L4/5 on MRI. He presented with mild sensory and motor deficits in the left foot. He was initially treated with aggressive pain control and steroids, but was subsequently taken to the OR on ___ for left lumbar hemi-laminectomy with left sided disectomy at L4/5. He tolerated the procedure well, was extubated, and was transferred to the PACU for further recovery without events. On ___, the patient remained at his neurologic baseline. He complained of incisional pain and left leg numbness, along with distal LLE weakness, both stable from pre-operative exam. He received Decadron while hospitalized for likely nerve root irritation; he should continue on a Medrol DosePak at discharge. He was seen by ___ and was unsteady on his feet, and thus rehabilitation was recommended at discharge. His pain meds were adjusted, and he was discharged on a combination of Tylenol, Valium, Gabapentin, and Oxycodone in addition to the aforementioned Medrol DosePak. He remained on his home medication regimen for HIV, Glaucoma, and recent left corneal transplant. He was monitored on continuous O2 monitoring for OSA without events. At time of discharge, the patient was ambulating with assistance, voiding, and tolerating a full diet. Pain is well-controlled on oral analgesics. Will return in ___ days for staple removal, and 12 weeks for routine post-operative exam. He should follow-up with his PCP for management of underlying medical issues. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo F with HTN, DMT2, asthma/COPD not on home oxygen, OSA previously on CPAP, and severe TBM s/p TBP on ___ complicated by persistent severe hypoxemic respiratory failure s/p trach/PEG on ___, now s/p T-tube for cervical tracheal malacia who presented to the ___ today with worsening dyspnea and mucus plugging for the last 3 days. CHEST (PORTABLE AP) showed Low lung volumes.Bibasilar subsegmental atelectasis with trace right pleural effusion. No definite focal consolidation to suggest pneumonia. Radiology showed No significant change. No new consolidation demonstrated. Radiology showed Stable findings in the thorax. No significant change from the exam done earlier. The patient was diagnosed with Shortness of breath. The patient was treated with Bronchoscopy (___) - showed granulation tissue and thin secretions. At the time of discharge, the patient had Primary: #Tracheitis #Shortness of breath Secondary: #Diabetes mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o woman with PMH notable for HTN, T2DM, asthma/COPD not on home O2, OSA previously on CPAP, and severe TBM s/p TBP on ___ c/b persistent severe hypoxemic respiratory failure requiring trach/peg on ___, now converted to T-tube, admitted for worsening dyspnea and mucus plugging for the past 3 days. She was initially admitted to medicine for what was felt to be tracheitis, for which she was started on unasyn. Otherwise, she received IV Zofran, lorazepam, oxycodone, and ibuprofen for pain control. On the night of admission, the patient developed worsening respiratory distress with increasing WOB per floor RN, but was maintaining saturation and stable VBGs. She was then transferred to the ICU for further care due to concern for tiring out and worsening distress. IP ___ patient and noted a small subglottic lesion, likely granulation tissue, but no significant mucous plugs that may be causing her symptoms. Sputum cx grew GPC ___ pairs. She was started on azithromycin. SHe was also treated with Lasix and methylprednisolone and her respiratory status improved, so she was then transferred to the floor on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o ESRD ___ DMII s/p LURT ___ sent to ED for evaluation by transplant nephrologist for outpatient labs demonstrating elevated creatinine and hyperglycemia. Transplant surgery service notified given patient is recent post-op. RENAL TRANSPLANT U.S. showed 1. Moderate-to-severe hydronephrosis, increased from prior. A ureteral stent is in place with proximal and distal tip seen within the renal pelvis and within the bladder. 2. Perinephric fluid collection consistent with hematoma measuring up to 11.9 cm, previously 4.9 cm. 3. Elevated resistive indices ranging from 0.77 to 0.84, similar to prior. RENAL TRANSPLANT U.S. RIGHT showed 1. Moderate hydronephrosis is re-demonstrated and slightly decreased compared to prior ultrasound. A ureteral stent is visualized within the renal pelvis, the distal tip is not well-visualized due to the decompressed bladder. 2. Stable perinephric fluid collection. 3. Mildly decreased resistive indices ranging from 0.70-0.78. The patient was diagnosed with Acute kidney failure, unspecified, Acidosis, Kidney transplant status. The patient was treated with ___: partial Ureteral stent removal (5cm removed). At the time of discharge, the patient had Acute kidney injury History of kidney transplant Hyperglycemia Retained ureteral stent. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o female with history of living unrelated kidney transplant on ___ who now presents with Acute kidney injury, creatinine increased to 1.9 ___s hyperglycemia at home. She recently had mycophenolate schedule changed to 500 mg four times a day which she reports has helped improve appetite . Ultrasound on admission showed new hydronephrosis. Foley catheter was placed and she received IV hydration. The creatinine was 1.9 on admission and has decreased to 1.6 on day of discharge. . Urology was consulted for ureteral stent removal when the Foley catheter placement did not improve the hydro on ultrasound. Stent removal was attempted at bedside, however, the stent broke off during removal at about 4-5 cm, so will need urology follow up with planned removal when internal suture dissolves as it seems the ureteral stent may have inadvertently been sutured in and will need to wait for the suture to dissolve before re-attempt by urology to get the stent removed. . She was also followed by ___ for help with blood glucose management. Adjustment has been made to both long and short acting insulins. . Immunosuppression was continued per home regimen of mycophenolate 500 mg four times daily (for help with nausea and anorexia at home). Tacro was dosed based on daily levels, and she is discharged on 2.5 mg twice a day. . Patient will be seen in clinic with labs on ___ and urology will make removal plans most likely in about 6 weeks. . She is ambulatory and tolerating a diet.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M h/o metastatic melanoma and recent cellulitis, enterobacter bacteremia, and spinal osteomyelitis c/b C diff infection presenting with failure to thrive at home and ongoing diarrhea. Chest radiograph showed 1. Right upper extremity PICC tip terminates in the right atrium, approximately 4 cm beyond the cavoatrial junction. Please no redundancy in the PICC in the area of the axilla. 2. Low lung volumes. Bibasilar atelectasis without focal consolidation. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:36 am, 2 minutes after discovery of the findings. MR ___ SPINE W/O CONTRAST ___ MR SPINE showed 1. Nondiagnostic exam. 2. Comparison MRI exam is essentially nondiagnostic as well. 3. CT lumbar spine recommended in further evaluation. 4. Abnormal L1-L 2, L3-L4 disc spaces, vertebral bodies, may represent disc space infection. 5. Probably mild L1-L 2, moderate L3-L4 central canal narrowing. RECOMMENDATION(S): CT lumbar spine CHEST (PORTABLE AP) showed The course of the right PICC line is unremarkable, the tip projects over the mid SVC. No complications, no pneumothorax. Lung volumes have decreased. Borderline size of the cardiac silhouette. Radiology showed Right PICC terminates in the mid SVC. No pneumothorax. The patient was diagnosed with Diarrhea, unspecified. At the time of discharge, the patient had Osteomyelitis of spine C diff infection Cirrhosis Melanoma on study drug Venous stasis bilateral Morbid obesity Failure to thrive in adult. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Brief summary: This is a ___ with metastatic melanoma and recent spinal osteomyelitis/ GNR bacteremia c/b C diff infection presenting with failure to thrive at home and ongoing diarrhea in setting of missed vanco doses, admitted for rehab placement and workup of ongoing severe back pain. Workup reassuring, doing well with nursing care and ___. Discharged to rehab facility.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old gentleman with history of HFpEF (last LVEF 50% to 55%), atrial fibrillation, and Alzehimer's dementia presenting for altered mental status and volume overload. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormalities. 2. Chronic infarcts right cerebellum, left frontal lobe. Chronic encephalomalacia anterior bilateral frontal and anterior right temporal lobes, likely posttraumatic. 3. Brain parenchymal atrophy. US BUTTOCKS, SOFT TISSUE RIGHT showed Induration of the skin and mild subcutaneous fat edema. No focal mass or fluid collection. The patient was diagnosed with Disorientation, unspecified, Altered mental status, unspecified. At the time of discharge, the patient had Primary Diagnosis - Community acquired pneumonia Secondary Diagnoses: - Acute on chronic diastolic heart failure - Acute metabolic encephalopathy - Alzheimers dementia - Non healing right thigh ulceration - Serofast state (history of latent syphilis). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman with history of HFpEF (last LVEF 50% to 55%), atrial fibrillation, and Alzehimer's dementia presenting for altered mental status and volume overload, found to have multifocal pneumonia & non healing right thigh ulceration. ====================================== HOSPITAL COURSE BY PROBLEM LIST ====================================== # Community acquired pneumonia, treated Patient admitted with cough and leukocytosis, with CXR concerning for multifocal pneumonia. Initially covered on vanc/zosyn, but narrowed to levaquin given low risk for resistant agents and clinical stability. Urine legionella negative. Remained afebrile and on room air during hospitalization, and finished a 5 day course in hospital on ___. # Acute diastolic heart failure exacerbation, resolving Per cardiology clinic note ideal weight of 170 to 175 pounds, admitted at 195 lbs (although this is bed weight). BNP 8744, at last admission for HF was in 6000s. JVD clearly elevated, although difficult to interpret in setting of TR. At home on bumetanide 2 mg daily, recently increased to BID. He was diuresed with lasix 80mg IV and then restarted on home bumetanide prior to discharge. He was 183 lbs on discharge. He has close cardiology follow up. # Acute metabolic encephalopathy, resolving # Chronic Alzheimer's Dementia Per collateral, patient more confused than at baseline. Likely secondary infection as above. Improved during hospitalization, discharged at baseline. # Chronic non healing ulceration right thigh # History of latent syphilis U/S right thigh ___ revealed induration of the skin and mild subcutaneous fat edema. No focal mass or fluid collection. No evidence to suggest skin or soft tissue infection. ACS evaluated patient and this does not need debridement. Recommend keeping the patient off of the right hip possible. Patient should follow up with General Surgery Dr. ___ as needed. The possibility of syphilitic gumma was invoked this admission, however, do not suspect tertiary syphilis. RPR titer was 1:2 likely indicative of serofast state given patient has been treated for syphilis x 2 (most recently in ___ ___ years ago according to family). Unable to obtain records from ___ this admission due to holiday. Likely right thigh ulceration is secondary to pressure of subcutaneous benign nodule (per prior biopsy results). # ___ Cr 1.3 peak from baseline 1.0, pre-renal versus cardiorenal in the setting of infection and heart failure exacerbation. Returned near baseline at time of discharge. Should repeat as outpatient at cardiology follow up. # Demand ischemia TNT 0.04 x 3. No EKG changes or angina symptoms. Likely demand ischemia in setting of infection and heart failure exacerbation. Not on aspirin, statin, or beta-blocker, presumably due to prior risk/benefit discussions. # Atrial fibrillation CHADS-2-Vasc 4, not on rate control as outpatient and not on anticoagulation due to prior history of BRBPR and goals of care discussions. Rates remained in ___. # Macrocytic anemia Chronic, close to baseline. ====================================== TRANSITIONAL ISSUES ====================================== [] Please recheck lytes at next appointment to monitor Cr [] Please ensure patient follows with cardiology outpatient as scheduled [] Please follow up on treponemal antibody (sent to state lab) given quantitative RPR reactive at titer 1:2 (this likely represents serofast state). Please obtain repeat RPR in 6 months to ensure stability in this titer. Consider referral to Infectious Diseases. [] Unable to retrieve department of public health records this admission regarding prior courses of syphilis treatment. He was treated in his ___ in the ___ per family and again in his ___ for reactive RPR in the ___. His last treatment was reportedly per family by Dr. ___ - ___ ___ Care ___. [] Wound care recs: 1. Commercial wound cleanser or normal saline to cleanse wounds. 2. Pat the tissue dry with dry gauze. 3. Apply No Sting barrier to ___ wound skin. 4. Apply nickel thick layer of Santyl to yellow necrotic tissue. 5. Cover with barely moistened saline gauze. Then cover with ___ ABD pad. Secure with medipore tape. Change daily. 6. Try to offload weight from right hip. [] If chronic non healing wound persists, patient should follow up with General Surgery Dr. ___ (has seen outpatient before) [] Discharged with Rx for home ___ given unsteadiness on feet #CODE: DNR/DNI (MOLST, confirmed with sister ___ #CONTACT: ___ - ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ y/o man with a PMH of COPD (2.5L home O2), HFpEF, AFib (on warfarin), CKD, and T2DM, recently discharged on ___ after admission for MRSA HCAP, C. difficile colitis, acute on chronic diastolic heart failure, and acute interstitial nephritis treated with prednisone, and recent discharge on ___ for acute CHF exacerbation who presents from ___ clinic to the ED for feeling dizzy during the visit, confused and found to BP of 84/40, HR of 50, and O2 Saturation of 84% on room air. The patient appeared very unsteady, trying to get out of chair. He was taken to the ED. On arrival to the ED his vitals were 0 97.5 74 101/48 24 86% Nasal Cannula. The patient was found to have slightly increased potassium and elevated leukocytosis. The patient improved on Nasal cannula. He was given levofloxacin (cephalosporin allergy) and vancomycin. The patient's potassium was stable for the 24 hrs in the ED. His creatinine was at baseline. Other labs were at baseline. The patient was continued on his home medications except for anti-hypertensives and his diuretics were held. He was found to the evidence of multifocal pneumonia on CT scan. He was given 2 L of NS and tolerated the fluids well. He was admitted to the medicine service. On arrival to the floor the patient's vitals were 97.9 157/59 79 19 100 on 4L. The patient was resting in bed. Able to respond to simple questions. A+O x 2 (name and place). The patient's daughter was at the bedside. Patient unable to perform extensive ROS. REVIEW OF SYSTEMS: Per HPI. Denies chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, rash. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality. CHEST (AP AND LAT) showed 1. Compared with the prior radiograph, increased left basilar and mid lung opacification, accompanied by increased pleural fluid. 2. Improved aeration of the right lower lung. 3. Persistent cardiomegaly. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Primary: Healthcare associated pneumonia with sepsis, hypoxemia Secondary: Diastolic heart failure without exacerbation, CKD, COPD, recurrent aspiration, CAD, HTN, Afib. The patient was given written instructions concerning 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 male with past medical history of chronic respiratory failure, COPD on home O2, chronic diastolic CHF, AFib, type 2 diabetes, recent admissions ___ for MRSA pneumonia, Cdiff colitis and acute interstitial nephritis, ___ for acute diastolic CHF exacerbation, admitted ___ with episode of hypotension and hypoxia with pneumonia, clinically improving on antibiotics and able to be discharged home on course of Levofloxacin and linezolid for MRSA and typical organisms. # MRSA Pneumonia - The patient presented to the ED with hypotension and multifocal opacities on chest Xray and CT scan. Of note, he was recently admitted for MRSA pneumonia so per the radiology team, it was difficult to determine if there was new pneumonia or whether the air space findings were unresolved findings consistent with recently treated pneumonia. Since the patient presented with hypoxia, still had significant disease on CXR, and is a somewhat frail patient, we decided the benefits of treating outweighed the risks. He was initially treated with Vancomycin and Levofloxacin, and then transitioned to PO Levofloxacin and PO linezolid to cover MRSA as well as atypical organisms. His hypoxia rapidly improved to home 2L, satting 100% by discharge. Of note, the patient had come in on 10 mg of Prednisone daily which was supposed to be a finished taper from his last discharge. He was given pulse dose of 40 mg Prednisone once in the ED, but then was tapered off of 10 mg Prednisone and is now not on any steroids whatsoever. Note: the etiology of his pneumonia was felt to likely be aspiration given known dysphagia and history of family being non-compliant with dysphagia diet. # Chronic Anemia: Likely anemia of chronic disease as TIBC low, iron low, and ferritin high-normal. ___ also be related to ESRD. Hemoglobin fluctuated between 7 and 8. Continued home iron supplement and it should be monitored as outpatient. # Hypotension: In setting of above hypoxia had 80's/40's in ED, which resolved after 2 L IVF. It was felt that the most likely cause of his hypotension was infection and overdiuresis (the patient was started on daily torsemide instead of prn torsemide on last discharge). He was treated for pneumonia as above and changed to Torsemide 20 mg every other day instead of every day to prevent overdiuresis. His Amlodipine was held and we continued to hold on discharge. We also held his Metoprolol during his hospitalization but it was restarted for discharge. #Goals of Care: Pt still currently Full Code. Further conversations can be continued in the outpatient setting with the physicians he knows best. Chronic issues # CKD stage V - secondary to recent acute interstitial nephritis. Per the patient during discussions during recent hospitalizations and in the outpatient setting, the family and patient have decided not to pursue dialysis but rather conservative care. We continued Sevelemer. Pt had previously been receiving a steroid taper for AIN but taper finished while hospitalized this time. He was given a low-K diet. # Atrial fibrillation. Apixaban changed to warfarin on prior admission. INR 1.9 on admission. We resumed warfarin without bridging given no h/o stroke. Of note, on the day of discharge his INR rose to 2.3 but the Warfarin dose was decreased from 3 mg qdaily to 2 mg qdaily due to drug interaction with Levofloxacin. Consider restarting 3 mg once Levofloxacin is discontinued. # T2DM. Steroid-induced. Restarted ISS in house due to steroid, but stopped on discharge. His sitagliptin was stopped during this admission due to severely impaired renal function. # COPD. On home ___ O2. No clear exacerbation currently. Continued home tiotropium & albuterol as above. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH ___, CAD, stable angina, hemorrhoids presented to ___ for chest pain. He had two episodes of usual nonradiating angina pain this AM that resolved with nitro patch and repeated in ___ that resolved with sublingual nitro; then the pain happened again an hour later with diaphoresis which prompted pt to go to ___. At the OSH, EKG found ST depressions in inferior and lateral leads with unremarkable posterior EKG. Additionally, he was hypotensive with SBP in the ___, acute on chronic renal failure with elevated K (5.9), +trop @ 0.31. He was found to be guaiac+ stool and grossly anemic 5.8/20.5, but pt denies frank melena, brbpr, or significant history of GI bleed. Although pt says that his hemorrhoids sometimes bleed with indomethacin. Transfused 1 unit pRBC, CP controlled with 6 mg morphine, and transferred here. Unclear if patient has a hx of liver disease. Patient usually gets care from ___ but was referred to ___ due to ___ having no available space. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. No intra extrahepatic biliary dilatation is seen. 2. There are no sonographically specific signs for acute cholecystitis identified. There is mild gallbladder wall edema measuring up to 5 mm. This finding is nonspecific and could be related to third spacing or in the right clinical setting could suggest cholecystitis. Radiology showed Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. HAND (PA,LAT AND OBLIQUE) BILATERAL showed Studies are compromised secondary to patient positioning and technique. Arthritic changes. Mild osteopenia. KNEE (2 VIEWS) BILAT showed Joint effusions. Right medial compartment narrowing. Vascular calcification. The patient was diagnosed with Anemia, unspecified. The patient was treated with EGD, cardiac cath. At the time of discharge, the patient had Primary ===== Type II NSTEMI Duodenal Polyp Gastric Ulcer Anemia Secondary ========= Polyarthritis New diagnosis of heart failure with reduced ejection fraction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ PMH ___, CAD, stable angina, hemorrhoids p/w chest pain likely demand NSTEMI and troponin bump in the setting of anemia of unclear etiology, concern for GI bleed, with astral ulcer and duodenal polyp found on EGD. Patient also found to have ___ on ___ likely in setting of hypotension and anemia. Also new reduced EF and RWMA on Echo. Course complicated by recurrent chest pain, s/p cath with 1DES placed and initiated on DAPT. Also acute flare of polyarthritis, likely gout, which required steroid treatment.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HTN, CHF, DM2, CAD s/p LAD PCI, ESRD on HD TRSa, seizure disorder, chronic pain, PVD who presents for evaluation of traumatic findings after fall with headstrike. He slid off his toilet last night, struck his head, and lacerated his penis. Was seen at ___, where he had normal NCCT head/cspine. Per OSH records, has been somnolent and "drowsy" since arrival to OSH. Was given TDAP, laceration to dorsal penis was repaired with 3 ethilon sutures, and MRI was obtained. This study was apparently notable for "soft tissue injury with edema around C3, C4" (per call in, MRI disc and report not seen in transfer paperwork). He was transferred here for spine eval. CT chest without intravenous contrast showed 1. No acute fracture or malalignment. There are multiple chronic bilateral rib fractures, grossly unchanged as compared to CTA chest ___. 2. No acute intrathoracic abnormality. 3. Mildly dilated main pulmonary artery is unchanged as compared to ___, nonspecific in etiology. This can be seen with pulmonary hypertension. 4. Prominent left axial lymph node is unchanged as compared to ___. This is nonspecific in etiology and could be reactive. MR ___ SCAN WITH CONTRAST T9412 MR ___ SPINE showed 1. At C3-C4 there is evidence of discitis and osteomyelitis. 2. Abnormal peripheral enhancement of a disc bulge at C3-C4 may represent infected disc protrustion, phlegmon or abscess. CT guided bone biopsy showed Successful C3 vertebral body biopsy with no immediate complication. The patient was diagnosed with Oth incomplete lesion at C3, init, Oth incomplete lesion at C4, init, Fall on same level, unspecified, initial encounter. The patient was treated with ___ biopsy of cervical spine (___). At the time of discharge, the patient had Primary diagnosis ================== - C3-C4 Discitis/Osteomyelitis Secondary diagnosis ==================== End-stage renal disease on hemodialysis Chronic pain Type 1 diabetes mellitus Hypertension 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>___ with hx of DM1 c/b prior L foot osteo with MRSA, ESRD on HD TRSa, chronic pain on methadone, HTN, CHF, CAD s/p LAD PCI ___, and seizure disorder (not on AED) who initially presented to AJ s/p fall, found to have possible C3-4 discitis/osteomyelitis on imaging, transferred to ___ for neurosurgical evaluation. Course complicated by frequent requests to leave against medical advice -- ultimately, interventional radiology able to perform bone biopsy on ___. All blood cultures remained negative for growth with normal inflammatory markers, lack of fevers or leukocytosis. Discharge plan was made with infectious disease, patient and his PCA/HCP ___ for the patient to be discharged off antibiotics after the bone biopsy with plan for close infectious disease follow-up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female HCV/cirrhosis with encepholopathy, polysubstance abuse, DM2, HTN, cryptococcal meningitis s/p VP shunt in ___ for hydrocephalus presenting with altered mental status and fall this morning. CHEST (PA AND LAT) showed Low lung volumes with streaky bibasilar opacities, likely atelectasis, but infection cannot be completely excluded. CHEST (PA AND LAT)CHEST (PA AND LAT)i showed Lung volumes are lower today, reflected in greater atelectasis in the right lower lung. Pulmonary vasculature is minimally congested although heart size is normal and there is no pulmonary edema. I see no evidence of pneumonia. There is no pneumothorax or appreciable pleural effusion. Radiology showed No displaced rib fracture. RENAL U.S. showed 1. No hydronephrosis. 2. Similar benign appearing renal sinus cyst on the left. The patient was diagnosed with RHABDOMYOLYSIS, ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had Primary diagnoses: Acute kidney injury Secondary diagnoses: Altered Mental Status Rhabdomyolysis Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ___ with HCV, cirrhosis, cryptococcal meningitis s/p VP shunt placement who presents with AMS after fall, found to have +tricyclics in serum, elevated CK and troponinemia. #Fall complicated by rhabdomyolysis (see below): CT head at outside institution was negative. C-spine was cleared clinically. PAtient had tenderness on chest wall, possibly secondary to fall or chest compressions. A rib series was performed which showed no fracture. The patient was followed by physical therapy throughout hospitalization and despite having some orthostasis and dizziness (which is her baseline) she had steady gait and was considered to be safe to be discharged with home ___. #TCA overdose: +tricyclics at OSH. Originally presented with dry MM, hypotension, AMS, concerning for TCA overdose. states that she took nortriptyline, but not more than usual. Possible signs of TCA overdose on EKG with slurring of deep S wave and widened QRS. Patient was given 50mg IV sodium bicab x3 and started on bicarb gtt. pH was monitored while on drip. Toxicology was consulted. EKG changes resolved and revealed NSR. #Altered mental status: Resolved by the time patient presented to ICU. DDx includes ingestion (marijuana vs TCA overdose) vs hepatic encephalopathy vs infection. UCx and BCx were collected and showed no abnormal growth for urine and blood cultures ___. Serum tox/Urine tox were negative here. The patient's mental status returned to normal by the time she was transferred to the floor. ___: Baseline Cr around 0.7-0.9, on admission Cr was elevated to 2.9, likely due to rhabdomyolysis given history of fall and elevated CK. Patient was bolused with fluids followed by maintenance IVFs. Urine output was monitored. The patient's creatinine rose up to 6.0 on ___. Nephrology was consulted. Analysis of urine electrolytes showed fractional excretion of sodium of 0.29%, consistent with prerenal kidney injury. The urine sediment showed no casts. With good PO fluid intake the patient's creatinine began to drop and by day of discharge was 1.7. She continued to have good urine output. #Elevated troponin and chest pain: The patient's chest pain was most likely musculoskeletal in nature, due to reproducibility on exam. Seen by by cardiology who felt that troponin elevation likely in the setting of rhabdomyolysis, with neg MB index. Rib series was done, as above. Cardiac enzymes were cycled. TTE was performed which showed mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function, high cardiac output. The patient's chest pain was managed with a lidocaine patch as well as acetaminophen. #Leukocytosis: On admission the patient presented with a leukocytosis, which was considered to be secondary to a stress response from a fall. Upon ICU admission the patient was empirically started on pip/tazo for possible aspiration pneumonia, given hte patient's initial O2 requirement, lung exam, and worsened CXR; however, this was was subsequently stopped. The patient's leukocytosis resolved but then uptrended slightly. Repeat urine cultures were drawn and results were pending on day of discharge. The patient denied any urinary symptoms throughout hospitalization. #HTN: The patient was not on any home meds. She developed hypertension with SBP into the 180s during hospital stay and was started on labetalol which was uptitrated to 400 mg TID and was also started on amlodipine. However, the patient had symptomatic orthostatic hypotension requiring cessation of all BP meds. She was not orthostatic at time of discharge and was not discharged on any BP medications. #VP shunt with exposed shunt hardware: Seen by neurosurgery. CSF with no evidence of infection. Plan for shunt hardware removal as an outpatient per neurosurgery. #DM: The patient was not on any medications, diet controlled at home. Placed on insulin sliding scale during hospitalization. # Bipolar Affective disorder: The patient's home lorazepam, quetiapine, sertraline and trazodone were initially held in light of possible AMS and EKG findings. After the patient returned to the floor from the ICU, sertraline and trazodone were restarted; however, lorazepam and quetiapine continued to be held. She was discharged home with a few tablets of lorazepam. Close follow-up was arranged with the patient's psychiatrist upon discharge in order to reconcile psychiatric medications. TRANSITIONAL ISSUES # ___: - At PCP follow up please check Chem-7 - Can make outpatient renal follow-up in ___ weeks if creatinine does not resolve back to baseline # Leukocytosis: - At PCP follow up please check CBC # Hypertension: - Check BP at PCP office and consider reinitiating antihypertensive therapy # VP shunt: - Patient has an appointment with neurosurgery to evaluate shunt hardware. # Bipolar affective disorder: - Psychiatry f/u to consider med adjustment. # Cirrhosis: - The patient will be called to schedule an appointment with Dr. ___ known ___ Will likely need AFP, EGD, RUQUS.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Chest: Frontal and lateral views showed Moderate pulmonary vascular congestion. Redemonstrated evidence of interstitial lung disease. ABDOMEN US (COMPLETE STUDY) showed No ascites seen in the abdomen. Chest radiographs, PA and lateral. showed Findings consistent with underlying interstitial lung disease, as seen previously on CT without any definite superimposed process. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had Primary diagnosis Acute heart failure exacerbation Interstitial lung disease Asthma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PATIENT SUMMARY =================== ___ year old woman with PMH significant for CAD s/p CABG (___), pAF on warfarin, HFpEF (LVEF 60% ___, COPD, ILD c/b moderate pulmonary HTN, CVA without residual deficits, HTN, HLD, who presented to the ED with 3 weeks of worsening dyspnea, found to have pulmonary congestion and elevated BNP, and admitted for heart failure exacerbation. She was diuresed with lasix to a dry weight of 146lbs and discharged to home. While hospitalized she was also evaluated by pulmonary out of concern for progression her lung disease. They recommended she continued to be followed as an outpatient and restart spiriva. She was evaluated by physical therapy who recommended discharge to home with referral to outpatient pulmonary rehab. ===================== TRANSITIONAL ISSUES ===================== [] Would discuss with outpatient PCP and cardiologist whether she could be a candidate for DOAC ?cost?. She has normal kidney function, normal BMI, no history of failed DOAC trial. [] She continues on her pre-admission Warfarin. Please check INR at least weekly, and at next visit. [] Please check electrolytes at next visit with PCP. [] Was started on Spiriva this admission, please insure she continues to use daily. [] Please insure she attends appointment with Dr. ___ on discharge for repeat PFTs with DLCO. [] ___ this admission recommended that she participate in outpatient pulmonary rehab. She was provided with resources to attend. Please continue to encourage her to attend rehab as outpatient. DISCHARGE WEIGHT: 145 lbs DISCHARGE DIURETIC: Torsemide 20mg every other day ___, TH) DISCHARGE CREATININE: 1.1 CODE: Full CONTACT: ___ Relationship: Daughter Phone number: ___ =============== ACTIVE ISSUES: =============== # Dyspnea on exertion # Acute on Chronic HFpEF: She presented with 3 weeks of dyspnea on exertion with pulmonary edema and increased BNP. The trigger for her presentation was not clear, she is adherent to her medications, no dietary changes. She responded to diuresis with some improvement in her breathing though with decreased output and still with DOE. Her LVEF is 60% in ___, repeat TTE this admission showed LVEF of 60% and IVC of 0.4 ___ edema improved with trace edema, CXR was without effusion or superimposed process, suggestion of fine reticulation in each lower lung c/w interstitial lung disease, abdominal US without ascites. Her home torsemide was increased to 20mg every other day for discharge. She was continued on her home metoprolol and spironolactone for neurohormonal blockade. # COPD: # ILD: She presented with dyspnea thought to be secondary to volume overload. However, she continued to be dyspneic despite being close to euvolemia with diuresis and home sildenafil, so pulmonology was consulted for other intervention and to consider if dyspnea could be explained by exacerbation of ILD or pulm HTN. Given RVSP appeared stable from ___, pulm thought worsening pulm HTN was unlikely. Pulm also determined that there was no indication for ILD directed therapy given disease appears stable on recent imaging. Her PFTs from ___ showed worsening obstruction, so she was recommended to continue Advair and albuterol and she was started on Spiriva for LAMA. She was seen by ___ who recommended that she see outpatient pulmonary rehab therapist. She will follow up with Dr. ___ in ___. # pAF: remained in NSR, chads2vasc 8 - continued home metoprolol tartrate 100 mg BID - continued home warfarin 1.5 mg/2 mg on alternating days - daily INR checks ================ CHRONIC ISSUES: ================ # Pulmonary HTN: last RHC in ___ with PA ___ (22) - continued home sildenafil 20 mg TID # CAD s/p CABGx3 - ___ - LIMA to LAD, SVG to PDA, SVG to the circumflex ___ - continued ASA, atorvastatin, metoprolol # DM: - held metformin while hospitalized, placed on insulin sliding scale, restarted metformin upon discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old gentleman with history of QT prolongation, CVA, hypertension, diabetes, who presents for large circumferential pericardial effusion without hemodynamic compromise. Chest: Frontal and lateral views showed Markedly enlarged cardiac silhouette with probable pericardial effusion. Portable AP chest radiograph. showed Interval opacification of the left lower lung, which may be due to atelectasis, a new pleural effusion or a localized increase in the pericardial effusion. No pneumothorax, no pulmonary edema. CHEST (PORTABLE AP) showed Stable position of the pericardial drain. Stable moderate cardiomegaly. No evidence of pneumothorax. No larger pleural effusions. No pulmonary edema. The patient was diagnosed with Pericardial effusion (noninflammatory). The patient was treated with Pericardial drain placement. At the time of discharge, the patient had Primary Diagnosis Pericardial effusion Secondary Diagnosis: Pneumonia Obstructive sleep apnea Hypertension Diabetes Mellitus Difficult Foley Placement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old gentleman with history of QT prolongation, CVA, hypertension, diabetes, who presents for large circumferential pericardial effusion without hemodynamic compromise s/p pericardiocentesis.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with asthma, ABPA on itraconazole, chronically elevated CK of unknown etiology, and hx of shoulder impingement who presents with left shoulder pain and left arm numbness. He was in his usual state of good health until 530PM on the day of presentation, when he was watching TV and developed a sharp pinching sensation at the left AC joint. Over the next two hours, the pain spread to involve the supraclavicular region and left lateral chest, and was worse with deep inspiration. He also noted numbness and heaviness of the left arm. He also felt cold. He felt that he was mentating normally, and had no visual changes, other weakness or numbness, HA, or facial droop. No CP or dyspnea. He texted a friend, who recommended he come to the ED to r/o stroke. In the ED intial vitals were: ___ 151/81 18 98% ra. Labs significant for CBC ___, ALT 77, AST 97, AP 82, Tbili 0.4, Alb 4.1. Lytes normal with bicarb 21 (gap 11). Trop 0.06 (most recent 0.08 and 0.09 in ___, CRP 2.1. Coags normal. CXR with no acute process. On ROS, he denied trauma to the shoulder or arm. He did lift weights two days prior to presentation, but did not note any pain following his workout. He has had calf pain since 3 days prior to presentation, which started when jumping rope, but no swelling. No recent dyspnea (he endorses about one year of decreased exercise tolerance, but is unsure whether this is due to weakness vs. SOB). Denies fever, cough, sputum production. CT HEAD W/O CONTRAST showed 1. No acute intracranial process. MRI is more sensitive for acute ischemia. 2. Bifrontal cortical atrophy, allowing for the patient's age. 3. Extensive paranasal sinus inflammatory disease, status post sinus surgery, incompletely imaged. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Left arm numbness Elevated CK 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>ASSESSMENT AND PLAN: ___ year old w/ hx of asthma, APBA, hyperCK of unknown etiology, and hx of shoulder impingement, who presents with left shoulder and chest pain and left arm numbness, now with resolved numbness but continued supraclavicular pain worse with inspiration. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ female smoker with no significant past medical history who presents with two week of progressive right side weakness. Patient reports that two weeks ago she started having a pins and needles feeling in her right foot. Then about 7 days ago she was unable to move her right foot. Since that time she has progressed to severe weakness in the RLE. She also reports that over the last two days her right hand has been clenching into a fist. She does not realize this is happening until she looks at her hand. She feels that her hand and arm are a little weak and she has noticed her writing has become worse. Last night, while eating dinner, she noticed she kept dropping her fork. Her son saw her last night and strongly encouraged her to go to the ED for evaluation. She presents today to ___ ED. ___ showed multiple areas of hypodensities, the largest left frontal concerning for underlying lesions. The neurosurgery team was consulted for evaluation. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Multiple brain lesions with edema suggesting metastases. MRI with contrast is recommended for further evaluation. 2. There is mass effect including left frontoparietal sulcal effacement, partial effacement of the left lateral ventricle and approximately 4 mm of left-to-right midline shift. The basilar cisterns appear patent. RECOMMENDATION(S): MRI brain with gadolinium is recommended to evaluate for underlying mass lesion/metastatic disease. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:41 pm, 10 minutes after discovery of the findings. MR HEAD W AND W/O CONTRAST ___ MR HEAD. showed 1. Multiple predominantly left hemispheric ring-enhancing lesions with varying degrees of surrounding vasogenic edema suggestive of metastatic disease, as above. 2. There is mass effect including partial effacement of the left occipital horn and 6 mm left-to-right midline shift. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 8:42 am, 5 minutes after discovery of the findings. Chest: Frontal and lateral views showed Essentially complete opacification of the left upper lobe. Given that the trachea is shifted toward the right(opposite side), this is worrisome for a space occupying process such as large consolidation and/or mass, with possibly some underlying atelectasis, but the major factor is space-occupying. CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS showed 1. There is a hypoattenuating lesion in the lower pole of left kidney which could represent a primary versus metastatic lesion. 2. Multiple hypoattenuating cystic lesions within the liver do not enhance and are most consistent with simple cysts. 3. Please refer dedicated CT chest for further characterization. CT CHEST W/CONTRAST showed Large 17 cm left mid and upper lobe mass with areas of central necrosis, mediastinal shift towards the right and invasion into the left upper lobe pulmonary artery and bronchi, highly concerning for malignancy with associated lung collapse. Tissue diagnosis is recommended. NOTIFICATION: The findings were discussed with ___, NP, by ___, M.D. on the telephone on ___ at 4:10 pm, 20 minutes after discovery of the findings. Ultrasound-guided Procedure showed Successful ultrasound-guided core biopsy of the left upper lobe mass. RECOMMENDATION(S): Follow-up chest radiograph in 1 hour following the procedure. Order placed in POE. Chest radiograph, portable AP upright view. showed No short-term change in the appearance of the chest. CHEST (PORTABLE AP) showed No significant interval change since ___. The patient was diagnosed with Other specified disorders of brain. The patient was treated with ___ ___ guided biopsy of L lung lesion. At the time of discharge, the patient had Metastatic Brain lesions Adenocarcinoma of the lung RLE>RUE paresthesias and weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with history of tobacco use without other known PMH presents with two weeks of RLE>RUE paresthesias and weakness for two weeks, found to have multiple brain lesions with vasogenic edema concerning for metastases with workup revealing a primary lung adenocarcinoma, with ?renal metastasis vs. primary, admitted to neurosurgery and later transferred to oncology for initiation of radiation therapy and underwent cyberknife therapy. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old healthy man presents with fever, productive cough, and dyspnea on exertion. Symptoms began 5 days ago. Associated vomiting and central chest pain with coughing. Significant anorexia and night sweats. No nasal congestion, sinus pressure, headache, or sore throat. Denies unintentional weight loss, hemoptysis. Traveled to ___ ___ years ago, otherwise no travel outside of country. No h/o incarceration or known TB exposure. HIV negative in ___. No known sick contacts. History of intermittent smoking as a teenager, no smoking currently. No history of asthma. No history of pneumonia in past. In the ED, initial vital signs were 102.3 98 146/85 20 97% RA. Labs notable for WBC 21.4 (81% PMN), lactate 2.7 (improved to 1.0 with 2L fluids), normal chem 7, UA without signs of UTI. CXR showed multifocal consolidating pneumonia. Received levofloxacin 750mg, azithromycin 500mg x1 and 250mg x1, acetaminophen and albuterol/ipratropium nebulizers. He was kept in ED observation overnight, but became tachypneic when walking short distances, so he was admitted. Vitals prior to transfer: 100 82 131/79 16 97%. Upon arrival to the floor, patient is slightly dyspneic, but satting well (99%) on room air. Radiology showed Multifocal consolidative opacities concerning for multifocal pneumonia. Followup radiographs after treatment are recommended to ensure resolution of these findings. Radiology showed Worsening pneumonia. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Primary: 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>___ year old healthy man presents with fever, productive cough, and dyspnea, found to have multifocal consolidative pneumonia. # Legionella pneumonia: Patient presented with five days of dyspnea. Chest x ray on ___ showed multifocal consolidative opacities concerning for multifocal pneumonia. Patient met SIRS criteria (temp >100.4, HR >90, leukocytosis) but with normal oxygen saturation. Community acquired pathogens (most likely S.pneumo) initially suspected. Influenza less likely given incidence has dropped with the finishing season (also he is ___ days from symptom onset which places him out of the window for treatment). Patient had no known TB exposure risk factors, but was checked for immunocompromised state given severity of pneumonia and ___ age. HIV antibody was negative. Notably he does not have underlying lung disease (no COPD/asthma). Sputum culture had extensive contamination with upper respiratory secretions. A urine legionella antigen was check and positive. Patient was started on levofloxacin 750mg for a 5 day course. He was also given albuterol and ipratropium nebulizer for wheezing on exam and subjective dyspnea. He was given mucinex as needed for cough and tylenol as needed for fever. Dept public health notified of positive legionella by the lab. # Obesity/Metabolic: Elevated blood glucose on testing, needs repeat HbA1C as an outpatient and well as ongoing dietary and exercise counseling.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient sustained multiple stab wounds and a right upper extremity bite wound during an altercation with his SO. Apparently this is not the first time he has been injuried by this particular individual TRAUMA #3 (PORT CHEST ONLY) showed No evidence of fracture or pneumothorax. The patient was diagnosed with INTRATHORAC INJ NOS-OPEN, ASSAULT-CUTTING INSTR. At the time of discharge, the patient had Stab wounds Human bite. The patient was given written instructions concerning 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. ___ AKA ___ was admitted to the trauma service after sustaining stab wounds x2 and a bite wound in the RUE. He was started on Prophylactic Augmentin and wounds were washed and examined. They were found to be rather superficial and did not violate fascia. The Chest wound was approximated with 3 stitches using sterile technique, leaving ample space for drainage in between. Serial abdominal exam was benign and unchanged. His pain was controlled with oral regimen. He remained afebrile and hemodynamically intact during the entire hospitalization. He felt well and was discharge in good condition with plan to continue 5 days of antibiotics. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a very pleasant ___ year old female with history of severe TBM, now POD ___ s/p tracheoplasty with mesh, bronchus intermedius and right main-stem bronchus bronchoplasty with mesh, and left main-stem bronchus bronchoplasty with mesh. She tolerated the procedure well and was discharged home on POD8. She reports that she was doing well until three days ago, when she began to have intermittent shortness of breath, which has progressively worsened. She reports air hunger and pleuritic chest tightness today. These symptoms are different from the symptoms she had prior to the procedure. Her chronic dry cough has improved and she reports ther her bilateral pretibial edema is stable. Radiology showed AP chest compared to ___: Changing contour of the right lung base is presumably an indication of decreased right pleural effusion due to interval thoracentesis. There is new focal opacity in the right upper chest at the level of the first anterior interspace. This could be loculated pleural fluid seen on the chest CTA ___. I don't see the region well enough to exclude pneumothorax, and therefore when feasible, conventional chest radiographs should be obtained. Heart is normal size. Left hemithorax unremarkable aside from mild basal atelectasis. The right lower lobe lung lesion, probably focal atelectasis, seen on the chest CT is also barely visible. The patient was diagnosed with RESPIRATORY ABNORM NEC, CHEST PAIN NOS. The patient was treated with Right pleural thoracentesis. At the time of discharge, the patient had Right pleural effusion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the Thoracic Surgerical Service on ___ after presenting to the ___ ED with worsening shortness of breath x3 days. Of note, was POD ___ s/p tracheoplasty with mesh, bronchus intermedius and right main-stem bronchus bronchoplasty with mesh, and left main-stem bronchus bronchoplasty with mesh. She was admitted to thoracic surgery, placed on a regular diet and home meds were continued along with scheduled nebulizers. On HD1 she underwent an uncomplicated thoracentesis by the interventional pulmonology team. At the time of discharge the evening of HD1 the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The post procedure chest xray was negative for an acute thoracic process. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is ___ with history of Hepatitis C, chronic pain on methadone, COPD on and off prednisone, esophageal stricture s/p dilatation ___ who initially presented to ___ with altered mental status. The patient's sister reports that the night prior to admission, he started developing nausea. She heard him in the bathroom, and reports that he had a normal BM. She denies him vomiting, but reports that he kept moaning and couldn't verbalize what was hurting him. Because of this unresponsiveness, the patient's sister called EMS. Radiology showed 1. Nondiagnostic study for pulmonary embolism as the lobar, segmental, and subsegmental pulmonary arteries were not assessed. No pulmonary embolus is seen within the left or right main pulmonary artery. 2. Multifocal consolidations in the right upper and bilateral lower lobes which may be due to aspiration or infection with superimposed scarring in the right lower lobe. 3. Mildly limited assessment of the abdomen secondary to motion. No acute intra-abdominal pathology to explain the patient's left lower quadrant pain. 4. Multiple compression deformities of the thoracic and lumbar vertebrae, which do not appear to be acute. Correlate clinically with history and symptoms. Radiology showed Left total hip arthroplasty without hardware complication, fracture, or periprosthetic loosening. The patient was diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS. At the time of discharge, the patient had 1. aspiration pneumonia 2. COPD exacerbation *Anticipated rehab course less than 30 days*. The patient was given written instructions concerning 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 ___ with history of Hepatitis C, chronic pain on methadone, COPD on and off prednisone, esophageal stricture s/p dilatation ___ who initially presented to ___ with altered mental status and hypotension in the setting of taking multiple sedating medications, found to have PNA on CT chest.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/PMHx CAD (AMI in ___ w/LAD stent. stenosis of RCA ___. ___ (LAD DES), DM, HTN p/w sudden onset of dull, pressure-like substernal, ___, chest pain for several hours. Started yesterday evening while he was driving his truck. Not alleviated by rest. Patient reports that the discomfort is similar in location to where he has had prior angina. He has difficulty characterizing the pain, however, states that this pain was different from prior MI, and more intense than before. He reports the discomfort was accompanied by some dyspnea and radiated to the back. He has not had any anginal symptoms since his last PCI in ___. Denies N/V, diarrhea, fever, chills, dizziness, diaphoresis or lightheadedness. In the ED, initial vitals were 97.8 68 136/74 18 95%. ECG showed no changes (per ED), troponin negative x 1. Was given 4 SL NG with no relief in pain, and subsequently given IV morphine, which resulted in rapid resolution of symptoms. On the floor this AM patient denies any current chest pain. No shortness of breath, diaphoresis, dizziness, or fatigue. Radiology showed Hyperexpanded lungs with increased left lower lobe peribronchial opacities, possible interval aspiration. The patient was diagnosed with INTERMED CORONARY SYND, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Primary diagnosis: chest pain Secondary diagnosis: coronary artery disease chronic systolic congestive heart failure hypertension hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with PMH significant for CAD s/p AMI with multiple DES and last PCI in ___. Has been chest pain free since this last procedure. Had episode of ___ chest pain at rest yesterday evening that lasted for several hours, and eventually resolved with IV morphine. No EKG changes or cardiac enzyme elevation to suggest ACS. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with CKD V s/p LUE brachiocephalic AVF ___ with Dr. ___ presents with erythema and drainage at his incision. The fistula was created out of concern that he may need dialysis in the near future, however, he has not yet required dialysis. For the past ___ days he has noticed that the incision has been draining and he has subjective fevers and chills. He denies paresthesia or pain of the ipsilateral hand. CHEST (PA AND LAT) showed No acute cardiopulmonary process. No focal consolidation. US EXTREMITY LIMITED SOFT TISSUE LEFT showed Adjacent to and overlying the fistula, there is a 2.6 x 1.2 x 2.6 cm heterogeneous fluid collection. Findings likely represent postoperative hematoma or seroma. Overlying infection is difficult to exclude. No evidence of pseudoaneurysm. The patient was diagnosed with Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init, Exposure to other specified factors, initial encounter, Chest pain, unspecified, Hyp chr kidney disease w stage 5 chr kidney disease or ESRD, Chronic kidney disease, unspecified, Pure hypercholesterolemia, unspecified. At the time of discharge, the patient had CKD Stage 5 Dialysis access incision 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>___ y/o male with CKD (not yet on hemodialysis) who had dialysis access created ___, who now returns with evidence of infection at the antecubital incision area. . Patient received IV Vancomycin during his stay. The cellulitis and erythema as well as purulent discharge evident on admission have decreased significantly. Access remains with positive bruit and thrill. Blood and urine cultures were sent, Urine has no significant growth and blood cultures are negative to date. . He will be discharged with 5 days of PO Keflex and a dry dressing over the incision area. Patient states wife will assist with dressing changes. . He is tolerating a regular diet. Home medications were continued as indicated. Appointment with Dr. ___ has been moved to ___ at 12 noon.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman with ESRD (on ___ HD, last HD ___, T1DM on insulin, and several other medical problems who presents with symptomatic hypoglycemia, found unresponsive. CHEST (AP AND LAT) showed Top normal heart size, otherwise unremarkable. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================== Hypoglycemia SECONDARY DIAGNOSES: ==================== T1DM ESRD HTN GERD Neuropathy Asthma Grave's disease HFpEF. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES: ==================== [] Titrate Gabapentin PRN pain [] DISCHARGE INSULIN PLAN: TAKE TRESIBA INSULIN 15 UNITS AT LUNCH TIME TAKE NOVOLOG BEFORE BREAKFAST, LUNCH AND DINNER ACCORDING TO THIS SCALE GLUCOSE BREAKFAST LUNCH DINNER BEDTIME <100 0 0 0 0 101-150 4 4 6 0 151-200 5 5 6 0 ___ 7 7 ___ 8 8 ___ 8 8 10 4 >400 10 10 12 5</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo R-handed man with history of multiple strokes who presents with slurred speech. CHEST (PA AND LAT) showed No focal consolidation to suggest pneumonia. Mild bibasilar atelectasis. CTA HEAD AND CTA NECK Q16 CT NECK. showed 1. The left internal carotid artery demonstrates calcified atherosclerosis and 50% stenosis by NASCET criteria. 2. Normal head CTA . 3. No acute intracranial process or hemorrhage. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Single punctate acute infarct in the anterior left frontal lobe. 2. Late subacute punctate infarct right frontal lobe. 3. Innumerable, small chronic infarcts cerebellum, brainstem, basal ganglia, cerebral hemispheres deep white matter. Severe chronic small vessel ischemic changes. Brain parenchymal atrophy. NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ (neuroradiology fellow) on ___ via telephone at 09:30 am The patient was diagnosed with Cerebral infarction, unspecified. At the time of discharge, the patient had Acute Ischemic Stroke in anterior right frontal lobe deep white matter. The patient was given written instructions concerning 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 right handed man with hypertension and a history of multiple prior strokes who is admitted to the Neurology stroke service with slurred speech secondary to an acute ischemic stroke in the anterior right frontal lobe deep white matter. His stroke was most likely due to poorly controlled hypertension, continued smoking and possibly a non-specific familial predisposition. His workup in the past has been extensive, including several TTEs, TEEs, hypercoagulable workup, NOTCH3 mutation. All have been negative. He reported taking ASA 81mg daily and has been compliant. At this time we would recommend switching from ASA to Plavix, but leave this decision up to his outpatient neurologist Dr. ___. His deficits improved greatly prior to discharge and the only notable weakness was in the left arm and leg, residual findings from his prior strokes. Of note he was also found to have a UTI for which he will complete a course of Ciprofloxacin HCl 250 mg. Of note he was seen by ___ who recommended that he stays one more day for closer assessment, which he refused. Thus, he will go home with home ___ at this time. =============================================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with PMHx notable for chronic thoracic myelopathy, recurrent UTIs, infectious endocarditis, diastolic heart failure, diabetes, HTN, HLD who was discharged one day ago after a 10-day admission for MRSA bacteremia with planned 6 week course of vancomycin. She presented from her rehab facility due to fever to 100.7F. She receives monthly steroids for her myelopathy and initially presented on ___ with lower extremity weakness, difficulty transferring and a recent fall at home. It was felt her exam was at baseline and she was found to have MRSA growing in 1 set of blood cultures drawn on admission. It was unclear whether this set was drawn peripherally or from her port, and subsequent sets were negative. ID was consulted who recommended a 6 week course of vancomycin ___, and recommended changing her port. The surgeon who placed her port (___) was concerned about difficulty replacing it due to her anatomy and it was ultimately left in place with vancomycin locks. She underwent a TEE that showed no vegetation and MR ___ given prior L3-L5 decompression and L4-L5 fusion with screws in place that did not show any fluid collection. In discussion with her outpatient neurologist it was decided to hold her monthly steroid injections during her MRSA treatment. In the ED, initial vitals were: 98.3 88 150/79 18 96% RA. Exam notable for bilateral lower extremity weakness that improved. IV/VI systolic murmur. - Labs notable for: Hgb 7.5, WBC 14, lactate 1.1, Flu negative - Imaging was notable for: retrocardiac opacity, more pronounced on the current examination than on the priors, may be compatible with pneumonia in the appropriate clinical context. - Patient was given: Vancomycin and cefepime Upon arrival to the floor, patient reports feeling completely well. Other than the fever (which she did not notice aside from the measurement) she has no complaints today. Specifically denies any subjective fever, chills, chest pain, dyspnea, cough, congestion, abdominal pain, N/V. Ostomy stool output is similar to her baseline right now. Review of systems was negative except as detailed above. CHEST (AP AND LAT) showed Retrocardiac opacity, more pronounced on the current examination than on the priors, may be compatible with pneumonia in the appropriate clinical context. The patient was diagnosed with Pneumonia, unspecified organism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with PMHx notable for chronic thoracic myelopathy, recurrent UTIs, infectious endocarditis, diastolic heart failure, diabetes, HTN, HLD was re-admitted after one day at rehab following 10-day admission for MRSA bacteremia with planned 6 week course of vancomycin. She re-presented from her rehab facility due to fever to 100.7F with concern for worsening infection. # MRSA BACTEREMIA Re-presented for fever to 100.7F at rehab facility on same day of prior discharge. Otherwise feeling completely well. Previous admission was for worsening lower extremity weakness with discovery of MRSA bacteremia. At that time was discharged with OPAT plan for prolonged course of vancomycin based on culture sensitivities from ___. TEE without vegetations. Management complicated by presence of chronic indwelling port which was left in place given significant anatomical complexity with original procedure and need for ongoing IV medications due to myelopathy. She remained completely stable and afebrile over course of this admission with borderline leukocytosis that was overall improved compared to prior admission. Continued vancomycin course with port vancomycin lock. Discharged with plan to continue antibiotic course as was prior to re-admission. # RETROCARDIAC OPACITY Noted to have retrocardiac opacity on CXR in ED with concern for pneumonia for which she received a single dose of cefepime. Remained afebrile and without any respiratory symptoms and so additional antibiotics were not continued. Asymptomatic and stable from respiratory standpoint. STABLE / CHRONIC ISSUES ================================= # CHRONIC MYELOPATHY / PARAPLEGIA Reportedly a sequela of Zoster infection. Wheelchair bound at baseline. Was previously on monthly Solumedrol treatments but those were held by neurology team during recent admission due to her bacteremia. Continued home muscle relaxants and pain regimen. # CHRONIC DIASTOLIC HEART FAILURE # AORTIC REGURGITATION Recent TEE demonstrated preserved LVEF though with moderate-severe aortic regurgitation, and so possible that it may be underestimating true cardiac output. Regardless, she was currently exhibiting symptoms of heart failure exacerbation. Unclear if she is on ACE and beta-blocker for cardioprotection (given pEF) or simply as anti-hypertensives. Continued home cardiac medications. Currently scheduled to follow in heart failure clinic. # HYPERTENSION - amLODIPine 10 mg PO/NG DAILY - Metoprolol Succinate XL 25 mg PO DAILY - Valsartan 80 mg PO/NG DAILY # Hx RECTAL TRAUMA S/P COLOSTOMY Stool output is currently at her baseline, relatively formed. Low suspicion for C. diff. Continued home bowel regimen. # DIABETES Non-insulin dependent. Blood sugar potentially improved given that she her Solumedrol is on hold in setting of bacteremia. TRANSITIONAL ISSUES ================================= [] Please trend CBC as outpatient, she has a anemia of chronic disease with discharge Hgb of 7.4 [] Vancomycin IV course ___ through her port WITH vancomycin antibiotic lock (see medication orders). [] Throughout the duration of her vancomycin course, she will need a weekly CBC w/ diff, BUN, Cr and vancomycin trough. All lab results will be followed up on by ___ clinic and should be faxed to ___ [] All questions regarding outpatient parenteral antibiotics after discharge should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when the clinic is closed. [] Steroid infusions for her myelopathy will be on hold through the duration of her MRSA bacteremia treatment. [ ] Currently on home PPI. Unclear if for GI prophylaxis given chronic steroids or for GERD. If steroids remain held would consider weaning PPI unless there is another indication. [ ] Discontinued Tamsulosin while admitted as unclear utility given patient is female. #CONTACT: ___ (nephew: ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year-old Female acute onset RUQ pain, nausea and vomiting since ___ which resolved spontaneously initially. On ___ she had a persistent episode of abdominal pain, fever, and vomiting. Radiology showed 1. Gallbladder distension with stone lodged in the neck and pericholecystic fluid worrisome for acute cholecystitis. 2. 3 cm hyperechoic nonshadowing lesion in the gallbladder, could represent mass lesion such as adenoma or malignancy. Alternatively, this may represent an adherent sludgeball with artifact mimicking vascular flow. Findings were discussed with Dr. ___ on ___ at 9:30 pm. Radiology showed Bibasilar atelectasis without definite consolidation or other acute cardiopulmonary process. Radiology showed 1. Findings consistent with acute cholecystitis with multifocal areas of interrupted mucosal enhancement worrisome for wall necrosis. No evidence of hyperenhancing lesion within the gallbladder, however evaluation by ultrasound would be more sensitive for this finding. No visualized adenopathy. 2. Hyperenhancement in the liver adjacent to the gallbladder fossa which could be due to adjacent inflammation; however, there is also suggestion of a thrombosed portal venous branch which can cause altered perfusion. 3. Free fluid seen tracking into the cul-de-sac. 4. Multifibroid uterus. Findings were discussed with Dr. ___ at approximately 9:30 p.m. on ___. Radiology showed Small bilateral pleural effusions with underlying atelectasis increased from ___. In the correct clinical context, superimposed pneumonia should also be considered. The patient was diagnosed with ACUTE CHOLECYSTITIS, ABDOMINAL PAIN RUQ, ABDOM/PELV SWELL/MASS UNSP SITE. The patient was treated with Open cholecystectomy on ___. At the time of discharge, the patient had Acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted on ___ for management of her acute cholecystitis. She was started on IV cipro and flagyl. This was subsequently changed to Vancomycin and zosyn once because of continual fevers. On admission, there was concern that she may have a gall bladder mass due to right upper quadrant ultrasound imaging. On ___, there was no mass visualized ___ the gallbladder during her open cholecystectomy. Her final pathology showed acute cholecystitis, no mass. She tolerated her open cholecystectomy well. A JP drain was left ___ place postop. and subsequently discontinued on day of discharge. She voided appropriately after her foley was discontinued. She was transitioned to a regular diet, which she was tolerating on discharge. Her pain was controlled on IV pain meds and toradol immediately postop. and then transitioned to oral medication. She was at her baseline functional status on day of discharge, ambulating independently. She had no complications during her hospital stay. She was discharged home without services. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PORTABLE AP) showed Bilateral ground-glass opacities noted diffusely most suggestive of pulmonary edema though a component of edema not excluded. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary arterial embolism. Evaluation of segmental and subsegmental arterial branches is limited by motion artifact. No thoracic aortic aneurysm, dissection or intramural thrombus. 2. Mucous plugging/aspirate in the lower lobe bronchi with associated marked dependent airspace consolidation predominantly in the lower lobes as well as to a lesser degree in the upper lobes with the distribution highly suggestive of massive aspiration/aspiration pneumonia. 3. Moderate centrilobular emphysema. CHEST (PORTABLE AP) showed Diffuse bilateral airspace opacities are not significantly changed when compared to the prior CT chest given differences in technique. These are suspicious for aspiration/pneumonia. The patient was diagnosed with Acute respiratory distress. At the time of discharge, the patient had PRIMARY ================================== Aspiration pneumonia SECONDARY ================================== COPD exacerbation MR ___ anemia Hypernatremia Lactic acidosis BPH Dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ======================= ___ w/h/o COPD, pHTN, mild cognitive impairment, heart failure and recent gradual decline in functional status, recurrent aspirations >6mo, fall who was admitted with acute hypoxemic respiratory failure c/b SVT, acute heart failure, ___ and hypernatremia. Patient initially managed in MICU and transferred to floor once stabilized but subsequently remained very weak with difficulty clearing secretions, ongoing cough, waxing and waning O2 requirements and likely recurrent aspirations. Speech language pathology evaluated and noted that there is a large risk of ongoing aspirations both with eating and drinking, but also of own saliva and secretions. Transitioned to comfort-oriented care on ___ following extensive goals-of-care discussion with patient and family and per their expressed goals. He was discharged to home with hospice, with hopes of making it to ___ birthday on ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man with a hx of ischemic cardiomyopathy (EF 40%) and HTN who presents with ___ weeks of gradually increasing lower extremity edema, dyspnea on exertion, scrotal edema, and abdominal distention. He presented to ___ clinic today to establish care with his new PCP. At that visit noted to be visibly dyspneic. Reporting productive cough with yellow-green phlegm ___ weeks. No fevers/chills. Of note his weight was up to 105.6 kg from 99.7kg last week. (D/c weight from ___. He checks his BP daily and noted to be elevated to the 180s/80-90s. He ran out of his Rx for lisinopril, Lasix, and atorvastatin so has not been taking the past ___ months. Has been taking metoprolol XL 12.5mg po daily and aspirin 81mg po daily. His BP in the office was noted to be 215/115. Exam with significant volume overload. ECG with SR, HR 78, mild V2 ST-E, similar to baseline. He was referred to the ED for further evaluation and treatment of CHF exacerbation. In the ED, initial vitals were: 99.8 96 ___ RA - Exam notable for: bibasilar crackles, abdominal distention, ___ SEM, and 3+ pitting edema - Labs notable for: BNP 2314, Cre 1.0, WBC 14.7, H/H 13.9/42.1, U/A unremarkable - Imaging was notable for: CXR without acute cardiopulmonary process - Patient was given: Furosemide 40 mg IV x 1, labetolol 100mg po x 1 - Decision to admit for CHF exacerbation - Vitals prior to transfer: 92 147/79 20 94% RA Upon arrival to the floor, patient reports that his cough has already improved with diuresis, although still present. Productive yellow sputum. Notes nasal congestion and itchy, watery eyes that generally happen this time of year. Reports noticing leg swelling because his skin felt tight. Feels his breathing and cough worsened over the past ___ days. No fevers/chills. No chest pain. No headaches or changes in vision. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI. Negative for fevers/chills, chest pain, palpitations, PND, orthopnea, focal numbness/weakness, diarrhea, BRBPR, melena. Chest: Frontal and lateral views showed No acute cardiopulmonary process. The patient was diagnosed with Essential (primary) hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old man with a past medical history including hypertension, HFrEF (TTE ___ EF 40% with basal inferior/inferloateral HK) presumed ischemic etiology although no prior stress test/catheterization who presents with ___ weeks of progressive lower extremity edema, dyspnea on exertion, scrotal edema, abdominal distension and weight gain. He had run out of lisinopril, lasix, and atorvastatin ___ months ago and was referred to ED by his new primary care physician. Likely etiology of uncontrolled hypertension and medication non-compliance. No active ischemia, new dietary indiscretion, hypothyroidism nor arrhythmia. Repeat TTE confirmed LVEF 40% and basal inferior/inferolateral hypokinesis. After extensive discussion of risk/benefit, patient refusing cardiac catheterization but ultimately decided to undergo STRESS MIBI which showed no reversible perfusion defect. He underwent IV diuresis with Lasix 40mg IV BID with transition to torsemide 40 mg PO daily, at new dry weight of 94 kg. Additionally lisinopril was uptitrated from 5mg daily to 40mg daily. Additionally given iron deficiency, iron was repleted IV for 8 days, he will continue on every other day oral iron. He will follow-up with cardiology and PCP. ================================= ACTIVE ISSUES ================================= # Acute exacerbation of chronic systolic congestive heart failure: # HFrEF: TTE of 40% in ___ with WMA c/w CAD, repeat TTE ___ confirmed EF 40%, and basal inferior/inferolateral hypokinesis. As above likely etiology of uncontrolled hypertension, high Na diet and medication non-compliance. No active ischemia, new dietary indiscretion, hypothyroidism nor arrhythmia. He declined catheterization or stress test to confirm ischemic etiology. Underwent IV diuresis to weight of 94 kg. Lisinopril was uptitrated to 40mg daily. Carvedilol 6.25 mg PO BID was initated. IV Iron supplementation was begun (as per EFFECT-HF) for 8 days given ferritin between 100-300 and transferrin saturation < 20%, he should continue on every other day oral iron. He will follow-up with PCP and cardiology. # History of likely CAD: No known history of chest pain, but TTE c/w CAD. No hx of cath or stress. Continued aspirin 81mg po daily, resumed atorvastatin 80mg po qhs. As above would likely ebenfit from stress or catheterization. # Hypertension: Elevated to 251/118 on admission. No evidence of renal dysfunction or ECG changes, and improved with diuresis and labetolol 100mg po x 1. Chronically with SBP in the 180s per patient report. Lisinopril was uptitrated to 40 mg PO daily. #conjunctivitis #sinusitis #cough: h/o seasonal allergies and here conjunctivitis likely viral given watery discharge without preauricular node however given limited ability for follow-up was covered for bacterial conjunctivitis with Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID Duration: 5 Days (___). Oxymetazoline 1 SPRY NU BID:PRN nasal congestion Duration: 3 Days, fexofenadine, fluticasone for sinus congestion. Cough from post-nasal drip treated symptomatically with cepacol, tessalon and Guaifenesin-Dextromethorphan ___ mL PO/NG Q6H:PRN. # Leukocytosis: Mild likely stress reaction vs viral conjunctivitis. No clinical evidence of other infection with unremarkable U/A and clear CXR. Has lower extremity erythema that looks more like stasis dermatitis rather than cellulitis. # Prediabetes: A1c of 6.2% in ___. Repeat A1c of 5.4%. Insulin sliding scale was discontinued on ___. ================================= CHRONIC ISSUES ================================= # Housing insecurity # Health literacy: Noted during last admission that the patient has a history of poor follow-up and difficulty understanding severity of illness. Patient was counseled regarding chronic nature of his condition, social work and nutrition also provided counseling and resources. He states that he prefers to frame issues in terms of cost-effectiveness and efficiency however he is very afraid of diagnoses such as stroke or heart attack given family experience. ================================= TRANSITIONAL ISSUES ================================= - CORONARIES: no prior cath or stress test - PUMP: LVEF 40% (on ___ TTE) - RHYTHM: NSR - to follow-up with ___ MD following HF NP visit - Continue 80mg oral iron every 48 hrs (after ___ et al. Blood ___ at least six weeks - ___ benefit from spironolactone if symptoms worsen and compliance on current regimen affirmed - Persistent cough possibly due to viral illness during admission but concern for potential lisinopril adverse effects. Please follow up sx w consideration if persistent as outpatient for ___ switch # DISCHARGE WEIGHT: 94kg # DISCHARGE DIURETIC: torsemide 40 mg PO daily # CODE: full # CONTACT: ___ (brother/HCP) - ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo F with CAD s/p CABG (___) with recurrent admissions due to chest pain with DES placed to LAD and POBA to ostial ___ diagonal artery on ___ who was transfered here from an outside hospital due to chest pain. The patient noted mild, left sided chest pain 2 days prior to admission. The patient has been compliant with her medications including aspirin and plavix. Last night, the pain became worse and woke the patient up from sleep around 1AM. The patient's pain starts under her left breast and radiates above the breast and across the chest. The pain also radiates to the left elbow. The patient describes this pain as the same as her cardiac pain prior to the stent placement. When the patient awaoke, she took 1 nitro with some relief. She awoke again with the same pain and took ___ more nitros. When the pain did not resolve, the patient called the ambulance. The patient says that she had mild nausea, diaphoresis, and palpitations associated with these episodes. She denied SOB. The patient says that the pain was worse with deep breaths but was not positional. At the OSH, the patient was given nitropaste, bloodwork did not reveal any abnormalities, and the EKG was not concerning. The patient was started on a heparin gtt and transfered here for further workup. . Initial VS: 99.2 72 118/48 12 100% 2L nc. On interview, the patient was chest pain free. . REVIEW OF SYSTEMS + recent Stroke On review of systems, no bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Radiology showed Small persistent left basilar opacity suggestive of small effusion and possible atelectasis. Two-view chest x-ray may offer additional detail if desired. Radiology showed No evidence of DVT. The patient was diagnosed with CAD UNSPEC VESSEL, NATIVE OR GRAFT, CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. The patient was treated with Cardiac Catherization ___. At the time of discharge, the patient had Primary diagnosis - Coronary artery disease - Unstable Angina Secondary diagnosis - Pulmonary hypertension - Hypertension - Hyperlipidemia - Diabetes Mellitus Type 2 - Hypothyroidism s/p thyroid irradiation - COPD - 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>___ yo F with CAD s/p CABG and recent cath with DES and POBA to LAD, multivessel disease planned for staged intervention who presents here with chest pain but negative CEs and no significant EKG changes. 1. Chest Pain: This is likely cardiac chest pain given the patient's risk factors, known CAD, and similar pain to previous. This is not likely stent thrombosis due to compliance with aspirin and plavix and negative enzymes, and quick resolution of pain. The patient underwent a cardiac cath that showed LAD with patent stent then 99% mid with distal filling from LIMA (no change from previous. RCA 40% proximal, 80% mid, 80% posterolateral. The patient underwent Rotoblator with 1.5 burr followed by DES of mid-RCA with 2 overlapping DES, Balloon PTCA of posterolateral with moderate residual stenosis but difficult to advance larger balloons. The patient also complained of bilateral leg tenderness, but LENIs were negative for any DVT. The patient will continue aspirin and plavix indefinitely. She will continue her metoprolol, lisinopril, nitro, and ranolazine as needed.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HTN, depression, abnormal LFTs and obesity who presents with 3 days of N/V, abd pain and fevers. She states that starting approx ___, she had malaise and pain in "every joint." She also began to have nausea and non-bloody non-bilious vomiting. She did not take much PO during this time. She reports that she felt warm, but did not have a thermometer to take her temp, she also endorses chills. No abdminal pain, no diarrhea or constipation. She endorses dysuria for the past day, no frequency or change in color/odor or urine. Lastly, she states she has been having low back pain in the ___ her back during the past few days as well. No coughing or SOB, no chest pain, no bloody of black stools. In the ___, she was hypotensive to the ___ systolic and initially febrile to 100.4F. UA was positive and she received ceftriaxone and 1L NS. Labs were notable for WBC 21, Hct 27, Lactate of 1.6. She was transferred to the ___ ___ because there were no ICU beds there. In the ___ ___, initial VS were 98.3 86 ___ 16 89% ra. CT abd/pelvis showed left perinephric stranding which was thought to be from pyelo vs diverticulitis. She received 2L NS, Flagyl 500mg IV, Zofran 4mg IV and 40mEq KCl. Labs notable for WBC of 19 with left shift, Cr of 1.7, Lactate of 2.6, INR of 1.5 and a grossly positive UA with >182 WBCs. Currently, she is feeling well with minimal complaints. She has mild nausea but no further vomiting. She denies any pain at this time. REVIEW OF SYSTEMS: Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed 1. Findings consistent with acute left sided pyelonephritis. 2. 7-mm left lower lobe pulmonary nodule. Per ___ Society guidelines, if patient is a nonsmoker and has low risk for malignancy, followup chest CT at ___ months initially is recommended. However, if patient is a smoker with high risk for malignancy, followup chest CT at 3 to 6 months is recommended. 3. Multiple gallstones. 4. Severe right hip degenerative changes and suggestion of superimposed inflammatory arthropathy. Findings wet read to the ER via electronic dashboard. The patient was diagnosed with URIN TRACT INFECTION NOS, DIVERTICULITIS OF COLON, HYPERTENSION NOS. At the time of discharge, the patient had Primary: sepsis from a urinary source (E. coli) with pyelonephritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ history of hypertension, obesity, depression, obstructive sleep apnea non-adherent to CPAP who presents with sepsis from a urinary source, namely left kidney pyleonephritis from pan-sensitive E. coli likely from ascending urinary tract infection. She presented with urinary symptoms, relative hypotension (SBP 150 --> 90-100) requiring approximately 6 L NS IVF resuscitation with clearance of lactate. She was started on ceftriaxone at ___ and transferred to ___ for ICU level of care due to bed shortage at ___. For unclear reasons, she was admitted to the medicine floor with above treatment of her sepsis complicated by mild pulmonary edema responsive to gentle diuresis. She was swithced to ciprofloxacin and will complete a 14-day total course. # Sepsis from a urinary source Patient presented with urinary tract infection symptoms with resulting ascending infection resulting in left pyelonephritis per CT scan. She had a relative drop in SBP from 150 to 100s requiring 5 L NS fluid resuscitation with resultant pulmonary edema that was responsive to diuresis. She stabilized and was switched from ceftriaxone 2 gm IV q 24 hr (___) to ciprofloxacin 500 mg PO q 12 hr (___-106) for a 14-day total course. # Acute renal failure Baseline Cr is 0.9 per records with admission Cr of 1.7. Etiology is likely pre-renal from insensible losses in setting of fever and poor PO intake. There was no evidence of intrinsic process such as hydronephrosis. Cr has improved with IVF with resolution of acute renal failure. # Normocytic anemia: Patient was noted to have Hgb of ___. The chronicity is unclear as there is no recent Hgb in our system with last from ___ (normal value). The blood bank did not an anti-C antibody in her blood with a negative Coombs. Her hemolysis labs and DAT were negative. The etiology likely represents a chronic process with some component of superimposed inflammation from the marrow and fluid shifts in the setting of sepsis as her other parameters such as RDW, MCH, MCHC are with normal limits. Her differential does not such as leukoerythoblastic process (like infiltration of the marrow by neoplasm as sometimes is seen in metastatic cancer). Reticulocyte index is suggestive of a hypo-proliferative marrow. Another consideration is that she has inadequate tissue level B12 although she is not macrocytic. Her B12 levels in ___ and ___ were 290-326 with no accompanying homocysteine or MM. Although this "serum level" is normal per lab reference, tissue level B12 can be inadequate with a serum B12 level below 400. Overall, she should have further outpatient work-up of anemia. #Elevated INR: Patient had elevated INR of 1.5 that was likely related to poor PO intake. Her fibrinogen was within normal limits. #Depression/anxiety: She displayed impaired coping skills during hospitalization course and did not want to be discharged home. She denies SI/HI. She was continued on effexor and ativan. # Hypertension: She was hypertensive to SBP 140-180s at times. Her home amlodipine was re-initiated. Her thiazide and ___ are being held to ensure that she has renal recovery and will be re-started as an outpatient. # CODE STATUS: FULL # Transitional issues - anemia work-up including routine healthcare maintenance such as colonoscopy - referral for ? sleep apnea and ? ENT evaluation given oropharyngeal anatomy - repeat CT Chest in ___ months given 7 mm left lower lobe pulmonary nodule in setting of tobacco abuse history - re-start thiazide and ___ if renal function has stabilized - work-up of severe right hip degenerative changes given suggestion of superimposed inflammatory arthropathy on CT Abdomen - repeat INR and work-up as indicated although favored to be nutritional. Consider nutrition consult - consider medical work-up for secondary causes of depression - further patient education regarding anti-C antibody in blood and carrying card in wallet regarding this finding if needs blood transfusion in future</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p left TKA in ___ and recent PJI in ___, now presents with another PJI and will undergo a left total knee revision on ___ KNEE (AP, LAT AND OBLIQUE) LEFT showed In comparison with the study of ___, there appears to be a new total knee arthroplasty in place, which appears well seated without evidence of hardware-related complication. KNEE (2 VIEWS) LEFT showed Status post explant of left knee total arthroplasty. Metallic staple is again seen along the lateral distal femoral metaphysis. Femoral and tibial intramedullary wires are seen. Antibiotic spacers are in place. Soft tissue gas, skin staples, and drains are consistent with perioperative state. Brace is seen overlying the knee. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM was done. The patient was diagnosed with Pain in left knee. The patient was treated with ___: left knee revision by ___, MD. At the time of discharge, the patient had left knee 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>The patient was admitted to the orthopedic surgery service on ___ after his left knee aspiration revealed 18,584 WBC, 90 poly's and grew staph aureus. His CRP was greater than 300. This was indicative of a prosthetic joint infection. He became febrile overnight with a temperature of 102, so he was started on vancomycin and zosyn. HD #1, he was seen by infectious disease which recommended discontinuing vanco and zosyn and start daptomycin given the sensitivities. On HD#2, he was made NPO and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH HTN, CAD, p/w dyspnea, productive cough and fatigue/dizziness for ___ days. He complains of a chronic cough for the past 2 months, which acutely worsened over the past several days. The patient stated that for ___ days he has had dyspnea at rest that is associated with productive cough. He describes the quality as greenish in nature. In addition, the patient is complaining of worsening BLLE swelling (R>L) for the past several years. He denied fevers/chills, chest pain, orthopnea, PND and palpitations. He denies sick contacts and recent travel. Per family at bedside, the patient refuses to go outside during the winter for fear of falling. They were attempting to convince him to visit his PCP for the worsening BLLE, however, he believed that due to his insurance, he was unable to see his PCP. The patient was transported via EMS to the ED. Radiology showed Right-sided central venous catheter line tip projecting over the lower SVC. No pneumothorax. Persistent right basilar opacity. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with Right internal jugular central line placement (___) and removal (___). At the time of discharge, the patient had Primary diagnosis: * Community-acquired pneumonia Secondary diagnoses: * Atrial fibrillation with rapid ventricular response * History of 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>PATIENT SUMMARY: ================ Mr. ___ is a ___ M with PMHx notable for HTN, CAD who was admitted to the MICU on ___ with a few days of fatigue, dizziness, productive cough, and dyspnea found to have right lobe pneumonia. He developed atrial fibrillation after receiving IV diuresis, hypotensive requiring levophed briefly. Hospital course complicated by pressor requirement and delirium, both now resolved.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p motorcycle vs deer last night at 2AM going approximately 50 mph. Had his motorcycle fall onto his left side. No headstrike/LOC. Inability to ambulate at scene. Taken to OSH where workup revealed L navicular fx and transferred for further eval. On arrival isolated complaint of left foot pain. No other painful areas. Also complaining of decreased sensation globally to left foot. Radiology showed Severely comminuted and displaced fracture of the left navicular bone with intra-articular extent. Cuboid and medial cuneiform fractures seen and other tarsal fractures suspected. CT could be performed for further evaluation. Orthopedic surgery consult is recommended. Navicular fracture and recommendations were reported to ___ by ___ by telephone at 9:30 a.m. on ___ at the time of discovery of these findings. Radiology showed Extensively comminuted fractures involving the mid foot and third and fourth metatarsal bases as described above; transverse fracture of the fifth proximal phalanx. The patient was diagnosed with FX METATARSAL-CLOSED, MV COLLIS NOS-MOTORCYCL. The patient was treated with ___ - Dr ___ - ___ placement, medial plantar fasciotomy ___ - Dr ___ - ___ dehiscence wound left foot. At the time of discharge, the patient had left foot navicular fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the Orthopaedic Trauma Service for repair of a left foot navicular fracture. The patient was taken to the OR and underwent an uncomplicated s/p ___ placement, medial plantar fasciotomy with subsequent closure of wound 3 days later. The patient tolerated the procedure without complications and was transferred to the PACU in stable condition. Please see operative report for details. Post operatively pain was controlled with a PCA with a transition to PO pain meds once tolerating POs. The patient tolerated diet advancement without difficulty and made steady progress with ___. Weight bearing status: non-weight bearing left lower extremity. The patient received ___ antibiotics as well as lovenox for DVT prophylaxis. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 4 weeks post-operatively. All questions were answered prior to discharge and the patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old female without significant past medical history status post 10 foot fall who was transferred by EMS with right knee and ribcage pain. The patient is an internal medicine physician at ___ who was standing on her deck and was leaning on a railing when it gave way and she fell about 10 feet. Patient denies any head strike or loss of conciousness. She fell onto her right side. She has pain along her right ribcage and right knee. She denies any abdominal pain, neck pain, nausea, or vomiting. Timing: Sudden Onset Severity: Moderate to Severe Duration: Hours Location: right side of body Context/Circumstances: status post fall Radiology showed Normal right shoulder and elbow radiographs. Radiology showed Normal left foot radiographs. Radiology showed Stable small right apical pneumothorax. Stable displaced right ___ and ___ rib fractures. No new fracture. The patient was diagnosed with FRACTURE TWO RIBS-CLOSED, TRAUM PNEUMOTHORAX-CLOSE, FALL FROM BUILDING. At the time of discharge, the patient had Trauma: fall Right rib fractures 3,4 small right pneumothorax right knee 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>The patient was admitted to the hospital after a 10 foot fall from a deck. Upon admission, the patient reported right sided rib pain and right knee pain. The patient was made NPO, given intravenous fluids, and underwent radiographic imaging. Head cat scan and cervical spine showed no intra-cranial abnormality or a cervical fracture. On chest x-ray imaging, she was reported to have displaced fractures of the posterior right third and fourth ribs and a non-displaced fifth rib fracture. She was also reported to have a small right apical pneumothorax. Her respiratory status remained stable. She was encouraged to use the incentive spirometer and her oxygen saturation was closely monitored. Because of her knee pain, she was evaluated by the Orthopedic service who recommended an x-ray of the knee which did not show any fractures or dislocations. and ___ brace was applied. X-rays undertaken of the right shoulder and left foot were normal. The patient was evaluated by physical therapy and recommendations were made for discharge home. Prior to discharge a repeat chest x-ray was done to determine the resolution of the right pneumothorax. A small right apical pneumothorax was still identified. The patient's respiratory status remained stable. Her vital signs remained stable and she was afebrile. On HD # 4, the patient was discharged home in stable condition. Follow-up appointments were ...........</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with hypertension, hyperlipidemia and OSA who presented to ___ with chest pain and dyspnea and was transferred to ___ for higher level of care given concerning ECG changes and an elevated troponin. He is transferred to the CCU for monitoring of a pericardial drain. To briefly review his course, he was in his usual state of health on the day of admission when he developed dyspnea with lifting a 30 pound box of chocolate chips at his bakery. The pressure was constant and non-radiating and he called EMS. On their arrival he was hypoxic to the 80's and transferred to ___. He was found to have an elevated high-sensitivity troponin of 189 that increased to 249, and a NT-proBNP of 6250. He had lateral T-wave inversion on ECG and was given ASA 325mg and two doses of SL nitroglycerin. He was also given 40mg IV Lasix and placed on BiPAP. Of note, patient was recently started on metoprolol tartrate 25mg daily for "tremor", however this was discontinued given severe fatigue associated with it. He was transitioned to propranolol 10mg BID which has been better tolerated. Interestingly, patient believes he is still taking labetalol, in addition to propranolol, however is not ___ sure. Has had lower extremity edema for several years, no worse recently, although was only started on furosemide 20mg daily in early ___ for this. On arrival to ___, he was started on IV heparin gtt for NSTEMI. An echocardiogram on ___ demonstrated a large pericardial effusion with tamponade physiology. He went to the cath lab on ___ for urgent pericardiocentesis with 650 cc serous fluid was drained and sent for studies. He underwent a cardiac catheterization which demonstrates severe multivessel coronary artery disease. Given severe left main disease, and IABP was placed. Cardiac surgery was consulted for revascularization. CHEST (PORTABLE AP) showed No previous images. There is marked enlargement of the cardiac silhouette with relatively mild pulmonary vascular congestion. This discordance is consistent with the diagnosis of pericardial effusion. Hazy opacification at the right base with obscuration hemidiaphragm is consistent with pleural fluid and volume loss in the right lower lobe. CHEST (PORTABLE AP) showed In comparison with the study of ___, the there is continued enlargement of the cardiac silhouette with decreasing pulmonary edema. Layering pleural effusion with compressive basilar atelectasis is again seen on the right, with less prominent effusion and atelectasis on the left. CHEST (PORTABLE AP) showed Worsening pulmonary edema. CHEST (PORTABLE AP) showed Comparison to ___, 07:44. The pericardial drain is in stable position. The patient has received a new aortic balloon pump. The tip of the pump projects approximately 28 mm be low the upper most part of the aortic arch. There is a linear lucent zone paralleling the pump. A repeat radiograph within 4 hours should be obtained to monitor this change. The pericardial drain is in stable position. Stable moderate cardiomegaly. Moderate right pleural effusion, minimal left pleural effusion. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed There are postsurgical changes from CABG. The endotracheal tube terminates 2.7 cm above the carina. The enteric tube terminates in the body of the stomach. A right internal jugular Swan-Ganz catheter terminates in the right interlobar pulmonary artery. A left chest tube is in place. The intra-aortic balloon pump terminates in the upper descending aorta, just below the aortic arch. Bilateral pleural effusions (right greater than left), cardiomegaly and mild pulmonary edema are unchanged. There is no focal consolidation or pneumothorax. CHEST (PORTABLE AP) showed There are postsurgical changes from CABG. The endotracheal tube terminates 4.4 cm above the carina. The right internal jugular Swan-Ganz catheter terminates in the right interlobar pulmonary artery. The enteric tube terminates in the body of the stomach. Mediastinal drains and a left chest tube are in stable position. The cardiomediastinal silhouette remains enlarged. The small to moderate right pleural effusion and small left pleural effusion are unchanged. Mild central pulmonary vascular congestion and mild pulmonary edema are also unchanged. There is no focal consolidation or pneumothorax. There are no acute osseous abnormalities. CHEST (PORTABLE AP) showed Comparison with the study of ___, the endotracheal tube and nasogastric tube have been removed. Swan-Ganz catheter again extends to the right pulmonary artery. Left chest tube remains in place and there is no evidence of pneumothorax. The left hemidiaphragmatic contour is now sharply seen, consistent with decreasing pleural effusion and volume loss in left lower lobe, though a more upright position of the patient could contribute to this appearance. Poor definition of the right hemidiaphragmatic contour with opacification at the bases consistent with pleural fluid and compressive atelectasis on this side. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the left chest tube is been removed and there is no evidence of pneumothorax. The Swan-Ganz catheter is also been removed. The cardiomediastinal silhouette is stable. Increasing engorgement of indistinct pulmonary vessels is consistent with increasing elevation of pulmonary venous pressure. Bilateral pleural effusions and compressive atelectasis, more prominent on the right. CHEST (PA AND LAT) showed 1. Interval decrease of pulmonary vascular congestion since ___. 2. Small pleural effusions are likely, unchanged. 3. Retrocardiac and left lower lung zone airspace opacities are likely due to atelectasis. Radiology showed Mediastinal wires are seen. There are very low lung volumes. There is cardiomegaly and prominence of the mediastinum. There is mild worsening of the now moderate pulmonary edema. There are bilateral effusions. There are no pneumothoraces. The patient was diagnosed with Chest pain, unspecified. The patient was treated with ___: Pericardiocentesis and drain placement ___: Intra-Aortic Balloon Pump Placement ___: Coronary artery bypass grafting x 5 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, diagonal artery and sequential reverse saphenous vein graft to the second and third obtuse marginal arteries.. At the time of discharge, the patient had Coronary Artery Disease Pericardial Effusion with Tamponade Physiology ST Elevation Myocardial Infarction Acute on Chronic Kidney Injury Acute Hypoxic Respiratory Failure Acute Heart Failure with preserved EF Secondary Diagnosis: Chronic Kidney Disease Deviated Septum Hyperlipidemia Hypertension Obesity 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>He was admitted to ___ on ___ for further management of chest pain and shortness of breath. He was noted to be hypoxic initially requiring BiPAP. NT-proBNP elevated to 6250 at ___ and 9214 at ___. CXR notable for pulmonary edema. Status post IV furosemide 40mg x2 ___ and ___ ED) which facilitated weaning of BiPAP to supplemental oxygen via nasal cannula. ECG upon arrival demonstrated ST elevations in V2-V3 of 1-2mm and poor positive septal forces. After pericardial drain placement on ___, he developed worsening chest pressure somewhat responsive to nitroglycerin and associated with ST elevations in anterior leads. He went for expedited coronary angiography which revealed three vessel disease and a balloon pump was placed. He was taken urgently to the operating room and underwent coronary artery bypass grafting x 5. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awoke neurologically intact and was extubated on POD 1. He was weaned from inotropic and vasopressor support. IABP was discontinued without incident. Beta blocker was initiated and he was diuresed toward his preoperative weight. Cultures from the pericardiocentesis were positive for Strep Viridans. Infectious Disease service was consulted. He should continue IV Ceftriaxone 2 grams IV Q24H thru ___. Etiology of pericardial effusion uncertain possible inflammatory process. Cytology results negative for malignancy. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. He developed acute on chronic kidney disease with peak creatinine of 4.4. Diuresis was held until his creatnine recovered. His foley catheter remained in for strict I/Os and following creatnine. By the time of discharge his renal function was improving and his creatnine was 3.2. Lasix was resumed. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #8 he was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. He was discharged to ___ in good condition with appropriate follow up instructions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old female with h/o EtOH abuse (prior ICU stays for withdrawal), h/o GIB, prior L hip fx s/p hemi and subsequent revision with fixation, presents after mechanical fall under influence of alcohol with L periprosthetic femur fx. FEMUR (AP AND LAT) LEFT showed Foreshortened and displaced obliquely oriented fracture of the midshaft of the left femur just inferior to the femoral component of a left hip prosthesis. FEMUR (AP AND LAT) LEFT showed Interval reduction of left midshaft femoral fracture which now appears in anatomic alignment. CHEST (PORTABLE AP) showed No acute intrathoracic process. PELVIS (AP ONLY) showed Limited exam without evidence of fracture. Radiology showed Fluoroscopic images demonstrate placement of a large lateral fracture plate stabilizing a periprosthetic fracture of the distal left femur adjacent to the distal femoral stem. There has also been removal of the proximal claw plate. There is a left hip bipolar hemiarthroplasty. The total intraservice fluoroscopic time was 118.7 seconds. Please refer to the operative note for additional details. The patient was diagnosed with Displaced oblique fracture of shaft of left femur, init, Periprosth fracture around internal prosth l hip jt, init, Fall (on) (from) other stairs and steps, initial encounter. The patient was treated with L proximal femur open reduction internal fixation. At the time of discharge, the patient had Left periprosthetic 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 be intoxicated and to have left periprosthetic femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for Open reduction internal fixation left proximal femur fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable with the following exception(s): Maintained on CIWA scale throughout admission given history of withdrawal. Valium given for mild AMS on HD 2 and 3. No acute decompensation and remained hemodynamically stable throughout admission At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TOUCH DOWN WEIGHT BEARING in the 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: Mr. ___ is a ___ man transferred from OSH with a GSW to the R thigh and R femur fracture. The patient states that on ___ around 8:30PM he was walking into a store when he noticed a car slowing down, followed by gun shots. He heard a loud pop and noted R thigh pain and fell to the ground, unable to bear weight. He was taken to ___ wherehe was found to have a GSW to the R thigh with radiographs demonstrating a femoral shaft fracture. No hard signs of vascular injury. He was given Ancef and morphine, and subsequently transferred to ___ for further evaluation and management. On arrival the patient complains of isolated R thigh pain. No pain in any other anatomic location. No numbness or paresthesias. Chest radiograph. showed 1. Comminuted proximal right femoral fracture with adjacent bullet fragments. 2. Clear lungs. FEMUR (AP AND LAT) RIGHT IN O.R. showed Intraoperative images from open reduction and internal fixation of a proximal right femoral diaphyseal fracture. Please see the operative report for further details. The patient was diagnosed with OPEN WND HIP/THIGH-COMPL, ASSAULT-HANDGUN. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right femur fracture and was admitted to the orthopedic surgery service. The patient elected to be treated non operatively after lengthy discussion. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications. The patient was given anticoagulation per routine. . 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 touch down weight bearing in the right lower extremity, and will be discharged on aspirin for DVT prophylaxis. The patient will follow up with the ___ orthopaedic trauma service per 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: HISTORY OF PRESENT ILLNESS: ___ year old woman with a history of lung adenocarcinoma with mets to her brain currently receiving brain radiation who was referred to the ED for altered mental status. The patient indicates that earlier morning of presentation she was at home, when she felt that her legs became weak. She then "collapsed" to the floor. She reports remembering everything that happened but when probed for specifics she is unable to, she also reports she fell in the bathroom. However, according to her son, and ___ EMS records she was found on the floor of her kitchen incontinent of urine and feces. When awakened she was confused, disoriented and not making sense. She went to an outside hospital (___), where she was found to by hypothermic and confused. Rectal temperature reportedly was 93.0 initially. She was warmed and temperature improved to 95.6. Received 1L NS and Keppra 500mg IV at OSH. She was also found to have elevated Troponin (Trop I 1.37). She was transferred to ___ for further evaluation. In the ED, initial vitals were: 94.2 92 100/66 16 95% RA. She was found to be A&Ox3 but forgetful, unable to recall certain treatments or details of her diagnosis. Respiratory effort easy and unlabored. Abdomen soft and no pain on palpation. Temperature 94.2 (temporal) in triage. Slightly tachycardic to 104bpm. Labs were notable for WBC of 12.4, elevations in AST and ALT, Trop of 0.14. EKG was sinus rhythm, 98, normal axis, QTC 488, ST segment elevation in leads V1, V2, ST depression in lead 2, aVF. Cardiology consulted felt likely demand ischemia in setting of presumed seizure. Oncology was consulted who deferred to medicine because primary oncologist is at ___ though she receives radiation oncology here. On the floor, she currently feels well but reports weakness, she is gernally independent with ambulation and plays gold 3 times per week but now feels her legs are weak and is having difficulty standing. She denies any headache no chest pain, shortness of breath, abdominal pain, nausea, vomiting. Of note, on ___, she received at L3-4 epidural injection for chronic LBP. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Otherwise ROS is negative. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Decreased 17 x 18 mm right frontal lesion and improved surrounding vasogenic edema. 3 mm cortical focus of enhancement posterior to this lesion seen on the prior study is no longer present. 2. 4 mm enhancing lesion in the right cerebellar hemisphere is stable without associated edema. 3. No new enhancing intracranial lesions identified. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with lumbar puncture ___. At the time of discharge, the patient had Primary: Seizure, acute encephalopathy Secondary: Adenocarcinoma of lung with brain metastases, ___ stomatitis, hypertension, hyperlipidemia, troponin elevation. The patient was given written instructions concerning 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 woman with a history of lung adenocarcinoma with mets to her brain s/p XRT, referred to the ED for altered mental status found to have likely seizure. # Encephalopathy/Seizure: Patient presented with altered mental status described as confusion, disorientation and less responsiveness following a spontaneous fall to the floor and found to be incontinent of urine and feces are all concerning for a seizure event, with mental status changes likely related to post-ictal state given initial resolution. She has never had a seizure before but has been maintained on Keppra empirically. The patient and outpatient oncology report that her dexamethasone has been downtitrated recently to 2mg BID from 4mg BID and the patient downtitrated her Keppra herself from 500mg to 250mg due to "feeling jumpy" on Keppra. MRI one month ago showed improvement in brain mets, but outpatient oncology also reported recent Keytruda initiation last week. Presentation most likely related to underdosing of sz ppx in the setting of increased inflammation from Keytruda per discussion with outpatient onc, rad onc, and neuro-onc. Per family, patient has been "off" since starting Keytruda. 24 hour EEG negative. UA negative for infection. Valproate level in low therapeutic level so dose increased prior to discharge. Despite some waxing/waning delirium during admission, significantly improved mental status approaching baseline per friends/family at time of discharge. Appreciate neuro-onc recs: stopped Keppra (mania is a known side effect) and gave 1000mg divalproex load, started on 500mg BID divalproex which was increased to 750mg BID on discharge. Patient may have leptomeningeal involvement leading to encephalopathy given the concerning appearance of frontal lobe lesion so will f/u LP results from ___. Appreciate rad onc recs: MRI appears improved, NTD from rad onc standpoint, defer to neuro-onc. During admission, kept on seizure precautions but no further seizures. Continued Dexamethasone 2mg PO BID. Discharged with ___ for home safety eval. # Adenocarcinoma of the lung with brain metastases: frontal and cerebellar lesions s/p radiosurgery with cyberknife having completed 3 treatments. Recently started Keytruda as outpatient last week (next due ___. MRI with interval improvement in brain lesions, though neuro-onc concerned for possibility of leptomeningeal involvement, with CSF cytology pending at the time of discharge. Continued Dexamethasone 2mg PO QAM and 2mg PO Q1400. # HTN/HLD/troponin elevation: Most likely neurogenic troponinemia though demand ischemia possible in the setting of recent seizure. Cardiology consulted in the ED and EKG reviewed, no evidence of STEMI and no chest pain or cardiopulmonary symptoms to suggest ongoing coronary lesion. EKG is non-dynamic and non-specific in T wave inversions isolated to V1 and V2. Repeat troponins significantly improved. Given low likelihood of ACS and likely noncardiac etiology, DC'ed beta blocker and ASA that had been started on arrival. Neuro-onc also recommended holding ASA and patient refused in any case given Celebrex rx. Continued home simvastatin, Losartan. # Leukocytosis/Dehydration/Lactic acidosis/Transaminitis: LFTs likely related to muscle break down secondary to seizure, supported by elevated CK. Now largely resolved. Elevated Hct to 48 and elevated WBCs, likely dehydration and stress reaction from seizure, now improved. Lactate 2.8, slightly elevated but largely stable from prior and likely related to recent seizure, given no evidence of poor perfusion. #Thrush: Continued on nystatin swish and swallow that she has been taking at home. #Social: Per RN, patient reports possible verbal abuse in home. Assessed by SW who felt this issue is no longer active as patient's left her ex-husband, who lives in ___, for this reason and is now feeling safe with her family in ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M->F transgender woman (goes by ___, DLBCL (dx ___, now on C3 of R-CHOP) s/p port placement ___, Cycle 3 R-CHOP ___ w/Neulasta ___, Latent TB (on INH), chronic hepatitis B (On lamivudine) who was recently admitted for presumed viral gastroenteritis 1 week ago, now returns with fever and night sweats and c/f possible port infection. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of lymphadenopathy within the abdomen or pelvis. 2. Several lucent lesions with a thick sclerotic rim and associated cortical thickening are present, as described above. Given the patient's history of malignancy, these lesions are concerning for osseous involvement, although the level of activity of these lesions cannot be assessed. Several of these lesions would be amenable to biopsy. 3. Please see separate chest CT report for details of intrathoracic findings. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 12:27 ___, 5 minutes after discovery of the findings. Chest CT showed Substantial improvement in the mediastinal lymphadenopathy an resolution of the bilateral axillary lymphadenopathy. Minimal apical emphysema. Status post bilateral breast implants. Port-A-Cath catheter tip terminates at the proximal right atrium. Suspected respiratory bronchiolitis. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had PRIMARY: DLBCL SECONDARY: Nicotine dependence, Latent TB. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ M->F transgender woman with a history of DLBCL (dx ___, now on R-CHOP) s/p port placement ___, Cycle 2 R-CHOP ___ w/Neulasta ___, Latent TB (on INH), chronic hepatitis B (On lamivudine) who was recently admitted for presumed viral gastroenteritis 1 week ago, now returns with diarrhea, fever and night sweats and reports of increased lymphadenopathy. Symptoms were concerning for progression of lymphoma so staging CT scan was obtained, which showed reduction in lymphadenopathy. Patient was afebrile during admission without any hemodynamic instability. She will return for cycle 3 on ___. #Diarrhea Patient with recent admission for diarrheal illness believed to be viral gastroenteritis representing for symptoms of fever, night sweats, diarreha and exam findings signifcant for RUQ pain and general aches. DDx is broad and included AE of R-CHOP versus viral/bacterial/parasitic etiology, additionally, patient known to have substance use history and narcotics contract and states that she lost her most recent prescription therefore possibly symptoms could represent withdrawl. Low suspicion for inflammatory bowel disease. Patient is immunosuppressed and chronic Hep B on viral suppressive therapy. At risk for uncommon infections. Prior diarrheal disease not resolved which was prominent prior to third cycle of R-CHOP decreasing likelihood of medication side effect. In setting of diarrhea and RUQ pain must also consider hepatitides and viral infection also associated with diarrhea however suspicion low given relatively normal LFTs. Patient on INH w/known potential hepatotoxicity, but LFTs normal at this time. Extensive workup sent for viral, bacterial and parasitic causes of diarrhea including serum and stool analyses. Negative for C. diff. Prior admission w/o test for norovirus. Negative on this admission. During admission patient expressed desire to obtain fourth cycle of R-CHOP early as she had a family vacation plan. Given extensive infectious workup for diarrheal disease and lack of significant symptoms on admission Tests still pending at time of discharge include: -Viral Panel: CMV Viral Load; Hepatitis C Viral Load; Hepatitis B Viral Load; HIV-1 viral load by PCR; Hepatitis C Viral RNA, Genotype; EBV PCR, Quantitative; Varicella zoster Antibody, IgM; Varicella Zoster (VZV) IgG Antibody; EBV Antibody Panel. Norovirus PCR -Parasitic: Cryptosporidium/Giardia (DFA); Cyclospora; Stool culture; Microsporidium; Stool culture - Yersinia; Stool culture - Vibrio; Ova and Parasites (1 of 3); -C. difficile DNA amplification assay;</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of ___, asthma/COPD, HTN, HLD, DMII, obesity c/b OSA/obesity hypoventilation syndrome p/w dyspnea, right lower extremity DVT on coumadin, who presents after a fall at rehab and progressive altered mental status over the last several weeks. Chest: Frontal and lateral views showed Pulmonary edema, increased since the prior study. Cardiomegaly, and probable small bilateral pleural effusions. PORTABLE HEAD CT W/O CONTRAST showed No evidence of infarction or large intracranial hemorrhage on this severely limited study. The patient was diagnosed with ENCEPHALOPATHY, UNSPECIFIED, LONG TERM USE ANTIGOAGULANT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with ___, OSA/obesity hypoventiliation, asthma/COPD, HTN, IDDM who was admitted from rehab for progressive AMS, and unobserved fall out of a chair. He was admitted to ICU and improved with BIPAP and diuresis, and has returned to his baseline mental status. He has signifncant edema and erythema in bilateral lower extremities, and is on coumadin for a DVT in his R calf. ACTIVE ISSUES # Altered mental status: Patient was admitted to ICU for Q1H neuro checks given altered mental status, anticoagulation and inability to obtain CT scan of the head. On arrival to ICU, patient remained altered, was disoriented and unable to answer questions. Patient was supratherapeutic on INR and warfarin was held. Portable CT head was negative. Records from rehab were reviewed and decreased weight and low FeNa were noted suggesting prerenal failure. In the setting of taking gabapentin and methadone, drugs levels may have contributed to increased somnolence. The patient also has a history of obesity hypoventilation syndrome. His gabapentin was initially held and he was started on IVF for his ___. His mental status improved back to baseline with initiation of BiPAP. With no eivdence of head bleed and return of neuropathic pain, he was restarted on warfarin and uptitrated on gabapentin. Given improvement in mental status, patient was called out to floor. # Acute kidney injury - The patient presented with elevated Cr, which was rising at rehab to 1.8. He was seen by Nephrology at the facility, who felt that ___ may have been precipitated by diuresis and recommended holding diuretics. There was also consideration that he may have had decreased preload from BiPAP. However, the patient had not been using it reliably. He was given IVF, after which urine output increased, Cr decrased, and the patient's mental status improved. He was ultimately diuresed 6L in the ICU. # Obesity hypoventiliation/OSA: Patient's mental deteriation thought to be due to hypercapnia. Pt had not been using BIPAP at rehab, and improved with BIPAP in the ICU. Mental status at baseline now. HOB elevated at night, and pt given BIPAP nightly, though did not use consistently. He will be set up with BiPAP as an outpatient and company called to deliver to his house prior to discharge. See transitional issues below. # Acute-on-chronic Diastolic CHF: Diuresed 6L with additional torsemide in the ICU, and another 1L on the floor until Cr bumped. He was continue on his home metoprolol. Torsemide was adjusted to 40mg daily due to rise in Cr and then titrated back up to original home dose of 60mg daily as outpatient. Discharge weight was 205.5 lbs. # Lower extremity edema: ___ to ___ and R DVT. Pt diuresed per above, and legs were elevated and wrapped. Coumadin continued. # DVT: Right gastrocnemius DVT diagnosed at rehab, and coumadin was started there. Coumadin was initially held on admission the setting of supratherapeutic INR, altered mental status, and inability to obtain a head CT. However, after CT was negative, warfarin was restarted. Discharged on 3mg daily with follow up with ___ clinic. # Penile lesion: suspicious for squamous cell carcinoma vs venous stasis ulcer. Underwent surgery with excision on ___ and pathology pending. Per Dr. ___ will notify patient of pathology results. # IDDM: Home insulin held in ICU ___ low sugars. on insulin slidin scale, recieving only ___ units daily. Discharging on significantly reduced long acting insulin of 8 units lantus daily with sliding scale. This will require ongoing titration and close follow up with PCP. # Right leg pain: Chronic pain likely ___ periperal neuropathy, exacerbated by increased swelling, DVT. Home gabapentin, methadone initially held due to mental status and then restarted. Topical lidoderm applied as needed. # HTN: Lisinopril was continued # Depression/anxiety: Home medications restarted after mental status cleared: citalopram, buspirone, quetiapine. hydroxyzine PRN insomnia. # Hyperlipidemia: Home simvastatin continued # GERD: Home omeprazole continued</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year-old right-handed man with hypertension and complete heart block s/p pacemaker who presents with "dizziness" since ___. He reports waking ___ morning, in the bathroom where he almost LOC and fell to the left. He proceded to feel dizzy with blurry vision in the distance while driving into work, felt nauseous and vomited so stayed home from work and rested. Symptoms improve/resolve with lying down. Continued to feel dizzy each day, again nausea and vomiting today. He is mail man with a foot route and has had trouble walking, feeling like he is falling to his left side, almost like he can't control it well, but doesn't report weakness. Does acknowledge it has been hot recently. Was seen by PCP today who referred in. Reports a somewhat similar sensation years ago that was brief and resolved, otherwise he is not a person who gets dizzy regularly, only time he lost consciousness was in the setting of heart block and very different (no dizziness symptoms, just sudden LOC). Denies headache, vertigo, diplopia, change in speech or comprehension, trouble swallowing, weakness, parasthesias or numbness anywhere. CHEST (PA AND LAT) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed No acute intracranial process. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. 2. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Left sided peripheral vestibulopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with history of CHB s/p PPM and HTN who presents with 3 days of "dizziness" which is described as blurry vision, feeling off balance, and difficulty with gait with notable consistent laterality to the history. His neurological exam was notable for HIT with corrective saccade to R, unter___ to L. Overall his exam was suggestive of L sided vestibular issue. His history and exam were most consistent with a L sided peripheral vestibulopathy. The exact etiology of his vestibulopathy was not clear. History not suggestive of BPPV ___ also negative), vestibular neuritis, labyrithitis, Meniere's. He had CTA h/n done in the emergency room, which was largely unremarkable. Orthostatic VS were negative. He mentions some blurry vision in a certain plane which is likely related to his vestibular function. He was evaluated by physical therapy and discharged home with outpatient vestibular therapy. MRI brain was not performed as suspicion for acute ischemic event was low. TRANSITIONAL ISSUES #peripheral vestibulopathy - follow up with neurology in ___ months, start vestibular therapy No changes were made to his home medications.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: He was at school today, in his usual state of health and sometime in the morning his legs began to feel odd in a hard to describe way, this then progressed to both legs feeling weak. He has still been able to walk. His R arm also felt odd, he comapred it to it feeling like it was asleep, this improved later in the day. When he was bending his neck today he sometimes felt an electric sensation in his neck. He was in his usual state of health prior to today. He denies any bowel bladder incontinence currently. He has not had any recent infectious symptoms or concern for infection. He states he cracks his neck often and wonders if it could be related to that. No shortness of breath. He denies any previous episodes of visual changes, eye pain, color vision changes, doubel vision, focal weakness, numbness. There is no family history of autoimmune disease. When he arrived home, his father, a card___, evaluated his symptoms and felt that the legs seemed weak perhaps ___ or so. He spoke with a neurologist he knows and decided to bring him in for evaluation in the ED. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. Mildly enhancing white matter changes in both corona radiata. Given the known enhancing white matter plaque along the cervical spine, concerning for intracranial demyelinating changes. 2. No evidence of acute infarction, hemorrhage or intracranial mass. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. The patient declined administration of IV contrast. 2. No evidence of thoracic or lumbar cord lesions. 3. Mild thoracic spondylosis with T6-T7 left paracentral disc protrusion and remodeling of the ventral cord but no cord signal abnormality. The patient was diagnosed with Weakness, Anesthesia of skin. The patient was treated with Lumbar puncture. At the time of discharge, the patient had Multiple Sclerosis. The patient was given written instructions concerning 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 male with a PMH of anxiety who presented due to feeling of b/l leg weakness and strange sensation in his R arm. In ED, he underwent an MRI of cervical spine which revealed a R C3 hyperintensity concerning for demyelinating lesion. He was admitted to General Neurology service and underwent spinal tap which was clean with further labs (including MS profile) pending. An MRI head was performed and showed multiple ___ hyperintensities, both enhancing and non-enhancing. He was determined to have presumed diagnosis of MS and was started on IVMP 1g for 5 day treatment. He completed 3 days while inpatient with some improvement in his sensory symptoms (he was seen to have no motor weakness upon initial bedside evaluation). Due to clinical stability, we agreed with family to complete last 2 infusions as outpatient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ male with a history of multiple myeloma, diabetes presenting with back pain and chest pain. He said the pain started at 11 ___ the night of presentation, he reports the pain as being higher up in his back and radiates across his chest. He denies any recent trauma, the pain came on while he was laying in bed. He says the pain comes on in spasms, describes as ___ in severity. Has never felt pain like this before. HE is scheduled to get stem cell transfusion on ___. Reports SOB with the chest and back pain. Took oxycodone when the pain started with no relief. Radiology showed Successful placement of a right internal jugular approach triple lumen temporary pheresis catheter. The line is ready to use. CHEST (PA AND LAT) showed 1. No acute cardiopulmonary process. 2. Similar appearance of a destructive right clavicular lesion as seen on recent PET-CT performed ___. CTA CHEST WITH CONTRAST showed 1. No pulmonary embolism or aortic injury. 2. No acute fractures involving the osseous structures of the chest. Please refer to recent ___ F FDG PET-CT from ___ for evaluation of osseous lesions. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Chest pain, unspecified. The patient was treated with pheresis line placement: ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================== MULTIPLE MYELOMA ACUTE PAIN SECONDARY DIAGNOSIS ===================== STEROID INDUCED DIABETES. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a pleasant ___ year-old male with hx of CAD, HTN, DL, OSA, ID-T2DM, and MM s/p Velcade, Dex, and Revlimid recently admitted from ___ for stem cell mobilization with Cytoxan. He presented to ED ___ with severe lower back, chest pain and associated SOB after beginning high-dose neupogen 960mcg daily on ___ in preparation for stem cell collection ___. #BACK AND HIP PAIN: #SOB (resolved): Presented with severe chest and back pain with associated SOB. Concern for PE especially as hypercoagulability is common in patients with MM vs. aortic dissection vs. ACS vs. bony pain secondary to GCSF. ACS less likely given NSR EKG and negative troponin. CXR showed no signs of aortic arch widening concerning for aortic dissection. CTA with no evidence of PE. Therefore, given above findings, pain in likely consistent with bony pain secondary to neupogen especially in the setting of administration of 960mcg neupogen daily since ___. Pain improves with PRN IV dilaudid now not requiring off neupogen. Discharged home to resume prior pain management regimen with PRN oxycodone. #IGG KAPPA MULTIPLE MYELOMA: #NEUTROPENIA: Presented in late ___ with 3 month history of neck pain, prompting imaging which showed concerning lesions for multiple myeloma. Work up was notable for a monoclonal IgG Kappa with one marrow biopsy confirming this diagnosis with plasma cells comprising approximately 70% of the total core cellularity. He received XRT to the right clavicle lesions and was initiated on treatment with RVD(Revlimid held with ___ cycle d/t ongoing XRT). He has received 4 cycles of treatment with an excellent response to his treatment based on monoclonal protein and free kappa levels. Treatment has been complicated by steroid induced diabetes as well as painful neuropathy of his legs. Velcade was held for Cycle 5 and he completed the 14 days of Revlimid(last dose on ___. As he has had an excellent response, the plan is to reassess his disease and move forward with autologous transplant. Bone marrow biopsy for disease assessment with marked decrease in involvement(< 5%). PET scan with decreased burden of disease. He received high dose Cytoxan for stem cell mobilization on ___, likely the etiology for neutropenia. He was discharged home ___ with instruction to administer daily 480mcg neupogen x6 days then to increase to 960mcg x3 days beginning on ___. He received 960mcg neupogen SC daily through ___. Now s/p pheresis line placement and stem cell collection ___, with collection >16. Continues on monthly Zometa outpatient per outpatient recs, last given ___. Levofloxacin prophylaxis discontinued ___ as no longer neutropenic. F/U scheduled with Dr. ___ admission for auto-SCT ___. #BOWEL IRREGULARITY (Resolved): No further episodes now constipated likely from narcotics. On admission patient reported 1 episode of loose stool ___ AM. Not associated with fevers, abdominal pain or cramping. Typical bowel pattern is formed BM Q3-4 days per patient. CHRONIC/RESOLVED ISSUES ============================= #NEUROPATHY: Marked increase in neuropathies of lower legs in the setting of Velcade and Revlimid. Most likely exacerbated by lumbar disc disease and diabetes. Requiring increasing amounts of Oxycodone, 2 tablets, now every 4 hours. Has now tapered off gabapentin as he felt it did not help and pain persisted. Prior to admission for acute pain, his pain regimen consisted of oxycodone, ___ tablets every ___ hours as needed for pain. Will continue home pain management regimen at discharge. #Abnormal uptake on Prostate noted on PET scan: Followed by Dr. ___. PSA in 3 range. Was supposed to get MRI for further evaluation and holding off on invasive procedures as able but not able to get MRI with the leg pain (could not lie still). #STEROID INDUCED DIABETES: Home regimen consisted of metformin, Lantus and Humalog sliding scale insulin. Better control without steroids. Restarted metformin at discharge. #SCC: Skin lesion biopsied which shows SCC extending to margins. Had surgical re-excision with no residual cancer and well healed area. CORE MEASURES =================== # CODE: Presumed Full # EMERGENCY CONTACT: ___ Relationship: Wife Phone number: ___ # DISPO: discharge to home ___ to follow up with Dr. ___ in clinic prior to admission for auto-SCT on ___. TRANSITIONAL ISSUES [ ] Patient will be seen by Dr. ___ prior to admission for auto-SCT-patient to be called with this appointment and time. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year-old gentleman with a PMHx of polysubstance abuse, hypertension, mood disorder, and hepatitis C infection presening with fever. He was admitted to ___ Inpatient Detox on ___ requesting benzodiazepine detox. He was initiated on phenobarbital and continued on methadone for which he is on maintenance for opioid abuse. Over the past day he was more fatigued, and on ___ he was febrile to 102.8F. He took ibuprophen with no effect. EMS was called and found his SpO2 to be 88% on RA, increasing to 95% on 4L NC. He was given Narcan without effect. He awoke slightly, and then had tonic-clonic acitivty en route to the ___. Given persistent somnolence, he was intubated for airway protection. CT head showed no acute process. LP showed 3 WBC. He was started empirically on ceftriaxone, vancomycin, and acyclovir. CXR was concerning for bilateral pneumonia, and meropenem was added. UTox screen was positive for methadone, cocaine, marijuana, benzos, barbituates, and TCAs. He was loaded with fosphenytoin given suspicion for seizure. On examination, a bag full of clonazepam was found in his rectum. CHEST (PORTABLE AP) showed 1. Satisfactory position of endotracheal and enteric tubes. 2. Heterogeneous bibasilar opacities concerning for multifocal pneumonia or aspiration. 3. Suspected left pleural effusion. ABDOMEN (SUPINE ONLY) showed No radiopaque foreign bodies seen in the region of the rectum. No evidence of obstruction. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little overall change. Endotracheal tube tip is about 4 cm above the carina. Patchy heterogeneous opacification at the bases, especially on the right, is again consistent with aspiration or infectious pneumonia. Small pleural effusion is again seen on the left. ABDOMEN US (COMPLETE STUDY) PORT showed 1. Splenomegaly, with the spleen measuring 20.0 cm. 2. Trace free fluid in the Morison's pouch with mild gallbladder wall thickening likely related to surrounding fluid. 3. Hepatomegaly with a heterogeneous echotexture of the liver parenchyma, reflective of chronic liver disease in this patient with hepatitis C. CHEST (PORTABLE AP) showed No previous images. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion. There is extensive opacification at the right base. Although this could represent atelectasis, in the appropriate clinical setting right middle and lower lobe pneumonia would have to be seriously considered. If the condition of the patient permits, a lateral view could be helpful. The patient was diagnosed with POIS-BENZODIAZEPINE TRAN, ACC POISN-BENZDIAZ TRANQ. The patient was treated with Endotracheal intubation, mechanical ventilation. At the time of discharge, the patient had Multisubstance abuse (opiates, barbituates, benzodiazepines, and cocaine) requiring intubation for somnolence and airway protection. Aspiration pneumonia.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ with a PMHx of polysubstance abuse, HCV, and mood disorder presenting from inpatient detox with fevers, hypoxia, and encephalopathy. # Fever: He had isolated fever at detox program to 102.8, with associated hypoxia documented by EMS, raising the concern for a pneumonia. LP was inconsistent with meningitis. UA without infection. CXR showed bilateral alveolar filling process at the bases with R>L, which seemed most consistent. He was started on vanc/levofloxacin for empiric coverage of pulmonary organisms and transitioned to Augmentin for CAP with anaerobic coverage for likely aspiration, with last day ___. # Respiratory Failure: He was intubated given somnolence and concern for seizures. He was initially sedated on fentanyl and midazolam given agitation in the ED. He was extubated after arrival to the MICU and maintained good oxygenation on nasal cannula. After transfer to the floor he was breathing well on RA. # Encephalopathy: By report he was somnolent and had tonic-clonic activity (patient denies any history of seizures other than in the setting of EtOH withdrawal). CT head at OSH unremarkable. His encephalopathy was likely secondary to polysubstance ingestion and improved with phenobarbital taper as below. He was also treated empirically for pneumonia as above. # Polysubstance abuse: He has a history of polysubstance abuse with benzos, EtOH, cocaine, and marijuana. Urine tox positive for benzos which he was getting detxoed from, barbituates which is consistent with phenobarbital use at detox, cocaine which he endorsed using recently, and methadone which he is on for prior opioid abuse. He also had cocaine and TCA positivity at ___. Per toxicology recommendations, EKG was monitored for QRS and QTc prolongation; his QRS never widened and his QTc was WNL. He developed worsening symptoms of alcohol/benzodiazepine withdrawal and received rescue load with 5mg/kg phenobarbital on ___, then self-tapered from that dose and was not given any further phenobarbital. Home methadone dose and psychiatric medications were resumed with QTc monitoring. Social work saw the patient but was not able to find a suitable residential treatment, so he was discharged to his mother/uncle's house in ___ with plan for Intensive Ouptatient Program at ___ which also runs his ___ clinic. He would benefit from a therapist and restrictions on benzodiazepines (his current prescriber per ___ Globe is #1 prescriber in ___). He did have a period of sobriety for several years during which he was working but currently feels disheartened about being able to stay clean in ___. #Diarrhea: on ___ he reported diarrhea for the last couple days with ~6BMs/day, so C diff was sent and was negative. Likely due to previous broad spectrum antibiotics, Augmentin, and resumption of diet. # Acute Kidney Injury: He presented with creatinine of 1.5, which was felt to be prerenal from infection, which downtrended to 1.1 on discharge. # Thrombocytopenia: Unkonwn baseline. No spontaneous bleeding. Given history of HCV and 20cm spleen on ultrasound, likely secondary to sequestration. # Mood disorder: Per patient report, has bipolar disorder although denies symptoms of manic episode. He has had problems with anger management recently but denies any legal problems. Continued citalopram, oxcarbazepine, seroquel. # Hypertension: Held anti-hypertensives in ICU given normotensive on admission. Restarted labetalol on ___ as SBPs 160s and hydrochlorothiazide on ___. He was still hypertensive to 180s so started on lisinopril 5 mg QD which is home med per patient report. # Hepatitis C: viral load not known. Follow-up with PCP.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ MEDICINE ATTENDING ADMISSION NOTE . PA and lateral chest on ___ HISTORY: ___ man with small cell lung cancer metastatic to the brain after chemotherapy and surgery. New delirium and pleural effusions. IMPRESSION: PA and lateral chest compared to ___ and ___: Moderate-sized right pleural abnormality has basal or dependent component larger today than it was on ___, stable since ___, probably pleural effusion. Thickening of the lateral costal and apical pleural margins is unchanged and therefore could be thickening as well as loculated fluid. Might be a nodule in the left mid lung or might be a prominent nipple shadow. There is no pneumonia. Heart size is normal. Infusion port catheter can be traced as far as the region of the superior cavoatrial junction. No pneumothorax or new mediastinal widening. showed PA and lateral chest compared to ___ and ___: Moderate-sized right pleural abnormality has basal or dependent component larger today than it was on ___, stable since ___, probably pleural effusion. Thickening of the lateral costal and apical pleural margins is unchanged and therefore could be thickening as well as loculated fluid. Might be a nodule in the left mid lung or might be a prominent nipple shadow. There is no pneumonia. Heart size is normal. Infusion port catheter can be traced as far as the region of the superior cavoatrial junction. No pneumothorax or new mediastinal widening. Radiology showed Nonobstructive bowel gas pattern, with overall fecal load within normal limits. Radiology showed 1. Moderate loculated right pleural effusion along with pleural calcifications. 2. Post-radiation changes. Limited evaluation for small cell lung cancer without IV contrast. 3. 4-mm left upper lobe nodule. In this patient with known diagnosis of small cell lung cancer, close interval followup is recommended. 4. Low-density area in segment IVB of the liver is likely fatty infiltration, attention on followup. The patient was diagnosed with ALTERED MENTAL STATUS , MAL NEO BRONCH/LUNG NOS, SEC MAL NEO BRAIN/SPINE. At the time of discharge, the patient had myxedema coma / hypothyroidism adrenal insufficiency gait instability. The patient was given written instructions concerning 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 small cell lung cancer with mets to brain s/p WBXRT and gamma knife followed by surgical resection of right temporal necrosis on ___ whose disease is thought to be in remission who p/w delirium and gait instability in the setting of not taking his medications. He was found to have adrenal insufficiency and myxedema coma/hypothyroidism. # Myxedema coma/hypothyroidism: Endocrinology was consulted. He was given IV levothyroxine and then transitioned to his oral levothyroxine. His mental status slowly improved back baseline at the time of discharge. TFTs should be followed up in ___ weeks. Follow-up was scheduled with ___ endocrine. # Adrenal insufficiency: He has been on a long course of prednisone and has had multiple episode of gait instability while stopping prednisone. It is unclear when he stopped prednisone. He had hypoglycemia and a low morning cortisol. A cosyntropin stim test did not show a robust response. Given the significant hypothyroidism, there was concern that replacing thyroid hormone could precipitate adrenal insufficiecny crisis. Thus he was treated with hydrocortisone 15mg qAM and 5mg qPM. Pt instructed to double his dose if he experiences fever or chills and call his doctor. Pt to follow-up with endocrine ___ weeks post discharge. # Pleural effusion: He presented with orthopnea. This resovled with treatment of the above conditions. However, he does have pleural effusion and thickening. This will need to be evaluated as an outpatient for recurrence of cancer. A CT scan was repeated and appeared stable. # Gait instability: He was started on hydrocortisone with XXX effect. In the past, he has gait instability while stopping steroids. He was evaluated by ___ and XXX. # Lung cancer: He will need to follow with his oncologist for further evaluation and management. # Incidental Lung Nodule: 4mm found in LUL. This information was explained to the patient and provided to the patients PCP via phone and hard copy. # Social: He needs ___ for medication management. He has had multiple episodes of suddenly stopping his medications, for which he often becomes very symptomatic. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo man with significant vascular risk factors who presents with slurred speech. CHEST (PA AND LAT) showed 1. Patchy opacities in the lung bases superimposed on a background of calcified pleural plaques may reflect atelectasis. 2. Small bilateral pleural effusions, unchanged. 3. Right apical nodule and bilateral hilar and mediastinal lymphadenopathy are better assessed on recent chest CT. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Dental almalgam streak artifact limits study. 2. No new acute territorial infarct, hemorrhage, mass, or mass effect. 3. The hypodensity within the bilateral centrum semiovale, likely reflecting evolving known punctate infarcts. 4. Intracranial atherosclerosis with chronic occlusion of the left M2 artery origin, diffuse mild luminal irregularity throughout the intracranial vasculature, and segmental significant stenoses at the bilateral intracranial internal carotid arteries. 5. Patent neck vasculature without significant stenosis by NASCET criteria. 6. Chronic dissection at the right brachiocephalic artery. 7. Solid and semi-solid nodules within the lung apices which are unchanged comparison to prior study and some which are new in comparison to ___. In addition there are unchanged prominent mediastinal lymph nodes. Given the changing appearance this may represent an ongoing infectious or inflammatory process, however a neoplastic processes not excluded. As per the recommendations on prior CTA of the head neck, recommend follow-up noncontrast CT of the chest in 3 months. 8. Please note MRI of the brain is more sensitive for the detection of acute infarct. RECOMMENDATION(S): As per the recommendations on prior CTA of the head neck, recommend follow-up noncontrast CT of the chest in 3 months. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Study is mildly degraded by motion. 2. Foci of slow diffusion within the right corona radiata which is mildly more confluent and extensive at its midportion as compared to prior study from ___ consistent with enlarging or new infarct. No evidence of hemorrhage. 3. Evolving punctate subacute left centrum semi ovale infarct. The patient was diagnosed with Transient cerebral ischemic attack, unspecified. At the time of discharge, the patient had TIA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of afib on Coumadin, PVD s/p peroneal bypass 10 days ago for which Coumadin was held and history of episodes of dysarthria x 2 with stroke who was admitted to the Neurology stroke service with a transient episode of slurred speech secondary to a TIA. MRI read as enlarging infarct of the right corona radiate, although thought to be expected MRI evolution of stroke. His TIA was most likely secondary to hypotensive episodes causing watershed poor perfusion given that his TIA occurred in the setting of SBP 80's, responsive to lying flat and fluids in the past. We did not consider this a failure of ASA/coumadin. He continued his antiplatelet therapy of ASA 81 ___s his lovenox bridge to Coumadin with goal INR ___. His deficits improved greatly prior to discharge and without notable deficits of speech, language, or any new focal weakness or sensory changes. His stroke risk factors include the following: 1) DM: A1c 5.41% - well controlled 2) Patient was off of Coumadin for 1 week prior to LLE bypass 3) Hypotensive episodes with recorded SBP 80's during TIA at home. However, his SBP has been 120's-150's as an inpatient with negative orthostatics. 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? () Yes (LDL = ) - (x) 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 >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? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: NAME: ___ MRN: ___ DATE: ___ ATTENDING: ___ CONSULTING SERVICE: ED CT of the left lower extremity without contrast. showed 1. Comminuted tibial fracture with extension to the tibial plafond. 2. Nondisplaced lateral malleolar fracture. 3. Small bubble of gas anterior to the talus suggests an open injury. 4. Incidental distal Achilles tendinosis and enthesophyte formation. ANKLE (AP, MORTISE AND LAT) LEFT IN O.R. showed Correlate with real-time findings and, when appropriate, correlative radiographs for full assessment. The patient was diagnosed with FX ANKLE NOS-CLOSED, STRUCK BY FALLING OBJECT. The patient was treated with ORIF left distal tibia. The patient was given written instructions concerning 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 left distal tibia fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF L distal tibia fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to homewas 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 NWB in the Left lower extremity, and will be discharged on aspirin for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a history of hyperlipidemia, chronic anemia, RCC status post left partial nephrectomy not on chemo presents with abdominal pain. Patient was recently admitted to this hospital for abdominal pain consistent with pancreatitis secondary to cholelithiasis. She is status post cholecystitis cystectomy on ___ and was discharged on ___ at which point she was feeling well up until yesterday. At this time she was started having increasing abdominal pain nonbloody nonbilious vomiting multiple episodes of loose stools decreased p.o. intake fevers and lethargy. When attempting to go to the bathroom today with her daughter's help she collapsed in her arms no LOC no head strike. They called an ambulance and brought her in for an eval. Radiology showed 1. Low lung volumes with bibasilar atelectasis. 2. Small left pleural effusion. 3. No evidence of free intraperitoneal air. Radiology showed 1. Acute pancreatitis with interval slight improvement of peripancreatic stranding since ___. No peripancreatic fluid collection. 2. Dilated and fluid-filled small bowel loops with transition point visualized in the right lower quadrant suggests small bowel obstruction. No ascites or bowel wall thickening to suggest ischemia at this time. 3. Extensive sigmoid colonic diverticulosis with new focal thickening of the sigmoid colon and faint pericolonic fat stranding suggests early acute uncomplicated diverticulitis. 4. Additionally there is slight mural thickening and thumbprinting of the transverse colon which is nonspecific and can be seen in C diff colitis. 5. No free air or free fluid in the abdomen. 6. Trace bilateral pleural effusions with minimal compressive atelectasis of the dependent lung bases. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:7am, 1 minutes after discovery of the findings. Radiology showed 1. Interval resolution of bowel obstruction. 2. No significant change in acute pancreatitis. No fluid collection. 3. Bilateral lower lobe peripheral airspace disease is slightly worse compared to yesterday and may represent atelectasis or pneumonia in the appropriate clinical scenario. 4. Additional stable findings, including a stable right renal mass, as above. Radiology showed Following removal of the nasogastric tube, there has been interval increase in small and large bowel dilatation suggestive of recurrence postoperative ileus, similar to ___. The patient was diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst. At the time of discharge, the patient had small bowel obstruction clostridium. difficile colitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female, s/p laparoscopic cholecystectomy on ___, returned to the hospital on ___ with abdominal pain, nausea, vomiting, and abdominal distention. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging which showed dilated and fluid-filled small bowel loops suggestive of small bowel obstruction. The patient had a ___ tube placed for bowel rest and was placed on serial abdominal examinations. On HD #2, she was noted to have an elevated white blood cell count to 35, but she remained afebrile. The patient had a stool specimen sent for c.diff which returned as positive and she was started on a 2 week course of oral vancomycin. Over the next ___ hours, the white blood cell count drifted down. The patient's ___ tube was removed and the patient was started on a regular diet. She continued to have mild abdominal distention and underwent an x-ray of the abdomen which showed bowel dilatation suggestive of an ileus. The patient continued on a diet as tolerated. Bowel function returned and the patient's diet was advanced. The patient was discharged home on HD #10. Her vital signs were stable and she was afebrile. She was tolerating a regular diet and voiding without difficulty. She was ambulatory and did not require analgesia. A follow-up appointment was made in the Acute care clinic. Discharge instructions were reviewed and questions answered. A prescription was provided for the patient to complete a 14 day course of vancomycin. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ year-old gentleman with a PMH of fistulizing Crohn's Disease c/b entero-splenic fistula s/p total abdominal colectomy (___) and on certolizumab/hydrocortisone/mesalamine, cholecytectomy and splenectomy, who now presents with one day of right lower quadrant abdomen pain and nausea. Of note, he was recently discharged from the hospital in early ___ with similar symptoms that improved with a 14-day course of PR mesalamine and PR hydrocortisone. This is his ___ occurrence over the past one year. Radiology showed Nonspecific bowel gas pattern with some air seen throughout non-dilated loops of small bowel and colon. No definite sign for obstruction. The patient was diagnosed with REGIONAL ENTERITIS NOS. The patient was treated with ___: flexible sigmoidoscopy. At the time of discharge, the patient had Primary diagnosis: Crohn's flare Secondary diagnoses: 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>Mr. ___ is a ___ year-old gentleman with a PMH of fistulizing Crohn's Disease c/b entero-splenic fistula s/p total abdominal colectomy (___) and on certolizumab/hydrocortisone/mesalamine, cholecytectomy and splenectomy, now admitted RLQ abdominal pain and nausea, consistent with prior Crohn's flares. # Crohn's flare: Patient with pain and nausea that usually characterizes his Crohn's flare, occurring approximately at the site of his ileo-rectal anastomosis. He believes that his pain is not severe enough to signify obstruction or perforation. He continues to have bowel movements at the same frequency and consistency as his normal. He had a KUB which showed no evidence of perforation. He was seen by GI and was treated with bowel rest, IV fluids and hydrocortisone enemas as well as mesalamine enemas. He was started on IV ciprofloxacin and flagyl which were converted to oral medications for a 7 day course on discharge. C. diff was tested and was negative. He had a flexible sigmoidoscopy which showed inflammation at the ileo-rectal anastomosis consistent with active disease. Pain was managed with IV pain medications and on discharge he was transitioned back to percocet. Stool studies were sent which are pending at the time of discharge, as is the CMV viral load. # Hyperkalemia: K was 5.9 on ___, rechecked at 4.8. In the setting of diarrhea this is unusual. His lisinopril was held temporarily and hyperkalemia did not recurr. # Smoking cessation: Counseled for 5 minutes regarding importance of quitting. Patient is highly motivated to quit and would like assistance during this admission. Quitting will also likely lead to fewer exacerbations of Crohn's. He was started on nicotine patch 21 mg daily and discharged with a prescription for nicotine patches. # Hypertension: On lisinopril and lasix at home, normotensive on arrival. His blood pressure medications were continued during hospitalization. - continue home BP meds # COPD: Takes Symbicort and albuterol at home, wheezing audibly on exam. He was continued on his home inhalers and given nebulizers as needed. He maintained good oxygen saturations throughout hospitalization. # Depression: Continued on home duloxetine and risperdal.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man ___ CAD s/p 5x CABG ___ CFA endarterectomy w/ SFA stenting x2 in ___, CLI s/p thrombolysis @ ___ ___, presenting on transfer from ___. He states that he developed a small cut on his right foot by his great toe roughly 1 month ago that never healed. He was seen in wound clinic, and had some improvement until last week, when his wound became significantly worse. He was admitted to ___, and an arterial duplex showed his SFA stent was occluded with poor ABIs. He was transferred to ___ due to a lack of access to specialist vascular surgery care at ___. Chest radiograph, portable AP upright. showed No evidence of acute cardiopulmonary process. ___ DUP UPPER EXT BILAT (MAP) showed Patent veins with diameters as noted above. ___ showed Occlusive clot in right distal clot does not qualify as a DVT. Remaining visualized vessels are patent with diameters as noted above. FOOT AP,LAT AND OBL RIGHT showed Unchanged appearances when compared to the prior study. FOOT SESAMOID SERIES AX,LO,MO RIGHT was done. FOOT 1 VIEW RIGHT showed Post right partial first ray amputation, without complication. Radiology showed Patient is status post amputation of the second and third digits. Well-circumscribed lucency projecting over the remaining base of the proximal phalanx of the right third toe, however it is uncertain if this is due to demineralization versus lucency in the overlying soft tissues. Consider dedicated toe films to better assess in different projections. Elsewhere, preserved mineralization. The patient was diagnosed with Type 2 diabetes mellitus with foot ulcer, Long term (current) use of insulin. The patient was treated with ___ RLE angio. At the time of discharge, the patient had Primary Diagnosis: Peripheral arterial disease, Right foot chronic wound Secondary diagnosis: T2DM neuropathy PAD prostate Ca ___ HLD Endocarditis CAD s/p MI (5x CABG ___ anxiety/depression Sciatica L Charcot foot TIA ___ (carotid US ___ b/l carotid a. stenosis). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ presented to the emergency department at ___ on ___ as a transfer from ___ with a nonhealing right first toe ulcer, as well as as reported right SFA stent occlusion and unknown runoff. He underwent a right lower extremity angiogram on ___, he tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. During his admission the podiatric surgery service was consulted given concern for his nonhealing right first toe plantar ulcer with exposed tendon. After appropriate revascularization, they underwent Right first ray resection. Patient was initially started on broad-spectrum antibiotics including vancomycin/cefepime/Flagyl. Patient was discharge on 10 day course of Augmentin. Patient arrived supratherapeutic on warfarin, he was given vitamin K and 1 unit of fresh frozen plasma prior to entering the OR. Perioperatively he was maintained on a heparin drip for anticoagulation. Neuro: Pain was well controlled on oral medications¦ 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. Had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially kept NPO after the procedure. The patient was later advanced to and tolerated a regular diet at time of discharge. Patient's intake and output were closely monitored GU: The patient had a Foley catheter that was removed prior to discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient was closely monitored for signs and symptoms of infection and fever. Heme: The patient had blood levels checked daily during their hospital course to monitor for signs of bleeding. The patient received subcutaneous heparin and ___ dyne boots were used during this stay, he/she was encouraged to get up and ambulate as early as possible. On ___, the patient was discharged to rehab. At discharge, he was tolerating a regular diet, passing flatus, voiding, and ambulating independently. He will follow-up in the clinic in 4 weeks. This information was communicated to the patient directly prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with a history of hairy cell leukemia s/p cladribine on ___ who presented to the ER with generalized weakness and a fall the day prior to admission. He reports feeling unwell for the past few days with fatigue and according to his wife has been eating and drinking much less. He cannot recall if he experienced any lightheaded symptoms prior to the fall and does not know the circumstances surrounding the fall. He was recently in a rehab facility after receiving Cladribine and was treated for PNA with levaquin, now home and off abx. Radiology showed Slight interval increase in size of moderate left pleural effusion. Left basilar opacity likely reflects atelectasis. Trace right pleural effusion also noted. Mild pulmonary vascular congestion, similar compared to the prior study. Radiology showed No intracranial hemorrhage or acute territorial infarction. Radiology showed 1. Cholelithiasis without cholecystitis. 2. Bilateral pleural effusions and abdominal free fluid. 3. Left upper pole nonobstructive 5 mm renal calculus. 4. Left lower pole renal cyst. Radiology showed Pacemaker leads in good position, no pneumothorax. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, OTHER MALAISE AND FATIGUE. The patient was treated with Dual chamber pacemaker placement ___. At the time of discharge, the patient had Primary: Symptomatic Bradycardia Secondary: Hairy Cell Leukemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ y/o M with PMH significant for atrial fibrillation, systolic & diastolic heart failure (EF 30%), hypertension, and hairy cell leukemia who was admitted to the oncology service with weakness and lethargy and was noted to have bradycardia was transferred to ___ for management of symptomatic bradycardia. # Symptomatic Bradycardia: Pt was noted to have HRs in the ___ on the onc service, which while not associated with syncope, may be leading to symptoms of weakness and lethargy. His recent decline in functional status may be due to bradyarrhythmia. He was on a beta-blocker at low dose which was stopped. Despite this, he continued to be bradycardic in the ___ and ___. Since patients weakness and lethargy could be from the bradycardia it was discussed with patient and family and decided that a pacemaker would be implanted to treat the bradycardia with the hope that this would improve his current symptoms. Pt had a dual chamber PPM permanent pacemaker placed on ___. He also had episodes of AVNRT so metoprolol succinate 25 mg PO daily was restarted. He was discharged on Cephalexin 250 mg PO Q8H Duration for 2 days for prophylaxis for pacemaker placement. # Atrial Fibrillation: CHADS2 score of ___ so should be on anticoagulation but is not currently. We held anticoagulation given that he needed a pacemaker insertion. Spoke with outpatient cardiologist who wants to hold off on anticoagulation given patients history of multiple prior falls at this time. Pt will consider starting coumadin when he follows up with his outpatient cardiologist. # chronic systolic & diastolic heart failure (EF 30%): We stopped his beta-blocker given his symptomatic bradycardia. We continued aspirin 325 mg PO DAILY. Would consider starting lisinopril 2.5 mg daily as outpatient if renal function and BP remains stable. # Dementia: Pt with normal TSH of 1.1 and Vitamin B12 level of 840. We stopped Aricept due to anticholinergic effect and continued Memantine 5 mg PO DAILY. # Hairy Cell Leukemia: Pt is s/p 1 cycle of Cladribine. Pt was going to get Rituxan on ___ but this is currently on hold. Pt will follow up with outpatient oncologist Dr. ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male hx of Hidrenitis (recurrent skin infections axilla/groin/face since ___ was ___ years old. Countless sets of antibiotics and many many I&D), OSA on CPAP, uncontrolled NIDDM2, HTN, gout, NAFLD, obesity who was referred to ___ ED from PCP office on ___ for cellulitis. US CHEST WALL SOFT TISSUE RIGHT; US MSK SOFT TISSUE showed Small very superficial complex collections in the areas of redness measuring 1.0 cm in the right chest wall and 0.8 cm in the left upper arm, as described above. The patient was diagnosed with Type 2 diabetes mellitus with hyperglycemia, Cellulitis of left upper limb. The patient was treated with I & D of two abscesses. At the time of discharge, the patient had Abscess, Cellulitis Type 2 diabetes poorly controlled. The patient was given written instructions concerning 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 history of Hidrenitis Supportivia, OSA on CPAP, uncontrolled NIDDM2 (last Hba1c 11), HTN, gout, NAFLD, obesity a/w cellulitis/abscess s/p drainage #Abscess/Cellulitis of chest wall and left arm #Hidrenitis Supportivia Clinically improved with decreased pain, no fevers, no wbc. Continued on IV antibiotics. The patient was seen by ACS who recommended ultrasound. This showed a small area of fluid which was likely to small to be drained. The patient remained afebrile with normal WBC Count. ___ requested to leave, and was therefore transitioned to oral clindamycin on discharge. ___ was counseled to seek care if erythema worsens, ___ develops a fever or has other concerning signs or symptoms. #Hidrenitis Supportivia Unclear diagnosis. If remained in house, plan to consult dermatology. Has been referred to ___ dermatology through care connections. Dischared with prescriptions for chlorhexidine 4% washes per week. Clindamycin 1% solution BID as first line therapy to prevent subsequent episode until sees dermatology #Uncontrolled hyperglycemia/diabetes type 2 not on insulin Patient with significantly elevated blood sugar and HgBA1C of 11.2. ___ was started on insulin which was uptitrated to Lantus 40units at bedtime, Humalog 12 units before meals plus sliding scale. The patient was seen by the diabetes educator and showed good understanding of diabetes management and has close PCP follow ___ was provided with prescriptions for all medications on discharge. Metformin was held due to poor tolerance by patient. Could consider re-introducing. #OSA -Continued CPAP qhs #Gout -Continued home colchicine -continued home allopurinol #OSA -Continue CPAP qhs #Gout -Continue home colchicine -continue home allopurinol</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ F with h/o HLD who presents as a transfer from ___ after finding of a right parietal IPH on head CT. The patient was in her usual state of health when she awoke early this morning with a severe posterior headache. She took some ibuprofen for the pain and went back to sleep. She awoke later and the headache continued. She went about her day and noticed that she seemed to be clumsy on the left side. She tripped slightly while walking up a flight of stairs, but did not fall. She later was out with a friend who noticed that her gait was off and recommeded presenting to the ___. The patient contacted her son, who is an EMT. Her son noticed again she she appeared to be clumsy on the left side and that she seemed to have some proprioceptive deficit, not lifting her left leg high enough to clear obtacles and missing the target when trying to place a bottle cap on a bottle. She presented to the ___ where a ___ demonstrated a right parietal IPH. MRI AND MRA BRAIN showed 1. Right parietal intraparenchymal hematoma, 2.8x2.5x2.7cm, unchanged compared to prior CT. Thick rind of slightly irregular and heterogeneous peripheral enhancement seen in/surrounding the hematoma on post-contrast images. This could be a finding seen with a subacute hematoma, however an underlying mass lesion cannot be completely excluded, given the thickness and irregularity. Close Followup is recommended to assess for interval change. 2. T2/FLAIR signal hyperintense focii in the periventricular, deep, and subcortical white matter which are nonspecific but most likely secondary to chronic small vessel ischemic disease. 3. Patent major dural venous sinuses CT HEAD W/O CONTRAST showed Stable right parietal intraparenchymal hemorrhage. No new hemorrhagic lesions. Radiology showed 3.0 cm right parietal intraparenchymal hemorrhage with associated edema. No new intracranial hemorrhage. The hematoma appears slightly increased in size which could be due to differences in slight selection or slight actual increase which can be assessed on follow up. Increased surrounding edema is noted without significant change in mass effect. . CTA HEAD AND CTA NECK showed 1. A 3.2x3.1cm right posterior parietal lobe acute intraparenchymal hematoma with some surrounding edema and mass effect. No abnormal vessels in the vicinity. Please see subsequent MRI for additional findings and discussion. 2. Patent major intra and extracranial arteries as discussed above. 3. Mild fullness in the left pyriform sinus and multiple small nodes not enlarged by size criteria however correlate clinically. The patient was diagnosed with INTRACRANIAL HEMORR NOS, HEADACHE. The patient was treated with n/a. At the time of discharge, the patient had Primary diagnosis: Left parietal intraparenchymal hemorrhage Secondary diagnosis: Hyperlipidemia Headache. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old woman with a past medical history of hyperlipidemia who was transferred to ___ ___ from ___ after presenting with a severe posterior headache with NCHCT demonstrating a right parietal intraparenchymal hemorrhage. She was evaluated by neurosurgery who did not feel there was a indication for surgical intervention. She was then admitted to the neurological ICU for further management. Repeat non-contrast head CT 24 hours after presentation demonstrated stability of her bleed. SBP was maintained at < 140. She was subsequently transferred to the floor stroke service. Anti-platelets and anti-thrombotics were held during hospitalization. Etiology of her intraparenchymal hemorrhage was further investigated and remained unclear at time of discharge. The hemorrhage location was characteristic of amyloid angiopathy; however, Ms. ___ young age and lack of other findings consistent with amyloid angiopathy on MRI made this diagnosis less likely. Still, this episode could have represented a first time amyloid bleed. Additionally, MRI/MRV did not demonstrate any evidence of a venous sinus thrombosis as a cause for her bleed but it did demonstrate enhancement with contrast surrounding the hemorrhage. This could be due to disruption of blood brain barrier at the site of the bleed or be due to the presence of a mass. Ms. ___ reported being up to date on her cancer screenings for mammogram, colonoscopy and pap smear. She will have a repeat MRI in follow-up for further investigation of this finding as the hemorrhage heals. Otherwise, hypertension as an etiology was unlikely as she did not have hypertension during hospitalization or prior history of hypertension. Ms. ___ suffered from severe headaches during hospitalization due to the hemorrhage. She was initially managed with IV dilaudid. She was starting on Oxycontin to assist with dilaudid wean. At time of discharge, pain was controlled with 2mg PO dilaudid q8 PRN, Oxycontin 30 BID, gabapentin 300 TID and Fioricet q4 PRN. Dilaudid will need to be weaned and discontinued in rehab. Repeat ___ ___ showed a stable hemorrhage. On day of discharge, Ms. ___ continued to have a headache controlled with pain medications. ======================= TRANSITIONS OF CARE ======================= -MRI showed: "Thick rind of slightly irregular and heterogeneous peripheral enhancement seen in/surrounding the hematoma on post contrast images. This could be a finding seen with a subacute hematoma, however an underlying mass lesion cannot be completely excluded, given the thickness and irregularity," indicating that she will need a repeat MRI for further assessment. This was scheduled at time of discharge. -If repeat MRI shows a possible mass, will need a CT torso and malignancy work-up. -Wean and discontinue dilaudid. -Wean Oxycontin as headache improves. ==================================================== AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (X) Yes [performed and documented by admitting resident] – () No 2. DVT Prophylaxis administered by the end of hospital day 2? () Yes - (X) No 3. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 4. Stroke education given (written form in the discharge worksheet)? (X) Yes - () No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 5. Assessment for rehabilitation or rehab services considered? (X) Yes - () No [if no, reason not assessed: ____ ]</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx morbid obesity, HTN, HLD, and T2DM presented with chest pain. On day of presentation noted onset of substernal chest pain which awoke her from sleep. Notably, the patient has a long standing history of intermittent chest pain. Evaluated in ___ ED 10 days prior to presentation with negative serial enzymes, D-dimer 876 and L>R leg edema, but CTA chest was negative. At that time an outpatient stress planned but not completed. Radiology showed Slight increase in interstitial markings compared to prior study likely indicates mild interstitial pulmonary edema. Moderate-to-severe cardiomegaly is unchanged. Radiology showed Limited study due to patient's body habitus. Calf veins not visualized. Limited evaluation of the distal superficial femoral and popliteal veins; however within these limitations, no DVT was identified. Radiology showed Substantial bilateral osteoarthritis. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Atypical chest pain Morbid obesity (BMI=60) Osteoarthritis of bilateral knees Left knee pain due to pes aneserine bursitis. The patient was given written instructions concerning 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: ___ with morbid obesity, HTN, HLD, DM presents with recurrent atypical chest pain.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman w/ PMHx of ___ disease, bilateral blindness, HTN, bronchitis who was admitted from ___ ED for unresolved cough and shortness of breath after 3 days of outpatient antibiotic treatment. Radiology showed No acute cardiopulmonary process. FOOT AP,LAT AND OBL LEFT showed There is marked osteopenia probably from disuse. A fracture could be missed in bones of this lucency. There are some hammertoe deformities of the second third and fourth toes. There is some soft tissue ossification that seen lateral to the first metatarsal head and at the second metatarsal phalangeal joint These could be due to old trauma. There is also deformity of the ankle mortise that is likely due to old trauma or degenerative changes. CT C-SPINE W/O CONTRAST showed 1. No acute fracture identified. 2. Severe cervical spondylosis with mild anterolisthesis of C2 on C3 and C7 on T1. Mild to moderate central canal narrowing without high-grade stenosis. 3. Anterior compression deformity of the T3 vertebral body is unchanged. CHEST (SINGLE VIEW) showed No acute intrathoracic abnormality. Consider dedicated spine imaging if there is clinical concern for thoracic spinal fracture. PELVIS (AP ONLY) showed No fracture identified. Marked generalized demineralization KNEE (AP, LAT AND OBLIQUE) BILATERAL showed No fracture. Prominent osteoporosis ANKLE (AP, MORTISE AND LAT) LEFT showed No fracture. Marked generalized demineralization. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Bronchitis vs airway reactivity after infection ___ disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ yo woman w/ PMHx of ___ disease who was admitted for unresolved SOB and cough despite antibiotic treatment for presumed pneumonia. # Bronchitis / ?Pneumonia. Recently diagnosed with pneumonia and completed antibiotic course of doxycycline. Per son had some intermittent cough and shortness of breath but CXR here showing no evidence of pneumonia. Currently she denies cough or SOB, has normal oxygen saturation and clear lungs on examination. Low suspicion for current bacterial process. She had occasional cough and wheezing after eating. She was evaluated by speech and swallow who thought she did overall well and did not think VSS indicated at this time. - Atrovent nebs q6h standing for 2 weeks - Fluticasone inhaler for reactive airways - Albuterol nebs PRN # Rash: developed pruritic rash after receiving Levaquin, no prior history of allergies per patient or son. ___ improved after Benadryl and currently resolved. - Added Levaquin as an allergy # ___ disease - Continue home meds. # Difficulty ambulating: Having worsening difficulty ambulating. ___ recommending rehab, patient and family only interested in ___ rehab where she has been before. ___ declined patient, so family decided to take her home with services. Code: Full code here Billing: >30 minutes spent coordinating discharge to home</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with history of end stage renal disease status post deceased after cardiac death renal transplant in ___, coronary artery disease, hypertension, and insulin-dependent diabetes ___ who presents with sudden-onset left flank pain radiating to the left upper quadrant. She reports pain radiates to the left lower quadrant and back and is associated with nausea, ___ episodes of nonbloody emesis, and nonbloody diarrhea; no history of kidney stones, has atrophic kidneys; denies burning with urination, positive urinary frequency; denies vaginal bleeding/discharge; denies fevers; nothing similar in the past; no sick contacts. RENAL TRANSPLANT U.S. showed 1. Unchanged complex cystic lesion in the upper pole of the transplant kidney, as previously characterized on MRI. 2. Minimal fullness of the upper pole of the transplant kidney without frank hydronephrosis. 3. Unchanged mildly elevated resistive indices. Patent vasculature. CT ABD AND PELVIS W/O CONTRAST showed 1. No retroperitoneal hematoma. 2. Transplanted kidney in right lower quadrant with 2.6 cm hypodensity in the upper pole, better characterized on MR dated ___. Interval decrease in fat stranding surrounding transplanted kidney. 3. Distended bladder. The patient was diagnosed with ABDOMINAL PAIN LLQ. At the time of discharge, the patient had Primary: Abdominal/back pain of uncertain etiology Secondary: End stage renal disease status post renal transplant Diabetes ___ 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 ___ with history of end stage renal disease status post deceased after cardiac death renal transplant in ___, coronary artery disease, hypertension, and insulin-dependent diabetes ___ who presented with sudden-onset left flank pain radiating to the left upper quadrant. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with history of CAD s/p CABG, Type II diabetes, hypertension, and chronic knee pain, who presents from rehab with chest pain. CHEST (PA AND LAT) showed No acute intrathoracic process. CTA CHEST showed No evidence of pulmonary embolus. No acute intrathoracic abnormality. The patient was diagnosed with Other chest pain. At the time of discharge, the patient had Diabetes, type II Coronary artery disease Anxiety Knee osteoarthritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of CAD s/p CABG, type II diabetes, hypertension, and chronic knee pain, who presents from rehab with recurrent chest pain with negative workup for acute cardiac cause, admitted as declined to return to nursing facility. Patient was ultimately discharged to a hotel as patient refused to return to prior SAR. # Coronary artery disease/Microvascular coronary disease: # Chest Pain: # Chronic stable angina: Patient with significant history of CAD and what is felt to be angina from microvascular disease. Multiple troponins negative and EKG without ischemic changes. No chest pain since arrival, and extensive recent workup, including nuclear stress last month. This was thought to be exacerbated by anxiety. patient also complained of pleuritic chest pain and lightheadedness and underwent a CT chest that was negative. # Osteoarthritis: # Knee pain: Patient is unable to ambulate as knees buckle, which has currently left him wheelchair-bound and previously in rehab. This is reportedly due to prior failed knee surgery. Plan for eventual surgery, though first would need to be improved from a cardiac standpoint. Discharged with wheelchair and bedside commode. #UTI -previously treated with cefpodoxime for a Klebsiella UTI, patient unaware if he received the antibiotics as he was in rehab. UA suggestive of infection. Culture pending at discharge. Given Cipro for 10day course. </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 past medical history of failed back surgery syndrome s/p nevro SCS implantation, who was recently discharged on ___ s/p removal of spinal cord stimulator and T8-T12 laminectomy. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. Laminectomies T8-9 through T11. Fluid collection at the laminectomy bed extending to the skin surface, with complex appearance, likely postoperative with blood products within it given mildly intrinsic bright T1. Severe central canal narrowing at this level, with cord compression without definite cord signal abnormality. 2. Thoracic epidural lipomatosis, contributing to moderate to severe overall central canal narrowing. 3. L1-L5 bilateral laminectomies, L1-L2 posterior spinal fusion, with extensive postoperative changes. Overall, the lumbar spine alignment and postop appearance has minimally changed dating back to ___. This includes multiple probable postoperative seromas. 4. Background multilevel spondylosis of the lumbar spine, as above, overall mildly progressed from the previous examination. 5. Arachnoiditis in the lumbar spine, stable. NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the telephone on ___ at 7:06 pm, 15 minutes after discovery of the findings. ULTRASOUND-GUIDED ASPIRATION showed Successful US-guided drainage of the right paravertebral soft tissue collection. Samples was sent for microbiology evaluation. The patient was diagnosed with Low back pain. The patient was treated with Ultrasound guided aspiration of ___ fluid collection ___. At the time of discharge, the patient had fluid collection of thoracic spine surgical bed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#LLE paresthesias/allodynia/hyperesthesia and lumbar back ___ The pt was evaluated in the ED and MRI of the T and L spine was revealing for fluid collection at the laminectomy bed with complex appearance, c/w postoperative blood products with severe central canal narrowing though without cord compression/definite cord signal abnormality. He was then admitted to the neurosurgical floor for frequent monitoring of his neurologic status and for ___ management. On HD2, ___, Mr. ___ underwent ultrasound guided aspiration of his ___ fluid collection, yielding 40cc of clear CSF-like fluid. There were no signs of purulence noted per ___ aspiration. The aspirate was also sent for gram stain and culture studies. Gram stain was negative for organism or PMNs. Cultures were pending as of the time of the patient's discharge. On HD3, ___, the patients thoracic midline incision and R lower flank incision were healing well. The sutures and staples at these incisions were removed at the bedside, revealing well healed, well approximated incisions with some scabbing noted centrally. ___ Mr. ___ is an established patient of Dr. ___ the ___ ___. He was evaluated by the inpatient service who recommended an inpatient ___ regimen of: 1. APAP 1GM TID po ATC 2. Consider Toradol 15mg IV Q6H ATC 3. Dilaudid 4mg po Q6H prn 4. Gabapentin 300mg po in AM and mid day, 600mg qhs, plan to uptitrate 5. D/C valium 6. Tizanidine 4mg po Q12H prn spasms 7. Morphine ___ IV Q4H prn severe ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ RHF with h/o recurrent UTI and non-convulsive status epilepticus who is well known to our service with multiple past admissions for AMS who now presents with ___ weeks of confusion. This is characterized by her sister as the inability to speak sensibly, and repeating the same words or phrases over and over again (of note, perseveration has been noted in clinic notes even during times when Ms. ___ mental status was not acutely altered). It appears that on occasion, she has also gotten agitated during this time with "excessive motor activity". She may have gotten LZP at her nursing facility earlier today per administration record, although ___ is unsure of this. Personally, she has not seen any actual seizure activity. The only other piece of information she stressed to me is that about ___ week ago, Ms. ___ had an episode of "her tongue feeling thick" and hanging out of the side of her mouth. Radiology showed Chronic changes within the right lung base with chronic pleural thickening. Chronic anterior dislocation of the left shoulder. Radiology showed No CT evidence for acute intracranial process. Radiology showed Ultrasound and fluoroscopically guided single lumen PICC line placement via the right brachial venous approach. Final internal length is 30 cm, with the tip positioned in SVC. The line is ready to use. The patient was diagnosed with ALTERED MENTAL STATUS , URIN TRACT INFECTION NOS. At the time of discharge, the patient had Confusion. The patient was given written instructions concerning 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 ___ RHF with h/o recurrent UTI and non-convulsive status epilepticus who is well known to our service with multiple past admissions for AMS who now presents with ___ weeks of confusion. # Encephalopathy/delirium Though available history is sparse, per report she has been confused, perseverative and intermittently agitated with excessive motor activity. No clear history of seizures though earlier today received PRN LZP at her facility. On exam, is somnolent and extremely perseverative with grasp and snout reflexes. There was no obvious focality. Differential diagnosis includes toxic-metabolic encephalopathy (likely due to recurrent UTI) vs non-convulsive status epilepticus given the prominent catatonic signs (perseveration, grasp, alternating agitation and withdrawal), recurrent NCSE is high on differential. Patient was admitted to neurology for monitoring. She has had no event overnight and by HOD two, her mental status was back to baseline. # enterococcus UTI In the past, urine cultures have grown VRE, MDR gram negatives and ___ species. At times, decision was made not to treat Ms. ___ (which always appear contaminated) until culture data are available. Patient was sgiven ceftriaxone and meropenem in the emergency department but we decided to hold any further antibiotic as patient seems to be have chronically positive UA from chronic Foley due to neurogenic bladder. Her urine culture came back positive >100,000 enterococcus. We made the decision along with infectious disease consultant to start patient on IV daptomycin given that her last enterococcus UTI was resistant to multiple agents and sensitive to only linezolid. Patient is allergic to linezolid (cause causes thrombocytopenia per record) and therefore daptomycin was started on ___. A PICC line was inserted for the administration of daptomycin. Urine culture final result indicates that the UTI is sensitive to vancomycin so we switched her daptomycin to vancomycin. Blood cultures were also obtained on the day of admission but has remained NGTD thus far. She got a PICC line on ___. She should get a vancomycin trough before the evening dose on ___. She should get vancomycin through ___. #F/E/N She was given IVF overnight because of concern for infection. She ate ground diet/nectar thick under supervision once her mental status improved. # Transitional Issues [ ] Please follow up final result of blood cultures [ ] She should get a vancomycin trough before the evening dose on ___. [ ] She should get vancomycin through ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PORTABLE AP) showed Moderate pulmonary edema, slightly more pronounced on the right. Probable bibasilar atelectasis. ABDOMEN US (COMPLETE STUDY) showed 1. Coarsened liver echotexture and nodular morphology. 2. Cholelithiasis without finding to suggest acute cholecystitis. 3. Splenomegaly, spleen measures 14.1 cm. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. CTA CHEST WITH CONTRAST showed 1. No evidence of central pulmonary embolism. Streak artifact limiting evaluation of segmental and subsegmental branches. 2. Diffuse bilateral, scattered ground-glass opacities, with lower lobes predominant ___ nodularity, likely reflecting infectious/inflammatory process, with aspiration pneumonia in the differential. 3. Nodular contour of the liver, with partially visualized splenomegaly, may reflect sequela of cirrhosis/chronic liver disease, hepatology consultation is recommended. 4. Cholelithiasis without evidence of cholecystitis in the partially visualized gallbladder. 5. Small hiatal hernia. RECOMMENDATION(S): Hepatology consultation. T935 showed Please note that this report only pertains to extracardiac findings. The liver is nodular in contour and heterogeneous in appearance, suggestive of cirrhosis. The spleen is enlarged up to 15 cm. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. The patient was diagnosed with Cardiac arrest, cause unspecified. The patient was treated with N/. At the time of discharge, the patient had Bradycardic arrest Vasovagal syncope Heart Failure with Moderately Preserved EF Diabetes Mellitus 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>Mr. ___ is a ___ y/o male with a history of HTN, HLD, DM, and obesity who presented to ___ for a bradycardic arrest (likely d/t vasovagal) after developing respiratory distress following a tooth extraction, hospital course c/b acute hypoxic respiratory failure ___ new CHF diagnosis Discharge weight: 109.8 kg (242.06 lb) Discharge Cr: 1.1 Discharge diuretic: torsemide 30 mg daily</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with a history of breast cancer s/p L breast mastectomy ___ years ago), squamous cell carcinoma of the larynx s/p radiation and chemotherapy ___ years ago), and COPD on home 4L, and recent admission (___/) for aspiration pneumonitis/COPD exacerbation who presents with sudden onset dyspnea since this afternoon. She reports that she may have aspirated on yogurt and this feels like prior COPD exacerbations. She denied recent travel. In the ED, initial vitals: 98.5 128 ___ 96% 4L NC. Exam notable for RR 30, tachycardia, decreased breath sounds bilaterally. Labs notable for WBC 16.9 with 89.7%, lactate 1.5, calcium 10.9. CHEST (PORTABLE AP) showed No significant interval change Radiology showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Slight interval increase in the dominant spiculated mass in the left lower lobe measuring 4.1 x 4.0 cm. 3. Unchanged spiculated mass at the right apex measuring 1.4cm. Confluent hilar and mediastinal lymphadenopathy. No changed in right lower lobe collapse. 4. Diffuse septal thickening with nodular opacities bilaterally measuring up to 5 mm concerning for lymphangitic spread with metastatic nodules. Radiology showed No significant interval change since prior study. No pneumothorax. Radiology showed Tip of the endotracheal tube is situated 9 mm above the carina. Radiology showed Right IJ terminates at the cavoatrial junction. No changed to the rest of findings within the chest. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, ACUTE RESPIRATORY FAILURE. The patient was treated with Intubation Central line placement. At the time of discharge, the patient had Primary: Recurrent aspiration COPD exacerbation New diagnosis of squamous cell carcinoma in lung (source unclear) Secondary: Multiple lung nodules on CT concerning for malignancy Chronic obstructive 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>___ year old female with a history of newly diagnosed invasive squamous cell carcinoma likely lung primary, remote history of breast and laryngeal cancer, and COPD on 4L home O2 who presented with acute respiratory distress. ACTIVE ISSUES # Mixed Respiratory Failure She had both hypoxia, hypercapnea and tachypnea leading to intubatioy. Etiology most likely multifactorial, including 1) Bilateral GGOs concerning for pulmonary edema vs infection, 2) Aspiration pneumonitis/pneumonia, and 3) COPD exacerbation. She was treated for COPD exacerbation with IV methylprednisolone, duonebs initially, then transitioned to PO prednisone. She was also started on inhaled fluticasone and tiotropium. She was treated for HCAP with vanco/cefepime/levoquin initially, but deescalated to levofloxacin on ___. Sputum culture revealed was contaminated. Viral respiratory screen was negative. Investigation for pulmonary edema including BNP, which was normal. She was extubated on ___ and transferred to the floor. She remained stable on home oxygen of 4L. Physical therapy saw the patient and believed she had returned to her baseline functional status. She was discharged home with home ___ and family support. She will complete Levofloxacin on ___. # Aspiration Prior evaluation has shows aspiration on all food consistencies. She is at risk for recurrent respiratory distress and failure because of her aspiration. However, the patient has determined multiple times and documented in OMR that she accepts the risks of aspiration and does not want a feeding tube. We have discussed with the patient and family (daughters) that she will likely always be aspirating, and we can modify but not eliminate this risk. The patient has elected to eat with nectar thick liquids and pureed solids, accepting the risk of aspiration. She is DNR/DNI, but ok for NIPPV. # Squamous Cell Carcinoma, Likely Lung Primary Leftu lng mass biopsy results from outpatient biopsy done ___ showed moderately differentiated SCC. In discussion with the pulmonary pathologist, it was felt that this was most likely a lung primary. Patient and family will discuss with her PCP after discharge seeing an oncologist as an outpatient. She may need PET CT and Brain MRI for further evaluation/staging. We did discuss with her and her family that given her chronic diseases, chemotherapy options may be limited. # Normocytic Anemia She received 1u pRBCs for Hgb of 6.9 on ___. She had no evidence of bleeding and very low reticulocyte count, so anemia was attributed to chronic illness and frequent phlebotomy in the setting of poor marrow response. TRANSITIONAL ISSUES - Started on tiotropium for severe COPD - Last day of levofloxacin for HCAP is ___. Her dosing for renal function is q48h, so she is due for one more dose on ___. - Lung biopsy done as outpatient resulted as squamous cell carcinoma, most likely lung primary. Consider PET CT and Brain MRI with referral to oncology as an outpatient. - Giver her severe COPD and chronic aspiration, along with baseline functional status, would recommended outpatient referral to palliative care to continue symptom management. - Despite known aspiration on all food consistencies, the patient reiterated her wish to continue to eat accepting the risk of aspiration. - Code: DNR/DNI, OK for non-invasive positive pressure ventilation - Contact: ___ (daughter) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Much of the history is obtained from the ED documentation, as Mr. ___ is very uncooperative as well as being confused. He is beligerent and cursing through much of the interview. Radiology showed Extennsive pulmonary metastases. No definite lobar consolidation concerning for pneumonia. Radiology showed Multiple hyperdense metastatic lesions, marginally increased, with surrounding edema. No herniation. The patient was diagnosed with FEVER, UNSPECIFIED, ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ HLD, past CVA, and colon cancer initially resected in ___ (refused adjuvant chemo), now with metastatic disease including several brain lesions with edemea. He presented to the ED today with confusion and a febrile illness, likely secondary to dehydration and heat stroke. . # Toxic metabolic encephelopathy: Confused, though largely just agitated and beligerent. This was initially thought to be related to his febrile illness and metabolic derangements. The patient was fluid resuscitated, had his blood sugars controlled and had his steroids briefly increased and quickly tapered. The patient's mental status improved to his baseline. . #. Fever: Unclear etiology although recorded at 103.8F rectally in the ED. UA negative. Culture and blood cultures negative. Head CT showed metastatic disease. CXR showed stable known metastatic disease. LP was negative. The pt received meningitis coverage in the ED but antibiotics were later held. The patient had no further episodes of fever during his hospital course. Thus, his fever was attributed to heat stroke. . #. Metastatic Colon Cancer: Mets to the brain. CT stable. Multiple brain lesions with vasogenic edema. The patients dexamethasone was increased from 2mg daily to 4mg QID while in house, this was tapered back down quickly to his home dose of 2mg daily prior to d/c as there was no apparent increase in his cerebral edema on CT. He was continued on his home dosing of Keppra. . #. Hyponatremia: Likely hypovolemic given insensible losses with fever, and very hot apartment without AC. It was also in the setting of likely hyperglycemia with potential some component of osmotic diuresis at home. The patient was given IVF and his Na improved from 125 to 129 while in house. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female who was brought into the hospital by EMS as a pedestrian struck. She was pinned between 2 cars, crushing both lower extremities. She had initially no pulses at the scene but transient lower extremity pulses while in route. She reports severe pain in both legs that recalls no other injuries and reports no pain in the head, neck, chest, hips, or arms. MR ___ WAND W/O CONTRAST ___ MR ___ SPINE. showed 1. No evidence of an epidural hematoma. No cord signal abnormalities identified. 2. No evidence of acute ligamentous injury identified within the anterior longitudinal ligaments. Previously noted widening of the anterior aspect of the C6-C7 vertebral body is likely degenerative in etiology. 3. Cervical spondylosis, as described in detail above most pronounced at C4-5 and C5-6. 4. Unchanged left internal carotid artery aneurysm, previously demonstrated by head CT on ___. CHEST (PORTABLE AP) showed Compared to chest radiograph ___. Patient still intubated, but the ET tube has been partially withdrawn, tip is now 5.5 cm from the carina and care should be taken not to start any further. Lungs are hyperinflated but grossly clear. Normal cardiomediastinal and hilar silhouettes and pleural surfaces. HAND (PA,LAT AND OBLIQUE) RIGHT showed 1. Diffuse osteopenia. 2. Prominent soft tissue swelling. 3. Suspected old healed distal right radial fracture. Clinical correlation to confirm this is requested. 4. Equivocal nondisplaced fracture in the proximal metaphysis of the fourth metacarpal bone, seen only on one view. Alternatively, this could reflect changes due to remote healed fracture or bony ridging at the base of the metacarpal. UNILAT UP EXT VEINS US showed No evidence of deep vein thrombosis in the right upper extremity. There is soft tissue edema within the right peripheral upper extremity. There is thrombus in the mid and peripheral right cephalic vein, which is considered a superficial vein. Radiology showed Right shoulder: No acute fractures or dislocations are seen. There are mild degenerative changes of both the AC and glenohumeral joints. There is a deformity of the superolateral humeral head suggestive of a ___ deformity related to prior anterior shoulder dislocation. Right elbow: Evaluation for joint effusion is limited due to patient positioning and technique. However, no displaced fractures or dislocations are seen. There is slight lateral elbow soft tissue swelling. FEMUR (AP AND LAT) IN O.R. RIGHT showed The laterality of this examination is not labeled on these images but is presumed to be a ORIF of the right femur. For further details please refer to the operative report in the ___ medical record. TIB/FIB (AP AND LAT) IN O.R. RIGHT showed Intraoperative radiographs. ORIF of the tibia. For further details please refer to the operative report in the ___ medical record. TIB/FIB (AP AND LAT) LEFT IN O.R. showed Severely comminuted tibial shaft, tibial plateau, fibular shaft and fibular neck fractures. External fixation hardware is in place with screws in the tibia and calcaneus. CHEST PORT LINE/TUBE PLCT 1 EXAM showed Compared to chest radiographs ___. New heterogeneous opacification at the base of the right lung could be pneumonia. A different appearing abnormality obscures the left diaphragmatic contour. It could be new consolidation, pleural effusion or delayed expression of left diaphragmatic injury. Lateral view is recommended if feasible. Mediastinum normal. Upper lungs clear. No pneumothorax. ET tube in standard placement. Esophageal drainage tube ends in the mid stomach. CHEST (PORTABLE AP) showed Comparison to ___. Stable appearance of the monitoring and support devices. The patient continues to be rotated. Mild to moderate left pleural effusion is unchanged. Subsequent areas of retrocardiac atelectasis as well as the parenchymal opacity at the right lung bases is stable. No new parenchymal changes. No evidence of pulmonary edema. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ and ___ at 00:54. Bibasilar consolidation has developed since ___, worsened on the right since ___, and accompanied by new small left pleural effusion. Findings suggest aspiration pneumonia. Upper lungs clear. No pneumothorax. Heart size normal. Hyperinflation is probably due to emphysema. ET tube and nasogastric drainage tube are in standard placements. Portable upright chest showed Interval placement of right jugular central venous catheter terminating in the distal SVC and no pneumothorax. Bibasilar opacifications left greater than right suggestive of developing pneumonia. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is seen. The tip of the endotracheal tube projects 4 cm above the carina. The course of the feeding tube is stable. Stable correct position of the right internal jugular vein catheter. Minimal increase in extent of the pre-existing pleural effusion on the left. Otherwise the appearance of the lung parenchyma and the pleura is unchanged. CHEST (PORTABLE AP) showed With the exception of slight decrease in size of bilateral pleural effusions, there has not been a relevant change in the appearance of the chest since the previous study of 1 day earlier. TIB/FIB (AP AND LAT) LEFT showed Fluoroscopic documentation of left lower extremity orif. No radiologist was present. ELBOW (AP, LAT AND OBLIQUE) LEFT showed No evidence of fracture or dislocation of the left elbow. Soft tissue swelling is present. CHEST (PORTABLE AP) showed In comparison to ___ radiograph, allowing for differences in patient positioning, there has not been a relevant change in the appearance of the chest. Chest and pelvis radiograph showed 1. No acute cardiopulmonary process. 2. Suspect acute fractures at the left superior and inferior pubic rami. DX BILATERAL FEET was done. FEMUR (AP AND LAT) RIGHT PORT showed Status post internal fixation of right femoral fracture with comminuted fracture of the mid to distal right femur appear. Although there is some displacement of the fragments, overall alignment is anatomic. TIB/FIB (AP AND LAT) BILAT showed Status post internal fixation of bilateral multifocal tibia fractures as detailed above, including a left tibial plateau fracture. Multifocal fractures of both right and left fibula also present, also detailed above. Irregular appearance to the posterior right calcaneus, with 2 ossific type densities noted in the lower calf soft tissues, along the expected course of the Achilles tendon. Clinical correlation is requested. This area is partially obscured by splint, but the appearance raises the possibility of a posterior calcaneal fracture, possibly with Achilles tendon avulsion. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are stable. However, there has been an increase in the layering pleural effusions bilaterally with compressive atelectasis at the bases. This makes it somewhat difficult to assess the pulmonary vessels, which are mildly engorged an ill-defined, consistent with some elevation in pulmonary venous pressure. CHEST (PORTABLE AP) showed Stable exam. Enteric tube tip is in the proximal stomach, should be advanced. CHEST (PORTABLE AP) showed Comparison to ___. No change in appearance of the monitoring and support devices. Stable bilateral moderate pleural effusions with subsequent areas basilar atelectasis. No cardiomegaly. No pneumothorax. HAND (PA,LAT AND OBLIQUE) LEFT showed No fracture or dislocation detected involving the left thumb. Severe first CMC osteoarthritis. Associated subluxation can occur due to osteoarthritis. Minimal subluxation at the first MCP joint, of indeterminate acuity. The appearance is compatible with mild laxity of the ulnar collateral ligament. If this represents a site of the patient's new-onset symptoms, this could reflect an injury to the ulnar collateral ligament. Small focus of lucency in the distal tuft of the left small finger distal phalanx. Unless there is focal tenderness in this location, this would likely be accounted for by degenerative changes. CHEST (PORTABLE AP) showed Left lower lobe consolidation has increased, concerning for pneumonia. Tracheostomy tube is in standard position. Right IJ catheter tip is in the lower SVC. NG tube tip is out of view below the diaphragm. Large bilateral pleural effusions are grossly stable allowing the difference in positioning of the patient. There is no evident pneumothorax. Radiology showed No significant interval change since the prior radiograph. CHEST (PORTABLE AP) showed ET tube tip as 5.5 cm above the carinal. Right internal jugular line tip is at the level of cavoatrial junction. NG tube tip is in the stomach. Heart size and mediastinum are stable. Bilateral pleural effusions are moderate. There is no pneumothorax. Radiology showed Dictating radiologist was not present during the procedure. Right and left is not clearly labeled on the images. Numerous fluoroscopic images demonstrate placement of external fixation pins in the calcaneus and proximal tibial shaft and in the proximal femoral shaft. There are displaced fractures seen of the mid femoral shaft with a prominent butterfly fragment, of the proximal tibial metaphysis, and a severely comminuted fracture through the distal lower leg involving the tibia and fibula. Please refer to the operative note for additional details. The total intraservice fluoroscopic time was 47.7 seconds. CHEST PORT LINE/TUBE PLCT 1 EXAM showed In comparison with the earlier study of this date, on the final image the opaque tip of the Dobhoff tube is in the lower stomach. Increasing opacification at the left base could be consistent with pleural fluid and atelectasis, though in the appropriate clinical setting it would be difficult to exclude superimposed pneumonia. FEMUR (AP AND LAT) RIGHT showed Intramedullary rod across mid diaphyseal fracture. KNEE (2 VIEWS) BILATERAL showed Postoperative changes, internal fixation bilaterally across fractures. TIB/FIB (AP AND LAT) BILATERAL showed Complex fractures, postoperative changes. CT OF THE CHEST ABDOMEN PELVIS AND LOWER EXTREMITIES showed 1. Extensive comminuted open fractures involving the bilateral lower extremities as described. The bilateral anterior tibial and peroneal arteries are not visualized distal to the level of the mid tibia, concerning for vascular injury. 2. Multiple pelvic fractures as described. There is no evidence of active extravasation or large extraperitoneal hematomas. 3. Small amount of simple ascites without evidence of traumatic injury to the intra-abdominal organs. 4. Small bilateral pleural effusions without evidence of acute intrathoracic injury. NOTIFICATION: The findings were discussed with Dr. ___ Dr. ___, ___. by ___, M.D. on the telephone on ___ at 12:10 AM, 5 minutes after discovery of the findings. CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormality 2. Peripheral calcification of the cavernous portion of the left internal carotid artery measuring 1.6 x 1.4 x 1.1 cm, highly suspicious for an underlying aneurysm. CT C-SPINE W/CONTRAST showed 1. Widening of the anterior disc space at C6-C7 which may reflect underlying ligamentous injury 2. High-density material in the posterior epidural space at C5-C6 and C6-C7, reflective of acute hemorrhage. Findings were communicated to and acknowledged by Dr. ___ Dr. ___ By ___, MD at ___ and ___ respectively, 20 minutes after discovery of findings. RECOMMENDATION(S): MRI of the cervical spine to assess the extent of injuries. The patient was diagnosed with Traumatic shock, initial encounter, Ped on foot injured pick-up truck, pk-up/van in traf, init. The patient was treated with ___: 1. Washout and debridement open fractures site right and left tibia down to and inclusive of bone. 2. Application uniplanar external fixator right and left tibia. 3. Closed reduction of distal tibia fractures bilateral with manipulation. 4. Application of uniplanar external fixator right femur. 5. Closed treatment right femur fracture with manipulation. ___: 1. Removal of external fixator under anesthesia, right lower extremity. 2. Irrigation and debridement, fracture, skin to bone, right tibia. 3. Retrograde femoral nail, right femur. 4. Anterior grade tibial nail, right tibia. 5. Debridement, fracture open skin to bone, left tibia, under separate prep and drape. ___: On the right lower extremity 1. A free gracilis flap. 2. Pedicled soleus flap. 3. Split-thickness skin graft 8 x 20. 4. Antibiotic impregnated cement spacer to tibia. 5. Surgical preparation site 20 x 8 cm. Left side 1. Pedicled soleus flap. 2. Split-thickness skin graft 8 x 17. 3. Surgical preparation of site 8 x 17 cm. 4. Excision of fibula with open fracture. ___: 1. Irrigation and debridement, fracture open skin to bone, left tibia. ___: 1. Irrigation and debridement, fracture open skin to bone, left tibia. 2. Removal of external fixator under anesthesia, left tibia. 3. Open reduction, internal fixation, Schatzker 6, bicondylar tibial plateau fracture. 4. Intramedullary nailing, left tibial shaft fracture. ___: Tracheostomy placement ___: RLE Split-thickness skin grafting, 14 x 5 cm. ___: PEG placement ___: Trach downsized to #6, non-cuffed, passey muir valve placed. At the time of discharge, the patient had Trauma: [] Bilateral lower long bone fractures [] Bilateral, open, comminuted lower extremity wounds [] Multiple pelvic fractures: comminuted fracture of the left iliac wing and fractures of the left superior and inferior pubic rami, with minimal diastasis of the left SI joint and pubic symphysis [] Subacute fractures of the right sixth and seventh ribs posteriorly. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to ___ on ___ after being pinned between two cars with bilateral lower extremity open fractures and right femur fracture. The patient was seen by Orthopaedics, Plastic Surgery and Vascular Surgery who coordinated her care. Regarding her bilateral open tibia/fibula fractures, and right femur fracture, she went urgently to the operating room for I&D and ex-fix of the R femur, R ankle ex-fix, and L ankle ex-fix. She maintained Doppler signals throughout. She was transfused as needed for bleeding/oozing originating from her leg wounds. She was transferred to the Trauma ICU for further care and required pressers. On ___, she underwent R antegrade tibial nail, R retrograde femoral nail, and washout of the LLE. RUE duplex demonstrated a superficial clot but was negative for DVT. Subcutaneous heparin was started. On HD4, the patient remained afebrile during the day, she was stable on the vent, and she was started on tube feeds and NG meds. She was given 1 unit PRBCs for drifting hematocrit. She had an initial ___ evaluation on ___. On ___, she underwent ORIF and L tibial nail as well as Right: free gracilis flap, pedicled soleus flap, split-thickness skin graft, antibiotic impregnated cement spacer to tibia, and excision of fibula with open fracture. At this date, she also had irrigation and debridement of left tibia, removal of external fixator, open reduction/internal fixator, and left tibial intramedullary nailing. On ___, the patient had a BAL which showed ___ e. coli. She was started on cefepime for the e.coli VAP. The patient was taken to the operating room and underwent ORIF of the L tibia & free flap, L gracili to RLE, and aspirin was recommended per Plastic Surgery. On ___, tube feeds were held secondary to concern for refeeding syndrome. Levophed increased from .06->.08 then decreased back to .06. On ___, the patient failed extubation trial and was reintubated. Tube feeds were resumed. On ___, the patient received 20mg IV lasix x2 with good response. On ___, the patient was taken to the operating room and underwent Tracheostomy. The patient tolerated this procedure well. On ___, the patient's WBC was 18.0, she desatted to the 70's, and she responded with increased FiO2. On ___, there were no acute events, she tolerated a trach mask all day, c. diff was negative. Her IJ was removed and her subcutaneous heparin was discontinued and she was started on Lovenox. On ___, Cefepime was discontinued. WBC decreased to 15,000 from 17,00. A passy muir valve was placed, but she could not tolerate the valve for long periods of time. On ___, a PEG was placed, foley catheter was removed, but was later replaced overnight for retention. On ___, the patient's tube feeds were increased to goal. On ___, the patient's foley catheter was discontinued at midnight but was then replaced on ___ for urinary retention. Per Orthopaedics, the patient should remain in b/l knee imobilizers, a short air cast for the LLE and a long aircast for the RLE, RUE in volar resting slab. On ___, the patient underwent and failed FEES with Speech & Swallow. She was made strict NPO and continued on tube feedings. The trach tube was down-sized on ___ to a #6 fenestrated, non-cuffed tube. She tolerated this well and underwent placement of passy-muir valve. She has had no difficulty in mobilizing her secretions. On ___, the patient went back to the OR with Plastic Surgery for a split thickness skin graft to the right lower extremity and for a PEG placement. Postoperatively, tube feeds were started and advanced to goal which she tolerated well. On ___, the VAC was taken down from the skin graft site, which appeared well-healing. The STSG donor site was left open to air. The patient continued to work with Physical Therapy and it was recommended that she be discharged to rehab to continue her recovery. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx DM (metformin controlled), HTN, HLD, GERD presents with substernal chest pressure prior to arrival. Chest pain onset during watching TV and unrelated with exertion or arm movement. Pleuritic in nature. No recent URIs, no subjective SOB. Pt says the pain went away without intervention. Also had mild concomitant back pain. Reported to have rhythm strips concerning for lateral ST depressions. Received SL NTG x 3, ASA, with normalization. Pt has noted some ankle edema but says this symptom comes and goes. Denies orthopnea, increasing SOB, significant weight gain (although she does not weigh herself regularly). At baseline she says she is 130lbs. Denies cough, fevers/chills, hematuria, new medications. In ED initial vitals were T 99.3 HR 94 BP 201/75 RR 34 SpO2 95% RA. Noted to have abnormal chem 7 with K of 5.4, HCO 12, BUN 91, Cr 9.0 (baseline 1.3 in ___. A troponinemia to 0.07 with CKMB 5. Noted to have HgB 6.2 under a baseline of 11.9. EKG showed NSR at 95 with almost LVH by voltage criteria without ST changes. Bedside echo showed no pericardial effusion. Renal ultrasound in ED showed atrophic and echogenic kidneys suggesting chronic kidney disease. No hydro, nephrolithiasis. Multiple cysts bilaterally showed no complex features. Guaic was negative. Of note: UOP was only 30ccs in the ED. Pt was given 2mg IV morphine, SL Nitro, Ativan, 2 units PRBC and 10mg IV Labetalol prior to MICU transfer. Radiology showed Pulmonary edema with large left and small right pleural effusions is concerning for heart failure. Post diuresis films to exclude underlying LLL pneumonia is recommended. Radiology showed 1. Atrophic and echogenic appearance of the kidneys is compatible with chronic kidney disease. No hydronephrosis or nephrolithiasis. Multiple cysts bilaterally show no complex features. No hydronephrosis. 2. Small right pleural effusion. Radiology showed Uncomplicated placement of a right-sided double-lumen 19 cm tip to cuff tunneled hemodialysis catheter via the internal jugular vein. Tip in right atrium. Ready to use. Radiology showed Patent left basilic and cephalic veins with measurements as shown. Patent brachial and radial arteries with no significant calcifications. Radiology showed No evidence of DVT within the right lower extremity. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, ANEMIA NOS. The patient was treated with Right IJ tunneled catheter. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRINCIPAL REASON FOR ADMISSION: ___ with h/o DM, HTN, HLD, GERD presents with substernal chest pressure and acute on chronic renal failure, found to be in hypertensive urgency</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with a history of Churg ___, COPD on 2___, esophageal dysmotility, aspiration PNA s/p PEG tube and history of PE s/p IVC filter presents to ED after having one day history of chest pain and shortness of breath. He reports having chronic rib cage pain associated with coughing. He reports since last night he has been having chest tightness like asthma and worsening of his rib cage pain for the past day which has lasted for hours. He reports that he felt shortness of breath like asthma again later on the day when his chest pressure had subsided.He does not report fevers, chills, vomiting, or diarrhea. He is currently on J-tube feedings due to his persistent reflux leading to recurrent aspiration pneumonia. He is on prednisone due to his eosinophilic lung disease which has been slowly tapered. He states he is taking his medications as he is instructed. He was recently hospitilized from ___ - ___ for aspiration pneumonia treated with augment. He was also hospitalized from ___ for pneumonia. In the ED, initial VS: 98.4 65 92/58 18 95% 4L. CXR demonstrated persistent and possibly worsening bilateral infiltrates. Labs notable for normal lactate and absence of leukocytosis. He was given solumedrol, albuterol nebs and levoquin for COPD exacerbation and subsequently admitted to medicine service for further evaluation and management. On the floor, he reports he feels better after steroids/nebs/abx in the ED. REVIEW OF SYSTEMS: Reports chronic constipation Denies headache, vision changes, rhinorrhea, congestion, sore throat, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena Radiology showed 1. No evidence of deep vein thrombosis in either leg. 2. Unusual echogenicities is with posterior shadowing suggestive of dystrophic calcifications in the superficial tissues of the left calf. A lower extremity x-ray suggested to evaluate for soft tissue calcifications. Radiology showed 1. Chronic adhesive atelectasis right middle and left lower lobes. 2. No current findings of eosinophilic or interstitial lung disease. 3. Severe atherosclerosis. 4. Progression of multilevel compression deformities, with T7 and T12 vertebroplasty. The patient was diagnosed with FOOD/VOMIT PNEUMONITIS. At the time of discharge, the patient had Primary Diagnosis Churg ___ syndrome Chronic musculoskeletal pain Secondary Diagnoses COPD Esophageal dysmotility. The patient was given written instructions concerning 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 history of Churg ___, COPD on 2LNC, esophageal dysmotility, aspiration PNA s/p PEG tube and history of PE s/p IVC filter, chronic chest wall pain presents with shortness of breath and chest, back, and hip pain. #Dyspnea: He presented with SOB and elevated eosinophil level suggestive of worsening of his Churg ___ syndrome. Alternately COPD exacerbation was also possible. His EKG was unchanged and two sets of cardiac enzymes were normal. His lower extremity US was did not show any signs of DVT making PE less likley. He was treated with prednisone 60 mg with a rapid taper with plan to taper back to 10 mg and follow up with his pulmonologist. He also received a short course of levofloxacin for COPD exacerbation or less likely aspiration pneumonia. His respiration improved and returned to his baseline. # Chronic Chest/abd/hip pain: Palliative care was consulted to assist in the management of his chronic pain. They suggested increasing his fentanyl pacth to ___s giving 10 mg ___ morphine for mild pain and 25 mg for more significant pain. He would also like to consider a hospice referral for further mangement of his symptoms. # Esophageal dysmotility: s/p G tube which appears to be functioning well. We discussed the risk and benefits of swish and spit and patient and he strongly desires to continue. He is also interested in a hospice referral. Reglan and lasoprazole were continued # Lower extremity calcifications: as above, lower extremity ultrasound showed no DVT, but did show vascular calcifications. On exam the patient had multiple small slightly tender subcutaneous nodules which were likely these calcifications. Xrays were recommended by radiology for further characterization, but we decided to defer more imaging given it would not change management and was not consistent with overall goals of care. # Hyperlipidemia: - continued pravastatin 40 mg hs # Depression: - continued celexa 30 mg qday # Hypothyroidism: - Continued levothyroxine 25 mcg qday # Bipolar d/o: - continued seroquel # OSA: Continued home BiPAP # Osteopenia: Ca + Vit D TRANSITIONAL ISSUES -Please refer patient to hospice for further management of his symptoms</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M w/PMHx diverticulosis, history of gastritis and history of GIB presents to ___ for evaluation of melena. Pt developed melena starting on ___ (2 days PTA). This was associated with light-headedness, dizziness and orthostatic symptoms. Mild SOB. He denies any abdominal pain, CP, vision changes. Of note, pt also had a fall in the setting of dizziness. No LOC headstrike. He fell on his Right elbow and continues to have significant pain in that arm. In the ED, initial vitals: 97.6 79 112/70 18 100% RA. Initialy hct was 27.7 (baseline ~40). Cr notably 1.5 (baseline 1.0). Pt was given 2x 1000cc NS boluses and admitted to the MICU for further monitoring pending potential endoscopy by GI on ___. On transfer, vitals were: 79 106/65 12 98% RA On arrival to the MICU, 98.8; 77; 105/47; 24; 98% RA. Pt reported feeling well, although he continued to complain of arm pain. DX HUMERUS AND FOREARM showed Images of the humerus and forearm demonstrate degenerative changes with osteophytes and enthesophytes at the shoulder and at the elbow. There is irregularity of the humeral head but it appears well corticated and therefore this may be secondary to old trauma. Please note that these images were obtained of forearm and humerus in this were not optimally obtained to assess the elbow joint. If there is clinical suspicion of radial head fracture dedicated elbow images should be obtained CTA ABD WANDW/O C AND RECONS showed 1. No evidence of active contrast extravasation within the alimentary tract. No significant intraluminal hemorrhage. 2. Colonic diverticulosis without diverticulitis. 3. Fusiform aneurysmal dilatation of the celiac axis. Focal short segment aneurysm at the origin of the left internal iliac artery. The patient was diagnosed with GASTROINTEST HEMORR NOS, AC POSTHEMORRHAG ANEMIA. The patient was treated with ___: EGD ___: Colonoscopy. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Gastrointestinal bleed Diverticulosis Anemia Thrombocytopenia SECONDARY DIAGNOSES: Cardiomyopathy, non-ischemic Ischemic stroke Hypertension Urinary incontinence Erectile dysfunction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ man with history of HTN, CVA, diverticulosis and prior GIB with unclear source in ___ who presented with melena, bright red blood per rectum, and lightheadedness. He was admitted to the MICU with a hematocrit of 27 (baseline 40); this stabilized after 4 units of pRBCs and he was transferred to the floor. EGD and colonoscopy did not identify a source, but did reveal many gastric and duodenal erosions, as well as diverticulosis.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M w/ PMH HTN, CKD, renal artery stenosis, PAD sent from urgent care for leg swelling. He notes that for a week he's noted swelling in his legs that is not painful. He has not had swelling previously. He has exertional chest pain going up the stairs, and can only walk about a block before stopping, but limited by chronic leg cramps. He denies dyspnea or orthopnea but sleeps w/ 2 pillows. He takes his medications daily with no changes in the past month. He has been eating salty canned fish more frequently. Radiology showed 1. Peribronchial opacities in the right lower lobe concerning for superimposed bronchopneumonia or aspiration changes. 2. Mild to moderate cardiomegaly, with mild interstitial edema. NOTIFICATION: The findings were discussed with urgent care by ___, M.D. on the telephone on ___ at 12:06 pm, 5 minutes after discovery of the findings. Patient has been sent to the emergency department Radiology showed There is mild cardiomegaly. No definite consolidation is seen. There are patchy opacities at the lung bases, more suggestive of atelectasis as opposed to pneumonia. There are no pneumothoraces. No overt pulmonary edema is seen. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Heart failure, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS Acute diastolic heart failure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with a PMH of HTN, CKD, renal artery stenosis s/p stent ___ and PAD who presents with recent history of exertional chest pain and new bilateral ___ edema, pulmonary edema on CXR and elevated BNP concerning for new diagnosis of heart failure. =================== TRANSITIONAL ISSUES =================== [] DISCHARGE WEIGHT: 54.7 kg (120.59 lb) [] DISCHARGE CREATININE: 2.3 [] This patient may require maintenance diuretic dose in the future. [] Please check CHEM 10 to evaluate renal function on ___ [] Please continue to monitor volume status and weight [] Call cardiologist if weight goes up by 3 lbs [] Consider addition of 20 mg PO Lasix for diuretic and for further hypertension control [] Please continue to discuss risks and benefits of aspirin with this patient - allergy to aspirin is listed as "upset stomach" [] Please follow up SPEP and UPEP # Suspected diastolic heart failure exacerbation Exam and labs suggestive of acute heart failure. Pt up ~12 lbs from dry wt of 120lbs. No prior history of CHF. Acute exacerbation likely due to increased salt intake, patient reported eating more canned foods lately. The history was not thought to be consistent with ischemic heart disease, but this patient would likely benefir from outpatient stress test. TTE showed EF 67% with grade II diastolic dysfunction, suspect from long standing hypertension. He was diuresed effectively with furosemide 20 mg IV. His hypertension was managed as below. # Hypertension Continue on home amlodpine, Imdur, and home metoprolol was switched to carvedilol. Lisinopril was changed to 20 mg qHS for ___ hypertension. # Renal Artery Stenosis # PAD Continued home Plavix. Please continue to discuss the risks and benefits of aspirin with this patient, as allergy to aspirin is listed as "upset stomach." # Hyperlipidemia Switched from lovastatin to atorvastatin 40 mg # GERD: continued home PPI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old patient who presents from the ___ with a R foot infection. He was seen by Dr. ___ today who recommended he present to the ED for admission and likely OR debridement. Over the past few days, the patient states he has noted fever, chills as well as increased erythema, edema, and drainage to right foot. He was placed on augmentin on ___ with no improvement of his symptoms. Podiatric surgery was consulted for further management. Radiology showed Plantar soft tissue ulceration at the level of the first MTP joint and concern for soft tissue gas. Cortical erosion at the lateral base of the first distal phalanx, new since ___, otherwise indeterminate age, acute osteomyelitis not excluded. Status post amputation of the distal phalanx of the second digit. Severe degenerative changes at the tibiotalar joint. FOOT AP,LAT AND OBL RIGHT showed No radiographic evidence of osteomyelitis. Severe degenerative changes unchanged. No short interval change The patient was diagnosed with ULCER OF OTHER PART OF FOOT, CELLULITIS OF FOOT. The patient was treated with ___: R foot I&D, debridement ___: R foot debridement, removal sesamoidectomies, plantar closure, dorsal packing. At the time of discharge, the patient had R foot infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the podiatric surgery service on ___ with a R foot infection. While ___ the ED, a bedside incision and drainage was preformed. On admission, he was started on broad spectrum antibiotics. He was taking to the OR for Right foot incision and drainage on ___ and for a R foot debridement with partial closure on ___. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events ___ the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU ___ stable condition, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis with IV pain medications for breakthrough pain. The patient remained stable from both a cardiovascular and pulmonary standpoint. He was placed on vancomycin, ciprofloxacin, and flagyl upon admission and switched to cefazolin, ciprofloxacin, and flagyl when culture data was received. Upon starting the patient on cefazolin, he began to develop a rash on his legs and arms. He did not have any respiratory compromise. Cefazolin was discontinued and he was started on benadryl and clindamycin. Dermatology was consulted who felt that his eruption was benign ___ appearance at this time with no further systemic involvement to prompt further intervention at this time. They felt this could be an early presentation of developing mild leukoclastic vasculitis (LCV) which may be associated with drugs such as medications, usually these are started a week or so before presentation so most likely culprit is Augmentin but cefazolin changed could be, or infection which patient is being treated for. Per dematology recommendation, he was given fexofenadine BID and triamcinolone 0.1% cream BID, and we began to notice improvement at time of discharge. His intake and output were closely monitored and noted to be adequate. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged while remaining NWB to his R forefoot. He was evaluated by physical therapy who felt he would benefit from rehab vs home with ___. Following multiple visits with physical therapy, physical therapy deemed him safe to return home with home ___ as well as a walker, commode, and wheelchair for long distances. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with services ___ place. The patient had been refusing all services while ___ the hospital. He was advised on multiple occasions that our advice would be that he have home nursing and home physical therapy. He was informed that home nursing would be able to monitor his wound and change his dressing as well as ___ work with him on his mobility. The patient adamantly refused services. He was informed that this was against medical advice. He acknowledged that he was aware of this, but would not accept services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH of prostate CA in remission, colon CA in remission, L MCA stroke in ___ with residual mild right-sided deficits, and afib/aflutter on dabigatran (recently increased), who is admitted from clinic after being found to have Hct 16.8 and guaiac positive stool. Pt states that he has been feeling completely well. No fatigue, no dyspena on exertion, no chest pain. No lightheadedness or fainting. No fevers, chills, night sweats, or weight loss. No nausea or vomiting. No abdominal pain. No diarrhea, no hematochezia, no melena, no bright red blood per rectum. Pt apparently went for routine clinic visits to his PCP, who ordered labs including Hct, and urology-oncologist, who performed a rectal exam and found brown stool that was guaiac positive. Pt was then sent to the ED after Hct returned 16.8. . In the ED, Pt's vitals were 98.4F 102 129/36 16 100%. Pt was started on 1 x pRBC transfusion and admitted to medicine for GI bleed. Pt was completely comfortable and mentating well. . Upon transfer, vitals were 97.4 po, 47, 126/60, 18, 100% RA . On arrival to the floor, vitals were 98.1F, 124/71, HR 48, RR 16, Sat 100% RA. . ROS: 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 Mild interstitial edema with small bilateral pleural effusions. The patient was diagnosed with ANEMIA NOS, HX OF COLONIC MALIGNANCY, HX-PROSTATIC MALIGNANCY. The patient was treated with blood transfusion upper endoscopy colonoscopy. At the time of discharge, the patient had Primary: severe microcytic anemia iron deficiency bradycardia ulcerations near the ileo-colonic anastamosis severe pulmonary hypertension Secondary: atrial fibrillation / atrial flutter. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ PMH of prostate CA in remission, colon CA in remission, L MCA stroke in ___ with residual mild right-sided deficits, and afib/aflutter on dabigatran (recently increased), who is admitted from clinic after being found to have Hct 16.8 and guaiac positive stool. . # severe anemia: due to Pt's anticoagulation with dabigatran and guaiac positive stool, suspect GI source. Pt has a history of prostate and colon cancer, both in remission. Given absence of constitutional symptoms, suspect more benign cause of GI bleed. Suspect lower GI bleed given absence of upper GI (or lower GI) symptoms, but cannot rule out upper GI bleed. No evidence of hemolysis; normal T bili, normal LDH, normal haptoglobin, no schistocytes on smear. Pt is very microcytic but was previously normal, suspect that this is a long, slow process, which has made him extremely iron deficient. Iron studies showed serum iron 12 (last 18 in ___, Ferritin 4.0 (last 57 in ___, TIBC 534, transferrin 411. Pt last took dabigatran ___ morning and appears to be very stable clinically. Conferred with GI fellow, who wanted to wait and scope Pt on ___ after dabigatran has washed out. Pt received 2 x PRBCs on the evening of admission with appropriate increase in Hct from 16 to 22. Hct remained stable and increase throught his admission to 24 on ___. Pt was started on ferric gluconate 125mg iv daily x 4 days (D1 = ___ for his severe iron deficiency anemia. Pt was also treated with pantoprazole 40mg iv bid given unclear source of GI bleed, though suspected lower GI. Pt's Hct remained stable throughout hospitalization, 24.0 on discharge. Pt's upper endoscopy on ___ was normal. His colonoscopy showed large non-bleeding internal hemorrhoids, and ulcerations and surrounding friability on both sides of the ileo-colonic anastamosis. There was bright red blood oozing from the borders of the ulcers. BI-CAP Electrocautery was applied for hemostasis successfully. Cold forceps biopsies were performed for histology at the ileocolonoic anastamosis. Per the GI service, these lesions did not look cancerous, but the biopsies will provide more definitive information. Their etiology remains unclear and they may continue to bleed despite coagulation. The situation was discussed with Dr. ___ Dr. ___ it was decided that Pt should remain off anticoagulation for now and will be discharged on aspirin 81mg po daily pending further discussion w/ his doctors next week. . # bradycardia: chronic. Physiologic vs AV nodal disease. Pt was noted to have several pauses in the 1.6 to 1.8 second range overnight when sleeping. No acute interventions, Pt was scheduled for follow-up w/ his outpatient cardiologist. . # atrial fibrillation / atrial flutter: chronic, s/p unsuccessful ablation procedure. Had a large MCA stroke off medication. Started on dabigatran afterwards w/ dose recently increased from 75mg po bid to ___ po bid. Repeat ECG showed sinus bradycardia with irregularly irregular rhythm. His dagibatran was stopped given his GI bleed, and Pt was started on aspirin 81mg po daily. CHADS2 score of 3 = 5.9% annual risk of stroke (for age and stroke). The issue of resuming anticoagulation will be determined by his PCP and neurologist. . # inspiratory crackles, pedal edema: seems to be new per Pt's daughter, likely over at least 2 weeks. Pt denies any dyspnea or weakness. BNP elevated at 1155, but no prior for comparison. Pt had inspiratory crackles and pedal edema. Given his severe anemia, Pt had an ECG, which showed no evidence of ischemia, and a repeat echo, which showed no focal motion abnormalities. Pt had moderately dilated left and right atria, LVEF > 55%, moderately dilated RV w/ preserved function. Pt also had moderate-severe TR, moderate MR, and severe pulmonary artery systolic hypertension. Pt has an appointment with his cardiologist to address these findings. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with history of dementia, HTN, bladder cancer status post recent open radical cystectomy, bilateral salpingo-oopherectomy, partial vaginectomy, ileal conduit urinary diversion (at the end of ___, discharged ___ transferred from ___ due to hypotension and lack of ICU beds. Portable AP chest showed Left basilar atelectasis or scarring not significantly changed. There is no acute intrathoracic process. CT abdomen and pelvis without contrast showed 1. No evidence of intra-abdominal infection. 2. Postsurgical changes from radical cystectomy with ileal conduit, bilateral salpingo-oophorectomy and partial vaginectomy, including a 1.6 cm hematoma in the left deep pelvis. The patient was diagnosed with Sepsis, unspecified organism, Severe sepsis with septic shock, Acidosis, Urinary tract infection, site not specified, Unspecified abdominal pain. At the time of discharge, the patient had Urinary tract infection Sepsis Metabolic acidosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY. This is a ___ with dementia, HTN, HL, bladder cancer status post recent open radical cystectomy, bilateral salpingo-oopherectomy/ partial vaginectomy/ ileal conduit urinary diversion complicated by mild-moderate acidosis, and admission in ___ for UTI, who was transferred from ___ with severe sepsis associated with hypotension likely due to UTI. She was treated with broad spectrum antibiotics which were eventually narrowed to ampicillin based on microbiology showing urine + for VRE. A blood culture was positive for CONS which was thought to be contaminant as multiple other sets were negative. She had significant metabolic disarray on admission which improved with fluid resuscitation and oral bicarbonate administration. She was recommended to go to rehab but refused and so was discharged home with services. DETAILED SUMMARY. # Sepsis associated with hypotension # Urinary tract infection: Patient presenting with fever, tachycardia, worsening leukocytosis, tachypnea, acute kidney injury concerning for ongoing sepsis. While CXR showed atelectasis vs PNA, I suspect that her most likely etiology of her infection is urinary given prior urinary tract infection and with ED nursing notes reporting that the patient has not allowed family to change urostomy bag. CT A/P without anatomic abnormality or evidence of obstruction that would increase risk of recurrent infections. Urine culture positive for large enterococcus, VRE, amp susceptible. Transitioned to amoxicillin at discharge. # Acute Renal Failure: Admission Cr of 1.9, up from a recent baseline of 1.0, likely ___ in the setting of hypotension and sepsis. If her creatinine fails to improve with IV fluid resuscitation, may also have a component of ATN in the setting of known hypotension. Slowly resolved, discharge Cr 1.0. # Anion Gap Metabolic Acidosis with Respiratory Compensation: Patient with anion gap and non anion gap acidosis, with respiratory compensation. Potential contributing factors included lactic acidosis, ketoacidosis, acute kidney injury, presence of ileal conduit, and significant resucitation with normal saline. Of note, patient was initiated on sodium bicarbonate by renal on her most recent hospitalization in response to an ongoing metabolic acidosis, however was not taking at home. Bicarbonate was resumed and titrated with improvement in acidosis. # Dementia with superimposed # Acute toxic encephalopathy: She had some waxing and waning alertness here, thought to be acute toxic encephalpoathy in setting of UTI. She has underlying dementia. She was alert, conversant, oriented to self, hospital, and month of the year at time of discharge. No focal neurologic deficit. # Possible bacteremia, likely contaminant: CONS in ___ from admission. Repeat cultures NGTD. # HTN: Stable. Toprol held here but resumed at discharge. # Hypothyroidism: Stable. Continued home levothyroxine 100mg daily. # Hyperlipidemia: Mild transaminitis noted on prior admission, for which atorvastatin was held upon discharge. Transaminitis has resolved. Atorvastatin therefore resumed. # Chronic anemia: likely ACD (prior ferritin ___ >30 minutes spent coordinating discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo ___, anemia presents with pleuritic chest pain. Pain woke pt from sleep this am at 5:15 was sharp, non-radiating and was followed by the development of fatigue, myalgias, fever to 101, nausea, headache, sore throat and a dry cough. Induced emesis without relief of symptoms. No diarrhea, constipation, rhinorrhea. Received flu vaccine this season. Radiology showed Subtle nodular opacity in the retrocardiac region seen only on lateral view which in the correct clinical setting may represent pneumonia. Possible hiatal hernia. Radiology showed 1. No acute aortic pathology or pulmonary embolism. 2. Multifocal pneumonia. 3. Moderate hiatal hernia and patulous upper esophagus. Circumferential, upper esopahgeal wall thickening could be due to esophagitis or chronic reflux. This may place the patient at risk for aspiration. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA. At the time of discharge, the patient had community acquired pneumonia 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>ASSESSMENT & PLAN: ___ yo ___ and anemia presents with pleuritic chest pain, found to have a multifocal pneumonia and hyponatremia. # Community acquired Pneumonia: The patient presented with a symptom complex that could be consistent with either viral or bacterial pneumonia. The patient was started on tamiflu and levofloxacin in the ED after getting a CT chest which showed multifocal pneumonia. The patients respiratory viral screen was negative, specifically for influenza. Her tamiflu was discontinued. The day following admission, the patient was much improved. She was satting well on room air and was eager to be discharged. A CBC was check in the ___ on the day of discharge and her WBC was down trending and she was a febrile. A safe discharge plan was discussed with her PCP and close follow up was arranged. She was sent home to complete a 7 day course of antibiotics, last dose should be on ___. . # Hyponatremia: This was likely due to decreased po intake. This corrected after given IV fluids. Po intake was encouraged at home. . # ___ The patient was continued on her home medications. . # Microcytic Anemia This has been an issue and been worked up by the outpatient GI team for the last several months. Her distant baseline is a Hgb in the 13 range. Recently it had been in the 9 range. She had a negative capsule endoscopy on ___ and GI rec'd a push enteroscopy which is currently scheduled for ___. She has previous labs that show evidence of iron defficiency anemia. When inquired why she was not on iron, the patient replied one of her teams of outpatient physicians indicated that she should not be on it. The patient showed no active signs of GI bleeding while in house or orthostasis. The patient should have a repeat CBC checked in one week and faxed to her PCP. At that time, po or IV iron should be considered once her acute infectious issues resolve. . # Transitional Issues: - complete antibiotic course, follow up pending blood cultures from ___ - Repeat CBC in 1 week and follow up with PCP to follow anemia and consider iron supplementation - continued GI follow up for further work up of anemia .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: A ___ female was transferred from ___ with the concern of salicylate toxicity presenting with ASA level >70. She was found to have altered mental status in ED there and was intubated for airway protection. Lab was noted for ASA level > 70. Bicarbonate drip IV was started at OSH. Her chest x-ray was also concerning for right middle lobe pneumonia and she was started on ceftriaxone and azithromycin. Per patient's sister there is concern that she chronically uses multiple herbal supplements. CT HEAD W/O CONTRAST showed Motion limited exam without evidence of acute intracranial abnormalities. CHEST (PORTABLE AP) showed Endotracheal and enteric tubes in standard positions. No acute cardiopulmonary process. CHEST (PORTABLE AP) showed Right internal jugular central venous catheter with tip projecting over the distal SVC. No pneumothorax or pleural effusion. New asymmetric increased opacification in the right apex, which may be a summation of shadows. Attention on follow-up is recommended. Chest radiograph showed Increased opacification in the right infrahilar region is new compared to most recent radiograph. In view of the clinical history, the possibility of aspiration or pneumonia cannot be excluded. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:05 pm, 5 minutes after discovery of the findings. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Hypoplasia of the distal segment of the right vertebral artery. Moderate stenosis of the right P1 segment otherwise, no evidence of significant stenosis or occlusion in the carotids, left vertebral artery, or in the principal intracranial branches. 2. Unremarkable CTA of the neck. No stenosis of the cervical internal carotid arteries by NASCET criteria. 3. Nonspecific subcortical hypodensities could represent chronic small vessel disease. No acute intracranial hemorrhage or large territory infarct. 4. Small right pleural effusion bilateral ground-glass opacities in the visualized upper lobes of the lungs, could represent infection. 5. Additional findings described above. Radiology showed No focal consolidation is identified. Pulmonary vascular congestion is present. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with ___ - intubated ___ - extubated. At the time of discharge, the patient had Salicylate Toxicity, resolved Respiratory alkalsosis, anion gap metabolic acidosis, resolved Community acquired pneumonia Encephalopathy, improved. The patient was given written instructions concerning 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 uterine fibroids s/p embolization ___ leading to premature menopause, formerly on HRT who was admitted to ___ on ___ as a transfer from ___ given AMS and aspirin toxicity. She was initially admitted to ___ MICU and required IV bicarbonate gtt for urine alkalinization. Her hospital course was complicated by pneumonia and toxic metabolic encephalopathy.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Ms. ___ is a ___ year old female with history of HTN, adult acne who presented to the ED with RUQ pain. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Cholelithiasis without findings of acute cholecystitis. Radiology showed 1. No acute cardiopulmonary process. MRCP showed 1. Findings are suggestive of acute calculus cholecystitis. 2. No evidence of biliary obstruction or choledocholithiasis. The patient was diagnosed with Right upper quadrant pain. At the time of discharge, the patient had Gallstone pancreatitis and cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#Suspected passed CBD stone/choledocholithiasis #Cholelithiasis #Gallstone pancreatitis -Elevated lipase suggests inflammation of pancreas likely related to a potentially passed gallstone. No ongoing pain now or evidence of SIRS at time of admission or discharge. Elevated LFTs most likely from passed stone and without symptoms at this time will not keep patient here. Discussed that patient should follow with primary care provider to get her LFTs rechecked this week to ensure downtrend. If uptrending she should return to the hospital at htat time. Patient did received 1 dose of Zosyn in ED, this was held after admission. ___ surgery was consulted while patient inpatient for possible cholecystectomy, but was not able to get a booking on the day of discharge. Patient feels well at this time so will d/c home with close followup from me (___) and Dr. ___ ___ timing of surgery in near future. At time of discharge patient was told she should return if she has return of symptoms/fevers/chills etc... </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a pleasant ___ with stage IV sigmoid adenocarcinoma s/p LAR (___) with subsequent POD involving spleen now s/p splenectomy/distal pancreatectomy/wedge gastrectomy (___) currently on palliative C1D25 Irinotecan and DVT on rivaroxaban who p/w diffuse abdominal pain, concern for malignant bowel obstruction. CT ABD AND PELVIS WITH CONTRAST showed 1. Findings concerning for small bowel obstruction secondary to a 3.2 cm omental implant in the left mid abdomen. No signs to suggest bowel ischemia. 2. Relatively hyperdense, asymmetric thickening of the bowel wall in the left mid abdomen (601:75, 2:48) likely represents an additional submucosal metastatic lesion. 3. Persistent moderate to severe right-sided hydroureteronephrosis with a delayed right nephrogram secondary to malignant obstruction of the right distal ureter, similar to prior. 4. Re-demonstration of the 3 previously noted omental implants in the abdomen/pelvis measuring up to 3.6 cm, similar to prior. 5. Re-demonstration of a large 7.1 cm mass in the splenectomy bed as well as a 2.2 cm omental implant fat in the liver dome. The patient was diagnosed with Other intestnl obst unsp as to partial versus complete obst. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>HOSPITAL COURSE: ===================== ___ with stage IV sigmoid adenocarcinoma s/p LAR (___) with subsequent POD involving spleen now s/p splenectomy/distal pancreatectomy/wedge gastrectomy (___) currently on palliative C1D25 Irinotecan and DVT on rivaroxaban who p/w diffuse abdominal pain, concerning for malignant small bowel obstruction. # Stage IV Sigmoid Adenocarcinoma s/p LAR ___ # S/p splenectomy/distal pancreatectomy/wedge gastrectomy (___) # Malignant SBO A CT scan performed on the day of admission showed a small bowel obstruction secondary to a 3.2 cm omental implant in the left mid abdomen and with no signs to suggest bowel ischemia. Pt noted his symptoms are continuing to improve since arriving to the ED. Upon discharge and during his hospital course, he did not have nausea or vomiting, and is passing gas. He did not pass any stool from the time of admission for discharge. His exam was not concerning for acute abdomen and was only notable for LLQ tenderness on palpation which started to resolve during his hospital course. After speaking to his oncologist (Dr. ___, it was determined that since he could tolerate clear liquids as well as yogurt, he could be discharged with close follow up. He will follow up with his appointment with Dr. ___ on ___. If he could not tolerate any PO intake, the plan was to start inpatient chemotherapy. Colorectal surgery was also consulted and agreed that surgery was not needed now if chemotherapy is an option. Please note that there have been some issues with compliance with chemotherapy in the past, there might be some process of denial. # hx DVT Due to his potential for surgical intervention, his rivaroxaban was held and he was started on a heparin gtt. After confirming that there was no need for surgery, he was restarted on his rivaroxaban. Greater than 30 min were spent in discharge coordination and care</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old gentleman with history of AAA s/p EVAR and fem-fem bypass, CAD s/p CABG (___) with bare metal stent placed in ___, severe AS with most recent echo showing AVR of 0.9 cm2 on echo ___, HFpEF with recent echo ___ EF >55%), COPD, CKD (baseline creatinine 2.0), afib (CHADS-VASC 5) on warfarin, who was noted to have elevated creatinine to 4.5 on outpatient laboratory evaluation. Patient was unable to void and presented to ___. At that time, creatinine was noted to be 4.6, with potassium of 6.1. For the hyperkalemia, received calcium gluconate, dextrose x 2, 2 units insulin. A foley catheter was palced and 750 cc urine was drained. CXR was performed "Cardiomegaly. Sternotomy. Blunted right costophrenic sulcus perhaps a tiny right pleural effusion." Of note, patient' most recent creatinine was 2.8 on ___. His diuretic regimen has been adjusted on ___ given fluctuations in his creaitnine. At his most recent nephrology appointment, decision was made to change diuretic regimen to 80 mg QAM, 40 mg QPM, reduce metolazone to 5 mg M, W, F. Patient recently had CTA chest with contrast on ___ for pre-eval for TAVR. Patient continued on the same diuretic regimen he had been on since ___ but began to gain approximately 12 pounds between ___, with bilateral lower extremity edema and shortness of breath. There were no dietary indiscretions. In the ED, initial vitals were: 96.6, HR 85, BP 116/61, RR 22, Pulse Ox 95% on nasal cannula. Labs were notable for WBC 11.8, H/H 7.6/23.5, platelets 101. proBNP elevated at 6,427. Chemistry notable for Na 131, K 5.3, Bun/Cr 88/4.8. Trop elevated at 0.07. Lactate 2.0. UA showed 77 WBC, few bacteria, >182 RBC. Patient received 40 mg IV furosemide x 1 and albuterol nebulizer x 1. Of note, during prior hospitalization in ___ patient was noted to be in heart failure after receiving blood for GI bleed (no active bleeding found but was noted to have AVM within the cecum on colonoscopy) During that hospitalization, he required IV Lasix 100-120 mg boluses and drip at ___ mg/hour. Diuresis was limited by orthostatic hypotension and patient was discharged hypervolemic with bibasilar crackles and pitting edema but diuresis was limited due to orthostatic hypotension and severe AS. On the floor, patient denies any fevers, chills, dysuria, chest pain, chest pressure, chest palpitations. He does note that his breathing has improved throughout the day. Denies any nausea or vomiting. Review of systems: Please see HPI. CHEST (PORTABLE AP) was done. RENAL U.S. showed 1. No evidence of hydronephrosis, as clinically questioned. 2. The bladder was not visualized. A Foley catheter is present. The patient was diagnosed with Heart failure, unspecified, Acute kidney failure, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES: ========================= Acute exacerbation of Chronic Diastolic Heart Failure Acute kidney injury on chronic kidney disease Severe aortic stenosis Atrial fibrillation Anemia Hypothyroidism Coronary artery disease SECONDARY DIAGNOSES: ========================= COPD Peripheral neuropathy Benign prostatic hypertrophy 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 an ___ gentleman with a PMH significant for severe AS ___ <0.9 cm2), HFpEF (EF 55%), severe MR, CAD s/p CABG (___) and NSTEMI (BMS in ___, CKD, AAA s/p repair, COPD, and recent admission for GI bleed who presents with ___. # Pulmonary Edema | Acute on Chronic Diastolic Heart Failure Patient presented with severe volume overload and biventricular CHF, likely secondary to lack of urine output from ___ as above. Symptoms worsened by severe AS and severe MR, which reduces his forward flow and makes him very volume sensitive. S/p furosemide IV 10mg/hr, pt was net neg 2L on ___ and 3L on ___, but still appeared volume overloaded, and O2 requirement was still at 2L. Pt was lightheaded w/ SBPs soft in ___ on ___, and diuresis was held, w/pt still having sufficient UOP. He received 1 unit pRBC + IV Lasix 80mg as ___ on ___ as below. Diuresis was then escalated to IV Lasix 80mg BID on ___, but patient continued to be hypervolemic on ___. He was then escalated to IV Lasix 120mg bolus x2 and Lasix gtt was started @10mg/hr, which was escalated to @20mg/hr in addition to metolazone ___ daily on ___. On ___, patient appeared close to euvolemic, Lasix gtt was discontinued, and patient was transitioned to Lasix PO 80mg daily on ___. Patient was discharged on a diuresis regimen of ***80 mg Lasix BID*** and his weight at time of discharge on ___ was 90.8 kg. Patient is not on a beta blocker or ___ due to ___ and history of hypotension. He should be evaluated for these agents in the outpatient setting. # ___ on CKD Patient with baseline Cr of 2.0, elevated to 5.0 on admission. Most likely etiology is contrast induced nephropathy given timing ___ that started ___ days after CTA with reduced urine output and acute Cr rise. Other contributing factors include his severe AS, severe MR, and heart failure. Obstruction was thought to be a contributor, but patient's Cr did not improve significantly after Foley placement, and renal U/S was w/o hydronephrosis. On presentation, he was hyperkalemic, but improved s/p insulin and dextrose and with diuresis as discussed. Patient's medications were renally dosed. As below, patient was diuresed for CHF exacerbation, initially with Lasix gtt @10mg/hr, which was escalated to @20mg/hr, along with metolazone 5mg + IV Lasix 120mg x2 boluses. Cr improved to 2.2-2.5. On ___, patient appeared euvolemic, and was transitioned to PO Lasix, receiving PO Lasix 80mg x1. Cr 2.5 on ___. Cr on ___ at time of discharge is 2.3. # Severe AS | Severe MR: Per TAVR team, pt will pursue TAVR in the outpatient setting for management of severe AS upon achievement of euvolemia and normalization of kidney function. TAVR team will contact patient regarding additional workup and plan contact: ___, NP on structural team. # Anemia | History of GI Bleed | Hematuria Patient was discharged with Hgb 9 last admission. On presentation, Hgb 7.5. No evidence of acute bleed currently. Most likely slow oozing from known gastritis that caused prior GI bleed. Also has history of mild, persistent thrombocytopenia w/plt high90s-low100s. Fe replete based on studies on ___. Also had some transient gross hematuria secondary to Foley trauma. Guaiac negative. Hb ranging from 7.6-7.7. He received 1U pRBC on ___, w/repeat H&H 8.6/26.5. Hgbs in 9's at time of discharge. Patient was continued on home pantoprazole 40 mg Q12H and iron supplementation. # COPD: Patient was audibly wheezing on admission, but this was most likely due to CHF, as his wheezing improved with diuresis. He received standing duonebs q6hr in house, but was restarted on tiotropium for discharge. # Orthostatic Hypotension: Patient had SBPs in ___ iso diuresis as above. He was continued on home midodrine 10 mg PO TID. # Atrial Fibrillation CHADS2-VASc of 8. Per daughter, patient has a history of TIA in the past (father "spaced out" in the kitchen and dropped a coffee cup) and his mother had stroke. His home dose warfarin is 2.5mg QD with goal INR 2.0-3.0. INR 3.4 on admission and patient had gross hematuria, and initially held warfarin. Warfarin was restarted at home dose of 2.5mg on ___ with heparin gtt bridge upon resolution of hematuria. Heparin gtt was discontinued on ___ when INR moved into range. Patient was continued on home regimen 2.5mg daily. INR at time of discharge was 2,5. # CAD Patient was continued on home aspirin 81 mg daily and atorvastatin 80 mg QHS. His home ranolazine 500 mg BID was held given soft SBPs in the ___ 100s and was not restarted for discharge. # Hypothyroidism: Patient was on levothyroxine 125mcg QD at home. TSH 0.21 on ___. Given concern for over-treatment of hyperthyroidism, repeat TSH ___ was 0.11. Levothyroxine regimen was changed from 125 mpg daily to 125mcg (___) and 62.5mcg on ___ (7% dose reduction). Patient should have repeat TFTs in six weeks (___). # Gout: Patient's home allopurinol ___ mg daily was held iso ___, and will be held until resolution of ___. # Peripheral Neuropathy: Patient's home gabapentin 100 mg QHS was held during hospitalization iso ___, and will be held until resolution of ___. # BPH: Patient retained urine requiring a Foley, which he will be discharged on. He was continued on his home tamsulosin 0.4 mg QHS and finasteride 5 mg daily. Patient will need urology outpatient follow-up for a voiding trial. DISCHARGE WEIGHT: ___90.8______ DISCHARGE CREATININE: ___2.3______ DISCHARGE INR: __2.5_______</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old ___ speaking woman, with history of dementia, recurrent UTIs, HTN, and hypothyroidism, who is presenting today with increased URI symptoms for the past 3 days. Patient's health aid had also noticed that for the past 3 days, she has had increased cough x 3 days, rhinorrhea, body aches, and subjective fevers with generalized malaise. She denies any chest pains, palpitations, shortness of breath, nausea/vomiting or diarrhea. Recently, she was seen by her PCP ___ ___ to have an e. coli UTI, and was started on a 5 day course of macrobid (last day ___. Radiology showed Interval development of diffuse bilateral interstitial opacities and small bilateral pleural effusions, consistent with mild pulmonary interstitial edema. The patient was diagnosed with Pneumonia, unspecified organism, Heart failure, unspecified, Dyspnea, unspecified. At the time of discharge, the patient had Primary Diagnosis: Community Acquired Pneumonia Pulmonary Edema Acute exacerbation of Congestive Heart Failure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with past history of hypothyroidism, dementia, recurrent UTIs who presented with cough, congestion concerning for pneumonia and partially treated UTI. #Pneumonia: Patient had increased cough, congestion and crackles over RML/RLL on exam on admission. Patient had a slightly elevated WBC. Influenza test was negative. Patient had a lactate of 2.5 that increased to 3.5 at peak. Lactate 2.5 persisted during admission. She was treated with ceftriaxone and azithromycin for community acquired pneumonia. Lactate subsequently downtrended, and she continued to demonstrate clinical improvement. On discharge, she was satting high ___ while ambulating. Discharged on cefpodoxime and azithromycin for a 7 and 5 day total course, respectively. #Acute Pulmonary Edema: #Unspecified acute congestive heart failure: Patient had small bilateral pleural effusions with increased vascular markings on CXR consistent with mild pulmonary edema and elevated BNP concerning for CHF exacerbation. Patient did not have a previous diagnosis of CHF or a previous TTE. Trops were negative and EKG was unchanged. She was given 20 mg IV Lasix BID for diuresis. Dry weight appears to be 162-163 lbs; was close to dry weight at 164.7 lbs on discharge. She will have TTE done as an outpatient; being discharged on 20PO lasix daily, with close follow up plan. #Dirty UA: Patient has UA with moderate leuks and few bacteria and 9 WBC. She was recently treated for an Ecoli UTI with macrobid (sensitivities above). Patient is asymptomatic so she was not treated for UTI. UCx was only contaminant. CHRONIC ISSUES # Alzheimer's Dementia: Patient is seen with cognitive neurology. Per recent neurology clinic note, she was at her baseline. She utilizes services for cleaning at her home. There has been some concern per neurology note of home safety for patient recently. Mini-mental status exam was ___. Continued Vitamin D, Aricept 10 mg daily # Hypothyroidism: Continued levothyroxine # GERD: Continued omeprazole # Chronic Knee Pain: continued tramadol 50 mg BID PRN # Insomnia: Continued trazodone 50 mg QHS #CODE: DNR/DNI #EMERGENCY CONTACT HCP: Niece ___, does not know phone number. ___ is in OMR as NOK. Phone number: ___ TRANSITIONAL ISSUES [] Outpatient echocardiogram to evaluate for heart failure [] Ongoing titration of diuretic medication, close follow-up of electrolytes</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with HTN who presented with ___ weeks of cough and 6 hours of chest pain associated with post-tussive emesis and shortness of breath. Chest radiograph showed 1. Mildly enlarged cardiomediastinal silhouette, which may represent cardiomegaly or pericardial effusion. 2. No focal consolidation. VENOUS DUP UPPER EXT UNILATERAL RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had -Acute Asthma Exacerbation -Acute Dyspnea -ACS r/o. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with HTN, HLD, pre-DM, obesity, and GERD who presented with atypical chest pain associated with acute shortness of breath in the setting of possible influenza 2 weeks ago and persistent dry cough likely new diagnosis of asthma with acute exacerbation </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ independently living woman with hx of BPPV, CABG in ___, hypothyroidism, hypertension and cervical stenosis who presents with unsteadiness and weakness/funny feeling in left leg. Last night, when she attempted to get out of bed to use the restroom, she was unsteady and unable to walk. Her unsteadiness symptoms have been persisting since that time, however she has not tried to walk since then. Radiology showed No acute cardiopulmonary process. CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. There is no evidence of hemorrhage, edema, mass effect, or acute vascular territorial infarction. 2. Unremarkable head and neck MRA. 3. Right maxillary canine dental ___ and periapical lucency should be correlated with dental examination to exclude active infection. UNILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Primary diagnosis: benign positional paroxysmal vertigo Secondary diagnoses: hypertension, hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is an ___ independently living woman with a history notable for BPPV, hypothyroidism, hypertension and cervical stenosis who presents with unsteadiness and weakness/funny feeling in left leg. ACTIVE ISSUES # Dizziness/unsteadiness: history of gait unsteadiness since ___, seen by multiple doctors. ___ presents with positional complaints similar to previous BPPV episodes, with head spinning and unsteadiness on standing. ___ maneuver negative, however. Neurology was consulted in the ED and found no central etiology (most likely peripheral vertigo), recommended against MRI. Orthostatics negative. CTA head and neck without intracranial abnormality or flow-limiting carotid stenosis. Evaluated by physical therapy and felt safe for discharge home, and to follow up as outpatient for vestibular ___. Meclizine previously ineffective, so avoided, given not effective & risk for adverse effects. # Left leg weakness: w resolved, per pt. Muscle strength in flexion & extension ___ bilaterally. Given calf pain, LENIs were obtained and were negative. CTA head/neck without flow limiting stenosis, occlusion, dissection, or aneurysm and with no acute intracranial abnormalities. ___ evaluated and recommended outpatient ___. Vitamin B12 and Hb A1C levels pending on discharge. CHRONIC ISSUES # Hypertension: normotensive in house. Continued on home quinapril BID. # Hypothyroidism: continued levothyroxine, 75mcg 3X/week, 50 mcg 4X/week. ====================================== TRANSITIONAL ISSUES ====================================== # BPPV: will need outpatient vestibular ___. Consider meclizine trial if ___ ineffective. # LABS: follow up pending B12 and A1C levels (checked for subjective LLE weakness) </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with CAD w/ CABG, CKD, on coumadin for mechanical valve, IDDM, who presents with syncope. Was out with home health aid when she felt light-headed. Made it to passenger seat of car and lost consciousness. EMS arrived and she arose to sternal rub. Taken to ___. At ___ she awoke and by report was agitated and required Ativan & seroquel. CT head there was negative for acute stroke or bleed but did show subacute to chronic left parietal infarct. In the ___ ED intial vitals were: 97.9 75 21 159/53 95%RA. Labs showed a therapeutic INR and no abnormalities aside from baseline CKD Radiology showed Mild-to-moderate pulmonary edema with vascular congestion. Radiology showed 1. No evidence of acute infarct. Chronic left parietal infarct. Right thalamic chronic lacunar infarct. 2. No new visualization of the left vertebral artery in the neck and in the head indicating occlusion. 3. Mild intracranial atherosclerotic disease involving the left middle cerebral artery and left posterior cerebral artery. The patient was diagnosed with SYNCOPE AND COLLAPSE. At the time of discharge, the patient had Primary Diagnosis: Seizure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with history of CAD s/p CABG, s/p mechanical AVR on coumadin, CKD, IDDM, and CVA in ___ w/ residual left parietal infarct who presents with syncope and question of AMS. ACTIVE ISSUES # Syncope Potential etiologies included worsening valvular disease, cardia arrythmia, MI, transient CHB, CVA, seizure, and orthostasis. No ECG changes and nothing initally on tele. CT shows no new findings from previous. Cardiac enzymes negative. Not orthostatic on exam. Story from home health aide consistent with seizure activity. Seen by Neurology who recommended starting on Keppra. MRI/MRA of head and neck unchanged from prior. Patient discharged on keppra with Neurology follow-up. # AMS Patient very lethargic morning of admission and no oriented to date or location. Potential etioligies include infection, CVA, thyroid dysfunction. In addition, patient received a lot of IV benzodiazepam at ___ prior to arriving to ___. Concern for infection, but UA normal, CXR clear, blood cultures negative. Normal TSH but low free T4. Patient became more awake/alert and ___ (not oriented to date). After discussion with family, they feel that this is close to her baseline. CHRONIC MEDICAL ISSUES # IDDM Patient no currently on any insult or oral diabetes medications per PCP. She was started on an insulin sliding scale and her blood sugars were well-controlled. # s/p MVR Patient sarted on heparin drip for coumdadin bridging given subtherapeutic INR. She was discharged on coumadin, INR goal 2.5-3.5 and plan for coumadin follow-up. # Afib Heparin and warfarin as above. Her atenolol was stopped as her blood pressure was low. # Hyperlipidemia Her atorvastatin was continued. # Depression Her home citalopram was held during admission and restarted at discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of UC s/p TAC and PSC complicated by chronic cholangitis and stricture, recently s/p exploratory laparotomy and lysis of adhesions for small bowel obstruction, now presents with abdominal pain. Reportedly, pain began ___ ago (localized to RUQ), although significantly worsened overnight (localized to lower abdomen) in association with nausea and 1 loose stool. Pain now localized to lower abdomen and reportedly feels similar to prior episode per patient. No emesis prior to presentation, has since vomited x3 in ED during/after contrast ingestion in preparation for the CT scan. Denies fever / chills, headache / dizziness, chest pain, shortness of breath, dysuria, and/or musculoskeletal pain. Radiology showed 1. Interval resolution of small bowel obstruction. Status post numerous bowel surgeries with multiple anastomoses and ileoanal J-pouch. No evidence of obstruction or abscess. 2. Stable intra- and extra-hepatic bile duct dilatation, compatible with known history of primary sclerosing cholangitis. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, ULCERATIVE COLITIS UNSPEC. At the time of discharge, the patient had Abdominal pain; suspected small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the transplant surgery service on ___ for bowel rest, fluid resuscitation and serial abdominal exams for evaluation of abdominal pain. CT scan obtained in Emergency Department demonstrated interval resolution of small bowel obstruction s/p numerous bowel surgeries with multiple anastomoses and ileoanal J-pouch although no evidence of obstruction or abscess. On HD2, she reported improvement in nausea and abdominal pain and +flatus/bowel movement. At this time, her diet was advanced to clear liquids and she was re-started on augmentin 875-125mg po q12h and ursodiol 300mg q12h (home medications). She continued to report improvement in abdominal pain, denied nausea / vomiting, and continued to have +flatus/bowel movements. Her diet was subsequently advanced to regular, which she tolerated. On HD3, she reported minimal abdominal pain, tolerated solid food, and was passing flatus / stool. Discharge to home was discussed and felt to be appropriate by the patient and the surgery team. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ COPD on 2.5L of home 02, HTN, s/p brain surgery ___, fibroscan showing fibrosis of the liver who c/o 10lb weight gain over 10 days with increased leg swelling x7 days and sob x1 day. Currently without any symptoms of sob as she is on baseline 2.5L of oxyogen at home and was sating well in ED. She denies headache, cp, abd pain, leg pain. feels that she has left>right leg swelling and a rash over this site. She notes that at urgent care her fsbg 505, no prior diagnosis of diabetes. sent here for new onset DM and electolyte imbalance. In the ED, initial vitals were: 97.6 69 100/50 16 97% Nasal Cannula - Labs were significant for: H&H of 8.8/___, WBC 12, Cr of 1.4, positive UA, and K+ of 3.0 - Imaging revealed new pulmonary congestion, moderate cardiomegaly - The patient was given 20 IV lasix and 40 PO K+ Vitals prior to transfer were: Upon arrival to the floor, pt endorces feeling more confused the last few months, more fatigued, and has developed a new tremor that appears more intentional than resting; however, on exam appears to be consistent with asterixsis. She also endorces having darker than normal stools, but unsure if they are black. She denies BRBPR, hematemsis, N&V. She denies ABD pain, chest pain, diarrhea, but does state she has burning with urination and has more difficilty urinating. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Chest radiograph showed Moderate cardiomegaly and mild pulmonary vascular congestion without frank pulmonary edema. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Patent hepatic vasculature. No ascites. Splenomegaly. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, ANEMIA NOS, DIABETES UNCOMPL ADULT. At the time of discharge, the patient had Primary: Acute diastolic congestive heart failure Urinary tract infection Diabetes Mellitus type 2 Anemia Secondary: Hypertension COPD (on home O2 2.5L) Fibrotic liver. The patient was given written instructions concerning 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 EtOH cirrhosis, HTN, and COPD (on 2.5L home O2) who p/w 10lb weight gain and increased leg swelling x1 week. Labs notable also for new undiagnosed DM2, anemia, and UTI. # HFpEF: The patient presented with ___ edema and 10-lb weight gain over 2 weeks. TTE ___ showed Grade II diastolic dysfunction with increased PCWP. BNP was only 352, but may be misleadingly low given obesity. Given her diagnosis of EtOH cirrhosis, we obtained a RUQ US, which showed no e/o Portal HTN or hepatic masses as source of hypervolemia. Pt. was treated with doses of 40mg IV furosemide with good effect. Her exam improved, and her weight decreased from 120.4 kg on admission to 117 kg (dry weight ___ was 117.5kg). Her creatinine level also improved slightly from 1.4 to 1.3. She was switched to torsemide 30mg (home dose 20mg) for maintenance. # ___: Baseline Cr is 1.0, and up to 1.4 on admission. Cr levels downtrended slightly to 1.3 with diuresis. Suspect combination of cardiorenal syndrome, hypertensive nephropathy, and diabetic nephropathy, though further diagnosis and management is deferred to outpatient provider. # UTI: Pt presented with pain on urination and 20 WBC on UA. She was started empirically on IV CTX. After urine cx was positive for enterococcus (which CTX does not cover), she was switched to Augmentin 875mg PO BID x5days (started ___ last day ___. Sensitivities confirmed bacterial susceptability to ampicillin. # Anemia: Hgb 8.5 on admission, down from baseline Hgb of 11 in ___. Fe studies showed low Fe and high transferrin, pointing to likely iron-def anemia. Peripheral smear showed some dysmorphic cells but no e/o shistocytes. Her Hgb was stable during her stay, and her guaiac tests were negative. She received Fe supplements, and received her home pantoprazole 40mg. # DM2: Patient presented with glucose levels in 300s and A1c 7.8%. Pt. given diagnosis of DM2 with suspected exacerbation secondary to infection. Inpatient, she was placed on an insulin sliding scale and her fingersticks were 100-200s. After her Cr level began to downtrend, she was switched to and discharged on metformin 1000mg. She worked with a ___ inpatient and would benefit from follow-up with a diet___ outpatient. # Transitional Issues: - Take Augmentin 875 twice a day to treat urinary tract infection (last day ___ - Torsemide was increased from 20mg to 30mg daily - Take metformin 1000mg once a day for diabetes type 2 - Continue iron supplements for anemia and consider EGD outpatient given epigastric pain. - Blood culture results pending at time of discharge - Please follow up with nutritionist for meal planning with diabetes - Please follow up with your primary care doctor regularly to monitor the status of your glucose control - Patient has essential tremors that affect her daily functions. Consider switching metoprolol to propranolol. - CODE: FULL confirmed - Contact: ___ (daughter) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ w/ no PMH s/p fall off bicycle while riding in JP. Pt lost control of his bicycle and fell onto his left elbow resulting in a comminuted proximal ulna/radius fx w/ ?radial head disloc. The pt had experienced a similar injury ___ years prior and underwent ORIF L elbow by Dr. ___. Radiology showed 1. Comminuted intra-articular distracted fracture of the proximal ulna and olecranon. 2. Impacted comminuted fracture of the radial head with the radial head appearing dislocated dorsally and laterally relative to the capitellum. 3. Associated joint effusion and extensive surrounding soft tissue swelling. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormalities. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No traumatic malalignment or acute fracture. 2. Likely congenital fusion of C3 and C4 vertebral bodies. Radiology showed 1. Comminuted intra-articular fracture of the radial head with a displaced intra-articular fragment measuring 9 mm. 2. Dislocation of the radiocapitellar articulation. 3. Comminuted displaced fracture of the olecranon. 4. Coronoid fracture with intra-articular fragments measuring up to 1.7 cm. 5. Large hemarthrosis. NOTIFICATION: At the time of dictation, the patient had been admitted and is scheduled to go to the OR today (___). ELBOW (AP, LAT AND OBLIQUE) LEFT was done. The patient was diagnosed with Unsp fracture of lower end of left humerus, init for clos fx, Pedl cyclst (driver) injured in oth transport acc, init. The patient was treated with s/p ulna ORIF ___, ___.. The patient was given written instructions concerning 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 proximal radius/ulna fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male severe asthma on Xolair presented to the ED with dyspnea. CHEST (PA AND LAT) showed In comparison with the earlier study of this date, the patient has taken a better inspiration. The area of increased opacification at the right base is much less prominent and probably merely represents mild elevation of pulmonary venous pressure and crowding of pulmonary vessels at the cardiophrenic angle. No evidence of acute pneumonia at this time. The patient was diagnosed with Unspecified asthma with (acute) exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with severe asthma presents with asthma exacerbation after having failed outpatient management.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CC: ___ pain Radiology showed 1. Distended gallbladder with possible edema of the gallbladder wall. Recommend clinical correlation and possible right upper quadrant ultrasound if indicated. 2. Lobulated contour at the upper pole of the left kidney concerning for enhancing mass, likely renal cell carcinoma. MR evaluation ___ multiphasic CT if patient not ammenable) is recommended. 3. Normal appendix. No fluid collection or abscess. Updated impression from wet read communicated to Dr. ___ at 7:22 p.m. on ___ by phone. Radiology showed Distended gallbladder with dependent sludge and possible tiny stone. No other findings to suggest acute cholecystitis. Radiology showed 1. Low level enhancing lesion in the upper pole of the left kidney, highly suggestive of a renal cell carcinoma and does not appear to represent a hyperdense cyst. Suggest Urology evaluation or further characterized by nonemergent MRI if clinically indicated. 2. Mild gallbladder distention and surrounding stranding without gallbladder wall edema or pericholecystic fluid, correlate clinically with symptoms. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, RENAL & URETERAL DIS NOS, HYPERTENSION NOS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>REASON FOR ADMISSION: ___ yo man, former smoker, p/w RUQ pain and newly discovered L upper pole kidney mass concerning for RCC.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female fwith history of breast cancer, GERD, HTN who presents from her assisted living facility ___) after being found unconscious sitting up on her porch. Patient was lowered to the ground by staff member and regained consciousness, but was reportedly confused. She was brought to the emergency department by EMS. Currently, patient has no complaints. She states that she was just sleeping on her porch. She is not sure why she was brought to the hospital. She does say that she felt a little bit lightheaded when she was woken up by the staff member at her assisted living facility. She denies any chest pain, palpitations, shortness of breath, abdominal pain, nausea, or vomiting, dysuria, fevers or chills. She states that she did eat breakfast this morning and has been drinking adequate amounts of water. In the ED, initial VS were: T 96.7, HR 61, BP 108/72, RR 10, RA 95% on RA Exam notable for: Head: AT/NC Eyes: PERRL, EOMi Heart: RRR, no murmur Lungs CTAB Abd: soft, tenderness to palpation Extremities: no edema ECG: SR @ 62 bpm, nl axis, nl intervals, no ST-T wave changes Labs showed: - UA with mod leuks, 47 WBCs, 5 RBC - Lactate 2.1 - Trop 0.01 - AST, ALT WNL, AP 114 - CBC 10.4/11.1/34.7/254 - Coags ___ CHEST (PA AND LAT) showed Compared to chest radiographs since ___ most recently ___. No pneumonia. Mild interstitial abnormality, probably chronic. Heart size top-normal. No pleural effusion. Chronic right apical scarring unchanged since at least ___ due to prior infection or radiation therapy. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute findings to account for hypotension and abdominal pain. 2. Incidental findings as detailed above. The patient was diagnosed with Syncope and collapse, Urinary tract infection, site not specified, Lower abdominal pain, 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>Ms. ___ is a ___ year old female with history of breast cancer, GERD, HTN who presents from her assisted living facility on ___ after being found unconscious with confusion, found to have hypotension, hypothermia, and a urinary tract infection. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female pt presents with epigastric and RUQ pain associated with N/V since 3 am. She reports the pain was about ___ radiating to the back but that now she has ___ pain and no nausea. She reports having previous intermittent episodes of RUQ pain since ___. She reports that the pain is aggravated with fatty foods. She also reports acid reflux especially at night after eating late. Radiology showed No acute intrathoracic process. Radiology showed 1. No pulmonary embolism or evidence of acute aortic pathology. 2. Left basal opacity is most compatible with atelectasis or scarring. Changes from the initial interpretation were discussed with Dr. ___ by Dr. ___ at 1110 on ___ by phone. Radiology showed Distended gallbladder with wall thickening and multiple gallstones concerning for acute cholecystitis. No evidence of intrahepatic biliary ductal dilatation. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, ACUTE CHOLECYSTITIS, CHEST PAIN NOS. The patient was treated with ___: Laparascopic cholecystectomy. At the time of discharge, the patient had Acute cholecytitis. The patient was given written instructions concerning 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 Acute Care Surgical Service on ___ for evaluation and treatment of abdominal and chest pain radiating to the back. A Chest CTA and CXR were negative for pulmonary embolism or evidence of acute aortic pathology or intrathoracic process, respectively. Additionally, nonspecific EKG abnormalities with normal troponins were noted. An abdominal ultrasound,however, was consistent with acute cholecystitis. The patient susbequently underwent laparoscopic cholecystectomy; please see operative note for details. After a brief, uneventful stay in the PACU, the patient was transferred to the general surgical ward for further observation. Post-operatively, the patient experienced nausea with emesis related to intravenous Morphine. The pain regimen was transitioned to intravenous acetaminophen with intravneous morphine prn until tolerating a diet. At this time, the pain regimen was transitioned to oral oxycodone and tylenol with adequate pain control. The diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge on POD3, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yr old female on ___ s/p a BEAM auto-HSCT for Hodgkin lymphoma. She was treated with ABVD for six cycles, which completed in ___. In ___, she was noted for an enlarged submandibular lymph node and unfortunately, PET imaging showed multistation FDG-avid lymphadenopathy within the neck, mediastinum, and retroperitoneum. Left neck biopsy on ___ showed recurrence of her classical Hodgkin's lymphoma. She subsequently was treated with ICE for three cycles from ___ to ___ and then received high-dose Cytoxan for stem cell mobilization followed by autologous transplantation with the BEAM regimen. Day 0 was on ___. She is currently undergoing brentuximab maintenance (last ___ dose on ___ now presenting with a few day history of occipital HAs now with two days of fevers and a progressively developing papular rash of the face and anterior chest with a patchy rash on the RLE. CHEST RADIOGRAPHS showed No evidence of acute cardiopulmonary disease. MRI AND MRA BRAIN AND MRA NECKMRI of the head with and without contrast.MRI AND MRA BRAIN AND MRA NECK showed There is no evidence of acute intracranial process. Scattered foci of high signal intensity detected on FLAIR and T2 weighted images, distributed in the subcortical and periventricular white matter, are nonspecific and may reflect changes due to small vessel disease.There is no evidence of abnormal enhancement. 1. No evidence of acute intracranial hemorrhage, mass effect, or acute infarct. 2. Brain parenchymal volume loss and probable sequelae of chronic microangiopathy. 3. No evidence of stenosis, dissection, or occlusion within the vasculature of the neck. The patient was diagnosed with FEVER, UNSPECIFIED, DIARRHEA, URIN TRACT INFECTION NOS. At the time of discharge, the patient had Hodgkins Lymphoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>IMPRESSION AND PLAN: ___ is a ___ yr old female on ___ s/p a BEAM auto-HSCT for Hodgkin lymphoma presenting with a few day history of occipital HAs now with two days of fevers and a progressively developing papular rash of the face and anterior chest with a patchy rash on the RLE. ## Papular rash of the face and anterior chest with a patchy rash on the RLE: The ddx is infection vs. drug reaction vs. combination of both these etiologies. Specifically, given the prodromal L occipital HA as well as current L ear pain/?vesicles, the most concerning etiology is herpes zoster; however given the lesions are not localized to a single dermatome, the concern would be dissemination. She was prescribed valtrex 1g TID and took 5 doses as an outpatient (she discontinued ___ AM as she thought it was causing diarrhea). In terms of medications, brentuximab can cause a rash and aside from restarting valtrex, this is the only new medication she has initiated. -Derm consulted, final path suggestive of drug hypersensitivity -Send VZV Abs (IgM)PND -HSV PCR PND -Discontinued IV acyclovir as final path on derm bx was not indicative of shingles, restarted prophy dose of acyclovir. -MRI head/neck ___, result pending -Will follow up outpt with neurology ## Fever: Fevers have resolved since admission. Localizing symptom is the new rash, myalgias (see note above r/t zoster), and now-resolved loose stools; there are no areas concerning for bacterial superinfection. She does have pyuria, but is asymptomatic with a urine culture pending. Blood cultures NGTD. Her CXR had no infiltrate concerning for infection. She did receive cipro/flagyl in the ED. -urine cx neg, cipro d/c'd ___ -F/U blood cultures -If she has recurrent loose stools, we will send a C. diff ## Bilateral thigh myalgias: She has notable TTP on exam. This occured with her first cycle of brentuximab and this seems to be the most likely etiology. CK wnl. ## Worsened thrombocytopenia and slight anemia: ? drug effect(brentuximab, bactrim) vs. ? viral suppression (? zoster) -No need for transfusion today -Tranfuse if hgb < 7 and plts < 10 -Held pharmacologic PPX given plts of <50 ## Relapsed Hodgkin Lymphoma: D ___ s/p BEAM auto-HSCT currently on brentuximab maintenance (last ___ dose on ___ ##Electrolyte imbalances - possibly due to hydration r/t IV acyclovir -on sliding scale -repeat lytes prn ## HTN: -Continue home dose of atenolol ## Esophagitis: -Continue home PPI ## DM: -Hold home metformin on admission as this was thought to contribute to her diarrhea, restarted at d/c -___ consult, insulin sliding scale started, BS between 100-170s -Check BS as ordered -Per ___, consider follow up with endrocrinologist locally</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with h/o alcoholic cirrhosis complicated by hepatic encephalopathy, coagulopathy, pancytopenia, SBP and ascites presenting with fever and altered mental status. Patient was last seen normal at noon ___. Later this afternoon, her daughter found her minimally responsive and lethargic. Finger stick for EMS was 199. She has had mild fatigue for the past few days. She reports 1 week of R leg swelling, pain, warmth and erythema, on top of chronic leg swelling bilaterally. Pt denies trauma to the area. She denies F/C, N/V, diarrhea, abdominal pain. She has been taking lactulose regularly, and has no recent changes to her medications. Radiology showed No evidence of acute intracranial process. Radiology showed No evidence of pneumonia. Unchanged mild cardiomegaly. Radiology showed No deep venous thrombosis within the right lower extremity. Non-visualized left peroneal veins. Radiology showed 1. Bidirectional portal vein flow is unchanged since ___. 2. Coarsened liver echotexture consistent with the provided diagnosis of cirrhosis. 3. A small amount of perihepatic ascites is new since ___. The patient was diagnosed with HEPATIC ENCEPHALOPATHY, OTHER MALAISE AND FATIGUE, CELLULITIS OF LEG, ALCOHOL CIRRHOSIS LIVER. At the time of discharge, the patient had Cellulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with a history of EtOH cirrhosis complicated by HE, SBP, ascites, no varices on most recent EGD, who initially came in w/ AMS and fevers found to have RLE cellulitis and initially admitted to the ICU given hypotension, stabilized and transferred to the floor ACTIVE ISSUES ============== # AMS/sepsis/cellulitis: AMS most likely due to acute insult of sepsis on top of cirrhosis. She initially met SIRS criteria based on tachycardia and fever to 103 (rectal). Lactate 4.8 initially, subsequently downtrending. Only identifiable source was RLE cellulitis. Less likely hepatic encephalopathy, given absence of asterixis and that MS cleared without additional lactulose. Toxicology screen negative, no head trauma, no recent changes in diuretics or other medications. IV vanc/cefipime were started in the ED and mental status cleared after 4L IVF. Given concern for cellulitis involving labia, broadened abx to vanc/cef/flagyl for anerobic coverage. Home dose furosemide and spironolactone were initially held due to hypotension, but were then restarted and well tolerated. Her cellulitis improved dramatically and she was transferred to the floor. She was transitioned to PO clindamycin and tolerated this well with continued improvement in her RLE cellulitis. She is discharged home to complete a 10 day course of antibiotics through ___. She was alert and oriented x3 when transferred to the floor and remained so for 48 hours until discharge. # Alcoholic cirrhosis: Baseline T bili 3.1 stable around recent baseline of ___. Has chronic ___ edema, on diuretics. Initially held home dose spironolactone and furosemide; however, these were then restarted and well tolerated. On ___, there was some concern for hepatic encephalopathy and the patient had not had a BM in 2 days, so lactulose was increased to q2hrs. Home dose cipro was held in the setting of receiving IV vanc/cef/flagyl. Her mental status quickly cleared and she was transitioned back to lactulose TID. Her cipro was restarted on discharge. CHRONIC ISSUES ================ # T2DM: Recently diagnosed with blood glucoses 400-500, multiple ED visits, followed by ___, insulin regimen appears to be in flux given recent dx. She was maintained on home ___ with good blood sugar control in house. She is discharged on her home regimen. # Back pain: Secondary to vertebral compression fractures, has chronically been on oxycodone since ___. Continued home oxycodone # Pancytopenia/coagulopathy: Chronic since at least ___, thought ___ cirrhosis. Stable INR up to ___ in ___, stable in-house ~ 1.7-2.1. Subqutaneous heparin was given for DVT prophylaxis and platelets were carefully monitored. # H/O adrenal insufficiency: Developed several years ago in the setting of withdrawing steroids for alcoholic hepatitis, does not appear to be active. Continued home dose midodrine. TRANSITIONAL ISSUES ==================== - Should received Hep B vaccine as outpatient (surface ab negative on ___ - Patient to take clindamycin through ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of asthma, bipolar, IBS, PCOS, chronic abd pain who was recently treated for presumed endocarditis due to blood cultures growing strep viridans from a left maxillary dental abscess- from ___ cultures d/c on ___ on ___ wks iv vanc with a picc line. She was at home on ___ was having F/C, N/v and feeling weak called the ambulance at they brought her to ___. She dislikes that hospital and asked to be sent to ___. The patient was diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS. The patient was treated with ___ transesophageal echocardiogram. At the time of discharge, the patient had Severe Sepsis Polymicrobial bacteremia Fungemia. The patient was given written instructions concerning 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 hx asthma, bipolar disorder, PCOS, IBS, Hep C, recent admission earlier last month for Strep viridens bacteremia in setting of dental abscess discharged on vanco with PICC line, chronic abdominal pain, who was recently admitted to OSH ICU for severe gram negative sepsis, left AMA, and came to ___ for further management. #Polymicrobial bacteremia: Her presentation was most concerning for intentional contamination of her PICC line with stool given blood cultures were consistent with fecal flora. At OSH she had blood cultures positive for 4 different gram neg species. Blood cultures drawn from ___ grew two types of enterobacter cloacae, klebsiella oxytoca, klebsiella pneumoniae. The microbiology lab at ___ was contacted klebsiella senstivity resistant to ampicillin, but sensitive to all antibiotics tested. Enterobacter was resistant to ampicillin/cefazolin, but sensitive to everything else. She had peripheral cultures growing yeast (non-albicans) and lactobacillus. Her initial PICC line was removed at OSH. With the polymicrobrial nature of her initial cultures she was started on IV vancomycin, aztreonam, and micafungin. TEE on ___ negative for valvular vegetations/abscesses. A new PICC line was placed for her IV antibiotics. During her hospitalization here, she had occasional fevers and a rapid increase in her WBC with return to normal a couple days later. These were thought to be secondary to continued contamination of her new PICC line. Her PICC was pulled on ___ and switched to po linezolid, ciprofloxacin, and voriconazole for a treatment duration of 2 weeks to end on ___. With combination of linezolid, voriconazole, and sertraline, patient is at increased risk for serotonin syndrome. Given that she is unable to have IV abx secondary to recurrent contaminations, her antibiotic options are limited and must remain on this regimen. The risks were thoroughly explained to her and she was instructed to notify her doctor if she experience any of the symptoms. Additionally, she was instructed to have CBC, BMP, and LFTs drawn twice a week with results faxed to ID department for the duration of her treatment. #?Factitious Disorder: Her presentation is most concerning for intentional contamination of her PICC line with stool or some other bodily fluid. The speciation of her cultures with lactobacillis, enterobacter, klebsiella, ___ is most consistent with fecal contamination. Her WBC count during admission (jumped up to 28) and returned to normal (5) from day to day. When her PICC was removed and she was transitioned to po antibiotics, she remained afebrile and WBC was normal. During the admission, patient denied any intentional tampering with PICC. Also consistent with her behavior is her intentional wheezing when given most drugs or antibiotics Pt is often found to have a forced upper airway wheeze with most medications (never has any uritcaria) and thus insists on benadryl. As per psych, this diagnosis is one of exclusion and cannot be made without actually witnessing alleged behavior. # Strep viridins bacteremia: Patient recently admitted ___ for S. viridens bacteremia ___ maxillary abscess from a tooth that she self-extracted. She was started on vanco on ___ and discharged with a PICC with plans for ___ecause she had an allergic reaction to pencillin. However, she was not compliant at home with vanco as per ID records in OMR. TEE during that admission was negative for valvular vegetations. As described above, she needed to be transitioned to po antibiotics secondary to self contamination of picc. She finished her antibiotic course as on ___ for strep viridins and polymicrobrial infection. #Medication allergies - Patient reports to have many allergic reactions to many different antibiotics in the past. She has been having "reactions" to both vancomycin and aztreonam, often witnessed to have an exaggerated forced wheeze. Never had any urticaria or true airway compromise. Her symptoms rapidly resolve with Benadryl. During this admission, she was administered benadryl prior to all antibiotic administration. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ female w/ history of VF arrest in the setting of inferolateral STEMI, status post DES to LCx ___ who presents with dizziness and dyspnea, reported 4 lb weight gain, admitted for management of suspected volume overload. CHEST (PA AND LAT) showed Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. No evidence of pneumonia The patient was diagnosed with Shortness of breath, Palpitations, Dizziness and giddiness. At the time of discharge, the patient had Primary diagnoses: # Palpitations - frequent premature ventricular contractions # Heart failure with recovered ejection fraction Secondary diagnoses: # Depression / anxiety # Rib fracture secondary to CPR # Hypertension # Anemia # Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female w/ history of VF arrest in the setting of inferolateral STEMI, status post DES to LCx (___) who presents with palpitations, dizziness, dyspnea, and reported 4 lb weight gain. ====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F s/p MVC, unrestrained driver in head-on collision. Taken to ___, where she was found to have left 6th rib fracture, small pneumothorax, left wrist fracture, right acetabular fracture, and 6 cm facial lac. At OSH, she was noted to have seizure-like activity and was intubated. Left chest tube and foley were placed. She appears to have received a bolus of fosphenytoin between ___ and MedFlight. She was transferred via MedFlight to ___ for further evaluation and management. ___ female status post trauma. showed Left sixth rib fracture, minimally displaced. Additional fractures better seen on outside CT examinations performed earlier today. Low lung volumes with a left basilar consolidation, may reflect aspiration and/or atelectasis. Blunting of the left costophrenic angle may reflect small pleural effusion. DX HAND, WRIST AND FOREARM showed Impacted, comminuted, and slightly displaced distal radial fracture. No definite intra-articular component, this is difficult to entirely exclude. Best appreciated on the lateral views, there is uplifting of the dorsal cortex. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormality. Subgaleal hematomas involving the right frontal subcutaneous tissues as well as left vertex with associated cutaneous staples noted. KNEE (AP, LAT AND OBLIQUE) LEFT showed No fracture. Soft tissue fat stranding and edema noted projecting over the prepatellar soft tissues and lateral knee on the AP view. FEMUR (AP AND LAT) RIGHT showed No femoral fracture. Right acetabular fracture better characterized on same day CT performed at outside facility. PELVIS W/JUDET VIEWS (3V) showed Fracture through the posterior aspect of the right acetabulum is better evaluated on same day CT performed at an outside facility. No evidence of dislocation. The proximal right femur appears intact. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. No acute fracture. Small right frontal scalp hematoma not fully imaged. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change in the appearance of the minimally displaced fracture of the sixth rib on the left. Chest tube is in place and there is no evidence of pneumothorax. Additional fractures were better seen on the outside CT examinations. There are are continued low lung volumes with opacification at the left base that could reflect areas of atelectasis or superimposed pneumonia. Monitoring and support devices are unchanged. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. No acute intracranial pathology. 2. Sphenoid and bilateral maxillary sinus air-fluid levels are likely due to intubation. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Allowing for streak artifact from the EEG leads, the noncontrast head CT demonstrates no evidence for acute intracranial abnormalities. 2. Slightly decreased right frontal subgaleal hematoma. Slightly increased left parietal/occipital hypodense subgaleal fluid collection. No evidence for a calvarial fracture. 3. Normal CTA of the head and neck without evidence for dissection or stenosis. 4. Comminuted fracture of the right anterior first rib is again demonstrated. Small bilateral pleural effusions with adjacent atelectasis are again partially visualized. Portable chest radiograph showed Increased bibasilar atelectasis, less likely developing pneumonia. The side port of the left chest tube very near to the intercostal plane. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 11:42 AM, approximately 30 minutes after discovery of the findings. PELVIS (AP ONLY) showed No appreciable interval displacement of the known right acetabular fracture. Findings suggestive of sacroiliitis, correlation with the patient's clinical history recommended. DX HAND AND WRIST showed Minimally displaced fracture through the distal radius. MR ___ SPINE W/O CONTRAST T___ MR SPINE showed 1. No evidence of fracture or intrinsic spinal cord signal abnormality. 2. Multilevel degenerative changes, with disc bulges at L3-4 and L4-5 causing mild spinal canal and bilateral neural foraminal narrowing, as described above. CHEST (PORTABLE AP) showed ET tube tip is 6 cm above the carinal. NG tube tip is in the stomach. Left chest tube is in place. Right basal consolidations are new and are concerning for interval progression of pneumonia or aspiration. RECOMMENDATION(S): Followup of right basal consolidations which are concerning for aspiration or developing infectious process. Portable chest radiograph showed New left basilar pneumothorax. Chest tube side port projecting over the lateral chest wall, position likely inadequate. Increased right perihilar and retrocardiac consolidations concerning for pneumonia. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 1:17 ___, approximately 160 minutes after discovery of the findings - initially paged resident approximately 15 minutes after discovery of the findings. CHEST (PORTABLE AP) showed ET tube tip is 4 cm above the carinal. NG tube tip is in the stomach. Heart size and mediastinum are stable. Bibasal consolidations appear to be unchanged involving the vast majority of the mid lung and lower lobes. The findings might representing combination of pulmonary edema and widespread infectious process, especially giving the lack of the findings back on the CT from ___ does pulmonary hemorrhage or lung contusion are not there reliably etiology. No definitive pneumothorax is seen. Small amount of bilateral pleural effusion cannot be excluded. CHEST (PORTABLE AP) showed As compared to ___, the left chest tube was removed. Better visualized than on the previous image is a slightly displaced left rib fracture. No pneumonia, mild pulmonary edema. Borderline size of the cardiac silhouette. Moderate retrocardiac atelectasis. No pneumothorax is identified. PELVIS (AP, INLET AND OUTLET) IN O.R. showed Screening for procedure guidance. CHEST (PORTABLE AP) showed As compared to previous radiograph of 1 day earlier, a bilateral and asymmetrically distributed pattern of pulmonary edema has shifted in distribution and overall slightly worsened in severity. No other relevant changes. CHEST (PORTABLE AP) showed Severe pulmonary edema has improved slightly on the right common not on the left. Heart remains moderately enlarged and mediastinal veins are engorged. Left pleural effusion is not large, right pleural effusion small if any. ET tube an transesophageal drainage tube are in standard placements. The patient was diagnosed with Disp fx of posterior wall of right acetabulum, init, Laceration w/o foreign body of oth part of head, init encntr, Driver injured in collision w unsp mv in traf, init. The patient was treated with - R Posterior Wall Acetabulum ORIF ___ (Dr. ___ - Closed reduction and percutaneous pinning of left distal radius fracture (Dr. ___. At the time of discharge, the patient had Motor Vehicle Collision Left 6th rib fracture Left pneumothorax Right acetabular fracture Left impacted/comminuted distal radial fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ F s/p MVC, unrestrained driver in head-on collision. Taken to ___, where she was found to have left 6th rib fracture, small pneumothorax s/p CT placement, left wrist fracture, right acetabular fracture, and 6 cm facial lac. At OSH, she was noted to have seizure-like activity and was intubated. Left chest tube and foley were placed. She appeared to have received a bolus of fosphenytoin between ___ and MedFlighted to ___ for further evaluation and management. Upon arrival to ED, patient intubated, primary and secondary revealed above documented lesions. She was transferred to Trauma SICU for close monitoring of seizure activity, ventilartoyr support. EEG obtained and neurology consulted. Per neurology team there were no seizure activity demonstrated on EEG. A CTA head/neck obtained demonstrated no abnormal findings. Results from a lumbar puncture performed by neurology were within normal limits. Her ICU course was remarkable for fevers on HD2. She was worked up with a bronchoscopy and BAL which returned positive for GPCs. Since HD2, she was started on Vanc/cefepime. On HD3 the chest tube was discontinued with no residual PTX. On HD4, she passed RSBI, extubated successfully, passed bedside swallow evaluation and patient self-limited to sips due to pain w/swallowing. She was transferred out of the SICU on HD5 with no active issues and uneventful hospital stay summarized below. On HD8, the patient had her foley removed. She then experience some urinary retention, and the catheter was replaced. It was removed on the following evening, and she voided without difficulty. On HD10, the patient went to the OR with the hand surgery team for closed reduction and percutaneous pinning of left distal radius fracture. For more details, see operative report. She was taken from the OR to the PACU in stable condition, and then moved to the surgical floor. She recovered from this procedure well. ___ and OT continued to work with the patient, and by day of discharge, ___, the patient was deemed safe to return home. On the day of her discharge, she was was tolerating a regular oral diet, pain was well controlled with oral medications, she reported normal bowel function and voiding, and she was able to ambulate with assistance. All of her questions were answered to her satisfaction. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of CAD with 3v CABG (___), HFpEF (TTE ___- LVEF of 50%, with grade 1 diastolic dysfunction, HTN, HLD, colon cancer, s/p resection, asthma/COPD (obstructive dz dx on last admission ___, arthritis, and GERD, who was referred to ___ ___ by his nursing home for evaluation of shortness of breath. The patient is ___ and is alert and oriented to his name only in the ___. He is unable to provide any meaningful history, stating "bien" when asked in ___ if he has any symptoms. He is denying shortness of breath or any pain at this time. Chest radiograph showed Somewhat low lung volumes. Mild vascular congestion. No pneumonia or pneumothorax. The patient was diagnosed with Other forms of dyspnea, Hypoxemia. At the time of discharge, the patient had PRIMARY DIAGNOSES: ================== Asthma COPD exacerbation Heart failure with preserved ejection fraction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ ___ speaking male with history of CAD with 3v CABG (___), HFpEF (TTE ___- LVEF of 50%, with grade 1 diastolic dysfunction, HTN, HLD, colon cancer, s/p resection, asthma/COPD (obstructive dz dx on last admission ___, arthritis, and GERD, who was referred to ___ ___ by his nursing home for evaluation of shortness of breath. # Dyspnea # Asthma/COPD exacerbation: Per patient's son, patient used to smoke in early adulthood, 1 cigarette/daily for ___ years. He carries a history of asthma, and is on albuterol inh as an outpatient. On prior admission last week ___, he had profound wheezing on exam c/w obstructive pulmonary disease. He was given duonebs Q6h:prn, was started Fluticasone-Salmeterol 250/50 inhaler BID with improvement, and both of these in addition to his albuterol INH were continued in house and for discharge. He also received PPSV on ___. On this admission, he presented with some dyspnea when sitting up or walking, diffuse expiratory wheezing on exam, but with O2 sats in the ___ on RA, and only mild pulmonary vascular congestion on chest x-ray. Overall, picture was more consistent with obstructive lung disease exacerbation vs heart failure exacerbation. patient was started on azithromycin, azithromycin 500mg x1, followed by 250mg daily x4 days (Day 5: ___. His fluticasone-salmeterol dose was increased to 500/50 BID, with a plan to continue this following discharge. He was continued duonebs q6:prn, which is being transitioned tiotropium for discharge. As above, he was continued on his albuterol INH q4:prn. Patient improved, was not longer dyspneic when sitting or walking, and had reduced wheezing on exam. At the time of discharge, he was able to ambulate without symptoms, and had sats 91-95%. Following discharge, patient should be evaluated with outpatient PFTs following resolution of acute exacerbation to delineate whether his primary process is asthma or COPD. # Hear failure with preserved ejection fraction (LVEF 50%): TTE obtained on prior admission last week ___ showed only mildly depressed EF of 50%, with grade 1 diastolic dysfunction. Discharge weight on ___ was 87.2 kg/192 lbs on 40mg PO Lasix once daily. Patient's exam was notable for absence of crackles, JVD, and peripheral edema, and overall did not appear volume overloaded. He was continued on his home furosemide 40mg daily, home metoprolol succinate 100mg daily, and home losartan 100mg daily, and home amlodipine 2.5mg daily. ===============</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with a history of left Hickman for home TPN, eosinophilic gastrointestinal disease, gastroperesis, and postural orthostatic tachycardic syndrome who presents with a 7 day history of headache and malaise and a one day history of fevers to Tmax 101. Chest radiograph. showed No evidence of pneumonia. Radiology showed Successful placement of a tunneled dual lumen ___ line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Successful removal of the existing left IJ tunneled catheter. Successful exchange for a new 18 ___ MIC J-tube. Radiology showed GJ tube projects over expected area, however, if exact tube location needs to be identified, repeat imaging with a small amount of enteric contrast administered through the GJ tube is recommended. J tube check showed The tip of the JG tube terminates in the jejunum. Radiology showed No significant interval change. Nonobstructive bowel gas pattern. Radiology showed Successful placement of a 10 ___ ___ double lumen tunneled line via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology showed Successful exchange of a junostomy tube for a new MIC-KEY ___ Fr 2.5 cm stoma jejunostomy tube. The tube is ready to use. The patient was diagnosed with Fever, unspecified. The patient was treated with Removal of ___ catheter with replacement by silicone catheter under general anesthesia (___). Replacement of J tube with GJ tube (___). Removal of left catheter and insertion of new tunneled catheter on the right (___) Replacement of GJ tube with J tube (___). At the time of discharge, the patient had Primary Diagnosis: ================ Bacteremia Fungemia Secondary Diagnosis: ==================== Eosinophilic gastrointestinal disease Peptic ulcer disease Postural orthostatic tachycardia syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with a history of left Hickman for home TPN, eosinophilic gastrointestinal disease, gastroperesis, and postural orthostatic tachycardic syndrome who presents with Enterobacter asburiae bacteremia and ___ parapsilosis fungemia. # Enterobacter asburiae bacteremia: the patient presented with enterobacter asburiae bacteremia, tachycardia, and fever, meeting SIRS criteria for sepsis. Her only positive blood cultures were in ___ bottles on the day of admission, ___. Given this, the most likely source was GI seeding, with low suspicion for port infection. She was initially treated with daptomycin/Zosyn, which was narrowed to Zosyn 4.5g q8hr on ___, and further to ceftriaxone 2g Q24H on ___. As some enterobacter species can become resistant to ___ generation cephalosporins, she was switched to cefepime 2g Q12H on ___. On ___ she had her Hickman line exchanged for a silicone line with ethanol lock. This line became displaced, and was replaced with a right tunneled silicone line on ___. She was discharged on ertapenem 1g IV Q24H, and will complete a 2 week course (last day ___. # ___ parapsilosis fungemia: Patient grew ___ parapsilosis in blood cultures drawn through her central line on ___. She had no other positive fungal or Gram stains. Patient has had no constitutional symptoms since the night of admission. She was started on fluconazole 400mg IV Q24H for 2 weeks (last day ___. # Nutrition: patient normally receives TPN daily, and has had no significant PO intake in ___ years. Patient's home TPN was initially held due to concerns of port infection. TPN was restarted following catheter replacement on ___. # J tube replacement: Patient has a G tube and J tube at baseline. On ___, her J tube was removed by ___ and replaced by a GJ tube. The event has been disclosed to the patient. ___ team as well as the primary team is aware. Patient has been provided information to contact patient relations. Quality improvement has also been contacted to prevent future similar events. This tube was replaced with a J tube on ___. # Eosinophilic GI disease: patient vented G tube frequently, had minimal PO intake. Her home GI medications were continued. Her pain was managed with her home fentanyl patch and additional dilaudid 1mg Q4H:PRN. Her nausea was well controlled with IV promethazine. # Pancytopenia: patient was down in all cell lines, consistent with lab values from previous infections. CBC was trended daily. CHRONIC ISSUES: ========================== # POTS: Patient was occasionally tachycardic to the 140s. - Home metoprolol was fractionated to 25 mg Q6H # Peptic ulcer disease: - Continued home pantoprazole TRANSITIONAL ISSUES ========================== - Patient is on 2 week ertapenem course on discharge, last day ___ - Patient is on a 2 week fluconazole course on discharge, last day ___ - Patient should establish providers in the ___ area, including GI, primary care, and chronic pain - monitor LFTs/triglycerides as patient is on TPN chronically</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In the ED, initial vitals were: 97 ___ 34 96% NEB FSBG 122 CHEST (PORTABLE AP) showed Central pulmonary vascular engorgement and mild cardiomegaly. Increased opacity projecting over the right mid to lower lung is concerning for pneumonia and/or aspiration The patient was diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation, Heart failure, unspecified, Shortness of breath. The patient was treated with Cardiac Catheterizaion ___ - No stents placed. At the time of discharge, the patient had PRIMARY: ========== - Takotsubo (stress induced) cardiomyopathy - COPD SECONDARY: =========== - Coronary artery disease - hyperlipidemia - 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>Ms. ___ is a ___ with a history of COPD/asthma, GERD, HLD, and Stage IIIA Colon Cancer s/p resection, and a recent TTE with inferior/posterior hypokinesis who presented with weeks of increasing dyspnea on exertion and orthopnea consistent with decompensated diastolic heart failure, found to have newly depressed EF. # CORONARIES: unknown # PUMP: LVEF 30% (___) # RHYTHM: sinus tachycardia #Shortness of breath: In the ED the patient was wheezy and appeared volume overloaded. She was given IV Lasix, nebulizers and empiric antibiotics. She was placed on BIPAP and sent to the Cardiac Care Unit for close monitoring. Her breathing quickly improved with diuresis and better control of COPD exacerbation. Determined to have no signs of PNA or infection and antibiotics were discontinued. Ultimately thought to be from COPD and decompensated cardiomyopathy (discussed separately below). ___ Induced Cardiomyopathy: Patient was found to have elevated Troponins and placed on IV heparin gtt. A TTE revealed a depressed EF from 60% in ___ to 30% on ___ this admission, with regional systolic dysfunction and apical aneurysm concerning for Takotsubo cardiomyopathy. EKGs were noted to have nearly global T-wave inversions. Unclear if was stress induced cardiomyopathy or ischemic pattern. Patient was taken for cardiac Catheterization on ___ which showed mild to moderate branch vessel CAD, not consistent with echo changes, confirming stress induced cardiomyopathy. Troponins likely stress induced. Patient was started on metoprolol and Lisinopril with plan to continue as outpatient. Given apical akinesis and aneurysm (no LV thrombus on TTE), she was discharged on lovenox bridge and Coumadin (plan for daily dosing of lovenox for ease of delivery by family member). Was discharged also on Lasix 20mg ___. #Asthma/COPD with Acute Respiratory Distress: Patient was admitted for severe shortness of breath and progressive worsening dyspnea on exertion. While CHF was thought to be contributory, still was noted to have diffuse wheezing on exam. Initially required standing duonebs, Spiriva, beclomethasone, as methylprednisone in addition to the diuresis. While D-dimer was >1700, patient was unable to tolerate lying flat for CTA chest. Given her rapid improvement with diuresis and nebulizers, PE thought to be less likely. The patient follows with ___, last ___, concern for worsening dyspnea due to cardiac and pulm processes. Discharged on home regimen with plan to follow up with pulmonary outpatient. CHRONIC ISSUES: ================= # Hyperlipidemia: Continued home atorvastatin 40mg # GERD: Asymptomatic, continued home omeprazole 20mg daily # L>R Shoulder pain: Continued on APAP 650mg TID standing per ___ protocol. # Stage IIIA Colon Cancer stage IIIA node-positive colon cancer status post lower anterior resection in ___ who did not receive adjuvant chemotherapy and has been monitored on surveillance. There were no sign of recurrence on ___ CT chest/abd/pelv. Patient is followed by Dr. ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ y/o M with PMH significant for GAVE syndrome (c/b chronic iron deficiency anemia), hx of aortic valve replacement (mech valve, on warfarin w/ goal INR 2.5), DM II, CAD, MGUS, who has had ongoing issues with chronic GI bleeding, and is s/p endoscopy/colonoscopy + polypectomy one week ago with GI here, who presents as a transfer from outside hospital for frequent dark stools for three days. CHEST (PORTABLE AP) showed Comparison to ___. Lung volumes are stable. Mild pulmonary edema persist. Moderate cardiomegaly is unchanged. No pleural effusions. No pneumothorax, stable mild retrocardiac atelectasis. CHEST (PORTABLE AP) showed Overall, persistent bibasilar atelectasis and possible small left pleural effusion, unchanged compared to the prior exam. DX CHEST PORTABLE PICC LINE PLACEMENT showed Comparison to ___. The patient has received a new left-sided PICC line. The course of the line is unremarkable, the tip of the line projects over mid to lower SVC. No complications, notably no pneumothorax. Otherwise unchanged radiograph. UNILAT UP EXT VEINS US LEFT showed 1. No evidence of deep vein thrombosis in the left upper extremity. 2. PICC in the left basilic vein. Chest radiographs, four AP upright views. showed Dobhoff tube terminating in the stomach. No evidence of acute cardiopulmonary disease. CHEST (PORTABLE AP) showed Compared to chest radiograph ___. Pulmonary vasculature is engorged. Edema minimal if any. Heart size borderline enlarged. No pleural effusion or pneumothorax. Patient has had median sternotomy and at least one cardiac valve replacement. Uppermost sternal butterfly wire is fractured but not miss aligned. Indwelling shunt catheter traverses the right neck, chest and upper abdomen. CHEST (PORTABLE AP) showed Persistent elevation the right hemidiaphragm with overlying right basilar subsegmental atelectasis. Overall, no significant interval change. Radiology showed Linear metallic densities over the right lower quadrant likely represent newly placed endo clips. The patient was diagnosed with Hemorrhage of anus and rectum. The patient was treated with Colonoscopy x 2 ___ and ___. At the time of discharge, the patient had Post- Polypectomy hemorrhage Anemia Delirium S/P mechanical valve on Warfarin Type 2 diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o GAVE c/b ___, hydrocephalus s/p VP shunt, prior ICH, mechanical AVR on warfarin, HFpEF on Lasix, CAD, DM2, and OSA on CPAP/ home O2 who presented with post-polypectomy bleed in the ascending colon causing hemorrhagic shock. # Acute GI Bleed # Acute on Chronic Anemia Prior to arrival to the ICU, the patient had received a total of 3 units of packed red blood cells (1 at OSH, 2 in the ED). His initial presenting hemoglobin in the ICU was 7.0, and he was hemodynamically stable. His bleeding was thought to be secondary to polypectomy on ___ during which a 4 cm sessile polyp was removed from the ascending colon. GI was consulted and the patient was prepped overnight for colonoscopy. Given that the only availability for colonoscopy was on the ___, the patient was transferred to the ___ ICU for further management prior to colonoscopy. Colonoscopy showed 4cm ulcerated area where the polypectomy was performed but no active bleeding. Clips were placed and APC was performed. He did not require any further blood. He ended up receiving a total of 4 units. He was restarted on a heparin drip following the procedure. He was improving with no further bleeding and was transferred to the floor. On ___, he returned to the ICU with after triggering on the floor for marked change in mental status as well as hypotension and increased melenotic stool. He received two additional units pRBCs during this time, with essentially no net change in his Hgb. He was taken back for urgent colonoscopy, where his oozing polypectomy site was injected with epinephrine, electrocauterized, and endoclipped with seven more endoclips. His anticoagulation was held for 48 hours, with permission of cardiology consultants. After this procedure, his GI bleeding remained fairly stable, although he was transfused one additional unit on the night of ___ (his eighth overall). A heparin gtt was started which he had tolerated for 24 hours without clinical evidence of re-bleed at time of transfer out of the ICU. On the floor he was restarted on coumadin with heparin gtt and discharged when his INR was >2.5. His H/H was stable on therapeutic anticoagulation. H/H on discharge was 8.1/___.4. # Mechanical Aortic Valve (INR goal 2.5-3.5) for bicuspid valve # Supra-therapeutic INR Patient has long history of mechanical aortic valve on chronic warfarin, where they target the lower end of his INR goal of 2.5-3.5. s/p reversal of warfarin with vitamin K 5 mg. On the floor he was restarted on warfarin with a heparin bridge until his INR was therapeutic. His goal INR is close to 2.5 given history of GAVE and bleeding. INR on discharge is 2.6. The patient generally takes between 7.5 and 10mg of Warfarin at home. He will be discharged on warfarin 10mg. Next INR should be checked on ___ and dose adjusted accordingly. # Mild delirium # Hydrocephalus s/p VP shunt Patient's cognitive status has declined over last few years because of this. He often takes a long time to wake up and his wife says he often doesn't realize he was dreaming for several minutes. In the hospital he had mild delirium manifesting as slight agitation, paranoia and emotional lability. It was attributed to elevated bicarb from OSA and CPAP was encouraged. He was given one dose of Seroquel 50mg for agitation which resulted in significant somnolence. This was subsequently avoided. His bicarbonate was stable at 36 on the day of discharge. The patient remains intermittently confused. # Leukocytosis (resolved) Unclear etiology, but likely stress response vs infection. Reassuringly afebrile and no localizing source. UA wnl. Blood cultures were NGTD throughout hospitalization. # DM II Patient normally on metformin, glargine BID, and ISS at home. Per the patient's family often snacks and eats in the middle of the night. The patient's home insulin dose was reduced to Lantus 25 units twice daily in addition to Humalog sliding scale. This is much lower than the patient's home regimen. Fingersticks should be checked 4 times daily and insulin titrated based on these fingerstick measurements. # Acute on chronic diastolic heart failure # CAD The patient has a known history of CAD based on ___ stress test at ___: Small, mild reversible inferoapical wall defect suggestive of zone of myocardial ischemia. LVEF of 51% with normal LV wall motion. Home Lasix dose 80 mg qAM/40 mg qPM. After blood transfusions/ volume resuscitation, the patient was volume overloaded requiring diuresis. He was ultimately transitioned to his home dose of Lasix prior to discharge. The patient is also on metolazone on this medication was not restarted you can consider restarting it if weight increases or respiratory status declines. The patient also takes supplemental potassium this was held on discharge as the patient's potassium levels were within normal limits without repletion. The patient's metoprolol and aspirin were both resumed prior to discharge. The patient is on his home ___ NC. # MGUS Patient has been worked up for myeloma in the past, which revealed MGUS which has been stable. # OSA (on 2L O2 at home and CPAP when sleeping Likely a mixed picture of central and obstructive sleep apnea. he was continued on CPAP here and should continue at home at night and for naps. The patient's bicarbonate is elevated on discharge at 36. #GAVE - continued PPI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with no significant known medical history presenting with epigastric/LUQ pain w/ CT abd/pelvis concerning for gastric volvulus. Patient was in her usual state of health until 12pm on ___ when she had shortness of breath. This resolved over time, then she had acute onset epigastric/LUQ abdominal pain starting at 5pm on ___ associated with vomiting of coffee ground emesis multiple times. This has never happened to her before, she has never had an EGD, no history of GERD. She initially presented to ___, where she had a CXR showing large hiatal hernia and CT abd/pelvis with gastric volvulus. Her lab work was significant for WBC 17, lactate 2.7. An NGT was placed which put out 500cc fluid and she was transferred to ___ for further care. CT CHEST/ABD/PELVIS W/ CONTRAST showed 1. Complete herniation of the stomach above the diaphragm, mildly decompressed following interval placement of an enteric tube, with redemonstration of a sharp transition point at the level of the pylorus. A small twist measuring approximately 90 degrees is at the level of the pylorus. No evidence of perforation or pneumatosis. 2. Ground-glass opacities of the bilateral lower lobes likely reflect aspiration, in the setting of the large hiatal hernia. 3. Compression deformities of the T10 and L3 vertebral bodies, of uncertain chronicity. CHEST (PORTABLE AP) showed Lungs are low volume with mild pulmonary vascular congestion. There is large hiatus hernia. The NG tube projects to the hiatus hernia. Cardiomediastinal silhouette is stable. No pneumothorax. No effusions. CHEST (PORTABLE AP) showed Lungs are low volume. The NG tube is coiled up within the stomach. There is a moderate to large hiatus hernia. There is mild interstitial edema. There are trace bilateral effusions. No pneumothorax. Cardiomediastinal silhouette is stable. There are no pleural effusions. Chest radiograph, portable AP semi-upright. showed Nasogastric tube terminating in hiatal hernia. Status post endotracheal intubation. Persistent large hiatal hernia with atelectasis at each lung base and possible small pleural effusions. CT ABDOMEN W/O CONTRAST Q421 showed Chest is reported separately. No significant abnormality involving the abdomen. CT CHEST W/O CONTRAST Q411 showed 1. Large hiatal hernia containing the whole stomach and a contrast fluid level. Less distention than before, however. Similar nonobstructed transverse colon within the hernia. 2. New moderately extensive multifocal opacities, left greater than right, suggesting pneumonia, possibly due to aspiration as an etiology. 3. Ground-glass opacities in the upper lobes, edema versus infection. 4. Suspected bronchomalacia. Abdominal radiographs, four views. showed Anterograde progression of enteric contrast, now mostly opacifying distal small bowel loops in the deep pelvis. CHEST (PORTABLE AP) showed ETT in situ and unchanged in position. Enteric tube in situ with the tip present in a large retrocardiac hiatal hernia. Background structural lung changes with increased superimposed airspace opacification is worsened compared to prior suggesting increased pulmonary edema. CHEST (PORTABLE AP) showed 1. Interval slightly enlarged hiatal hernia likely secondary to distended stomach. 2. Interval slightly worsening pulmonary vascular congestion. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___. Stomach and loops of bowel in the large hiatus hernia are now fluid filled. Previous mild pulmonary edema has improved. Small right pleural effusion has increased. Basilar atelectasis is presumed, but not clearly changed. Upper lungs are clear. No pneumothorax. Healed rib fractures fractures noted right lower chest cage laterally. CHEST (PORTABLE AP) showed Cardiomegaly and superimposed large hiatal hernia artery demonstrated. Since previous examination there is no substantial change in small bilateral pleural effusions but there is more of vascular congestion currently present. No pneumothorax. No definitive consolidation to suggest aspiration in the lung bases but the assessment is difficult giving the dilated stomach projecting over the substantial portion of the lung bases. Mid left lung opacity might potentially be new and reflecting aspiration. CHEST (PORTABLE AP) showed With worsening interstitial abnormality. Widened cardiomediastinal silhouette is stable. There are no pleural effusions. No pneumothorax is seen. Video oropharyngeal swallow study. showed Trace penetration with thins by cup and straw without gross aspiration. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). The patient was diagnosed with Other diseases of stomach and duodenum. The patient was treated with ___ EGD ___ Intubation. The patient was given written instructions concerning 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 recently diagnosed late onset Alzheimer's disease and recent falls who presented with epigastric/Left upper quadrant pain and coffee-ground emesis. She underwent CT scan that was consistent with a gastric volvus with large hiatal hernia. She was treated for aspiration pneumonia and was intubated for an EGD showing the hernia and no significant other abnormalities. She was not considered a surgical candidate for her hernia. She was converted to DNR/DNI. Speech and swallow recommended the patient remain NPO based on multiple bedside swallow examinations. On ___ she had a video swallow study that showed no aspiration with pureed food and thin liquids. She was recommended to have a modified diet, frequent small meals, and to remain upright for at least 1 hour after eating due to risk of late aspiration with her hiatal hernia. =================== TRANSITIONAL ISSUES =================== [ ] Patient is at risk of aspiration and should have close supervision of all meals and should remain upright at 90 degrees for 60min after every meal due to risk of late aspiration [] will need ongoing discussion with family about goals of care however, PEG tube/J tube is not an options for her given her complicated anatomy [] Holding home donepezil 5mg daily, buspirone 10mg TId, quetiapine 50mg BID, and mirtazapine 15mg daily due to strict NPO status. New Medications -----> Lansoprazole 30mg daily -----> Acetaminophen 650mg q6hrs PRN pain Code Status: Full ============= ACTIVE ISSUES ============= #Aspiration Concern Patient presented with epigastric pain and was found to have a large hiatal hernia. She was also hypoxic and in respiratory distress and was treated for an aspiration pneumonia, after which time her respiratory status improved. She failed multiple bedside swallow examinations and was therefore recommended to be strict NPO given concern that her anatomy was leading to aspirations which ultimately cause her respiratory failure. She was maintained on maintenance fluids while the palliative team was consulted and goals of care were reviewed with the family. The family expressed a desire to pursue long-prolonging measures. PEG and NG could not be placed due to her anatomy. On ___ she had a video swallow study that showed no aspiration with pureed food and thin liquids. She was recommended to have a modified diet, frequent small meals, and to remain upright for at least 1 hour after eating due to risk of late aspiration with her hiatal hernia. Her diet was therefore re-introduced on ___. Of note, late aspiration can not be fully ruled out by this study and she is therefore thought to be at risk for this. #Goals of Care Both the ethics team and the palliative care team were consulted for Ms. ___ case. Family identified longer life as a high priority, but also value comfort and dignity. At this time, the family is not interested in a comfort-focused approach to hydration and nutrition. The patient was made DNR/DNI during the hospitalization. We were initially faced with a very challenging decision when she was recommended to be NPO due to failing her swallow studies, but fortunately on ___ a video swallow showed she did not aspirate with thin liquids and pureed solids and therefore we were able to introduce a diet. #Hiatal Hernia Found to have a very large hiatal hernia with almost her whole stomach in her chest. She had an EGD that did not show significant erosions. Given her high risk of morbidity and mortality from a corrective surgery, there were no operative intervention available. She was stared on a PPI. #Anion Gap Metabolic Acidosis Mild metabolic acidosis noted on ___ with anion gap. Likely driven by ketones from lack of eating for prolonged period. Thankfully started eating today so will not treat further. #Dementia</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old nursing home resident noted 3 days prior to admission to have breakdown of the skin on her scalp and visible shunt and shunt hardware. Per the patient's son, nursing home staff had noted a scab over the site of her proximal VP shunt tubing; while brushing her hair, the scab fell off revealing exposed tubing. CTA NECK WANDW/OC AND RECONS Q25 CT NECK showed 1. Complete occlusion of the left internal carotid artery by calcified atherosclerotic plaque proximal to the left bifurcation. 2. Mild narrowing of the right internal carotid artery, proximal to the carotid bifurcation. 3. Patent bilateral vertebral arteries. CTA chest showed Limited evaluation for pulmonary embolism due to motion artifact. Within this limitation, no large central PE is identified. Severe atherosclerotic disease within the thorax. Please refer to the concurrent CTA of the head and neck for details on the arch vessels Multiple subcentimeter ground-glass nodules in the right upper lobe with a branching distribution and underlying patchy ground-glass opacification. Findings may represent areas of mucous impaction in small airways disease possibly likely reflective of aspiration/aspiration pneumonia. Trace right pleural effusion with associated atelectasis. Radiology showed The final image demonstrates the tip of the Dobhoff to project over the stomach. Mild pulmonary edema and right lower lobe atelectasis. KNEE (2 VIEWS) RIGHT showed There is no acute fracture or dislocation seen. Severe degenerative changes are present, particularly involving the medial tibiofemoral compartment. Mild degenerative changes are present around the lateral tibiofemoral compartment and patellofemoral compartment. There is no joint effusion. The bones are diffusely demineralized. There is apparent subcutaneous emphysema projecting adjacent to the fibular head. Clinical correlation is recommended. No underlying focal osteopenia or periosteal reaction. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. New heterogeneous opacification at the base the right lung could be pneumonia, probably small to moderate right pleural effusion as well. New large elliptical opacity projecting over the right main bronchus could be external, or, if internal, loculated fissural pleural fluid. It should be evaluated with conventional radiographs as soon as feasible. Left lung is clear. Heart size is normal. No pneumothorax. Feeding tube passes below the diaphragm and out of view. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:31 am, 1 minutes after discovery of the findings. Radiology showed The NG tube is unchanged. Lungs are low volume. Small bilateral effusions right greater than left are stable. Cardiomediastinal silhouette is unchanged. No pneumothorax is seen. Mild interstitial edema is stable. Radiology showed Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is stable. The NG tube is unchanged. There are trace bilateral effusions. No pneumothorax is seen Radiology showed NG tube is unchanged. Cardiomediastinal silhouette is stable. Small bilateral effusions are unchanged. There is bibasilar atelectasis. No pneumothorax is seen CT HEAD W/O CONTRAST showed 1. Possible minimal, if any, increase in ventriculomegaly. Interval redistribution of intraventricular air, decrease in lateral ventricles and increased in the left temporal horn. 2. Stable right frontal approach ventriculostomy with surrounding pneumocephalus. 3. Interval resolution of intraventricular hemorrhage. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval exchange of a ventriculostomy catheter with a new left frontal approach ventriculostomy catheter seen terminating with the tip near the left foramen of ___. No new intracranial hemorrhage or acute major infarct. 2. Stable hydrocephalus with ventriculomegaly as compared to the recent prior studies. Radiology showed Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is stable. The NG tube projects below the left hemidiaphragm and projects over the stomach. There is a small left effusion. No pneumothorax is seen Radiology showed Mild positioned right-sided PICC line, traversing cranially through the neck, with the tip out of view of this film. NOTIFICATION: The findings were discussed with ___: ___ by ___ ___, M.D. on the telephone on ___ at 2:58 pm, 10 minutes after discovery of the findings. Radiology showed Right-sided PICC line appropriately terminates within the mid SVC. CT ABDOMEN/PELVIS WITH CONTRAST showed 1. No source of infection identified in the abdomen or pelvis. 2. Additional incidental findings as above. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is noted. The right PICC line and the feeding tube are in stable correct position. Borderline size of the cardiac silhouette without pulmonary edema. No pneumonia, no pleural effusions, no pneumothorax. CT HEAD W/O CONTRAST showed 1. Right internal carotid artery aneurysm clip and overlying hardware streak artifact limits examination. 2. Grossly stable ventriculomegaly with evolving postoperative changes as described. 3. Grossly stable position of left frontal approach ventriculostomy catheter. 4. No new acute intracranial hemorrhage. 5. Stable paranasal sinus disease as described above. Radiology showed No interval change. Radiology showed No focal consolidation or evidence of pulmonary edema. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are unchanged. There are lower lung volumes, but otherwise no evidence of cardiomegaly, vascular congestion, or acute focal pneumonia. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Again seen, is a left frontal approach ventriculostomy the tip terminating in the left ventricle. 2. No interval change in ventricular size when compared to prior dated ___. 3. Unchanged right frontoparietal and left parietal temporal encephalomalacia. No acute intracranial hemorrhage or large territory infarct. 4. Interval improvement in degree of pneumocephalus. Video oropharyngeal swallow study showed Penetration without aspiration. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Status post left frontal EVD removal. Stable diffuse ventriculomegaly. 2. Increased pneumocephalus compared to ___ within right greater than left frontal horns and along the right frontal parenchymal tract of the more remote right VP shunt catheter which was last seen on ___. However, there is no evidence for pneumocephalus along the left frontal track of the recently removed left EVD. 3. No evidence for acute hemorrhage or new areas of edema. 4. Left parietal/posterior frontal encephalomalacia, and mild volume loss in the anterior temporal lobe, are again demonstrated. CT HEAD W/O CONTRAST Q111 showed 1. Stable ventriculomegaly. New small focus of pneumocephalus along the catheter tract. No evidence of new hemorrhage. 2. Unchanged encephalomalacia within the left parietal and right temporal lobes. Radiology showed Right-sided VP shunt which coils distally in the pelvis. No definite shunt discontinuity or kink. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of intracranial hemorrhage. 2. Right frontal approach VP shunt terminates in body of the right lateral ventricle. The ventricles appear prominent, with possible mild hydrocephalus. Interval change cannot be evaluated due to lack of prior examination. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. A right frontal approach ventriculostomy catheter tip remains in unchanged position. 2. Unchanged ventriculomegaly. 3. New small hyperdense blood within the dependent regions of the occipital horns. 4. Pneumocephalus which is new since the previous CT and could be related to manipulation of the shunt catheter. Radiology showed Lungs are low volume with bibasilar atelectasis. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. Patchy parenchymal opacity in the left lung base most likely represents subsegmental atelectasis. The VP shunt has been removed in the interim. The patient was diagnosed with Oth complication of nervous system prosth dev/grft, init, Oth places as the place of occurrence of the external cause. The patient was treated with ___: Externalization of VP shunt and wound revision ___: Removal of right frontal EVD ___: Placement of left frontal EVD ___: Removal of left frontal EVD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ Nursing Home resident s/p aneurysm rupture in ___ s/p clipping and VP shunt placement presents with exposed VP shunt hardware. Patient was admitted to the Neurosurgery service. #Exposed Shunt Hardware NCHCT and shunt series were obtained to evaluate shunt. Patient was taken to the OR on ___ for shunt externalization of proximal tubing, distal tubing removed, wound closure. Proximal shunt attached to EVD system leveled at 15. CSF sent from OR for culture grew gram negative rods. ID was consulted and patient was placed on Meropenem. CSF cultures growing E.coli, meropenum was changed to ceftriaxone per ID. Repeat CSF was sent per ID. Blood cultures obtained. EVD was dropped to 5cm and draining clear CSF. EVD was subsequently dropped to 0cm however there was no change in output. Output remained between 110cc and 130cc in a 24 hours period. Her exam fluctuated slightly, likely in setting of her infection and respiratory illness however she remained easily arousable and following commands. ICPs remained single digits. Given positive CSF cultures On ___, the patient was taken to the operating room and the right frontal EVD was removed and an EVD was placed on the left side. She recovered in the PACU and was later transferred to the ___ for close neurologic monitoring. EVD was weaned and clamp trial was done on ___. Repeat CT on ___ showed stable vents and the patients exam remained stable in the setting of the clamp trial. On ___ the EVD was removed. A post-pull head CT was obtained and was stable. She was transferred to the floor, and continued to do well without evidence of delayed hydrocephalus. #Infectious Disease CSF culture from initial shunt externalization was positive for gram negative rods, ecoli. Infectious disease was consulted. She was started on a course of Meropenem. PICC line was placed. She will continue IV Meropenem through ___. #Allergic Reaction On ___ patient developed red urticarial rash over chest, back, arms, thighs. Given solumedrol, Benadryl, cetirizine. Patient was transferred to ICU. Allergy team was consulted. Reaction likely to IV CT contrast, possibly meropenem. Patient underwent meropenem desensitization on ___ in the SICU. Following desensitization the patient tolerated the meropenem without issue. #Dysphagia Given aspiration event patient was evaluated by speech and swallow. She was made NPO. NGT was placed for TF. She underwent video swallow and diet was progressed to puree/nectar. Tube feeds were discontinued and PO intake encouraged. She tolerated the diet and NGT was discontinued. #Aspiration and Respiratory Distress Patient vomited after eating and likely had aspiration event evening of ___. Overnight she became increasingly tachypneic and tachycardic with a new oxygen requirement. Initial CXR unrevealing but strong suspicion for aspiration pneumonitis vs. pneumonia. Patient was transferred to the ICU for closer monitoring given respiratory status. CTA chest was done to rule out PE which revealed no evidence of PE however ground glass nodules concerning for aspiration/aspiration pneumonia. Serial CXRs did not show focal consolidation and her oxygen requirement decreased. She was transferred to the ___ on ___ when she tolerated supplemental oxygen wean to ___ via nasal cannula. A CXR performed on ___ showed low lung volumes bilaterally a small left pleural effusion. The patient ultimately maintained an oxygen requirement, however multiple chest x-rays did not reveal evidence of cardiomegaly, vascular congestion, or acute focal pneumonia. #Carotid Stenosis Home Plavix for known carotid stenosis was held. CTA neck was done to evaluate stenosis which revealed occlusion of the left ICA. The patient was restarted on her home Plavix due to risk for stroke. #Multiple Chronic Pressure Ulcers RLE Wound consult was placed for management and care of the patient's known and pre-existing pressure ulcers and to prevent further skin breakdown. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o severe HTN, Hep C, stage IV CKD ___ cryoglobulinemia/MPGN, SBO from internal hernia s/p reduction ___ by ___, transferred from ___ for management of SBO seen on imaging. Patient reports ___ days of intermittent crampy upper abdominal pain, radiating to lower abdomen. Progressive abdominal distention, no BMs, no flatus as well for ___ days. +NBNB emesis for ___ days now. Presented to ___, had a KUB there with +dilated small bowel loops and air fluid levels suggestive of small bowel obstruction. NGT was placed, unknown amount of output at ___. Given that patient has most of her care here, she was transferred to ___ for further management of her SBO. Radiology showed AP chest compared to most recent prior chest radiograph ___: Nasogastric tube ends in the distal stomach. Gastric fundus is not distended, but the rest the stomach is excluded from the examination. Mild cardiomegaly unchanged. Moderate left lower lobe atelectasis and small to moderate left pleural effusion both increased. Small right pleural effusion unchanged. Lungs are otherwise clear. No pneumothorax. Radiology showed 1. High-grade, partial small bowel obstruction with a possible transition point in the right upper quadrant, likely related to surgical adhesions. No free air. 2. Small right nonhemorrhagic pleural effusion. These findings were discussed with ___ by Dr. ___ telephone on ___ at 3:00 ___, time of discovery. Radiology showed 1. No contrast is identified in the small or large bowel. 2. Dilated loops of small bowel consistent with obstruction. Radiology showed Persistent left base opacity, likely combination of pleural effusion and atelectasis. Radiology showed Right PICC ends in the low SVC. Unchanged small left pleural effusion and left basilar atelectasis. Radiology showed Mild dilatation of the small bowel is consistent with ileus. Radiology showed No evidence of renal artery stenosis. There is a slight increase in size of the right upper pole simple cyst. Radiology showed Successful placement of a right internal jugular line with tip in the mid SVC. No pneumothorax. Radiology showed 1. New moderate amount of non hemorrhagic ascites. There is no evidence for leak or perforation. 2. No obstruction. Nonspecific scattered air fluid levels within large and small bowel without dilatation. Edematous loops of bowel within the mid abdomen. 3. Prominent ascending aorta, measuring 4.3 cm. These findings were discussed with Dr. ___ by Dr. ___ at the time of image acquisition in person. Radiology showed Technically successful ultrasound-guided diagnostic and therapeutic paracentesis yielding 1 liter of serous ascites. Radiology showed Decrease in small bowel dilatation with forward progress of oral contrast from prior CT now reaching the sigmoid colon. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. The patient was treated with Small bowel resection, lysis of adhesions. At the time of discharge, the patient had Primary: Small bowel obstruction, hypertensive urgency, acute on chronic kidney disease, Cryoglobulinemia Secondary: hepatitis C, chronic systolic congestive heart failure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o severe HTN, Hep C, stage IV CKD ___ cryoglobulinemia/MPGN, SBO from internal hernia s/p reduction ___ by ___, presents with abdominal pain and KUB findings suggestive of SBO. # SBO: History and KUB from OSH consistent with SBO. Has h/o prior SBO from strangulated internal hernia. NGT placed at ___, bolused 1L IVFs there. Seen by surgery in ED, recommended admission to ___ given uncontrolled BPs. She underwent ex lap, LOA and SBR with Dr. ___. Postoperatively she had an ileus and required NGT replacement. This remained in place for two days and then the ileus resolved and NGT was removed. She regained normal bowel function and tolerated a regular diet without difficulty. # Severe hypertension: Patient has long-standing history of poorly controlled hypertension, on multiple agents at home. Reportedly has had secondary hypertension w/u (renovascular w/u negative). No evidence of end-organ ischemia and EKG largely unchanged from priors with strain pattern. Was initially treated with labetalol drip. Postoperatively she was managed with a nicardipine drip. She underwent plasmapheresis for five treatments in attempt to assist in BP control. She was weaned off of IV BP meds and was restarted on oral BP meds. Her SBP ranged from 130-150s prior to discharge, which is reportedly her baseline. # AOCKD/cryoglobulinemia from Hep C: Baseline creatinine appears to be around 2.5. CKD thought to be secondary to MPGN from cryoglobulinemia. Previously had been on rituximab for cryoglobulinemic syndrome, unclear if she is still on this. Current ___ likely pre-renal from hypovolemia. Creatinine returned to baseline postoperatively. She underwent 5 phresis treatments total, which were well tolerated. She will follow-up with her outpatient nephrologist to continue to monitor. # Bacterial peritonitis: During the hospital course, she complained of severe abdominal pain and fever, and was noted to have some ascites. Paracentesis was performed, and ascitic fluid was consistent with peritonitis, which could be spontaneous or secondary to a surgical cause as she was post-op. She was initially started on iv antibiotics and successfully transitioned to cipro and flagyl with no further episodes of fever. She will complete a total 10 day course. She was also instructed to continue taking cipro ongoing for prophylaxis against additional SBP. She will follow-up with her hepatologist as an outpatient for additional monitoring. # HCV: Chronic hepatitis C genotype 1B with a previously low viral load and normal liver transaminases as well as liver biopsy in ___ showing mild disease, grade 1 inflammation and stage I liver fibrosis. Not a candidate for interferon given cardiac and renal disease reportedly. HCV viral load was elevated on this admission. She was scheduled to follow-up with her outpatient hepatologist after discharge. # Chronic systolic CHF: Most recent echo with EF ~40-45%. She did not have any active issues on this admission. She was maintained on ACEi, BB, low-sodium diet and 2L fluid restriction. She was not on aspirin or statin on admission, and consideration can be given to starting these meds as an outpatient. TRANSITIONAL ISSUES: - consider starting aspirin, statin</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with multiple medical problems here with BLE weakness found to be due to an L4 vertebral fracture. Patient called PCP yesterday complaining of BLE weakness. She uses walker at baseline, but over the ___ hours prior to presentation she had been unable to get out of bed. There was no lateralization or upper extremity symptoms. At some point, patient rolled out of bed and hit back. No head strike or LOC. Patient is unable to tell me exactly when this happened. She says it was ___ or ___ but does not believe it was 1 week ago. Patient's PCP called EMS and patient was BIBA for evaluation. In the ED, initial vital signs were 98.6, 64, 230/78, 20, 95% RA. Labs were remarkable for Hgb 10.4 (baseline), Cr 2.2 (baseline), troponin 0.29 (baseline), BNP 20,384, and lactate 0.9. Imaging was remarkable for CT ___ with burst fracture of L4 vertebral body with 6 mm of retropulsion. MRI ___ with no abnormal cord signal and mild canal narrowing. Ortho Spine consulted. They recommended against MRI. The recommended that TLSO brace to be worn out of bed. No need for cervical or log roll precautions. Patient was given gentle IVF and hydralazine with some improvement in hypertension. She was admitted to Medicine. On transfer, vital signs were 98, 60, 197/80, 22, 95% RA. On the floor, patient reports that she is feeling well. She denies back pain, although she did have some mild lumbar back pain earlier. Patient denies fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, and urinary symptoms. She reports that her lower extremity strength and sensation feels at baseline. She denies fecal or urinary incontinence and saddle anesthesia. Review of Systems: As per HPI CT HEAD W/O CONTRAST showed 1. No signs of intracranial bleed. 2. Involutional changes and probable chronic small vessel ischemic disease. RENAL U.S. showed 1. No evidence of tardus parvus waveforms. 2. Patent bilateral main renal veins. 3. Multiple bilateral renal cysts which appear simple. The patient was diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL, CONGESTIVE HEART FAILURE, UNSPEC. At the time of discharge, the patient had Primary L4 burst fracture Hypertensive Emergency/Urgency Hypernatremia 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>___ yo F with multiple medical problems here with BLE weakness found to be due to an L4 vertebral fracture. ACTIVE ISSUES # Hypertensive emergency/urgency : Blood pressure 208/70 on admission without end-organ damage. Per review of OMR, patient is typically fairly hypertensive (many SBP's in 180's). SBP in 200-210s earlier on admission. ___ AM, had one episode of nausea/voming concerning for end-organ damage from hypertensive emergency. Had CT head w/o contrast done for eval of bleed given nausea/vomiting. CT unremarkable. Last admission, had similar episodes of hypertensive emergency. SBP was better controlled with labetalol. Labetalol switched to carvedilol in the past given concern for bradycardia at cards f/u. Pt was started on amlodpine 5mg daily and home clonidine increased from 0.2 to 0.3/day and valsartan from 80mg BID to ___ BID. Switched carvedilol 25mg BID to labetalol, but switched back given bradycardia to upper ___, low ___. No sign of RAS on U/S. Renin ___ sent, pending on discharge. SBPs improved with discharge SBPs 130-160. # Spinal fracture: L4 vertebral burst fracture. Most likely traumatic from fall out of bed. Patient seen by Ortho Spine in ED. They recommended LSO while OOB and follow-up in clinic. Got LSO brace on ___. Evaluated by ___ and discharged to rehab. Advised to follow up with orthospine in 1 week. # acute on chronic kidney injury: increase from baseline of 2.2 to 2.7, most likely pre-renal in the setting of poor po intake. Home lasix held on discharge. Will need daily BMP check and lasix should be restarted when Cr downtrending or patient develops signs of volume overload. CHRONIC ISSUES # Hyperlipidemia: Continued statin. # Type 2 diabetes: Diet-controlled. sliding scale as needed. # Chronic Diastolic CHF: BNP elevated but, but most likely in the setting of renal failure. No evidence of volume overload. given ___, lasixx held on discharge. # Gout: Continued allopurinol. # OSA: on CPAP at home, continued on CPAP =========================== TRANSITIONAL ISSUES =========================== -LSO brace while OOB until f/u in ___ clinic. -Medication change: Increased dose of valsartan, clonidine and started amlodipine with good BP control. -Cr increased on day of discharge to 2.7 from 2.5(baseline around 2.2). Home lasix discontinued. Please check electrolytes daily, and encourage PO intake. Restart lasix when creatinine downtending or any signs of volume overload. -7 mm peripheral nodular density in the right lower lobe, possibly scarring from prior infection. Followup chest CT is recommended in three months to ensure stability -Aldosterone pending result at discharge. CODE: FULL</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yoF with extensive CAD history with numerous stents most recently last year on Plavix, h/o instent restenosis, HTN, IDDM, and HLD who presents with an acute onset of left back, shoulder, and chest discomfort, as well as nausea and lightheadedness. She states that she has experienced progressive worsening of DOE, generalized fatigue, and chest discomfort over the past 3 days. Pain is described as dull, non-pleuritic, radiating to the back, and without exacerbating factors. CTA chest showed 1. Motion-limited study. No evidence of an acute central pulmonary embolus or an acute aortic abnormality. 2. A 4 x 8-mm nodule in the right upper lobe is stable since ___, but does not yet demonstrate over ___ years of stability. Therefore, an ___ follow-up chest CT is suggested. 3. Multiple right thyroid nodules, one measuring at least 2 cm in size for which non-urgent thyroid ultrasound is recommended to further evaluate. 4. Small hiatal hernia. RECOMMENDATION(S): 1. One year followup chest CT for the right upper lobe pulmonary nodule.. 2. Non-urgent thyroid ultrasound. NOTIFICATION: The findings and recommendations were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 4:09 ___, 10 minutes after discovery of the findings. The patient was diagnosed with Other chest pain. The patient was treated with Left heart catheterization ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Chest pain SECONDARY DIAGNOSIS: DM Type 2 HTN. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yoF with extensive CAD history with numerous stents most recently last year on Plavix, h/o instent restenosis, HTN, IDDM, and HLD who presented with an acute onset of left back, shoulder, and chest discomfort concerning for ACS. #Chest pain: In the ED she was started on nitro gtt as SLN did not relieve chest pain. She was able to be taken off nitro gtt without recurrence of chest pain. Trops were neg x3 and EKG did not show ischemic changes. CTA ruled out PE and aortic dissection. However, given extensive CAD history as well as history of MI without changes in EKG or cardiac enzymes, she was taken to cath which showed 3 vessel native CAD angiographically unchanged from prior cath in ___. 2 of 3 bypass grafts were widely patent. Negative pressure wire study across moderate in-stent restenosis in SVG to D1. She was discharged home with PCP and cardiology ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of idiopathic chronic pancreatitis s/p pancreatectomy with islet cell autotransplantation in ___, alcoholism, splenectomy, appendectomy, complication of bowel obstruction and resection, gallbladder surgery, type 1 diabetes now ID, non compliant, found by sister in ___ with dark stool around the apt, pale/altered, brought to ___. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality on noncontrast CT head. Specifically no acute large territory infarct or intracranial hemorrhage. CHEST (PORTABLE AP) showed NG tube projects below the left hemidiaphragm and the tip projects over the stomach. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. Patchy opacities are seen in both lower lobes. Radiology showed Nonspecific, nonobstructive bowel gas pattern. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Heterogenous liver parenchyma without evidence of concerning liver lesion 2. No evidence of intrahepatic biliary duct dilation. 3. Patient is status post cholecystectomy, total pancreatectomy and splenectomy. CT ABD AND PELVIS WITH CONTRAST showed 1. Nonocclusive left common iliac, external iliac, and common femoral deep vein thrombosis. 2. Nonspecific mesenteric lymphadenopathy more notable for lymph node number than size, measuring up to 1.3 cm. 3. No evidence of acute hepatobiliary pathology. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 8:08 pm, approximately 20 minutes after discovery of the findings. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with EGD ___. At the time of discharge, the patient had Primary diagnosis: duodenal ulcer Secondary diagnosis: proximal iliofemoral 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>___ with hx of idiopathic chronic pancreatitis s/p pancreatectomy with islet cell auto-transplantation c/b bowel obstruction and bowel resection, T3c DM, iron Deficiency Anemia with recurrent Feraheme transfusions, alcoholism (reported last drink ___ who presented with DKA and Upper GI Bleed requiring MICU admission, found to have non-bleeding ulcer on EGD and new proximal iliofemoral DVT</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a pleasant ___ ___, right-handed woman, currently 19 weeks pregnant, as well as a history of focal epilepsy since ___, who presents with acute worsening of her seizure frequency starting on 2 days prior to admission, patient started to have ___ of her typical focal seizures per day. Radiology showed Low lung volume without focal consolidation, pulmonary edema, or pleural effusion. The patient was diagnosed with Diseases of the nervous sys comp pregnancy, second trimester, Other epilepsy, not intractable, without status epilepticus, 19 weeks gestation of pregnancy. At the time of discharge, the patient had Focal 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>Patient was admitted to the epilepsy service from ED for vEEG monitoring and titration of medications. The increased seizure frequency was thought to be due to decreased sleep for the past several days, a new UTI, and questionable adherence to medications. The urinary tract infection was treated with macrobid, plan for 7 days. Keppra was increased from 1500 mg QAM and 2250 mg QPM to 2250 mg BID. During her stay, patient had 4 of her typical seizures captured on EEG associated with tachycardia, but without electrographic correlate. Oxcarbazepine was increased from 600mg QAM and 900mg QPM to 900mg QAM and 1200mg QPM. Patient was strongly advised to stay in the hospital for an additional night for continued EEG monitoring and AED titration. However, patient insisted on leaving AMA, despite multiple providers counseling her otherwise. Information about SUDEP was provided. Patient instructed to follow up with Dr. ___ ___ weeks and to return to hospital immediately if she has increased seizure frequency compared to baseline. Transitional Issues [ ] follow seizure frequency on increased dose of Trileptal and keppra [ ] please check a sodium level and oxcarbazepine level 1 week after AMA discharge on (___) [ ] 7 days of treatment for UTI with macrobid [ ] MFM follow up [ ] follow up with Dr. ___ on discharge</s>