Datasets:

Jarmac

/

llama2_bhc_dataset_train_prompt

like 0

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old female with HFpEF in the setting of atrial fibrillation on apixaban, numerous valve diseases including 4+TR and 2+MR, multi vessel CAD s/p DES to RCA, mod pulmHTN with significant PR, tachy-brady syndrome s/p PPM, breast cancer s/p left lumpectomy, and known left sided pleural effusion (from last hospitalization ___, never sampled) who presents from her outpatient interventional pulmonary clinic due to shortness of breath and hypoxia. Radiology showed Large left pleural effusion appears grossly unchanged compared to the prior exam. Worsening opacities within the mid to lower right lung, could be seen in the setting of aspiration/infection. CT CHEST W/O CONTRAST showed Partial loculated left pleural effusion, only partially assessed due to lack of IV contrast administration Left breast soft tissue that should be further correlated with dedicated breast imaging if clinically warranted Bibasal areas of atelectasis Cardiomegaly Right pleural effusion, minimal. The patient was diagnosed with Pleural effusion, not elsewhere classified, Other fatigue, Heart failure, unspecified. At the time of discharge, the patient had Pleural effusion 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 ___ woman with HFpEF in the setting of atrial fibrillation on apixaban, valvular disease including 4+TR and 2+MR, multi vessel CAD s/p DES to RCA, mod pulmHTN with significant PR, tachy-brady syndrome s/p PPM, breast cancer s/p left lumpectomy, and known left sided pleural effusion (from last hospitalization ___, never sampled) who presented with generalized fatigue/tiredness and worsening hypoxia. # Hypoxia # L sided pleural effusion Patient has known L pleural effusion which developed during her last hospitalization in ___. No intervention was made at the time and she was to follow up with IP for re-evaluation outpt on ___. At ___ clinic on ___ pt found to be hypoxic with O2 sat of 86% in room air. She was sent to the ED. Patient reported on admission her baseline O2 sat has been 89-91% on RA at home since her last discharge. CXR showed her left-sided pleural effusion is unchanged from prior but the opacities within the mid to lower right lung were more pronounced suggesting possible aspiration/infection. While she may have had some aspiration, she was afebrile, has no cough, no fever, chills, etc. Did not appear volume overloaded on physical exam and was stable at her discharge weight. IP evaluated her lungs with ultrasound and reported that there is a very small pocket of fluid if anything, and that thoracentesis would be more risk than benefit in this pt. CT chest on ___ showed a partially loculated left pleural effusion and significant atelectasis, which is likely contributing to her hypoxia. ___ reviewed this CT and again did not feel that the effusion would drain easily and would probably not improve her oxygenation much. Pt and son agreed that she would likely not want a more invasive procedure (i.e. thoracic surgery consultation), especially since the benefit would likely not outweigh the risk. On ___ ambulatory oxygen saturations were obtained and the patient was found to be hypoxic to 87% on room air, thus she will qualify for home oxygen. She will be discharged with home oxygen and follow-up with her primary care physician. # Chest wall pain On admission pt reported having severe sharp pain across her left anterior chest, then on R on day 2 of hospitalization. Has had in past and was told it is musculoskeletal. This pain was reproducible by palpation on physical exam and was intermittent throughout her hospitalization. This was treated with Tylenol, Lidoderm patch, and lidocaine jelly as needed. # ___ Recently hospitalized on CHF service for acute diastolic HF exacerbation requiring 40-160mg IV Lasix and IV Diuril boluses. ECHO during previous admission showed LVEF >55% with less vigorous RV free wall motion and mild aortic valve stenosis. CXR on admission showed no signs of pulmonary edema. Currently, she does not appear volume overloaded (stable weight since discharge, no ___ edema, JVP elevated but in the setting of 4+ TR) and thus will continue home diuretic without additional IV diuresis. We feel that her hypoxia is unlikely to be from acute HF exacerbation. Of note, on ___ evening, we did give her an additional dose of diuresis with 140mg IV lasix, given her acute desaturation episode, and she improved afterwards, but do not think improvement was from the lasix as she did not have drastic output (and we think the O2 tubing was loosely connected to the wall during this episode). She was maintained on and will be discharged on her home heart failure regimen (torsemide 60 twice a day, verapamil 160 every 8 hours). Her weight on day of discharge is 126 pounds. # Atrial fibrillation # Tachy-bradycardia syndrome Patient has known history of afib on apixaban and tachy-bradycardia syndrome s/p ___ dual chamber pacemaker. Pacemaker was interrogated in ED due to concern for bradycardia and was found to be working properly. EKG showed afib. While she has no history of stroke, her CHADSVASC score is 5 and thus she was started on a heparin bridge for possible ___. AC (apixaban) was held on ___ in case of procedure, restarted ___ evening when decision for no procedure was made. # ___ on CKD Baseline Cr 1.1. On last admission for CHF, Cr fluctuated from 1.2-1.7. On BID torsemide, likely bumped in the setting of diuresis; improved to 1.2 on ___. Cr 1.1 on day of discharge. __________________ CHRONIC ISSUES # Gout Flare in left great toe during last hospital course iso diuresis. She was discharged on colchicine on her last admission, which we discontinued this admission. We started her on allopurinol ___ daily ___. # CAD s/p DES: Continued home atorvastatin. # Hypothyroidism Continued home levothyroxine # GERD: Continued home omeprazole </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ present status post unwitnessed fall, fell OOB this am. The majority of the history is from the patient's daughter ___ ___ HCP). The patient reports that she does not remember exactly what happened, but thinks that she slid to ground landed on buttocks. She does not remember if she hit her head. She was on floor seated with back against bed for several hours. C/o mid back pain which she reports is chronic in nature. Family notes that she usually walks with a walker and her husband usually helps her out of bed. This is the first time that this has happened. She notes that she has some neck pain. She does not remember if she had chest pain or shortness of breath. Family reports pt has been taking her husband's oxycodone for past 10 days due to shoulder pain from a very ?torn left rotator cuff. She develop vessicle 1 day ago on an erythematous base (erythema started ___ days ago), consistent with shingles. Radiology showed No acute cardiopulmonary process. Radiology showed 1. No intracranial hemorrhage or fracture. 2. Extensive white matter hypodensities compatible with chronic small vessel ischemic disease, similar to ___. Radiology showed 1. No fracture, acute alignment abnormality, or prevertebral soft tissue abnormality. 2. Mild-to-moderate cervical spine degenerative changes with C3-4 disc bulge. 3. Large left thyroid nodule containing calcifications, similar to ___ thyroid ultrasound. The patient was diagnosed with URIN TRACT INFECTION NOS, HERPES ZOSTER NOS, HYPERTENSION NOS, SENILE DEMENTIA UNCOMP. The patient was given written instructions concerning 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 a ___ yo F with PMH sig for dementia (AxOx2-3 at baseline), HTN, DM, CAD s/p MI, CVA in ___ with R side weakness/loss of sensation, here after unwitness fall, UTI, and shingles in the T1-2 dematome. #. UTI- The patient per family report was a little more altered for the 10 days prior to admission. She has bowel and bladder incontinence at baseline. A UA concerning for UTI. Urine cultures grew back a likely containment of between ___ colonies of Coag Negaive Staphlococcus. She was treated with 3 days of ceftriaxone and will not need antibiotics after discharge. #. Shingles- The patient has vesicular rash on erythematous base in T1-T2 dermatome. The vesicle started approximately 1 day prior to admission. The patient was started on a day course of Valacyclovir 1000mg BID and will need an additional 6 days after discharge. She was also started on tylenol ___ TID, gabapentin and oxycodone prn for pain control. The pain was still better controlled at the time of discharge. # Diabetes mellitus type 2. sugars well controlled on home dose with a humalog insulin sliding scale. Her home doses are NPH 32 units in AM and 14 units in ___ #. R leg venous stasis dermatitis- no obvious cellulitis or open ulcers. #. Dementia of Alzheimer's type. continued home dose of donepezil #. Hypercholesteremia. continued home dose of simvastatin #. Hypertension. continued home doses of lisinopril and furosemide.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ y/o woman with h/o NIDDM, asthma, hypothyroidism, GERD, chronic back/shoulder/toe pain and right MTP septic arthritis in ___ s/p debridement presenting to the ED with chest pain, shortness of breath and generalized malaise. CHEST (AP AND LAT) showed No acute cardiopulmonary abnormality. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. INJ/ASP INTERMED JT W/FLUORO showed Uneventful fluoroscopic guided lavage and aspiration of the left great toe MTP joint. The lavage fluid was sent for cell count and culture. CT HEAD W/O CONTRAST Q111 CT HEAD showed Unremarkable noncontrast head CT. The patient was diagnosed with Chest pain, unspecified. The patient was treated with ___ ___ guided arthrocentesis to LEFT ___ MTP. At the time of discharge, the patient had Primary diagnoses ========================= Orthostatic hypotension Hypoglycemia Costochondritis Migraine headaches Secondary diagnoses ==================== Type 2 diabetes Hypothyroidism Hyperlipidemia GERD Insomnia Depression Anxiety Fibromyalgia 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>Outpatient Providers: ___ y/o F with h/o NIDDM, asthma, hypothyroidism, GERD and right MTP septic arthritis in ___ presenting to the ED with chest pain (negative cardiac work-up), shortness of breath, headache, dizziness, and generalized malaise. ACUTE ISSUES ======================== #Costochondritis #Chest pain #Palpitations. Cardiac etiology of chest pain unlikely given negative trops, no EKG changes and negative stress test. Does not appear exertional. Pain reproducible with palpation. No events on telemetry. Treated with naproxen 500mg BID with improvement in pain. #Headache #Right face numbness. History of migraine headaches though has had daily headaches over the past ___ weeks associated with sensitivity to light and sound. Also complained of right-sided face numbness that may be associated with migraines. Head CT without acute abnormalities. To follow-up at outpatient ___ headache clinic for consideration of trigger point injections due to headaches possibly related to MSK pain. ___ MTP Pain. History of septic arthritis of ___ MTP in ___ s/p antibiotics and debridement. Has been followed with orthopedics since given ongoing pain in the left toe with evidence of hallux deformity of the toe as well as arthritis. Had ___ arthrocentesis to r/o septic arthritis in ED per ortho recs though exam without evidence of inflammation or erythema concerning for an active infection. No generalized evidence of infection though ESR 35, CRP 23.8 on ___ at ___. Given stability of exam compared to priors, pain most consistent with arthritis of the joint. Cell counts and cultures negative for infection. #Pre-syncope #Orthostatic hypotension. Symptoms most consistent with orthostatic hypotension iso symptom onset with standing and resolved spontaneously. Has had poor PO intake over the past week as well. No vertigo and non-focal neuro exam. Orthostatic vitals positive initially that resolved after fluid administration. #Dyspnea #Asthma. No apparent infectious etiology without fever, leukocytosis, or evidence of infection on CXR though with poor penetration given body habitus. No hypoxia, tachycardia or changes on EKG concerning for PE with negative ___ Doppler and Well's score of 0. Pro-BNP of 25 making CHF unlikely. Last PFT in ___ without obstructive defect though with mild component of airway hyperactivity. Continued on home fluticasone-Salmeterol and given albuterol PRN. Shortness of breath improved at the time of discharge. #Hypoglycemia #DM type 2 #Generalized malaise. Last HgbA1C 7.1%. Notes intermittent episodes of symptomatic hypoglycemia to 60's throughout the day while only on Metformin. Given only on Metformin would not except medication induced hypoglycemia and may be related to poor PO intake. No hypoglycemia noted in house. Metformin held while in-house and at discharge to be restarted by PCP. #Anemia #Gastritis/GERD. Iron studies consistent with iron deficiency anemia. Focal erythema in fundus on EGD in ___. No evidence of melena or hematochezia. Started on lasoprazole outpatient 30mg BID by GI doctor. Last colonoscopy in ___ with polyp in the rectum, diverticulosis of the sigmoid colon, and grade 2 internal hemorrhoids. Received IV ferric gluconate 125mg. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs ___ is an ___ female with a past medical history of hypertension, hyperlipidemia, atrial fibrillation not currently anticoagulated, cauda equina with resultant bilateral lower extremity paralysis, who presented to OSH ___ with left upper abdominal pain, nausea and vomiting. She was admitted to ___ floor and subsequently transferred to the ICU after being found hypotensive and tachycardic on admission to the floor. Portable chest radiograph showed 1. A right IJ central venous catheter terminates near the superior cavoatrial junction, possibly in the proximal right atrium. 2. There is atelectasis, scarring, and/or a trace left pleural effusion at the left costophrenic angle. Radiology showed Dilated loops of small bowel measuring up to 4.3 cm, consistent with small bowel obstruction. The patient was diagnosed with Urinary tract infection, site not specified. The patient was treated with ___ Central line placement. At the time of discharge, the patient had PRIMARY Partial small bowel obstruction Hypotension Atrial fibrillation with rapid ventricular rate ___ SECONDARY Cauda Equina syndrome Hypothyroidism Depression Bacterial Conjunctivitis. The patient was given written instructions concerning 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 ___ F with a past medical history of atrial fibrillation, cauda equina complicated by bilateral ___ paralysis, chronic constipation s/p colectomy with end-ileostomy, urinary retention s/p suprapubic catheter placement presenting to OSH with abdominal pain/N/V complicated by hypotension and afib with ___ transferred to ___ for ongoing management with hospital course complicated by hypotension, ___, and partial SBO. # Abdominal Pain: patient presented with several days of nausea/vomiting and increasing abdominal pain. OSH CT concerning SBO. Given concern for need for surgical intervention, she was transferred to ___. ACS was consulted on transfer, who felt CT was not consistent with complete SBO or other acute surgical pathology. Her abdominal exam was notable for mild distension, LLQ TTP, no rebound/guarding. Stool studies and c diff were sent and are negative so far. She was started on empiric antibiotics but these were discontinued. She received IVF and was kept NPO. Following transfer, her abdominal pain started to improved. She had resumption of her ostomy output along with gas. She was trialed on and tolerated a clear diet, which was advanced to softs. # Leukocytosis: patient presented to OSH with hypotension, tachycardia, and leukocytosis concerning for sepsis. Exam consistent with volume depletion. She received IVF with improvement in her BPs. Her lactate was trended and downtrended with IVF resuscitation. Etiology was felt to be viral. She was started on empiric ceftaz, flagyl. She was pan-cultured. Culture data notable for multi-organism urine culture, consistent with colonization. Urology was contacted, who felt there was no need to change her suprapubic catheter. She was narrowed to cipro/flagyl but these were discontinued as no evidence of bacterial infection was found and patients symptoms were attributed to hypovolemia in setting of partial SBO. # ___: on admission, patient with noted to have ___ with Cr 2.8; she received IVF resuscitation with subsequent downtrend consistent with pre-renal ___. Her Cr was trended and nephrotoxic medications were avoided. She maintained good UOP via suprapubic catheter. # AFib with RVR: patient with chronic atrial fibrillation, rate controlled at home on diltiazem and metoprolol. On presentation to OSH, patient was noted to be in atrial fibrillation with RVR; she received additional diltiazem and IVF with improvement in rate control. She was restarted on home medications after improvement in hypotension and initiation of antibiotics. Of note, patient has refused anticoagulation and re-stated this during her admission. # ___: ECG on admission concerning for ST depressions, likely type II in setting of demand. Trops were trended and were flat. She remained chest pain free. The plan was to initiate a heparin gtt, however patient refused. She was continued on medical management with metoprolol and statin. #Right breast fungal rash Continued nystatin ointment #Left eye bacterial conjunctivitis polymyxin B QID for 7 day course (Day ___, last day ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with a PMH significant for ESRD secondary to DM-I, s/p LRRT in ___, as well as PVD, who was transferred from ___ after presenting for feeling unwell. He reported that over the preceding ___ weeks, he had been feeling more fatigued, with constant nausea, and occasional vomiting. The emesis was mostly food, though occasionally gastric acid, without blood or bile. He has had decreased PO intake of solids, though reports good PO intake of liquids. He presented to ___ on ___ for the above symptoms, where he was given IVF and told to return if symptoms persisted. Since the above symptoms persisted, and he had a 24 hour period of anuria, he returned. There, he was found to have a Cr elevated to 2.3 (baseline 1.5-1.7), so he was transferred to ___. He reports that he has had abdominal pain in the RLQ over the transplanted kidney, which he only noticed after being examined. He's never had this before. He denied abdominal pain in any other areas, as well as abdominal distension or bloating. He had no dysuria, fever, chills, night sweats, sick contacts, pets, travel or hematuria. He described "ale" colored urine, which is abnormal for him (it is usually clear, pale yellow). In the ED, initial vitals were: 98 67 136/70 14 97% RA. - Labs were significant for Cr 1.8 (baseline 1.5-1.7), anemia (Hgb 10 range), mild hyponatremia (132), BUN 39 and bicarbonate 21 - Renal ultrasound showed normal transplant ultrasound - The patient was given 1L NS - Urine studies were sent Upon arrival to the floor, he reports feeling well otherwise. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. Radiology showed 1. Significant colonic fecal loading. 2. No evidence of ileus. Radiology showed 1. Nonspecific bowel gas pattern . The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Primary: Nausea ___ on CKD Secondary: PVD ESRD s/p transplant HTN CAD s/p CABG Neuropathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo man with a history of ESRD ___ T1DM /p LRRT (___), ___ (___) with subsequent failure and explantation in ___, and severe PVD, transferred for ___, oliguria, and nausea. He had initially presented to OSH ED with a ___ week history of nausea and poor po intake. His symptoms improved with IV zofran and he was discharged from the ED. At home, he noted decreased urine output and so re-presented to OSH ED, where he was noted to have creatinine 2.3 from baseline 1.5-1.7. He was transferred to ___ given ___ and his history of renal transplant. ___ on CKD: Patient with history of ESRD secondary to DM-I, with LRRT (___), on prednisone & tacrolimus. Urine electrolytes were consistent with pre-renal etiology in setting of poor po intake and nausea. Nausea may initially have been ___ uremia in setting of ___. Renal ultrasound obtained in ED showed normal transplanted kidney. Given a concern that his creatinine of 1.4 may represent more severe disease in this man with bilateral BKAs, he had 24H urine and cystatin for more accurate estimation of GFR, which was calculated to be 40. He was continued on his immunosuppresion with tacrolimus and prednisone, with tacrolimus levels checked daily. His lisinopril was held during the course of the admission and held on discharge. #Nausea: Unclear etiology. Most likely ___ constipation vs medication effect vs less likely uremia. He had a KUB consistent with severe fecal loading and so started on BID tap water enemas and bowel regimen. However, follow up KUB showed improvement in fecal loading and patient continued to c/o nausea. After resolution of his constipation, the differential includes primarily medication effect given that he does have a GFR of 40, making uremia less likely. Given concern for medications causing nausea, his gabapentin dosing was decreased substantially. His narcotics may be a large contributor both to nausea and to constipation; however, patient was not amenable to changing narcotics regimen, as he has been stabilized on dosing for some time. Gastroparesis is possible but his nausea is not related to meals and is constant. He may have small bacteria overgrowth as has been seen previously. GERD is less likely given the constant nausea unrelated to meals or positioning. He does have a small bowel resection of 26 cm due to incarcerated bowel but it is less likely that he has short gut given that he has no other symptoms except nausea. His lack of abdominal pain and fevers points away from infectious etiology, and stool studies during this admission have been negative. At this point, he may warrant further work up that may be pursued as a an outpatient per GI. By the time of discharge, he was tolerating po with oral Compazine and Zofran, which he will be discharged on. GI was consulted during admission and guided management. #T1DM: s/p failed pancreas transplant and explantation (___). A1c this admission 6.5%. Continued home insulin. #Peripheral neuropathy: Continued gabapentin at reduced dose as above #CAD: S/P CABG. Continued home atorvastatin, aspirin, metoprolol #PAD: S/P multiple stentings and bypass. Continued clopidogrel. #HTN: Continued amlodipine at increased dosing, metoprolol. Lisinopril held given ___. TRANSITIONAL ISSUES - Patient's home lisinopril was held upon admission due to ___. He was subsequently hypertensive to 140s-160s and so his amlodipine was increased from 5 to 10 mg daily with improvement in blood pressure control. Consider re-starting as outpatient as indicated</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with severe COPD on 3L on hospice care, who presents with shortness of breath and dizziness. Of note, she is a poor historian. The patient reports developing shortness of breath the morning of admission. At baseline, she is able walk just under one block without symptoms. Today, she believes she cannot even walk 10 feet. She also reports increasing cough but the amount of sputum has not changed. She also describes dizziness most often with standing, but occurs at rest as well. She describes feeling off balanced rather than vertigo. She denies any headaches or changes in her vision. She does report some abdominal pain, though no fevers, chills, and diarrhea. She denies any sick contacts. The patient took her usual inhalers without improvement in symptoms, therefore she presented to the ED. In the ED, initial vitals were: 98.6 85 166/97 18 100% NC. She was found to have markedly limited ambulatory tolerance with immediate desaturation to 88% after walking 10 feet. Labs were notable for WBC 10.0m H/H 9.2/31.9, HCO3 33, Cr 1.7 (baseline 1.1), BNP 964, trop <0.01.. EKG showed sinus rhythm, no ST changes. CXR was unremarkable. The patient was given azithromycin, duonebs, and prednisone 60mg. Vitals prior to transfer were: 98.9 74 ___ 100% NC. Upon arrival to the floor, the patient reported improvement in her breathing. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. Emphysema. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had Primary diagnosis: Presyncope from dehydration Secondary diagnoses: Chronic obstructive pulmonary disease Hypertension Hyperlipidemia Irritable bowel syndrome Low back pain Renal cell carcinoma Spinal 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>___ is a ___ woman with severe COPD (on 3L home oxygen, with hospice care), who developed light-headedness and shortness of breath after standing up from a chair in the context of reduced PO intake over the past several days. ACTIVE DIAGNOSES ================ # Lightheadedness/dizziness: Patient reports feeling unbalanced, mostly with standing but occasionally occurs at rest as well. Likely orthostatic presyncope, given decreased PO intake over the past several days, dry mucus membranes, and orthostatic hypotension on exam. There was a creatinine bump concerning for dehydration-related ___, but BUN was not elevated. Neuro exam was nonfocal. No signs of cardiac etiology. Her symptoms improved with 2L NS and at the time of discharge, orthostatics were negative and she had no dizziness with standing or ambulation. #Shortness of breath: the patient originally reported mild shortness of breath, prompting initial treatment for COPD exacerbation. CXR was unrevealing. At time of discharge, however, the patient does not report any dyspnea and says that her presentation is not similar to her previous COPD exacerbations. Her oxygen saturation has been 100% on home oxygen levels. We continued her home medications. # ___: Last Cr 1.1 in ___. Cr on admission 1.7, which then trended downwards to 1.5 after 1L NS. Patient has had decreased intake over the past several days, in the setting of bactrim. The creatinine bump may be due to dehydration (although BUN is not disproportionally elevated), a bactrim-related drug effect, or more chronic kidney disease, given no recent Cr on file. CHRONIC ISSUES =============== # HTN: we held her triamterine/HCTZ due to ___, but continued her metoprolol. She was instructed to restart her home medication on ___. # GERD: Continued home omeprazole. # SPINAL STENOSIS: Continued home oxycontin and tylenol. Oxycodone PRN written for breakthrough pain. TRANSITIONAL ISSUES =================== - would avoid Bactrim in the future as it seems patient did not tolerate well - patient instructed to retart her home antihypertensives (diuretic) on morning of ___ - Patient may benefit from further goals of care discussion as outpatient with providers who have long term relationship with her - she remains on hospice care and has been on hospice for ___ years</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of traumatic colon injury following blunt trauma, s/p end colostomy and subsequent reversal in ___ ___s multiple incisional hernia repairs with mesh, most recently ___ at ___, presents with worsening abdominal pain. The patient states that the pain started around midnight and was severe across his RUQ/RLQ and associated with three episodes of non-bloody emesis. He denies fevers, chills, recent illness, chest pain or shortness of breath. CT abdomen and pelvis with contrast showed 1. Several dilated loops of proximal small bowel, measuring up to 3.7 cm, with a possible transition point in the anterior mid abdomen, and decompressed terminal ileal loops. The appearances are concerning for developing small bowel obstruction. 2. Small volume ascites. The patient was diagnosed with Right lower quadrant pain. At the time of discharge, the patient had Small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient with h/o multiple abdominal surgeries was admitted to the ACS Service for evaluation of abdominal pain. CT scan on admission revealed small bowel obstruction. Patient was made NPO and started on IV fluid for hydration. Patient did not required NGT placement. On HD 2, patient had a bowel movement. On HD 3, patient's diet was advanced to regular and was well tolerated. Patient was discharged home in stable condition. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is an ___ year old woman with known CAD (chronically occluded RCA), CHF (EF 35%), PAF, hyperlipidemia, hypertension, Stage III CKD, DM (HgA1c ___ in ___, hx of multiple TIA, and COPD who presented to the ___ ED from her nursing home because her ___ was concerned that she was slurring her speech and stuttering her words. ED CODE STROKE ONLY CT showed 1. No acute intracranial process. If there is continued clinical concern for acute stroke an MRI may be performed to further assess. 2. Old infarcts as described. CHEST (PORTABLE AP) showed Increasingly prominent interstitial structures and nodular opacities within notable absence of pleural effusions, which is not typical for an hydrostatic pulmonary edema. Other possible etiologies including lymphangitis or fibrotic lung disease should be considered. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 11:18 AM, 10 minutes after discovery of the findings. The patient was diagnosed with OTHER SPEECH DISTURBANCE, ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had Primary: - Toxic-metabolic encephalopathy with recrusdescence of stroke sx - Angina pectoris Secondary: - CKD stage IV - Paroxysmal atrial fibrillation - Left MCA CVA with mild expressive aphasia (___) - CAD w/ totally occluded RCA with L->R collaterals (cath ___ - Ischemic systolic HF with LVEF 40-45% - GERD - Hypothyroidism - Hyperlipidemia - Hypertension - COPD - Pernicious Anemia - Gout - Leg/pelvic fractures due to MVA in ___. - s/p cholecystectomy. The patient was given written instructions concerning 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 hx of CHF, HTN, HLD, CKD (baseline Cr 2.0), multiple strokes/TIAs presenting today with word finding difficulties and acute on chronic renal failure. Hospitalization complicated by several episodes of chest pain.</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 mild dementia, hypothyroidism who presents for evaluation of a syncopal event. She has had recurrent episodes of syncope, this being her third spell. Her husband notices this consistently has happened in the mornings after she takes donepezil. She took it this morning and a short time later did not feel well, then fainted. No tonic/clonic activity. Eyes had rolled back in her head. No urinary incontinence. She woke quickly, was slightly confused, but soon returned to baseline and went upstairs to sleep. This was similar to her previous syncope event ___ weeks ago. No recent fever, cough, nausea, vomiting, diarrhea. Her husband called Dr. ___ neuro) who spoke with Dr. ___ referred the patient to the ED. Of note she recently had a 24 hour holter and ECHO, both of which were unrevealing. In the ED, initial vitals were: 97.5 85 171/81 14 99% RA Labs were notable for: WBC 14.9 (85% PMNs). Chemistry panel WNL (creatinine at baseline). UA bland. Imaging notable for: CXR with "patchy left lower lobe opacity is subtle and may represent atelectasis or pneumonia". She received: Azithromycin 500mg and CTX 1gm at 20:00. Azithromycin was stopped early due to nausea. Vitals on transfer: 98.0 65 180/74 18 96% RA On the floor, she appears comfortable. She acknowledges that she has had recurrent syncopal episodes, but feels that her last episode occurred a few days ago while she was out walking. She is unable to recall the events of the day. She does not recall being nauseous in the ED. She denies chest pain, palpitations, dyspnea, cough, abdominal pain, nausea, vomiting, diarrhea, urinary symptoms, arthralgias, myalgias. She states her appetite has been good. Chest: Frontal and lateral views showed Patchy left lower lobe opacity is subtle and may represent atelectasis or pneumonia. The patient was diagnosed with Pneumonia, unspecified organism, Syncope and collapse. At the time of discharge, the patient had Primary diagnosis: Syncope: Secondary diagnoses: Hypothyroidism Osteoporosis Hyperlipidemia 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>Ms. ___ is a ___ year old woman with a history of dementia, and hypothyroidism who presents for evaluation of a syncopal event. # Recurrent syncope: Hx not consistent with seizure. Patient had EKG w/o arrhythmia or AV block and telemetry monitoring was unremarkable. Orthostatic vital signs were normal. Hx was not c/w seizure. Patient has had outpatient echo, which was normal, and a ___ hour holter monitor this month, which was unrevealing. Per the patient's husband, her events have been related to donepezil administration, which does have a 2% risk of syncope. Donepezil was discontinued during this hospitalization. Her labs were only note-able for a mild leukcocytosis upon admission, that resolved on hospital day 2. She did have a faint opacity on CXR but no other clinical s/sx of infection or pneumonia, so she was not treated with full course of abx. The etiology of her syncope remains unknown although donepezil may be the culprit. She was set up with a long term 30 day cardiac monitor upon discharge and has follow up with her PCP and cognitive neurologist. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: droop, left weakness, and left paresthesias MR HEAD W AND W/O CONTRAST T___ MR HEAD. showed Several small cortical foci of slow diffusion suggestive of subacute infarcts in the right precentral gyrus, as well as a focus in the left postcentral gyrus. Distribution is concerning for embolic etiology. No evidence of intracranial metastases. The patient was diagnosed with Facial weakness. The patient was treated with N/A. At the time of discharge, the patient had Bilateral punctate ischemic strokes. The patient was given written instructions concerning 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: ___ is a ___ year-old man with a PMHx of pancreatic cancer with metastasis to liver on chemotherapy (gemcitabine and abrexane, last dose 2 weeks ago), melanoma, HTN, HL, and T2DM who presents with recurrent episodes of dysarthria, left facial droop, left hand weakness and left arm and leg paresthesias. By history His exam is notable for dysarthria (waxing/waning, worse with guttural sounds), mild left upper motor neuron pattern of weakness (in 4+/5 range), and question of mild left nasolabial fold flattening. He was found to have multiple punctate, bilateral, cortically based infarcts on MRI. Etiology for the patient's symptoms is most likely due to underlying hypercoagulability from his malignancy, given the MRI findings of stroke in multiple vascular distributions. Unlikely related to intracranial stenosis given no significant stenosis noted on CTA Head/Neck. Patient remains in house due to persistent orthostatic hypotension. HOSPITAL COURSE BY PROBLEM: #Acute bilateral, punctate ischemic strokes: Workup included MRI brain with and without contrast revealed several small cortical based subacute infarcts in the right precentral gyrus, as well as a focus in the left postcentral gyrus. Distribution is concerning for embolic etiology. No evidence of intracranial metastases. For stroke workup, risk factors included LDL 78, hemoglobin a1c 6.0. Given that stroke from underlying hypercoagulability was most likely--given pancreatic cancer (particularly prone to hypercoagulability related complications) and multiple affected vascular distributions--the patient was started on therapeutic lovenox. This was discussed with his oncologist, Dr. ___. Initially, given concern for perfusion related deficits the patient was placed head of bed flat, but he was able to advance his activity without neurologic symptoms. Otherwise his sugars were well controlled, UA negative for infection and CXR with mild cardiomegaly without infiltrate. Patient expressed willingness to continue therapeutic lovenox moving forward. Neurology follow up was arranged. #Orthostatic hypotension: Patient was noted to have profound orthostatic hypotension during ___ eval on ___. His SBP went from 120s sitting to ___ upon standing. He was symptomatic with mild lightheadedness upon standing as well. He received IVF bolus, low dose IV fluids and started on ___ stockings. Etiology was thought to be due to hypovolemia given poor PO intake in setting of cancer. On ___, he was started on fludrocortisone 0.1mg daily. #Pancreatic Cancer: Defer chemotherapy given acute illness. Patient's oncologist was contacted to inform her about the hospitalization. For pain control, increase MS contin to 60mg TID with immediate release morphine 30mg q4h PRN after discussion with the patient's outpatient palliative care provider. Follow up was arranged with palliative care and oncology. #Anemia of chronic disease: The patient's hemoglobin remained at baseline of ~7.8-8.5. No clinical evidence of bleeding. This was trended daily. **************</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with no significant past medical history presents with left arm pain. Patient was in the ___ 2 nights ago when she fell getting out of the bathtub. Positive head strike questionable LOC. Was unable to get up due to left-sided rib pain and arm pain. She went to the emergency room found to have multiple fractures in her left arm was placed in a cast and sent home because they said they could not do surgery there and would have to go to the ___. She has had continued pain over this time but no shortness of breath fevers chills lightheadedness nausea or vomiting neck pain. She remembers the entire event. She has not been taking anything for pain Chest radiograph showed -No acute intrathoracic abnormalities. -No displaced rib or scapular fractures. Humerus and elbow showed Limited evaluation of the humerus and the elbow due to overlying cast material and patient's inability to mobilize the arm for positioning. Within these limits, oblique fracture of the distal humerus with 6 mm displacement of the fracture fragment. CT left upper extremity without contrast showed 1. Unusual impaction fracture along the anterior margin of the left humeral head, this appearance can be seen with posterior dislocations and a reverse ___ lesion. Correlate with clinical history. 2. T-shaped supracondylar and intercondylar distal humerus fracture with extension to the articular surface of the radiocapitellar joint. The patient has subsequently undergone open reduction internal fixation of this fracture. 3. Possible radial head fracture. 4. Moderate elbow effusion. 5. Tiny left upper lobe pulmonary nodules are pleural-based and likely reflect either scarring or intraparenchymal lymph nodes. These measure greater than 6 mm: For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ NOTIFICATION: Findings in addition to the wet read regarding the humeral head fracture were discussed with Dr. ___ ___ by Dr. ___ ___ by telephone at 13:30 on ___, within in 30 minutes of discovery. Radiology showed Fluoroscopic images demonstrates placement of fracture plates medially and laterally within the distal humerus fixating a complex fracture of the distal humerus. Please refer to the operative note for additional details. The total intraservice fluoroscopic time was 82.2 seconds. The patient was diagnosed with Unsp fracture of lower end of left humerus, init for clos fx, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with left distal humerus open reduction internal fixation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospitalization Summary (ED Admit) The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left distal humerus fracture and left proximal humerus fracture was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for an open reduction internal fixation of the left distal humerus, 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. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with OT who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with a history of secondary sclerosing cholangitis and biliary cirrhosis complicated by recurrent hepatic encephalopathy, ascites, portal hypertension with varices, portal hypertensive gastropathy, who has had upper GI bleeding from polyps s/p thermal therapy (with a port-a-cath bc of frequent transfusion need) as well as portal vein thrombosis seen on recent CT scans, presents with FUO. Radiology showed No acute cardiopulmonary process. Radiology showed Trace amount of ascites in the right lower quadrant which would be difficult to sample. The patient was diagnosed with FEVER, UNSPECIFIED. At the time of discharge, the patient had PRIMARY DIAGNOSES: clostridium difficile SECONDARY DIAGNOSES: Secondary biliary cirrhosis Anemia 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>___ with hx of secondary sclerosing cholangitis and biliary cirrhosis complicated by recurrent hepatic encephalopathy, ascites, portal hypertension with varices, portal hypertensive gastropathy, who has had upper GI bleeding from polyps, s/p thermal therapy as well as portal vein thrombosis seen on recent CT, who presented with fever. # C diff: Pt presented with report of fevers and increased stools and was placed on empiric abx with ceftriaxone and flagyl to cover SBP vs. acute hepatobiliary infection. There was insufficient ascites on ultrasound for paracentesis.Pt's indwelling port-a-cath was considered as an infectious source, but blood cultures were negative. Urine cultures were also negative. Stool studies revealed positive c diff PCR and patient was switched to PO vancomycin given prior episode of C diff in ___. Stool frequency decreased and patient was discharged with plan to complete 10 day course PO vancymycin. # Secondary biliary cirrhosis: Complicated by varices, hepatic encephalopathy and SBP and recently found to have likely chronic portal vein thrombosis. Home lasix and aldactone were continued as was home nadolol given h/o grade 2 varices. Bactrim prophylaxis was held while patient on ceftriaxone/flagyl, but restarted at discharge. She was discharged with plan to follow-up with Dr. ___ have MRI in ___ for portal vein evaluation. # Hepatic encephalopathy: Patient had a history of recurrent hepatic encephalopathy, but without signs of HE this admission. Home lactulose and rifaximin were continued. # Anemia: Iron deficiency anemia as well as anemia of chronic disease. Iron supplementation was continued. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Female found on floor ___ after sustaining an unwitnessed fall with a posterior head strike. Patient states she was closing the door to her room when she slipped and fell and struck the occipital region of her head. She did no have a loss of consiousness, visual changes, loss of bowel or bladder continence or headache. She was found by the staff in a seated position and not altered from her baseline. Of note this is the third fall this year requiring ED treatment (___). Her baseline is that she lives in a dementia unit, but cooperates with staff and spends most of her time apparently on the patio but does participate in the local activities on the unit. CT HEAD W/O CONTRAST showed 1. No evidence of fracture or hemorrhage. 2. Age-related involutional changes and sequela of chronic small vessel ischemic disease. CT C-SPINE W/O CONTRAST showed No evidence of fracture. Mild anterior subluxation of C7 on T1 likely degenerative. No other evidence of malalignment, or prevertebral soft tissue abnormality. CHEST (SINGLE VIEW) showed Findings consistent with CHF with interstitial edema. Doubt but cannot entirely exclude an underlying infiltrate. No effusions. No displaced rib fracture detected on these lung technique films. The patient was diagnosed with URIN TRACT INFECTION NOS, OTHER FALL. At the time of discharge, the patient had Primary: Mechanical Fall Secondary: Delirium Hypertension Acute Kidney Injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with dementia, hypothyroidism s/p thyroidectomy presented s/p mechanical fall, after several recent mechanical falls. ================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ Critical is a ___ ___ male with a PMHx of stroke ___ years ago, incidental finding on imaging), DM, HTN, HL, and blindness ___ B/L glaucoma, per dtr) who presents with left hemibody weakness. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Moderate narrowing of the right proximal to mid M1 segment, right P1, and right P2 segments and moderate to severe narrowing of the right distal V4 segments, likely related to atherosclerotic disease. 2. Occlusion of the left distal P1 and P2 segments with reconstitution of the left P3 and P4 segments with chronic infarction along the left PCA distribution. 3. Approximately 30% stenosis of the left internal carotid artery at its bifurcation by NASCET criteria. No evidence of right internal carotid artery stenosis by NASCET criteria. 4. Age indeterminate lacunar infarctions in the right caudate and left basal ganglia. 5. Multiple small nodules in a peribronchovascular distribution in the upper lobes, likely infectious or inflammatory in etiology. Radiology showed 1. No acute cardiopulmonary process. 2. Dilated tortuous aorta with concern for aortic root aneurysm. Further evaluation with chest CTA could be considered if clinically indicated. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. Study is mildly degraded by motion. 2. Right pons 11 x 7 mm acute to subacute infarct with no evidence of hemorrhagic transformation. 3. Findings suggestive of right globe vitreous hemorrhage, as described. While finding may be related to choroid detachment, an intra-ocular tumor is not excluded on the basis of this examination. Recommend correlation with ophthalmologic exam. If clinically indicated, contrast-enhanced MRI of the orbits may be obtained. 4. Age-related volume loss with chronic infarct in the left occipital lobe. RECOMMENDATION(S): Findings suggestive of right globe vitreous hemorrhage, as described. While finding may be related to choroid detachment, an intra-ocular tumor is not excluded on the basis of this examination. Recommend correlation with ophthalmologic exam. If clinically indicated, contrast-enhanced MRI of the orbits may be obtained. The patient was diagnosed with Cerebral infarction, unspecified, Essential (primary) hypertension, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac. At the time of discharge, the patient had Acute Ischemic Stroke Diabetes Mellitus Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo male who was admitted on ___ due to concerns for acute ischemic stroke. He was admitted with a 3 day history of fluctuating L arm and leg weakness. In the ER a NCHCT was performed and did not demonstrate an acute infarction or hemorrhage but was notable for old occipital stroke. CTA demonstrated significant stenosis of multiple intracranial arteries likely related to atherosclerotic disease. Although there was concern for stroke, TPA was not given as it was deferred by the patient's family. He was started on Aspirin and admitted to the Neurology service for further workup. An MRI w/o contrast was performed and demonstrated a right pons 11 x 7 mm acute to subacute infarct without hemorrhagic transformation. His home Amlodipine of 2.5 mg qDay was increased to 5 mg qDay due to ongoing high blood pressure. Closer BP control with SBP 120-150 was recommended along with improved glucose control with goal 150-180. He was observed overnight with slight improvement in LUE strength but persistent LLE weakness. There were no new symptoms. He was evaluated by ___ who recommended ___ rehab but family preferred discharge to home with outpatient ___. Patient was advised to follow up with his PCP regarding adjustment of his Metformin for better blood sugar control. Lipid panel was notable after discharge for elevated Triglycerides, low HDL (37), and normal LDL (89); no medications for hyperlipidemia were started during this hospital course; further treatment will be deferred to PCP. Of note, his MRI demonstrated a R globe vitreous hemorrhage, likely contributing to pain. This was discussed with ophthalmology who recommended further evaluation with his primary opthalomogist. Finally, Mr. ___ was on a course of Levofloxacin at the time to admission for CAP; daughter reported he had completed a 5 day course so the medication was discontinued. 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 -ASA () No 4. LDL documented? (X) Yes (LDL = 89) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (X) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No 9. Discharged on statin therapy? () Yes - (X) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (X) Yes [Type: (X) Antiplatelet -ASA () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (X) N/A </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male w/ extensive PMH including dementia, COPD, AFIB, Myeloproliferative disoder, and recent admission 1 week (___) ago for PNA complicated by hypoactive delirium and discharged on Levofloxacin (last dose ___ presents to the ED with congestion and lethargy. Has had some resolution of symptoms since last hospitalization, but continued to be very congested after discharge. His daughter reports she did think he mildly improved while taking the levoflox, as he was coughing less. Then, the day after his last dose 3 days prior to presentation, he started coughing frequently again and developed significant rhinorrhea. She could tell he was congested, but was not able to clear his phlegm. The night prior to admission, he received chest ___ and guaifenesin, with little improvement. Then, on the morning of presentation he appeared as if he was taking long deep breaths, significantly more congested and extremely lethargic, barely able to sit up. At that point she called EMS. Radiology showed More conspicuous left mid lung to basilar opacity when compared to most recent exam, compatible with pneumonia in the proper clinical setting. Recommend repeat after treatment to document resolution. Radiology showed 1. Multilobar small airways disease accompanied by dependent lower lobe peribronchial consolidation. Considering esophageal distention and central airway secretions, multifocal aspiration or aspiration pneumonia should be considered. There are no obstructing airway lesions. 2. Coronary artery and aortic valvular calcifications as well as mild dilation of ascending aorta, the latter slightly increased from ___. 3. Calcified gallstone. Radiology showed Penetration with thin liquids. One episode of aspiration with consecutive sips of thin liquids. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. The patient was treated with ___ - midline catheter 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>IMPRESSION: ___ with extensive PMH including dementia, COPD, atrial fibrillation, and myeloproliferative disoder who was admitted for congestion, lethargy, and hypoxemia with CXR concerning for healthcare pneumonia. # HEALTHCARE ASSOCIATED PNEUMONIA - CT chest revealed multilobar PNA with bibasilar atelectasis. Recent hospitalization within 90-days warrnated treatment with Vancomycin and Cefepime. Had received Levofloxacin previously without resolution. There was also some concern for aspiration, so metronidazole was added to the regimen. He clinically improved and was weaned from supplemental oxgyen to ambient air. PICC line was placed, but was pulled back to midline given that it was inadvertently in the inominate vein. Leukocytosis and fever resolved. Cough improved. Discharged with 8-day course of cefepime IV and oral metronidazole. # CHRONIC ASPIRATION - Video swallow evaluation was reassuring per speech therapist. Was cleared for monitored oral intake. Treated for pneumonia, as above. # TOXIC METABOLIC ENCEPHALOPATHY - Patient had evidence of hypoactive delirium in the setting of above infection which rapidly improved with antibiotics.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ yo F with a history of obesity, hypothyroidism, DM, HTN, DJD and depression who presents with worsening depression and failure to thrive and was found to have new EKG changes. She was sent in by her pcp for ___ evaluation. Patient denies headache, chest pain, abdominal pain, back pain, shortness of breath, dysuria. States her depression and anxiety is worsening, especially in the setting of her husband's chronic illness. Her cymbalta was recently increased without improvement in her depression. . In the ED initial VS were: pain 0, T 98.6, HR 66, BP 144/58, RR 18, O2 sat 98% RA. Exam was notable for ?R facial droop and slight tachypneia. Labs were notable for creatinine 1.8, troponin-T 0.04, INR 2.7, and negative UA. CT head and CXR were unremarkable. EKG showed afib with ST depr V4-5 and TWI inferiorly that were new. She was evaluated by psychiatry who felt that she did not need ___ or inpatient psychiatry evaluation but did recommend neurology evaluation. She received aspirin 325 mg and was admitted for ___. VS on sign-out were: 97.1 68 158/58 18 98%RA. . On arrival to the floor, the patient was comfortable. She denied any chest pain or shortness of breath today or in the last few days. She also noted unsteadiness in her gait. . Per phone conversation with her son, he thinks the facial droop may have been present for a couple of days, but is not certain. He notes that her psychomotor slowing started several weeks ago after she returned home from rehab and that she is able to answer some questions readily, but that she has difficulty answering questions related to her experience of the world. . REVIEW OF SYSTEMS: + constipation, no BM x 5 days? Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed No evidence of pneumonia or congestive heart failure. Radiology showed No acute intracranial abnormality. The patient was diagnosed with DEHYDRATION, ABNORM ELECTROCARDIOGRAM, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS. At the time of discharge, the patient had Primary Diagnosis: Failure to Thrive Secondary Diagnosis: Depression Type 2 diabetes mellitus Atrial fibrillation, on coumdin 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>___ yo F with multiple medical problems (obesity, hypothyroidism, DM, HTN, DJD), admitted for worsening depression, failure to thrive, new T wave inversions with elevated troponin, and facial assymetry of unclear duration. . </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 known AAA s/p MV repair in ___ plus multiple vascular procedures who just completed a course of chemotherapy and radiation for lung cancer when a follow-up PET scan revealed a type A aortic dissection. In retrospect, Mr. ___ states he likely has had chest pain off and on over the past two weeks. He was transferred from ___ for surgical evaluation. Radiology showed Known aortic dissection is better assessed on concurrent CT chest from today. Clear lungs. The patient was diagnosed with DISS ABDOM AORTIC ANEURYSM. At the time of discharge, the patient had AAA followed by Dr. ___ on coumadin, MVP, HTN, COPD, DM2, Stage II lung CA s/p radiation and chemo completed 1 month ago, swallowing difficulty. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with stage II squamous cell lung CA who was being treated with chemo/radiation for the past ___ weeks because presumably his PFTs showed that he would not tolerate a R pneumonectomy that would have been required for removal of the mass. He had a presyncopal event in his PCP's office, and his ___ work up showed INR 5.9 and CT scan showed proximal ascending aortic dissection (5.5cm), beginning at sinuses of Valsalva and extending to just proximal to the origin of the brachiocephalic artery with coronary sinuses arising from the true lumen. This dissection was not seen on his prior imaging ___. He was transferred to ___ for further evaluation and admitted to the ICU for blood pressure control with IV nicardipine and INR correction. His transthoracic echocardiogram here was evaluated by Dr. ___ and the dissection was felt to be subacute. Given his lung CA history, severity of his PFTs, previous cardiac surgery, significantly elevated INR, and his asymptomatic condition, medical management was recommended. His coreg was increased to 25mg BID, lisinopril 40mg daily was added, and he was weaned from nicardipine and transferred to stepdown ___. Norvasc 10mg daily was added ___ AM for asymptomatic hypertension (160s) and the lisinopril was increased to BID, and he remained inpatient for further blood pressure monitoring. His SBP remained 110-120s at rest during the day, increasing to 130s with ambulation. On the day of discharge, he did have random elevation to 158 at 4am that was asymptomatic and resolved to 100-110 with his AM medications. His INR decreased to 2.7 after Vitamin K 10mg po on ___. He was restarted on coumadin ___ with goal INR ___ for atrial fibrillation. Dr. ___ for Dr. ___, was contacted and notified of the hypertension and coumadin medication changes during this admission, and Dr. ___ ___ will receive the INR on ___. He repeatedly denied chest pain, palpitations, syncope, or lightheadedness. His only complaint was headaches, which are chronic for him and relieved by tylenol.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with recent R TKA on ___ ___ for evaluation of wound at anterior knee. Her surgery has been complicated by admission for wound evaluation treated with IV antibiotics and discharged on ___. Arthrocentesis during that admission was normal. Was transitioned to Bactrim DS for 2 weeks thereafter. She has been seen in clinic at follow up with healing wound, per PA notes. She is still on a 2 week course of Keflex ___ QID. Today, ___ noticed some drainage and so she was referred to ED. Her pain with ambulation is unchaged. Endorsing some chills. Tmax 100.1. Denies weakness, decreased po, n/v. Otherwise feels well and using crutch to ambulate for comfort as bearing weight is painful. Notes adequate ROM. KNEE (AP, LAT AND OBLIQUE) RIGHT showed 1. Persistent moderate to large joint effusion. 2. Status post total right knee replacement without evidence of hardware related complications or change in alignment. The patient was diagnosed with Disruption of external operation (surgical) wound, NEC, init, Oth surgical procedures cause abn react/compl, w/o misadvnt. The patient was treated with bedside debridement of anterior knee wound. At the time of discharge, the patient had right knee wound dehiscence. The patient was given written instructions concerning 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 lower extremity wound dehiscence and chornic non-healing wound, and so was admitted to the orthopedic surgery service. The patient's wound was evaluated by both orthopaedic and plastic surgery and it was determined to treat this conservatively with daily wet to dry dressing changes after bedside debridement by plastics. The patient was continued on her previously prescribed oral antibiotics (Keflex ___ QID) and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on should not require 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: ___ yo M hx depression who was witnessed to have a seizure and fall to the ground at work today. EMS was initiated and patient was taken to OSH where he had 2 more seizures described as GTC within 10 minutes. ___ was given Ativan 4mg for SZ and CT head showed 7mm left frontal vertex EDH. Pt was intubated for persistent lethargy, loaded with dilantin and transferred to ED for further evaluation. Of note there are reports that he has recently been drinking heavily. He told the OSH ED that he recently hit his head on a box (unclear when). CHEST (PORTABLE AP) showed Slightly low lying endotracheal tube with tip terminating approximately 2.6 cm from the carina. This be withdrawn by approximately 1 cm for optimal positioning. Otherwise, no acute cardiopulmonary abnormality. CT HEAD W/O CONTRAST showed A 7 mm biconvex hyperdense extra-axial hematoma overlying the left frontal lobe, possibly a subdural hematoma. Additional small right parafalcine hematoma and two small intraparenchymal hemorrhagic contusions are noted within the bilateral inferior frontal lobes. No fracture identified. NOTIFICATION: The findings were discussed by Dr. ___ with ___ in personon ___ at 4:50PM, 2 minutes after discovery of the findings. CT HEAD W/O CONTRAST showed 1. Slight interval increase in size of intraparenchymal hemorrhages within the bilateral inferior frontal lobes. 2. Stable appearance of the biconvex hyperdense extra-axial hematoma overlying the left frontal lobe and right parafalcine hematoma. Effacement of the left frontal sulci is stable. 3. No new foci of hemorrhage identified. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Similar size of intraparenchymal hemorrhage within the right inferior frontal lobe with slightly increased surrounding vasogenic edema. 2. Stable extra-axial hematoma overlying the left frontal lobe with associated sulcal effacement. CT HEAD W/O CONTRAST showed 1. Stable biconvex extra-axial hematoma in the left vertex, concerning for epidural hematoma. 2. Expected interval evolution of bifrontal hemorrhagic contusions. No new hemorrhage. The patient was diagnosed with Traum subdr hem w/o loss of consciousness, init, Contus/lac/hem crblm w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Left frontal SDH Bifrontal contusions. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>On ___ the patient was admitted to the neurosurgery service at ___ after having multiple witnessed seizures. A NCHCT was performed and was consistent with a 7mm left frontal vertex EDH. On exam the patient was intubated and his pupils were equal round and reactive to light, 5 to 3 mm bilaterally. he had normal bulk and tone bilaterally. No abnormal movements,or tremors, and strength equal and strong throughout. Neurology was consulted for his seizure presentation and he underwent a trauma evaluation in the ED for fall hx. CT Cervical spine was performed at OSH and was negative for fracture. On ___ the patient remained hemodynamically and neurologically intact. He had a repeat NCHCT which was stable. The patient was transferred to the floor on telemetry and placed on EEG to rule out seizures. On ___ pt refused EEG leads and requested they be removed. He remained neurologically intact. His and his mother's questions were answered in full. At the time of discharge he is tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old man with hypertension, CAD, pre-diabetes, and remote history of smoking who presents from the ED from his PCP's office with 1 week of pain and "weakness" on his right side. Radiology showed No acute cardiopulmonary process. CTA HEAD AND CTA NECK showed 1. No acute large territory infarction intracranial hemorrhage. The vessels of the head and neck appear patent and without evidence of stenosis, occlusion, or aneurysmal change. MR HEAD W/O CONTRAST showed 1. No acute infarcts, mass effect or hydrocephalus. 2. Moderate-to-severe cerebellar atrophy. Brainstem atrophy. 3. Mild changes of small vessel disease. CT ABD AND PELVIS WITH CONTRAST showed 1. No definite findings of intra-abdominal malignancy. 2. There is no acute process within the abdomen or pelvis. 3. There is mild dilatation of the left ureter without hydronephrosis which is nonspecific. No cause identified on this study. No prior imaging studies available to evaluate for stability. Urology referral advised. 4. Please refer to dedicated CT chest for further description of chest findings RECOMMENDATION(S): Urology referral for evaluation of the patient's left ureteric dilatation. Video oropharyngeal swallow showed 1. Mild penetration with thin liquids. 2. No 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 CHEST W/CONTRAST showed 1. No intrathoracic metastatic disease, pneumonia or lymphadenopathy. 2. Mild, diffuse bronchial wall thickening, and some retained secretions are due to inflammation, perhaps infection. 3. Mild centrilobular emphysema. The patient was diagnosed with Weakness. The patient was treated with Lumbar Puncture ___. At the time of discharge, the patient had lumbar radiculopathy dysphagia polyneuropathy. The patient was given written instructions concerning 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: ==================== [] Follow up on pending labs, including ___, protein electrophoresis, lyme antibodies and CSF studies (paraneoplastic studies) [] Follow up on biopsy results from EGD [] The CT abdomen and pelvis is mostly negative with the exception of dilated left ureter with recommendation to consider urology for further evaluation with cystoscopy. [] Ongoing work-up of weight loss as outpatient</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ woman with a history of multiple recent admissions to ___ for ___ and ___ s/p fall, as well as ___ and hyponatremia, who presented to the ED with confusion. She was first hospitalized on ___ for a fall in the setting of a UTI, which resulted in orbital and temporal bone fractures, SAH, and a small SDH. She was stabilized and discharged to rehab on ___, but was shortly readmitted for ___ and hyponatremia, thought to be related to hypovolemia, which improved with IVF, with a Cr of 1.5 at discharge on ___. She was again admitted on ___ for body shaking and altered mental status, concerning for seizure, with labs again c/w hypovolemia. She was placed on renally dosed Keppra and no seizure activity was seen on EEG monitoring. She was discharged to a SNF on ___ after her mental status improved with hydration. CHEST (AP AND LAT) showed No acute cardiopulmonary process. Left-sided pleural calcifications and volume loss likely reflective of fibrothorax. CT HEAD W/O CONTRAST showed 1. Motion degraded examination. 2. Decreased size of right frontoparietal convexity hypodense subdural collection and resolution of additional previously noted areas of extra-axial hemorrhage. No new intracranial hemorrhage or mass effect. 3. Unchanged chronic fractures involving the occipital bones bilaterally. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Primary diagnosis: UTI Toxic Metabolic Encephalopathy Acute Kidney Injury Hypernatremia Secondary diagnoses: Prior subdural hematoma and subarachnoid hemorrhage Mood disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ woman with recent admissions for traumatic SAH and SDH, as well as ___ and hyponatremia in the setting of hypovolemia, who initially presented with confusion, found to have an ___, and a UA consistent with urinary tract infection. # Toxic Metabolic Encephalopathy: Thought to be likely multifactorial delirium given waxing and waning mental status. Contributors include UTI, hypovolemia recent fall, recent hospitalizations, ___, uremia, medication induced. CTH negative for new intracranial process. Her exam is not suggestive of a post-ictal state, making seizure an unlikely cause of her altered mental status. She was treated for her UTI as below. She was frequently reorientated, her sleep/wake was optimized, and disturbances were minimized. Sertraline was d/c'ed and Mirtazapine started. at discharge, patient was near her baseline, oriented to self and date and alert. # UTI: Her confusion and poor orientation on presentation to the ED are most consistent with delirium, the source of which could be a urinary tract infection, given her leukocytosis and UA consistent with UTI and suprapubic tenderness on exam. There is nothing to suggest another source of infection, and her negative chest x-ray and clear lungs on exam suggest pneumonia is unlikely. She received a 3 day course of ceftriaxone 1 gm IV Q24h, from ___. Urine culture grew pan-sensitive pseudomonas aeruginosa, and she received a 3 day course of ceftazidime 500 mg IV Q12H from ___. #C Diff: uptrending leukocytosis during admission and then patient developed diarrhea. c dif was sent and positive. patient started on oral vancomycin QID x 10 days. Day ___. # Hypernatremia: serum Na rose to 148 on ___, resolved w/ fluid resuscitation and stable with PO intake prior to discharge. # ___: Admission Cr 2.9, baseline around 1.1. Her initial BUN:Cr ratio was elevated at ~25:1, suggesting a pre-renal cause of decreased kidney function. In the context of her previously observed hypotension and exam findings, hypovolemia, perhaps due to poor PO intake in the setting of altered mental status, could be the precipitating factor. Her Cr improved to baseline (down to 1.1 from 2.9) with IV hydration. # Chronic hypertension: BPs remained within acceptable range throughout her admission. Given ___, her lisinopril and hydrochlorothiaze were initially held pending improved renal fxn. She received her home amlodipine and metroprolol. Given that patient has had multiple readmissions for ___, decision was made to tolerate a more liberal blood pressure goal to prevent recurrent ___. Discharged on amlodipine and metoprolol. HCTZ and lisinopril were held during admission and at discharge. # Chronic constipation: She received a bowel regimen of docusate sodium and senna. # Recent SAH/SDH/seizure ppx: Home Keppra was discontinued per recommendation from patient's outpatient neurologist. # HCM/home meds: Her home sertraline was switched to remeron (for improved sleep/in light of recent weight loss). She was continued on her home aspirin, multivitamin, thiamine 100 mg, and folic acid. CODE STATUS: DNR/DNI OK FOR NIV =================================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH of ESRD ___ to SLE s/p renal transplant ___ who presents with worsening renal function. He reports he has been in his usual state of health when he was found to have uptrending Cr on outpatient labs. He denies any fever/chills, chest pain/pressure, SOB, n/v/d, abdominal pain, dysuria, hematuria. He does report recent reduction in urinary frequency by about 50% (previously gong ___, now ___, still tolerating PO intake and compliant with medications. He has noticed worsening lower extremity edema, which he attributes to being on his feet more since discharge, but has also noticed worsening orthopnea over the past few weeks. He notes new rash over his arms and face and some stiffness in his bilateral hands. Of note, he was recently admitted ___ - ___ for renal biopsy, findings felt to be consistent with recurrent lupus nephritis. He was started on IVIG with plan for outpatient rituximab. He was also started on furosemide for lower extremity edema. In the ED, initial vitals were: 98.2 95 132/85 17 99% RA - Exam notable for: 2+ pitting edema bilaterally, lungs clear - Labs notable for: 134 | 96 | 51 --------------< 160 3.6 | 29 | 3.3 7.6 > 14.8/45.7 < 217 UA with small amount of blood (3 RBC), 300 protein - Imaging was notable for: Renal transplant us with 1. Mild hydronephrosis of the transplant kidney. 2. Normal waveforms and resistive indices of the vasculature in the transplant kidney. - Renal transplant was consulted: hold diuresis overnight, continue IS: cyclosporine 200 mg PO q12h, prednisone 60 mg PO daily (in the AM), mycophenolate sodium 1080 PO BID - Patient was given: cyclosporine 200 - Vitals prior to transfer: 98.0 73 163/100 20 96% RA Upon arrival to the floor, patient reports continues to feel well. No significant complaints at this time. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI RENAL TRANSPLANT U.S. showed 1. Mild hydronephrosis of the transplant kidney. 2. Normal waveforms and resistive indices of the vasculature in the transplant kidney. CHEST (PORTABLE AP) showed No acute findings. RENAL TRANSPLANT U.S. showed -Minimal interval decrease in right hydronephrosis, now mild. -Normal renal transplant resistive indices. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Primary Diagnosis ================= Acute kidney injury secondary to acute kidney rejection Secondary Diagnosis =================== Systemic lupus erythematosus Transaminitis 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>___ w/ PMH of ESRD ___ to SLE s/p DDRT renal transplant ___ who presents with worsening renal function. Patient had significant proteinuria and volume overload, particularly of the lower extremities. He was started on Lasix IV and diuresed 5L with improvement in his lower extremity edema. He was transitioned to oral Lasix. Additionally, his carvedilol was increased to 6.25mg BID. Patient was given IVIG at 1g/kg for treatment of acute rejection with plan to complete course of rituximab on ___. # ___ ___ acute rejection s/p DDRT # Volume overload History of renal transplant ___, recently admitted for ___ with Cr ~ 2.0 on discharge on ___ with Cr elevated to 3.3 on admission. Patient has transplant ultrasound that showed mild hydronephrosis around the transplanted kidney. Foley was placed with mild improvement in hydronephrosis, but without significant change in Cr. He had a negative urine culture. Given significant volume overload likely due to nephrotic range proteinuria, he was started on diuresis with intravenous Lasix for volume overload. He was diuresed with Lasix 80mg BID with good output. He received 62.5mg albumin BID for two days, but was diuresed on the remaining days without albumin with good response. He was net negative 5kg over the hospital stay. He was then transitioned to Lasix 80mg twice daily, which he will continue after discharge. Acute worsening in kidney function was felt to be due to acute rejection as opposed to worsening of SLE based on most recent renal biopsy. He received 1 dose of IVIG at 1g/kg on ___. He will complete course of rituximab on ___ for rejection. Prednisone was decreased to 50mg daily and will continue to be titrated at 10mg per week. He was continued on valgancyclovir for ppx at a reduced dose of 450mg daily based on kidney function. He was continued on immunosuppression with cyclosporine and MMF, with doses unchanged. He will need repeat BK virus testing in ___. # SLE: Patient with positive ___ in the past although negative dsDNA. He was continued on home hydroxychloroquine 200mg daily. # HTN Patient had hypertension to SBP 150s during the admission. Carvedilol was increased from 3.125mg BID to 6.25mg BID. # TRANSAMINITIS: Patient had mild elevation in transaminases during admission with ALT 115 and AST 47 at discharge. Hepatitis serologies were negative. ___ be related to underlying inflammatory process vs medications vs ___. Will continue to trend after discharge and perform RUQ u/s if continues to be elevated with consideration of biopsy if significantly worsens. # RASH: Pustular/papular rash on extremities likely steroid induced. Patient was not bothered by the rash and it was stable during the admission. Transitional Issues: ==================== - Discharge Cr: 3.1 - Discharge Weight: 94.8kg For any questions, please contact outpatient nephrologist ___, MD: ___. - Ensure f/u with transplant nephrology - Increased furosemide to 80mg BID - Please re-check labs in ___ days with CBC, Chem 10, and LFTs. Please send results to Dr. ___: fax ___. - If LFTs continue to increase, consider - Please continue prednisone taper according to the following schedule: ___ 50mg daily ___ 40mg daily ___ - ___ daily ___ 20mg daily ___ 10mg daily - Prophylactic valgancyclovir reduced to 450mg daily based on GFR. Continue daily for total of 4 week course to end on ___. - Continue to adjust carvedilol for goal <140/90 - Elevated ALT/AST: HBV/HCV/CMV testing negative, would trend and consider RUQ ultrasound as an outpatient # CODE: Full (confirmed) # CONTACT: ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ man with history of ___ gangrene (___), urethral strictures s/p dilation, type 2 diabetes, and COPD on 2L oxygen who presented to ___ on ___ for altered mental status, fever to 102.4, dyspnea, and increased urinary frequency; was found to have ?pneumonia, urinary tract infection, and scrotal cellulitis; and was transferred to ___ for further management. CHEST (PORTABLE AP) showed Stable or slightly improved pulmonary edema. Redemonstrated cardiomegaly and increased lung volumes. The patient was diagnosed with Other pneumonia, unspecified organism, Urinary tract infection, site not specified, Cellulitis of perineum. The patient was treated with Midline placement ___. At the time of discharge, the patient had PRIMARY ======== CAUTI Scrotal cellulitis SECONDARY ========== CODP DMII. The patient was given written instructions concerning 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/ hx of recent admission for ___ ___, urethral strictures s/p dilation, DMII, and COPD on nocturnal 2L O2 who presented with urinary frequency, fever, AMS, and scrotal swelling concerning for CAUTI and scrotal cellulitis. Urology evaluated the patient and assessed his infection as superficial, and not a recurrence of ___ gangrene. A foley was replaced to prevent urinary contamination to the scrotal area. The patient was started on broad spectrum antibiotics until urine cultures from ___ showed Serratia marcescens and Enterobacter cloacae, sensitivities, allowing for tailored therapy. Because of the resistance patterns, the patient was transitioned to ertapenem as an outpatient to complete a 10 day course. TRANSITIONAL ISSUES ==================== [] Please continue ertapenem for a 10 day course (___) [] A foley was placed this admission to keep the penoscrotal area dry. The patient should have urology follow up with a voiding trial to determine if the foley can be discontinued. [] TSH was found to be mildly elevated, please repeat thyroid studies as outpatient. [] Would recommend repeating CBC and chemistries in PCP follow up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with history of HTN, HLD, CKD presenting with 2 large episodes of BRBPR starting at 3 pm ___. She denies abdominal pain, black stools, chest pain, palpitations, dyspnea, N/V, lightheadedness. In the ED, rectal exam showed BRB and no melena. She received 2L NS with resolution of tachycardia as well as 40mg IV PPI. At 0730 on ___ she had painless episode of 500cc BRB with clots. GI was consulted and recommended CTA given active bleeding. 2 PIVs placed and T&C obtained but no blood given as initial H/H consistent with prior. (11.8/36.5 at ___ ___. While obtaining CTA, patient was standing up and had a syncopal episode with HR rising to 150, BP dropping to 90/60, and transient HR to ___ with rapid resolution of sx and VS abnormalities upon lying down. She was given 2 units pRBC prior to transfer. CTA ABD AND PELVIS showed 1. No active hemorrhage / GI bleeding identified. 2. Diverticulosis without secondary signs of diverticulitis. 3. The sigmoid colon is collapsed, thereby limiting assessment of the wall; however, there is suggestion of vascular engorgement in the sigmoid colon without fat stranding - cannot exclude an early sigmoid colitis. 4. Right upper renal pole hyperdense lesions vs partial volume averaging. Further characterize first with renal ultrasound if not already characterized. Communicated with ___ in the ___ ICU at 630 pm on ___. 5. Incidental 3-mm left lower lobe lung nodule. If low risk, no follow-up needed. If high risk patient, dedicated chest CT in 12 months is recommended using ___ Guidelines. This recommendation was communicated to ___ ___ in the ___ ICU at 640 pm on ___. RENAL U.S. showed 1. Several bilateral simple renal cysts, two in the right upper pole and one in the left upper pole. 2. 1.6 x 1.2 x 1.0 cm cystic lesion that contains a 0.6 cm intracystic nodule, likely corresponding to the finding on the recent CT abdomen. Given this somewhat atypical appearance, an MRI is recommended for further evaluation. 3. 1.0 x 1.5 x 1.5 cm left lower pole cyst containing a 2 mm avascular septation. RECOMMENDATION(S): MRI abdomen for further characterization of the right lower lesion containing in intracystic nodule. NOTIFICATION: Entered into critical results dashboard by ___ ___ at 6:45PM. The patient was diagnosed with GASTROINTEST HEMORR NOS. The patient was treated with 2 units PRBC transfusion on ___. At the time of discharge, the patient had Gastrointestinal bleeding Acute blood loss anemia Likely diverticular bleeding. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F w/ PMH of HTN, HLD, CKD who presented with one day of BRBPR with associated tachycardia and hypotension responsive to IVF and blood transfusion. . # BRBPR # Acute blood loss anemia # Presumed diverticular bleed Presented with two episodes of BRBPR. She was hemodynamically stable apart from episode of orthostatic hypotension to 90/60 in the ED. She received 2L NS and 2 units of PRBCs. Her HCT nadir was 29.3 and responded appropriately to 35 with the 2 units PRBC. CTA was negative for any active source of bleeding. Home anti-HTN's (atenolol, amlodipine, torsemide and losartan) and ASA were initially held. She was restarted on low dose metoprolol after she remained hemodynamically stable in the ICU. She remained without further episodes of BRBPR. She was seen by GI consult, and GI consult felt that her bleed was most likely secondary to diverticular bleeding that self-resolved. They did not recommend inpatient colonoscopy, and would defer to outpatient setting for consideration of colonoscopy if within patient's goals of care. . # HTN: Longstanding hypertension. Had orthostatic episode in ED prior to blood transfusion. Home anti-HTN's were initially held. She was later restarted on metoprolol as above in the ICU, but this was transitioned back to atenolol, and her other home antihypertensives and diuretic were resumed without incident . # CKD: III Hx of partial nephrectomy (for renal oncocytoma), longstanding hypertension, proteinuria Creatinine was at baseline. Held home torsemide given hypovolemia and concern for developing hypotension, but this was ultimately resumed. . Continued calcium and vitamin D. . # Preglaucoma: continued home latanoprost eye drops. . # HLD: - held ASA in the setting of active GI bleed - ultimately pt. confirmed that she has not been taking this (not one of her medications - confirmed with pt. and dtr at bedside) - Held statin in hospital, as she has listed adverse reaction to atorvastatin and simvastatin but her home lovastatin is not on formulary at ___ ultimately pt. confirmed that she had not been taking a statin (not one of her medications - confirmed with pt and dtr at bedside) .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o F w/PMHx stage ___ cervical ca s/p chemo and XRT, multiple pelvic fx's, nephrostomy tube with prior urosepsis, who presented overnight with diarrhea and AMS. Radiology showed No signs of pneumonia. Radiology showed 1. No acute intracranial process. 2. MRI is more sensitive for ischemia if of concern. 3. Status post prior pituitary adenoma resection with post-operative changes. Radiology showed 1. No acute intraabdominal or intrapelvic process such as colitis or diverticulitis. 2. Known gallbladder fundal adenomyoma. 3. Stable position of right nephrostomy tube. 4. Cervical cancer status post radiation treatment for known metastasis to posterior bladder wall. 5. Stable post radiation pelvic bones with remote right superior ramus fracture and subacute sacroiliac insufficiency fractures and right inferior ramus fracture, as well as mild wedge compression of L4. The patient was diagnosed with URIN TRACT INFECTION NOS, HX-CERVICAL MALIGNANCY. The patient was treated with Colonoscopy. At the time of discharge, the patient had Radiation Proctitis. The patient was given written instructions concerning 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 stage ___ cervical cancer (s/p chemo and xrt), multiple pelvic fractures, nephrostomy tube with recurrent UTIs/prior urosepsis, who was admitted with severe watery, and ocassionally bloody, diarrhea. Hospital Course --------------- #. The patient presented to the emergency department in the setting of frequent episodes of diarrhea and confusion. In the ED the patient was noted to be very confused and agitated. Laboratory studies remarkable only for mildly elevated lactate of 1.2 and abscence of leukocytosis. A UA was concerning for UTI and she was started on ceftriaxone. A head CT was performed and was unremarkable. A CT abdomen/pelvis was also largely unremarkable and did no explain the ___ symptoms. Given 2L of IVF and stress dose steroids (on chronic steroids). Admitted to the floor. On the floor the patient remained confused and combative. Required restraints. Fluid resus was continued. The ___ mental status improved by HOD #2 however she continued to have diarrhea. Her hematocrit trended downwards and she developed grossly bloody stool with clots. Received 2 PRBC transfusions and seen by GI who performed a colonoscopy revealing radiation proctitis. The patient had no further bleeding and was discharged with plans for close oupatient PCP ___. The patient required frequent electrolyte repletion in the hospital and was discharged on a potassium and magnesium repletion regimen. #. UTI: In the ED, the patient had a UA concerning for UTI and she was started on ceftriaxone. Her urine culture grew klebsiella and she was switched to ampicillin. THis was further modified to ciprofloxacin after sensitivities returned. Planned to complete 8 day course of antibiotics for complicated cystitis then return to macrobid prophylaxis. The ___ right nephrostomy tube functioned well and was not changed. #. Known Pelvic Fractures: Appeared stable on imaging. Has chronic pelvic pain due to this and is on hydromorphone at home for the pain. Independent on ambulation/ADLs. Continued on opiates for pain control once delerium cleared. #. Hx benign pituitary adenoma: Resected many years ago. Was on levothyroxine and low dose predisone for years as a result of hypopituitarism that followed. Got stress dose steroids in the ED then returned to ___ daily of prednisone. A TSH was checked and measured <0.02 in the setting of acute illness. A T4 was WNL. The patient was continued on her home levothyroxine dose. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Of note, pt. was very sedated from narcotics during history. Mr. ___ is a ___ y/o male with past medical history significant for renal colic without evidence of nephrolithiasis, interstitial cystitis s/p simple cystectomy with suprapubic prostatectomy and creation of ileal neobladder in ___, and multiple admission for recurrent orchitis and sterile pyuria ___ and ___, treated with pain control and anti-inflammatories; of note admission ___ - pt. had presumed episode of ACS, s/p negative cardiac cath) who presents with acute exacerbation of his chronic suprapubic pain. Pt. reports that 3 days prior to admission, pt. noted the gradual worsening of sharp stabbing suprapubic pain with radiation to the left testicle. At this time, he took vicodin and phenazopyridium without effect. The pain will wax and wane approximately every ___ minutes. This pain is similar to symptoms he has had in the past. He also notes dysuria, but denies urinary incontinence, urgency, or change in urine color. He does endorse chills and rigors 1 day prior to admission. For worsening symptoms, the patient elected to present to the ED. Four hours of chest pressure. PA and lateral upright chest radiographs were reviewed in comparison to ___. Heart size and mediastinum are unremarkable in appearance. Previously seen bilateral areas of linear atelectasis have resolved, and there is no evidence of pleural effusion or pneumothorax. Overall, the appearance of the chest is unremarkable. was done. The patient was diagnosed with URIN TRACT INFECTION NOS, CHEST PAIN NOS. At the time of discharge, the patient had PRIMARY chronic suprapubic and testicular pain SECONDARY interstitial cystitis s/p ileal neobladder GERD Anxiety Depression Asthma Vitamin B12 Deficiency. The patient was given written instructions concerning 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 STATEMENT: Mr. ___ is a ___ y/o male with past medical history significant for renal colic without evidence of nephrolithiasis, interstitial cystitis status post simple cystectomy with suprapubic prostatectomy and creation of ileal neobladder in ___, and multiple admission for recurrent orchitis and sterile pyuria ___ and ___, treated with pain control and anti-inflammatories; of note admission ___ - pt. had presumed episode of acute coronary syndrome, status post cardiac cath which was negative for coronary artery disease) who presents with acute exacerbation of his chronic suprapubic pain. # Suprapubic and Testicular Pain: The patient presented with worsening sharp waxing and waning suprapubic pain. He has several recent admissions with scrotal pain with sterile pyuria. On these admissions, his urine analysis was without positive nitrites. On this admission, his presenting urine analysis was positive for nitrites As such, the patient was placed on broad spectrum antibiotic treatment with meropenem given his history of extended spectrum beta-lactam E.Coli. He continued to have some symptoms despite antibiotic treatment. The patient remained without fevers, without leukocytosis, and with no growth on urine culture. Given the lack of infectious findings, the patient was discharged home with PO pain control off of antibiotics. On the day of discharge, the patient's urologist, Dr. ___ was contacted who also agreed with the plan. The patient remained hemodynamically stable and was discharged with outpatient follow-up. #Chest Pain: The patient complained of heavy chest pain several days prior to admission. He had a normal CXR, ECG unchanged from prior without evidence of ischemia, and negative troponins x1.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ F with history COPD on 3L oxygen, DM on insulin, HTN, schizoaffective disorder, tardive dyskinesia recently admitted in ___ s/p syncopal event who was sent in by ___ from ___ for confusion and tachycardia. Per report from PCP, ___ she had been having memory difficulty x 2 weeks and altered mental status progressively worsening for past week. At ___ office she was noted to be tachycardic to 110 and hypertensive also with encephalopathy and difficulty following commands. Sent to ED for evaluation for underlying infectious process, urinary, respirtory or hepatic sources. Patient denies chest pain, orthopnea or PND but reports shortness of breath, labored breathing. . In discussion with granddaughter, ___, the patient has been experiencing frequent short term memory defecits. She forgot how to use her walker, has to be isntructed to eat, forgot how to turn the water faucet off. These memory deficits have been progressive for past few days. . In the ED, initial vitals 98.2 ___ 16 98% 2l. CT head showed No acute intracranial process. No hemorrhage. No fracture. Age related atrophy and chronic small vessel ischemic disease. CXR with Stable appearance of the chest, without evidence for acute disease. EKG in the ED SR 88, NA/NI, c/w prior. Vitals prior to transfer 98.4, 77, 132/45, 18, 98% RA . On arrival to floor, patient hypertensive but stable with O2 sats in mid-90s%. She appears to have labored breathing, using accessory muscles but maintaining O2 sats in 92-96% range on RA. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed Stable appearance of the chest, without evidence for acute disease. Radiology showed 1. No acute intracranial process. 2. Chronic small vessel ischemic disease. 3. Age-related atrophy. 4. Hypodensities in the bilateral thalami, left greater than right, and genu of the right internal capsule that are unchanged compared to ___ suggesting small old lacunar infarcts. Radiology showed No acute infarct seen. Moderate brain atrophy and moderate small vessel disease. Chronic lacunes in the basal ganglia. No acute infarcts. The patient was diagnosed with SEMICOMA/STUPOR, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, 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>___ F with history COPD on 3L oxygen, DM on insulin, HTN, schizoaffective disorder, tardive dyskinesia sent in to the ED for increasing confusion and forgetfullness. # Encephalopathy: Acute short term memory loss without obvious preceeding event. Inattention on exam but oriented indicating most likely delirium versus acute progression of dementia. Acute onset and with possible stepwise decline is curious for vascular dementia. CT head also showing some small vessel ischemic disease which may be consistent with vascular dementia. MRI head did not show acute process or acute stroke. In addition, chronic psychiatric disease with dopaminergic medications may be exacerbating her clinical status. Toxic-metabolic work up all negative except for low TSH but FT4 is 1.0. B12, Folate and RPR all normal/negative. After reading prior neuro notes she did not seem far off from baseline. Neurology was consulted who requested an EEG which showed mild diffuse background slowing and disorganization, indicative of a mild diffuse encephalopathy which is etiologically non specific. There were no epileptiform features. Final diagnosis was polypharmacy induced encephalopathy. Benadryl was discontinued, Clonazepam tapered down and discontinued and Tetrabenzaprine dose halved. Plan to discontinue Tetrabezaprine all together but patient requested it continued. Neuro also felt she definatively has sleep apnea which is likely contributing to poor morning arousability. CPAP was started on the floor and continued as an outpatient. # COPD: Oxygen-dependent COPD (3LPM), s/p respiratory arrest in ___ with protracted intubation course. Labored, tachypnic breathing on admission though without oxygen requirement. After being placed back on home O2 of 2L NC her respiratory status improved and she maintained O2 sats in >95%. Continued home regimen of Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN, Fluticasone Propionate NASAL 1 SPRY NU DAILY, Ipratropium Bromide Neb 1 NEB IH Q6H, Dulera *NF* (mometasone-formoterol) 100-5 mcg BID and supplemental O2 at 2L NC. No acute exacerbation during admission. Patient is on Azithromycin chronically as an outpatient, unclear if this can be continued, defer to outpatient pulmonary for that decision. # Glycosuria: 1000 Glu on UA. Serum glucose only 200 so unclear why she is spilling so much glucose. Possibly Fanconi syndrome though patient with normal renal function, phosphate and bicarb slightly elevated. Elevated bicarb likely compensating for chronic CO2 retention, no evidence of RTA to look for Fanconi's. Dilute urine may also indicate she is not concentrating appropriately. Repeat urine continued to show glycosuria. This can be monitored as an outpatient. # Hypertension: Chronic, uncontrolled, asymptomatic at this point, not being treated as an outpatient. Allergy to ACE-I and ARBs which would be first line given possibly renal dysfunction with glycosuria. Consider starting Chlorthalidone as an outpatient. # Diabetes Mellitus: Type II, insulin dependent, complicated by vascular disease. Continued Lantus 20 units QHS and QACHS ___ and HISS, held Metformin while inpatient # Schizoaffective disorder: On typical antipsychotics complicated by movement disorders and tardive dyskinesia. Consider changing medications as there may be contributing to AMS deterioration. Discontinued Clonazepam 1 mg PO/NG QHS due to lethargy but continued Perphenazine 8 mg PO/NG QHS, Olanzapine 5 mg PO HS, Tetrabenazine 25 mg Oral QHS </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o male poor historian with a h/o anxiety disorder ?h/o bipolar. The patient initially presented to ___ after a low speed MVA, where he was restrained and hit a wall. At the seen the patient had an odd affect and balance difficulty and was sent to ___. The patient had difficulty answering questions about why he came in. Additionally, the patient's brother reports that the patient has had multiple falls recently and the patient reports that he fell down the stairs at his house ___ and injured his foot. He has had pain in his foot with ambulation since. The patient denied pain in the ED at rest, but endorsed pain in left foot with walking. No swelling in foot. The patient also endorses ongoing fatigue for some time. No CP, SPB, fevers/chills. Radiology showed No fracture or dislocation. Radiology showed Mild improvement in the left upper lobe subpleural consolidation, which may represent pneumonia or pulmonary hemorrhage. Radiology showed 1. Large left upper lobe necrotic lung lesion may represent necrotizing pneumonia. Potential considerations include fungal infection or necrotizing malignancy. Mediastinal lymphadenopathy noted. 2. Multiple other pulmonary nodules as described above including a suspicious spiculated right lower lobe 1 cm lesion with pleural traction, concerning for malignancy. 3. Small left and moderate right pleural effusion and pericardial effusion. 4. 5.7 cm infrarenal abdominal aortic aneurysm without evidence of dissection or impending rupture. ___ communicated findings to Dr ___ at 12:21 on ___ via telephone 1 hour after findings are discovered. Evaluation of the patient with ultrasound-guided transbronchial biopsy. Fourteen images obtained during fluoroscopy as spot views were brought to our review. The total fluoroscopy time of 228.3 seconds was recorded. The images demonstrate the process of transbronchial biopsy of the left upper lobe. Note is made that the radiologist was not attending the procedure. was done. Evaluation of the patient after left upper lobe biopsy to check for pneumothorax. COMPARISON: ___. The patient is after transbronchial left upper lobe biopsy. The current study demonstrate left upper lobe opacity, slightly more progressed as compared to prior study, most likely related to post-biopsy minimal hemorrhage. No appreciable pneumothorax is seen. The rest of the findings are unchanged. was done. The patient was diagnosed with OTHER MALAISE AND FATIGUE, ANEMIA NOS, PAIN IN LIMB. The patient was treated with ___ Bronchoscopy. At the time of discharge, the patient had Primary: --Pneumonia Secondary: --falls --anemia --altered mental status. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ y/o male poor historian with a h/o anxiety disorder ?h/o bipolar who has been admitted s/p MVA with repeated falls found to have necrotizing pulmonary lesion.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old right-handed woman with alzheimer's, hx Bell's Palsy, HTN, chronic gait instability, recent stroke identified incidentally on o/p MRI who presents as a transfer from ___. Radiology showed No evidence of hemodynamically significant internal carotid stenosis on either side. The patient was diagnosed with OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had gait instability chronic left basal ganglia stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with a history of likely Alzheimer's disease, prior left Bells Palsy, HTN, and relatively recent left basal ganglia ischemic stroke (incidental finding on mri few months ago), who was admitted given concern of gait instability. She had presented to ___ after a presyncopal event that led to gait unsteadiness. This event was most likely vasogaval/orthostatic event or TIA. She was transferred to ___ for stroke work-up. Her gait was veering with unsteadiness and she warranted admission for both ___ evaluation of gait and completion of her stroke work-up with a carotid ultrasound. Carotid ultrasound was negative for critical stenosis. Other elements of stroke workup were done recently and thus not repeated and are included in her OMR (A1c, LDL, MRI, echo). She will follow-up with Dr. ___ on ___ in clinic. Her medications (including ASA 81mg) were not adjusted. Her gait was only mildly unsteady by the time she was evaluated on the floor. She had veering to the right and motor impersistence. She benefited from a walker, but was actually able to maintain balance without an aide. After ___ eval, she was recommended home with ___ ___ services. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who has had multiple falls at home and newly requiring a walker to ambulate. The PCP ordered cardiac workup and brain MRI to rule out any etiology to the falls. MRI read concerning for brain mass. Patient was contacted and sent to the ER for neurosurgical evaluation. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. Extra-axial homogeneously enhancing mass arising from the posterior fossa with severe mass effect and remodeling on the upper cervical spinal cord/craniocervical junction, most consistent with a meningioma. No evidence of significant parenchymal FLAIR signal abnormality. At the level of the craniocervical junction, minimal to no CSF is seen. 2. Moderate to severe enlargement of the ventricular system may in part be due to hydrocephalus caused by the mass at the craniocervical junction, however there is no evidence of transependymal CSF flow to suggest acute hydrocephalus. Close attention on follow-up is recommended. 3. No evidence of acute infarction or intracranial hemorrhage. PRE-SURGICAL WAND OR THERAPY PLANNING ___ MR HEAD showed No significant change in appearance of the extra-axial, homogeneously enhancing posterior fossa mass with stable mass effect on adjacent structures. CHEST (PRE-OP PA AND LAT) showed No prior chest radiographs available. Lungs grossly clear. Normal cardiomediastinal and hilar silhouettes and pleural surfaces. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Postsurgical changes in the bilateral posterior inferior cerebellar artery territories, likely secondary to recent suboccipital craniotomy for resection of an extra-axial mass of the cervicomedullary junction. 2. Postsurgical linear enhancement surrounding the resection cavity without evidence of residual tumor. 3. Patent dural venous sinuses and vertebral arteries. 4. Right frontal approach ventriculostomy catheter without ventriculomegaly. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Dental amalgam and hardware streak artifact limits study. 2. Expected postsurgical changes related to recent posterior fossa meningioma resection. 3. Stable mild ventriculomegaly with a right frontal approach EVD. Radiology showed There is an endotracheal tube whose tip is 3.4 cm above the carina, appropriately sited. Lungs are grossly clear. There are no pneumothoraces. Degenerative changes of the thoracic spine are seen. There is high-riding bilateral humeral heads consistent rotator cuff rupture. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval development of a 1.3 cm density in the right lateral ventricle and linear density in the third ventricle may represent intraventricular blood products, new since prior but less likely to hyper acute given its density. Stable bilateral layering intraventricular hemorrhage in the occipital horn. 2. Status post posterior fossa craniotomy and resection of meningioma with increased extent of hypodensity in the right cerebellum and similar hypodensity in the medial left cerebellum with persistent effacement of the fourth ventricle. 3. Mild interval decrease in size of right lateral ventricle. 4. Interval substantial decrease in amount of pneumocephalus. Chest radiograph, portable AP upright. showed Status post endotracheal extubation. No evidence of acute cardiopulmonary disease. Radiology showed No signs of ileus or obstruction. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval removal of right trans frontal ventriculostomy catheter. 2. Significant increase in degree of pneumocephalus, particularly along the anti dependent portions of the bilateral frontal horns and right temporal horn of the lateral ventricles, slightly increasing the size. The remainder of the ventricles remains similar in size. 3. Slight interval increase in dependent hemorrhage in the left occipital horn, potentially secondary to redistribution. No other new hemorrhage identified. 4. No acute large territory infarct. No acute osseous abnormality. Right occipital craniotomy and underlying resection with encephalomalacia of the right cerebellar hemisphere and edema pattern is unchanged. RECOMMENDATION(S): Close interval follow-up is recommended to document stability. The patient was diagnosed with Ataxia, unspecified, Unsteadiness on feet. The patient was treated with ___ - Posterior fossa craniotomy for resection ___ - Right frontal EVD placement ___ - Right frontal EVD removal. At the time of discharge, the patient had Posterior fossa lesion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#Brain Mass MRI of the brain revealed an extra-axial homogeneously enhancing mass arising from the posterior fossa with severe mass effect and remodeling on the upper cervical spinal cord/craniocervical junction, most consistent with a meningioma. The patient was admitted to the neurosurgery service for further workup and discussion for possible surgical intervention. She was started on dexamethasone for cerebral edema. After review of imaging and discussions with the family, it was determined that it was not safe to remove the entire tumor, but to take her to the OR for debulking. Patient was taken to the OR on ___, for posterior fossa craniotomy and C1 resection and debulking. Patient tolerated the procedure well, please see separate documentation in ___ for specific details of the operative case. An EVD was placed in the OR for management of ICP and proper wound healing. EVD was leveled at 10cmH2O at the tragus and kept open to drain as needed. Patient remained intubated post-operatively and was transferred from the OR to the Neuro ICU for close neurological monitoring. Patient with increased blood pressures requiring a nicardipine drip in the ICU, and was closely monitored and titrated until she was able to tolerate PO medications and was weaned off. Patient was extubated on POD 1, ___ and tolerated well. Post-operative CTH with expected post-operative changes with small amounts of scattered pneumocephalus. Post-op MRI stable to prior CTH. On POD 3 patients EVD stopped draining with interrupted waveform, EVD catheter was flushed distally and proximally overnight and then again in the AM. EVD began draining slowly, however waveform continued to be poor. Patient was transferred to the ___ on POD 3. Shortly after transfer in the evening of ___ patient became increasingly lethargic and had 2 episodes of emesis, Zofran was given with another episode of emesis. Patient was sent for STAT CTH which was stable to improved compared to prior post-operative imaging. Patient with continued lethargy and loose stools. CXR negative for any acute process. KUB was obtained which revealed dilated loops of bowels however no obstruction. UA and blood cultures were ordered on ___ and were unremarkable. Patients exam slowly began to improve on ___. On ___, Ms. ___ exam was stable in the morning. Her EVD was raised to 20. On ___, her clinical exam remained stable, and the right frontal EVD was removed after being clamped overnight. Her clinical exam was followed after removal, and on ___ she was noted to be more somnolent. Head CT was obtained which showed an increase in pneumocephalus. She was placed on a NRB for 24 hours and her exam improved. Her exam continued to improve. She was discharged to rehab at her neuro baseline on ___ in stable condition. #Tachycardia/Hypertension Patient with acute tachycardia post-operatively. Patient was managed initially with a nicardipine gtt which was weaned and she was tolerating PO Labetalol. On ___ patient was transitioned from labetalol to Metoprolol 25mg PO BID with IV labetalol and Metoprolol PRN. #Type II Diabetes Patient with history of type II diabetes on home Metformin and Glipizide. While hospitalized these medications were held due to surgery as well as decreased PO intake. Patient's blood sugars were evaluated before each meal and every night and she was given insulin per sliding scale PRN. She may be restarted on glipizide and metformin as appropriate. #Disposition ___ evaluated patient and recommended rehab. She was discharged to rehab on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old male with a history spontaneous pneumothorax, 1 left sided, 2 right sided treated with chest tubes, last incident treated with Right VATS right upper lobe blebectomy and mechanical and chemical pleurodesis on ___. Beginning this morning patient reports onset of right chest discomfort consistent with previous episodes of pneumothorax. Discomfort worsened throughout the day and he eventually decided to present to ED for further workup after speaking with Dr. ___. He denied any dyspnea and pain had resolved by the time he presented to ED but he reports he continues to have an odd feeling that he can best describe as the feeling of air outside of his lung. He currently denies any fevers, chills, chest pain, shortness of breath, nausea, vomiting, subcutaneous emphysema, of difficulty swallowing. He does endorse a slight headache from this morning. Radiology showed New moderate right pneumothorax. No significant shift of the mediastinal structures, although there is some mild splaying of the ipsilateral ribs, suggesting some degree of tension. Ordering physician aware on ___ and CT scan performed shortly after this examination. Radiology showed Right-sided pneumothorax. No significant shift of mediastinal structures. Radiology showed Right pneumothorax with minimal leftward mediastinal shift; findings were relayed to interventional pulmonology team as they were placing a chest tube at 11:22 am on ___ by ___ over the phone. Radiology showed Continued tiny right apical lateral pneumothorax without evidence of tension. Radiology showed AP chest compared to ___ shows little change in the volume of the very small pleural air collection primarily along the upper costal surface of the right lung, but a significant increase in moderate right pleural effusion. Secondary atelectasis is relatively mild. The heart is normal size and the mediastinum is not shifted. Left lung is clear. Apical pleural pigtail drain unchanged in position. Dr. ___ and I discussed these findings by telephone at the time of dictation. The patient was diagnosed with CHEST PAIN NOS, OTHER PNEUMOTHORAX. The patient was treated with ___ Right pleural pigtail placement. At the time of discharge, the patient had Spontaneous right pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>mr. ___ was evaluated by the Thoracic Surgery service in the Emergency Room and admitted to the hospital for management of his right pneumothorax. His chest pain resolved and his oxygen saturations were 95% on room air. On ___ he had a pigtail catheter placed with subsequent talc pleurodesis. He had some problems with pain from the talc and was placed on a Dilaudid PCA. His chest tube remained on suction and serial films showed improvement. He daveloped nausea and vomiting from the Dilaudid but was better after discontinuing it and his pain was relieved with Ultram. He was then able to tolerate a regular diet and stay hydrated. His pigtail catheter was removed on ___ and the post pull film showed persistent, small pockets of air in the R lung apex. Pt remained hemodynamically stable, and was saturating well on room air. He felt well enought to be discharged home. Prior to discharge he was educated regarding his follow up plans post discharge and he verbally expressed understanding and agreement with these plans. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yoM with history of HTN, afib, and new diagnosis of MDS in ___ who presented to clinic on the afternoon of admission for a therapeutic and diagnostic thoracentesis of a new pleural effusion. 2.5L of straw colored transudative fluid was removed. A post-thoracentesis CXR revealed a small apical pneumothorax. The patient was called and told to return to the ED for possible chest tube, but thoracics deemed that the PTX was not large enough to need a chest tube. Instead, the plan was to keep the patient on non-rebreather overnight to aid in PTX reabsorption and to check serial CXRs. . His Onc hx: -- In ___ his CBC revealed a new anemia (hgb 10.9) and thrombocytopenia (35). He was referred by his PMD to heme at ___ for BMBx, but cancelled appt since he was anxious about the pain. He notes in the past 2 months he has had increased fatigue and has needed to walk slower and rest. He continued his daily 30 minutes walks until 2 weeks PTA, when he was too fatigued and SOB. Over the prior month he also reported decreased appetite. -- ___ consulted for new anemia and thrombocytopenia by the ER. He was sent in to ER by PMD for critical platelets 11 and Hgb 7.0. Initial peripheral Smear (pre transfusion): anisocytosis, normocytic to microcytic (as oppose to mcv 115), + tear cells, + reticulocytes, nl pmn, lymphocytes, eosinophils, with few atypical cells. No blasts. with no evidence of blasts. no evidence of schistocytes. no hypersegmented neutrophils. significantly decreasedplatelets with rare gaint platelets. Admitted for transfusion with 3 pRBC and 1unit of platelets. -- ___ BMBx: HYPERCELLULAR BONE MARROW WITH DYSPLASTIC TRILINEAGE HEMATOPOIESIS, CONSISTENT WITH A MYELODYSPLASTIC SYNDROME, BEST CLASSIFIED AS REFRACTORY CYTOPENIA WITH MULTI-LINEAGE DYSPLASIA (RCMD) (WHO CLASSIFICATION). -- ___ Discharged; Hospitalization included BMBx, treatment for CAP for leukocytocysis, cough and CXR with atelectasis vs PNA and tamsulosin started for urinary retention. . In the ED, initial VS were: 100.2, 121/67, 115, 20, 95%. The patient was placed on a nonrebreather. A CXR was done that showed a slightly smaller apical PTX. The patient had slight increase in his HR, c/w his afib. He was given a dose of 10mg Diltiazem and transfered to the floor. . On arrival to the MICU, the patient is in NAD. He said that he had a slight cough after the ___, but no recent fevers, chills, or respiratory symptoms. He is comfortable on NRB. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. 10lb weight loss last year. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Radiology showed Left-sided pneumothorax 3.8 cm in maximal dimension. These findings were reported to Dr. ___ via phone at 4:35 p.m. by ___. Radiology showed 1. Moderate left hydropneumothorax and small right pleural effusion. 2. Extensive left lung consolidation and airway plugging, worst in the left lower lobe. 3. Anasarca. The patient was diagnosed with IATROGENIC PNEUMOTHORAX, ABN REACT-FLUID ASPIRAT. At the time of discharge, the patient had pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ gentleman with Afib, HTN, MDS and new left pleural effusion who underwent an outpatient thoracentesis complicated by apical PTX requiring MICU admission for 100% NRB to help reabsorption. He was discharged home the next day. . #. PTX: Complication from thoracentesis, resolving. Interventional Pulmonology felt no chest tube was needed. He was admitted to the MICU for non-rebreather treatment overnight. On imaging, the PTX was still present but not growing. He had no O2 requirement; will follow up in I.P. clinic after discharge. . #. Left lung consolidation and airway plugging: no clinical manifestations. He had no change in his repiratory status; imaging revealed these findings and he was advised to undergo bronchoscopy, but he declined. He will follow up in I.P. clinic after discharge. . #. Afib: Not rate controlled. Patient is not on Warfarin or beta blocker at home. Heart rate was 100-120. It was felt that his tachycardia could be contributing to an element of diastolic HF so he was started on Metoprolol with resulting rate ~100. He will follow up in I.P. clinic. . #. MDS: with cytopenias. Not an active issue this admission. He will follow up with his Oncologist. . #. Transitional Issues -pending at discharge: ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY --DVT: Pneumoboots # Access: peripherals # Communication: Patient # Code: DNR/DNI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of DM and left BKA who is presenting for worsening left leg pain and warmth ___ the setting of home IV antibiotics after left BKA c/b osteomyelitis requiring fluid drainage on ___ and ___ with recent discharge from medicine service on ___. Plan from ID was to treat for 6 weeks for osteomyelitis with daptomycin 450 mg IV q24 and ciprofloxacin 500mg PO Q12. He states things have been going well after his discharge for the past two weeks and then last night started to have severe worsening of the pain and feels like it is hot to the touch. He states he feels like his foot is still ___ place. He endorses chills and feeling queasy. He denies fevers, vomiting, diarrhea. Radiology showed 1. Interval worsening of cellulitis with slightly smaller, but persistent stump abscess causing increased osseous destruction consistent with worsening cellulitis and osteomyelitis. 2. New abscess medial to right tibial plateau. Ultrasound-guided aspiration showed Technically successful ultrasound-guided aspiration of a left medial knee complex fluid collection likely in large part chronic hematoma. The sample was sent for microbiology evaluation. The patient was diagnosed with Pain in left leg. The patient was treated with ___: Drainage of Left BKA abscess ___: I&D of Left BKA. At the time of discharge, the patient had Primary Diagnosis ================== Left BKA abscess and osteomyelitis Phantom Limb pain Secondary Diagnosis =================== DM1 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>___ with hx of DM1, MRSA bacteremia with bilateral lower extremity osteomyelitis that required bilateral BKAs, HTN, h/o PE on warfarin, and recent admission for left stump abscess and osteomyelitis currently on 6 week treatment (Start Date: ___ Projected End Date: ___ with daptomycin and ciprofloxacin who presented after increased left stump pain found to have new left leg abscess. # Left stump pain with abscess and osteomyelitis: Patient presented with increased left stump pain for two days. He has been on daptomycin/ciprofloxacin since ___ for abscess and tibial osteomyelitis (fluid collection were likely sterilized prior to collection). He has a history of MRSA bacteremia with bilateral lower extremity osteomyelitis that required bilateral BKAs so he was discharged on daptomycin/ciprofloxacin (allergy to vancomycin) for 6 week course. Representation with increased pain, swelling, chills. CT done ___ ED was concerning for new abscess and worsening osteomyelitis. There was worry for failure of antibiotic therapy likely d/t lack of source control or gram negative or polymicrobial infection that is not covered by Cipro. His CRP and ESR were not elevated but he had been experiencing rapid fluctuations ___ blood sugar and increased lactate upon arrival was worrisome for inflammatory process. ID was consulted and recommended ___ drainage of abscess. Fluid from abscess was sent and had GPCs and GPRs on gram stain but did not grow on culture likely d/t antibiotic therapy. He went for I&D of medial abscess with vascular surgery on ___. Drainage was bloody and old clots. Suggesting possible infected hematoma. This fluid also didn't grow on culture. Wound from I&D was left open to heal by secondary intention. Since only gram positive organisms were seen on gram stain he was switched to monotherapy with daptomycin. He will follow up with vascular surgery and ID closely after discharge. Pt will need weekly OPAT labs drawn and sent to ___ clinic for safety monitoring, instructions faxed to ___ on ___. ___ addition, he will have wound care by ___ as an outpatient. #Increased phantom limb pain : Pain was described as shooting pain that runs up from phantom foot, behind his keen and up to his hip. The pain was severe and sharp and causes a "pop rocks" sensation. Description seemed consistent with neuropathic pain possibly increased by irritation from worsening infection ___ stump or compression from new abscess. He had taken gabapentin and lyrica ___ the past and both didn't help. Amitriptyline helped but made him fatigued. We discussed with patient the other options for neuropathic pain such as duloxetine or restarting amitriptyline. He was interested ___ trying duloxetine for his neuropathic pain. It was started while he was admitted. His pain was difficult to control and he was started on duloxetine, naproxen 500mg BID, Tylenol, lidocaine patch, capsasin cream, and dilaudid. He was discharged with a small dose of dilaudid with plan for aggressive wean off as the wound heals. He was scheduled to see his PCP for pain control and will follow up with chronic pain as an outpatient. ___: Initially Cr was increased to 1.1 from baseline of 0.9. This was most likely d/t pre-renal etiology given evidence of hemoconcentration on admission labs and mildly elevated lactate. Cr down trended to baseline with fluid resuscitation. # Diabetes type 1:Patient reported that sugars have been poorly controlled recently with rapid hypoglycemia. During admission he had episodes of rapid symptomatic hypoglycemia requiring D50. ___ was consulted for assistance ___ insulin regimen. He will have close follow up with his PCP and endocrinology for management of his insulin regimen. He was discharged on the following insulin regimen. Breakfast: Glargine 10u, Humalog 2u Lunch: Humalog 5u Dinner: Humalog 4u Bedtime: Glargine 12u Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose ___ mg/dL 0 Units 0 Units 0 Units 0 Units 101-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 0 Units 0 Units 0 Units 0 Units 201-250 mg/dL 1 Units 1 Units 1 Units 1 Units 251-300 mg/dL 2 Units 2 Units 2 Units 2 Units 301-350 mg/dL 3 Units 3 Units 3 Units 3 Units 351-400 mg/dL 4 Units 4 Units 4 Units 4 Units # Prior venous thromboembolism: Prior dose of warfarin decreased on last admission ___ setting of ciprofloxacin potential to elevate INR ___ setting of warfarin. He was initially subtheraputic on presentation. He was restarted on home dose after ___ drainage and vascular I&D of left BKA abscess. He will follow up with his PCP for monitoring of his INR. Transitional Issues ============== MEDICATIONS STARTED: Acetaminophen 1000 mg PO/NG Q8H, Capsaicin 0.025% 1 Appl TP TID neuropathic pain ___ left BKA, DULoxetine 30 mg PO DAILY, HYDROmorphone (Dilaudid) 2 mg PO/NG Q4H:PRN Pain - Severe, Lidocaine 5% Patch 1 PTCH TD QAM, Naproxen 500 mg PO BID left knee MEDICATIONS STOPPED: Ciprofloxacin [] Follow up with Chronic Pain for phantom limb pain [] Follow up with ___ about your insulin regimen [] Continue Daptomycin through ___ and follow up with Infectious disease Dr. ___. OPAT MONITORING LABS TO BE DRAWN WEEKLY BY ___ AND FORWARDED TO ___. ___ ___. [] Follow up with Vascular surgery as scheduled [] Consider up titrating duloxetine as an outpatient for phantom limb pain [] Consider adjusting insulin regimen to reduce hyperglycemia but limit hypoglycemia [] Discharged on short course of dilaudid for pain control with plan to wean as wound heals. Pain regimen can be reevaluated by PCP at his ___ appointment [] Patient discharged on the following insulin regimen: Breakfast: Glargine 10u, Humalog 2u Lunch: Humalog 5u Dinner: Humalog 4u Bedtime: Glargine 12u with insulin sliding scale</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old right handed female with past medical history remarkable for multiple sclerosis, sciatica, and migraines who presents today with ___ day history of difficulty with cognition described as word finding difficulty as well as sudden onset on the morning of presentation of left anterior leg pain 2-3cm rostral from the ankle which she described as alternating in character from sharp stabbing to burning initially static and then after ~1 hour radiating up the anterior aspect of the shin across the lateral aspect of the thigh and into the lateral left lumbar region of the back. Of note, the patient reports the pain distribution has been relatively constant with some amelioration over the course of the day and exacerbation mostly noted in the initial location of complaint and in the lateral left lumbar region of the back. She notes this is not consistent with previous MS flares, the last she notes was in ___ timeframe which was treated with steroids; also, this pain is inconsistent with her sciatic pain in character, distribution, and duration. She also reports some abdominal pain which feels musculoskeletal in character and is congruent with the pain in the left lumbar back. In terms of her left lower extremity, around midday she noted an "increase in heaviness" noting the initial pain caused some "weakness because of the stinging" which changed to more "heaviness, like the leg is too heavy to lift". Radiology showed Normal chest. Radiology showed Normal bowel gas pattern with no evidence of ileus or obstruction. Radiology showed Stable examination. No evidence of disease progression or new enhancing plaques. Radiology showed No evidence of new enhancing plaques. Previously visualized enhancing plaque no longer seen. Diffuse high signal throughout the cervical cord in keeping with sequelae of demyelinating disease. The patient was diagnosed with MULTIPLE SCLEROSIS. At the time of discharge, the patient had Lower extremity 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># NEUROLOGICAL: The patient was admitted for further workup of a suspected flare given her atypical distribution of weakness. Initially given some disparity in her day to day symptoms, it was unclear whether this was a presentation of MS ___ which she last experienced a flare in ___ or if this was lower extremity pain and some bloating causing her distress. After attempts to control her pain with Ketorolac for 3 days which per the patient was minimally helpful for her LLE pain, left lumbar and abdominal pain, as well as headache of which all symptom severity was out of proportion with presentation, an MRI Brain and C-Spine were obtained which demonstrated no new active flare which could explain her symptoms. While inpatient, Ms. ___ was maintained on her home dosages of clonezepam for anxiety. # GASTROINTESTINAL: Ms. ___ noted abdominal pain initially was not typical of stomach pain, or normal GI distention, however as time progressed, the patient endorsed her pain to be severe and bloating in character. An abdominal plain film was obtained which showed a normal bowel gas pattern and no obvious intraabdominal process. To treat her pain - simethicone, calcium carbonate, and tramadol were used. # GENITOURINARY: Ms. ___ noted some pelvic discomfort on discharge, but was recommended to follow up with her PCP if complaints continue.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female who underwent a laparoscopic-assisted sigmoid colectomy with takedown of colovaginal fistula by Dr. ___ on ___, which was done for symptomatic colovaginal fistula which had developed likely secondary to her prior resection of ovarian cyst in ___. Her hospital stay was notable only for transient post-op ileus, which was successfully managed with an NGT, and she was discharged on ___ in good condition, tolerating POs and with good pain control. Radiology showed 1. Dilated loops of small bowel in the mid abdomen with a long transitional zone to distal decompressed loops is concerning for partial or early small bowel obstruction. 2. Postsurgical changes in the pelvis related to prior colovaginal fistula take-down and sigmoid resection. No evidence of abscess or recurrent fistula. 3. Nonocclusive thrombus in the right portal vein with extension into the anterior and posterior branches is of indeterminate age. Correlation with prior outside imaging, if available, would be helpful. 4. Open surgical wound in the soft tissues overlying the anterior abdominal wall, with no evidence of abscess formation or transgression through the abdominal wall. The above findings were communicated to Dr. ___ resident) by Dr. ___ in person at 07:34, 5 min after discovery. Radiology showed Bibasilar atelectasis. Dilated bowel loops within the left upper quadrant; please refer to the report of CT abdomen and pelvis obtained the same day for further details. The patient was diagnosed with VOMITING. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ was admitted after nausea, vomiting, and elevated white blood cell count. Infectious workup was performed, and a wound VAC was placed on her abdominal wound that had been previously packed in clinic. Her wound became erythematous, so Bactrim was started. A UTI grew GNRs, and Cipro was started and discontinued because of similar coverage as Bactrim. Her WBC count was 9.3 and so she was doing well, afebrile, and so discharged to home. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ with a hx of T3N0 esophageal cancer s/p MIE c/b recurrent anastomotic stricture and stent placement ___, underwent EGD and stent removal today and developed rigors and chills several hours later. CHEST (PA AND LAT) showed Patchy opacities within the lung bases concerning for aspiration. Small right pleural effusion. The patient was diagnosed with Postprocedural fever, Elevated white blood cell count, unspecified. At the time of discharge, the patient had Primary: Aspiration pneumonitis Secondary: Esophageal stricture and cancer, HTN, T2DM. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Summary ___ with a hx of T3N0 esophageal cancer s/p surgical resection complicated by recurrent anastomotic stricture and stent placement ___, underwent EGD and stent removal the day of admission (___) and developed rigors and chills several hours later. Acute issues # Rigors and chills # Aspiration pneumonitis The patient went to the ___ ED where his max temperature was ___. He got 1 dose of 4.5g IV zosyn, 1g Tylenol and some IV fluids. He got a chest x-ray that showed bibasilar patchy opacities, stable from prior imaging. His rigors and chills resolved while he was in the ED. He was admitted to the medicine floor for observation. He remained afebrile and had no focal signs of infection and was well appearing, although his white count remained elevated at 15.6. His presentation was most consistent with aspiration pneumonitis in the setting of MAC sedation for his stent removal. He was well appearing, afebrile, euvolemic and discharged home after 24h observation without additional antibiotics. Chronic issues #Esophageal stricture s/p stent removal ___. Pt has no pain, no dysphagia or odynophagia at present, low concern for perforation. Will follow with Dr. ___ as outpatient. # T2DM: Last A1C 7.3%. Recently stopped insulin due to well controlled sugars. - Put on HISS while in house # HTN: currently well controlled - SBPs were 110s during this admission. His amlodipine was stopped (was taking 2.5mg daily); his atenolol was reduced by 50% (was taking 50mg qHS, reduced to 25mg qHS). The atenolol can be further tapered as outpatient if he remains normotensive.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male who arrives via EMS after he was a pedestrian struck by a car. The car was traveling at approximately ___. He denies any loss of consciousness. Per EMS he has a hematoma over the left eye. He denies pain with movement of the left eye. He denies any surgeries in the past. Radiology showed 1. No acute intracranial abnormality. 2. Large left periorbital hematoma. The globe appears intact. There is no evidence of retrobulbar hemorrhage or stranding. Radiology showed 1. No evidence of fracture. 2. Large left frontal and periorbital hematoma. The globe is intact. There is no evidence of retrobulbar hemorrhage or fat stranding. Radiology showed 1. No evidence of fracture or acute malalignment. 2. Moderate multilevel degenerative changes. Radiology showed Soft tissue swelling following reduction of a dislocated proximal interphalangeal joint of the left ring finger. No fracture seen. The patient was diagnosed with HEAD INJURY UNSPECIFIED, CONTUSION OF FACE, SCALP, & NECK EXCEPT EYE(S), ABRASION HEAD, MV COLL W PEDEST-PEDEST, TETANUS-DIPHT. TD DT. The patient was treated with Reduction of dislocated middle phalanx of the left finger. At the time of discharge, the patient had Left Ring Finger Middle Phalanx Dislocation Left Periorbital Hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___, was brought in to ___ ED by ambulance after being struck by a car. He underwent complete physical exam, multiple imaging studies and blood tests. Abdominal and pelvic Xray, CT of head, C-Spine and Chest showed no injuries. He was found to have left periorbital hematoma and left ring finger middle phalanx dislocation in finger Xray, which was reduced and splinted at bedside. Post-reduction Xray was taken which showed soft tissue swelling following reduction of a dislocated proximal interphalangeal joint of the left ring finger, no fracture seen. He was admitted to Acute Care Surgery for overnight observation. His pain was well controlled with oral Tylenol and oxycodone. Tertiary survey was completed on HD2, no additional traumas were identified. Orthopedic surgery recommended the that the finger splint should remain in place until the follow up appointment in ___ weeks. Ophthalmology was consulted as well to evaluate the left periorbital hematoma and possible eye injury. No globe injuries were identified. They recommended ice to the left forehead and eye for 3 days and lubricant eye drops for eye irritation and follow up in clinic in ___ days. Pt's vital sings have been monitored and been within normal limits, Ins and Outs have also been recorded and been adequate. Physical and Occupational therapists also evaluated the patient and they recommended that he would benifit from short term rehabilition center. Mr. ___ was discharged to a rehabilitation center on ___ in good condition with discharge and follow up instructions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female presents with the above fracture s/p mechanical fall while intoxicated. Patient is visiting from ___ for a friend's wedding, which she was celebrating earlier this evening. She had multiple alcoholic drinks and tripped and fell, endorsing immediate pain and deformity to RLE. She endorses some numbness and tingling diffusely in her foot and toes. Denies headstrike or LOC. TIB/FIB (AP AND LAT) RIGHT showed Fractures, distal right tibia and fibula as described. No apparent joint involvemen. Chest radiograph. showed No acute thoracic abnormality. ANKLE (AP, MORTISE AND LAT) RIGHT showed Interval splinting of distal tibial spiral fracture and distal fibular oblique fracture, which are unchanged in alignment. CT right lower extremity without contrast showed 1. Spiral fracture of the distal tibial diaphysis with mild displacement. 2. Mildly displaced distal fibular fracture without intra-articular extension. 3. Mild subcutaneous edema at the fracture site. TIB/FIB (AP AND LAT) RIGHT IN O.R. showed Spot images are submitted for documentation of an invasive procedure performed under imaging guidance with no radiologist in attendance. For details of the procedure, please refer to the operative report. The patient was diagnosed with Pain in right lower leg. The patient was treated with right tibial IMN. The patient was given written instructions concerning 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 right tibial shaft fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right tibial IMN, 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. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on 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: The patient is a ___ year old man who reportedly was intoxicated at a party with friends this evening when there was an altercation. He was struck in the head and fell backwards, hitting the back of his head. Unknown whether there was any LOC. He was then brought to an outside hospital where a CT scan (~2:30am) demonstrated a depressed right-sided skull fracture. Reportedly he was waxing and waning in mental status and vomited twice in the other hospital, for which the decision was made to intubate the patient (he was given etomidate, succinylcholine, versed, and fentanyl). He also received a dose of ancef and dilantin as well as a tetanus shot at the other hospital. He was transferred to ___ on a propofol drip. Upon arrival at ___ (~5am) his propofol was stopped and he was placed on a fentanyl infusion. A repeat head CT was obtained at 5:25am. This history is obtained from a review of the medical records and from the patient's mother and stepfather. CT HEAD W/O CONTRAST showed 1. Depressed right parietotemporal skull fracture with subjacent intraparenchymal contusion with some subarachnoid hemorrhage and small right frontal extra-axial hemorrhage. Hemorrhage within the contusion with some subarachnoid hemorrhage appears slightly more prominent since the outside study but similar in distribution. 2. Small left occipital scalp laceration 3. Other details as above CHEST (PORTABLE AP) showed Nasogastric tube is seen coursing below the diaphragm with the tip projecting over the stomach. Overall cardiac and mediastinal contours are within normal limits. The lungs appear well inflated without evidence of focal airspace consolidation, pleural effusions or pneumothorax. The left costophrenic angle is not entirely included on the study. CT HEAD W/O CONTRAST showed 1. Status post cranioplasty for the right parietotemporal depressed skull fracture with the bone now appearing to be in anatomic alignment. 2. Stable appearance of parenchymal hemorrhage/ contusion deep to the fracture with unchanged subarachnoid hemorrhage. The patient was diagnosed with CL SKULL VLT FX-COMA NOS, ASSAULT NEC. The patient was treated with ___- Craniotomy for elevation of depressed skull fracture.. At the time of discharge, the patient had Depressed Skull 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>This is a ___ year old male who presented on ___ s/p assault while intoxicated with Right frontal depressed skull fracture s/p crani for elevation. The patient was taken to the OR for washout and elevation of depressed fx. The patient was extubated in the afternoon. The patient was alert and oriented to person place and time and was neurologically intact. On ___ the patient was alert and oriented to person place and time. The patient was moving all extremities with full strength and his pupils were equal round and raectice to light, 3-2mm bilaterally. Transfer orders were written and the patient was called out to the floor. A physical therapy consult was placed for the patient, and the patient was started on a regular diet. On ___, the patient remained neurologically stable. His dressing was removed. Physically therapy re-evaluated the patient and felt he needed another day before discharge due to issues with dizziness. On ___, the patient remained neurologically stable. He was re-evaluated by OT who recommended discharge to home with 24-hour supervision for all independent ADLs (includeing cooking and medication management) and ___ recommended discharge to home with a prescription for outpatient physical therapy. The patient was discharged home in stable condition to the care of his parents.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o man with history of dilated cardiomyopathy (LVEF 22%; s/p BiVICD), CAD s/p CABG, valvular heart disease (3+MR, 2+TR), atrial fibrillation, DMII, HTN, HLD, infrarenal AAA (6.1cm) awaiting endovascular repair, COPD, cirrhosis secondary to congestive hepatopathy who presented for elective AAA repair and was found to be hypotensive with acute on chronic anemia. CTA torso showed 1. Large infrarenal abdominal aortic aneurysm measuring up to 6.0 x 6.0 cm, previously 6.3 x 5.7 cm without evidence of active rupture. 2. Stable left common iliac, left internal iliac and right common iliac artery aneurysms. 3. Central hypoattenuation in the left common femoral vein (2:146) is not well demonstrated on sagittal or coronal reformats and may be artifactual in nature however, cannot definitively exclude venous thrombus. If clinically indicated may consider further evaluation with dedicated lower extremity ultrasound. 4. New subacute to acute left L2 and L3 transverse process and posterolateral left ___ and 12th rib fractures are new compared to ___. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:30 pm, 5 minutes after discovery of the findings. Radiology showed No acute fracture of the left humerus. UNILAT UP EXT VEINS US LEFT showed 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Subcutaneous edema in the left upper extremity. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. ELBOW (AP, LAT AND OBLIQUE) LEFT showed No acute displaced fracture of the left elbow. If there is continued clinical concern for an occult radial head fracture, a repeat radiograph in several days or further evaluation with cross-sectional imaging could be obtained. WRIST(3 + VIEWS) LEFT PORT showed No acute fracture is identified at the level of the left wrist. FOREARM (AP AND LAT) LEFT showed No acute fracture is identified within the left ulna or radius. CT left upper extremity showed Findings consistent with a large intramuscular hematoma within the extensor compartment of the left arm. No underlying fracture associated. Limited evaluation for any ongoing extravasation due to lack of intravenous contrast. Small hyperdense foci in the lateral partially imaged gluteal soft tissues may represent small hematomas, clinical correlation recommended. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Extensive chronic infarcts, stable. 2. No definite evidence of acute intracranial findings. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Linear filling defect in the proximal right internal carotid artery which by virtue of its location is more likely to be a carotid web. 2. Bulbous tip of the basilar artery with protuberance without a well-defined aneurysm. Otherwise no evidence of aneurysm or occlusion of the head neck. No significant ICA stenosis by NASCET criteria. 3. Moderate narrowing at the origin of the left ACA A1 segment, presumably on an atherosclerotic basis. 4. A couple pulmonary nodules measuring up to 6 mm in the right upper lobe. Per the ___ ___ criteria a 3 to 6 month CT chest follow-up is recommended in low risk patients with further follow-up considered at ___ months. In high-risk patients an initial follow up CT is recommended in ___ months and a follow-up at ___ months if there is no change. NOTIFICATION: For incidentally detected single solid pulmonary nodule --- Choose one --- See the ___ ___ Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Carotid Doppler Ultrasound showed 1. Short segment focal dissection again noted in the proximal right ICA. 2. Intimal thickening and heterogeneous plaque seen bilaterally in the internal carotid artery. Mild stenosis (less than 40%) is seen bilaterally in the ICA. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with EGD ___ Colonoscopy ___. The patient was given written instructions concerning 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 for Admission: ================================ Mr. ___ is a ___ y/o man with history of dilated cardiomyopathy (LVEF 22%; s/p BiVICD), CAD s/p CABG, valvular heart disease (3+MR, 2+TR), atrial fibrillation, DMII, HTN, HLD, infrarenal AAA (6.1cm) awaiting endovascular repair, COPD, cirrhosis secondary to congestive hepatopathy who presented for elective AAA repair and was found to be hypotensive with acute on chronic anemia. Anemia felt to be initially in setting of upper GI bleed, however patient's EGD and colonoscopy were without acute source of GI bleed. Additionally patient with a left arm hematoma (and subsequent compressive radial nerve neuropathy) that could have contributed. He received 2 units pRBC and hemoglobin stabilized. His anticoagulation and anti-hypertensive medications were initially held and restarted prior to discharge once his hemodynamics stabilized. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Mr. ___ is a ___ male with history of pituitary adenoma on hCG presenting with hemoptysis and leg pain. UNILAT LOWER EXT VEINS LEFT showed Nonocclusive deep venous thrombosis in the anterior left posterior tibial vein. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality. 2. Focal area of hypoattenuation within the right lower lobe concerning for pneumonia. 3. Mild airway wall thickening suggestive of mild bronchitis. 4. Bilateral lower lobe pulmonary nodules measuring up to 3 mm. Please see recommendations below. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ The patient was diagnosed with Other pneumonia, unspecified organism, Acute embolism and thrombosis of left iliac vein, Chest pain, unspecified. At the time of discharge, the patient had Community-acquired pneumonia L leg 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>___ male with history of central hypogonadism (on HCG) and Rathke's cleft cyst presenting with cough/hemoptysis and L leg pain, found to have community-acquired RLL pneumonia and LLE DVT. # Dyspnea on exertion: # Cough: # Scant hemoptysis: # RLL community-acquired pneumonia: Patient presented with a few days of high fevers and cough 1 week prior to admission. Fevers resolved, but mild cough with scant hemoptysis persisted. Outpatient CXR at time of initial fevers without clear evidence of pneumonia. CTA chest this admission showed no e/o of PE but did demonstrate focal RLL opacity consistent with community-acquired PNA, likely explanatory. Although he is from ___ originally, TB was thought very unlikely in the absence of immunosuppression (HIV neg) or other clear risk factors and without LAD or weight loss (of note, his respiratory symptoms preceded his recent trip to ___. He was treated with CTX/azithromycin in the ED, transitioned to levofloxacin on admission with improvement in his cough and dyspnea. No e/o hypoxia. Hemoptysis had resolved at discharge, despite initiation of therapeutic anticoagulation as below. He will be discharged on levofloxacin 750mg daily to complete a 5-day course through ___. PCP ___ scheduled for ___. # Provoked LLE DVT: P/w L leg pain that developed a few hours after return flight from ___. Found to have nonocclusive deep venous thrombosis in the anterior left posterior tibial vein. CTA chest neg for PE. Likely provoked in setting of immobility, but patient reports that his father was recently diagnosed with extensive blood clots raising possibility of underlying hypercoagulable disorder. Home HCG therapy may put him at increased risk, as does his tobacco use. Treated initially with heparin gtt, transitioned to apixaban on ___ after discussion of the risks and benefits of therapy. Hgb remained stable without e/o ongoing hemoptysis with therapeutic anticoagulation. He will be discharged on apixaban 10mg BID x 7d (___) then 5mg BID; would likely treat for 3 months for provoked DVT. Consideration of hypercoagulable w/u deferred to PCP. He was counseled on the importance of smoking cessation. # Central hypogonadism: # Rathke's cleft cyst: Followed by Dr. ___ at ___. On HCG 2500u 2x/week. ___ increase risk for VTE as above. Would recommend addressing with outpatient endocrinologist. # Pulmonary nodules: 3 mm nodules seen on CT chest. Low suspicion for malignancy given young age and social tobacco use, but likely warrants 12 month ___ CT. ** TRANSITIONAL ** [ ] levofloxacin through ___ [ ] apixaban 10mg BID through ___, then 5mg BID thereafter; likely 3 month course for provoked DVT [ ] consideration of hypercoagulable w/u deferred to PCP [ ] consider alternative therapies to HCG if feasible given reports of slightly increased risk of VTE with therapy [ ] ongoing smoking cessation counseling [ ] ___ CT chest 12 months for pulmonary nodules</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 alcoholic and HCV cirrhosis decompensated by ascites with a history of SBP, hepatic encephalopathy, and variceal bleeding s/p banding who presented to clinic today for follow-up and was referred to the ED for admission for IV diuresis + albumin, expedited inpatient transplant workup and feeding tube placement. He says he last had a therapeutic paracentesis last ___ where 5L were removed. MRI of the Abdomen showed 1. Cirrhotic liver morphology with stigmata of portal hypertension including varices, splenomegaly, and moderate to large amount of ascites. No concerning focal liver lesion is identified. The calculated liver volume: 1389.1 cc 2. An enlarged 1.5 cm perigastric lymph node is noted, possibly reactive. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Cirrhotic liver with patent main portal vein with hepatopetal flow. Large volume ascites. Splenomegaly. Please refer to same-day MRI of the abdomen for further details. Ultrasound-guided paracentesis showed 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 1.75 L of fluid were removed and sent for requested analysis. CHEST (PA AND LAT) showed Small posterior pleural effusion. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed 2 sequential images demonstrate advancement which ultimately extends to the stomach. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed In comparison with the study of ___, there has been placement of a new Dobhoff tube that extends into the mid to upper stomach, further than the position on the prior study. Cardiac silhouette is more prominent and there has been the development pulmonary edema with layering right pleural effusion and compressive atelectasis at the base. The patient was diagnosed with Alcoholic cirrhosis of liver with ascites, Abdominal distension (gaseous), Dyspnea, unspecified. The patient was treated with ___ ___ paracentesis: 1.75L removed, no e/o SBP.. At the time of discharge, the patient had #Decompensated cirrhosis Secondary diagnoses: Anasarca Ascites Malnutrition. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with Child C alcoholic and HCV cirrhosis decompensated by ascites w/ a history of SBP, hepatic encephalopathy, and variceal bleeding s/p banding who was admitted for fluid overload, malnutrition, and expedited transplant work-up. diuresis and initiation of enteral feeding. He was actively diuresed with IV Lasix and switched to PO torsemide 40 BID prior to discharge. ___ ___ guided para was performed with removal of 1.75L fluid. Dobhoff was placed on ___ and tube feeds were initiated on ___. #CIRRHOSIS #ANASARCA #ASCITES Patient presenting with anasarca and refractory ascites. No clear reason for decompensation at this time. Reports compliance with medication, no signs of bleeding, RUQUS showed cirrhotic liver and large volume ascites. ___ guided paracentesis on ___ was performed with 1.75L removed - no e/o SBP at that time, but he was continued on home cipro. He was diuresed with IV Lasix 40 and switched to PO torsemide 40mg BID with discharge weight of 220 lbs. #MALNUTRITION. ___ was placed ___ and tube feeds were started, with plan to continue at home. #LIVER TRANSPLANT EVALUATION. Per outpatient provider, liver transplant eval was expedited during admission. He is hepatitis C positive and is untreated and has higher chance to receive an organ with a lower meld score if there is a positive hep C organ offer. Most of his work-up was completed during this admission. Labs ordered, but pending at discharge include: LMK antibody, IGRA. Studies to be performed include: DEXA which could not be done as inpatient, and EGD which he preferred to get done as outpatient. # CODE: Presumed FULL # CONTACT: Name of health care proxy: ___ ___: wife Phone number: ___ Cell phone: ___ TRANSITIONAL ISSUES ==================== []Will need to complete DEXA, EGD for transplant work-up. []Will need ___ antibody, IGRA. []Monitor for fluid overload. Discharge Weight: 220 lbs, Discharge Cr: 1.0 []Should have weekly MELD labs []Should continue to have therapeutic paracenteses as needed</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p slip and fall on wooden floor at home, sustaining a left tibial plateau fracture. (-)head strike, (-) LOC, unable to ambulate on LLE after fall. No other injuries sustained. Orthopaedic surgery consulted to assess for tibial plateau fracture. Radiology showed 1. Comminuted, depressed fracture involving predominantly the lateral aspect of the tibial plateau, with intra-articular extension. 2. Small suprapatellar joint effusion. Radiology showed 1. Comminuted lateral tibial plateau fracture with 1.5 cm of depression. Fracture line extends to the tibial spines and the posterior medial most aspect of the medial tibial plateau. 2. Tiny fracture fragment at the fibular head. Radiology showed Multiple views of the left proximal tibia and fibula. Status post ORIF of the lateral tibial plateau with plate and screws. Improved alignment of the fracture. The hardware appears intact. Please see operative report for further details. Radiology showed 1. Suboptimal opacification. No evidence of large or central pulmonary thromboembolic disease. No pulmonary arterial hypertension or right heart strain. 2. No pulmonary mass, nodules or consolidations. No intrathoracic or axillary lymphadenopathy. The patient was diagnosed with FX UPPER END TIBIA-CLOSE, UNSPECIFIED FALL. The patient was treated with ORIF L 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 L tibia fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF L tibia, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The medical service was consulted for a sinus tachycardia. He was started on Amlodipine and will follow-up with the medical service. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TDWB in the LLE extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with a h/o CAD s/p DES to RCA, ___, DM2, ESRD s/p cadaveric transplant, with recent hospitalizations for decompensated heart failure and hypoglycemia, discharged ___, now re-presenting with worsening dyspnea and hypoxia. Patient became dyspneic and hypoxic at home on the day following discharge. She was given lasix 80mg with metolazone 2.5mg without improvement and went to the ED. Radiology showed 1. Bilateral pulmonary ground-glass densities along with septal thickening consistent with pulmonary edema. Small right and trace left-sided pleural effusion. 2. Extensive coronary artery calcifications. 3. Fissural opacities most likely atelectasis, however nodules cannot be ruled out. Follow up scan in 3 months to ensure resolution is recommended. Radiology showed 1. Absence of diastolic flow in the main and interpolar renal arteries is similar to ___. This is a nonspecific finding of parenchymal processes including rejection. 2. Sharp arterial upstrokes. No evidence of renal artery stenosis. Radiology showed Right PICC catheter tip malpositioned in the right IJ. Recommend repositioning. These findings were discussed with ___, IV nurse by Dr. ___ at 9:45am. Radiology showed 1. Irregularity of the lateral tibial plateau, which could represent a stress fracture in the correct clinical setting. If there is high concern, an MRI would be helpful. 2. Degeneratives of the patellofemoral compartment with medial 13 mm loose body. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS. At the time of discharge, the patient had Primary diagnosis: # Congestive heart failure exacerbation # 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>___ yo F with h/o CAD s/p DES to RCA, ___, DMII, ESRD s/p transplant, with multiple recent admissions for SOB attributed to decompensated heart failure, now re-presenting with worsening dyspnea. # SOB/dyspnea/hypoxia- Patient has had multiple episodes of flash pulmonary edema with the acute onset of shortness of breath with evidence of volume overload on exam. She has been difficult to diurese secondary to worsening renal function s/p transplant. During this admission, while diuresing patient on lasix gtt, other underlying causes for shortness of breath were explored. CT of the chest did not show any evidence of interstitial lung disease or other intrapulmonary processes. She was noted to have some pulmonary hypertension on echocardiogram, however this was more likely related to volume overload with elevated left sided pressures. Pulmonary was consulted and recommended re-trying CPAP, as patient had severe OSA on a past sleep study ___ years prior. Patient tolerated CPAP well. In addition, patient was ruled out for acute coronary syndrome with negative cardiac enzymes x 3, stable EKG, and normal stress test. Patient was diuresed on lasix gtt and lung crackles, shortness of breath, and hypoxia resolved. Once euvolemic, she was transitioned to oral torsemide 100mg daily. She maintained weights and her ins and outs were even on this dose. # ESRD s/p transplant- Baseline creatinine was 2.0-2.4, which has steadily risen during the last 3 admission. Urine sediment has been bland, supporting more hemodynamic instability and poor forward flow, as underlying cause of worsening renal function. Ultrasound of transplanted kidney showed no evidence of arterial stenosis or rejection. Tacrolimus levels were monitored throughout admission, and tacrolimus was titrated to goal trough ___. Patient was continued on mycophenolate mofetil as well. With lasix gtt, creatinine began to downtrend, likely due to improved renal perfusion. Creatinine was slightly increased to 4.5 on torsemide, and renal was aware. She will follow up closely with her nephrologist. # Diastolic heart failure- As above, decompensated heart failure drove shortness of breath and hypoxia. Ruled out for acute ischemic event causing decompensation. no clear precipitating factor for decompensation identified. Patient was diuresed on lasix gtt. Medical management of CHF was altered to decrease risk of ischemia; carvedilol was switched to metoprolol and isosorbide mononitrate was started. Amlodipine was also discontinued as blood pressures were well controlled on the above regimen. # Left leg pain- Patient complained of left leg pain, with point tenderness along tibia. X-ray showed no acute fracture. She was able to bear weight on the leg, and pain improved with standing tylenol ___ TID which should continue until pain improves. # CAD s/p DES to RCA- As above, ruled out for acute ischemic event. Continued aspirin 81mg daily and atorvastatin. # DMII- Patient's blood sugars have been very labile during past admissions, with hypoglycemic episodes. ___ followed closely during last admission with several changes, including discontinuing NPH BID and starting lantus 12 units qHS and repaglinide with humalog sliding scale. Patient was continued on this regimen and blood sugars remained stable. No changes were made to this regimen. # Hypothyroidism- Continued home levothyroxine # Transitional issues- - please continue autoset CPAP at ___ - patient will follow-up with pulmonologist Dr. ___ home CPAP - weight on discharge 63.7kg (140lb)- if weight increases, please increase torsemide dosing</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo M with a history of afib on Coumadin s/p cryoablation 1 month ago, RNY gastric bypass, and OSA who was admitted to the Acute Care Surgery Service on ___ with right upper quadrant abdominal pain. Ultrasound imaging showed distended gallbladder with thickened wall and perihepatic ascities. Given history of atrial fibrillation on Coumadin with recent cryoablation decision was made to proceed with percutaneous cholecystostmy. he was d/c after doing well, afebrile with stable vital signs. he reports drainage of 100-150cc bilious content per day ever since and came to the ED after the drain had stopped draining abruptly. Denies any fever, chills, nausea, vomiting. Continues to pass gas and have bowel movement. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. The cholecystostomy tube, although seen in the subcutaneous tissues in the right upper quadrant, is not definitively seen within the gallbladder and may have dislodged. 2. The gallbladder is mildly distended with mild asymmetric wall thickening compatible with known cholecystitis. 3. The gallbladder contains an echogenic focus near the neck of the gallbladder which may represent previously seen gallstone. 4. Dilation of the common bowel duct measuring 10 mm is new since the prior study. 5. Borderline splenomegaly. RECOMMENDATION(S): CT or fluoroscopic tube study recommended to confirm placement of the cholecystostomy tube. T-TUBE CHOLANGIO (POST-OP) showed Cholecystostomy tube has displaced with the tip at the level of the right lateral abdominal wall. MRCP showed 1. Interval improvement in the appearance of the gallbladder now partially distended with layering sludge. Persistent 2.0 cm stone in the gallbladder neck. No wall thickening or edema to suggest acute cholecystitis. 2. No pericholecystic fluid collection to suggest bile leak. 3. Cirrhotic liver morphology with small volume ascites and intra-abdominal/paraesophageal varices. 4. Unchanged fusiform dilation of the celiac trunk. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 8:54 am, 5 minutes after discovery of the findings. Radiology showed Percutaneous placement of a cholecystostomy tube into the gallbladder was attempted. The pigtail of the cholecystostomy tube was noted to be outside the gallbladder, located between the gallbladder and the hepatic flexure of the colon. An attempt to reposition the tube into the gallbladder was unsuccessful. The surgical attending taking care of the patient was contacted immediately and a decision to remove this tube surgically was made. The patient was then transferred to the surgical ICU in a hemodynamically stable condition. Radiology showed Percutaneous placement of a cholecystostomy tube into the gallbladder was attempted. The pigtail of the cholecystostomy tube was noted to be outside the gallbladder, located between the gallbladder and the hepatic flexure of the colon. An attempt to reposition the tube into the gallbladder was unsuccessful. The surgical attending taking care of the patient was contacted immediately and a decision to remove this tube surgically was made. The patient was then transferred to the surgical ICU in a hemodynamically stable condition. CHEST PORT LINE/TUBE PLCT 1 EXAM showed The endotracheal tube tip lies approximately 3.5 cm above the carina. Orogastric tube extends to the stomach, though the side port is at or above the esophagogastric junction. It should be pushed forward at least 5-8 cm. When compared with the study of ___, there are much lower lung volumes, which, in addition to the supine rather than upright position of the patient, may account for the the substantial increase in the transverse diameter of the heart and with the mediastinum. No evidence of pulmonary vascular congestion. Although no discrete consolidation is appreciated, given the low lung volumes and size of the cardiac silhouette, it would be impossible to exclude superimposed pneumonia/aspiration in the appropriate clinical setting, especially in the absence of a lateral view. CHEST PORT. LINE PLACEMENT showed In comparison with the earlier study of ___, the right IJ catheter extends to the mid SVC. No evidence of pneumothorax. Otherwise, little change. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are unchanged. Again there is substantial enlargement of the cardiac silhouette with pulmonary vascular congestion and bilateral layering pleural effusions with compressive atelectasis at the bases. Given the extensive changes described above, would be very difficult to exclude superimposed aspiration/pneumonia in the appropriate clinical setting, especially in the absence of a lateral view. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___. Previous mild pulmonary edema is almost resolved. Severe cardiomegaly and mediastinal venous engorgement have improved. Patient has been extubated, but atelectasis is relatively mild, right lung base. Small bilateral pleural effusions persist. No pneumothorax. Right jugular line ends in the upper SVC. Radiology showed Streaky opacities in both lower lungs likely reflect atelectasis. No evidence of pulmonary edema. The patient was diagnosed with Displacement of internal prosth dev/grft, init, Exposure to other specified factors, initial encounter, Unspecified abdominal pain, Unspecified atrial fibrillation, Long term (current) use of anticoagulants. The patient was treated with ___: Diagnostic laparoscopy, biliary drain removal and replacement, extensive lysis of adhesions, vac placement, hernia repair. ___: Transesophageal Echocardiogram (TEE) ___: Electrical cardioversion of atrial fibrillation to sinus rhythm.. At the time of discharge, the patient had Displaced percutaneous cholecystostomy tube Sepsis Uncontrolled arial fibrillation with rapid ventricular response. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ old man with a history of cholecystitis and atrial fibrillation with rapid ventricular response and recent cardiac ablation, who presented ot the ED on ___ when he noted that his percutaneous cholecystostomy tube had been dislodged. He did get a drain study in the ED, which noted the cholecystostomy tube in his subcutaneous tissue. He was admitted to the hospital thereafter because he felt uncomfortable, but that this point he was afebrile with stable vital signs within normal limits, he had no abdominal tenderness, and he had normal LFTs. Interventional radiology was consulted for replacement of the perc chole tube, but given that he had normal labs and was asymptomatic and they were hesitant about reinserting the tube, we agreed to obtain an MRCP to discern if the cystic duct was still obstructed and that he would still need gallbladder drainage. On HD#2, he received 2 units of FFP for elevated INR (patient takes Coumadin at home for afib), and MRCP was performed showing persistent obstruction of cystic duct. Overnight, he developed afib with RVR, and was treated with IV metoprolol. On HD#3, he was triggered for Afib RVR and hypotention requiring fluid bolus, IV metoprolol, and IV diltiazem. He was given another 1U FFP and 10mg IV vitamin K to reverse his INR. With the development of Afib RVR, Mr. ___ then also started to appear diaphoretic, and he did develop some abdominal pain. At this point, since his clinical picture appeared to be trending towards sepsis/recurrent cholecystitis, he was taken urgently to ___ for replacement of the cholecystostomy tube. At this point he was also started on antibiotics. For full details of this procedure, please refer to the separately dictated procedure note. Briefly, the cholecystostomy tube appeared to be inserted through and through the gallbladder and there was some concern of other visceral organ penetrance as there was difficulty withdrawing the tube. He did also develop rigoring and continued to be in rapid ventricular response from afib. He was transferred emergently to the ICU for resuscitation where he was intubated, got an arterial line and central line, and was then taken to the operating room for exploratory laparoscopy. He underwent an exploratory laparoscopy, right upper quadrant washout, removal and replacement of percutaneous cholecystostomy, and midline would vac placement. He appeared to tolerated the procedure well, but was on a low dose of neosynephrine drip by the end of the case, so remained intubated and was transferred back to the ICU for further monitoring. For full details of this procedure, please refer to the separately dictated operative report. He was started on an amiodarone drip overnight for improved rate control with good effect. On POD#1, as he was still on vasopressor, this was changed from neosynephrine to levophed for presumed sepsis. He was weaned to minimal ventilator settings. On POD#2, he was weaned off of levophed. He was extubated without issue. He started to trial a clear liquid diet which he tolerated well. His amiodarone drip was transitioned to PO; however, he then briefly required a diltiazem drip for rate control. He was changed to PO overnight. He was briefly on neosynephrine again overnight, but this was weaned off by POD#3. On POD#3, his PO diltiazem was increased in dosage. He was allowed to have a regular diet, which he tolerated well. His wound vac was changed and the base appeared to be clean and healing well. His foley was discontinued, along with his arterial line and central line. He was restarted on his home Coumadin. At this point, he was deemed stable for transfer to the floor. POD4 the patient completed course of antibiotics. Physical therapy worked with the patient and was recommending rehab. The patient continued to have episodes of atrial fibrillation with RVR. Cardiology was uptitrating medications without good effect in controlling heart rate. The patient was also having episodes of hypotension, which were responsive to fluid resuscitation. Given the inability to control the patient's rates with antiarrhythmics and nodal blockade, cardiology opted to proceed with TEE due to subtherapeutic INR ___ followed by DC cardioversion. On ___, the patient underwent successful DC cardioversion, which he tolerated well. Post cardioversion, the patient was in normal sinus rhythm. He resumed his home AF regimen of digoxin and amiodarone, and was educated on the importance of maintaining a therapeutic INR and cardiology follow-up. Physical therapy re-evaluated the patient and he was cleared for discharge home with ___. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin until INR was therapeutic, and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The percutaneous cholecystostomy tube was draining bile and the patient's surgical wound was filling in with healthy granulation tissue. The JP drain was draining serosanguinous fluid. The patient was discharged home with ___ services for wound VAC care and drain care. The patient and his partner received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with the past medical history of Roux-en-Y gastric bypass ___, recent laparoscopic cholecystectomy, recent admission for abdominal pain and transaminitis thought to be secondary to passed stone (discharged ___, who presents to the ER with continued abdominal pain. She stated that she was pain-free on discharge, but it returned 2 days after discharge. It is sharp, sever, some radiation to the right and left aside, associated with nausea, but not vomiting, and not improved or worsened with eating. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Status post cholecystectomy. No sonographic evidence of choledocholithiasis. Mildly dilated common bile duct, measuring up to 7 mm distally, presumably secondary to cholecystectomy, noting that caliber has somewhat fluctuated compared to prior CT and MRCP. NOTIFICATION: The updated impression was discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 8:10 am, 10 minutes after discovery of the findings. MRCP showed 1. Expected postsurgical changes post cholecystectomy with mild intrahepatic biliary duct dilation. No common bile duct dilatation or choledocholithiasis. Normal pancreatic duct. 2. Postsurgical changes from Roux-en-Y gastric bypass. 3. Replaced right hepatic artery. Radiology showed No evidence of pneumoperitoneum. Nondilated air-filled loops of small and large bowel are likely the result of recent upper and lower endoscopies. The patient was diagnosed with Right upper quadrant pain, Left upper quadrant pain, Melena. The patient was treated with Colonoscopy and EGD ___ Advanced upper endoscopy with suture removal ___. At the time of discharge, the patient had Internal Hemorrhoids Abdominal pain possibly secondary to a retained stitch after gastric bypass surgery. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with the past medical history of Roux-en-Y gastric bypass ___, recent laparoscopic cholecystectomy, recent admission for abdominal pain and transaminitis thought to be secondary to passed stone (discharged ___, who presents to the ER with continued abdominal pain and concern for GI bleeding.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ y/o M with SCC of esophageal with bony metastases, here with uncontrolled back pain at home. Of note, patient was recently admitted ___ with severe lower back pain. During that admission, he was found to have new spinal mets to T8, T12 and L5 with pathologic compression fracture of L5 with retropulsion, S1 cord impingement and spinal stenosis. He was initially placed on dexamethasone due to concern for cord compression but his neurologic exam was intact and steroids were stopped. His home oxycontin was increased and he was continued on oxycodone for breakthrough pain. Radiology showed 1. Transitional anatomy at the lumbosacral junction. Correlation with the CT portion of the ___ FDG tumor imaging study demonstrates that there are 12 rib-bearing vertebrae, four lumbar-type vertebrae, and a partially sacralized L5. Please note that this numbering is discordant with ___ MRI report. 2. Lytic lesion in the L4 vertebral body with a pathologic fracture, retropulsion, and epidural mass, resulting in severe spinal canal narrowing. The spinal canal is better assessed on the preceding MRI. The patient was diagnosed with BACKACHE NOS, SECONDARY MALIG NEO BONE. At the time of discharge, the patient had Esophageal Adenocarcinoma with bone and pulmonary metastases Back Pain New vertebral lesion. The patient was given written instructions concerning 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 metastatic esophageal cancer to bone s/p recent left femur intramedually nail placement and XRT and recent hospitalization with discovery of new spinal mets presenting for pain control. Hospital course is summarized by problems below: # Back Pain/Spinal metastasis: At time of last presentation patient found to have new spinal mets to T8, T12 and L5 with pathologic compression fracture of L5 with retropulsion, S1 cord impingement and spinal stenosis. He was evaluated by the ortho-spine service and kyphoplasty was considered but his pain improved with conservative therapy and this was deferred. He was also seen by XRT and underwent a session of radiotherapy to his spine for pain control. His home oxycontin was increased and he was continued on oxycodone for breakthrough pain. Currently patient is presenting with worsened back pain poorly controlled on home medications. CT of lumbar spine was done and showed new L4 lesion with repropulsion resulting in severe spinal canal narrowing. Patient was evaluated by orthopedic surgery and declined surgical intervention at this time. He was provided at ___ back brace to wear at all times while out of bed. He was evalauted by physical therapy and did well, thus being cleared for discharge home. He was continued on oxycontin and oxycodone for pain control. He was started on steroid taper with demathesone 8 qam and 4 qpm. He was continued on calcium carbonate for. He was instructed to wear back brace while out of bed. # Metastatic SCC of the esophagus: Patient is status post liver biopsy with pathology consistent with metastatic esophageal adenocarcinoma. Dr ___ was made aware of patient's admission. #Hyperglycemia: Patient had recordings of critically high blood sugars since starting steroids. He was started on lantus and ISS. Wife was taught how to administer insulin. Patient was provided detailed instructions to stop lantus once am blood sugar less than 150. Hyperglycemia will improve with steroid taper. Patient will benefit from HgA1C in the future. # Prostate CA - ___ 6, s/p XRT, in remission. # EtOH-related cirrhosis: No current asterixis or signs of hepatic encephalopathy. Continued on rifaximin and lactulose # ___ disease s/p left hepatic lobectomy and cholecystectomy for left hepatic duct stricture ___: Continued on ursodiol.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ right hand dominant male who had a fall onto his left shoulder the day prior to admission while playing soccer. He denied headstrike or loss of consciousness. Initially evaluated at a local ED, then followed up in ___ clinic at ___, where he was referred to ___ ED for surgical consultation. Endorses paresthesias overlying the deltoid, lateral arm and forearm, and entire hand. No weakness. No pain elsewhere. HUMERUS (AP AND LAT) LEFT IN O.R. was done. Left shoulder CT showed Comminuted fracture of the proximal left humerus, detailed above, with impaction and anterior displacement of the major distal fragment and extension into the articular surface of the humerus. Posterior subluxation of the humeral head with respect to the glenoid. Radiology showed There is a fracture plate with associated screws fixating a surgical neck fracture of the left humerus. Fracture extends into the greater tuberosity. No hardware related complications are identified. The patient was diagnosed with Unsp disp fx of surgical neck of left humerus, init, Fall on same level, unspecified, initial encounter. The patient was treated with ORIF, left proximal humerus fracture. At the time of discharge, the patient had Left proximal humerus fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left proximal humerus fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction and internal fixation, 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 home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is moderate risk for DVT 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: ___ ___ speaking woman with history of DM, non-insulin dependent, with gradual onset left wrist pain, redness, swelling over course of last 3 days. Denies similar findings anywhere else on body or hx of this in the past. Denies injury to the area. Denies fevers/chills, N/V/D. Denies any lymph node swelling. Has not taken anything for pain. Radiology showed No evidence of fracture or dislocation. The patient was diagnosed with CELLULITIS OF ARM, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. At the time of discharge, the patient had Cellulitis without joint involvement. The patient was given written instructions concerning 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 AND ACTIVE ISSUE 89 ___ speaking woman with left wrist pain, redness, swelling concerning for cellulitis. Seen by Plastics in ED for rule out compartment syndrome. No proximal tendon involvement or significant pain on palpation of cellulitic area. Given mobility of joint this is unlikely septic arthritis although osteoarthritis in that joint would predispose. Given diabetes treated this as complicated skin infection with one day of vancomycin switching over to Keflex and Bactrim to complete a 10 day course of total antibiotics (to finish on ___. Overnight on ___ had sundowning which was treated with 2.5mg olanzapine. INACTIVE ISSUES # DM: Non insulin dependent at home. Held home glipizide, metformin and placed on diabetic diet with ISS in house. # HoThyroid: cont home Levo # HTN/Hyperlipidemia: continued home atenolol, amlodipine, lisinopril, ASA TRANSITIONAL ISSUES # DNR/DNI cooberated with patient # Assess for resolution of infection</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a history of hypertension, hepatitis C s/p Harvoni with negative viral load ___, alcohol abuse, and biopsy-proven cirrhosis, who presents with abdominal distension, nausea and vomiting. He was recently discharged to rehab on ___ for ORIF of R bimalleolar fracture after tripping on a curb. Patient had acute onset of nausea and bilious vomiting since 8pm last night. He initially had some epigastric abdominal pain last night but his pain has since resolved. He is not passing flatus, and his last bowel movement was 1 week ago. He denies chest pain, shortness of breath, fevers, or chills. He states he has not had alcohol since his hospitalization. He has no history of abdominal surgery, and he has never had a bowel obstruction in the past. His last colonoscopy was ___ which showed several polyps. His last EGD was in ___ which showed absence of esophageal varices. CHEST (PORTABLE AP) showed Malpositioned nasogastric tube coiled in the upper neck. Otherwise, no acute findings. RECOMMENDATION(S): Follow-up x-ray to verify location of the repositioned nasogastric tube. NOTIFICATION: Findings were discussed with ___ MD at 5am. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___. Nasogastric drainage tube ends in the upper portion of a nondistended stomach. Lungs clear. Heart size normal. No pleural abnormality. CT ABD AND PELVIS W/O CONTRAST showed 1. Slight decrease in caliber of some small-bowel loops in the right lower quadrant. Findings probably reflect a degree of persistent partial small bowel obstruction. Enteric contrast material has diluted and/or passed. 2. Indeterminate 1.1 cm left adrenal nodule. Consider adrenal protocol CT or MRI. 3. Multiple soft tissue lipomas. A right serrated anterior lipoma is heterogeneous, but unchanged in size since at least ___ and therefore likely benign. Heterogeneity may reflect edema or inflammation given the asymmetric presence of edema in the adjacent right lateral chest wall. Attention on any follow-up imaging. RECOMMENDATION(S): Indeterminate 1.1 cm left adrenal nodule. Consider adrenal protocol CT or MRI. Radiology showed Multiple dilated loops of small bowel with some gas within the colon, consistent with a partial small bowel obstruction. Abdominal radiographs, four views. showed Persistent dilatation of proximal small bowel with air-fluid levels. In the early postoperative course, ileus is most likely although the imaging pattern can be seen with obstruction. Continued follow-up radiographs may be appropriate. Chest radiograph, portable AP upright. showed No evidence of acute cardiopulmonary disease. CHEST PORT. LINE PLACEMENT ___ showed Compared to chest radiographs ___ through one ___. New endotracheal tube in standard placement. Lungs grossly clear. Heart size top-normal. No pulmonary mediastinal vascular engorgement. No pleural abnormality. Right jugular line ends in the low SVC. No mediastinal widening. Esophageal drainage tube ends in the upper portion of a nondistended stomach. Source of lactic acidosis, showed 1. Small bowel loops are seen dilated up to 4.5 cm, without definite transition point seen. The distal small bowel is collapsed. This most likely represents small bowel ileus. An evolving small bowel obstruction would be difficult to exclude. 2. The gallbladder contains multiple small stones, with wall thickening. There is small amount of fat stranding surrounding the gallbladder, with irregularity of the wall, but with no distention, query cholecystitis. Recommend further evaluation with ultrasound. 3. Small amount of new ascites, which could be within normal limits postoperatively. 4. Please see the report of the CT chest performed on the same day for details on the chest RECOMMENDATION(S): Recommend further evaluation of the gallbladder with ultrasound. CT CHEST W/CONTRAST showed Severe bilateral pulmonary embolism with right heart strain. No evidence of parenchymal infarction. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, there is been a and neck mo insertion. The endotracheal tube tip lies approximately 1.5 cm above the carina. Right IJ catheter extends to the mid SVC. Nasogastric tube loops within the upper stomach. No evidence of pneumothorax. There are lower lung volumes with stable cardiomediastinal silhouette. Indistinctness of pulmonary vessels suggests some elevation of pulmonary venous pressure. Increased opacification at the left base with obscuration hemidiaphragms could reflect merely atelectasis and effusion. However, in the appropriate clinical setting, would be difficult to exclude aspiration/pneumonia. BILAT LOWER EXT VEINS showed 1. Deep venous thrombosis extending from the right popliteal vein to the peroneal and posterior tibial veins. 2. Deep venous thrombosis extending from the left femoral vein to the peroneal and posterior tibial veins. RECOMMENDATION(S): The findings were discussed with ___ team, M.D. by ___ ___, M.D. on the telephone on ___ at 9:57 am, 1 minute after discovery of the findings. CHEST (PORTABLE AP) showed 1. New right upper lobe opacity with volume loss, presumably collapse. 2. Persistent bibasilar atelectasis and small pleural effusions. 3. Midline radiopaque ribbon in place. Presumably part of the buttress for the open chest. Attention follow-up is needed. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:07 am, 1 minutes after discovery of the findings. CHEST (PORTABLE AP) showed 1. Right upper lobe collapse is unchanged, status post bronchoscopy. 2. Endotracheal tube terminates 2.6 cm above the carina. Radiology showed Support lines and tubes are unchanged in position. Cardiomediastinal silhouette is within normal limits. There is a persistent left retrocardiac opacity. There has been improved aeration of the right upper lobe collapse since previous. There remains low lung volumes. There are no pneumothoraces. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. Mildly cirrhotic hepatic parenchyma without focal lesion. Trace perihepatic ascites. 2. Patent hepatic vasculature. 3. Small right pleural effusion. CHEST (PORTABLE AP) showed New right middle lobe atelectasis and small bilateral pleural effusions. CHEST (PORTABLE AP) showed Interval re-expansion of the right lower lung. CHEST (PORTABLE AP) showed In comparison with the study of ___ the 5, the right hemidiaphragmatic contour is obscured and there is hazy opacification at the base, consistent with layering pleural effusion and compressive atelectasis. Poor definition of the minor fissure could represent loculated fluid. Poor definition of the left hemidiaphragm is unchanged. The monitoring and support devices are stable. Indistinctness of pulmonary vessels suggests some increasing pulmonary venous pressure. CHEST (PORTABLE AP) showed Moderate right greater than left pleural effusions and atelectasis, increased. CHEST (PORTABLE AP) showed 1. Interval removal of ECMO cannulation devices. 2. Persistent moderate pulmonary edema and layering small to moderate size right pleural effusion. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 6:22 pm. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring support devices are stable. Continued elevation of pulmonary venous pressure. The layering pleural effusions with basilar atelectasis appear less prominent than on the previous study, though this could merely represent a more upright position of the patient. CHEST (PORTABLE AP) showed Interval prominence of the mediastinum, presumably postprocedural. No large pneumothorax. Pulmonary edema and bilateral pleural effusions persist. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the monitoring and support devices are stable. The and margin of the aortic arch is now sharply seen. Continued pulmonary vascular congestion with bilateral layering pleural effusions and compressive atelectasis at the bases. Radiology showed Interval improvement in the extent of small-bowel dilatation. Radiology showed There is a distal fibular fracture plate and three syndesmotic screws. No hardware related complications are seen. Ununited fracture of the medial malleolus is not fixated. Ankle mortise is relatively preserved. There is soft tissue swelling. There are no new fractures. Degenerative changes of the talonavicular joint are stable. CHEST (PORTABLE AP) showed In comparison with the study of ___, following chest tube removal there is no evidence of pneumothorax. Other monitoring and support devices are stable. Cardiomediastinal silhouette is unchanged though there is increasing bilateral pleural effusions with compressive basilar atelectasis and continued pulmonary vascular congestion. CT ABD AND PELVIS W/O CONTRAST showed 1. Overall improved distention of the small bowel suggesting resolving ileus. Oral contrast from prior exam reaches the terminal ileum. 2. Oral contrast from current exam reaches the second portion of the duodenum where there is slight wall thickening which may represent edema or underdistention, incompletely assessed. This could be further evaluated with endoscopy or fluoroscopy on an outpatient basis. 3. Enteric tube terminates in the stomach with side port beyond the gastroesophageal junction and tip abutting the gastric wall. Given high residuals, this could be advanced slightly for optimal positioning. 4. Postoperative changes with mild anasarca. No drainable fluid collection. 5. Severe bibasilar atelectasis and small pleural effusions, partially visualized. 6. Previously seen pericholecystic stranding has resolved. 7. Borderline nonspecific porta hepatis and pericaval lymph nodes, possibly reactive. CR - CHEST PORTABLE LINE TUBE PLACEMENT 4 EXAMS showed There are postsurgical changes from CABG. There has been interval placement of a Dobbhoff enteric tube which terminates in the distal body of the stomach on the final image. The remaining support lines and tubes are in stable positions. Small to moderate bilateral pleural effusions (right greater than left) are not significantly changed compared to prior study. The cardiac silhouette is mildly enlarged with pulmonary vascular congestion but no overt pulmonary edema. There is no focal consolidation or pneumothorax. The osseous structures are stable in appearance. Radiology showed There is an enteric tube which now terminates in the second portion of the duodenum. Surgical skin staples are seen along the right to lower mid abdomen. There are surgical clips in the right groin. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. A moderate right and small left pleural effusion, appear unchanged compared to prior study. CHEST (PORTABLE AP) showed Enteric feeding tube advanced into the stomach. CHEST (PORTABLE AP) showed Comparison to ___. All monitoring and support devices are in stable position. Lung volumes have minimally decreased. The pre-existing bilateral pleural effusions have also slightly decreased, with resulting improved ventilation of the lung bases. No other relevant changes are noted. Stable correct alignment of the sternal wires. CHEST (PORTABLE AP) showed Interval removal of endotracheal tube and enteric tube. Small bilateral pleural effusions, as before. No new focal consolidations. CHEST (PORTABLE AP) showed NG tube projects below the left hemidiaphragm. Right IJ line is unchanged. Lungs are low volume with bibasilar atelectasis. There are small bilateral effusions. Cardiomediastinal silhouette is stable. Mild pulmonary vascular congestion is unchanged. No pneumothorax. ANKLE (2 VIEWS) RIGHT showed There is a distal fibular fracture plate with 3 sin dense ___ screws, unchanged in position since the prior study. No hardware related complications are seen. Note is again made are ununited fracture of the medial malleolus, which was not fixed. Ankle mortise is relatively preserved. Soft tissue swelling is unchanged. No new fractures are seen. There are degenerative changes involving the talonavicular joint, unchanged. A calcaneal spur is also noted. CT LOW EXT W/O C RIGHT Q61R showed Trimalleolar right ankle fracture status post ORIF, in near anatomic alignment without evidence for hardware complication. No evidence of osseous bridging or significant callus formation. CHEST (PA AND LAT) showed 1. Interval improvement in pulmonary vascular congestion, now mild with minimal residual interstitial pulmonary edema and small pleural effusions, if present at all. No pneumothorax. 2. Bibasilar airspace opacities may represent atelectasis in the setting of low lung volumes, however superimposed infection is difficult to exclude. The patient was diagnosed with Nausea with vomiting, unspecified. At the time of discharge, the patient had Primary: Small Bowel Obstruction s/p ex lap PE s/p thrombectomy, Bilat DVT s/p IVC filter Cardiogenic shock/Right heart failure s/p VA ECMO hypoxic respiratory failure rt ankle ORIF HIT positive Pseudomonas UTI Secondary: PMHx: cirrhosis, EtOH abuse, up to a pint of rum daily, HYPERTENSION, HEPATITIS C, KNEE PAIN, SEXUAL DYSFUNCTION, OSTEOARTHRITIS, H/O ELEVATED BLOOD SUGAR. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ was recently admitted to our institution after an unwitnessed fall on ___ while intoxicated. He broke his ankle, and was admitted to the Ortho service after ORIF of the ankle. He returned to the hospital on ___ with abdominal pain and was diagnosed with SBO. He was managed conservatively initially, but ultimately went to the ___ for exploratory laparotomy on ___. No transition point was identified, and no bowel resection or further intervention was required. Since then, Mr ___ was doing well until he became acutely short of breath, and was transferred to the TSICU. He was intubated, and required pressors- his lactate was elevated to 10. Cardiac troponin was also elevated to 0.15. A bedside echocardiogram was performed with RV enlargement, and in this setting a CT angiogram was performed that identified proximal R and L main PA clots. MASCOT and cardiac surgery were consulted for additional recommendations and management of massive PE. He was again brought to the operating room on ___ for emergent pulmomary embolectomy/VA ECMO(right femoral). He was brought to the CVICU in critical condition with an open chest. He returned to the operating room the same day for re-exploration related to bleeding, the bleeding was controlled and he returned to the CVICU in critical condition on multiple pressors and inotropes. He continued to be supported for cardiopulmonary failure on ECMO for several days, during that time he was paralyzed and sedated d/t open chest, he was also found to be HIT positive and was started on bivalrudin. He weaned from ECMO and returned to the operating room for chest closure and decannulation on ___. Over the next week he was started on tube feeds and gradually weaned from the ventilator and his vasopressors. He was extubated on ___ but remained in the CVICU for several more days to monitor his pulmonary status and to wean off hiFlo oxygen. He finally transferred to stepdown floor on ___ for continued care and recovery. During this time he continued to be evaluated by speech and swallowing service and his diet was gradually advanced. He was found to have a Pseudomonas UTI and was initially started on Cipro but developed a prolonged QT and was therefore changed to Ceftazidime. He continued to be extremely deconditioned, progressed slowly and was screened for rehabilitation. He transferred to ___ ___ on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is an ___ y/o M with PMHx significant for prostate CA c/b recent large bowel obstruction s/p resection with colectomy and end-ileostomy, also with chronic indwelling Foley, here with hematuria since ___. Since ___, urine has become progressively more dark and red, with clots present. Patient also endorses generalized fatigue, weakness, lightheadedness. Also with recent SOB and associated chest heaviness. He does endorse recent mechanical fall. No head strike, no LOC. No prodromal symptoms. In addition to the above s/s, the patient endorses some intermittent discomfort from his urinary catheter as well as some discomfort at his incision site. ROS also significant for LOA and weightloss. Radiology showed 1. Moderate bilateral hydronephrosis, unchanged in appearance from previous CT examination. 2. Two simple-appearing right renal cysts. Radiology showed 1. Occlusive thrombus in the left lower extremity: common femoral, superficial femoral, popliteal, and one of the peroneal veins. 2. No evidence of deep vein thrombosis in the right lower extremity. Incidentally, an enlarged lymph node is seen in the right inguinal area 2.1 cm in short axis. The above results were communicated via telephone by Dr. ___ to Dr. ___ at 3:53 p.m. on ___. This finding was discovered at 3:48 p.m. on ___. The patient was diagnosed with URIN TRACT INFECTION NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, HX-PROSTATIC MALIGNANCY. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Pt is an ___ y/o M with PMHx significant for prostate CA c/b recent large bowel obstruction s/p resection with colectomy and end-ileostomy and with chronic indwelling Foley presented with hematuria since ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: EU Critical ___ is a ___ old woman with a history of hypertension and partial gastrectomy who was brought to OSH after she was found aphasic and received tPA. CHEST PORT. LINE PLACEMENT showed Endotracheal and endogastric tubes positioned appropriately. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No evidence of hemorrhage, infarction, or edema. Age-appropriate diffuse parenchymal volume loss. 2. CTA head demonstrates no stenosis, occlusion, or aneurysm greater than 3 mm. Moderate calcifications of the cavernous segments of bilateral internal carotid arteries without stenosis. 3. CTA neck demonstrates vascular calcification without stenosis, occlusion, or dissection. 4. Mild emphysematous changes with pleuroparenchymal scarring and atelectasis. Degenerative changes of the cervical spine. Nonspecific enlargement of the left thyroid gland with atrophy on the right. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. Previous mild pulmonary edema has cleared, but moderate to severe cardiomegaly is unchanged. No appreciable pleural effusion. No pneumothorax. Tip of the endotracheal tube with the chin flexed, though only 2.5 cm from the carina is probably acceptable. Nasogastric drainage tube passes into the stomach and out of view. MR HEAD W/O CONTRAST showed 1. There is no evidence acute intracranial process or hemorrhage. Scattered foci and areas of T2/ FLAIR high-signal intensity are seen in the subcortical and periventricular white matter, which are nonspecific and may reflect changes due to small vessel disease. 2. Mucosal thickening is identified in the sphenoid sinus and anterior ethmoidal air cells, suggesting an ongoing inflammatory process. The patient was diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac. The patient was treated with - Endotracheal Intubation (11.29). At the time of discharge, the patient had Acute Ischemic Stroke Atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented with aphasia and was given tPA. She was found to be in atrial fibrillation. She also had a GTC seizure shortly after the tPA administration, for which she was briefly intubated. She was monitored and her symptoms improved the day after admission. She continued to have mild aphasia, but by day 2 was at baseline. CTA and MRI brain were negative for occlusions or infarcts, old or new. EEG was negative for any epileptiform activity. - She was started on Eliquis 2.5mg BID as she was also found to be in new onset afib. We discussed this with the patient and told her of the risks benefits and she decided to accept treatment in order to prevent any future strokes given her a-fib. - She was also started on Keppra 500mg BID. This will be continued for 2 months only. - She will follow-up with Dr. ___ of stroke neurology. -Patient was also monitored closely on ___ protocol given her history of heavy recent alcohol use (multiple drinks of wine per day). She did not require any additional medications. She was also started on folate and thiamine for nutrition supplements. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (X) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented? (x) Yes (LDL =82 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A TRANSITIONS OF CARE ISSUES: 1. Patient to take apixaban 2.5mg BID for new onset afib for stroke prevention 2. Patient to also take keppra (levericeteram) 500mg BID for the next two months 3. You will follow up with the neurologist after discharge on the appropriate appointment date 4. Please also follow up with your PCP ___ ___ weeks from discharge </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with pulmonary sarcoidosis, seizure disorder on lacosamide and zonesamide, chronic back pain on ___, closed treatment of her right proximal humerus fracture in ___, right bimalleolar ankle fracture and psychotic disorder NOS. She presents to ED with one day history of sudden onset pain to the right thigh, extending from her knee to her hip. It started yesterday when she bent over to get something under her bed. When she stood up she started getting pain in her thigh. Throughout the day, she was moving several small boxes in and out the closet. Per husband, she has had several musculoskeletal strain on her right side due to falling after seizures (she was previously going to physical therapy for her R ankle and arm). Radiology showed No definite acute cardiopulmonary process. Proximal right humeral fracture which is incompletely visualized and may be old; however, clinical correlation is suggested and dedicated exam can be performed if clinically indicated. Radiology showed No fracture. Radiology showed No right lower extremity deep vein thrombosis. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, RESPIRATORY ABNORM NEC, PAIN IN LIMB, SARCOIDOSIS. At the time of discharge, the patient had Right groin muscle strain Epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with pulmonary sarcoidosis, seizure disorder on lacosamide and zonesamide, chronic back pain on ___, closed treatment of her right proximal humerus fracture in ___, right bimalleolar ankle fracture and psychotic disorder NOS presents with one day history of right thigh pain complicated by seizure in the ED. # Seziure. History of seizure disorder on AED. It appears she missed her AEDs in setting of the all the events of the day. s/p ativan and versed. Could be secondary to underlying metabolic or infectious etiology. Has normal electrolytes. CXR normal. UA normal. Restarted home lacosamide 250 mg po BID and zonesamide 100 mg TID . Neurology saw the patient with no new recs and concluded seizure likely part of her known seizure disorder. Patient had no other seizure episodes in the hospital. . # Right thigh pain: Physical exam intact with no signs of neurological cause, septic joint or trauma. Pain is diffuse throught the thigh and not localized to one anatomical site or structure. Negative straight leg raise, no neurological deficits on physical exam. Studies for fracture and DVT negative. Likely IT band or muskuloskeletal. . # Leukocytosis: Unsure of the etiology. Stress vs infectious. UA normal. CXR normal. Blood cultures are pending. Low pre-test probability for septic joint. Leukocytosis normalized prior to discharge. # Psychotic disorder NOS: One night during hospitalization reported hearing voices. Continued home haldol 10 mg po qhs. EKG normal QT interval. Made appointment to follow up with Dr. ___ (___) on ___. # chronic overactive bladder: patient on enablex ___ qd but did not take during hospital stay. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ with a history of bowel obstruction in setting of metastatic colon cancer s/p multiple surgeries including palliative partial colon resection (___), hemicolectomy with end to end ileocolostomy (___), and duodenal and ureteral stenting (___) now presenting from OSH with 48 hrs of intractable nausea, vomiting, and abdominal pain. He reports vomiting a total of 14 times and describes contents as bilious or undigested food (if recently eaten). Pt is currently undergoing chemotherapy (C1D4 of irinotecan, last dose on ___, for which he takes zofran for expected nausea, but he was unable to keep meds down. Denies hematochezia, fever, chills. Last meal before symptoms began consisted of chicken; no new or uncooked foods.Abdominal pain is concentrated in the periumbilical area and relieved with emesis. Last BM was this morning and was rather small consisting of a few drops (after beginning chemo, pt has had constant diarrhea). Last time pt passed gas was during BM in AM. Since then, pt denies passing any gas. OSH's KUB revealed air/fluid levels consistent with obstruction. Radiology showed 1. Small-bowel obstruction with a point of transition in the right hemiabdomen and adjacent to the previously visualized collection and tumoral enhancement. 2. Previously visualized subhepatic right upper quadrant collection has decreased in size and now measures 4.5 x 0.9 cm compared to 9.3 x 2.8 cm previously. The previously visualized pigtail catheter has been removed. 3. Stable appearance of peritoneal carcinomatosis as well as anterior abdominal wall extension near the umbilicus. Radiology showed Interval left upper extremity PICC placement with the tip at the cavoatrial junction. Radiology showed 1. Interval progression of the small-bowel obstruction with small bowel loops now dilated up to 5.3 from previously 4.1 cm (___). 2. Large contiguous tumor mass extending from the duodenum into the right lower quadrant causing small-bowel obstruction by encasing a right lower quadrant small bowel loop and extending anteriorly into the rectus muscle (L>R), umbilicus and linea ___, and peritoneum, unchanged since ___. 4. There is no free fluid and no free air. 5. Mild-to-moderate right hydronephrosis, progressed since ___. 6. Splenomegaly measuring 14 cm. The patient was diagnosed with INTESTINAL OBSTRUCT NOS, MAL NEO RETROPERITONEUM, SEC MALIG NEO SM BOWEL, MAL NEO LYMPH INTRA-ABD, HX OF COLONIC MALIGNANCY. The patient was treated with ___ Colonoscopy with ileocolic dilitation. ___ Laparotomy with enterocolostomy. At the time of discharge, the patient had Bowel obstruction- malignant Tachycardia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted on ___ to the General Surgical Service for evaluation and treatment of his small bowel obstruction. Patient was initially managed conservatively with bowel rest. He had a nasogastric tube inserted and was NPO/ IV fluids with antiemetics for nausea. On ___ the patient had a colonoscopy performed along with dilitation of the ileocolonic anastamosis. Following the procedure the patient continued to be NPO and on IV fluids. Over the course of the next few days the patient had episodes of emesis of both "feculent material" and bilious material. A repeat CT scan on ___ showed progression of the small bowel obstruction with dilatation of the small bowel loops up to 5.3 cm from the previous 4.1 cm. The patient had a PICC line inserted and was started on TPN. On ___ he was taken to the operating room for an intestinal bypass. The operation went well without complication. Please refer to the Operative Note for details. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids, with a foley catheter, and an epidural and PCA for pain control. The patient was hemodynamically stable.His hospital course following the jejunocolostomy is described below: Neuro: The patient received an epidural and pca with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. The patient complained of pain with several pain medication regimens. His pain was well controlled with Methadone PO 10 mg q 8 hours and methadone IV 10 mg every 8 hours. The patient was discharged on this regimen and advised not to take any of his home narcotics(morphine), sedatives, or alcohol with this medication. The patient was neurologically stable during this admission. CV: Following the operation the patient had episodes of sinus tachycardia with heart rates as high as 130-140's. Patient was asymptomatic and continued to produce good urine output. Over the following days the patient's tachcardia improved and fell to the low 100's and high 90's. He was started on metoprolol 25 mg bid and was discharged on this medication. Patient was hypertensive throughout this hospital admission with blood pressures as elevated as high 160's/ high 80's. He does have a past medical history of hypertension. Vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO/TPN/IV fluids. The patient tolerated the TPN well and as his bowel function returned his diet was advanced appropriately. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Given that he was experiening frequent bowel movements of 5 loose bowel movements per day, he was restarted on Lomotil 1 tablet every 4 hours as needed for diarrhea with a goal of no more than 2 bowel movements per day. Patient had his indwelling foley removed on post-op day 4 when his epidural was removed. Patient had no difficulty voiding afterwards. Patient was transitioned to a regular diet and was taken off TPN. He had no issues tolerating the regular diet. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Wound was routinely monitored and showed no signs of infection. Endocrine: The patient's blood sugar was monitored throughout his stay; Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin;He was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. He was discharged with nursing for ___ care with the understanding that his PICC would likely be removed on ___ in his followup visit with Dr. ___. He received 1 B12 injection while in house and was advised that he would need these injections monthly as an outpatient. Patient was instructed that his narcotic regimen and metoprolol would be adjusted with his PCP or oncologist on the follow-up visit. His oncologist was verbally informed about the plan and agreed to manage his narcotics on an outpatient basis.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ pMHx HTN, COPD, and cervical radiculopathy and DJD who presents with acute on chronic low back pain. She reports having had R sided lower back pain x 3 weeks. She reports that the pain is sharp and radiates down her R leg with any movement. Her pain started on ___ and was preceded by her carrying a heavy trunk at home. She was initially evaluated at ___ where X-rays of her hip showed only arthritis of the L-spine and no pathology of the R hip. She has been on pain medication and anti-inflammatories without any significant pain relief. She denies any associated numbness or tingling. She was subsequently seen in Pain Clinic on ___ at which time she had a trigger point injection performed of her R piriformis. Per the Spine Clinic note, she also had a lumbar spine MRI which is unavailable in our system. She was started on a 5 day course of PO prednisone 50 mg daily as well as cyclobenzaprine prn. She re-presents for ongoing R-sided low back pain. In the ED, initial vitals were 96.4 55 191/79 18 99% on RA. Her systolic BPs improved to the 130s with improved pain control. Exam was notable for significant limited R hip ROM limited by back pain. R straight leg test produced shooting pain down her RLE; contralateral straight leg test was negative. No labs were drawn in the ED. UA was positive for small leuk, positive nitrites, 1 epi. R pelvis/hip Xray showed no acute process. The patient was evaluated by Ortho Spine who reviewed her outpatient MRI which reported showed mild lumbar foraminal stenosis and narrowing without evidence of cord compression. Physical therapy cleared the patient to return home with outpatient ___, but given significant ongoing back pain despite receiving morphine and valium, required medical admission. Patient refused ibuprofen b/c of concern for dyspepsia. Vitals prior to transferwere 98.6 87 156/106 18 95% RA. Upon arrival to the floor, initial VS 98, 183/92, 85, 18, 96% on RA. Patient endorses ___ RLE and back pain. She denies any symptoms of dysuria. Radiology showed No acute fracture. The patient was diagnosed with LUMBAGO. At the time of discharge, the patient had lumbosacral radiculopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is an ___ year old woman with HTN, and cervical radiculopathy and DJD who presents with acute on chronic low back pain. On admission she had already had outpatient workup with X-rays of her hip showed only arthritis of the L-spine and no pathology of the R hip and MRI of the lumbar spine reportedly showing foraminal narrowing but no cord compression. Prior to admission, she had been treated with trigger point injection of the R piriformis without relief and had had minimal to no relief from NSAIDs, acetaminophen, cyclobenzaprine, prednisone (5 day course of 50 mg). In the ED, X-rays of the pelvis and hip were done and were were consistent with the earlier X-rays. She was seen by ortho spine and by ___ and was ultimately admitted for pain control. She was treated with ketorolac, oxycodone, and acetaminophen overnight with some relief of pain. The following day she described a burning, tingling pain on her thigh, so was given gapabentin with improvement of this pain. She was discharged with instructions to follow up with pain clinic, ortho spine, and ___. For short-term pain management, she was given IM toradol and discharged with acetaminophen, gabapentin, and oxycodone 5 mg.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with extensive poorly differentiated tumor in the right temporal fossa s/p right craniotomy for resection of intracranial portion in ___ and 6 cycles of chemotherapy who presents with headache. CHEST (AP AND LAT) showed Low lung volumes with mild bibasilar atelectasis. No definite focal consolidation to suggest pneumonia. Radiology showed No acute fracture or dislocation. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Status post right craniotomy and sub total tumor resection in the right middle cranial fossa and infratemporal fossa. Residual soft tissue density in the resection bed likely reflects residual tumor, but would be better assessed with MRI with IV contrast. 2. Persistent vasogenic edema within the right cerebral hemisphere with continued sulcal effacement of the right cerebrum, but with minimal interval decrease of effacement of the right lateral ventricle and leftward shift of midline structures when compared to MR head dated ___. 3. No acute intracranial hemorrhage. 4. Paranasal sinus disease as described above. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Findings compatible with tumor progression, with significant interval growth of enhancing lesion in the right middle cranial fossa extending along the right frontal convexity and sylvian fissure, which permeates through the right parietal, temporal and sphenoid bones to involve the right masticator space and muscles. 2. There is extension of the tumor into the right sphenoid sinus. 3. Mass-effect from the tumor effaces the right lateral ventricle and results in 6 mm leftward midline shift. No developing hydrocephalus at this time. 4. Additional findings as described above. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of metastatic disease in the abdomen or pelvis. 2. Nonspecific heterogeneity of the bone marrow within the pelvic bones bilaterally. Attention on follow-up imaging is recommended. 3. Since ___, unchanged lobulated cystic lesion in the low left pelvis. CT CHEST W/CONTRAST showed No definite evidence of metastatic disease in the chest. A nodular opacity seen along the right internal mammary chain is nonspecific and attention on follow-up imaging is recommended. Of note, this was not FDG avid on the recent prior PET-CT. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Postsurgical appearance status post right craniotomy and subtotal tumor resection in the right middle cranial fossa and infratemporal fossa, with new foci of intraparenchymal hematoma and small subarachnoid hemorrhage in the right frontotemporal region. 2. Increased vasogenic edema and increased leftward midline shift, measuring up to 8 mm. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:13 pm, 2 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Stable residual tumor intracranially, and right infratemporal fossa. 2. Stable small parenchymal, subarachnoid hemorrhage right hemisphere. 3. Stable parenchymal edema, similar midline shift. 4. Moderate paranasal sinus disease. 5. Increasing ventricular size since ___, suggestive of mild hydrocephalus CT HEAD W/O CONTRAST Q111 CT HEAD showed Marked decrease in tumor burden following recent therapy, perhaps even resolve, associated with resolution of mass effect. Right frontal and temporal white matter changes associated with mild residual vasogenic edema and/or radiation change, but overall also decreased. However, new small hemorrhages in the right temporal and frontal lobes, the latter the larger measuring only 11 mm. However, based on high attenuation, these are too relatively acute or early subacute new small intraparenchymal hemorrhages whereas earlier ones have resolved. RECOMMENDATION(S): Findings in the final report discussed with Dr. ___ ___ at 23:50 by telephone on ___. CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS showed 1. Prominent 9 mm gastrohepatic node, recommend attention on follow-up. Otherwise no evidence of metastatic disease in the abdomen or pelvis. 2. Filling defect in the left internal iliac vein concerning for thrombus. 3. Heterogeneity of the pelvic bones and sacrum, which may be due to osteopenia. A bone scan can be performed for further evaluation. 4. Please refer to the separate report for the same day CT chest for intrathoracic findings. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:38 pm, 5 minutes after discovery of the findings. CT CHEST W/CONTRAST showed Although the study is not optimized for evaluation of the pulmonary vasculature, there are bilateral nonocclusive filling defects within the lobar and segmental branches of the right lung and the left lower lobe consistent with bilateral non occlusive pulmonary emboli. Additionally there is a nonocclusive thrombus within the confluence of the right subclavian and right brachiocephalic vein which is likely the source of bilateral pulmonary emboli. No pulmonary infarct or evidence of right heart strain. NOTIFICATION: The findings were discussed with ___. by ___ ___, M.D. on the telephone on ___ at 4:47 pm, 1 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Allowing for differences in technique 1.0 cm hypodensity along the right convexity, likely a small intraparenchymal hematoma about the resection bed, is not significantly changed, previously measuring up to 0.8 cm. Consider short-term interval follow-up, if clinically indicated. 2. Otherwise, no new acute intracranial hemorrhage with stable post treatment changes. 3. Additional stable findings as described. SHOULDER ___ VIEWS NON TRAUMA BILATERAL showed Mild left biceps tendon calcifications. The patient was diagnosed with Dizziness and giddiness. The patient was treated with Radiation therapy: completed ___. At the time of discharge, the patient had PRIMARY ======= - Metastatic neuroendocrine tumor - Intraparenchymal hemorrahge - Subarachnoid hemorrhage SECONDARY ========= - Oropharyngeal candidiasis - Hypoglycemia in the setting of steroid taper. The patient was given written instructions concerning 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 =================== Ms. ___ is a ___ woman with extensive poorly differentiated carcinoma in the right temporal fossa s/p rightcraniotomy for resection of intracranial portion in ___ and 6 cycles of Carboplatin-etoposide (C6D1 ___ who presented with severe right-sided headache that was most likely due to tumor invading the right skull base & sphenoid/maxillary bones and complicated by intracerebral hemorrhage. She received radiation therapy which she completed on ___. She was started on a steroid taper in the last week of her radiation therapy to help her mental status which was then complicated by some asymptomatic hypoglycemic episodes secondary to increased insulin. Given her persistent altered mental status, lethargy, and poor candidate for rehab, family meeting was held with her HCP and decision was made to send her to hospice. TRANSITIONAL ISSUES =================== [] please control pain with po liquid oxycodone and IV ketorolac and increase frequency as needed [] please turn q2hrs [] for diet, recommend small bites with soft solids and thin liquids [] patient on dexamethasone taper for her altered mental status: discharged on 8mg qam ___, 6mg qam ___, 4mg qam ___, 2mg ___, 1mg ___ ACUTE ISSUES ============ # Poorly Differentiated Neuroendocrine Carcinoma # Headache # Right-sided head & face pain # Focal neuro deficits: facial droop, LLE weakness # Encephalopathy Has poorly differentiated neuroendocrine carcinoma in R temporal fossa s/p resection and 6 cycles of chemotherapy. CT torso w/o evidence of metastatic disease. Her hospital course was complicated by a brain bleed (new foci of intraparenchymal hematoma and small subarachnoid hemorrhage in the right frontotemporal region). Neurosurgery evaluated and said there was no plan for surgical intervention. Chronic Pain team was consulted and she was not a candidate for pericranial nerve block due to tumor invasion through temporal bone at that site. She was started on SBRT by Radiation Oncology on ___, received 15 daily fractions during this admission with improvement in headache and facial pain. She was given dexamethasone 4mg Q6H with calcium (with planned taper) and Bactrim for PCP prophylaxis while on dex. Palliative Care was consulted for goals of care discussion and symptom management, recommended regimen of tapering her steroids and not checking her vitals at night. Throughout her hospitalization, the patient had episodes of hypersomnolence. Repeat NCHCT showed stable bleed. Her mental status also waxed and waned in the few days prior to discharge. It was deemed that waxing and waning encephalopathy is partly related to intraparenchymal hemorrhage, hospital stay induced delirium, fluctuating blood glucose, and residual effects from her tumor. # GOALS OF CARE Given patient's somnolence and confusion in her final week in the hospital, her deconditioned state, and her poor candidacy for rehab, family meeting held and goals of care clarified. Patient's HCP ___ expressed that patient did not want to "be connected to lines and tubes without chance of recovery." Medical team described that she would likely not benefit from immunotherapy given her current clinical state and decision was made to arrange for hospice. # HYPOGLYCEMIA During her steroid taper, she continued to have BGs in the AM around 50's and 60's. For this we decreased glargine to 9 units and short acting to 6 BF, 10 lunch, 4 dinner. We continued to monitor for signs of hypoglycemia. As she is going to hospice, she will not need further insulin. # HYPERCALCEMIA Serum calcium level gradually trended up while she was here. Initially this was attributed to HCTZ. She was also given IV fluids to help correct her calcium. Corrected calcium on discharge 11. # SHOULDER PAIN Patient complained of right shoulder pain acutely, likely secondary to her myeloma. X-rays on ___ showed no acute fracture or osteosclerotic lesions # Acute Kidney Injury She had ___ while she was here, most likely ___ her poor PO intake. She received IVF 500cc bolus x 2 and the ___ resolved. On discharge, Cr was 0.9. # Thrush During her hospitalzation she was found to have oropharyngeal thrush. She attempted clotrimazole troches but could not tolerate this well. Her thrush improved on oral fluconazole 200mg q24hours for 7 days and nystatin suspension four times a day. On discharge she had no signs or sx of thrush. # Internal iliac vein thrombosis CT abdomen with incidentally noted filling defect in the left internal iliac vein concerning for thrombus. Given her recent IPH (___), she was not put on systemic anticoagulation. # Dysphagia # Nutrition Pt with poor PO intake in setting of dysphagia ___ IPH and midline shift. Nutrition consulted, started multivitamin with minerals, Glucerna shake supplements. SLP evaluated, recommended small bites with soft solids and thin liquids. # Hypertension Continued home amlodipine at higher dose as well as lisinopril. Her HCTZ was discontinued as she was hypercalcemic during her hospitalization. Stopped anithypertensives on discharge. # Mild leukocytosis Mild leukocytosis likely ___ dexamethasone. Pt afebrile and HDS. No new localizing infectious symptoms. UA without bacteria. # Anemia: microcytic, has been stable above transfusion threshold throughout her hospital stay This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with history of hypothyroidism, HTN, bipolar disorder, nephrolithiases who presented with constipation. CT abdomen pelvis showed 1. No evidence of obstruction. Oral contrast passes to the level of the rectum. 2. Diffusely fluid-filled ascending and transverse colons may be compatible with enteritis. Large amount of formed stool noted in the rectal vault. The patient was diagnosed with Constipation, unspecified. At the time of discharge, the patient had Primary: Constipation Musculoskeletal back pain Secondary: Hypothyroidism Bipolar disorder Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#Opioid induced constipation, resolved -Seemingly resolved since disimpaction in ED and passage of large bowel movement on day of admission and ongoing bowel movements and passing gas this morning. -Etiology is probably from her taking the oxycodone several days prior. She was counseled on this. -The patient was given an option of discharge yesterday but said she preferred to stay until the morning to make sure she doesn't have recurrent constipation -Given that she continues to move her bowels well, will discharge with bowel regimen. -Regular diet -Daily miralax, senna, Colace - prescriptions given for discharge #Question of enteritis -Fluid filled ascending/transverse colon on CT A/P. This is nonspecific and she does not likely have true inflammatory colonic pathology at this point; may have been related to her constipation that is now relieved. Clinically she is afebrile, well-appearing, and her slight leukocytosis yesterday is downtrending. #Lower back pain Patient endorsed musculoskeletal lower back pain today. She was able to ambulate in the hall though she was concerned about managing at home, especially with her disabled husband, so arranged home ___. She received toradol x1 and naproxen x1 which helped her. Discharged with prescription for naproxen. #Hypothyroidism - continued home synthroid #HTN -Continued home lisionpril #Bipolar disorder -Continued home valproate</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx. asthma, bipolar disease, eczema, hypothyroidism, MRSA colonization with recurrent cellulitis presenting with foot pain. Patient reports right sided foot pain for last 10 days, says onset was gradual over last 10 days, denies any trauma or injury. Area did become mildly swollen, however, and difficult to walk on over the last few days She also noticed increased redness/erythema over upper extremities for last ___s ___ eruptions over her neck/back. She had similar skin changes during her last flare of MRSA cellulitis. She mentioned these skin changes to her dermatologist today who recommended she continue with her 'prior treatments for MRSA' which patient reports include steroid creams. She then called her PCP who ordered plain films of her foot and arranged for an outpatient orthopedics evaluation - as per patient orthopedic physician was not concerned for fracture, she was eventually told to the ED, however. She denies any fevers or chills. She is having a headache, which she said she had with her prior MRSA infection. Denies any new medications or environmental exposures. In the ED, initial VS were 97.6 86 129/78 16 98%. Labs include lactate 1.2, Hct 38.4, plt 228. Chem-7 unremarkable. Blood cultures were sent (x2). Foot three way xray performed, with wetread showing possible stress fracture ___ metatarsal. Patient received 1g vancomycin and was admitted. On arrival to the floor, patient reports continued right foot pain, currently ___. No headache at this time. Otherwise feels well except for ongoing skin eruptions, which are mildly pruritic. REVIEW OF SYSTEMS: 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. All other 10-system review negative in detail. Radiology showed Area of sclerosis at the distal ___ metatarsal is suspicious for an occult nondisplaced stress fracture. Given the degree of osteopenia, the possibility of early stress reactions elsewhere in the foot cannot be excluded. No bone destruction to suggest osteomyelitis. The suspected ___ metatarsal fracture findings were communicated to Dr. ___ by telephone at the time of discovery by Dr. ___. Radiology showed 1. Possible fracture of the third metatarsal. This finding was previously communicated to Dr. ___ by telephone at the time of the prior study. 2. Possible old stress fracture of the fourth metatarsal. 3. A lucency is seen in the navicular bone which is non-specific but has a non-aggressive appearance and likely represents a cyst or intraosseous lipoma. The patient was diagnosed with PAIN IN LIMB. At the time of discharge, the patient had primary diagnosis: cellulitis eczema. The patient was given written instructions concerning 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. asthma, bipolar disease, eczema, hypothyroidism, MRSA colonization with recurrent cellulitis presenting with foot pain. ACUTE CARE # Foot pain: plain films of foot reveal possible stress fracture and patient has pain to palpation over area of ___ metatarsal. Also with overlying area erythema. Pain likely due to stress fracture, although there was also mild concern for cellulitis. The finding of the stress fracture was discussed with the patient's orthopedic surgeon who she had seen in clinic who recommended possible MRI, which was discussed with the patient. She was advised to avoid strenuous, high-impact activity. # Cellulitis vs Eczema: the patient had 3 areas of erythema: an area on the dorsum of her foot, and areas on her bilateral forearms. Her forearms were scaly with areas of excoriations, thus raising concern for eczema with possible super-infection given erythema that did improve with antibiotics. She also had erythema on the dorsum of her foot which did not have an eczematous appearance. She was empirically started on IV Vancomycin and was discharged on Bactrim with Keflex (she has a history of penicillin allergy but has tolerated Keflex in the past). This plan was discussed with her ID team as well as her PCP, both of whom she will see in clinic within the next week to ensure improvement. Of note, the patient had significant anxiety that she was apparently re-infected with MRSA given the fact that she had previously gone through decoloniziation. A MRSA swab from ___ was sensitive to bactrim thus prompting this antibiotic choice. CHRONIC CARE # Eczema: patient evaluated by ___ clinic today, recommended continuing outpatient steroid therapy. Of note, patient with multiple hives, suggesting allergy/histamine component and was advised to take an anti-histamine and continue home eczema medications. # Bipolar Disorder: Continued quetiapine, gabapentin, ativan at night # Asthma: Continued advair, zafirlukast # Hypothyroidism: Continued home synthroid TRANSITIONS IN CARE CODE: Full EMERGENCY CONTACT HCP: ___ ___ PENDING: BLOOD CULTURES X2</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with PMH etoh abuse p/w withdrawal seizures. History provided by partner, ___, who lives with pt and has known her for ___ years. He reports that pt drinks daily, usually vodka with sprite. He cannot estimate how much she drinks because he is at work all day. He does report that she has insomnia and will often drink alcohol early in the AM if she cannot sleep. She has been "sick" for a few weeks, characterized by nausea, vomiting, and inability to tolerate any po. This led pt to stop drinking about 3 days ago since she would vomit up anything she drank anyway. She reportedly has an abd pain at baseline ___ an ulcer but partner denies any report of increase in baseline pain. She had a witnessed seizure at 1am and at noon the day of admission characterized by "tightening up" and biting her tongue, causing bleeding. No incontinence of bowel or bladder. Pt did not remember seizure and was reluctant to come in. ROS unable to obtain but ___ says that pt has been c/o dizziness for several weeks and says that she frequently reports a fear of falling because she is clumsy. She bruises easily on aspirin, which she takes at home, and has bruises on her legs from falling when trying to walk up stairs. He does notice gait instability which has occurred when she is both sober and inebriated. He also reports she has poor po intake. No other notable sx per partner. Pt brought to ___ where she was found to be hypokalemic to 2.2 and in torsades. trop 0.06 (high). She was given Mg with some improvement but was experiencing intermittent NSVT. Had a long QTc. Received valium 5mg iv and ativan 8mg iv. Thiamine and magnesium repeleted. Potassium infusing at time of transfer. No seizure there. Transfer here for multiple issues. In the ED, VS 98.9 64 124/78 16 100% 3L. alert, AAOx ___ (hospital, self, not time or reason here). EKG showed sinus tach at 103, NA, QTc appears prolonged >450, NS ST depressions II/III/F, laterally. She was monitored on tele and had intermittent NSVT. K 2.8 on arrival to ___. She was given K, Mg, phos. K came up to 3.9 prior to transfer. head CT - no acute intracranial process. VS on transfer 96 116/84 16 100%. On arrival to the MICU, VS 98.4, 140/87, 95, 23, 100% RA. pt sleeping and snoring. unable to provide history. speech unintelligible. Radiology showed 1. No focal infiltrate to suggest aspiration or pneumonia. 2. Possible mild cardiomegaly, with upper zone redistribution, but no overt CHF. 3. Prominence of the right mediastinum, ? due to unfolded aorta. Recommend PA and lateral view when the patient is stable to confirm this. The patient was diagnosed with HYPOKALEMIA, ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-CONTIN, SEMICOMA/STUPOR. At the time of discharge, the patient had Urinary Tract Infections Alcohol withdrawl seizures 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>___ yo F with PMH etoh abuse p/w withdrawal seizures with exam findings concerning for ___'s encephalopathy. # EtOH withdrawal: completely disoriented and speaking gibberish on admission exam. in setting of poor po intake, etoh abuse, and history of gait disturbance, behavior was concerning for wernicke's ___ thiamine deficiency so treated empirically for this with high dose thiamine 500mg IV x 1 after which patient improved and switched to 100mg thiamine daily. She was also treated with IVF, multivitamin, and folate. CXR neg for acute process. Maintained on CIWA scale in house q2h with diazepam 10mg po for score >10 and scored four times. Electrolytes repleted aggressively. AAOx3 on discharge. Social work consulted and recommended therapy, which pt was open to and expressed desire to stop drinking. Unable to arrange therapist prior to discharge but PCP is aware she needs this and is willing to assist with it. PCP states that her office will call to schedule a follow up visit in one week if patient does not call. # hypokalemia: Upon review of prior EKGs, findings on the EKGs that were provided were not consistent with torsades. Therefore, it is possible that she was not in torsades but rather having runs of Vtach. On arrival to ___ she continued to have runs of NSVT. Her hypokalemia was aggressively repleted and her rate normalized. Also checked cardiac enzymes which were neg x 3. # UTI: WBC and bacteria on u/a. unable to obtain ROS so were not sure if pt symptomatic or not. Awaited UCx results (pansensitive E. coli) and then treated with Bactrim for 3 day course. Pt later denied dysuria. # gait instability: per partner, pt has had multiple falls and often expresses fear of losing her balance. She was evaluated by ___ who recommended home with ___. They also noted a ___ strength with left dorsiflexion and ___ strength in all other muscle groups. PCP aware of this and will work it up when she comes in for follow up. # pos urine bHCG at OSH: neg at our ED. serum bHCG done to confirm and was also neg</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In brief, Mr. ___ is a ___ year old man s/p motorcycle accident on ___. His right ankle and left hand were sutured at ___. On ___ he saw his PCP and was cleared to return to work. However, ___ days ago he noticed increased pain and swelling on his R ankle. He presented to the ED ___ with swelling, erythema and SIRS (WBC 18, 90% PMNs, fever 102, tachycardic to 103). A collection near his medial malleolus was drained in the ED and revealed 5cc serosanguinous non-prurulent fluid, sent for culture. On consult, orthopedics was not concerned for septic joint. Radiology showed No subcutaneous gas or radiographic evidence for osteomyelitis. Please note that MRI would be a more sensitive modality to assess for osteomyelitis. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. Soft tissue edema in the right ankle without fluid collection. The patient was diagnosed with OTHER POST-OP INFECTION, CELLULITIS OF LEG, ABN REACT-SURG PROC NEC. The patient was treated with n/a. At the time of discharge, the patient had Primary: Cellulitis Secondary: hepatitis C virus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted on ___ with cellulitis of his right lower extremity ___ days after having a leg laceration primarily repaired in the ___ ED. A small collection overlying the medial malleolus was I&D'd in the ED. He was treated initially with IV vancomycin and ceftriaxone (1 dose) and transitioned to oral antibiotics once he remained afebrile for 48 hrs. The leg dramatically improved on examination and he was discharged to complete a fourteen day course of oral antibiotics.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with left side 0.9mm obstructing left proximal ureteral stone with sepsis now s/p urgent cystoscopy, Left Ureteral Stent Placement, Left Retrograde Pyelogram Radiology showed Moderate to severe left hydroureteronephrosis secondary to an obstructing 7 x 4 x 9 mm proximal ureteral stone. No perinephric collection. The patient was diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic. The patient was treated with ___: Cystoscopy, Left Ureteral Stent Placement, Left Retrograde Pyelogram. At the time of discharge, the patient had SIRS: fever, + Urinalysis, leukocytosis, pain, tachycardia Surgeon's Preop Diagnosis: Left Ureteral Calculus, obstructing Findings: large left proximal ureteral stone. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to urology for nephrolithiasis management with a known 0.9mm obstructing left proximal ureteral stone and presenting with fever, tachycardia; sirs. She was immediately started on IV antibiotics and tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed. At discharge on POD1, patient’s pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty and without fever for over 24hrs. She was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of breast ca with bone mets last chemo 2 months ago presents to the ER with syncope, fatigue, fever and cough. She states that she has been experiencing significant fatigue for the past ___ weeks, recently where she is unable to keep her eyes open when sitting at the table for meals. Her dose of Gabapentin was decreased from total of 500mg daily to a total of 300mg daily in fractionated doses without significant effect. She also was told to stop taking her beta blocker for the past 2 days which she does not think made any difference. She also notes that she has intermittant confusion but without headaches, N/V or vision changes. The morning of admission, she was going to the shower when she was so weak, she fell, hitting her right shoulder. She does not remember losing consciousness but her family noted that she probably did. She was found on floor near shower with bruises and abraisions to right side of head, right shoulder and arm. She also endorses having a dry cough for the past week without rinorrhea, sore throat, or chest pain. She experienced a fever the morning of admission, which along with the fall, prompted her to ___ to the ER. . Vitals in the ER: 100.6 95 138/71 18 97% RA. She received Dexamethasone 8mg IV for vasogenic cerebral edema, Gabapentin 100mg PO, Tetanus shot, Tylenol, and Ceftriaxone 1g IV. . Review of Systems: (+) Per HPI (-) Denies chills, night sweats. Denies blurry vision, headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. . Radiology showed Patient with osseous metastatic disease as above, involving the right shoulder as well as right-sided ribs. Possible loose body(ies), as above. No acute fracture or dislocation. Radiology showed 1. No acute intracranial process. 2. Increased size of left parietal dural lesion since ___. MRI is more sensitive in evaluating small intracranial lesions. Radiology showed 1. Extensive sclerotic metastases of the skullbase, cervical vertebral bodies, and posterior elements. 2. Disc osteophyte complexes at C3-C4 and C5-C6 cause moderate canal narrowing and predispose this patient for cord contusion. 3. Anterolistheses of C2 over C3 and C7 over T1 of unknown chronicity, likely chronic. Radiology showed 1. Interval growth of the left frontal and parietal and right temporal dural metastases since ___, with increased associated vasogenic edema in the underlying brain in the left parietal lobe. Heterogeneous marrow signal throughout the calvarium, clivus, visualized upper cervical spine compatible with metastatic disease. No new intracranial lesion. 2. Generalized volume loss. White matter signal abnormalities, likely reflecting sequela of chronic small vessel disease in a patient of this age. Radiology showed Extensive osseous metastatic disease. No acute cardiopulmonary process, including no definite focal consolidation. The patient was diagnosed with FEVER, UNSPECIFIED. At the time of discharge, the patient had metastatic breast cancer UTI. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>. # UTI - u/a suggestive, urine culture showed no growth. Continued cipro for total 3 days. . # Cerebral edema - from brain metastases. Patient was maintained on dexamethasone. Initial read of MR brain showed increased size of parietal and frontal lesions on left, with some edema. MR final read pending at time of discharge. After discussion with Dr. ___ was discharged to obtain previously scheduled PET CT for restaging. Dr. ___ NP ___ follow up with patient once results are finalized. Continued dexamethasone, instructed patient to monitor weight, as steroid therapy may lead to increased fluid retention. . # Fatigue with Syncope s/p fall - secondaty to poor PO intake and global weakness for months in setting of acute UTI. ECG no ischemic changes, and with no chest pain, do not suspect this was a malignant arrhythmia. TSH and cortisol normal. Will need to follow up PET CT and MR brain as noted above. . # Chronic, stable, diastolic CHF - Lasix 20mg PO PRN at home, monitoring weights as above - Continued carvidelol and lisinopril . # Metastatic breast CA - Pt and family are discussing home hospice, last treatment was in ___ . # PPx - heparin BID, continued home PPI . # FULL CODE ___ M.D. ___ ___ M.D. ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of IDDM, ___ s/p renal transplant, CHF, tracheal stenosis from prolonged intubation after cardiac arrest ___ sepsis from HD catheter infxn) in ___ and elective T-tube placement on ___ s/p OR placement of custom T-tube and removal of granulation tissue on ___. Recent admission from ___ where patient remained in the hospital overnight for monitoring of his blood sugar and oxygenation. He was discharged home on ___ NC. His sputum culture grew coag + staph aureus with 3+ PMNs. He was afebrile and asymptomatic, but given the degree of inflammation he was treated for tracheitis and discharged with a 7 day course of Bactrim (day ___. However the patient reports that he did not start his course of Bactrim at home. CHEST (PORTABLE AP) showed As above. CHEST (PORTABLE AP) showed As above CHEST (PORTABLE AP) showed Comparison to ___. The tracheostomy tube is unchanged. Unchanged massive cardiomegaly, unchanged mild to moderate pulmonary edema. Areas of bilateral atelectasis are visualized. No larger pleural effusions. The patient was diagnosed with Other specified respiratory disorders. The patient was treated with Custom T-tube revision ___. At the time of discharge, the patient had Primary Diagnosis: 1. T tube revision by interventional pulmonology Secondary Diagnosis: 2. Hyperglycemia from Diabetes Mellitus 3. Tracheitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with history of IDDM, RCC s/p renal transplant, dCHF, tracheal stenosis from prolonged intubation after cardiac arrest ___ sepsis from HD catheter infxn) in ___ and elective T-tube placement on ___ who s/p uncomplicated OR placement of custom T-tube, w/ current migration of T tube s/p retrieval on ___. # S/P T-tube retrieval Patient s/p elective T tube placement on ___ s/p recent custom T tube placement, removal of subglottic granulation tissue, s/p migration and retrieval on ___ with IP. Patient monitored over the evening in the ICU, given albuterol nebs, continued on 7 day course of Bactrim for tracheitis (___). Pain management with home oxycontin/oxycodone for chronic knee pain, breakthrough pain with dilaudid PRN and magic mouthwash for throat pain. # Chronic HFpEF Recent TTE ___ with EF >55%. CXR with evidence of pulmonary edema, and patient has evidence of bibasilar crackles and lower extremity edema consistent with volume overload. Per recent discharge patient needs outpatient cardiologist for management and optimization of medications. Patient digressed with IV lasix bolus, resumed home torsemide on discharge, continued ASA. Currently not on beta blocker at home or ___. TTE as transitional issue below. # IDDM: Poorly controlled, last HbA1C ___ was 10.6%. Home regimen lantus 90 u BID, humalog 24 u with meals TID. # RCC s/p right partial nephrectomy in ___, ESRD s/p LRRT in ___ Current Cr 1.4, stable. Patient did not take AM dose of tacrolimus on ___ prior to procedure # HTN Currently normotensive. Not on home beta blocker or any other anti hypertensives at this time. # Chronic pain: - Continued home oxycontin and oxycodone for chronic knee pain # HLD - not currently on statin, appears to have been discontinued when patient had been prescribed colchicine TRANSITIONAL ISSUES [] Needs to follow-up with new cardiologist (Dr. ___, ___ for a TTE and to optimize his medications. He reports not taking carvedilol after it was discontinued in a prior admission. [] Patient will call to schedule outpatient CXR and PFT. [] Patient will call to follow-up in clinic with interventional pulmonology in 2 months. [] Follow-up procedure in OR: Fleb bronch + /- rigid bronch + T tube revision in 2 months. [] Patient will call to schedule regular follow-up with renal transplant team and for tacrolimus level monitoring. [] Keep T tube capped during the day, uncapped at night. [] Continue Guaifenesin 1200 mg po bid [] Bactrim for 7 days ___ to ___ # CODE STATUS: Full (confirmed) # CONTACT: ___ (wife), ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ woman with a remote history of migraine headaches, right frontoparietal oligoastrocytoma (discovered in ___ s/p radiotherapy, chemotherapy and a resective procedure who presents to the ER with left-sided weakness and facial droop. History is obtained from the patient as well as the neurology note. She has in general has been living at home and doing reasonably well. She saw Dr. ___ yesterday in the ___ clinic where the decision was made to pursue more avastin/bevacizumab therapy for tumor progression. She is here in the ED today because starting last night, she has noticed some pressure like pains in the right orbital region extending backwards to behind her ear. She did not sleep well last night, and this morning she has been quite nauseous. She did not take any of her pills. She called Dr. ___ office to see what to do, and she was asked to come in to the ED for an evaluation. . While here in the ED, vitals 97.7 127 152/78 18 96% RA. She was noted to have a left sided facial droop which is new, and recognized as new by her sister. She also had some new left hand weakness which has not been reported on serial neurological examinations. She received Keppra 1g IV and Dexamethasone 10mg IV. On arrival to the floor, she states that she feels fine. She has the phone to her ear and says she is waiting for her sister to pick up but the phone is not on. She otherwise seems logical. . REVIEW OF SYSTEMS: (+) Per HPI; cough for 6 months from viral URI, unchanged (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. All other ROS negative . Radiology showed No evidence of acute disease. Radiology showed Findings compatible with the recent prior MR study, including mild leftward shift of midline structures associated with an extensive expansile hypodense abnormality involving white matter in the right frontal lobe. The patient was diagnosed with MALIG NEO BRAIN 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>___ yo F with right frontoparietal oligoastrocytoma (discovered in ___ s/p radiotherapy, chemotherapy and a resective procedure who prsented with left-sided weakness and facial droop. # Oligoastrocytoma: Patient has Grade 2 R frontoparietal oligoastrocytoma s/p chemotherapy, radiation and resection. Patient presented with new L sided facial droop and left upper extremity weakness. A CT head showed... She was initially started on dexamethasone 4 mg every 6 hours tapered to 4 mg every 12 hours. On ___, she developed new onset seizures while on video EEG monitoring. She was loaded with 1600 mg phenytoin and started on 150 mg IV q 8hrs. She continued to frequent have seizures and was started on lacosamide 200 mg IV load and lacosamide 100 mg IV BID with resolution of seizures. This regimen was transitioned to PO lacosamide 150mg BID and phenytoin 200 mg BID. Her neurological status improved significantly with near complete resolution of left lower face paralysis and left upper extremity weakness. # Hypertension, seconsary to bevacizumab. Well-controlled with therapy, continued metoprolol Tartrate 25 mg BID. # Cough: Patient has had for 6 months, secondary to viral URI. Continued home Tessalon and Albuterol PRN. #GERD - Continued PPI, and increased dose as prophylaxis while on steroids.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENTING ILLNESS: ___ year old male with past history of CAD s/p stent at ___ E's ___, NIDDM, hypertension, hyperlipidemia who presents with several weeks of intermittent chest pain and a week of exertional dyspnea. He initially attributed this to his asthma. The patient has also noted recent lower extremity swelling over the past ___ days and PND. He has a stable ___ pillow orthopnea. His chest pain is intermittent and not necessarily exertional, but is typically relieved by nitroglycerin. He does use an exercise bike at his house for 1 hour each day with no issue. Chest radiographs. showed No acute cardiopulmonary process. The patient was diagnosed with Heart failure, unspecified. The patient was treated with Stress echocardiogram ___. At the time of discharge, the patient had Primary Diagnosis: - Diastolic Heart Failure - Coronary Artery Disease - Hypertensive Urgency Secondary Diagnosis - Hyperlipidemia - Diabetes - Asthma - Obstructive Sleep Apnea - Low back pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with past history of CAD s/p stent at ___ E's ___, NIDDM, hypertension, hyperlipidemia who presents with several weeks of intermittent chest pain and a week of exertional dyspnea concerning for fluid overload and heart failure. # Coronaries: 100% chronic total occlusion of proximal total R PDA, s/p PCI to midLAD and Lcx, stent in midLAD, unknown type. (per ___ records) # Pump: normal EF # Rhythm: sinus #HFpEF exacerbation: Patient had progressive swelling of lower extremities with DOE and PND concerning for heart failure exacerbation. Trop neg x1. EKG had T wave flattening but no specific ST changes concerning for acute MI. Patient was started on IV Lasix for diuresis and transitioned to PO regimen of 40 mg Lasix. He was started on lisinopril 10 mg and carvedilol 12.5 mg PO BID. Echo records from outside hospital showed normal EF in ___. He also had records from ___ which showed chronic total occlusion of RCA and stent placed to mid-LAD. Stress echocardiogram was done which showed no inducible ischemia and stress ECG was without ischemic changes. He was discharged on atorvastatin 40mg, carvedilol 12.5mg BID, furosemide 40mg BID and lisinopril 20mg. He will follow up with an outpatient cardiologist, Dr. ___, for further management. Discharge weight: 130.8kg #Hypertensive urgency: Patient non-compliant with HTN meds at home (takes HCTZ intermittently) and found to have elevated SBP 180s on floor, asymptomatic. Home amlodipine, HCTZ, and verapamil were d/c'ed and patient was transitioned to lisinopril 20mg and carvedilol 12.5mg for both HTN and CAD/HF management. BP should be monitored and medications titrated as needed. #Low back pain - patient uses gabapentin, tramadol, and naproxen at home. Naproxen was discontinued given concern for ___ and cardiovascular risk. #Diabetes: Insulin sliding scale while inpatient. Restarted metformin on discharge. #Asthma: Controlled with Albuterol inhaler prn #OSA: non-compliant with CPAP. Encourage use as outpatient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old gentleman with PMHx significant for cognitive impairment and absence of a sternum (congenital) who presented to ___ with syncope and respiratory arrest). ___ DUP EXTEXT BIL (MAP/DVT) showed Occlusive thrombus in the right popliteal vein. The right-sided peroneal veins were not visualized by ultrasound. No DVT in left lower extremity. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 10:30 on ___, immediately after discovery. The patient was diagnosed with PULM EMBOLISM/INFARCT. The patient was treated with - systemic thrombolysis with low dose tPA (___). At the time of discharge, the patient had ================= PRIMARY DIAGNOSES ================= - massive pulmonary embolus (unprovoked) - Deep vein thrombosis of lower extremity =================== SECONDARY DIAGNOSES =================== - Cognitive impairment with developmental delay - Bipolar disorder - Hypertriglyceridemia - Congenital heart disease - Pectus excavatum. The patient was given written instructions concerning 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 PMHx significant for cognitive impairment, who presented to ___ due to syncope with questionable cardiac arrest, who was found to have saddle pulmonary embolus. #) UNPROVOKED ACUTE SADDLE PULMONARY EMBOLISM: The patient presented to ___ with syncope and respiratory arrest after being at his usual state of health. His initial exam was consistent with PE which was confirmed with a CT angio of the chest showing massive saddle PE. He was given 60mg of enoxaparin prior to transfer. Upon arrival to the ___ echo showed RV dilation. The patient received half-dose lysis with tPA, which he tolerated well. After receiving tPA the patient was transitioned to ___ to Rivaroxaban, with medication obtained with the assistance of case management. #) LEUKOCYTOSIS: Patient presented with leukocytosis to 17.5, which was attributed to a stress response both from the pulmonary embolus and the chest compressions he received prior to presenting to ___. WBC count downtrended to 12.8 on the day of discharge. No signs or symptoms of infection were noted throughout hospital stay, urine culture was negative. CHRONIC ISSUES: ================ #) COGNITIVE IMPAIRMENT: The patient suffers from cognitive impairment. However, he can fully engage in a conversation. The patient has a legal guardian (___). He was cleared for discharge back to his prior caregiver arrangements, with assistance from both case management and social work. #) Bipolar disorder: The patient was continued on his home regimen of buspirone, gabapentin, olanzapine, and risperidone. =================== TRANSITIONAL ISSUES =================== # Medication changes. The patient has been started on rivaroxaban daily for anticoagulation. # Unprovoked pulmonary embolism. Please consider hypercoagulability work-up with antithrombin functional tests, factor V leiden, homocystein, protein C/S, and prothrombin mutation analysis as an outpatient. # Hypertriglyceridemia. Please consider treatment and follow-up as outpatient # Code: Full # Contact/HCP: ___ (___)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old with past medical history of ESRD on HD TThS, Neprhogenic systemic sclerosis, reported GPA, prior PE and recurrent DVT on warfarin, h/o ischemic bowel s/p resection, reported ulcerative colitis, nutcracker syndrome, chronic pain who presented to ED at ___ by her dentist who recommended extraction of multiple teeth but was not comfortable due to medical comorbidities. Patient was sent to ___ for ___ evaluation. Radiology showed 5 mandibular teeth remain. Subtle periapical lucency at the lateral-most left mandibular tooth. Please refer to same-day CT for further details. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT. showed 1. 9 x 3 mm fluid collection anterior to teeth ___ # 23 and 24 associated to apical lucencies and large cavity, with extensive cellulitis involving the anterior aspect of the mandible. No abscess. Reactive lymph nodes in level 1. 2. Lung apices are notable for emphysema. The patient was diagnosed with Periapical abscess without sinus. The patient was treated with Incision and drainage. At the time of discharge, the patient had Left mandibular abscess. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old with past medical history of ESRD on HD TThS, reported GPA, prior PE and recurrent DVT on warfarin, h/o ischemic bowel s/p resection, reported ulcerative colitis, nutcracker syndrome, chronic pain who presented with facial swelling and jaw pain, found to have mandibular abscess s/p I&D discharged on oral Clindamycin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with no significant PMH/PSH who presents with 3 days of abdominal pain, initially associated with fevers/chills, and nausea. She reports being in her usual state of health when she noted an acute onset of malaise, associated with fevers/chills and initially vague mid-abdominal pain which then migrated to the RLQ and has intensified in the past day. The fevers/chills resolved 2 days prior without intervention, but the pain has persisted and worsened. She has also had associated nausea, but no vomiting, and has a had a decrease in appetite. No similar such episodes in the past, no sick contacts. She has been passing flatus and having normal BMs, most recently 2 days ago. No CP/SOB, no dysphagia, no BRBPR/melena. RENAL U.S. PORT showed Unremarkable renal ultrasound. No evidence of renal calculi. PELVIS U.S., TRANSVAGINAL; US APPENDIX showed 1. Small amount of complex pelvic free fluid with internal septations and echogenic material and without vascularity, centered in the right adnexa medial to the right ovary. This appearance is nonspecific, differential includes hemorrhagic fluid from recent ruptured cyst which is not currently seen, infectious process, and hydrosalpinx/salpingitis given linear nature of the focal fluid. 2. Normal ovaries. 3. Appropriately positioned IUD. 4. Appendix not seen. PELVIS U.S., TRANSVAGINAL; US APPENDIX showed 1. Small amount of complex pelvic free fluid with internal septations and echogenic material and without vascularity, centered in the right adnexa medial to the right ovary. This appearance is nonspecific, differential includes hemorrhagic fluid from recent ruptured cyst which is not currently seen, infectious process, and hydrosalpinx/salpingitis given linear nature of the focal fluid. 2. Normal ovaries. 3. Appropriately positioned IUD. 4. Appendix not seen. Radiology showed Findings concerning for acute appendicitis. Note, due to the position of the cecum, the appendix extends posteriorly into the right hemipelvis. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:05 ___, 5 minutes after discovery of the findings. The patient was diagnosed with Unspecified acute appendicitis. The patient was treated with ___: Laparoscopic appendectomy. At the time of discharge, the patient had Acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o F with no pmh, who was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis. On HD1, the patient underwent laparoscopic appendectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor on IV fluids, and po oxycodone and acetaminophen for pain control. The patient was hemodynamically stable. 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 actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. On POD #1, the patient had a urine test positive for chalymadia trachomatis. The patient was informed of this finding and she was written for a one time dose of azithromycin 1gm and an educational packet was provided. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Neurology at bedside for evaluation after code stroke activation within: <5> minutes CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No acute intracranial findings. 2. Approximately 50% stenosis of the proximal right internal carotid artery. 3. No evidence of occlusion or aneurysm of the intracranial circulation. Atherosclerotic disease is seen affecting bilateral cavernous and supraclinoid internal carotid arteries. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. No acute intracranial abnormality on noncontrast MRI head. 2. Chronic left basal ganglia lacunar infarct and left frontal encephalomalacia. 3. Unchanged periventricular and subcortical T2/FLAIR white matter hyperintensities, nonspecific, but compatible with chronic microangiopathy in a patient of this age. The patient was diagnosed with Aphasia. The patient was treated with N/A. At the time of discharge, the patient had Transient Ischemic Attack (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>Dr. ___ is a ___ year old right-handed man with a past medical history of atrial fibrillation on coumadin, prior left MCA distribution infarction and TIAs with Left CEA for symptomatic stenosis and CAD with prior MI who presented on ___ for evaluation of an acute language change. History is notable for a possible last known well at perhaps, though not clearly 1215 on ___, followed by a mild aphasia characterized principally by paraphasic errors. The symptoms were quite similar to his prior stroke. He was admitted due to concern for a TIA or stroke in the distribution of the left MCA in the setting of a subtherapeutic INR. Patient underwent MRI brain on ___ which was negative for acute infarct, revealing findings consistent with his prior, chronic strokes. By examination on ___ in the morning, the patient's aphasia had resolved and he felt back to baseline. Discussion was held with the patient regarding optimal anticoagulation moving forward. Consideration of changing to a newer anticoagulation such as Apixaban was discussed given his fluctuating INR and for improved ease of administration. However, the patient reported he was not willing to change his anticoagulation at this time until discussion with his outpatient cardiologist, Dr. ___. Patient was counseled about importance of remaining in house to clarify the anticoagulation situation and promptly place him on therapeutic anticoagulation. However, he reported strong desire to leave the hospital due to personal affairs. He expressed understanding of the risks and benefits of remaining in house to clarify his anticoagulation issue and be placed on optimal therapy for stroke risk reduction. Stroke risk factors included LDL 25, hemoglobin A1c 5.9 at time of discharge. *************</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o right handed-man with PMH significant for epilepsy (on VPA) and CAD s/p ___ MIs and 8 stents, who was transferred from OSH for mutliple seizures today. He woke up this morning with chest tightness associated with breathing difficulties. No recent infectious symptoms. He drank 4 beers today. His fiancee noted his eyes to briefly roll back while on the couch, but he said he was ok. He then got up to go to the bathroom and collapsed, falling face-down on the floor. EMS was called and he was brought to OSH. He says his first memories upon arousal were at OSH. He was post-ictal, but had no incontinence or tongue biting. While at OSH, his fiancee notes he had up to 6 "small seizures," which included shaking of his hands and legs with decreased responsiveness. He reportedly never returned to baseline between seizures; he would be post-ictal for a while and would then start having another one. Per the tranfer notes, he was having intermittent ___ minute myoclonic and at times, clonic seizures. While at OSH, he received Ativan 6 mg and Dilantin 1 gram. He was then transferred to ___ for further evaluation. While in the ambulance on the way over, he had another seizure with unresponsivess and generalized convulsions, lasting 5 minutes and resolved with Ativan 2 mg. Some of his seizures have been preceeded by an aura of flashing lights. He says he currently has a headache and persistent chest and jaw pain, concerning for cardiac event as this is similar he experienced in past with his MI. With regards to his epilepsy, he has a long-standing history of epilepsy since childhood; believed to be most likely primary generalized epilepsy. Of note, he was admitted to Epilepsy service earlier this month with status epilepticus in the setting of medication noncompliance (undetectable Depakote level) and alcohol ingestion. During that admission, he was given an additional bolus of Depakote and restarted on his home dose of medication; per the discharge summary this dose is Depakote 1000 mg q8h, but he says he currently takes a dose of 1000 mg four times a day. He says he has been compliant with his medication. He has had no seizures since his discharge, prior to today. At the time of that admission earlier this month, his last seizure had been 3 months prior. Before that, he was having seizures about twice per month. Radiology showed No acute intrathoracic process. Radiology showed No DVT in both lower extremities. Radiology showed No acute intrathoracic process. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, CHEST PAIN NOS, HYPERCHOLESTEROLEMIA, PARKINSON'S DISEASE. At the time of discharge, the patient had Epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with Epilepsy and multiple cardiovascular risk factors presents with increased seizure frequency in the setting of a likely URI and cocaine+ urine. He has not had a seizure since transfer. However he appeared to have a worsening respiratory function with an Aa gradient on the morning after admission. . . # Neuro: seizures under control during this hospitalization on outpatient regimen. Likely triggerd by cocaine and alcohol use and recent infection (URI). He was continued on VPA 1000mg Q8H . # Respiratory: new oxygen requirement without clear finding on CXR. He was 93% on RA on arrival to outside hospital and continued with slightly low oxygenation during his hospitalization. He had a recent URI, is a smoker and might have aspirated during his seizures. The differential included PE and PNA. He had a D-dimer that was low. His repeat CXR did not show evidence of acute processes. He was started on Azithromycin and his respiratory status improved during the day . # RLS: continue home meds ropinirole, pramipexole . # HL: - continued statin . # CAD: - continued aspirin/plavix </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo M w/ hx Hodgkins and non-Hodgkin's Lymphoma, hypogammaglobulinemia, HTN, HLD, CKD, asthma, psoriasis, pAfib p/w palpitations and found to have Afib with RVR as well as elevated troponins. Mr. ___ states that he has not had any issues with his Afib for ___ years, but over the last week he had noticed two episodes of palpitations. Today around 4pm he noticed palpitations again and checked his HR at which time he observed rates in the 140s. He was found to have afib with RVR at urgent care so sent into the ED. He denies f/c, chest pain, SOB, orthopnea, PND, ___ edema, urinary sx, n/v/d, abd pain, cough, sore throat. He does note that he typically takes his albuterol 1x/day but over the last several days has been taking it 4x/day. He has been taking his metoprolol regularly. Of note, patient states that his PCP and his cardiologist have had extensive discussions and they have all agreed to avoid anticoagulation up to this point. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. Chronic post radiation fibrosis involving the medial aspects of both upper lobes. CHEST (PORTABLE AP) showed In comparison with the study of ___, the cardiac silhouette is at the upper limits of normal in size. The configuration of the mediastinal contour is again consistent with known radiation fibrosis with associated bronchiectasis of the upper lobes. There is interval increase in the indistinctness and engorgement of pulmonary vessels, consistent with the clinical diagnosis of volume overload. Blunting of the costophrenic angles with poor definition of the hemidiaphragms is consistent with layering effusions and atelectatic changes at the bases. The patient was diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, ATRIAL FLUTTER. The patient was treated with ___: Left heart catheterization with DESx1. At the time of discharge, the patient had Primary Diagnoses: - Atrial fibrillation - NSTEMI Secondary Diagnoses: - Asthma - Hypertension - Hyperlipidemia - Hypogammaglobulinemia - GERD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M w/ hx Hodgkins and non-Hodgkin's Lymphoma, hypogammaglobulinemia, HTN, HLD, CKD, asthma, psoriasis, pAfib p/w palpitations and found to have Afib with RVR as well as elevated troponins with EKG consistent with NSTEMI now s/p DESx1. ================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p fall down 8 flights of steps after slipping while descending stairs on ___. CTA showed 2 active regions of extravasation in the right gluteus muscle. Patient's hematocrit remained stable during his course of hospital stay and he was subsequently discharged on ___ without embolisation performed. he re-presented today with complaints of new bruise over anterior thigh not noticed before. Area is not tender to touch nor indurated. Mobilising better and feels gluteal region more comfortable than before. He does not complain of fever, light headedness, palpitations or SOB. CTA PELVIS WANDW/O C AND RECONS showed Hematoma measuring up to 12.2 cm superficial to the right gluteal muscle, with evidence of active extravasation. NOTIFICATION: These findings were discussed in person by Dr. ___ with Dr. ___ at 00:45 on ___, during initial review. The patient was diagnosed with BUTTOCK CONTUSION, FALL ON STAIR/STEP NEC. At the time of discharge, the patient had Right Gluteal Hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to ___ following a fall and a right gluteal hematoma. He had a CTA which showed mild extravasation of blood into the hematoma. He was admitted for observation and serial hematocrits. On HD 2 his HCT had stabilized and he was assymptomatic for this. He did have some pain, which was controlled with dilaudid and tylenol. He was able to ambulate without difficulty, but did continue to experience some discomfort when sitting. However, since he was doing well, he was discharged home with PCP and ___ clinic follow up. He was tolerating PO without difficulty, his pain was well controlled and he was independently ambulating at the time of discharge </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a PMHx of schizophrenia, depression, ADHD, TBI, and seizures presenting with altered mental status and a report of hypotension with SBP around ___ from ___ ___. Radiology showed No acute cardiopulmonary process. CT HEAD WITHOUT CONTRAST showed 1. No evidence of acute intracranial process. 2. Small right posterior scalp hematoma without underlying skull fracture. 3. Brain atrophy, particularly bifrontal, and evidence of chronic microvascular ischemic disease. The patient was diagnosed with ALTERED MENTAL STATUS . At the time of discharge, the patient had Primary Diagnosis: Hypotension; Altered Mental Status Secondary Diagnosis: Acute kidney injury; Schizophrenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo male with a hx of seizure d/o, schizophrenia, TBI, and ADHD presenting from OSH with report of hypotension improved with fluids, as well as altered mental status and ___, currently improved. # Hypotension: Pt presenting from outside facility with report of hypotension with SBP in the ___. Improved with 2L of IVF in the ED. Likely hypovolemic possibly from poor po intake, although unclear at events that occurred prior to admission. Dehydration consistent with Cre 1.6, lactate 2.6, specific gravity of 1.020 and hyaline casts in urine. No clear source of infection with normal CXR, and U/A with WBC:3. Blood cultures sent, and currently pending. Blood pressure has been stable throughout admission, and he was eating and drinking well prior to discharge. # Altered mental status: Pt presenting with altered mental status, and neurologic exam consistent with possible expressive aphasia. Pt speaking in fluent language, although unable to name objects or repeat phrases initially. Otherwise neurologic exam was intact. Thought to be secondary to medications or less likely his underlying schizophrenia. Non contrast CT of his head showed atrophy with microvascular disease, although no acute process. Serum and urine tox screen negative. Infectious work-up negative including clear chest XRay, normal WBC, and no growth in cultures. B12 and TSH wnl, and RPR nonreactive. Does not appear to be post-ictal with no reported seizure activity, tongue bites, or incontinence. Pt also on numerous medications which could contribute to AMS. The patient was given IVF and started initially on high dose thiamine as unknown ETOH use. His bupropion and dextroamphetamine-amphetamine were held on presentation, and his mental status improved greatly in 24 hours. He was transitioned to po thiamine, and was alert and oriented x 3 prior to discharge. # Acute kidney injury: Pt presenting with creatinine elevated to 1.6. OSH with Cre:1.23. After 2L of IVF, his creatinine improved to 0.9, consistent with prerenal azotemia. He remained well hydrated on PO fluids. # Schizophrenia: Recently admitted to inpatient psychiatric unit. Notes indicate that he was previously on quetiapine 300mg po daily and clonidine 0.2mg po BID, although recently discontinued on most recent med list from psychiatric facility. These medications were not given, and he denied any auditory hallucinations during hospitalization. His PCP was contacted and did not have a record of schizophrenia. # Depression: At home on buproprion 200mg po BID and clonazepam 2mg po TID. Due to concern that AMS was triggered by medications, his clonazepam was made prn, and his bupropion was discontinued. His mental status improved during admission as stated above. # ADHD: On dextroamphetamine-amphetamine 20 mg oral TID. As patient was climbing out of bed on presentation, this medication was held. His mental status improved off of medication, so it was held on discharge. He should not have amphetamines permanently. CHRONIC ISSUES # Seizure disorder: Pt with known seizure disorder with no reports of recent seizure activity for about ___ years. He was continued on his home levetiracetam 1000 mg po BID. # BPH: Stable during admission and was continued on home tamsulosin. ***TRANSITIONAL ISSUES*** -Pt admitted that he sometimes "cheeks" medications. He should be monitored when he takes medications as this may have precipitated altered mental status on admission. -Of note, per pt's PCP ___ was not noted to have schizophrenia on his last visit. His mood disorder may be medication induced, and this should be further evaluated at crisis ___ -Discontinued both dextroamphetamine-amphetamine and bupropion during admission. -Call ___ lab to follow up on final result of blood culture from ___ -CODE: Full -Contact: ___ (Friend) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: For complete admission H&P see medicine nightfloat admission note dated ___, but ___ brief, ___ w/ PMH of HBV c/b HCC now s/p liver transplant ___ ___ on sirolimus presenting with cough and presyncope ___ the setting of dizziness and diaophoresis. He has had a URI for the past 2+ weeks and was seen ___ our ER ___ and diagnosed with a viral URI. He endorses ongoing low grade fevers. ___ the ED, initial VS were stable, labs were at baseline and Influenza PCR was negative. CXR was clear. Patient received 1L NS, Ceftriaxone + Azithro, and IV Ketorolac and was admitted. On the floor, the patient felt better. He noted his cough had been ongoing since before ___ and associated with some wheezing and better today. He denies any associated shortness of breath. He notes that he has been checking his temperature at home and that it has been around 99.0 consistently. He denies chills, nausea, vomiting, abdominal pain or diarrhea. Yesterday he notes he was walking with his students to the elevator and turned his head suddenly and subsequently felt the room spin around him (this is what motivated him to come ___. He sat down and had some flushing at the time and drank some water. He denies falling, head strike, or any loss of consciousness. This had not recurred since. He also denies chest pain or palpitations at the time. CT CHEST W/O CONTRAST showed 1. Multifocal areas of consolidation in the lower lobes worrisome for pneumonia. 2. Bronchial wall thickening, bronchiectasis and multiple sites of peribronchial opacification. 3. Mild dilation of the main pulmonary artery may reflect pulmonary hypertension. NOTIFICATION: The findings were telephoned to ___ by ___ at 15:30, ___, 5 min after discovery. The patient was diagnosed with Syncope and collapse, Acute upper respiratory infection, unspecified. At the time of discharge, the patient had Primary: Community-acquired pneumonia, dyseqillibrium Secondary: Chronic hepatitis B virus infection complicated by hepatocellular carcinoma status post liver transplant, osteopenia, neuropathy, fibromyalgia, gastroesophageal reflux disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ PMH of HBV c/b HCC now s/p liver transplant ___ ___ on sirolimus and previously azathioprine (stopped 3 months ago) presenting with cough and dizziness. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with history of with four suicide attempts by overdose and hanging, chronic lower extremity ulcers, domestic violence resulting ___ multiple spinal fracture and difficulty with ambulation. Patient is currently wheelchair due to these injuries. Patient was sent to the ED on ___ after approaching ___ securitiy complaining of depressed mood. She notes worsening of low mood since the anniversary of several traumatic events ___ her life including the death of her daughter and grandmother ___ a fire ___ ___ and attempt on her life by her boyfriend ___ ___. She continued to note flashbacks and nightmares related to the latter event. She has been feeling increasingly helpless with thoughts of taking all of her pills with intent to kill herself. Radiology showed Three views of the left foot show that there has been an amputation of the third ray at the level of the body of the proximal phalanx of that toe, after prior amputation of the left second ray, at the level of the metatarsophalangeal joints. Without earlier postoperative films, I cannot say whether there is a change in the extent of demineralization and cortical irregularity of the incised end of the proximal phalanx of the third toe. Prior radiographs needs to be obtained to see if this is evidence of osteomyelitis. There are mild-to-moderate degenerative changes including joint space narrowing and sclerosis of articular endplates. Radiology showed Moderate bilateral tibial artery occlusive disease, right greater than left. ABIs may be falsely elevated. Clinical correlation is warranted. Radiology showed Uncomplicated ultrasound and fluoroscopic-guided placement of 4 ___ 36.5 cm single-lumen PICC via the patent left basilic vein and with its tip in the lower SVC. PICC is ready for use. Radiology showed 1. Abnormal increased signal intensity and enhancement within the remnant of the third proximal phalanx may represent post-surgical inflammatory change; however, underlying osteomyelitis cannot be entirely excluded. No surrounding soft tissue masses or fluid collections are seen. 2. Degenerative changes are seen at the head of the third metatarsal. Intact third MTP joint. Radiology showed 1. Thoracic spinal hardware is again seen. A left subclavian PICC line remains in place with the tip difficult to identify on the current examination as it overlies the spinal hardware but it is likely not significantly changed in position with its tip somewhere within the mid-to-distal superior vena cava. Overall, cardiac and mediastinal contours are stable. Lungs appear well inflated without evidence of focal air space consolidation to suggest pneumonia. A linear opacity in the left base is again seen, likely reflecting scarring or subsegmental atelectasis. No pneumothorax. No evidence of pulmonary edema. Radiology showed No DVT in the visualized veins. Peroneal veins not visualized bilaterally. Subcutaneous edema in the bilateral calves. Radiology showed 1. Coarsened hepatic echotexture could be secondary to underlying hepatitis, although cirrhosis could also have this appearance. 2. Hypoechoic 16 x 9 mm structure within or just adjacent to the pancreatic neck could be a lymph node or pancreatic lesion. Further evaluation with CT or MRI is recommended. Pertinent findings and recommendations were discussed with Dr. ___ by Dr. ___ at 11:31 p.m. via telephone on the day of the study. Radiology showed No interval change in the mild abnormal signal within the remnant third proximal phalanx with mild enhancement. The ddx includes post-surgical change, but osteomyelitis is not entirely excluded. The patient was diagnosed with DEPRESSIVE DISORDER, SUICIDAL IDEATION. At the time of discharge, the patient had PRIMARY DIAGNOSIS Wound infection Difficulty with ambulation SECONDARY DIAGNOSIS suicidal ideation substance abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o homeless wheelchair bound female with a history of several traumatic spinal fractures who initially presented with SI. Hospital course complicated by foot wound infection (recent amputation at ___), blood stream infection with multiple highly resistant bacteria and yeast while on broad-spectrum antibiotics, raising high suspicion for self-contamination of PICC line. Patient left AMA after her PICC-line was removed after switching from IV to PO antibiotics. # Multi-organism bacteremia: Pt was originally started on bactrim for possible infection of site of left toes amputation. Wound grew proteus not sensitive to bactrim, and patient was started on vanc/zosyn, continued for 2 week course on vanc/cefepime which was then changed to vanc/ctx. Blood cultures negative until ___, the last day of her 2-week course, when she spiked a fever to 103. Over the course of the next 2 weeks, blood cultures from the PICC line, grew Ochrobactrum, Enterococcus, Lactobacillus, Trichosporon, and Rothia Mucilaginosa. Patient remained afebrile with normal WBC. It was felt that pt was tampering with her PICC line as it seemed unusual that she would be growing so many different organisms from the blood ___ such a short period of time while on broad spectrum antibiotics. Abx initially changed from from vanc/CTX to vanc/cefepime, then patient developed eosinophilia, and cefepime was felt to be the culprit. She was put on vanc/meropenem. Her urine grew out VRE and so vanc was changed to IV daptomycin. Micafungin started once blood grew yeast, then narrowed to voriconazole once yeast identified as Trichosporon. Ophthalmology eval showed no concern of eye infection. TEE was negative and foot MRI x2 showed likely post-op changes (though could not r/o osteomyelitis). ___ the setting of patient likely contaminating her PICC-line, she was given 2 weeks of Meropenem, then Daptomycin switched to Linezolid (last day ___, Voriconazole was to end on ___. Plan is to follow up ___ ___ clinic. However, patient left AMA on ___ without an appointment. Case manager attempted to obtain Linezolid and Voriconazole for patient at the ___ pharmacy, but she refused and left AMA with prescriptions only. # Eosinophilia - pt developed eosinophilia up to 20+%, with absolute eosinophil count >1000 for several days. Was felt to be possible allergic reaction to cefepime which was changed to meropenem. However, eosinophilia did not resolve after cefepime was discontinued. Unclear source. Could be from contamination of PICC. Pt denies urticaria/shortness of breath. No evidence of foreign objects. # L toe amputation- Patient had amputation of a toe on her left foot the week prior to admission due to ___ bite and osteomyelitis. The incision site was noted to have a small amount of purulent drainage with a foul odor. She was seen by podiatry who recommended foot xrays which showed no clear evidence of osteomyelitis but difficult to assess. Bone biopsy sent during the amputation at ___ with report that there was no concern for osteomyelitis, sample with clean margins. See antibiotics course as above. MRI of foot x2 showed enhancement at site of amputation, likely post-op changes but could not rule out osteomyelitis. Given the multi-organism blood stream infection, foot is a very unlikely source. At the time of discharge, her foot wound was clean and dry. # SI- patient initially endorsed SI with plan to overdose on medications. She was initially met ___ criteria per psychiatry. She subsequently reported resolution of suicidal intent. Psychiatry felt she was no longer a threat to herself and therefore did not require psych hospitalization. # Placement- Patient was evaluated ___ the ED by physical therapy and occupational therapy who felt she would benefit from SNF placement. Patient reports she has not been doing well at her shelter and also feels she would benefit from placement. Patient was denied at ___ and other rehab centers due to prior poor behavior. She was to be discharged home (ie, she would have to arrange her own shelter stay or stay with friends), but left AMA. # Chronic pain- Patient has chronic pain resulting from several past traumas. She was maintained on her home MS ___ with PO dilaudid for breakthrough pain. # Urinary incontinence- Patient with long history of urinary incontience. Symptoms were stable throughout this hospitalization. # Lower extremity edema - Likely from dependent positioning. Pt without known CHF and TTE without structural or functional heart abnormalities. Pt has history of hep C, could be caused by cirrhosis. RUQ u/s suggestive of cirrhotic liver. Started on IV lasix with good diuresis and improvement ___ swelling. DC'd on 40mg PO daily of lasix. # Pancreatic mass -could be pseudocyst, pt w/ history of IVDA probably significant alcohol use. Pt is complaining of abdominal pain, although found to have evidence of cirrhotic liver on u/s. Lipase 11. Abdominal pain improved by discharge. Plan for outpatient follow up with imaging either CT/MRI to eval pancreatitis mass. # Transaminitis - pt with mildly elevated LFTS but h/o hep c. no abd or RUQ pain. No diarrhea/n/vomiting. RUQ U/S showed "coarsened hepatic echotexture" ___ hepatitis vs cirrhosis. TRANSITIONAL ISSUES - Patient was full code throughout this admission - Plan to continue Linezolid (___) and Voriconazole (___) till ___ clinic follow up - Started lasix this admission- follow up response and electrolytes - Outpatient imaging to eval pancreatitis mass - Outpatient follow up with ___ Podiatry (amputation ___ ___ - PCP follow up with Dr. ___ on ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ y/o male with little past medical history who suffered a motorcycle accident on ___. He "flipped" on his motorcycle, and was transferred to ___ for right tib/fib fracture, fractured right sided ribs (with pneumothorax) and right scapular fracture. He underwent debridement followed by placement of gastrocnemius flap and was transferred to rehab on ___, where he remains non weight bearing on the right leg and with the leg immobilized. He had an ultrasound on ___ for unclear reasons (he had no pain, had decreased swelling on the right leg) and was found to have a partial thrombosis ___ the common femoral vein on the right and was started on systemic anticoagulation with lovenox twice a day and then Coumadin was started. He tells me that no lovenox doses were missed. He experienced a syncopal episode at his rehab on ___ - after his first long, warm shower. His wife caught him so there was no head strike. He did have urinary incontinence with this episode. He felt like he was about "to pass out" on ___ when ___ rehab. He felt clammy, sweaty so he was sent to ___ ___. While there he developed right sided chest pain and shortness of breath so they did a PE CT and found a RLL PE with ? of pulmonary infarction so he was sent to ___. Of note, INR was 2.4 at ___. At present he states that the right sided chest pain that he experienced ___ the ED is largely gone, as is his shortness of breath. No fevers/chills/n/v/constipation. He has no prior history of syncope. He is presently non weight bearing on the right leg and participates ___ three one hour sessions of ___ daily. He is eating well and has gained about 20 lbs ___ rehab. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right common femoral, femoral, and popliteal veins. Calf veins not imaged secondary to bandaging and skin graft. Radiology showed 1. Examination limited by streak artifact from extensive orthopedic hardware. Within these limitations, no focal fluid collection is detected. 2. Post ORIF of comminuted right tibial and fibular fractures. 3. Small knee joint effusion, with tiny locules of air likely related to recent surgery. TIB/FIB (AP AND LAT) RIGHT showed In comparison with the study of ___, an external device is in place. Again there are medial and lateral fracture plates and graft material in the proximal tibia without evidence of hardware-related complication. Fracture of the proximal fibular shaft is again seen with apparently less angulation. The surgical skin staples have been removed. Radiology showed Satisfactory position of the left-sided PICC line. Interval decrease in size of the right-sided pneumothorax. No left-sided pneumothorax. Chest single view showed Clear lungs. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had Pulmonary Embolism Skin and soft tissue infection under flap of right lower leg Hardware 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>Patient is a ___ y/o male with recent leg immobilization after motorcycle accident of ___, s/p Tib/fib fracture, now with cement spacer, admitted after near syncope event at rehab. He had been on Coumadin and lovenox for a DVT, but developed chest pain and shortness of breath while ___ the ED and the CT scan showed acute right sided pulmonary embolism, with question of infarction, despite being on anticoagulation. He was incidentally found to have an infection under his flap on the right leg based on the physical exam performed by plastic surgery. # Pulmonary Embolism: Hematology was consulted - the patient was taking lovenox 80 mg sc bid at rehab, and his weight based dose is 100 mg sc/bid based on his weight. He has also had some recent subtherapeutic INRs. It was felt that the development of acute pulmonary embolism ___ the setting of a previously seen DVT no longer visualized, was due to embolization and suboptimal anticoagulation rather than warfarin failure. He was countinued on warfarin and bridged to a therapeutic INR with a heparin drip ___ the ___ period. He may be bridged ___ the future with lovenox, but he should be on the 100 mg sc bid dose. He should be continued on Coumadin 8 mg dose and INR followed closely. Recommend minimum of 3 months of anticoagulation for provoked PE. He was seen by the ___ hematologists who made these recommendations. # Leg infection - under flap and over hardware: He was taken to the ___ by plastic surgery and d "There was found to be fibrinous debris and purulence directly over bone and plate" according to the ___ report. They irrigated and derided the area as much as possible. Cultures grew Coag+ staph, Enterobacter, and Enterococcus. Infectious diseases also saw the patient and recommended treatment with IV vancomycin (1 gram tid) and IV ertapenem (1 gram daily) until ___. He has followup scheduled with infectious diseases. He had a PICC line placed for this. He fill followup with plastic surgery for removal of sutures and the drain.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o cryptogenic cirrhosis (dx in childhood), ? sarcoidosis, presenting with 1d of RUQ pain with radiation to side and back. This is the ___ such episode in the last 2.5w. Notably this patient was discharged on ___ after being admitted for a similar episode, during which he was found to have an obstructing gallstone in GB neck on US, which was later found to be dislodged on MRCP. He has not been offered cholecystectomy or ERCP due to his long-standing liver disease. Has been getting ___ endoscopies, last saw only varices, otherwise normal. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Markedly limited exam due to the presence of overlying bowel gas obscuring the midline structures. The gallbladder, common bile duct and main portal vein could not be well assessed. If there is continued concern for choledocholithiasis, MRCP is recommended. 2. No intrahepatic biliary duct dilatation. 3. Cirrhosis with splenomegaly and massive splenorenal shunt. AP chest x-ray. showed Left greater than right mild asymmetric pulmonary edema. Focal opacity within the left lung apex may reflect superimposed infection. CTA thorax. showed 1. Consolidations in the apices as well as the superior segment of the left lower lobe. These may be sequelae of sarcoidosis, however superimposed pneumonia cannot be ruled out. Correlation with older exams presumably performed elsewhere would help assess for interval change. 2. No evidence of pulmonary embolism to the proximal segmental level. Subsegmental pulmonary arteries are not well evaluated due to timing of bolus. 3. Cirrhosis, splenomegaly, multiple abdominal varices including gastroesophageal varices. The patient was diagnosed with CIRRHOSIS OF LIVER NOS, HYPOXEMIA, CHOLELITHIASIS NOS. The patient was treated with Bone marrow biopsy. At the time of discharge, the patient had Biliary colic Sarcoidosis Cryptogenic cirrhosis, compensated Pancytopenia, neutropenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ h/o cryptogenic cirrhosis (dx in childhood), ? sarcoidosis, presented to ED with 1d of RUQ pain with radiation to side and back. This is the ___ such episode in the last 2.5w RUQ US showed only non-dilated common bile duct (although a recent admission showed cholelithiasis on US and MRCP), pt also had CXR for desat to 78%/RA in ED. He then received CTA after a concerning opacity was visualized. He recieved one dose of levofloxacin, but this was discontinued after learning more about his extensive pulmonary history of ?sarcoidosis, with large desats and consolidation on imaging at baseline. His CBC also revealed pancytopenia. He was admitted to medicine for symptomatic management of his biliary colic. On the medical floor his pain was managed with oxycodone. He was also seen by the Heme/Onc team who performed a bone marrow biopsy for his pancytopenia. The transplant team also paid a visit. They still believed that his operative risk for CCY was too high, and so recommended that he try low-fat diet first. Surgery also recommended listing Mr. ___ for liver transplant prior to surgery given MELD=15 and risk of hepatic decompensation after surgery. After the bone biopsy, Mr. ___ pain was managed with oxycodone. There was no bleeding or bruising from the site. He was discharged in no pain, with stable but pancytopenic CBC, and baseline low O2 sats. ___ with PMH of possible pulmonary sarcoid, cryptogenic cirrhosis (since age ___, and recent admission for gallstone pancreatitis who is presenting from OSH for further evaluation of epigastric pain radiation to RUQ concerning for biliary colic # Cholelithiasis: Patient with recent admission for gallstone pancreatitis, for which no surgical intervention was offered given high operative risk in the setting of cirrhosis and not on transplant list. Patient now representing with pain concerning for biliary colic. Lipase 60 and no signs to suggest pancreatitis or cholangitis. Tbili was initially up but downtrended. Placed on low-fat diet, met with nutrition, and manage pain with conservative PO pain medication. Patient will likely need cholecystectomy and should have expedited work up for possible transplant listing prior to surgical intervention. Was seen by surgery and scheduled to see transplant surgery as outpatient with Dr. ___ ___. Patient was counseled about risks of complications and possible need for future surgery. Need to discuss transplant surgery referral if faster to work up at ___ given testing already done at ___. # Hypoxia: Patient with ___ years of chronic hypoxia, with baseline O2 sat 90%RA. He is followed by Tuft Pulmonary (Dr. ___ who after extensive work-up has diagnosed him with likely pulmonary sarcoid. However, some notes also mention possibility of hepatopulmonary syndrome. Patient found in ED initially to be at baselin hypoxia but then desatted (asymptomatic to high-70s) of unclear duration. Saturation then recorded as 92-93% on RA. Had elevated Ddimer and CTA which was negative for PE but showed multifocal consolidations which could be consistent with prior sarcoid but no prior imaging available for review. Suspicion for pneumonia remains low given he states his breathing is at baseline (has baseline AM cough), clinically without fever, and no leukocytosis or left shift on labs (Flu negative as well). Overnight, received diuresis with 10mg IV lasix and was negative 1800cc. Likely overdiuresed given not clearly overloaded and now not feeling well with mild tachycardia, weakness, and headache. Received 500cc IVF back. Will follow up with outpatient Pulmonologist (Dr. ___ of ___. He was given CD of CT scan from ___ which should be compared by pulmonologist to prior CTs. Ambulatory sat was 82%. Patient was counseled to use oxygen while ambulating but refused. # Cryptogenic Cirrhosis: Patient diagnosed at age ___ with cryptogenic cirrhosis followed by Dr. ___ at ___. Currently Child B and MELD 15. MELD 14 on discharge. Patient has follow up scheduled for ___ with her. Would recommend that patient be worked up for transplant listing given high risk of complications from cholethiasis and if needs emergent surgery at some point, would want to be listed for transplant prior. # Pancytopenia: unclear etiology. Heme/Onc was consulted last admission and recommended outpatient visit for work up. However, patient was discharged prior to being seen by heme/onc and did not return phone call for scheduling from secretary. Heme/Onc saw the patient during this admission. Concerned for congenital MDS vs. impact of liver disease. Continued home folate and B12 supplementation. Had bone marrow biopsy on the day prior to discharge. Patient was neutropenic for the two days prior to discharge but not significantly worse than prior admission. Counts improving on day of discharge. Patient was counseled multiple times to stay while he was neutropenic. However, patient insisted on leaving. He understood the risks of neutropenic infection. He understood to return to the ED at any signs of infection or not feeling well. He will see heme/onc 3 days after discharge. # GERD: Continued home omeprazole # Code: Full # Emergency Contact: ___ (Wife) ___ **Transitional Issues** - continue to follow low fat diet, was seen by nutrition - follow up bone marrow biopsy results and will need ongoing evaluation by hematology for pancytopenia - follow up beta-glucan, galactomannan, respiratory viral panel, and IgG level - Patient was discharged with CD of imaging from stay, please compare CT chest here to prior CTs - If CT chest from admission is not consistent with priors, should have work up for possible indolent infection given neutropenia and can consider bronch - MELD 14 on discharge - Consider working up patient for liver transplant list as he is at high likelihood of having complication from his cholethiasis and may need surgical intervention - Patient was counseled to remain inpatient pending work up and improvement of WBC. However, insisted on leaving. He was counseled on risks and to return to ED at first sign of any infection, fever, or not feeling well</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a longstanding history of GERD/gastritis, ___, HTN, esophageal dysmotility in 20% of the esophagus who presents with dysphagia of solids and was found to have several impaired electrolyte levels. Patient was recently admitted in ___ at ___ for the same reasons. She had a follow up visit with her PCP (___) who upon routine lab screening noted that the patient had an elevated Cr with electrolyte abnormalities. The patient was asymptomatic at the time. Radiology showed Bibasilar opacities more conspicuous linear opacities at the left lung base. Findings may be due to pneumonia. Recommend repeat after treatment to document resolution of the findings. The patient was diagnosed with VOMITING, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOKALEMIA, HYPOSMOLALITY/HYPONATREMIA. At the time of discharge, the patient had Primary Diagnosis: Acute Kidney Injury Secondary Diagnosis: Dysphagia, dysthymia with superimposed adjustment disorder in the setting of recent stressors and medical issues. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a longstanding history of GERD/gastritis, ___, HTN recent esophageal manometry this ___ showing occasional esophageal dysmotility in 20% of the esophagus who presented with dysphagia of solids and was found to have several impaired electrolyte levels and acute kidney injury. # Dysphagia: The patient has a long-standing history of GERD, ___ esophagus, and recent diagnosis of 20% esophageal dysmotility on manometry. Barium swallow study showed mild esophageal dysmotility and mild reflux. She also underwent a video swallow that revealed no upper esophageal sphincter dysfunction despite very mild narrowing at the sphincter, felt highly unlikely to be the cause of her symptoms. Zinc level low so on zinc supplementation. Neurology evaluated the patient, and does not think there is neurologic contribution to dysphagia, recommended outpatient follow-up for cerebellar process. Psychiatry also evaluated the patient, and did not think there was any particular pathology but did think patient had poor coping with her dysphagia. Nutritionist also evaluated the patient adn created a concreate list of foods/liquids that patient can tolerate while providing adequate calorie and nutrition intake. PCP follow up was arranged for the patient with recommendation for nutrition referral as an outpatient. # Acute Kidney Injury: baseline 0.5-0.6 (likely from malnourishment) but up to 2.7 on admission. The acute kidney injury is likely secondary to volume depletion given history of poor PO intake and use of furosemide, as well as possible ATN from prolonged dehydration. Pt was resuscitated with fluid. Microscopic examination of urine was normal. Her creatinine decreased to 1.2 with continuous PO encouragement, this new value may be reflective for patien'ts new baseline. #Electrolyte disturbances: hyponatremia (baseline 130), low potassium, magnesium, chloride consistent with severely poor PO intake. also may have contribution from lasix. EKG was without significant abnormalities. Electrolyte abnormalities resolved after fluid resuscitation as well as electrolyte repletion. Pt was instructed to take multivitamins with minerals to maintain magnesium levels. CHRONIC ISSUES ISSUES: # Insomnia: The patient was continued on her home trazadone 50mg without complications. # ___ swelling: The patient takes furosemide at home. Given that this like contributed or preipitated her electrolyte abnormalities, the patient was encouarged to stop furosemide. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a heavy smoker who presented to an outside hospital with complaint of 6weeks of abdominal pain, he was found to have U/S e/p abdominal mass and lymphadenopathy, he was referred to the hospitalist service for further evaluation and management of his symptoms Chest radiograph showed No pulmonary effusion. No obvious focal pulmonary mass. Radiology showed 1. Nodular appearance of the liver, suggesting cirrhosis, with a hypodense 2.8 cm segment V mass measuring 2.7 x 2.8 cm and portacaval and peripancreatic lymphadenopathy and multiple peritoneal nodules concerning for metastatic disease. A definite primary lesion is not identified. Given suspicion of cirrhosis, intrahepatic cholangiocarcinoma or mixed HCC/cholangiocarcioma is possible given aggressive appearance of the lymphadenopathy and distal spread; extrahepatic primary remains a possiblity. Biopsy recommended. 2. 7 mm right lower lobe pulmonary nodule is suspicious for metastasis. RECOMMENDATION(S): US guided biopsy of the liver mass. CTA HEAD WANDW/O C AND RECONS showed 1. No sequela of prior hemorrhagic infarct. 2. No evidence ofaneurysm, dissection or vascular malformation, or significant luminal narrowing. CT CHEST W/O CONTRAST showed 1. Large lytic lesion at T8 with associated soft tissue mass apparently extending into the spinal canal; the latter is difficult to assess on this unenhanced CT. Further evaluation with MRI of the thoracic spine is recommended. 2. Several upper lobe predominant 2-3 mm diameter nodular opacities are a nonspecific finding. Followup CT in 3 months may be helpful to exclude the possibility of metastatic disease at 1 are more of the sites. 3. Mild emphysema, findings suggestive of chronic bronchitis, and likely associated respiratory bronchiolitis. 4. Diffuse coronary artery calcifications. 5. Please see full report of abdominal CT of ___ for complete description of subdiaphragmatic findings. RECOMMENDATION: Thoracic spine MRI for further evaluation of the T8 lesion. NOTIFICATION: Dr. ___ communicated these findings by telephone with Dr. ___ on ___ at 11:10 AM, 5 minutes after discovery of the findings. Radiology showed Uncomplicated 18-gauge targeted liver biopsy x 2, with specimen provided to the cytologist. MR ___ ANDW/O CONTRAST T___ MR SPINE showed 1. T8 right vertebral body enhancing mass extending from posterior right vertebral body through right pedicle and lamina into right transverse process with questioned minimal epidural extension, and mild vertebral canal and neural foraminal stenosis at T8-9 level, as described. 2. No additional mass identified. 3. 7 mm right lower lobe pulmonary nodule. 4. Previously noted upper lobe pulmonary nodules not well visualized on current study. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with ___ liver biopsy ___. At the time of discharge, the patient had Abdominal pain Liver tumor Thoracic spine tumor Hepatitis C. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with +smoking history, remote h/o CVA with residual L sided weakness, and no medical care for the past several years presented to an outside hospital with 6 weeks of worsening abdominal pain and weight loss, found to have new liver lesion. He was transferred to ___ for further workup. # Liver lesion: Imaging was initially concerning for HCC vs cholangiocarcinoma. ___ guided biopsy was performed on ___. Lab workup revealed an elevated AFP and positive HCV antibody, making HCC the most likely diagnosis. CT imaging for staging revealed abdominal LN involvement as well as a large lytic T8 lesion. The patient will follow up with oncology and hepatology at the multidisciplinary liver tumor clinic on ___ for further management. # T8 spinal lesion: The patient did not have any neurologic findings suggestive of cord impingement. An MRI T spine was performed for further characterization. # Possible cirrhosis: Patient's CT a/p showed heterogenic, nodular appearance to the liver consistent with cirrhosis. Although, labs indicate that he has good liver function. No history of alcohol abuse. Likely secondary to HCV. He was instructed to avoid tylenol and alcohol. # H/o CVA: Patient reports having had a bleed in the brain ___ yrs ago with residual L sided weakness, consistent on exam. CT interestingly shows no evidence of stroke. He is not on ASA.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p distal radius fracture on ___, managed with closed reduction in ___ ED on . On morning of presentation, ___, he awoke with feeling of numbness in the median nerve distribution. Endorses ongoing pain in his left wrist since his injury yesterday. No other sites of pain or injury. The patient was diagnosed with CARPAL TUNNEL SYNDROME, FX DISTAL RADIUS NEC-CL, ACCIDENT NOS. The patient was treated with open reduction and internal fixation of left distal radius fracture and carpal tunnel release. At the time of discharge, the patient had left distal radius fracture, acute carpal tunnel 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>As noted above, the patient was admitted to ___ on ___. He underwent open reduction and internal fixation of left distal radius fracture, as well as carpal tunnel release. This was performed by Dr. ___ tolerated. Subsequently admitted to the Orthopaedic Trauma service. Neuro: Postoperatively, pain controlled with dilauid PCA and then PO oxycodone and acetaminophen, to good effect. CV: Hemodynamically stable. Pulm: No respiratory issues. GI: Tolerated regular diet postoperatively. ID: Received periop ancef. DVT: Received ASA 325mg; will complete a ___ctivity: Seen by OT while in-patient and deemed safe for home. On day of discharge, POD1, he was afebrile with good pain control. He had stable paresthesias in hand, secondary to acute nerve insult following fracture. We expect this to improve slowly with time. He will remain non-weight-bearing with left upper extremity and follow-up in clinic in 10 day for orthoplast splint. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with hx of recurrent, resistant UTIs/urosepsis for several years, medullary sponge kidney bilaterally with recurrent nephrolithiasis, anorexia nervosa, bilateral iliac artery thrombosis requiring bilateral AKAs in ___ thought to be secondary to sepsis, SAH, who presents after positive UA and UTI symptoms. Radiology showed No hydronephrosis. Small stable simple right renal cyst. Nephrolithiasis consistent with the patient's known medullary sponge kidneys. Radiology showed Stenosis at the confluence of the left basilic and axillary veins precluding PICC placement. Ultrasound and fluoroscopically-guided single-lumen PICC line placement via the left brachial venous approach. Final internal length is 40 cm, with the tip positioned in SVC. The line is ready to use. The patient was diagnosed with URIN TRACT INFECTION NOS. The patient was treated with Placement of PICC on ___. At the time of discharge, the patient had PRIMARY: recurrent urinary tract infection SECONDARY: Medullary sponge kidneys, nephrolithiasis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F with b/l AKA and b/l medullary sponge kidneys c/b nephrolithiasis and recurrent resistant UTIs/urosepsis, presenting for UTI. # Recurrent UTI: patient with dysuria, frequency, urgency and hx of several UTIs growing pseudomonas resistant to cipro/gentamicin/tobra and intermediate resistant to ceftaz, sensitive to zosyn. At risk of recurrent UTIs and potential complications (ie pyelo, urosepsis) given medullary sponge kidneys. Physical exam with mild L CVA tenderness, but no casts in urine, no leukocytosis, afebrile and hemodynamically stable. Renal ultrasound was performed and showed no hydronephrosis, small stable simple right renal cyst, and nephrolithiasis consistent with the patient's known medullary sponge kidneys. Urine culture was contaminated, but urine culture from PCP obtained prior to admission were positive for pseudomonas sensitive to zosyn. On admission, she was started on zosyn 2.25g IV q6h and a PICC was placed on ___. ID was consulted. Patient discharged with 3.375g q8h to complete a 10 day course (last day on ___ as complicated UTI due to her anatomy. Patient remained clinically well throughout her hospitalization. Prior to admission, patient was taking monurol every 10 days starting in ___ and cranberry juice to prevent UTI per ID recommendations. No UTI from ___ until now since starting the medication (previously had UTI every 2 months). Per ID recommendations, holding monurol until after completion of zosyn; fosfomycin sensitivities were also added to urine culture from PCP (___) to determine if appropriate to continue monurol for ppx. # hx of bilateral nephrolithiasis: secondary to medullary sponge kidneys, which likely contributes to the recurrent UTIs. ___ placement of stent and lithotripsy of left ureteral and renal stones in ___. Last laser lithotripsy on ___. Followed by urologist and last seen on ___ and at the time had a KUB that only showed chronic medullary sponge kidney. Patient is on potassium citrate BID at home for nephroithiasis, but was NF and not available at hospital. She will resume taking medication at discharge. # cachetic/poor appetite: per patient, had anorexia from age ___, but has since been eating well, although has poor appetite. Albumin on ___ was 4.4. She ate well throughout her hospitalization and given ensure supplementation TID. # phantom/amputation pain: continued with fentanyl patch, gabapentin 600mg QID, and dilaudid 2mg q8h:PRN # Depression: continued with duloxetine, mirtazapine, bupropion # GERD: continued with Pantoprazole 40 mg PO Q12H # chronic low BP: continued with midodrine # TRANSITIONAL ISSUES -PICC placed and patient to complete 10 day course of zosyn for pseudomonas UTI (last day on ___ -holding monurol until after completion of zosyn -fosfomycin sensitivities added to urine culture from ___ ___, please follow up with results -please follow up with pending blood cultures </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 testicular cancer s/p right radical otchiectomy and 3 cycles of BEP who presents with shortness of breath and cough. CTA chest. showed 1. Segmental and subsegmental PEs, as described, within the lingula, left lower lobe and right lower lobe. No evidence of right heart strain. 2. 6 mm nodule in the right lower lobe, previously 9 mm. NOTIFICATION: The updated findings, including the right pulmonary nodule, were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 5:20 pm, 5 minutes after discovery of the findings. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale. At the time of discharge, the patient had Acute Pulmonary Embolism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of testicular cancer s/p right radical orchiectomy and 3 cycles of BEP who presents with shortness of breath and cough found to have bilateral PEs. # Pulmonary Embolism: Patient found to have bilateral PEs in setting of shortness of breath and cough. Also has had intermittent bilateral leg tenderness concerning for DVT but this was ruled out by bilateral lower extremity dopplers. No signs/symptoms of heart strain which was confirmed by TTE. Currently hemodynamically stable with sinus tachycardia on ambulation and dyspnea on exertion without hypotension or hypoxia. Patient was started on Lovenox injections on admissions with plan to continue this on discharge pending discussion with Dr. ___ clinical trial comparing Apixaban to dalteparin. Ultimately patient and wife decided to not enroll in the clinical trial and he was discharged on enoxaparin for at least 1 month. >30 minutes spent on complex discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Male with multiple orthopedic problems in his legs, walks with a cane, presents with knee pain after ___t home. He has trouble getting around in general, and is out on disability, several days prior to admission he slipped and fell down a flight of stairs injuring his left knee and left ankle. He states he heard a pop in his ankle, and has been unstable on his feet since then. Since that fall he was seen by his orthopedist where he had an MRI of the left ankle which by report showed achilles tendonitis. Radiology showed No acute intracranial process. The patient was diagnosed with PAIN IN LIMB, HISTORY OF FALL. At the time of discharge, the patient had Primary diagnoses: - Left knee pain Secondary diagnoses: - Hypertension - Chronic back pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>HOSPITAL COURSE: ___ w/ recent fall ___ 'knee buckling' who presented a few days after the fall for pain managment. Dc/ed on home pain meds as has MRI and outpt followup with Orthopedics as outpt. Monoarticular Arthralgia: The patient's pain is well out of proportion to this exam. Likely traumatic injury, and given his ability to ambulate he does not have a tibial plateu fracture or other major bone injury, and while he may have ligamentous or tendon injury these are not likely to be serious given the benign exam. It is possible that his falls are related to instability which might indicate a ligament tear or meniscal injury, however, the pt is back to baseline on his home pain regimen. Physical therapy was called to see him who cleared him for home d/c. He already has an outpatient MRI of his knee arranged from prior to the admission on in 3 days. Benign Hypertension: stable. We continued HCTZ 25mg QD, atenolol 25mg QD and lisinopril 40mg QD, Bipolar Disorder: stable. We continued buspirone 30mg TID prn, alprazolam 2mg ___, Chronic Lumbar Back Pain: stable. We continued gabapentin 600mg TID and restarted home oxycodone 10mg Q3h prn pain. Insomnia: stable # CODE: Full </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ F with HTN, h/o colon cancer s/p colectomy ___ years ago, h/o PE on coumadin, who presents with ___ weeks of discomfort with swallowing and feeling that food is getting 'stuck' below her throat, acutely worsened over the past several days leading to poor PO intake. She describes the swallowing action as fine, but then feels that food gets stuck several inches below the throat and doesn't go down. It is much worse with solids than with fluids, but she does have some degree of discomfort even with fluids. She denies odynophagia. Over the past several days she has barely been able to eat and she has not been drinking enough. She has had intermittent nausea and several episodes of NBNB emesis. She denies abdominal pain, chest pain, SOB, change in bowel or bladder function, BRBPR, hematochezia, or melena. She has had a dry cough for several days. Radiology showed 1. No radiopaque foreign body. The plain film finding is accounted for by internal carotid calcification. 2. Two 2-mm nodules in the right upper lobe which in the absence of risk factors such as smoking require no further followup. If patient has risk factors for lung cancer according to ___ criteria such as smoking, additional followup chest CT is recommended in 12 months. The patient was diagnosed with OTHER SYMPTOMS INVOLVING HEAD AND NECK, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT, HX OF COLONIC MALIGNANCY DYSPHAGIA, UNSPECIFIED, DEHYDRATION, RENAL & URETERAL DIS NOS, ABNORM ELECTROCARDIOGRAM. The patient was treated with EGD. At the time of discharge, the patient had Primary diagnosis - hiatal hernia - gastritis - gastric polyp Secondary diagnosis - hypertension - 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>This is a ___ F with HTN, h/o colon cancer s/p colectomy, h/o PE on coumadin, who presents with ___ weeks of dysphagia that is recently worsened, poor PO intake, tachycardia, ___, and supratherapeutic INR. ACTIVE ISSUES # DYSPHAGIA: The exact etiology for pt's dysphagia is still unclear. Pt underwent neck X-ray and CT in the ED, without evidence of foreign objects or mass. She also underwent EGD, which showed a hiatal hernia with small tear vs erosion at EGJ, a stomach polyp and erythema and erosion consistent with gastritis. Pt also was evaluated by speech and swallow team, whose studies showed normal swallowing with thin liquid, regular and dry solids without concerns of aspriation. Yet, pt continue to complain of dysphagia. She was therefore scheduled to have motility studies at the ___ clinic. We started her on pantoprazole 40 mg bid. # SUPRATHERAPEUTIC INR: patient is on 2mg coumadin daily for DVT/PE prophylaxis. Her INR on admission was 8.7 in the setting of significantly decreased PO intake. She denies any history of high INRs. No other clear etiology of the increase. We held her coumadin initially, and gave her vitamin K 5 mg IV given the need for urgent EGD. # EKG CHANGES: Patient was found to have ST depressions and TWI in the lateral and precordial leads. She has no known history of CAD, but with carotid calcification on CXR suggesting likelihood of coronary atherosclerosis. Her Tropononin were neg x3 during this admission. There were never chest pain. # ACUTE KIDNEY INJURY: Pt presented with ___ with Cr 2.5. Her Cr improved with to 1.3 after fluid and nutrition support. # HYPOTENSION: Pt has a history of hypertension. She however presented with hypotension in the ED. We felt that this is from dehydration and ___. We held her lisinopril, hydrocholothiazide and amlodipine during this admission. Her BP at the discharge was reassuring. We restarted her on amlodipine. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of Metastatic poorly differentiated neuroendocrine carcinoma (s/p 5 cycles carboplatin/etoposide, currently on surveillance), HTN, Pathologic compression fracture at L3 (c/b cord compression s/p XRT) who initially presented to OSH with vomiting/abdominal pain, found to have malignant gastric outlet obstruction, now awaiting advanced endoscopy consult Radiology showed The tip of an enteric tube projects over the stomach. The patient was diagnosed with Adult hypertrophic pyloric stenosis. The patient was treated with ___ Endoscopic Duodenal Stent Placement. At the time of discharge, the patient had Primary Diagnosis: ================== Gastric Outlet Obstruction Metastatic poorly differentiated neuroendocrine carcinoma Leukocytosis Secondary Diagnosis: =================== Hypertension Hyperlipidemia Diarrhea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospital Course: Ms. ___ is an ___ y.o. female with poorly differentiated neuroendocrine carcinoma metastatic to bone, nodes, and liver (s/p 5 cycles carboplatin/etoposide (last ___, currently on surveillance), HTN, Pathologic compression fracture at L3 (c/b cord compression s/p XRT) who initially presented to ___ ___ with non-bloody emesis, abdominal pain, and was subsequently transferred to ___ on ___ for management of a malignant gastric outlet obstruction. ================ Acute Issues ================ #Metastatic high-grade neuroendocrine tumor She is s/p 5 cycles of carboplatin/etoposide (completed ___ and presented with evidence of disease recurrence, complicated by gastric outlet obstruction. After a discussion with Dr. ___, Dr. ___, Dr. ___ the patient, it was decided that she would undergo re-treatment with carboplatin/etoposide after duodental stenting. She began C6 carboplatin/etoposide on ___ and had her last dose on ___. Follow-up at ___ was coordinated such that she would receive Neulasta there on ___. #Malignant gastric outlet obstruction #Non-bloody emesis #Abdominal pain She was scheduled for an outpatient staging CT abd/pelvis on ___ which showed increased size of two hepatic metastases and an exophytic lesion arising from the pylorus with new invasion into the liver and slightly increased size of periportal lymphadenopathy concerning for disease progression. Subsequently, she developed symptoms of nausea, vomiting, abdominal pain and presented to ___ where a repeat CT abd/pelvis on ___ re-demonstrated similar findings, but with increased distension of her stomach since the prior study, suggesting gastric outlet obstruction secondary to the exophytic duodenal bulb/pyloric mass. An NG tube was placed at ___ and she was transferred to ___ where duodenal stenting could be performed. Duodenal stenting was completed on ___. She was started on a clear liquid diet, eventually advancing to a low-fiber diet, as per GI. She was seen by Nutrition prior to discharge, who provided her with additional information on diet s/p duodental stenting. #Hypertension She was hypertensive to 150-170s systolic and had one episode at night in which her systolic BP was elevated to 190s. She was given IV hydralazine and BP subsequently lowered to 150s systolic. Although Lasix was originally written for lower extremity edema, we restarted her home medications as she was no longer NPO. #Diarrhea She had episodes of multiple loose stools after duodenal stent placement. C diff assay was neg and she was given Imodium prn with improvement in decreasing stool output. #Hypernatremia #Hypochloremia As she was NPO throughout her initial hospital stay, she was given continuous IVF (normal saline); however, she became hypernatremic to 154 and hypochloremic. She was switched to ___ normal saline IVF and her electrolyte abnormalities resolved thereafter. #Hypokalemia She was hypokalemic at admission and was replected with vitamin K IV as needed. #Leukocytosis She initially presented with a WBC of 16.2 at admission, which downtrended and resolved prior to discharge. #Elevated Lactate Her lactate was elevated to 2.8 at ___ and ___ thought to be secondary to hypovolemia from GI losses. A repeat lactate obtained prior to discharge was 1.2 after receiving continuous IVF. ================ Chronic Issues ================ #Chronic Ankle Edema Her home Lasix was held, as she was NPO upon arrival and prior to her procedure. We resumed her home Lasix when she was no longer NPO. #HLD Her home statin was held, as she was NPO upon arrival and prior to her procedure. We resumed her home statin when she was no longer NPO. ================ Transitional Issues ================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ smoker with a PMH notable for HFpEF, paroxysmal AFib not on anticoagulation secondary to patient refusal, craniopharyngeoma c/b DI/AI/hypothyroidism, CKD (baseline Cr 2.0) and COPD on home O2 2L who presents with failure to thrive without having eaten over the past 5 days, noting nonspecific body pain and cough. She has been unable to eat or drink for 5 days ___ nausea, and stopped her medications since she did not know whether or not to take medications on an empty stomach. She endorses nausea with +emesis x2 (white, then green) on ___ and ___. Ms. ___ reports having been exhausted for as long as she can remember. She has had ongoing weight loss (128 to 122 on ___ reported, inconsistent with records), and describes not having an appetite since she was a little child for an unknown reason. CHEST (AP AND LAT) showed 1. Moderate to large right and moderate left bilateral layering pleural effusions, not substantially changed in size from the previous study with associated bibasilar atelectasis. 2. Moderate cardiomegaly with mild pulmonary edema, also similar to prior. 3. Left basilar bronchiectasis with airway wall thickening suggestive of inflammation or infection. CT abdomen and pelvis. showed 1. Moderate right greater than left pleural effusions with bilateral lower lobe atelectasis. 2. Large umbilical hernia containing loops transverse colon without evidence for obstruction or complications. 3. No evidence of small bowel obstruction. 4. Calcified fibroid uterus. 5. Hyperdense liver likely secondary to amiodarone use. 6. Probable cholelithiasis. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. GB Adenomyoma. Cholelithiasis with no evidence cholecystitis. 2. Large right pleural effusion is incidentally noted. The patient was diagnosed with Cough. At the time of discharge, the patient had Primary: Failure to thrive Transaminitis secondary to amiodarone use UTI Community acquired pneumonia Secondary: Paroxysmal atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ smoker with chronic HFpEF, paroxysmal AFib (not on anticoagulation secondary to patient refusal), craniopharyngeoma with subsequent panhypopituitarism (DI/AI/hypothyroidism), CKD stage III (baseline Cr 2.0), and COPD on home O2 2L who presents with failure to thrive without having eaten or taken medications due to n/v (x2, white then bilious) during 5 days prior to presentation, noting intermittent abdominal pain and often productive cough, found to have UTI, transaminitis, and possible COPD exacerbation. # FTT - abdominal pain / nausea / anorexia: Patient presented with intermittent tenderness to palpation in RUQ, yet inconsistently reports pain. Most likely hepatotoxicity given use of amiodarone therapy and transaminitis with AST>ALT elevations (downtrending since ___ and modest-normal AlkPhos elevations. ___ also have contributing depression given her ability to eat (albeit decreased appetite) until brother's wife departed from visiting Ms. ___ 1wk prior to Ms. ___ anorexia as well as impactful loss of her husband. Concerned about malignancy given general malaise. CT Abd/Pel did not find lesions but transudative pleural effusion w/u in the past was not the best screening for cancer, esp given her long hx of smoking. Unlikely mesenteric ischemia or biliary colic, although this could drive previous subconscious nauseous reaction to thought of food. Liver/GB US (___) describes focally thickened GB fundus consistent with adenomyomatosis, also noting cholelithiasis and a simple hepatic cyst. Patient does not demonstrate symptoms typical for biliary colic. Currently increasing dietary intake (___). HAV Ab positive indicating past exposure to Hepatitis A virus. HCV Ab negative, HBsAg negative, and HBsAb negative. GI consult unable to convince her to have colonoscopy/EGD, patient aware that work-up would be for malignancy. LFTs downtrended throughout admission. Nutrition team was consulted. She was able to increase her food intake. #UTI: On presentation, she endorsed a “stinging pain” with urination, but noted resolution upon receiving 1mg of ceftriaxone (___). Urine culture ___ found to contain Klebsiella sensitive to CTX. US (___) did not identify hydronephrosis. She was transitioned to PO Cefpodoxime to be continued until ___. #Chronic hypoxemia / PNA: Patient on home O2 of 2L without current respiratory distress but notable for increased cough +/- white sputum. Requiring 2L to maintain O2sat 97% and requiring fluticasone-salmeterol diskus 2x daily, montelukast, ipratropium-albuterol nebs w/ azithro during hospital stay. Presumed secondary to chronic CHF vs. COPD exacerbation vs. PNA. Chest XR with possible infectious process in L base, however symptoms inconsistent. Crackles but no wheezing on exam. She was started on IV ceftriaxone and azithromycin (for UTI and presumed COPD exacerbation, but would also cover possible PNA), transitioned to PO Cefpodoxime and PO azithromycin to be continued until ___. We continued inhalers, montelukast, duonebs, and nasal spray. # Social: Concern about her functioning status upon discharge home. Spoke with brother, ___, who lives in ___ and ___ contacted Ms. ___ two weeks prior via phone conversation. During this conversation, Mr. ___ insisted that his sister went through rough times of being in and out of the hospital following the passing of her husband, but had been functioning well otherwise. He has hosted Ms. ___ at his ___ house several times over the past few years, and did not notice any change in behavior. Since Ms. ___ usual caretaker/home supporter, her cousin ___, has been visiting ___ recently, Mr. ___ wife has made two trips (1 wk, 3 ___ to provide Ms. ___ with community. Mrs. ___ left two ___ ago, after which Ms. ___ called Mr. ___ to notify him of her complete loss of appetite - "no matter how much she tried to force food down." He has never heard her behave this way, but he figured that the hospital would help her eat. When discussing Ms. ___ discharge life planning, Mr. ___ would like for Ms. ___ to move into his ___ house permanently, where she has previously enjoyed her stay ___ yrs prior). He was provided with Ms. ___ hospital room phone number, as she has been unable to contact anyone due to her phone minutes depletion. Although she may not have many local social supports, she does have multiple ___ supports including a ___, telehealth, and a home care assistant. Her ___ was contacted and had no concerns about patient's medication compliance although agrees that patient has had a hard time since her husband passed away. At time of discharge, patient agrees that she would like to increase her food intake and is amenable to appetite stimulants. She was seen by the inpatient palliative care team as well and may benefit from palliative care to help with her appetite. Chronic issues: # Hypomagnesemia: Unclear etiology and has been recurrent issue. Could be associated with pt's PPI use or loop diuretic. ___ also be in setting of malnutrition. Repleted 1x in ED. # CKD: Patient remains near baseline Cr of 2.0. # HFpEF: Echo ___ demonstrated mild ___, L-to-R shunt across the interarterial septum at rest. Mild (1+) mitral regurgitation. Estimated LVEF of 60-65%. Previous discharge weight 62kg, whereas she is now closer to 58kg. Was on torsemide 40mg daily, but does not demonstrate ___ edema or JVD (negative hepatojugular reflux). Received 1L NS in ED (___). Given 500 mL D5W bolus over 120 min (___) due to hypotension. Negative orthostasis. Torsemide was held due to low blood pressures. # Craniopharyngioma: Supra-sellar mass most consistent with a craniopharyngeoma by MRI characteristics (___) s/p XRT as well as DI and panhypopituitarism including hypothyroidism, hyperprolactinemia, hypogonadism, and ___ deficiency and adrenal insufficiency due to exogenous steroid use (for COPD). Originally found to be abutting and elevating optic chiasm with bitemporal hemianopsia. Completed fractionated radiation therapy from ___ to ___ (52.2 Gy over 29 fractions). Receives ddAVP (desmopressin) for DI. TSH is within normal limits. We continued hydrocortisone, desmopressin, and synthroid. # Paroxysmal afib: CHADS2-VASC score 4. Not on anticoagulation given fall risk, past discussion with NSG, and patient reluctance. Currently in NSR with irregularly irregular rhythm auscultated on exam. We continued ASA 325. We held amiodarone in setting of LFT abnormalities. # Adrenal insufficiency: Diagnosed originally in ___ due to exogenous steroid use (for COPD). Continued home hydrocortisone 10mg in AM and 2.5mg in ___. # Depression, anxiety: Continued home sertraline # GERD: Continued home PPI # Anemia: stable. Continued PO iron supplements # Allergic rhinitis: Continued nasal spray # OSA: refused CPAP</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old M with cAD, HTN, BPH s/p TURP who was recently seen in the ED on ___ for gross hematuria and discharged with foley who presents with fall. Pt was eating at home stood up to go look into some noise coming from outside his home and says ___ tripped on a rug and fell in the staircase. ___ does not think ___ lost consciousness and remembers a family member coming to his aide immediately. ___ did have a head strike in the occipital region. ___ was brought to the ED for evaluation. Trauma scan was negative including CT head an c-spine were negative. ___ did not have chest pain at home but reported some pain on his L chest while in the ER. ECG was negative and initial troponin was negative. His pain resolved prior to arrival to the floor. ___ did have some worsening of his hematuria since the fall. ___ was evaluated by urology who recommended flushing with plan for outpatient workup for his hematuria as long as pt remained stable. Radiology showed No evidence of injury. RIGHT KNEE RADIOGRAPHS showed No evidence of injury. Moderate to severe medial osteoarthritis, similar to prior findings. Vascular calcifications. Radiology showed No evidence of retroperitoneal hematoma. No other acute pathology identified. Moderate to large hiatal hernia. Enlarged irregular prostate without clear change; malignancy is not excluded however. Faint corticomedullary nephrograms and hyperdense gallbladder contents, which could be seen with slow excretion of a recent contrast injection in the appropriate setting; correlation with whether there has been a recent injection, as well as with renal function, is recommended. HEAD CT showed 1. No evidence of acute intracranial process or injury. 2. White matter disease probably due to small vessel related ischemic change and small probably chronic lacunar infarcts. 3. Findings suggesting chronic inflammatory disease of paranasal sinuses. CERVICAL SPINE CT showed 1. No evidence of acute injury. 2. Moderate cervical spondylosis. 3. Multiple nodules of the lung apices, probably inflammatory and suggesting that a chronic process, such as perhaps atypical mycobacterial infection, has persisted. However, only the lung apices are imaged on this study. The patient was diagnosed with HEMATURIA, UNSPECIFIED, SYNCOPE AND COLLAPSE. At the time of discharge, the patient had Mechanical fall, atraumatic Hematuria, possibly related to benign prostatic hyperplasia Chest pain, musculoskeletal versus a bout of stable angina. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ISSUES ADDRESSED THIS HOSPITAL STAY: # Fall: Purely mechanical by history. Cleared by ___ for home with cane and home ___. Daughter is very supportive and will assist patient with all ADLs. - Home ___ # Hematuria: Thought most likely BPH with some component of trauma during the fall to explain the worsening on admission, +/- UTI. Gross hematuria resolved by the AM of discharge. Seen by Urology on ___ and again on admission. Plan is for foley catheter to remain in place at least until Urology appointment next ___. Urology recommended ciprofloxacin for a 5 day course on discharge. - Urology followup next week # Chest pain: Resolved on its own. Trop negative. EKG stable from priors. In setting of fall, ddx is stable anginal episode versus musculoskeletal. Continued his home medications. ___ was not put on a BB because of a history of bradycardia and syncope that resolved with discontinuation of BB. - Cardiology f/u in ___ # Anemia: Likely acute blood loss in setting of two bouts of hematuria. Hct 30 (above goal even for CAD), worked fine with ___, so no transfusion given. - Would certainly monitor Hct as outpatient, and if develops symptoms or Hct continues to fall, would consider transfusion at that time. # Thrombocytopenia: Plt count was stable in the low 100s here. Simply monitored. - Deferred further workup to outpatient setting # HTN: Continued his home medications.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old right-handed woman with a history of unprovoked DVT, primary generalized epilepsy on 3 AEDs who presents for evaluation of worsening slurred speech, dizziness, and unsteady gait. ___ CLINIC PROTOCOL WANDW/O CONTRAST showed Unremarkable MRI of the brain without any acute intracranial abnormality. The patient was diagnosed with Dizziness and giddiness, Myoclonus. At the time of discharge, the patient had Primary Generalized Epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old right-handed woman with a history of idiopathic generalized epilepsy who presented to the ___ ED with worsening slurred speech, myoclonic jerking, dizziness, and unsteady gait following changes to her antiepileptic medication regimen in ___. In the ED, CTA imaging of her head and neck did revealed patent vessels, but a ? pons hypodensity. Her MRI was negative for acute intracranial abnormality. Ms. ___ was subsequently admitted to the epilepsy service for long-term monitoring on video-EEG and optimization of her antiepileptic medications. She was tapered off perampanel with subsequent improvement of presenting symptoms and no electrographic seizures. She was tapered off of vimpat and gabapentin were discontinued, because both AEDs can worsen idiopathic generalised epilepsy. Onfi was started. There were no electrographic seizures, but her EEG was notable for subclinical generalized epileptiform discharges. She improved to discharge home with epilepsy followup. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with PMH of achilles tendon repair in ___ (off Lovenox x 1 month) and breast cancer (remission since ___ who was brought to ED by EMS for 2 hours of sudden onset substernal chest pain and dyspnea. The pain started on the morning of presentation while the patient was bending down in the shower. The patient had never had pain like this previously. She described it as sharp, pleuritic, and associated with mild dyspnea and tachypnea. She denied feeling of palpitations, lightheadedness, or dizziness. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Central pulmonary emboli involving the left and right pulmonary arteries extending into the lobar branches of the all lobes. Enlargement of the right ventricular diameter compared to the left suggesting component of right heart strain. 2. Up to 4 mm bilateral pulmonary nodules for which a followup can be performed in ___ year if the patient has risk factors, such as smoking or malignancy, otherwise no additional imaging is necessary. ___ DUP EXTEXT BIL (MAP/DVT) showed 1. Left leg DVT with occlusive thrombus seen involving the popliteal vein and calf veins. In addition there is occlusive thrombus in the left lesser saphenous vein. 2. No right leg DVT. Findings discussed with Dr. ___ via telephone ___ 10 min after initial discovery. The patient was diagnosed with PULM EMBOLISM/INFARCT. At the time of discharge, the patient had primary diagnosis: pulmonary embolism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ yo F with recent immobility ___ achilles tendon repair who presented with chest pain and was found to have bilateral PEs. # PULMONARY EMBOLISM: She was found to have large bilateral pulmonary emboli. It was likely provoked by her recent orthopedic surgery and subsequent immobility. Her case was discussed with her oncologist, who felt that this was not likely related to her malignancy as she has been in remission for the last year. Her Chest CT and subsequent TTE showed some evidence of right heart strain with dilation of the right ventricle. However, LV function was not impaired and the patient did not have any clinical evidence of hemodynamic compromise (no hypotension, tachycardia only with exertion). She had lower extremity venous dopplers that also showed DVT. She was started on therapeutic lovenox to bridge to warfarin. # Achilles repair (___): She was evaluated by physical therapy who recommended the patient continue with ___, wear bearing on LLE with boot. She will require ambulance or lift assistance with the stairs to her apartment and will need to be homebound for now. # Pulmonary nodule: The patient was incidentally found to have a 4mm pulmonary nodule on Chest CT. She will need follow-up imaging in one year. # Glaucoma: Continued eye drops TRANSITIONAL ISSUES =================== [] Pulmonary nodule (4mm): Need f/u CT in ___ year to trend. [] Anticoagulation f/u (titration of warfarin)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old man with AML who is admitted from the ED after developing fever and rigors following outpatient blood transfusion. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. No evidence of abscess. 2. Multiple, prominent bilateral cervical lymph nodes. Chest CT. showed 1. Multifocal ground-glass opacities, most predominant within the right upper lobe, likely infectious or inflammatory in etiology. Findings are concerning for pneumonia, but limited in extent. 2. Mild, bibasilar atelectasis. 3. A few bilateral pulmonary nodules, measuring up to 5 mm. 4. Trace bilateral pleural effusions. 5. Multiple, bilateral renal stones measuring up to 6 mm, incompletely evaluated on this study. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ The patient was diagnosed with Other neutropenia, Fever presenting with conditions classified elsewhere, Thrombocytopenia, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES ACUTE HEMOLYTIC REACTION FEBRILE NEUTRAPENIA PNEUMONIA AFIB WITH RVR RELAPSED AML. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old male with AML who is admitted from the ED after developing fever and rigors following outpatient blood transfusion and precipitous decline in H/H c/f acute hemolytic reaction. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ yo M with a PMHx of Hypertension who presents for headache and CT revealing SAH. Patient reports a sudden pounding head behind his eyes beginning suddenly on ___ when he was in the bathroom. He then had an episode of nausea and vomiting. Since then he has had persistent headache and nausea. He reports some improvement of the headache with advil. He denies visual changes, weakness, numbness or tingling. He denies any recent falls or trauma with headstrike. He does not take any anticoagulation or antiplatelet agents. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. 4mm left MCA bifurcation aneurysm. 2. Subarachnoid hemorrhage largely in the left cerebral hemisphere, but also in the right parietal lobe. No new hemorrhage. 3. Emphysematous changes noted in the partially visualized lungs. NOTIFICATION: Updated findings were telephoned to Dr. ___ by ___ ___ on ___ at 4:42PM, time of attending readout. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. Radiology showed Coil embolization of ruptured left middle cerebral artery aneurysm, ___ ___ grade 2 I, ___, participated in this procedure. I, ___, was present for the entirety of this procedure and supervised all critical steps. I, ___, have reviewed the report and agree with the fellow's findings. RECOMMENDATION: Followup closely for vasospasm CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Decreased conspicuity of the subarachnoid hemorrhage in the left sylvian fissure could be related to streak artifact from the new coil pack within the treated left middle cerebral artery aneurysm. Otherwise, left greater than right subarachnoid hemorrhage does not appear significantly changed. 2. No evidence for an acute major vascular territorial infarction. CTA HEAD WANDW/O C AND RECONS showed 1. Somewhat bulbous appearance of left MCA proximal to the coil, however without evidence of stenosis or occlusion in any of the major intracranial artery vessels. No evidence of vasospasm. Known bilateral SAH, left greater than right, without new hemorrhage. Radiology showed Interval insertion of a right internal jugular catheter with the tip the mid to lower SVC. No Pneumothorax. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. CTA HEAD WANDW/O C AND RECONS showed 1. Somewhat bulbous appearance of left MCA proximal to the coil, however without evidence of stenosis or occlusion in any of the major intracranial artery vessels. 2. Known SAH in the bilateral parietal region, left greater than right, without new hemorrhage. The patient was diagnosed with SUBARACHNOID HEMORRHAGE. The patient was treated with ___: Cerebral angiogram and coiling of L MCA. At the time of discharge, the patient had Subarachnoid hemorrhage Left MCA aneurysm. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>On ___, Mr ___ presented with 5 day history of headache, followed by sudden pain behind his eyes and nausea/vomiting. Head CT showed diffuse SAH. Follow up CTA showed a 4mm left MCA bifurcation aneurysm. His neuro exam remained stable and nonfocal. He was admitted to the ICU under Dr. ___ close neuro monitoring. On ___, the patient remained stable and was brought to the neurovascular suite for cerebral angiogram. He was found to have a left MCA bifurcation aneurysm which was successfully coiled. He returned to ___ for close neuro monitoring. He neuro exam remained stable with no focal deficit. Head CT was done which showed the MCA coil and stable subarachnoid hemorrhage. On ___, the patient remained stable with a stable neuro exam. He remains in the ICU for spasm watch and TCDs were ordered. On ___, the patient remained stable with a stable and nonfocal neuro exam. TCDs showed some increased velocity within the right MCA and ACA which was thought to be likely related to hyperemia. On ___, later in the morning the patient became lethargic and developed a slight left pronator drift. A CTA was obtained and showed mild vasospasm, however per prelim report was negative for vasospasm. He was started on a Levophed drip to increase perfusion and his IVFs was increased to 125ml/hr. TCDs showed increased velocity to RMCA and RPCA. The patient complained of leg pain, LENIs were ordered and showed no DVTs. Over the weekend of ___ the patient remained neurologically intact. He was weaned off the pressor and was kept even to positive. On ___, the patients neuro exam remained stable. He underwent bot Head CTA and TCDs which showed increased velocities RMCA and RPCA. The CTA showed mild vasospasm per ICU read, however the radiology read was negative for vasospasm. The patient remained stable and was therefore transferred to the floor. On ___, the patient's fluid balance was running negative overnight, so he was given a 1 liter bolus 0700 in the morning. The patient's foley and TLC were removed; his IV fluid was kept at 75cc/hr. He no longer necessitated in/out balance goals. ___: The patient remained stable overnight. He was stable and ready for discharge with nimodipine and keppra. His discharge exam was non-focal; he remained neurologically intact.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male fell off bike today at 1 pm. Obvious deformity of left arm. Sent to outside hospital where he was splinted and referred to orthopaedics at ___. Also has scalp lac, denies LOC. Radiology showed Radius and ulna fractures. Small irregularity along the scaphoid, doubtful for fracture, but correlation with physical findings suggested. Radiology showed Fractures of the radius and ulna, each along the mid diaphysis, with mild displacement of the radial fracture. The patient was diagnosed with FX SHAFT RAD W ULNA-OPEN, PED CYCL ACC-PED CYCLIST, ACTIVITIES INVOLVING BIKE RIDING. The patient was treated with ___ 1. Open debridement down to and inclusive of bone of ulnar shaft fracture. 2. Open reduction internal fixation of radius and ulnar shaft fracture.. At the time of discharge, the patient had grade 1 open Left both bone forearm 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 open grade 1 left both bone forearm fracture. The patient was taken to the OR and underwent an uncomplicated I&D and ORIF. 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: NWB LUE; ok to come out of splint for supervised gentle PROM but otherwise wear splint while ambulating / sleeping. 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 does not require further chemical DVT prophylaxis since he is up and ambulating normally. He does not need further antibiotics. 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: NEUROLOGY STROKE ADMISSION/CONSULT NOTE MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. Study is moderately degraded by motion. 2. No acute intracranial abnormality with no definite evidence of acute infarct. 3. Severe changes of chronic white matter microangiopathy. 4. Global parenchymal volume loss. The patient was diagnosed with Weakness. At the time of discharge, the patient had Encephalopathy, transient, of undetermined etiology (possibly hypertensive). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted with an episode of pallor, feeling 'stuck' or 'shut down', with particular difficulty moving both legs, with preserved ability to stand and walk with assistance. This does not localized to a focal neurologic deficit and is therefore unlikely to reflect TIA. The closest localization would be bilateral ACA territory, and to have vascular lesion in this region alone requires an azygous ACA, which Mr. ___ does not have. MRI brain confirmed no ischemia, but showed atrophy and severe microvascular white matter changes. CTA head/neck shows scattered moderate atherosclerotic changes, but they are unlikely to be related to the etiology of this event given that it cannot be localized to a vascular territory. Possible etiologies for the event include hypertensive encephalopathy (supported by SBP>200 on EMS arrival), arrhythmia or vasovagal event(supported by pallor). Seizure possible, but less likely. Extended routine EEG performed prior to discharge, results pending at time of discharge but preliminarily without epileptic activity. Additionally, his history of a year or more of fluctuating cognitive decline, falls (all backward), anosmia, restless leg syndrome, combined with his exam findings of masked facies, reduced blink rate, hypophonia, slowed and hypometric upward saccades, bradykinesia and rigidity that augments, as well as postural instability with retropulsion all raise high suspicion for an underlying neurodegenerative condition, likely a Parkinsonian syndrome. He will need follow up with Neurology. =================================== Transitional Issues: [ ] PCP: refer to ___ Neurology, prefer ___ if possible given his subspecialization in movement disorders. [ ] PCP: consider workup for cardiopulmonary causes of this event. [ ] Neurology: consider underlying Parkinsonian syndrome</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ with hx of HTN and HLD, who presented to ___ ED after an unwittnessed fall from standing height to sidewalk resulting in facial trauma. On admission, he was intoxicated and unable to recall events leading to his fall. GCS was 14 on scene. HEAD CT showed Extensive acute intracranial hemorrhage, including subcortical intraparenchymal hemorrhages worrisome for shear injuries. CT OF THE FACIAL BONES showed Fractures primarily involving the left orbit including involvement of posterior lateral and inferior walls. At the latter site inbowing bone may impinge slightly on the lateral rectus. Inferior rectus appears perhaps pulled downward somewhat but not herniated within the defect; instead there is possible tethering however. Small intraconal hemorrhages on both sides accompanied by bilateral proptosis although not necessarily due to trauma; correlation with physical findings is suggested. Fractures involving the left maxillary sinus walls and zygomatic arch. CT C-SPINE W/O CONTRAST showed No evidence of acute cervical spine fracture or subluxation. CHEST RADIOGRAPH showed Upper mediastinal widening, although probably not due to trauma. Correlation with planned CT is suggested. No definite evidence of acute injury. CT TORSO W/CONTRAST showed 1. No evidence of acute traumatic injury to the chest, abdomen, or pelvis. No fracture identified. 2. 3.5 cm infrarenal abdominal aortic aneurysm for which ultrasound follow-up in 6 months is recommended. CT HEAD W/O CONTRAST showed Redistribution of multifocal intracranial hemorrhage, as above. A single focus of right frontal intraparenchymal hemorrhage appears new. No evidence of downward herniation. Note on attending reviewe: A few foci of intraparenchymal hemorrhage in the left frontal lobe and in the left middle cranial fossa are slightly increased compared to the recent CT head study of ___ Close followup as needed The patient was diagnosed with SUBDURAL HEM W/O COMA, OTHER FALL. At the time of discharge, the patient had Left maxillary sinus fracture, left posteriorlateral orbital wall fracture, non-displaced left sphenoid fracture, left sided subdural hematoma, focal right lateral ventricular hemorrhage, and small left frontal subcortical hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Imaging studies were obtained to determine the extent of injuries from his fall. The following injuries were found: left maxillary sinus fx, left posteriolateral orbital wall fracture, SAH, small left SDH, focal right IVH, small left frontal subcortical bleed, non-displaced left sphenoid fracture. He was evaluated in the ED and admitted to the ___ for further care. Plastic surgery was consulted for the facial fractures and concern for eye entrapement. Plastics concluded that because there were no findings of entrapment, there was no surgical intervention indicated at this time. Opthalmology was also consulted and requested outpatient follow-up for dilated eye exam. Neurosurgery followed patient closely during his hospitalization regarding the ___ and ___. Repeat noncontrast CT on ___ showed redistribution of multifocal intracranial hemorrhage, a single new focus of right frontal intraparenchymal hemorrhage, and no evidence of downward herniation. GCS remained 15 throughout the ICU stay. The patient was deemed stable and was subsequently transferred to the floor. His c-collar was cleared. By time of discharge, he was tolerating a regular diet, ambulating, and pain was well controlled. Patient was seen by ___ and social work and cleared for discharge. He was discharged on ___ to report directly to his opthalmology appointment for further evaluation. Follow-up appointments were made with neurosurgery and plastic surgery. Patient was in agreement with discharge plans and all questions were answered. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ patient transferred from nursing home for confusion, agitation and no PO intake for past ___ days. Was diagnosed w/ UTI 1 day PTA with UA on ___ that showed >100,000 cfu/ml of P. mirabilis sensitive to CTX. Was started on cefpodoxime. CBC showed WBC count 2.2, Hb 9.7, Hct 32, plt 155, Na 133, K 4.2, BUN 79, Cr 1.4 In the ED initial vitals were: 98.6 126 139/73 16 95%. Labs were significant for CBC 2.2>11.8/37.4<167, N:25%, Band:2%, L:50%, M:22%. Coags normal, chem-7 ___ and glucose 157. Urine was purulent with very + UA. Trop <.01. LFTs mostly normal with AP 126, Albumin 2.8. Serum tox + only for Acetaminophen 6. Lactate 2.6 -> 1.7 with fluids. CXR showed mild vascular congestion. U/s showed full IVC. Patient was given Zosyn, Vancomycin and 2Ls of fluid with improvement in tachycardia and hypotension. Vitals prior to transfer were: 97.7 90 99/42 18 97% RA On the floor, patient is confused but in NAD, slightly dyspneic. CHEST (PORTABLE AP) showed Mild pulmonary vascular congestion. Radiology showed Air within the soft tissues posterior to the sacrum with limited evaluation for underlying osteomyelitis. Recommend further evaluation with MRI. Age-indeterminate compression fracture deformities of L2, L3 and L5. Mild anterior subluxation of L4 on L5. The patient was diagnosed with SEPTICEMIA NOS, CYSTITIS NOS, SEPSIS , ACCIDENT NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Urinary tract infection SECONDARY DIAGNOSES: Dementia, Stage IV decubitus ulcer, hypertension, hearing loss, L3 compression fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo lady with dementia who presented from her nursing home with AMS found to have urosepsis. ACTIVE ISSUES # Urosepsis: Prior to admission, she was diagnosed with a UTI (Proteus mirabilis, sensitive to ceftriaxone) and give cefpodoxime - she received one dose. The following day, she came into the ___ ED with altered mental status and purulent urine. Given OSH sensitivities showed Proteus mirabilis sensitive to ceftriaxone, the patient was started on ceftriaxone with improvement in symptoms. Her blood pressure and mental status improved with antibiotic treatment. She remained afebrile during her stay. She will complete a 7 day course of ceftriaxone. # AMS: Patient admitted to hospital with confusion. Likely ___ infection on baseline substrate of dementia. In house her mental status improved to baseline (A&O x1). CHRONIC ISSUES # Neutropenia: On admission patient labs demonstrated WBC 2.1 with N 47%. Upon review of the patient's past medical records, the patient is at baseline leukopenic between ___. # Stage IV Decubitus Ulcer Wound care consulted and recommended aggressive wound care. Given CRP of 166 in the setting of a decubitus ulcer, osteomyelitis underlying this ulcer was consider as a potential contributing factor. However, the patient quickly improved with treatment of her UTI. The possibility and further work-up of osteomyelitis was discussed with healthcare proxy. HCP did not wish to pursue invasive work-up or wound debridement. Given these care goals, MRI was not done and surgery was not consulted for debridement. Wound care was continued and will be continued at rehab after discharge. # HTN: Antihypertensives were held in the setting of admission hypotension. After IVF, BP normalized and patient remained normotensive in house. Medications were held at time of discharge with recommendation to restart as an outpatient if needed.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female social worker with PMH of UC presents with sharp and colicky pain in the right lower abdominal quadrant that started ___ as mild pain but progressed over the last few days to severe pain, intermittent, worsens with eating, resolves spontaneously usually within minutes. Associated with mild nausea, no vomiting. Loose stools but she always had loose stools since her colectomy. No fevers, chills, night sweats or bleeding per rectum. Radiology showed No significant interval change in dilated small bowel loops projecting over the lower mid abdomen and pelvis. Radiology showed No significant interval change of gas-filled small bowel loops projecting over the lower abdomen and pelvis. To follow-up with barium through rectal tube on subsequent imaging. The patient was diagnosed with Unspecified abdominal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with US/ total colectomy presents with abdominal pain</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of HTN, HLD, CAD, prostate carcinoma, and likely dementia who presents for GIB and NSTEMI. CHEST (PA AND LAT) showed Compared to chest radiographs since ___ most recently ___. Moderate pulmonary edema is new. Given the severity of pleural calcification obscuring large areas of lung, subtle pneumonia might not be appreciated. Small pleural effusions are likely. Borderline cardiomegaly unchanged. Radiology showed Unchanged calcified pleural plaques, somewhat obscure optimal evaluation of the underlying lungs, within this limitation there is improvement in pulmonary edema relative to ___ with no new lobar consolidation. Mild cardiomegaly. Chest radiograph AP and lateral showed Extensive interstitial opacities as before. CT CHEST W/O CONTRAST showed 1. No evidence of pneumonia. 2. Subpleural reticulation and nodularity with parenchymal bands, most concerning for early asbestosis in this patient (numerous calcified pleural plaques in keeping with prior asbestos exposure). Alternatively, it is possible the reticulation could simply be age-related if clinical suspicion is low. Radiology showed Overall, slight interval improvement of diffuse bilateral extensive parenchymal opacities compared to the radiograph performed 1 day prior. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with EGD ___. At the time of discharge, the patient had Primary: acute blood loss anemia secondary to GI bleed acute on chronic systolic heart failure NSTEMI complicated UTI delirium nighttime hypoxia Secondary: dementia CKD chronic lymphedema severe AS pleural plaques. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year old gentleman with a history of HTN, HLD, CAD, prostate carcinoma and dementia who presents with GIB, NSTEMI, and hypoxia. # GIB # Acute blood loss anemia Granddaughter reported change in stool appearance, increased confusion, tremulousness and nearly collapsing at home, thought to have melena on exam in ED, though more difficult to tell due to chronically taking iron. Symptoms were most suspicious of upper GIB given reports of melena. He was hypotensive to SBP 88 on arrival to ___, clinically improved after 2u pRBC with no further episodes of hypotension, though was in the MICU on arrival, quickly transitioned to the floor. He was started on PPI. Risk/benefit of EGD was discussed extensively with granddaughter. Patient underwent EGD ___ which was unrevealing for a source of bleeding. Attempted to prep for colonoscopy to further evaluate multiple times but patient was unable to tolerate the prep and given his clinical stability, this was deferred. He was discharged home with 40 mg daily Pantoprazole for presumed UGIB which he could continue for empiric 8 week course. He should have GI followup outpatient. Iron supplement was held on discharge while on treatment for UTI. # Pulmonary Edema # Acute on chronic systolic heart failure # Severe aortic stenosis # Moderate pulmonary hypertension Multiple cardiac comorbidities. Not on home O2, takes Lasix 40 mg daily at home. Cardiology consulted in MICU for NSTEMI (see below). TTE ___ demonstrated severe AS with Grade 1 diastolic dysfunction and mild regional left ventricular systolic dysfxn ___ CAD (EF 40%). Severity of AS reported as worse. Per prior admission cardiology consult, he was advised last year to follow up with Dr. ___ consideration of TAVR for his AS but appears that he did not keep his appointment. Pt had new O2 requirement of 2L NC in setting of transfusion and decreased mobility. CXR ___ showed new moderate pulmonary edema. This resolved with 40 mg IV Lasix. Prior to discharge, he was restarted on home Lasix and had intermittent desaturations to high ___ which were thought most likely related to undiagnosed sleep apnea (below). Discharge weight 202.82 lbs. # Fever # Complicated UTI Patient with fevers for days without obvious source. No other localizing symptoms for infection, although patient a poor historian on exam. Urine and blood cultures initially were unrevealing. CT chest performed ___ due to intermittent hypoxia, was without evidence of pneumonia. Repeat UA was positive with large ___ and 80 WBC, no bacteria, started empiric treatment for UTI with Ceftriaxone ___, culture grew pan-sensitive E coli, transitioned to PO Bactrim for 5 days to complete 7d course for complicated UTI ___ - ___. # Nighttime hypoxia Noted to desat overnight regularly, per granddaughter, no history of OSA, no witnessed periods of apnea, but he snores heavily and she may have witnessed him gasping/grunting more recently. Trialed empiric CPAP and patient had no recorded episodes of hypoxia, suggesting possible sleep apnea. Will continue CPAP at rehab, but will need outpatient sleep study prior to getting CPAP at home. # NSTEMI # CAD s/p MI (STEMI ___ s/p RCA BMS, NSTEMI ___ s/p LCx BMS Troponins elevated on arrival to the ED in the setting of acute anemia in the absence of reported chest pain, peaked at 0.56. Cardiology was consulted in the ED. Serial EKGs demonstrated an intermittent LBBB which was not new. Echo relatively stable from prior, did show somewhat worsening AS, but no new WMA. Taken together, these were consistent with demand ischemia due to active bleed on background of CAD. Home aspirin and metoprolol were initially held, resumed prior to discharge, atorvastatin was continued. Metoprolol was fractionated to tartrate 6.25 mg Q6H however patient had episodes of SBP < 100 and HR in the ___ so was decreased to BID on the day of discharge. Home metoprolol succinate was held until further dose adjustments could be made. # Delirium on Dementia Pt lives at home with granddaughter who says he is able to walk at home without assistance and occasionally uses walker outside. Mental status baseline is unknown, but granddaughter reports it has worsened. Patient's first night in the hospital he became agitated and required restraints but did not receive pharm intervention, subsequently was calm and very pleasant, though occasionally noted to be picking at his sheets. ___ was consulted and recommended rehab prior to home.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with history of RA p/t ER with 5 days of RLQ pain. She initially thought it was related to constipation and took MOM without improvement ___ the pain. No N/V. Yesterday she had some subjective fevers for which she went to her PCP today, who sent her to the ER @ ___. A CT performed there revealed perforated appendicitis with a 5cm abscess. She was transferred here for further management. She denies any dysuria/hematuria CT-guided drainage of a right lower quadrant collection. showed Successful CT-guided placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. The patient was diagnosed with AC APPEND W PERITONITIS. The patient was treated with ___: ___. drainage catheter into right lower abdominal collection. At the time of discharge, the patient had perforated appendix. The patient was given written instructions concerning 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 with 5 days of right lower quadrant pain. She followed up with her primary care provider where she was sent for a cat scan. On cat scan imaging she was found to have perforated appendicitis with a 5cm abscess. She was transferred here for further management. Upon admission, the patient was made NPO and arrangements made for ___ drainage. The patient was started on a course of ciprofloxacin and flagyl. On HD #1, the patient was taken to Interventional Radiology where an ___ Fr. catheter was placed into the abdominal abscess. Approximately 10 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. The patient resumed a regular diet after the procedure. Her vital signs remained stable with a white blood cell count of 8. She was voiding and ambulating without difficulty. On HD #2, the patient was discharged home with ___ services to assist with the care of the drain. The patient was instructed to complete a 14 day of antibiotics. A follow-up visit was scheduled with Dr. ___ ___ 1 week. Instructions ___ care of the drain were reviewed with the patient. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ year old right handed man with PMH significant for seizure disorder and intellectual disability (both since birth per family), chronic kidney disease and schizophrenia who presents from his group home after a witnessed seizure. History was gathered from family, group home representative and OMR. For the past month the patient has been having episodes of what are being interpreted as headaches. These spells either occur at night (about ___ hours after getting into bed) or during the day at his day program. The patient will grab his head and repeat "itch itch itch!" Sometimes the patient will scream or cry. Sometimes he will slam the door repeatedly or smash things(like his television). He usually settles down after some time without major interventions. These events do not happen every night (___). They have not been associated with any ther symptoms. He has not had any recent changes to his medications. He has, as a result, not been sleeping well over the past month. The patient was seen in neurology clinic by Dr. ___ felt these events were likely either headache or behavioral in nature. given the patient's poor verbal communication skills he agreed to schedule the patient for neuro-imaging. Prior MRI attempts were made but failed due to poor patient understanding (it appears that really only the family can communicate with him - in a version of ___. MR HEAD W AND W/O CONTRAST showed 1. Study is mildly degraded by motion. 2. 6 x 3 x 8mm, 2 x 1 x 2mm, and 2 x 2x 2 mm nonenhancing intraventricular nodules, arising from lateral and superior margins of left lateral ventricle as described, with no definite associated ventriculomegaly and no definite blood products or mineralization. Differential considerations include subependymoma, subependymal hamartomas of tuberous sclerosis. Recommend clinical correlation and attention on followup imaging. 3. Focal area of left parietal chronic injury as described. Recommend clinical correlation. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY. At the time of discharge, the patient had Epilepsy Intellectual Disabilities Chronic Kidney Disease Schizophrenia. The patient was given written instructions concerning 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 a past medical history significant for epilepsy and intellectual disability (both since birth per family), chronic kidney disease and schizophrenia who presents from his group home after a witnessed generalized seizure. The patient's seizure was likely triggered by sleep derivation due to night time episodes of grabbing his head and screaming/crying that can last for hours. This are likely a primary headache disorder, though behavioral episodes are difficult to rule out. Infectious workup is negative and AED levels are at baseline. In the ED, in the setting of missed night time AEDs, he had another seizure. After being admitted to the Neurology Inpatient Service, his AEDs were initially continued. However, during the hospitalization, his Phenobarbital was increased from 45mg twice a day to 45 mg in the morning and 60mg in the evening. He had an overnight EEG to try to capture events. No typical events were captured. However, his EEG did not show any epilptiform activity. Additionally, due to possible headaches as the reason for the patient of grabbing his head and screaming/crying, a MRI was done. The MRI showed encephalomalcia in the left parietal lobe. This is chronic. Additionally, 6 x 3 x 8mm, 2 x 1 x 2mm, and 2 x 2x 2 mm nonenhancing intraventricular nodules were seen. These arise from the lateral and superior margins of left lateral ventricle. There was no hydrocephalus. No signs of increased intracranial pressure. These findings are most likely not the cause of possible headaches. Mr. ___ did not have any further seizures after being admitted to the hospital. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ yo female with PMH notable for 20+ pack year history, metastatic breast cancer controlled with Faslodex now presenting with shortness of breath. Patient reports on the day prior to admission she had some mild nasal congestion. That night she went to sleep and woke up feeling short of breath. She initially sat up in bed and thought she felt better, but laying down continued to feel that her breathing was uncomfortable. She got up and started walking around, but she continued to be short of breath, at this point feeling that her breathing was unchanged based on position. During this, she started to have a dry cough. She has never felt this way before. After a sleepless night, the patient came to the ED via ambulance. Radiology showed No CHF or definite infiltrate. Please see results of chest CT obtained the same day. Radiology showed 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. No evidence of pneumonia or pleural effusion. 3. Minimal interval increase in the size of several mediastinal and hilar lymph nodes. The patient was diagnosed with RESPIRATORY ABNORM NEC, SECONDARY MALIG NEO BONE, HX OF BREAST MALIGNANCY. At the time of discharge, the patient had COPD exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with PMH notable for significant smoking history and metastatic breast cancer now admitted with shortness of breath.</s>