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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH of Roux en Y gastric bypass ___ ___, multiple
SBOs requiring resection, cholecystectomy, and ampullary
stenosis
s/p PTCD with multiple rounds of dilation recently admitted for
abdominal pain and placement of PCBD conversion of ampullary
drain who presents 3 days after discharge with progressive
abdominal pain, fevers to 101 and purulent drainage from her
cholecystostomy site. CT abdomen pelvis showed 1. Interval development of small subcapsular fluid collection (1.2 x 2.2 x 2.4
cm) along the PTBD as it exits the liver anteriorly, likely representing
biloma though cannot exclude abscess.
2. Small volume ascites. Radiology showed 1. Successful exchange of existing 12 ___ PTBD catheter with a new 12
___ PTBD catheter.
2. Successful performance of 12 mm balloon cholangioplasty/sphincteroplasty
3. Percutaneous aspiration of 2 cm perihepatic collection surrounding the
liver entry site of the existing catheter, with minimal fluid aspirated. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with 1. PTBD Exchange
2. Balloon Cholangioplasty / Sphincteroplasty. At the time of discharge, the patient had PRIMARY DIAGNOSIS: 1. Ampullary Stricture with PTBD Drain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female, with past history of
Roux-en-Y Gastric Bypass ___ ___, Multiple SBOs requiring
cholecystectomy, and ampullary stenosis s/p PTCD with multiple
rounds of dilation recently admitted for abdominal pain and
placement of PCBD conversion of ampullary drain who presents
with progressive abdominal pain, fevers to 101 and purulent
drainage from her cholecystostomy site 3 days after returning
from the hospital.
.
>> ACTIVE ISSUES:
# Possible recurrent biliary obstruction
abdominal wall cellulitis at site of biliary drain
Upon admission, given concern for prior PTBD manipulation,
patient underwent CT Abdomen scan which was remarkable for a
subcapsular fluid collection along the PTBD as it exited the
liver anteriorly, concerning for a biloma but could not exclude
abscess. Patient also was found to have small volume ascites.
Given this, patient underwent immediate uncapping of her PTBD
drain, and then underwent procedure on ___: Exchange of the
exisiting PTBD catheter with a new catheter, and performance of
dilation with cholangioplasty / sphincteroplasty. Patient also
had percutaneous aspiration of perihepatic collection with
minimal fluid aspirated. Cultures returned negative ___ blood.
Patient's abdominal pain improved with tube replacement, and
felt that ampulla had been stenosed, and that repeated dilation
has been only moderately successful. Patient underwent
successful capping trial on ___, and given stability,
patient stable for discharge. Pain regimen was converted from IV
Dilaudid to oxycodone, and was dispensed #30 tablets after
verification with PMP. Furthermore, patient was found to have
redness at drainage site concerning for abdominal wall
cellulitis, and therefore initially treated with broad spectrum
antibiotics, narrowed to TMP-SMX to complete course. Wound care
supplies were given to patient, along with prescriptions for
refills.
.
>> CHRONIC ISSUES:
# Constipation: Given increased narcotic load for abdominal
pain, patient placed on aggressive regimen and had several bowel
movements during hospital stay prior to discharge.
.
# Depression: Patient was continued on home citalopram.
.
# Vasovagal Syncope: Patient was continued on home
fludrocortisone. Patient did not have any hemodynamic
instability during hospital stay.
.
# Chronic Pain / Fibromyalgia: Patient was continued on home
gabapentin.
.
# Papillary Thyroid Cancer s/p Resection: Patient continued on
home levothyroxine supplement.
.
>> TRANSITIONAL ISSUES:
# Cellulitis: Please complete TMP-SMX antibiotic course until
___
# PTBD: Please continue to maintain PTBD drain site, and check
CBC, Chem-7, and LFTs upon discharge follow-up.
# Pain Regimen: Patient was given oxycodone, and bowel regimen
upon discharge for maintenance of pain. PMP checked prior to
prescription.
# Pending Labs: Please f/u blood culture obtained ___ (No
growth upon discharge).
# CODE STATUS: Full
# CONTACT: HCP ___ ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with a history of morbid obesity, superficial
thrombophlebitis (on enoxaparin until stopped ___, LTBI
(completed 9 months of isonizaid), Hep C (neg VL ___,
previous IVDU (last use ___ years ago), PTSD, presenting with 1
day of increased abdominal redness swelling and warmth as well
as arm shaking chills and fever to 101. Pt states was in usual
state of health until day prior to admission. In ___ had sudden
onset chills, subjective fevers, and noticed increasing redness
in lower abdomen. Sensation of fevers and chills lasted
approximately one hour, but resolved without intervention. On
the day of admission, patient awoke in the morning with another
episode of chills, headache and diffuse body aches and measured
temperature to be 101.3. At this time she presented to the
emergency department. Apart from these two episodes, the
patient denies any other recent symptoms. No cough, shortness of
breath, n/v/d, or urinary symptoms recently. The patient notes
that she has not used IV drugs for over ___ years, and that she
is no longer taking subcutaneous lovenox since her prescription
ran out in ___. She denies back pain, flank pain, weakness
numbness or tingling. CT abdomen and pelvis with contrast showed 1. 3.6 x 5.5 cm right upper abdominal subcutaneous fluid collection appears
similar in appearance to prior ultrasound dated ___. Previously
demonstrated left lower quadrant fluid collection is no longer visualized. No
evidence of a new fluid collection in the subcutaneous tissues of the left
lower quadrant.
2. Cellulitis involving the lower abdominal wall.
3. Mild positioned IUD. Further evaluation with pelvic ultrasound may be
considered.
4. Moderately enlarged spleen measuring up to 17 cm. The patient was diagnosed with Cellulitis of abdominal wall. At the time of discharge, the patient had Primary Diagnosis: Erysipelas. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with a history of morbid obesity, superficial
thrombophlebitis (on enoxaparin until stopped ___, LTBI
(completed 9 months of isonizaid), Hep C (neg VL ___,
previous IVDU (last use ___ years ago), PTSD, presenting increased
abdominal redness swelling and warmth found to have erysipelas.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo F with history of significant for
atrial fibrillation (currently on lovenox with plans to resume
coumadin), rheumatoid arthritis (on prednisone), perforated
diverticulitis s/p Hartmanns procedure (___) complicated by
pelvic hematoma (without drainage) and ostomy revision (___)
who now presents with concern for significant rectal bleeding
and associated hemodynamic instability. ACS is consulted for
urgent management. CTA ABD AND PELVIS showed Rim enhancing pelvic hematoma is slightly decreased in size as well as density
compared to prior imaging.
No evidence for active extravasation of contrast.
The patient is status post ___ pouch and redo left lower quadrant
colostomy.
No new/acute intra-abdominal or pelvic pathology.
Unchanged pancreatic hypodensities which most likely represent side branch
IPMNs ranging up to 21 mm.
RECOMMENDATION(S): Follow-up MRCP recommended in ___ months to reassess
pancreatic cystic lesions. CT interventional showed Successful CT-guided placement of a ___ pigtail catheter into the pelvic
collection. Samples were sent for microbiology evaluation. CT ABD AND PELVIS WITH CONTRAST showed 1. Interval decrease in size and density of pelvic fluid collection status
post drain placement. There is persistent fluid and air bubbles within the
collection.
2. No evidence of new intra-abdominal or pelvic pathology.
3. The patient is status post ___ pouch and redo of left lower quadrant
colostomy with adjacent postsurgical changes.
4. Unchanged pancreatic hypodensities which most likely represent side branch
IPMNs measuring up to 20 mm.
5. There is a locule of air at the superior aspect of the urinary bladder
please correlate with possible history of recent catheterization or
urinalysis.
RECOMMENDATION(S): A follow-up MRCP in the ___ months is again recommended
to further characterize the pancreatic lesions, or can be followed on future
followup examinations. US BUTTOCKS, SOFT TISSUE RIGHT showed No superficial drainable collection in the area of clinical concern. CT ABDOMEN AND PELVIS WITH CONTRAST showed 1. The posterior approach percutaneous drain has been withdrawn, now
terminating outside the rim enhancing fluid collection in the perirectal
space.
2. The pelvic fluid collection has minimally decreased in size, now measuring
approximately 6.5 x 4.4 cm, previously 7.3 x 4.6 cm. However, the collection
closely abuts the cecum along its superior anterior margin and it is unclear
if there is a fistulous connection. If further evaluation is desired,
contrast could either be administered via the ostomy or via the percutaneous
drain once it is replaced.
3. No evidence of leak from the rectal stump.
4. Stable pancreatic hypodensities measuring to 1.9 cm in the pancreatic head,
which most likely represent side branch IPMNs.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:06 pm, 2 minutes
after discovery of the findings. The updated findings and recommendation were
discussed with ___ at 19:19 on ___. CT Guided Drainage showed Remove of withdrawn/malpositioned ___ pigtail catheter and successful
CT-guided placement of a ___ pigtail catheter into the collection.
Samples were sent for microbiology evaluation.
RECOMMENDATION(S): Flush catheter at least q 12h The patient was diagnosed with Abnormal uterine and vaginal bleeding, unspecified, Other shock, Syncope and collapse, Unspecified atrial fibrillation, Long term (current) use of anticoagulants. The patient was treated with ___: ___ placement of 10 ___ pelvic drain
___: Removal of withdrawn ___ pigtail catheter and
successful CT-guided placement of a ___ pigtail catheter
into the collection.. At the time of discharge, the patient had Pelvic abscess / 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>Patient is a ___ year old female with a history of perforated
diverticulitis s/p ___ complicated by a pelvic hematoma and
later complicated by ostomy detachment s/p colostomy revision,
who presented to ___ on
___ with concern for rectal bleeding. She was found to
actually have vaginal bleeding with a small defect present at
her vaginal cuff (from her prior hysterectomy), concerning for
drainage from her known pelvic hematoma versus new active
hemorrhage. She was initially tachycardic to the 150s upon
arrival in the ED with SBP in the 130s. Her tachycardia improved
with fluid resuscitation. In this setting, she was admitted to
the trauma ICU for hemodynamic monitoring and serial
hematocrits.
The patient was kept NPO, on IV fluid resuscitation. She was
continued on cipro/flagyl (which she had been taking at home as
directed after hospital discharge). underwent pre-treatment for
a contrast allergy in preparation for a CTA. Imaging
demonstrated a rim-enhancing large pelvic hematoma with no
active extravasation. As such, her vaginal bleeding was presumed
to represent drainage of her old hematoma rather than
active/acute new hemorrhage. She remained hemodynamically stable
with stable hematocrits. She did not require any blood
transfusions after leaving the ED (where she received only 1u
pRBCs due to concern for active bleeding and hemodynamic
instability). On ___, the patient underwent CT guided placement
of ___ transgluteal drain into her pelvic hematoma. Cultures
were sent, and she was found to be growing enterococcus. Her
antibiotics were broadened to vancomycin, cipro, and flagyl
pending sensitivities. On ___, she was started on ___, her
foley was removed, and she was deemed appropriate for transfer
to the surgical floor. Her therapeutic Lovenox and remainder of
home meds were resumed on ___.
On ___ her cultures speciated with enterococcus gallinarum,
which was resistant to vancomycin. Her antibiotic therapy was
advanced to IV Linezolid while cipro/flagyl continued until the
course was completed on ___. Her vac was also changed and her
Coumadin was resumed for hx of afib. On ___ she underwent cat
scan to evaluate for interval change of pelvic collection and CT
showed persistent collection. Her drain was then manipulated by
___ team on ___ and irrigated with TPA. She was re-scanned on ___
and drain found to no longer be in communication with her fluid
collection. On ___ she had ___ drain removed and ___ drain
placed in interventional radiology with good effect. She
tolerated the procedure well. Her wound vac was changed and
antibiotic course was changed from intravenous to oral therapy.
On ___ her antibiotic therapy regimen was completed and on ___
she was cleared for discharge to home at which time she
complained of mild lightheadedness while walking. Orthostatic
blood pressures were then checked. She also reported she
believed she would benefit for home physical therapy in addition
to visiting nurses, and case management was notified and
services arranged.
At the time of discharge, the patient was doing well. She was
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home with
services and received discharge teaching. A follow-up
appointment was made and discharge instructions were reviewed
with reported understanding and agreement.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with a PMH notable for Hep C, HIV on HAART,
prior heroin use on methadone therapy, bipolar disorder, ADHD,
HTN, and asthma presents with 6 weeks atraumatic right hip pain. Radiology showed Expected postsurgical findings status post right total hip arthroplasty. PELVIS (AP ONLY) PORT showed As above. DX PELVIS AND FEMUR showed Dysmorphic, collapsed, flattened right femoral head, compatible with advanced
AVN. Mild lateral subluxation and significant DJD also noted at the right
hip. INJ/ASP MAJOR JT W/FLUORO showed 1. Imaging Findings - see above.
2. Procedure - Technically successful aspiration of the right hip joint.
I Dr. ___ personally supervised the Fellow during the key
components of the above procedure and I have reviewed and agree with the
Fellow findings/dictation. The patient was diagnosed with ASEPTIC NECROSIS FEMUR, JOINT PAIN-PELVIS, ASYMPTOMATIC HIV INFECTION. The patient was treated with Right hip aspiration. At the time of discharge, the patient had Primary: right femoral avascular necrosis
Secondary: Hep C, HIV, HTN, HLD, bipolar disorder, panic
disorder, ADHD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old woman with a PMH notable for Hep
C, HIV on HAART, prior heroin use on methadone therapy, bipolar
disorder, ADHD, HTN, and asthma who presented due to
uncontrolled pain from her recently diagnosed right hip
avascular necrosis.
# Right femoral AVN:
She had been recently diagnosed as an outpatient and requiring
increased support for ambulation and activities of faily living
(using a cane, etc). She lives alone and had reached the point
where she felt her pain and limited mobility were no longer
compatible with living alone in a ___ floor apartment. She was
assessed by ___, who agreed. Ortho was consulted in the ED, who
aspirated the hip and ruled out infection. Her pain was
controlled with her usual methodone, as well as PRN oxycodone.
She went to the orthopedic surgery service with plan for right
total hip arthroplasty.
#HIV: On HAART therapy, which was continued (Truvada, Reyataz,
Norvir). No signs or symptoms of infection. Creatinine was WNL,
no dose adjustments needed.
#Hepatitis C: LFTs were within normal limits. She says she was
told to avoid acetaminophen and declined to take this for pain
control.
#HTN: Continued metoprolol 50mg and HCTZ 25mg.
#HLD: Continued Tricor 145mg daily.
#Methadone maintenance: Her home dose of 170mg daily was
comfirmed by the ED and continued without event in the hospital.
#Bipolar disorder: Continue Depakote 250mg q AM and 500mg q ___.
#Panic disorder: Continued Klonopin 1mg TID.
#ADHD: Held Adderall while inpatient given it is nonformulary
and she did not have her own medications.
# Right hip THA: pain well controlled with PRN oxycodone. She is
touchdown weight bearing on the right lower extremity, with
posterior hip precautions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ man with a history of heart
failure with reduced ejection fraction (EF 35%), right
ventricular dilation with free wall hypokinesis, moderate
tricuspid regurgitation, permanent atrial fibrillation on
rivaroxaban, chronotropic incompetence while in AF status post
single-chamber pacemaker (___), severe OSA, DMII, prostate
cancer status post TURP, chronic lower back pain, depression and
history of medication nonadherence who presents with lower
extremity swelling and shortness of breath concerning for heart
failure exacerbation. CHEST (PA AND LAT) showed 1. Mild pulmonary edema, similar to prior.
2. Indistinct left hemidiaphragm with patchy left lower lobe opacities may
reflect atelectasis, although pneumonia cannot be excluded in the proper
clinical setting. UNILAT LOWER EXT VEINS RIGHT PORT showed No evidence of deep venous thrombosis in the right lower extremity veins. ABDOMEN US (COMPLETE STUDY) showed 1. No focal liver lesion identified. No biliary dilatation.
2. Mild splenomegaly.
3. No ascites visualized in the abdomen. CHEST (PORTABLE AP) showed -Similar to slightly increased mild-to-moderate pulmonary edema.
-No pneumothorax. CHEST (PA AND LAT) showed Mild cardiomegaly with the left basilar and retrocardiac opacification.
Atelectasis versus pleural effusion. The patient was diagnosed with Heart failure, unspecified, Dyspnea, unspecified. The patient was treated with Right heart cath ___
Placement of ___ coronary sinus lead ___. At the time of discharge, the patient had PRIMARY:
- Acute heart failure reduced ejection fraction from ventricular
dyssynchrony
SECONDARY:
- Atrial fibrillation
- 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>___ man with a history of heart failure with newly
reduced ejection fraction (EF 35%), right ventricular dilation
with free wall hypokinesis, moderate tricuspid regurgitation,
permanent atrial fibrillation on rivaroxaban, chronotropic
incompetence while in AF status post single-chamber pacemaker
(___), and DMII presenting with lower extremity edema and
dyspnea consistent with heart failure exacerbation. He was found
to have newly reduced ejection fraction this admission, which
was attributed to dependence on single chamber pacing causing
dyssynchrony. He was taken for biventricular pacemaker placement
on ___. He was restarted on maintenance diuresis and discharged
with plan for close followup.
CORONARIES: recent negative stress test; declined cath in past
PUMP: 35%
RHYTHM: AF, V-paced </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with ___, CKD stage 4, LLE DVT ___
complicated by BRBPR now off coumadin who presents with two day
history of left lower extremity swelling noted by her daughter
who is a ___. She does not report chest pain, shortness of
breath, orthopnea, paroxysmal noctural dyspnea, long travels,
plain rides, trauma or BRBPR.
In the ED, initial VS 99.5 72 157/91 18 99% RA. Labs notable for
creatinine of 1.8 (baseline) and BNP in 6000s (better than
baseline in 9000s). LLE US showed left common femoral and
femoral vein similar to ___ and thus started on IV heparin
without bolus and admitted to medicine for further management.
On the floor, she reported no complains. Radiology showed Chronic-appearing thrombus of the left CFV and superficial
femoral vein with incompletely assessed calf veins bilaterally. No right
lower extremity DVT was seen. This was discussed with Dr. ___ by Dr. ___
at 2320 on ___ by phone. Radiology showed Right lower lobar opacity could reflect scarring from prior
pneumonia, though recurrent pneumonia cannot be excluded. The patient was diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY, CHEST PAIN NOS, ATRIAL FIBRILLATION. At the time of discharge, the patient had Primary:
Chronic Deep Venous Thrombosis
Secondary:
Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with dCHF, CKD stage 4, LLE DVT ___
complicated by BRBPR s/p discontinuation of coumadin in ___
who presents with a two day history of left lower extremity
swelling, found to have persistent DVT on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs ___ is a pleasant ___ woman who presented to ___
___ on day of admission with complaints of nausea, NBNB
vomiting, and intermittent RUQ abd pain. She states that the
nausea was worse than the abd pain, which was moderate in
severity. Her last episode of emesis was on ___, however
the nausea has been present for the last ___ days, and the abd
pain started last night. She has had poor PO intake because of
her sxs, however is now feeling improved with the fluids and
anti-emetics that she received in the ED. No fevers, chills, no
previous history of abdominal pain. Last BM was 2 ays PTA and
was loose. She presented to the ED today because her urine was
become darker and she was concerned that she was becoming more
dehydrated. Please evaluate if patient passed stone.
COMPARISON: None available
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 tesla
magnet, including dynamic 3D imaging, obtained prior to, during, and after the
uneventful intravenous administration of 0.1 mmol/kg (7 cc) of Gadavist
gadolinium contrast. Patient also received 2.5 cc of Gadavist gadolinium in
75 cc of water for oral contrast.
FINDINGS:
Patient is apparently status post ERCP the morning prior to this study,
although report is not available at this time. There is persistent moderate
diffuse intrahepatic and extrahepatic biliary ductal dilatation, the common
bile duct measures 10 mm in diameter. There is diffuse peribiliary enhancement
consistent with cholangitis, including enhancement about the intrahepatic and
extrahepatic bile ducts as well as the gallbladder wall. In the more inferior
common bile duct is a small likely partially obstructing hypointense calculus
measuring 6 mm in diameter. 2 smaller filling defects are seen superior and
inferior to this lesion, these may represent additional nonobstructing
calculi. Smaller filling defects are also seen in the distalmost common bile
duct near the ampulla, with note also made of ampullary edema and hyperemia.
No evidence of abscess formation. The gallbladder is nondistended but filled
with sludge and stones with wall hyperenhancement which may represent
secondary or chronic cholecystitis. 6 mm simple appearing cyst in the left
hepatic lobe. There is minimal dilatation of the pancreatic duct measuring 4
mm. Mild fat stranding is seen surrounding the pancreatic head. The
pancreatic parenchyma appears to have preserved enhancement.
Bilateral simple appearing renal cortical cysts measuring up to 8 mm in the
right upper pole. Spleen, pancreas, bilateral adrenal glands appear
unremarkable. Normal caliber abdominal aorta. No evidence of significant
lymphadenopathy. Visualized small and large bowel appear unremarkable. No
evidence of ascites. Small fat containing umbilical hernia.
IMPRESSION:
1. Persistent moderate intrahepatic and extrahepatic biliary ductal
dilatation suggestive of distal CBD obstruction. Multiple common bile duct
stones measuring up to 6 mm in the inferior common bile duct, with small
stones seen near the ampulla, along with ampullary edema and minimal
pancreatic ductal prominence. Cannot exclude tiny stone impacted at the
ampulla. Extensive cholelithiasis.
2. Findings suggestive of associated cholangitis with secondary or chronic
cholecystitis. showed 1. Persistent moderate intrahepatic and extrahepatic biliary ductal
dilatation suggestive of distal CBD obstruction. Multiple common bile duct
stones measuring up to 6 mm in the inferior common bile duct, with small
stones seen near the ampulla, along with ampullary edema and minimal
pancreatic ductal prominence. Cannot exclude tiny stone impacted at the
ampulla. Extensive cholelithiasis.
2. Findings suggestive of associated cholangitis with secondary or chronic
cholecystitis. The patient was diagnosed with CHOLELITHIASIS NOS, HYPERTENSION NOS. The patient was treated with ___ ERCP
___ Laparoscopic Cholecystectomy. At the time of discharge, the patient had 1. Choledocholithiasis
2. Cholelithiasis
3. Pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ woman with a past medical history
significant for HTN, anxiety, and depression, who is admitted
with cholelithiasis, choledocholithiasis, and gallstone
pancreatitis.
# CHOLELITHIASIS, CHOLEDOCHOLITHIASIS, GALLSTONE PANCREATITIS:
Mrs ___ is a pleasant ___ woman with a history of
hypertension and anxiety who is admitted with pancreatitis in
the setting of choledocholithiais. Patient initially presented
to ___ with abdominal pain and dark urine. At ___,
labs were significant for: ALT: 813 AP: 596 Tbili: 4.61 Alb: 4.3
AST: 514 TProt: 7.2 ___: Lip: 1050. US showed cholelithiasis
without other sonographic evidence of acute cholecystitis as
well as dilated intra and extra hepatic bile ducts. An MRCP
done on ___ confirmed that there were still stones in the CBD
and dilated ducts. The patient went for an MRCP on ___ which
demonstrated CBD stone. The stone was extracted, a
sphincterotomy was performed and she was transferred to surgery
for a cholecystectomy. On ___ the patient underwent a
laparoscopic cholecystectomy. She was taken to the operating
room and underwent a laparoscopic cholecystectomy. Please see
operative report for details of this procedure. She tolerated
the procedure well and was extubated upon completion. She we
subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
# POSITIVE U/A: Patient with positive u/a at ___. She
was asymptomatic and was not treated for UTI. Microbiology
report pending.
# HTN, BENIGN: Patient was continued on atenolol and
lisinopril.
# DEPRESSION: Patient was continued on paroxetine.
On the afternoon of ___, Mrs. ___ was ambulating from the
bathroom to her bed when she became "dizzy" and fell forward on
to her knees. This was witnessed by her roommate. The patient
denied any LOC or head strike. She was assised to bed and
placed in the supine position. Her SBP was approximately 115
and her blood gluocse level was 126. She felt better once she
was settled in bed. She was given a liter of fluid for likely
orthostasis and placed on telemetry to assess for any
dysrhythmias. A complete blood count and basic metabolic panel
was obtained. Results were within normal limits.
On the morning of ___, Mrs. ___ felt much better than the
prior day. She had no further episodes of dizziness on
ambulation. Telemetry showed her in sinus rhythm and no ectopy
was observed. Nursing and the patient's husband ambulated with
the patient during the day and she did well. Mrs. ___ was
tolerating a regular diet and voiding without issue.
On the afternoon of ___, Mrs. ___ was discharged home in
the care of her husband. She was afebrile, hemodynamically
stable and in no acute distress. She was discharged home with
scheduled follow up in ___ clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/h/o critical aortic stenosis, CAD, CHF, presents from
assisted living facility with SOB. Radiology showed 1. Mild interstitial pulmonary edema with small right pleural effusion.
2. Mild cardiomegaly.
3. Multiple thoracolumbar spine compression deformities of indeterminate age. Radiology showed Thrombosed right common femoral artery pseudoaneurysm. Minimal residual blood
flow visualized in the pseudoaneurysm neck without any flow in the hematoma.
Findings discussed with Dr. ___ by Dr. ___ at 8:15 p.m. on ___ NON-INVASIVE PERIPHERAL ARTERIAL STUDY showed 1. Unchanged narrow neck of arterial blood flow extending radially right CFA.
2. Stable, adjacent 1.7 x 1.3 cm soft tissue hematoma without internal flow. CT ABD AND PELVIS W/O CONTRAST showed 1. Large, right retroperitoneal hematoma extending from the right inguinal
region through the iliacus muscle plane up to the anterior superior iliac
spine.
2. Extensive colonic diverticulosis.
3. Severe atherosclerotic calcifications of the aorta and its major branches.
4. Bilateral inguinal hernias.
NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___ telephone
at 12:41 on ___, 1 min after discovery. The patient was diagnosed with RESPIRATORY ABNORM NEC, CAD UNSPEC VESSEL, NATIVE OR GRAFT. The patient was treated with + Aortic Valvuloplasty - ___. At the time of discharge, the patient had PRIMARY: Aortic stenosis status post valvuloplasty
SECONDARY: Acute Kidney Injury. Retroperitoneal 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>___ w/h/o critical aortic stenosis, CAD, CHF, presents from
assisted living facility with symptomatic AS s/p valvuloplasty
___ c/b psuedoaneurysm in R femoral artery.
# Critical Aortic Stenosis: Pt had been scheduled for
valvuloplasty in ___, but was transferred from ___ for
earlier intervention given symptoms. Pt was hemodynamically
stable during pre-hospitalization without CP, SOB. She underwent
a successful valvuloplasty on ___ that was complicated by
formation of right femoral artery pseudoaneursym as well as a
large retroperitoneal bleed. Procedure also complicated by
development ___ likely from hypotension, blood loss anemia
and cholesterol embolization. Deferred TAVR workup (CT
angiogram of the aortic annulus and peripheral vessels) given
patient's wish to limit interventions.
# Right femoral psuedoaneurysm and retroperitoneal hematoma: Was
transfused 3uPRBCs with appropriate bump in Hct and improvement
in blood pressure. Hct nadir 23.5 and systolic blood pressures
as low as 80 (asymptomatic). She was hemodynamically stable and
Hct stable x 48 hours by time of discharge. Surgical
intervention was deferred given patient's desire to avoid
further interventions. Please recheck Hgb, Hct 48 hours after
discharge.
# ___: Acute rise overnight from 1.0 to 1.7. Concerning for
embolism, prerenal ___, or other etiology. FeNA <1% suggestive
of pre-renal etiology. Cr downtrended to 1.2 prior to discharge.
Home ACE-inhibitor was held. Please recheck electrolytes on ___
and consider restarting ACE-inhibitor if Cr has normalized back
to baseline.
#CAD: Continued BB, ASA, Imdur. Will restart Ace-I if needed for
blood pressure control.
#Hyperlipidemia: Continued atorvastatin
#Hypertension: Well controlled during hospitalization. On
metoprolol.
#GERD: Continued omeprazole
#Hypothyroidism: Continued levothyroxine.
# Discontinued lasix, monitor volume status and consider
restarting if clinically indicated (weight gain, worsening ___
edema)
# ACE-inhibitor held during this admission given renal
dysfunction. Recheck electroyltes at follow-up appointment, if
Cr normal then restart ACE-inhibitor (Cr 1.2 on discharge).
# Recheck Hgb/Hct 48 hours after discharge (___) and at
outpatient f/u given recent bleed
# Pt will follow-up with Cardiology (Dr. ___ next month
# Code: DNR/DNI
# Emergency Contact: ___
Phone number: ___
Cell phone: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ampullary carcinoma, CVA with r-sided deficits, htn, afib
on coumadin, h/o basal ganglial hemorrhage, and urinary
retention who presents with fevers and AMS. Patient recently
treated for ESBL E. coli UTI on ___ with Marcrobid and since
that time has had increasing confusion. Spiked a temperature to
105.7 at his facility today and was given some Tylenol and sent
to ___. CT HEAD W/O CONTRAST showed No acute hemorrhage and no evidence of other acute intracranial abnormalities. Radiology showed No focal consolidation. The patient was diagnosed with URIN TRACT INFECTION NOS. The patient was treated with ___ Midline placement at the bedside. At the time of discharge, the patient had ESBL E. coli UTI
Anemia, likely anemia of chronic disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ampullary carcinoma, CVA, afib on coumadin, basal ganglial
hemorrhage, and urinary retention who presents with fevers and
AMS with known ESBL E. coli UTI.
.
#Fever / #Delerium / #UTI:
On presentation, patient had known ESBL E.coli UTI that was
treated as an outpatient with Macrobid. On admission, Head CT
was unremarkable, but UA continued to show evidence of
infection. He initially received broad-spectrum coverage with
IV Zosyn and IV gentamicin, however, once sensitivities of his
ESBL E.coli were reviewed, he was placed on Meropenem. On IV
antibiotics, his mental status cleared quickly and he returned
to his baseline, confirmed by his brother / HCP ___. Repeat
UCx interestingly grew Pseudomonas, but pan-sensitive, so
Meropenem was continued. A midline was placed for access for
prolonged IV antibiotic course. The plan is to treat him with
Ertapenem as an outpatient, to complete a total of a 10 day
course ___ - ___ of appropriate IV antibiotics for his
complicated UTI. However, for his Pseudomonas, he will need
additional PO ciprofloxacin to complete a treatment course. He
could be covered with frequent Zosyn or Meropenem to cover both
organisms, however, his facility cannot due Q6 or Q8 hour dosing
of IV antibiotics. During hospitalization he initially did have
a Foley catheter placed, however, this was discontinued and he
has resumed intermittent straight cath as previous.
.
#Afib:
His appears to have paroxysmal afib, although on day of
discharge, he was in atrial fibrillation with irregularly
irregular rhythmn on physical exam. His HR is well-controlled
with beta-blockade. He p/w supratherapeutic INR to 6, but did
not have any evidence of bleeding. The elevated INR was likely
due to combination of poor PO intake recently as well as oral
antibiotics as an outpatient. Coumadin was initially held and
he was given Vitamin K 5mg x 1 to reverse his INR so a midline
could be safely placed. Given that his CHADS2 score is 2 (as
documented by outpatient Cardiology notes, and presumably his
CVA is not included as it was a hemorrhagic event on Coumadin),
briding therapy was not felt to be indicated. He was given
Coumadin 4mg on ___ with INR of 2.4. INR on day of discharge
was 1.5. He should continued on Coumadin 4mg daily for the next
3 days with repeat INR on ___ with further Coumadin dosing
TBD pending INR results.
.
#Anemia, likely of chronic disease: Patient noted to have lower
than baseline Hct of high 20's vs baseline of low 30's. He did
not have any evidence of active bleeding. Vitamin B12 level was
adequate. Iron panel suggests anemia of chronic disease. This
can be further worked-up as an outpatient.
.
#HTN: Continued home meds of clonidine, metoprolol and
amlodipine. BP in good range.
#GERD: Continued home PPI.
#BPH: Continued home Proscar, Flomax and bethanechol. He had
Foley catheter placed briefly during hospitalization but it has
since been discontinued. He should resume intermittent straight
catheterization 4x daily.
#Hypothyroidism: Continued home Synthroid dose.
#ACCESS: midline
#CODE STATUS: FULL CODE. Confirmed with HCP (Brother ___
___. Previous documentation at nursing home had
documented to attempt resuscitation but do not intubate, however
this is often not possible, so further d/w HCP to clarify was
done.
#CONTACT: HCP, brother ___ ___
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with a PMH notable for
metastatic rectal cancer status post laparoscopic
abdominoperineal resection and colostomy, chemotherapy, and
radiation along with right lower lobe segmentectomy for lung
metastases who presents with acute onset of abdominal pain,
nausea, and vomiting. CT abdomen and pelvis with IV contrast. showed 1. Small-bowel obstruction with a transition point in the right lower
quadrant, proximal to the small bowel anastomosis. No bowel wall thickening,
pneumatosis, or pneumoperitoneum.
2. Small rim enhancing fluid collection within the presacral surgical bed,
measuring up to 4.8 cm, significantly decreased in size compared to ___.
3. Increased fat stranding surrounding a moderate-sized periumbilical fat
containing hernia, incarcerated fat not excluded. Chest: Frontal and lateral views showed Right-sided PICC terminates in the low SVC/cavoatrial junction without
evidence of pneumothorax.
Mild left base atelectasis. The patient was diagnosed with Unspecified intestinal obstruction. At the time of discharge, the patient had PRIMARY
- recurrent small bowel obstruction
SECONDARY
- metastatic rectal cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY
=============
___ w/ metastatic rectal CA (s/p rsxn, colostomy, on FOLFIRI
C1D1 ___ w/ lung mets s/p RLL segmentectomy), DM, recent
admission for SBO (s/p lyses of adhesions & partial rsxn c/b
MSSA bacteremia and L5-S1 osteomyelitis), admitted w/ recurrent
partial SBO that was managed conservatively with improvement.
ACTIVE ISSUES
=============
#) PARTIAL SMALL BOWEL OBSTRUCTION
Pt presented with acute onset of abdominal pain, nausea and
vomiting. Imaging was notable for small bowel obstruction with
a transitional point in the right lower quadrant, proximal to
the small bowel anastomosis. Colorectal surgery was consulted
and recommended conservative management and no acute surgical
intervention. Patient was made NPO and given IVF. The
following day, patient began to have output from the colostomy
and was advanced to a clear liquid diet, which he tolerated
well. TPN was continued. Patient discharged on a clear liquid
diet with a plan to advance diet over the next several days.
#) SUSPECTED UPPER GI BLEED
Pt initially with reported coffee ground emesis but had no
further evidence of bleeding during admission and did not
require a transfusion. Managed with IV PPI during admission,
which was discontinued on discharge given low suspicion for GI
bleed.
CHRONIC ISSUES
==============
#) METASTATIC RECTAL CANCER: patient scheduled for follow up
with Dr. ___ further management
#) ANEMIA: remained at baseline and did not require transfusion
#) DIABETES: managed with glargine and insulin sliding scale
while inpatient
#) HYPERLIPIDEMIA: continued home atorvastatin
#) BPH: continued home tamsulosin
TRANSITIONAL ISSUES
=======================================
#) Discharge diet: clear liquids, advance slowly
#) Patient scheduled for follow up with Dr. ___
# Contacts/HCP/Surrogate and Communication: ___
(HCP, mother, ___, cell ___ ___
(alternate, brother, cell ___, home ___
# Code Status/ACP: DNR/DNI</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with no significant PMH but
a few prior epiodes of abdominal pain who presents with a 2-day
history of nausea/vomiting and diffuse abdominal pain. Symptoms
started with nausea/vomiting without any clear inciting cause 2
days ago; she denies any recent travel outside of the ___
___, denies sick contacts, denies consumption of any new or
unusual foods, and denies any recent antibiotic use. CT ABD AND PELVIS WITH CONTRAST showed 1. Narrowed segment of terminal ileum with wall edema, mucosal hyperemia and
prominence of the Vasa recta consistent with terminal ileitis. This could be
due to inflammatory bowel disease, infectious or ischemic causes.
2. Just proximal to the inflamed loop of bowel there is a focal narrowing
which could reflect peristalsis; however, an underlying stricture is possible.
3. Proximal to the inflamed ileum, the small bowel is dilated and fluid-filled
with multiple air-fluid levels consistent with some degree of obstruction or
ileus. The patient was diagnosed with REG ENTERITIS, SM INTEST. The patient was given written instructions concerning 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 no known PMHx but possibly significant EtOH use p/w
2-day hx n/v/ diffuse abd pain found to have normal creatinine
and lipase, no leukocytosis, LFTs/amylase/lipase normal and CT
abd/pelvis with evidence of terminal ileitis admitted for
further management.
#N/V/diffuse abdominal pain: She presented with a 2-day history
of nausea,vomiting and diffuse abd pain found to have normal
creatinine and lipase, no leukocytosis, LFTs/amylase/lipase
normal, elevated CRP and CT with evidence of terminal ileitis.
She was then admitted to the medicine floor for further
management. Upon arrival on the floor, she was also dry on exam
and was hydrated with IVF bolus and maintenance NS which was
then switched to LR given given continuous nausea and vomiting.
Family history significant for brother with GI problems never
formally diagnosed concerning for inflammatory/ autoimmune
process. Patient has had previous self-limited similar episodes
in past ___ years, possible IBD given history of constipation
with breakthrough diarrhea. Data suporting an inflammatory
process substantial elevation of CRP to 136.7. ESR 16. Physical
exam was pertinent for diffuse abdominal pain but normal bowel
sound and no concern for acute abdomen. Hemeoccult negative in
ED. No hx of colonoscopy. Other etiology include partial SBO in
the setting dilated and fluid-filled with multiple air-fluid
levels supported by her chronic constipation at presentation. We
also considered viral gastroenteritis, but strange to be so
limited to terminal ileum. Given her CT finding and concern for
IBD, she was started on ciprofloxacin and flagyl in the
emergency room which was continued upon admission. She was
switched to Unasyn on ___ when her blood culture grew GPRs but
d/c'ed on ___ w/ low suspicion for bacteremia. She initially
could not tolerate PO due to worsening abdominal pain so she was
maintained NPO and diet was advance when she was clinically
improved. Her pain was well controlled with IV morphine as
needed and her nausea with zofran. Her symptoms significantly
improved by day-4 of stay and she was able to tolerate a regular
diet without pain or nausea. She was transitioned successfully
to PO oxycodone and d/c'ed on it for pain control. We consulted
the GI service who recommended steroid if symptoms do not
resolve and follow-up colonoscopy as outpatient. This will help
to narrow the differential and possibly arrive at a final
diagnosis. At discharge, she was tolerating regular diet without
worsening abdominal pain or nausea, ambulating with benign
abdominal exam. Per GI recommendation, we sent for TPMT enzyme
assay, hep B serology and placed a PPD in preparation should she
need to be started on Azathioprine in the future, pending
further outpatient work-up. She is also to start Entocort 9mg
qAM after discharge. She is set to follow-up with Dr. ___ ___
in 2 weeks and a colonoscopy in 4 weeks. PPD to be read on
___ as an outpatient.
# + blood cx: Blood culture with anaerob GPRx1, thought to be
most likely P. acne. Covered on unasyn starting on ___, but we
feel contaminant, so we d/c'ed uansyn prior to discharge. Final
cultures pending at time of discharge.
#B12 deficiency: B12 level of 234 consistent with mild B12
deficiency. Possible cause include decrease absorption i/s/o
terminal GI disease (most likely) vs decrease intake i/s/o
chronic n/v. Started on PO Cyanocobalamin 2000mcg/day on ___.
# FEN: Pt had low Mg, K, and P which were repleted prn/ regular
diet at discharge
TRANSITIONAL ISSUES
# After discharge, patient second BCx botle grew GNRs. Although
it seems most likely to be a contaminant as it has been 5 days
since culture was sent. Please see WebOMR note on ___ with
details on communication with patient regarding these results
and further management.
#Concern for IBD. No colonoscopy in the past. Pt follow-up with
GI as outpatient as well as a colonoscopy 2 weeks and 4 weeks
from now, respectively
# CODE STATUS: Full (confirmed)
# Emergency Contact: Friend ___ ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ recently diagnosed with sigmoid diverticultis w/ phlegmon
extending to left adnexa in ___ after she presented with
LLQ pain. She as admitted for 3 days, and completed a course of
augmentin for 10days. Her symptoms improved, until ___, she
began having copius vaginal dischage. She went to the ER, a
repeat CTAP was done and showed mild improvement. She was
discharged with 10day course of levaquin and flagyl. Radiology showed 1. Wall thickening and mild surrounding fat stranding of the mid sigmoid
colon compatible with known diverticulitis with associated 3.1 x 2.0 x 1.6 cm
pericolonic abscess. No intraperitoneal free air. Extensive pan colonic
diverticulosis.
2. Multi lobulated lesion at the left adnexa containing small hypodensities
measuring up to 1.2 cm. It is unclear whether this is reactive inflammation
from surrounding diverticulitis or involvement of the ovaries/fallopian tubes.
Continued followup is recommended following treatment.
3. Compression deformities of the L1 and L2 lumbar vertebral bodies, worse in
the L2 level without CT findings to suggest acuity however are of unknown
chronicity. Correlate with focal tenderness.
4. Moderate hiatal hernia. The patient was diagnosed with ABDOMINAL PAIN LLQ, INTESTINAL ABSCESS. At the time of discharge, the patient had Diverticulitis with pericolonic 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>After undergoing a CT that showed a diverticular abscess, Ms.
___ was admitted to the Colorectal Surgery from the ER for
further management. She was started on IV antibiotics
(ciprofloxacin & Flagyl). By HD2, her LLQ pain had largely
resolved. She was advanced to a regular diet and tolerated it
well. Her antibiotics were transitioned to PO. She was afebrile
and hemodynamically appopriate. She was discharged home on a
3-week course of oral antibiotics (Augmentin), after which she
will have repeat imaging to re-assess her diverticular abscess
and have subsequent follow up with Dr. ___ to discuss surgical
management. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ old right-handed man with a history of
asthma, prior smoking history, and family history of stroke who
presents with acute-onset, persistent symptoms of unsteadiness
lasting all day as well as progressive headache, blurry vision,
and intermittent sensory loss. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Focal hypodensity with loss of gray-white differentiation in the right
posterior cerebral artery distribution involving the right occipital lobe,
right inferior medial temporal lobe, compatible with an evolving acute
infarct.
2. Hypodensity of the right thalamus is identified, which may represent
prominent perivascular space versus sequela of lacunar infarct.
3. Complete occlusion of the right common carotid artery just distal to the
bifurcation with a tapering configuration, potentially secondary to
dissection.
4. Otherwise, unremarkable CTA of the head and neck. CHEST (PA AND LAT) showed 1. Bilateral lower lung interstitial abnormality is of indeterminate
chronicity, but new since ___. If the patient has clinical evidence
pointing to a specific pulmonary problem, consider chest CT for further
evaluation.
2. No focal consolidation concerning for pneumonia.
RECOMMENDATION(S): If the patient has clinical evidence pointing to a
specific pulmonary problem, consider chest CT for further evaluation. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Study is moderately degraded by motion.
2. Redemonstration of known right PCA distribution infarcts with evidence of
hemorrhagic transformation, as described.
3. Redemonstration of complete occlusion of right common and cervical internal
carotid arteries, with flow noted within right supraclinoid internal carotid
artery and distal branches.
4. Within limits of study, no definite focal dissection identified of right
common or cervical internal carotid artery.
5. Paranasal sinus disease as described.
NOTIFICATION: The impression ___ were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:00 ___, 2 hrs after discovery
of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Hemorrhagic transformation of right temporal occipital infarct wild new
since the CT of ___ is unchanged from the MRI of ___. The
area of infarct appears stable in size. CHEST (PORTABLE AP) showed Comparison to ___. The lung volumes have increased, likely
reflecting improved ventilation. Minimal left basilar atelectasis. Mild
elongation of the descending aorta. No pneumonia, no pulmonary edema, no
pleural effusions. The patient was diagnosed with Headache. At the time of discharge, the patient had -Right PCA territory stroke
-R ICA occluded from common carotid to intracranial portion
where it reconstitutes - unknown chronocity. The patient was given written instructions concerning 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 ___ old right-handed man with a prior
smoking history and family history of stroke who presented with
sudden onset of lightheadedness and stepwise worsening of
symptoms of blurry vision, double vision, lightheadedness and
headache throughout the day. On initial examination in the ED,
he has a left homonymous hemianopsia, hypometric saccades on
leftward gaze, left appendicular ataxia and inability to walk in
tandem.
CT/CTA shows a right PCA territory stroke with patent posterior
circulation as well as a R ICA which is occluded from the common
carotid to the intracranial portion where it reconstitutes. MRI
revealed right PCA distribution infarcts with evidence of
hemorrhagic transformation. Repeat NCHCT 24 hours after
demonstration of hemorrhagic confirmation showed stability
without increased hemorrhage.
The patient was started on Aspirin 81mg Daily for stroke
prevention. LDL 68. A1C 5.8. TSH normal. Echocardiogram did not
reveal intracardiac thrombus, EF 70%. He was monitored on
telemetry without arrhythmia. He will be discharged to home with
___ of Hearts monitor.
The etiology of his stroke was not clear. He does have complete
occlusion with reconstitution of the R common carotid with no
evidence of dissection (but fat sat sequence not obtained) and
does have extensive collaterals. Though dissection is on the
differential, given his bleed he would not be an immediate
candidate for dual antiplatelet therapy or anticoagulation, so
further imaging was not pursued to classify this during
admission.
It is possible, though rare, that he could have a dissection
near the origin of the common carotid; however, he has no prior
traumatic history to support this. Collagen vascular disease is
another consideration, but he has no hypermobile joints,
hyperextensible skin or valve abnormalities to support this.
Given a stroke of unknown etiology, he will be discharged with a
heart monitor to observe for any evidence of a. fib and undergo
carotid US in ___ weeks as an outpatient. If not revealing, a
TEE may be considered at that time. Additionally, a
hypercoaguable work-up was initiated -- with protein C/S,
antithrombin, beta-2-glycoprotein, cardiolipin ab, and
antiphosphlipid Ab were pending at the time of discharge. He
will have prothrombin and factor V Leiden sequencing tested as
an outpatient. D-dimer pending at the time of discharge which
will be followed, and if significantly elevated a CT Torso will
be pursued to evaluate for malignancy.
He was evaluated by OT who felt his balance was appropriate and
stable for home. However, given his visual field deficit, he
cannot drive.
Of note, his CXR did reveal a lower lung interstitial
abnormality, and a chest CT can be considered as an outpatient
by PCP. He had a low grade fever to Tmax 100.5, with repeat UA
negative, blood culture no growth to date, and CXR negative for
consolidation. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with crohn's disease with recent
hospitalization for SBO with perforation, complicated by
intraabdominal abscesses requiring drainage procedures and
placement of wound VAC and post-operative pulmonary embolism,
who presents with a abdominal pain. She notes the pain started
six days ago and is associated with nausea/vomiting. Pain is in
LUQ, is ___. She has been unable to keep fluids food or
fluids down as a result. She notes that her emesis has appeared
to look like food content with associated fever and chills. She
denies blood in her stool or melena. She has had increased
watery consistency of ostomy output. Denies slowing of output
concerning for obstruction. She notes that her symptoms are most
consistent with prior episodes of c. diff colitis. CT abdomen and pelvis showed 1. Enhancing pelvic fluid collection appears minimally increased in size from
the prior examination in ___ and shows adjacent fat stranding.
2. Overall size of perihepatic, and perisplenic fluid collections are
decreased from ___. Mild small bowel mucosal hyper enhancement as well as
enhancement within the mesentery and omentum also appears minimally decreased
from the prior examination.
3. No free air in the abdomen or pelvis. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormalities Radiology showed No evidence of free air. Several dilated small bowel loops, may represent
obstruction or focal ileus. CT can be performed for further evaluation if
clinically indicated. PELVIS, NON-OBSTETRIC showed Pelvic fluid collection consistent with abscess. No evidence of ovarian
torsion. . Radiology showed Successful CT-guided aspiration the presacral collection. Samples was sent for
microbiology evaluation. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with ___ aspiration of perirectal abscess. At the time of discharge, the patient had Pancreatitis
Perirectal 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>___ woman with Crohn's disease with recent
hospitalization for SBO with perforation, complicated by
intraabdominal abscesses requiring drainage procedures and
placement of wound VAC and post-operative pulmonary embolism,
who presents with a abdominal pain consistent with acute
pancreatitis, found to have a perirectal abscess s/p aspiration.
In summary, the patient presented with a several-day history of
LUQ worsening pain, nausea/vomiting, and poor PO intake, and
decreased ostomy output. CT abdomen and KUB did not reveal any
perforation. However, CT abdomen/pelvis revealed a perirectal
fluid collection, and per colorectal surgery recommendation, it
was aspirated by ___ (fluid culture pending). The patient was
norovirus and C diff negative. ___ procedure, the patient
spiked a fever to 101.8, which could be due to the abscess site,
and she was placed on IV cefepime and flagyl. There was lower
concern for an infection, and flagyl and cefepime were
discontinued.</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 metastatic melanoma to the
lungs, brain, and left lower extremity who recently initiated
PD-1 (nivolumab, ipilimumab) 12 weeks ago presenting with 1 week
of neurologic changes. Radiology showed Considerable increase in size in the left frontal lobe
subcortical lesion measuring now 3 cm compared to 5 mm on the previous study
with a thick rim of enhancement and intrinsic restricted diffusion likely
secondary to melanin pigments or blood products. The previously seen two
right frontal lobe lesions also now have increased in size and measure
approximately 6 mm compared to punctate enhancement on the previous study with
mild surrounding edema. No midline shift is seen, and there is no
hydrocephalus. Findings were added to the critical communication dashboard
for communication with the referring physician. Radiology showed No interval change in the appearance of the left frontal lesion demonstrated
on MR 3 days ago. No evidence of new lesions, hemorrhage, or infarction. Radiology showed No interval change status post left frontal craniotomy and biopsy. No
hemorrhage identified. Radiology showed 1. Progression of retroperitoneal lymphadenopathy.
2. New metastases in the ileocecal valve and left diaphragmatic crura are
suspacted .
3. Enlarging subcutaneous metastases. Please see concurrent CT chest report
regarding supradiaphragmatic metastasis.
4. Nonspecific trace pelvic free fluid. Radiology showed 1. Diffuse pulmonary and chest wall metastases as described above,
representing marked progression from ___.
2. Please correlate with report of CT abdomen and pelvis regarding
subdiaphragmatic metastases. The patient was diagnosed with NAUSEA WITH VOMITING, SEC MAL NEO BRAIN/SPINE. The patient was treated with Stereotactic biopsy of the left frontal lesion ___. At the time of discharge, the patient had Metastatic melanoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ year old male with metastatic melanoma to the
lungs, brain, and left lower extremity who recently initiated
PD-1 (nivolumab, ipilimumab) 12 weeks ago presenting with 1 week
of neurologic changes.
# Neurologic decline: His neurologic decline was thought to be
due to increase in metastatic focus in brain with surrounding
edema, and with question of possible underlying seizure
activity. He underwent stereotactic brain biopsy of the lesion,
and pathology showed changes consistent with cerebral edema and
necrosis in response to PD-1, rather than progressive metastatic
disease. He was started on decadron and keppra on admission,
but his mental status continued to be A&O x 2 daily. He
continued to be confused, and confabulated, and was tearful and
emotional at times but unable to verbalize his thoughts clearly.
20-minute EEG showed findings consistent with mild/moderate
encephalopathy with no evidence of ongoing or potential seizure.
His neurologic exam was otherwise nonfocal and he had no other
deficits that were noted during hospital course. He was cleared
for home with home ___.
# Melanoma - Patient was on PD-1 as outpatient, and had recently
completed week 9, dose 5. He had known mets to his lungs, brain
and left leg, but on admission was also found to have new
fungating lesion on his left chest wall, as well as a
subcutaneous pigmented lesion on his left abdomen along with
growth in his brain met. CT torso showed progression of his
disease; decision per outpatient oncology team was to stop PD-1
therapy. He will instead start treatment with a BRAF inhibitor,
which will arrive in the mail.
# Hemochromatosis - Patient has history of hemachromatosis - not
currently being treated.
# Leukocytosis - Noted to have leukocytosis on starting
dexamethasone without fevers, localizing symptoms or signs of
infection. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo man with CAD, DM2, sCHF (EF <40%),
afib, and CKD, recently found to have a cerebellar mass (likely
metastatic lung primary), s/p VP shunt placement on ___ and
undergoing WBXRT, who presents today with worsening slurred
speech over the last one week and a left sided facial droop. Per
report, the patient's sons have reported that he has been less
attentive and less ambulatory over the last one week, with
increasingly slurred speech and gradually worsening facial
drooping.
.
He was initially diagnosed with the cerebellar mass on ___,
when he presented to ___ with several weeks of
unsteady gait. Brain CT there showed the right cerebellar mass,
and CXR showed a left lingular mass and left hilar fullness. CT
Torso showed peripheral LUL mass with left hilar and mediastinal
LAD. He was transferred to ___, and brain MRI ___ showed
the right cerebellar mass with surrouding edema. He was started
on steroids. The neurosurgery service did not recommend surgical
intervention. Lung bx ___ showed poorly differentiated
carcinoma. Since that time, he has had issues with gait
unsteadiness. On ___ he underwent elective VP shunt
placement, with an uncomplicated OR course, and post-op head CT
stable without new hemorrhage. Exam was intact, and the pt was
discarged on ___. His Coumadin had been on hold due to
bleeding risk, while he continued in atrial fibrillation. Radiology showed Unchanged appearance of the ventricular size. Although the
cystic lesion in the right middle cerebellar peduncle appears slightly larger,
the surrounding edema and the associated mass effect is not significantly
changed. No hemorrhage seen. Radiology showed Unchanged exam compared to the study performed earlier today at
8:54 a.m. No evidence of hemorrhage. Radiology showed Intact course of ventriculoperitoneal shunt. The patient was diagnosed with BRAIN CONDITION NOS, FACIAL WEAKNESS, VENTRICULAR SHUNT STATUS. At the time of discharge, the patient had Primary:
Cerebellar mass
Carcinoma of the lung
Urinary tract infection
.
Secondary:
Diabetes
Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is an ___ man with CAD, DM2, sCHF (EF <40%), afib,
and CKD, recently found to have a cerebellar mass (likely
metastatic lung primary), s/p VP shunt placement on ___ and
undergoing WBXRT, who presents today with worsening neurologic
symptoms over the last week.
.
# Progressive neurologic symptoms: Per family, Mr. ___ has
had intermittent facial droop, slurred speech, confusion since
the VP shunt was placed. These progressive symptoms are most
likely secondary to increased edema surrounding the right
cerebellar mass. He was evaluated by neurology in the ___, and
other etiologies such as stroke, seizure, and GBS were thought
to be much less likely. Additionally, shunt series revealed the
VP shunt to be intact. In the ER, he received 6mg IV decadron
and was started on standing dose on the floor. EEG was obtained
which showed diffuse slowing but no epileptiform activity. On
discharge, he will taper to Dexamethasone 6mg PO bid. In the
setting of high dose steroids, he should continue Famotidine for
prophylaxis and blood glucose should be monitored with
fingersticks and insulin sliding scale. He was also started on
Keppra 500mg PO bid for seizure prophylaxis. Whole brain xrt was
continued during the admission. On discharge, Mr. ___ will
f/u with Dr. ___ neuro-oncologist.
.
# UTI: Positive UA in ___, culture with contamination. Given
recent UTI and possible contribution of infection to confusion,
treated with anbitiobics. Will complete 7 day course of
cefpodoxime 200mg PO qd on ___.
.
# DM II: maintained on an unknown dose of 70/30 insulin at home.
Blood sugars likely to elevate in setting of Decadron use.
Patient was on Lantus 10 U qam and humalog ISS in house.
.
# Afib: Not anticoagulated due to recent cranial surgery.
Continued home digoxin, carvedilol.
.
# sCHF: non-ischemic, EF <40%: Continued home digoxin,
carvedilol.
.
# CAD: Continued home statin and carvedilol.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with no PMH apart from h/o acute leukemia diagnosed in the
past week, now admitted for chemotherapy.
.
She has experienced 1 month of nightsweats and fatigue plus dry
cough x 1 week (cough now resolved). No fever, no N/V/C.
Describes poor appetite and 6 lb weight loss over several weeks.
At initial eval, PCP found leukopenia on screening labs.
Referred to hematologist who performed BM bx ___ - preliminary
BM bx results showed acute leukemia concerning for AML.
.
Patient presented to the ___ ED for admission to the ___
service.
.
In the ED, initial VS T99.6 HR 136 BP123/67 RR18 99/RA. While in
the ED she triggered for tachycardia, which improved to HR ___
greatly after 2L NS IVF. Labs remarkable for WBC 0.7, HCT 33.1,
platelets 174, 19% PMNs, 77% lymphs, 2% monos, 1% eosinophils.
.
On the floor, she feels well except for 1 month mouth dryness
and bilateral eye redness/swelling. Tried eyedrops per
ophthalmology recommendation (beta blocker eyedrops,
prescription unknown) without no improvement.
.
ROS: As per HPI. Full 12-system ROS negative including GI/GU
issues, CP, palpitations, SOB, abd pain. Radiology showed No evidence of pneumonia. No acute cardiopulmonary process. Radiology showed 1. Occlusive thrombis in the right basicilic and axillary veins, surrounding
the PICC. Non-occlusive thrombus within the medial brachial vein.Possible
thrombus extending into the right subclavian vein around the PICC, which would
be non-occlusive if present. The patient was diagnosed with OTHER MALAISE AND FATIGUE, ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION. At the time of discharge, the patient had acute myeloid leukemia
left upper extremity deep vein thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Summary: Ms. ___ is a ___ yo woman with newly diagnosed AML,
treated with 10d course of decitabine, course c/b PICC DVT and
transaminitis.
.
#New AML: NPM1 mutation postive. Her counts increased
substantially on the day of discharge. Acyclolvir, fluconazole,
levofloxacin were started for prophylaxis.
.
# Transaminitis: Stopped fluconazole, enoxaparin, and
levofloxacin and LFTs improved. However, most likely that
increase was due to the chemotherapy. Levo was restarted, and
LFTs did not increase over several days. Fluconazole was started
just prior to discharge. LFTs should be monitored as an
outpatient.
.
# R upper extremity DVT: Associated with PICC, which was
discontinued on ___, and enoxaparin was stopped on ___ after
the patient became thrombocytopenic.
.
#HYPERTENSION: Held lisinopril
.
# Thigh Plaques: Neutrophilic vasculitis according to derm
biopsy. Likely in setting of losartan. Improved markedly this
admission.
.
====</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of glaucoma, ? dementia, COPD, Rheumatoid arthritis,
DVT/PE, who presents after being confused about his PCP
___. Pt reports that yesterday AM, he was notified that
he had an appointment for the next day. He took a nap, woke up
in the afternoon, but thought it was the next morning, and
proceeded to go to ___ for his PCP ___. At ___, given that
he was confused, he was told to go to the ED. He was then
admitted for concern for poor self care. Radiology showed Mild interstitial edema. Left basilar opacity may reflect atelectasis though
infection can be considered in the appropriate clinical setting. The patient was diagnosed with Altered mental status, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ y/o ___ speaking man
presenting after mistakenly going to the hospital for an
unscheduled appointment. TSH within normal limits, RPR with
stable titer in the setting of known latent syphilis. Patient
was found to be B12 deficiency with elevated methylmalonic acid.
Supplementation with vitamin B12 was started. Physical therapy,
occupational therapy evaluated patient and recommended initially
that he be discharged to a rehabilitation facility, subsequently
revised their suggestion to home with ___ supervision. It was
determined that safest discharge would be to with his sister
with services, to which both he and she were agreeable.
#Self care:
Patient lives alone. In light of gait instability observed by ___
and concern by OT that he sometimes forgets to turn off the
stove, ___ supervision was advised. Much has been done in the
past to try to assist the patient. He has frequent follow-up
with his PCP, ___ extensive resources through HCA.
Following extensive discussion with case management, it was
determined that he did not qualify for ___
rehabilitation, and other placement options were financially
prohibitive. Following extensive discussion with his PCP and
case management, it was determined that safest discharge would
be to live with his sister, to which both the patient and his
sister were agreeable. A multidisciplinary family meeting,
including both inpatient and outpatient providers, was held on
the day of discharge, with emphasis to the patient and his
sister on the importance of his new living arrangements for his
optimal safety.
#Confusion/dementia
Patient appears back at baseline. TSH within normal limits. RPR
titer stable; in discussion with his ID provider, Dr. ___,
___ stable titer, recent rule-out for neurosyphilis, and
recent treatment for latent syphilis, no further work-up or
treatment needed at this time. Patient may be b12 deficient as
discussed below.
#B12 deficiency
Patient with low B12 level with elevated methylmalonic acid. ___
be secondary to PPI use and poor absorption. Started B12
supplementation with 1000mcg daily.
#Glaucoma:
Continues to have bilateral eye pain and erythematous sclerae.
Patient has appt with ophthalmologist on ___. Per
ophthalmology, his glaucoma has been difficult to control. His
conjunctival hyperemia is secondary to his eye drops which helps
to control his pressures. Continued home eye drops:
dorzolamide/timolol.
#Sore throat
___ be viral pharyngitis. Centor score of 1, therefore unlikely
strep pharyngitis. Was given lozenges for symptomatic relief.
Patient continued to have persistent sore throat. Swab for strep
pharyngitis pending at discharge and subsequently returned
negative.
#Weight loss: Outpatient PCP performing occult malignancy
work-up. Weight appears back up at 200lb on this admission.
Continue outpatient workup. Patient was seen eating well while
hospitalized. ___ be due to poor access to food.
#Pulmonary Embolism
Continued xarelto for 6 months of treatment (last dose ___.
#History of hepatitis B.
Continued lamivudine.
#Seropositive rheumatoid arthritis.
Continued prednisone 5 mg daily and methotrexate 25 weekly
#COPD
Continued home tiotroprium, and albuterol prn
#Gerd:
Continued omeprazole 20mg BID.
# Chronic Back Pain:
Continued home tramadol
***TRANSITIONAL ISSUES***
- Pt has chronic glaucoma, pain in eye, and conjunctival
hyperemia. Has an appointment with ophthalmologist on ___.
- Patient with B12 deficiency, persistent sore throat, weight
loss, consider workup of possible malignancy, as has been
ongoing in the outpatient setting.
- Consider further work-up of etiology of vitamin B12
deficiency, including IF Ab and EGD.
- Continue to monitor vitamin B12 level and MMA; oral
supplementation was chosen for patient convenience, but may
consider IM injections if deficiency does not improve with oral
supplementation or concern for malabsorption.
New medications: Vitamin B12 1000mcg
# CODE: full
# CONTACT:
Name of health care proxy: ___
___: sister
Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ male who slipped on wet rocks and
fell, worked up at OSH and found to have left ankle fracture,
then transferred to ___. He was in his usual state of health,
was walking, slipped on some wet gravel with inversion injury
and then fell over with immediate pain and inability to
ambulate. He was found to have comminuted distal tibia/fibula
fracture with intra-articular extension. He was admitted to the
orthopaedic team and treated with external fixator on ___. Radiology showed Distal tibia and fibula fractures in unchanged overall alignment. Radiology showed Markedly comminuted displaced intra-articular fractures of the distal tibia
and fibula, as described above. TIB/FIB (AP AND LAT) LEFT showed Multiple images from the operating room shows placement of extensive fixation
device about the comminuted fracture of the distal tibia. Further information
can be gathered from the operative report. The patient was diagnosed with FX TIBIA W FIBULA NOS-CL, UNSPECIFIED FALL. The patient was treated with Left tibia external fixator. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left comminuted distal tibia/fibula fracture with
intra-articular extension and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for placement of external fixator, 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
patient's home medications were continued throughout this
hospitalization. The orthopaedic team determined that discharge
to home was appropriate with follow up with a surgeon closer to
the patient's home in ___. 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 non-weight-bearing in the left
lower extremity with ex-fix, and will be discharged on lovenox
for DVT prophylaxis. The patient will follow up with an
orthopaedic surgeon closer to his home in ___. 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: ___ with heart failure w/ preserved ejection fraction, PAH,
AF, DM, hypothyroidism, p/w ___ year old female with chief
complaint of dyspnea and hypoxemia. 2L o2 at home, sats 92% at
baseline presenting with dyspnea and hypoxia.
Reportedly, over the past 10 days, she has had worsening
dyspnea, hypoxemia (down to 85%). She uses O2 at home. She
reports shortness of breath, even with small activities and
bending over to look down at her feet. She was seen on ___ and
was noted to have an unchanged weight with mild R-sided chest
pain, baseline O2 sat at rest, but with sats that dropped to the
___ when she was taken off her O2 (usually she is in the ___ off
O2). No lightheadedness, headache, f/c, n/v/d, myalgias.
Although medication compliance has been an issue in the past,
she reports taking her torsemide every day.
In the ED, initial vitals were: 96.8 F, BP 150/70s, HR ___, RR
20, 96% on 2 L NC. CT chest without contrast. showed 1. Diffuse ground-glass pulmonary opacities with smooth interlobular septal
thickening likely represents pulmonary edema in the setting of cardiomegaly.
Although less likely, this could alternatively be related to infectious or
inflammatory process.
2. Stable large hiatal hernia.
3. Increase in number of mediastinal lymph nodes. These are not enlarged by
CT size criteria and demonstrate ___ years of stability, and may represent a low
grade lymphoproliferative process.
4. Interval increase in size of cystic lesion within the pancreatic body
measuring up to 2.5 cm. Further evaluation with MRI may be helpful if
desired.
5. No significant change in right adrenal adenoma and left adrenal
myelolipoma.
6. A 15 x 30 mm left thyroid nodule, for which further evaluation with
nonemergent thyroid ultrasound is recommended. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had Primary:
===========
Acute Diastolic heart failure exacerbation
Acute on chronic hypoxemic respiratory failure
Severe pulmonary 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>___ with known heart failure and AF p/w increasing dyspnea over
___ days, +bibasilar crackles, found to have elevated BNP and
CXR with evidence of fluid overload concerning for HF
exacerbation.
# Acute HFpEF exacerbation (severe pHTN, moderate severe TR):
Patient came in with elevated BNP and e/o pulmonary edema on CXR
and CT chest. Despite this patient weight on admission 71.3 kg
was below her previous dry weight of 74.4kg from ___.
This was after she was diuresed with 120 IV Lasix in the ED with
good output and some resolution of her symptoms. She was given
further IV diuresis with BID bolus of 120-160 IV Lasix without
much change in her weight, but some evidence of being
hypovolemic by labs (bicarb of 30). Ultimately patient was felt
to be euvolemic at discharge and declined further invasive
testing such as a RHC and/or coronary angiography to evaluate
further for etiology of her worsening symptoms. TTE was done as
an inpatient and was largely unchanged. Etiology of exacerbation
determined to be under diuresis taking 40 mg torsemide instead
of 60 mg that was prescribed by Dr. ___ of a desire
to decrease frequency of urination. Will have close follow up in
the CDAC.
# Acute on chronic hypoxemic respiratory failure: likely ___
patients pHTN. Patient O2 rq increased form home 2 L to 4 L at
the hospital with desaturation with exertion even on this. At
home she was intermittently compliant with her O2. O2 titration
study revealed patient needed to be on 4L O2 by NC at home.
# HTN - patient was noted to be hypotensive with ambulation down
to SBP into the 60's. There were concerns about whether patient
was taking her prescribed BP regimen at home given hypotension
observed in the hospital. Medications were significantly
changed: taken off of felodipine was stopped, losartan was
stopped, metoprolol was decreased from 150 mg BID of succinate
to 100 mg daily.
# Afib: DDD pacemaker. Paced rhythm while in house. Metoprolol
decreased as above. Continued on Eliquis. No ASA
# DM2: Given ISS in house
# GERD:
- continued home PPI
# hypothyroidism:
- checked TSH, was on the high at 4.8 but dose of synthroid was
not adjusted. Should be adjusted by PCP as an outpatient
- continue home levothyroxine
# depression:
- continue sertraline
# insomnia:
- continue Zolpidem
# OA - continued home tramadol
# OSA - patient refused CPAP while in house.
TRANSITIONAL ISSUES
- checked TSH, was on the high at 4.8 but dose of synthroid was
not adjusted. Should be adjusted by PCP as an outpatient
-Interval increase in size of cystic lesion within the
pancreatic body
measuring up to 2.5 cm. Further evaluation with MRI may be
helpful if desired.
- A 15 x 30 mm left thyroid nodule, for which further evaluation
with
non-emergent thyroid ultrasound is recommended.
- Please monitor patients weight. Call her cardiologist to
change torsemide dose if weight increases by 3 lb or more.
___
- Patient should be on 4 L of O2 at home.
- Patient enrolled in PACT program.
- Discharge Creatinine: 1.6
- Discharge weight: 71.4 kg</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm.
2. Patent bilateral cervical carotid and vertebral arteries without evidence
of stenosis, occlusion, or dissection.
3. Unchanged acute nondisplaced fracture of the left transverse process of T1.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No significant change in the subarachnoid hemorrhage involving the
perimesencephalic cisterns, superior cerebellar sulci and left sylvian
fissure, as above. No new or expanding intracranial hemorrhage. Carotid Artery ultrasound showed Right ICA <40% stenosis.
Left ICA <40% stenosis. The patient was diagnosed with Traum subrac hem w LOC of unsp duration, init, Fall (on) (from) other stairs and steps, initial encounter. The patient was treated with N. At the time of discharge, the patient had Subarachnoid hemorrhage
Type 3 left AC joint separation
Nondisplaced left transverse process of the T1 vertebra
Severe orthostatic hypotension
Syncope
Recurrent falls
___ 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>SUMMARY:
========
Mr. ___ is an ___ year old M w/ hx of CAD s/p multiple PCI
including to LAD with last in ___ after STEMI from in-stent
restenosis, HTN, migraines, and ___ with history of
falls who presented after a fall at home, found to have a
subarachnoid hemorrhage and non-displaced T1 fracture with
vitals notable for significant orthostatic hypotension.
ACTIVE ISSUES:
==============
# Type 3 left AC dislocation
# T1 non-displaced transverse fracture
He was evaluated by the trauma service and images done
demonstrated that he had suffered a subarachnoid hemorrhage,
non-displaced T1 transverse process fracture, and a type 3 left
AC dislocation. He was admitted to ACS/Trauma service for
further treatment of his injuries. The Orthopedic surgery
service was consulted for the left AC joint separation and they
recommend conservative management with a sling, WBAT, and clinic
follow up in ___ weeks. No surgical intervention for patient's
T1 TP fracture, just pain control as needed.
# Subarachnoid hemorrhage
He was assessed by the neurosurgery service regarding his SAH.
They recommended conservative treatment with neurological
checks, keep SBP < 160, and hold patient's home ASA/Plavix for 3
and 7 days respectively. Plavix can be restarted on ___.
# Orthostatic hypotension
# Dysautonomia
# Syncope
# Recurrent falls
# ___ disease:
Since the patient experienced lightheaded prior to his fall, he
was ordered for a syncopal workup with EKG, TTE, and carotid
duplex. He also was checked for orthostatic hypotension, which
was positive. However, due to his extensive cardiac history and
___ disease, he was transferred to the medicine service
for further management of his medical comorbidities. On the
medicine service, all of his home antihypertensives and beta
blockade were held. Unfortunately, he remained orthostatic, so
his case was discussed with his outpatient Neurologist and he
was ultimately changed to Carbidopa-Levodopa (___) 1.5 TAB
PO/NG 5X/DAY, Carbidopa-Levodopa CR (___) 1 TAB PO DAILY at
2300, and ropinirole was decreased to 4 mg BID. He was given an
abdominal binder and TEDS stockings. ___ evaluated him and
recommended discharge to rehab, which he refused and had
capacity to do so. He stated multiple times that he understood
the risks of going home including recurrent falls and head
strikes which could lead to permanent neurologic damage or
death. His family was informed that we unfortunately could not
force him against his will to go to rehab since he had capacity
to refuse. He was discharged home w/ ___. He was instructed on
fall prevention and management of orthostatic hypotension. While
his blood pressures were still orthostatic before discharge, his
symptoms had resolved and he was able to do the stairs multiple
times. He also did not show any signs of overt stiffness from
his ___, although was feeling some of the effects of his
decreases doses of medications. He should have very close follow
up with Neurology and Cardiology. He and his wife were
instructed that he should not drive.
# Chronic HF, borderline EF
# HTN
# Hx of CAD s/p 2 PCI to LAD
EF 45%, worsening from prior. Imaging consistent with LAD +/-
RCA distribution ischemia. Patient was euvolemic on exam. His
home metoprolol and isradipine were all held given severe
orthostasis. He was intermittently hypertensive to the 160s, but
this quickly resolved. Aspirin held for 3 days and Plavix held
for 7 days per NSGY (restart on ___. He remained on his
home atorvastatin. Consider outpatient stress test given
worsening regional wall motion abnormalities
CHRONIC/STABLE ISSUES:
=======================
# Chronic thrombocytopenia
Plts in 130s going back to ___. Stable.
# Depression
Continued home Fluoxetine daily
# Chronic pain
Held home gabapentin given fall
# GERD
Decreased home pantoprazole to daily as no indication for BID </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history with history gallstone
pancreatitis s/p ccy, and recent admission at ___ for
pancreatitis p/w epigastric pain. Radiology showed Normal bowel gas pattern with no evidence of obstruction. Radiology showed 1. Prior cholecystectomy. There is evidence of common bile duct dilatation
without obstruction or mass lesion. The possibility of sphincter of Oddi
dysfunction cannot be excluded.
2. There is a left upper pole renal cyst measuring 1.4 cm. It could not be
assessed adequately due to the susceptibility artifact from the metallic
hardware within the patient's spine. The patient was diagnosed with ACUTE PANCREATITIS. The patient was treated with ___ Esophagoduodenoscopy (EGD). At the time of discharge, the patient had Abdominal pain of unclear cause
Antral (stomach) erythema -- biopsies pending
Insomnia
Mild intermittent 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>___ year old female with history with history gallstone
pancreatitis s/p ccy, and recent admission at ___ for acute
pancreatitis p/w epigastric pain. s/p EGD here showing antral
erythema, bx pending. MRCP ordered (ERCP team following).
.
Abdominal pain
- unclear etiology, pancreatitis seems unlikely given her barely
elevated lipase levels (which are non-specific), the lack of
imaging evidence of pancreatitis, and the very quick resolution
- ddx includes biliary tree problem, versus an antral process,
although this seems unlikely
- ERCP consult followed the patient
- EGD showed antral erythema, biopsies pending
- MCRP showed common bile duct dilation -- could be secondary to
sphincter of Oddi dysfunction
- the patient will follow-up with GI after discharge
.
Renal cyst seen on MRCP
- the patient will follow-up with her PCP about this to
determine if more imaging is needed
.
Asthma
- Continued home albuterol
.
Other
- trazodone PRN insomnia
.
Day of discharge
Interval history: Felt much better today. Hasn't need any pain
medication. Tolerated lunch with some nausea, but would like to
go home. We discussed her plan of care and the importance of
follow-up. She understood, and I answered her questions.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female past medical history of psoriatic arthritis,
presents as a transfer from ___, with a left
intertrochanteric femur fracture after a fall while getting up
from the toilet. On exam the patient is closed neurovascularly
intact with left lower extremity which is externally rotated and
shortened. X-rays demonstrate a comminuted left inner troches
femur fracture. FEMUR (AP AND LAT) LEFT showed Intraoperative images were obtained during open reduction internal fixation of
a intertrochanteric left hip fracture. Please refer to the operative note for
details of the procedure. CHEST (PORTABLE AP) was done. The patient was diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall on same level, unspecified, initial encounter. The patient was treated with ORIF left intertrochanteric hip fracture. At the time of discharge, the patient had Left intertrochanteric hip 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 orthopaedic surgery team. The patient was found
to have left intertrochanteric hip fracture and was admitted to
the orthopaedic surgery service. The patient was taken to the
operating room on ___ for ORIF left intertrochanteric hip
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male, with past history ESRD ___
DM Type I, s/p kidney/pancreas (bladder drained at ___,
___ transplant in ___, with recent bladder to enteric
drain scheduled and undergone ___, CAD, OSA with severe
pulmonary HTN, paroxysmal atrial fibrillation on amiodarone (not
currently on anticoagulation), who is presenting with concern
for new acute heart failure with lower extremity edema. CHEST (PA AND LAT) showed COPD with superimposed pulmonary edema. RENAL TRANSPLANT U.S. LEFT showed Continually elevated resistive indices. No hydronephrosis or significant
perinephric fluid collection is identified. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. No change in paranasal sinus disease compared to ___, as detailed
above. Demineralized cribriform plates and uncinate processes indicate
chronic inflammation. No evidence for fluid levels.
2. Unchanged polypoid soft tissue density in the left naris. A polyp is not
excluded. The patient was diagnosed with Heart failure, unspecified. The patient was treated with n/a. At the time of discharge, the patient had Primary diagnosis:
Acute CHF exacerbation with preserved EF (45-50%)
Hypertension
Chronic sinusitis
Secondary diagnosis:
S/p kidney/pancreas transplant. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male, with past history of ESRD ___ Type I DM, now
s/p kidney/pancreas transplant in ___, with recent admission
for conversion of bladder drain to enteric, presenting with
hypertensive urgency and CHF exacerbation. He was treated with
IV Lasix x2 days and put out well. TTE showed EF 45-50% with
changes consistent with known CAD. Cardiac biomarkers were
negative and BNP was in the 9000s. He remained in normal sinus
rhythm. He had head CT for c/o ongoing sinus issues which showed
changes suggestive of chronic sinusitis. He also was started on
new blood pressure medication of amlodipine.
#CHF exacerbation: Presented with dyspnea, orthopnea and lower
extremity edema. VS notable for BP >200s in ED. Labs notable for
elevated BNP. Echo with EF 45-50%, ECG stable, CXR with no
underlying infection but notable for pulmonary edema, telemetry
with no events. Etiology attributed to uncontrolled
hypertension. Patient was treated with labetolol and IV Lasix
20mg BID and then transitioned to amlodipine and 40mg PO
furosemide. After adding carvedilol, patients blood pressure
dropped to 110s, so it was held. Plan for discharge was
initially for just amlodipine for BP control, but after
discharge, plan was changed to carvedilol BID. Patient was
informed via voicemail and prescribed the medication
electronically. Negative orthostatics and ambulatory saturation
within normal limits.
# Uncontrolled HTN: Admitted with SBP 190-200s, please see above
for more detail. Discharged on amlodipine, carvedilol, 40mg
furosemide.
# Type I DM c/b ESRD s/p Kidney/Pancreas Transplant: Renal
ultrasound stable. Amylase, lipase and blood sugars were
monitored daily and stable.
- continued tacrolimus 3 mg BID with tacro levels
- continued prednisone 5 mg daily
- continued azathioprine 100 mg daily
- continued batrim for PJP prophylaxis.
# Chronic sinusitis: Secondary to NG tube placement in the past,
now with significant pain. CT scan c/w chronic sinusitis. ENT
consulted in patient and recommended nasal spray, fluticasone,
neti pot and Augmentin for three weeks. Plan is to follow up as
outpatient with ENT.
# CAD: Known CAD with prior cardiac catherization in ___ per
reports. No chest pains, palpitations, or ischemic changes seen.
Trops negative, EKG stable, echo stable.
- continued aspirin
# Obstructive Sleep Apnea: With PHTN on echo. Noncompliant with
cpap machine, counseled extensively on risks. Patient f/u with
PCP for further management.
***Transitional issues***
- amlodipine for hypertension. Please check blood pressure
regularly and follow up with providers regarding hypertension.
- no changes to immunosuppression regimen. Tacro trough on day
of discharge 5.0.
- will take Augmentin for 3 weeks (___). Follow up with ENT.
- will be discharged on 40 mg PO Lasix daily. Titrate as needed.
Patient will have labs checked in 3 days to monitor electrolytes
and Cr. Admission Cr .9, discharge Cr 1.1.
- Admit weight 210lb, discharge weight 205.8 lb.
FULL CODE </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F PMHx COPD metastatic lung adenoca (new dx during recent
hospitalization, d/cd ___, plan to start
carboplatin/pemetrexed tomorrow, on home 3L NC) p/w worsening
dyspnea. Pt reports that her breathing has been worse over the
past week and she has developed a productive cough, no
hemoptysis, for the past 3 days. She has had productive cough
off and on for the past several weeks History of COPD. States
she has not noticed wheezing or fever at home. NO fevers/sore
throat. no sick contacts. No lower extremity swelling or weight
gain. No chest pain or palpitations. Chest radiographs showed 1. Interval increase in interstitial markings in the left lung, suggestive of
progressing widespread disseminated metastases or possibly concurrent
infection.
2. Previously seen pneumonia in the right lung has improved in the interval,
but still substantial.
3. Small right pleural effusion. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or acute aortic pathology.
2. Significant interval worsening of widespread metastatic disease including
innumerable parenchymal nodules and lymphangitic carcinomatosis.
3. Widespread mediastinal, hilar, retrocrural, and paraesophageal
lymphadenopathy. Enlargement of gastrohepatic lymph node.
4. Osseous metastatic disease. The patient was diagnosed with Dyspnea, unspecified, Hypoxemia. At the time of discharge, the patient had primary: non small cell lung cancer; COPD exacerbation.
secondary: type 2 diabetes; hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ w/ PMHx COPD (on 3L oxygen at home) and newly
diagnosed metastatic lung adenocarcinoma who presents with
worsening dyspnea with CTA negative for PE/PNA, but showing
progression of disease.
#Worsening dyspnea/hypoxia: likely secondary to combination of
progression of disease and underlying COPD. CTA obtained which
did not reveal PNA or PE but demonstrated significant interval
worsening of widespread metastatic disease including innumerable
parenchymal nodules and lymphangitic carcinomatosis. She was
pre-treated with dexamethasone and received carboplatin and
pemetrexid on ___ without issues. Breathing noted to
improve significantly with steroids and duoneb therapy. Oxygen
was downtitrated to 3L NC.
#Metastatic lung adenocarcinoma: Recently diagnosed on
admission ___. Negative for EGFR. As mentioned above,
lymphangitic spread was noted to have worsened over short
interval and thus she was given carboplatin/pemetrexid on ___.
Patient with worsening pain from known bone mets. Fentanyl patch
was added to pain regimen and she was given zoledronic acid on
___. Further chemo as per new oncologist.
#Hyponatremia - Sodium persistently in low 130s on this
admission, requiring no intervention.
# Type II Diabetes: Initially had elevated blood sugars in
setting of high dose steroids managed with SSI. After finishing
steroids, blood sugar consistently < 200 and required no
insulin. Given risk of hypoglycemia, home glyburide held out of
concern for hypoglycemia to restart at PCP ___.
# Hypertension: SBP 150 on arrival. Continued amlodipine 5 mg
daily and lisinopril 10 mg daily. HCTZ 50 mg held.
TRANSITIONAL ISSUES:
- Next chemo to be determined by Dr. ___.
- Patient started on fentanyl patch for pain on this admission.
- Glyburide not restarted due to BS in the 100's with no insulin
requirements by discharge
- Will need ongoing assessment of pulmonary status and titration
of oxygen requirements.
- Code status: DNR/DNI, BiPAP is OK</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMHx metastatic pancreatic cancer (lung, liver mets) on
chemotherapy presenting s/p fall this morning when his feet felt
weak. He has baseline bilateral neuropathy in the lower
extremities which he feels contributed to the fall. No
lightheadedness, chest pain, shortness of breath, abd pain,
diarrhea, vomiting, or presyncopal component to the fall. Fell
directly onto his left side without HS or LOC. Since then he has
been having pain directly over his left hip. Denies numbness,
weakness, or tingling.
For the past ___ days the patient has been having intermittent
spiking fevers, worsening fatigue, malaise, and decreased PO
intake, and is undergoing infectious workup with outpatient
providers, without ___ source yet found. Of note, bilirubin was
noted to be rising suggestive potentially of the palliative
biliary stents as etiology. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. No evidence of mandible fracture.
2. Mild asymmetric widening of the left temporal mandibular joint space
relative to the right could suggest subluxation without evidence of frank
dislocation.
3. Missing right mandibular first molar.
4. Paranasal sinus disease as above with probable active sinusitis. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Overall similar alignment to the prior CT with multiple levels of mild
anterolisthesis and retrolisthesis as above.
2. No evidence of acute cervical spine fracture.
3. Severe multilevel degenerative changes as above with multiple levels of
severe narrowing of the central canal and and bilateral severe neural
foraminal narrowing, most pronounced at C5-6 and C6-7. These degenerative
changes predisposes the patient to cord injury in the setting of minimal
trauma. Consider MRI for further assessment of cord injury if there are
neurological symptoms referable to a specific level.
RECOMMENDATION(S): Consider MRI for further assessment of cord injury if
there are neurological symptoms referable to a specific level. CT torso showed 1. Mildly displaced and angulated acute left subcapital femoral neck
fracture.
2. Interval progression of known metastatic pancreatic cancer with growth in
the pancreatic head mass and loss of fat plane between the mass and the
adjacent proximal duodenum, persistent contact with multiple peripancreatic
vessels as above, growth in peripancreatic lymphadenopathy, increased size and
number of hepatic metastases, and a new left lower lobe pulmonary nodule,
likely a metastasis.
3. No specific CT evidence for intra-abdominal infection or abscess.
4. Unchanged position of the common bile duct stent with pneumobilia
confirming stent patency, although there is a small amount of debris within
the common bile duct stent.
5. No pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:45 ___, 60 minutes after discovery
of the findings. Radiology showed Nondisplaced left mid cervical femoral neck fracture. No dislocation. Radiology showed Left hip ORIF. Please see operative note for further details. The patient was diagnosed with Unsp intracapsular fracture of left femur, init for clos fx, Fall on same level, unspecified, initial encounter. The patient was treated with 1. Left hip ORIF. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
1. Left femoral neck fracture
2. Hypophosphatemia
SECONDARY DIAGNOSIS:
1. Metastatic Pancreatic Cancer
2. Hyponatremia
3. Dehydration. The patient was given written instructions concerning 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 metastatic pancreatic
cancer (known metastasis to the liver and lung, on palliative
chemotherapy), who presented after a fall at home. He was found
to have a L femoral head fracture, underwent fixation by
orthopedic surgery on ___ and was transferred to the
medicine service for management of subacute generalized
weakness. He was found to have dehydration, severe
hypophosphatemia, as well as progression of pancreatic cancer on
imaging.
.
>> ACTIVE ISSUES:
# Fall/Left Femoral Neck Fracture: Patient fell at home while
getting out of bed, thought to be ___ to generalized weakness
from underlying progressive metastatic pancreatic cancer,
nutritional deficiency, peripheral neuropathy ___ to
chemotherapy, as well as increased dehydration. patient was
found to have a left femoral neck fracture, underwent fixation
by Orthopedic Surgery on ___. On POD#1, patient was then
transferred to the medical service, and continued to have
physical therapy. Given underlying progressive metastatic
disease (see below), further discussions regarding optimizing
post-operative care was discussed with family. Patient continued
to work with physical therapy, ambulate, and continued on DVT
prophylaxis while in house. It was discussed with family to
continue to limit medications and discussed < 5 days further DVT
prophylaxis with anticoagulants as an outpatient for which
family then declined given not within goals of care, and
enrollment into hospice program. Patient was instructed to
continue to work with physical therapy, weight bearing as
tolerated and continue to ambulate maximally given underlying
risks. Hospice services to continue to work with patient, with
daily sterile dressing changes, and follow up within 2 weeks for
orthopedic surgery evaluation.
.
# Severe hypophosphatemia: Patient was noted to have a phosphate
of 1.2, that depleted again rapidly even after IV repletion.
This is likely explained by hypermetabolism from his pancreatic
cancer. He was started on a standing PO phosphate repletion
regimen and was ultimately discharged on phosphate supplement.
He was instructed to follow up closely with his oncologist's
office near home for frequent electrolyte monitoring and IV
repletion as needed.
# Metastatic Pancreatic Cancer (lung, liver), with progression:
Patient has been on palliative chemotherapy with
gemcitabine/abraxane regimen at ___ with Dr.
___. Unfortunately, interval imaging this admission does
suggest disease progression on this regimen. He also had an
elevated bilirubin on admission that downtrended; imaging
demonstrated patency of the CBD stent without need for stent
exchange (this was discussed with Dr. ___, but it was
believed that he likely had a mild obstruction that relieved
without need for antibiotics or intervention. After discussion
with Dr. ___ and with the patient and his wife, it was decided
to enroll the patient in Hospice Services. He will follow up
closely with Dr. ___ on ___ for further discussion of his
treatment goals and plans. He will likely need to come in to the
office for electrolyte checks and repletion and IV fluids on an
as-needed basis.
#Adrenal insufficiency: Patient has chronically been on 20mg
prednisone daily at home for symptom management related to his
cancer. He was noted to be persistently hyponatremic with high
urine sodium during this admission and given recent orthopedic
surgery he was started on stress dose prednisone at 60mg on
___. He was discharged with this dose and asked to follow up
with Dr. ___ on ___. He had no vital sign instability or
other signs of adrenal insufficiency.
# Hyponatremia: Pt with Na in the 120s, which did not improve
with fluid rescusitation. In the context of elevated urine Na of
172, the patient was started on stress dose prednisone (60mg)
for likely adrenal insufficiency as he is chronically on 20mg of
prednisone. His sodium then improved to 133 on the day of
discharge.
# Cervical Spine foraminal narrowing: Imaging indicates
extremely severe foraminal narrowing, pronounced at C5-C7, with
degenerative changes predisposing patient to cord injury in the
setting of minimal trauma. The patient remained asymptomatic
this admission.
# Hyperbilirubinemia: Mildly elevated 1.7 on arrival, which
normalized. Patient with low grade fevers at home and may have
had a transient CBD stent obstruction, but imaging demonstrated
___ stent patency without need for stent exchange. This was
discussed with Dr. ___.
# Thrombocytopenia and anemia: Likely ___ to chemotherapy and
marrow suppression. Remained stable.
#Sinus Tachycardia: Patient was tachycardic from 100s-130s this
admission, which did not correct with hydration. We spoke with
the patient's oncologist office, and the patient appeared to
have been tachycardic on several office visits prior to this
admission. It was believed that this was ___ metastatic
pancreatic cancer.
#?Sinusitis: Imaging concerning for sinusitis, with parnasal
sinus disease. Patient was asymptomatic and fevers resolved
during this admission without antibiotics, so likely not active.
#DVT prophylaxis: At time of discharge patient had 5 days
remaining for total course of DVT prophylaxis with home
injections of lovenox. This was discussed with the family, but
they ultimately decided that was not within their goals of care
and declined.
=====================================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Ms. ___ is a ___ female with ESRD due to
hypertensive nephropathy on HD via RUE AV graft (TuThSa), who
presents for evaluation due to report of bleeding from a new
ulceration on her AVG. Radiology showed Successful placement of a 23cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use. The patient was diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS, END STAGE RENAL DISEASE. The patient was treated with ___ Revision and thrombectomy of RUE AVG. At the time of discharge, the patient had ESRD. The patient was given written instructions concerning 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 ___, she underwent revision and thrombectomy of right
upper extremity arteriovenous graft for bleeding/ulceration of
AVG. Surgeon was Dr. ___. Please refer to operative
note for details. PTFE graft was placed, and some clot was
removed prior to assuring hemostasis, and at the end of the case
there was an excellent thrill.
She did receive two units of FFP to reverse the INR of 2.6
Patient was stable at the end of the case and transferred to
PACU.
Patient had received a dose of Vancomycin, based on the open
area of the graft prior to excision, however during surgical
inspection it was not felt that this was an infection in the
graft and no antibiotics were continued.
Due to the extensive nature of the revision, it was decided the
graft should be rested and healed, and a tunneled line placed
for hemodialysis in the meantime.
Patient receives dialysis two times a week, and there was not an
urgent indication for the line placement. The line was finally
placed on ___. A potassium of 5,5 on POD 1 was controlled
using Lasix and a dose of kayexalate with good results.
Low dose Coumadin was continued as patient has been
anticoagulated for graft patency.
After the line was placed the patient underwent routine
hemodialysis without difficulty.
The revised access has a bruit and thrill, and the suture line
was clean dry and intact upon discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man with COPD, orthostatic hypotension, and recent
admission for sepsis likely from osteomyelitis (vs HCAP), who
was referred to the ED on ___ for removal of his PICC line. In
the ambulance, pt was found to be altered, hypoxemic to the ___,
and hypotensive. On arrival the ED, pt was arousable only by
sternal rub, with blood pressures in the 70's/40's. He
reportedly was grimacing with palpation over his abdomen.
However after 2L NS, he became verbal and responsive, without
any localizing symptoms. Pt has dementia at baseline, but is
normally able to answer yes/no questions.
He was discharged from ___ on ___ after a long
hospitalization for sepsis, likely due to osteomyelitis of his R
great toe. During that admission, vascular and podiatry followed
closely, and the foot wound was debrided at the bedside. He was
not deemed a surgical candidate for aggressive amputation given
his multiple co-morbidities and overall frailty. His course was
also complicated by HCAP, for which he completed a 7-day course
of antibiotics. Of note, he has HCPs on file which were not
reachable (has been a problem in the past as well), and so legal
guardianship was obtained. He was discharged to ___ to complete
a prolonged course of vancomycin, through ___.
In the ED, initial vitals were: 97.7 65 74/43 30 100% RA
Exam notable for: apparent abdominal tenderness, interactive
and answering questions after 2L NS
Labs notable for: Hgb 6.2, trop 0.06 -> 0.04
Imaging notable for: head CT without acute process, CT
abd/pelvis without acute process (circumfrential bladder wall
thickening of unclear significance)
Patient was given: 2L NS, 1g vanco (12:49), 2g cefepime x2
(12:07 and 22:45)
Vitals prior to transfer: 97.6 70 147/80 18 100% RA
On the floor, pt is conversant and has no complaints, including
no abdominal pain, no leg pain, and no shortness of breath. He
is oriented to being in the hospital, and understands that he
has a severe infection in his foot. CHEST (AP AND LAT) showed Interval removal of the left PICC. Improvement in the right basilar patchy
opacity likely reflective of chronic aspiration with resolution of previously
noted small right pleural effusion. CT HEAD W/O CONTRAST showed 1. No evidence of acute intracranial process.
2. Chronic left frontal lobe encephalomalacia.
3. Basilar invagination of the odontoid process with significant narrowing of
the foramen magnum, unchanged and likely chronic, however a cervical spine MRI
is recommended, if not already obtained, as suggested on the prior CT.
RECOMMENDATION(S): Basilar invagination of the odontoid process with
significant narrowing of the foramen magnum, unchanged and likely chronic,
however a cervical spine MRI is recommended, if not already obtained, as
suggested on the prior CT. CT abdomen and pelvis with IV contrast. showed 1. Circumferential bladder wall thickening, which should correlated with
urinalysis for signs of urinary tract infection.
2. Resolution of the right pleural effusion, with persistent but improved
ill-defined right basilar opacification, likely due to chronic aspiration.
3. Cholelithiasis without cholecystitis.
4. Aneurysmal dilatation of the ascending aorta measuring up to 4.8 cm.
5. Infrarenal abdominal aortic aneurysm measuring up to 3.7 cm with a chronic
dissection flap extending into the proximal right common iliac artery. Radiology showed There has been placement of a left-sided PICC line with the distal lead tip in
the distal SVC. Heart size is enlarged but stable. Patient is somewhat
rotated on the study. No focal consolidation or overt pulmonary edema or
pleural effusions are seen. There are no pneumothoraces. The patient was diagnosed with Hypotension, unspecified. At the time of discharge, the patient had Primary: Osteomyelitis
Secondary: Anemia of chronic disease, atrial fibrillation,
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>___ man with COPD, orthostatic hypotension, and recent
admission for sepsis likely from osteomyelitis (vs HCAP), who
was referred to the ED on ___ for removal of his PICC line and
found to be hypotensive with AMS likely due to hypovolemia.
Blood pressure improved following fluid administration. Patient
not able to tolerate PICC (pulled out twice), so he was
transition to oral Linezolid for osteomyelitis of R foot.
Patient was transitioned to hospice given patient's age, altered
mental status, impaired functional status and R foot
osteomyelitis without definitive treatment. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of coronary artery disease presents to the
emergency room with progressive L shoulder pain after recent ICU
stay at ___ for pancreatitis and alcohol withdrawal. CHEST (PA AND LAT) showed Right lower lobe opacification concerning for pneumonia, with small right
pleural effusion. Radiology showed Status post left total shoulder arthroplasty without hardware complications or
alignment change. No acute fracture or dislocation. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had PRIMARY
Non-ST Elevated MI
L shoulder pain
Coronary Artery Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with CAD and recent admission at ___ for alcoholic
pancreatitis presents with progressive L shoulder pain and found
to have an elevated troponin concerning for an NSTEMI.
#L Shoulder Pain
#Elevated troponin:
Patient present with acute on chronic L shoulder pain after
recent ICU hospitalization requiring intubation for pancreatitis
and pneumonia. The shoulder pain is likely MSK in etiology as he
said it is an exacerbation of his pre-existing pain. He states
that the pain started to get worse towards the end of his recent
hospitalization due to lying in bed while intubated. He had no
ECG changes though his troponin was noted to be elevated to
0.47. His CK-MB was flat, therefore this likely represents a
resolving Type II NSTEMI from his recent critical illness rather
than a true NSTEMI. He was started on a heparin gtt which was
quickly discontinued and he was begun on aspirin and
atorvastatin. Interestingly, the patient has had a stress test
from ___ which demonstrated an area consistent with a prior MI
without an area of inducible ischemia. This therefore suggests
pre-existing CAD. Reassuringly, a recent TTE performed during
his last hospitalization showed no WMA. Although due to
non-compliance with prior medications, the patient would not be
a good stent candidate so angiography was differed. He underwent
a PMIBI to assess if he had CAD to require ongoing medical
optimization. PMIBI showed Reversible perfusion defects
involving anterior septal wall apical area with associated wall
motion defect He was continued on his home metoprolol and was
initiated on aspirin and atorvastatin. The Cardiovascular
institute was contacted to arrange a follow up appointment with
the patient within the next month.
#History of Pancreatitis: Patient presented to ___ with
alcoholic
pancreatitis after binging on alcohol after his benzos were
d/c'd
by his outside provider. Currently without abdominal pain.
Lipase
wnl.
#History of EtOH Abuse: Prior history of heavy use, quit ___
years
ago, then restarted as above. Last drink was prior to recent CHA
admission. Out of the window for withdrawal.
-started on folate, thiamine, MVI
#Anxiety: Patient appears anxious on exam with tangential
thought
process. Was previously on multiple medications including
buspirone, gabapentin and trazadone, but these were discontinued
during his last hospitalization. Patient was not started on any
new psychiatric medications. Will defer initiation of
anxiolytics/antidepressants to PCP.
#Anemia:
#History of Polycythemia ___:
Prior history of PV thought to be from cigarette smoking due to
negative mutation testing. Previously treated with phlebotomy.
Currently anemia is below baseline, but is stable from recent
hospitalization without evidence of bleeding. No abdominal pain
to suggest hemorrhagic pancreatitis.
#Thrombocytosis: Newly elevated from prior ___ labs in ___.
Was elevated to 400s at CHA, currently 550. Likely reactive due
to stress of recent critical illness. However, given h/o PV, may
suggest underlying marrow disease.
#Exposure to TB: Patient's PCP notified us that he was notified
that the patient was exposed to TB during a recent
hospitalization at ___. We became aware of this
information as the patient was being prepared for discharge. He
was having no symptoms of active TB. Therefore, we will defer TB
testing to his PCP follow up appointment.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ was recently discharged to rehab following admission
(___) for a bile duct transection sustained during
laparoscopic cholecystectomy at an OSH. On ___, she underwent R
PTC placement. Post-procedure, she developed a hemodynamically
significant bleed that required exploratory laparotomy & washout
on ___. She was discharged with the PTC/biliary drain and 2
PTCs.
She returns to ED w/ band-like central abd pain since yesterday
afternoon. She reports it worsened last night. She is unable
to
say whether it is better/worse/the same right now. She denies
fevers, chills, and nausea; however, she reports night sweats
overnight. She vomited (undigested food, no blood, no bile) 4
days ago and reports she has not eaten anything since then
because she doesn't like the food at rehab. She says she drinks
water, but is unable to quantify the amount. No diarrhea; she
had 2 normal BMs yesterday. Radiology showed Small right pleural effusion with bibasilar atelectasis. Elevation of the
right hemidiaphragm is due to the presence of a right subcapsular complex
hepatic fluid collection as seen on CT. Radiology showed Technically successful ultrasound-guided drainage of right upper quadrant
subcapsular hepatic collection with 2.1 liters of cloudy yellow-green fluid
withdrawn. A small sample was sent for analysis. No immediate post-procedural
complications. Radiology showed Placement of right PICC line with the tip projecting into the
right atrium. For approximate placement at the cavoatrial junction, this
should be pulled back by no less than 3 cm.
These findings were relayed to the venous access team, at 9:48 a.m. on the day
of the examination. Radiology showed 1. Interval placement of a nasogastric tube with its tip projecting over the
expected location of the stomach. The right subclavian PICC line is unchanged
in position with its tip in the mid SVC. Lung volumes are lower and there is
a moderate-sized right pleural effusion which may have somewhat increased in
size since ___. Left lung grossly clear given interval reduction in
lung volumes. Overall, cardiac and mediastinal contours are likely stable.
No pneumothorax. Radiology showed Significant interval decrease in size of the subcapsular biloma status post
percutaneous drainage catheter placement. There does remain a persistent
collection though, which would benefit from continued percutaneous drainage.
Stable organizing hematoma around multiple proximal loops of jejunum.
Worsening right-sided pleural effusion and right lower lobe atelectasis. Radiology showed Successeful placement of a 10 ___ external biliary drainage
catheter on the left. Successful exchange of a right biloma drain with a new
10 ___ drainage catheter. The patient was diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS. The patient was treated with ___: Technically successful ultrasound-guided drainage of
right upper quadrant subcapsular hepatic collection with 2.1
liters of cloudy yellow-green fluid withdrawn. A small sample
was sent for analysis. No immediate post-procedural
complications.
.
___: Successeful placement of a 10 ___ external biliary
drainage catheter on the left. Successful exchange of a right
biloma drain with a new 10 ___ drainage catheter.. At the time of discharge, the patient had 1. Hepatic subcapsular biloma
2. Biliary sepsis
3. Failure to thrive. The patient was given written instructions concerning 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 well know for Dr. ___ was admitted to the
___ Surgical Service for evaluation and treatment of new
subcapsular fluid collection. Patient was admitted ___ the ICU
secondary for hypotension requiring pressors support and sepsis.
She was started on IV Vancomycin and Zosyn empirically.
Patient's INR was 2.3 on admission and she received 3 units of
FFP on HD # 1. She underwent ultrasound-guided drainage of
right upper quadrant subcapsular hepatic collection and fluid
was sent for cultures. On HD 3, patient's Levophed was weaned
off. On HD # 4, patient was transferred on the floor on regular
diet, on IV fluid and antibiotics, with Foley, biliary drain and
2 old JP drains. The patient was hemodynamically stable.
Neuro: The patient received PO Oxycodone with good effect and
adequate pain control.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: The patient was advanced to regular diet, her albumin was
2.0 and NJ tube was placed on HD # 5. Nutrition was called for
consult and tubefeed was started. Calorie count demonstrated
poor oral intake and tubefeed will be continued post discharge.
Patient's bile was refeeded back to the patient via NJ tube from
left sided drain catheter. On HD # 6 patient lost her biliary
drain and ___ was called to replace the drain. ___ requested new
CT and abdominal CT was obtained on HD 7. CT demonstrated
significant interval decrease ___ size of the subcapsular biloma,
with still large residual collection. On HD 8, patient underwent
placement of right and left hepatic drains. Old JPs were removed
on HD 9 as output was low.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Patient was started on
IV Zosyn/Vanc on admission. Her bile cultures grew Staph aureus
coag positive and Enterococcus. She underwent treatment with IV
Zosyn/Vancomycin for 8 days. Prior discharge patient's
antibiotics were changed to PO Augmentin. She still to have
mildly elevated prior discharge.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; 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 tubefeed
at goal, 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: ___ with hx of HTN, DM, HLD, dCHF, Afib not on warfarin,
Dementia who presents from her nursing home s/p fall found to
have R hip fracture. Per nursing home reports, patient fell ~1
week ago and xray was equivocal for fracture. She was then
monitored for a week but fell again on day of admission and had
signficiant R hip pain on external rotation per report therefore
she was transferred to ___ for further eval. Radiology showed Comminuted avulsion fracture of the right greater trochanter again seen, in
keeping with findings on the ___ CT scan.
In addition, curvilinear marrow edema traversing the intertrochanteric portion
of the right femur suggests the presence of an occult, more extensive
intertrochanteric fracture component than suggested on the recent CT scan.
Surrounding edema, fluid and hemorrhage noted.
No other fractures detected in the pelvic girdle.
15.6 mm rounded high T2 focus left pelvis raises the possibility of a left
adnexal cystic structure in this patient status post prior hysterectomy.
Clinical correlation and if indicated, followup assessment assessment by
ultrasound in ___ months to assess for stability, could be considered. Chest radiograph showed Mild interstitial pulmonary edema, improved from ___. HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R. showed Images from the operating suite show placement of a fixation device about
previous fracture of the proximal femur. Further information can be gathered
from the operative report. The patient was diagnosed with Disp fx of greater trochanter of right femur, init, Fall on same level, unspecified, initial encounter, Unspecified atrial fibrillation, Long term (current) use of anticoagulants, Unspecified dementia without behavioral disturbance. The patient was treated with ___ - Intrameduallary nail placement (short trochanteric
fixation nail), right hip. At the time of discharge, the patient had Primary Diagnoses
==================
Right intertrochanteric hip fracture
Leukocytosis
Urinary Tract Infection
Hypoxia
Delirium
Acute Kidney Injury
Secondary Diagnoses
==================
Atrial fibrillation
Dementia
Congestive heart failure
Gastroesophageal reflux disease
Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of HTN, DM, HLD, dCHF, Afib not on Warfarin,
Dementia who presents from her nursing home s/p fall found to
have R hip fracture.
#Mechanical fall complicated by comminuted avulsion fracture of
R greater trochanter: The patient presented from nursing
facility after two falls at her rehab facility. CT head negative
for acute intracranial process, CT C Spine negative for acute
fracture or pre-vertebral soft tissue swelling. Right hip XR and
subsequent CT of right lower extremity revealed minimally
displaced comminuted fracture of the right greater trochanter.
Trauma surgery evaluated the patient in the ED and no other
injuries were identified. Orthopedic surgery was consulted who
recommended MRI of the right hip or further evaluation of the
fracture. This revealed a comminuted avulsion fracture of the
right greater trochanter. The patient underwent uncomplicated
intramedullary nailing of the right hip with orthopedics on
___. Post operatively the patient was continued on daily SC
lovenox, and pain was well controlled with oral pain
medications. The patient was tolerating an oral diet well. The
patient as evaluated by ___ who recommended discharge to rehab.
# Leukocytosis:
The patient developed a mild leukocytosis on POD #1. that was
likely a stress reaction. The patient had been previously
treated with IV ceftriaxone for a susceptible E coli UTI. There
were no pulmonary symptoms or CXR evidence of pulmonary
infection. The leukocytosis resolved on POD #2.
#UTI:
Patient presented with + UA and UCx growing E coli, in the
setting of multiple recent falls and leukocytosis. Unclear if
symptomatic on exam though concerning for contribution to fall
and delirium as below. Patient received Ceftriaxone in ED
without reported issue, and daughter unaware of ___ allergy
reported. The patient was successfully treated with ceftriaxone
x 3 days for an uncomplicated UTI.
# Hypoxia:
The patient developed acute hypoxia on ___ with an SpO2 of 80%
of unclear etiology. EKG was non ischemic, and troponins were
negative. There was no evidence of significant volume overload
on exam or CXR. There was no tachycardia to sugest PE, and the
patient had been maintained on DVT prophylaxis. There was no
evidence of focal infiltrate on CXR. This was thought to have
been secondary to microaspiration. This resolved rapidly and did
not recur.
#Delirium:
The patient developed worsening delirium on HD #2 likely
secondary to infection, fracture, and hospital environment
overlying underlying dementia. There was concern that the micro
aspiration event as above may bave been the trigger given the
acute changes. The patient had no further episodes of acute
agitation.
# ___:
The patient developed ___ on HD#3 thought to be pre renal
secondary to her NPO status pre operatively and concuren
diuretic use for CHF. The ___ resolved with IV fluids and
holding home furosemide. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ ia ___ ___ woman with hypertension
as well as past history of H. pylori gastritis presenting with
abdominal pain.
Per review of OMR, patient with history of chronic GI
complaints; per ___ note, PCP ___ that Ms ___ had
been experiencing intermittent nausea, belching, bloating, and
occasional epigastric discomfort. At that time symptoms were
thought secondary to gastritis and GERD. Work-up in the past,
including an EGD in ___ showed evidence of gastritis and
H. pylori. She was placed on omeprazole with some improvement in
symptoms.
Patient was in OSH when developed right sided abdominal pain on
___. Pain, described as sharp, is poorly localized but most
severe in RUQ'epigastrium with occasional radiation to the back.
No clear trigger to pain onset. No correlation with eating,
urinating, defectating. Moving aggravates pain. Laying still
seems to alleviate pain. No associated back pain, No associated
GYN symptoms with last menses ___. Denies melena, BRPBR.
Pain prompted presentation to ___ over the weekend with largely
negative work-up. CT A/P: non cont> few small calc in liver.
RUQ: NL study, no GB stones. Per patient returned home and
developed worsening pain as well as vomiting and represented to
___.
In the ___ ED, 97.5 63 121/54 16 100% RA. Labs unremarkable.
UA negative. RUQ: Mildly distended gallbladder, sludge,
equivocal positive sonographic ___ sign. No pericholecystic
fluid or gallbladder wall thickening. "In the correct clinical
setting this may represent acute cholecystitis". CT abdomen
pelvis also performed without findings to explain the patient's
abdominal pain. Decision made to admit to medicine for ?
cholecystitis and likely HIDA
On arrival to the floor, patient reports pain is "better" and
currently a ___. No episodes of vomiting today but notes ___
NBNB episodes yesterday. Denies recent NSAID use; consumption of
alcohol. Drinks one caffenated beverage/day. Radiology showed No acute cardiopulmonary process. Radiology showed Mildly distended gallbladder which contains sludge. Positive
sonographic ___ sign. No gallbladder wall thickening or pericholecystic
fluid. Given above findings, acute cholecystitis is not excluded in the
appropriate clinical setting. Consider further evaluation with HIDA if
clinically appropriate. Radiology showed No CT findings to explain the patient's abdominal pain. The patient was diagnosed with ABDOMINAL PAIN RUQ, HYPERTENSION NOS. At the time of discharge, the patient had Primary Diagnosis:
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>___ female with HTN and h/o H.pylori who p/w acute onset of RUQ
pain and nausea/vomiting.
ACTIVE ISSUES
# Abdominal Pain. Unclear etiology; differential included
gallbladder pathology or hepatobiliary pathology given location,
however, LFTs, bili, amylase, electrolytes, WBC all wnl and CT
abd without findings. Had HIDA scan which was negative for
cholecysitis. CXR was normal indicating no possibility of lower
lobe pneumonia causing the pain. Had constipation/gas over last
few days prior to admission. Pain management overnight; patient
felt much improved the following day and nausea resolved. Diet
was advanced and this was tolerated well. Patient has
outpatient colonoscopy scheduled and GI was contacted to
recommend adding endoscopy given h/o gastritis.
CHRONIC ISSUES
# HTN. Normotensive, home HCTZ continued.
TRANSITIONAL ISSUES
-Patient recommended to have EGD in addition to colonoscopy
scheduled for ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presents with 2-week history of abdominal pain, originally
across upper abdomen, now predominantly band-like pain in lower
abdomen presented to ___ on ___. Sought medical attention
twice at urgent care clinic and diagnosed with constipation.
Presented to PCP earlier
today and referred to ED for a CT scan given ongoing pain, which
showed perforated appendicitis with abscess formation. Patient
denies fevers, chills, nausea, vomiting, melena, hematochezia.
Had constipation but now diarrhea after having taken stool
softeners. Currently feels weak and dehydrated. Had colonoscopy
years ago with unremarkable results per patient. CT INTERVENTIONAL PROCEDURE. showed 1. CT-guided placement of a ___ pigtail catheter into the presacral
abscess. A sample was sent for microbiology evaluation.
2. Ultrasound-guided placement of a 10 ___ pigtail catheter into the right
lower quadrant abscess. A sample was sent for microbiology evaluation.
3. Hyperdensity within the right lower quadrant collection is likely an
appendicolith.
RECOMMENDATION(S): Followup microbiology.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephoneon ___ at 2:30 ___, upon procedure
completion. Radiology showed 1. Complete decompression of previously seen right lower quadrant and
presacral fluid collections since prior study. Right lower quadrant and
presacral drainage catheters are again in appropriate position. R ght lower
quadrant mesenteric fat stranding likely inflammatory changes.
2. Small 2.7 x 2.4 cm fluid collection likely an abscess in the right mid
abdomen which appears smaller from comparison study.
3. Radiopacity within the right lower quadrant likely representing fecalith or
appendicolith. The patient was diagnosed with Right lower quadrant pain. The patient was treated with Interventional drainage of abscess and placement of drain. At the time of discharge, the patient had ruptured appendicitis complicated by 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>___ with 2-week history of abdominal pain due to perforated
appendicitis with subsequent abscess formation and significant
leukocytosis (though also component of hemoconcentration) who
presented to ___ on ___. Patient was admitted to ___
surgery service for IV antibiotics (zosyn), IV fluids, pain
control and ___ consult for drainage. CT scan done at this time
showed loculated fluid collection in the pelvis concerning for
large periappendiceal abscess. In particular, 2 large pockets
were present (one within right hemipelvis adjacent to the cecum
and one in the deep pelvis). ___ was consulted on ___ and
patient underwent drainage of fluid collections with subsequent
placement of ___ pigtail ___. Two ___ pigtail
catheters were placed, one in the right lower quadrant and one
placed presacral region. After undergoing ___ drainage, patient
was monitored with serial exams, continued antibiotics and seen
by social work and case management. Her diet was advanced and
drain output decreased. On ___, a repeat CT and drain study
was ordered to assess the patency of drains and remnant fluid.
Interval decrease in size of the fluid collections. The drains
were left in place and the patient was then transitioned to PO
antibiotics (Augmentin) for a 14 day course. The patient
continued to do well and was discharged home with ___ services
and close family supervision on ___ in good condition.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ man with HFrEF (EF 40%), LBBB, HTN,
HLD who presents with dyspnea, progressive leg swelling, and
weight gain consistent with acute on chronic heart failure
exacerbation. CHEST (PA AND LAT) showed No significant interval change. Chronic blunting of the right lateral
costophrenic angle lead, likely due to component of pleural thickening and
effusion. No definite superimposed acute process. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the imaged portion of the right or
left lower extremity veins. Bilateral posterior tibial and peroneal veins not
well assessed due to edema, similar in appearance to prior. CT CHEST W/O CONTRAST showed 1. No acute cardiopulmonary process.
2. Moderate atherosclerotic calcifications of the thoracic aorta and marked
coronary artery disease.
3. Trace bilateral pleural effusions. Lower lobe bronchiectasis.
4. 1 cm hypodense nodule in the right thyroid lobe.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150. The patient was diagnosed with Heart failure, unspecified. The patient was treated with CORONARY ANGIOGRAPHY (___). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with HF recovered EF (EF 40%), LBBB, HTN, HLD
who presents with dyspnea, progressive leg swelling, and weight
gain consistent with acute on chronic heart failure exacerbation
with associated elevated cardiac enzymes. Warm and wet on exam
s/p diuresis. Repeat TTE with preserved EF, now s/p RHC/LHC with
low filling pressures but multivessel disease pending csurg
eval.
# Acute on Chronic Heart Failure Exacerbation
# HFpEF:
Patient with signs of volume overload and elevated proBNP on
admission. Concern for ischemia as provoking factor given
elevated cardiac enzymes, though no acute ischemic changes noted
on EKG and recovered EF on TTE with no FWMA. Cardiac involvement
from his known Inclusion Body Myositis is unlikely. Coronary
angio with multivessel CAD. The patient was diuresed, seemingly
euvolemic on discharge. Cardiac surgery was consulted and did
not feel he was a surgical candidate given his frailty. He was
actively diuresed and then transitioned back to his torsemide 40
mg qd, metop XL 25 mg qd was started, he was continued on his
spironolactone 25 mg BID. Lisinopril was not added due to
orthostatic hypotension.
# NSTEMI:
# Multivessel CAD:
Suspected etiology of CHF exacerbation. Trop and MB rose on
admission and peaked to 1.19. Continued heparin gtt for 48
hours. Coronary angio ___ showed multivessel disease not
amenable to PCI. Cardiac surgery consulted for CABG evaluation
and patient initiated on workup, however, he was ultimately
declined for surgery. Complex PCI is deferred at this time given
his frailty and lack of continued ischemic symptoms and
preserved EF. Discussion will need to be continued with
interventional cardiology as an outpatient. He was started on
atorvastatin 80 mg qd in addition to metoprolol 25 mg XL qd. His
aspirin 81 mg qd was continued.
# Diarrhea:
Multiple loose stools iso neutrophilic predominance and elevated
white count. White count improving and C diff negative. Improved
prior to discharge.
CHRONIC CONDITIONS
=====================
# Normocytic anemia:
Hgb at recent baseline ___. Last colonoscopy ___ with
fragments of adenoma on biopsy, was supposed to have repeat
scope in ___ years. Iron studies unremarkable. Likely anemia of
chronic disease iso myositis. Should have scheduled repeat
outpatient colonoscopy.
# HTN:
Recently amlodipine and metop succ discontinued. Continued
spironolactone and re-added metoprolol. His orthostatic
hypotension prevented starting Lisinopril.
# Inclusion Body Myositis:
Followed at ___. Not on any therapy other than NSAIDs as disease
traditionally poorly responsive to immunosuppresants. No known
history of cardiac involvement. Deferred sending
rheumatologic/inflammatory markers as these are commonly not
elevated in ___. Held NSAIDS during admission and on discharge
given volume overload. Should follow w/ Dr. ___ in
___ clinic. CK was elevated on admission (~200-300),
likely secondary to NSTEMI, started atorvastatin and several
days later CK normalized.
# Depression:
# Insomnia:
Continue home citalopram and zolpidem.
# Gout:
Continued home allopurinol.
TRANSITIONAL ISSUES
==================
-His predicted LOS at rehab will be less than 30 days.
-He will follow-up with his PCP, who is also his cardiologist.
He will also follow-up with his neurologist as an outpatient.
-DISCHARGE WEIGHT: 122 kg
-DIURETIC: Torsemide 40 mg qd (continued home dose)
-NEW MEDICATIONS: Atorvastatin 80 mg qd, metoprolol succinate 25
mg qd
-STOPPED MEDICATIONS: Ibuprofen (please discuss restarting as an
outpatient)
-DISCHARGE CR: 1.1
-DISCHARGE HGB: 11
-Please recheck a chem10 1 week upon discharge to evaluate
electrolytes and kidney function. Consider checking a CK 1 week
after discharge. He was started on a statin with a normal CK
after 4 days of being on a statin.
-Colonoscopy: He had adenoma in the past which was not
completely excised. He will need colonoscopy as an outpatient to
evaluate.
#CODE: full with limited trial
#CONTACT: HCP: ___ (wife) ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is an ___ left handed man with a history of hypertension,
BPH, dementia of unkwown variety, history of longstanding
tobacco abuse and recent hospitalization for a drug resistant
UTI who presents to the ED as a transfer
from an OSH where a subacute stroke was discovered on CT scan. Radiology showed 1. Unchanged cortical foci of low attenuation, consistent with
acute infarction in the right frontal and anterior parietal lobes, right
middle cerebral artery territory. No evidence of hemorrhagic transformation.
2. Periventricular white matter changes suggest chronic small vessel ischemic
disease. Radiology showed 1. Multiple cortical foci of acute infarction in the right frontal and
anterior parietal lobes, in the right middle cerebral artery territory. No
significant mass effect at this time. No evidence of hemorrhagic
transformation.
2. Two punctate chronic microhemorrhages in the paramedian right frontal
lobe, which could be related to amyloid angiopathy, hypertension, or less
likely a cavernous malformation.
3. Unremarkable neck MRA.
4. The superior and inferior division branches of the right middle cerebral
artery are smaller in caliber compared to the left. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. At the time of discharge, the patient had Primary Diagnosis: right frontal and parietal ischemic stroke,
dementia, hypertension, urinary tract infection, hypoactive
delirium
Secondary Diagnosis: benign hypertrophic prostate. The patient was given written instructions concerning 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:
[] Complete course of IV meropenem for urinary tract infection
[] f/u as urology as outpatient for further management of his
recurrent urinary tract infection/BPH
** Stroke Core Measure **
[ AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack ]
1. Dysphagia screening before any PO intake? (x) Yes - () 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 = 89) - () No
5. Intensive statin therapy administered? (for LDL > 100) (x)
Yes - () No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
___ left handed man with PMH of HTN, BPH, dementia and recent
hospitalization for MDR UTI who p/w new difficulty speaking and
L sided weakness, found to have posterior right frontal and
parietal infarct. His examination is limited by his inattention
and motor left hemineglect, but shows nonfluent aphasia with
anomia and left/right confusion.
#NEURO: patient with acute posterior right frontal and parietal
infarct, appears embolic given the scattered lesions. He was
started on aspirin 325mg daily. BCx and TTE were done to rule
out endocarditis given recent infection and did not show any
evidence of endocarditis. He passed bedside dysphagia screen and
was started on pureed diet and nectar thick liquid. MRI showed
the right frontal and parietal infact. His hospitalization was
complicated by fluctuating awakefulness during the
hospitalization, and EEG was done which did not show any
seizures but there was one event questionable for seizure. He
was started on Keppra for this event. His labs showed LDL of 89,
so his home simvastatin was continued. His A1C was 6.2% and
patient did not require insulin during this hospitalization. He
was seen by ___ who recommended discharge to rehab.
Patient did have periods of decreased arousal and poor PO
intake, NG tube placement was attempted but patient resisted the
attempts. Spoke with the daughter ___ who stated that
patient frequently refuses medications and food when he is not
feeling well, and that she did not want him to undergo
procedures he did not want such as NG tube placement or PEG
placement.
#CV: no known cardiac history but patient with multiple risk
factors, also with mild troponinemia on admission, which was
likely due to demand ischemia with elevated BP on admission
given low CK and flat MB in setting of kidney disease. His
troponin decreased on its own. His blood pressure was managed
with his home metoprolol after 2 days. He was continued on home
simvastatin for hypercholesterolemia.
#ENDO: His TSH was 1.8 and his A1C was 6.2%
#RENAL: creatinine 1.5 on admission and remained stable
throughout this hospitalization. Unclear baseline, though
reportedly had acute kidney injury in the setting of recent MDR
E coli UTI. His medications were renally dosed.
#ID: recent MDR E Coli UTI per family requiring IV abx at home
(was on imipenem). No WBC or fevers to suggest ongoing
infection. UA without evidence of UTI on admission, but patient
developed malodorous urine and repeat UA showed moderate leuk
esterase and increased WBC. He was started on meropenem and his
UCx showed E Coli that was sensitive to meropenem and
ciprofloxacin. Given his age, IV meropenem was continued. TTE
was also done to rule out endocarditis as the cause of stroke,
and it was negative.
#GI: dysphagia screen was done and patient was cleared for puree
diet and nectar thick liquid. Patient occasionally had poor PO
intake in setting of decreased level of arousal.
#GU: continued on flomax for BPH. Will require outpatient
urology follow up appointment for recurrent urinary tract
infection.
#FEN: heart healthy diet after passing bedside s/s
#PPx: heparin SQ TID, bowel regimen
#CODE: DNR/DNI </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ year old ___ woman who comes in with LOC
and a MVC who is 5 weeks pregnant with a history of anxiety,
depression, ADHD, OCD, migraine headaches, h/o gastric bypass
___ and subsequent 130 lb wt loss. We were consulted to
evaluate
___ weeks of episodes of bizarre visual symptoms,
lightheadedness, syncope. MRV HEAD W/O CONTRAST showed No evidence for dural venous sinus thrombosis. Arachnoid granulations
invaginating into the left transverse sinus versus fenestrations, which may be
better defined with conventional routine brain MRI, if clinically warranted. EARLY OB US <14WEEKS showed 1. Single live intrauterine pregnancy with gestational age of 6 weeks 3 days
correlating with estimated due date of ___
2. 7 mm echogenic focus within the right ovary likely representing an ovarian
dermoid. Recommend followup ultrasound after pregnancy.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 13:20 AM MR HEAD W/O CONTRAST showed 1. No increased signal on T1 or FLAIR and no evidence of negative
susceptibility in the medial left transverse sinus to suggest thrombosis. The
finding seen on the MRV is likely due to slow flow.
2. The tiny filling defect in the lateral left transverse sinus is below the
resolution of this exam. No T2 hyperintense signal to suggest an arachnoid
granulation. If there is still concern for a small dural venous thrombosis,
consider CTV The patient was diagnosed with OTH CURR COND-ANTEPARTUM, MYALGIA AND MYOSITIS NOS, MV COLLISION NOS-DRIVER. At the time of discharge, the patient had SYNCOPE
MOTOR VEHICLE ACCIDENT
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># Neuro: Ms. ___ was admitted and had a MRI of the brain that
was normal. She had an EEG that was also normal. She did not
have any further episodes while admitted. She had CT scans of
the spine that were unremarkable. She was given oxycodone for
pain management due to musculoskeletal pain ___ her MVA.
#CV: She had an echocardiogram and a EKG of her heart that were
both unremarkable. due to concern that her symptoms are not
epileptic and may be cardiac in etiology, we have ordered a
holter monitor to be done as an outpatient. She will be
discharged with the instructions to go to cardiology department
to be fitted with the holter.
# OB/GYN: She was seen by obgyn who stated that it was fine to
continue the diazepam. She had a pelvic US that showed an
intrauterine fetus. She stated her desire to terminate the
pregnancy and has an outpatient appointment scheduled with
obgyn. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with H/O CAD s/p CABG x 3v in ___, S/P permanent pacemaker
for paroxysmal atrial fibrillation with sick sinus syndrome,
with recent admission for chest pain with recent
dipyridamole-MIBI showing no reversible defects (but chest
discomfort with vasodilator administration), who presents with
several day history of jaw and left arm pain (which is her
anginal equivalent), chest pain, and dyspnea. Chest radiograph showed No acute pulmonary process identified. Stable elevation of the right
hemidiaphragm. Stable atelectasis/scarring at both bases. Radiology showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild bibasal linear atelectasis.
3. Multiple hepatic cysts versus biliary hamartomas. The patient was diagnosed with Other chest pain. The patient was treated with Cardiac catheterization ___. At the time of discharge, the patient had - Shortness of breath
- Chest wall pain unlikely to be ischemic in origin
- Costochondritis
- Coronary artery disease
- Prior coronary artery bypass surgery
- Sick sinus syndrome
- Paroxysmal atrial fibrillation
- Prior implantation of a dual-chamber permanent pacemaker
- Hyponatremia
- Chronic back pain
- Gastroesophageal reflux disease
- Chronic abdominal pain
- Depression and anxiety
- Insomnia
- Raynaud's disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with H/O CAD s/p CABG x 3 in ___ (LIMA-LAD, SVG-OM,
SVG-RCA), S/P permanent pacemaker for paroxysmal atrial
fibrillation with sick sinus syndrome in ___, with recent
admission for chest pain with no objective evidence of ischemia
on dipyridamole-MIBI, who presented now with several day history
of jaw and left arm pain (which is her anginal equivalent),
chest pain, and dyspnea.
# Chest pain, CAD s/p CABG: Patient re-presenting with jaw and
left arm pain with chest pressure and shortness of breath, her
known angina equivalent. She had been admitted ___ with
similar presentation, which was thought to be musculoskeletal in
origin. She had a similar presentation during this admission.
Chest pain was not relieved with SL NTG. ECG was benign, and
troponin-T negative X 4. Since she had continued chest pain
despite a recent negative and reassuring pharmacological stress
test, cardiac catheterization was undertaken via the right
femoral artery which showed a normal LVEDP of 10 mm Hg. The LAD
had moderate disease with a patent LIMA. The RCA had moderate
ostial and disease disease. The CX was patent, as was the
SVG-OM. The SVG-RCA was not imaged. There was no evidence of
significant valvular or structural abnormalities by TTE.
Ultrasound technologist was able to reproduce Ms. ___
symptoms with pressure over sternum, directly over surgical
scar. There was no evidence of aortic dissection or pulmonary
embolus on chest CTA. Patient discharged on acetaminophen 1 g
TID for presumed musclosketal pain/costochondritis and diltiazem
30 mg TID for possible coronary microvascular disease. Given
prior CABG, her atorvastatin was increased from 20 mg BID to 40
mg BID. She was continued on home dose of ASA 81 mg daily for
cardiovascular prevention. Patient was not on a beta-blocker
given H/O exacerbation of Raynaud's with beta-blockers.
# Dyspnea - Chronic shortness of breath with acute worsening.
Limited functional capacity due to exertional dyspnea. No clear
cardiac etiology with vasodilator stress test negative for
imaging evidence of ischemia (and no reported bronchospasm).
LVEDP normal at left heart catheterization, and very low
NT-Pro-BNP twice. Pulmonary workup as an outpatient seems
warranted.
# Sick sinus syndrome/paroxysmal atrial fibrillation: s/p PPM.
A-paced with HR of 60. Pacemaker interrogated by EP at prior
admission and rate responsiveness was increased. Dyspnea did not
improve following adjustment of settings, suggesting non-optimal
pacemaker settings are unlikely to be contributing to her
respiratory complaints. CHADS2VASC score 4 suggested she may
benefit from anticoagulation, which she elected to discuss with
her outpatient providers.
# Hyponatremia: Patient intermittently hyponatremic in the past,
baseline Na of 129-135. On presentation had Na of 127, which
improved to 134 on discharge with fluid restriction.
# Chronic abdominal pain/IBS/GERD: Changed home dexilant 60 mg
daily to omeprazole 40 daily due to non-formulary. Continued
hydrocortisone suppository daily PRN.
# Chronic back pain: No pain. Held home cyclobenzaprine PRN.
Continued lidocaine patch BID PRN
# Anxiety: Continued home lorazepam 0.5 mg TID.
# Depression: Continued home Lexapro BID.
# Insomnia: Continued home Ambien 5 mg qHS.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with BRCA1 mutation, breast cancer s/p
mastectomy and axillary lymph node dissection, chemotherapy and
radiation, prostate cancer, melanoma, and left ___ DVT s/p
coumadin treatment presenting with abdominal pain. The
patient's history is challenging secondary to slight confusion
from dilaudid in the ER and his admittedly being overwhelmed
with being told he likely has metastasis in the ER. He states
that he has chronic abdominal pain but the morning of admission,
it awoke ___ from sleep. It was on the right side of his
abdomen, ___ in intensity, sharp, and not relieved by Maalox.
He also "slipped" but did not his his head. He was admitted at
another hospital 3 days ago for a routine endoscopy which was
unrevealing; he was also started on Bactrim there for a UTI
which he does not like because sulfa upsets his stomach. On
arrival to the floor, he is anxious, frustrated, and overwhelmed
but has less abdominal pain with the dilaudid.
.
Review of Systems: Unable to obtain complete ROS secondary to
patient not cooperating. Radiology showed No acute cardiopulmonary abnormality. Radiology showed 1. At least two new ill-defined hypodense hepatic lesions, measuring up to
2.0 cm, with new distal CBD wall enhancement and thickening resulting in
intra- and extra-hepatic biliary obstruction. Findings are concerning for
metastases from breast cancer involving the liver and distal common bile duct,
although primary cholangiocarcinoma with hepatic metastases may also be
considered. ERCP/MRCP is recommended for further evaluation.
2. Innumerable subcentimeter hepatic hypodensities, previously characterized
as biliary hamartomas, grossly stable in size and number.
3. Chronic left renal obstruction due to staghorn calculus.
4. Numerous bilateral renal cysts, one of which has enlarged and another of
which is complex. Renal ultrasound may be obtained for further evaluation if
indicated.
5. No evidence of bowel obstruction or diverticulitis. Radiology showed Technically successful ultrasound-guided 18-gauge core biopsy of
segment VIII liver lesion. Onsite cytology confirmed sample adequacy. No
immediate complication. The patient was diagnosed with ABDOMINAL PAIN RUQ. The patient was treated with Liver biopsy ___.. At the time of discharge, the patient had 1. Abdominal pain.
2. New liver metastases.
3. Breast cancer.
4. Chronic right arm and chest pain/neuropathy.
5. Urinary tract infection (UTI).
6. Kidney 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>___ man with BRCA1 mutation, breast cancer s/p right mastectomy
and axillary lymph node dissection, chemotherapy and radiation,
prostate cancer, melanoma, and LLE DVT s/p warfarin [on
tamoxifen] admitted for abdominal pain and new liver lesions.
.
# Abdominal pain: Likely due to new liver mets. Liver biopsy
done ___ without complication. Started OxyContin, increased
to 20mg BID. Mr. ___ noted improvement in pain with OxyContin
and PRN hydromorphone.
- F/U LIVER BIOPSY, RESULTS PENDING.
.
# Breast cancer: Likely new liver mets. CEA 19, ___ 52.
Mr. ___ admitted to ___ with tamoxifen, but may be
open to trying it again. Liver biopsy done ___, results
pending. Consulted Social Work. Anti-emetics PRN. Restarted
tamoxifen.
.
# Hypotension: Improved with IV fluids. Unclear etiology. Low
AM cortisol, but did not do Cosyntropin stim test as BP improved
with IV fluids.
.
# UTI: TMP-SMX changed to ciprofloxacin due to GI upset. Urine
culture negative.
.
# Right chest pain from radiation changes and peripheral
neuropathy: Titrated up gabapentin to 600mg TID. Continued
temazepam.
.
# Anemia: Secondary to inflammation. Chronic, stable.
.
# Depession: His family believes he is depressed, but Mr. ___
denied this. Consulted Social Work.
.
# GERD: Chronic, stable. Continued PPI and aluminum/mag
hydroxide PRN.
.
# Constipation: Continued bowel regimen.
.
# DVT PPx: Heparin SQ.
.
# FEN: Regular diet. IV fluids.
.
# Precautions: Fall. ___ consulted.
.
# Lines: Peripheral IV.
.
# CODE: FULL.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with history of untreated HTN and 80 pack-year
smoking history, presenting with progressive dyspnea. CHEST (PRE-OP PA AND LAT) showed Mild pulmonary edema, improved. CHEST PORT. LINE PLACEMENT showed There are postsurgical changes from mitral valve replacement. The
endotracheal tube terminates 5.4 cm above the carina. The right internal
jugular Swan-Ganz catheter terminates in the main pulmonary outflow tract.
The enteric tube terminates in the fundus of the stomach. A left chest tube
and pericardial and mediastinal drains are in place.
The cardiac silhouette remains enlarged. There is mild widening of the upper
mediastinum, in keeping with recent postsurgical changes. Patchy opacities in
the left lung most likely represent asymmetric pulmonary edema. No pleural
effusion or pneumothorax is identified. No acute osseous abnormalities are
identified. Radiology showed Endotracheal tube, Swan-Ganz catheter, feeding tube, and chest tube have been
removed. There is a residual right IJ Cordis. There is cardiomegaly which is
stable. There has been mild improvement of the pulmonary edema which is now
mild. No large pleural effusions or pneumothoraces are seen. Old left upper
posterior rib fractures are seen. CHEST (PORTABLE AP) ___ showed Compared to postoperative chest radiographs ___.
Mild pulmonary edema has developed since ___. Postoperative appearance
of the cardiomediastinal silhouette is expected, and unchanged. Pleural
effusions are small if any. No pneumothorax. CHEST (PA AND LAT) showed Mild pulmonary edema has resolved. Small bilateral pleural effusions. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with ___ TEE
___ Cardiac Catheterization
___ CABG x1 (SVG-PDA), MVR (31mm ___ tissue valve). At the time of discharge, the patient had Primary:
Acute mitral regurgitation
atrial fibrillation
Secondary:
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 ___ male with no significant past
medical history presenting with subacute onset of dyspnea, found
to have evidence of pulmonary edema, with ECHO concerning
for severe mitral regurgitation. He underwent cardiac
catheterization which showed single vessel coronary disease. He
underwent TEE to help evaluate the mitral valve prior to
surgery. He then was transferred to C-Surg for surgical repair.
Mr. ___ was brought to the Operating Room on ___ where
the patient underwent CABG x1 (SVG-PDA), MVR (31mm ___
tissue valve). Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker start was delayed due
to junctional rhythm. Low dose Lopressor was trialed with SB
___ on POD 2, but patient's HR dropped to ___ and he remained in
ICU for Apacing support. Coumadin was started for goal INR ___.
Chest tubes were removed per protocol. POD 3, he developed
rapid atrial fibrillation and was treated with IV/PO Amiodarone
and lopressor. He was gently diuresed toward the preoperative
weight and was transferred to the telemetry floor for further
recovery. He remained in NSR and his pacing wires were removed
on POD 6 (delayed d/t INR 2.1). The patient was evaluated by
the Physical Therapy service for assistance with strength and
mobility. His Lasix was increased for serous sternal drainage,
but the bone and wound itself remained stable. By the time of
discharge on POD 7, he was ambulating with rolling walker, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home with ___ and ___ services in
good condition with appropriate follow up instructions. Patient
had no prior medical doctors and ___ to arrange a formal PCP.
At time of discharge, ___ office is waiting to confirm
follow up visit with Dr. ___ who saw patient at ___
___ preoperatively. Dr. ___ will manage INR
dosing until patient's PCP or ___ follow up can be
confirmed and management transitioned.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo M with hx of aortic stenosis s/p AVR
(tissue), CAD s/p CABGx2 ___, DM, ESRD on HD (MWF), HLD,
HTN,
AV block who presents with progressively worsening dyspnea for
___ days despite regularly scheduled dialysis sessions. Dyspnea
worse with minimal exertion, initially saw PCP on ___, who
recommended ED evaluation but he instead went to scheduled
dialysis and had 2.2L fluid removed which improved his dyspnea.
However, since then, dyspnea worsened. He slept in chair the
night before admission and notes increased leg swelling
particularly starting last night. He notes improving chest pain
surrounding his sternal incision (required less pain medicine).
On exertion, patient sometimes has chest tightness and
lightheadedness with SOB, but none at rest. Denies palpitations
and syncope. Most recent TTE on ___ showed mild LVH and normal
LV systolic function (EF > 55%) with well-seated biopresthetic
AVR, no aortic regurgitation and mild pulmonary artery systolic
hypertension (PASP 31) Chest: Frontal and lateral views showed Increasing pleural effusions, now moderate on the right and small on the left
with worsening atelectasis. CTA chest showed 1. No evidence of acute pulmonary embolism.
2. Interval minimal dehiscence of the median sternotomy by 4 mm with erosion
of the margins and stranding of the overlying subcutaneous tissue, concerning
for inflammation/infection. No drainable fluid collection. Wires are intact.
3. Near complete collapse of the right lower lobe, progressed since ___. Mild enlargement of the bilateral nonhemorrhagic pleural
effusions, moderate on the right and small on the left.
4. Stable solid lung nodules as described above. 8 mm ground-glass nodule is
likely inflammatory given short term interval change. Please refer to the
prior exams for follow-up. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. Moderate
right pleural effusion and severe right lower lobe atelectasis are unchanged.
Moderate enlargement of the cardiac silhouette has increased and mild
interstitial edema has developed best appreciated in the left lower lung. No
pneumothorax.
Right jugular line ends in the right atrium as before. Radiology showed Moderate right and small left pleural effusions with overlying atelectasis. Radiology showed The tip of a right hemodialysis catheter extends to the right atrium. The
patient is post median sternotomy and aortic valve replacement.
Atelectasis is noted at the right lung base as well as a small pleural
effusion. No pneumothorax. Pulmonary vascular congestion is present without
frank pulmonary edema. The size of the cardiac silhouette is enlarged but
unchanged. Chest radiograph showed Mild venous congestion with unchanged small right and minimal left pleural
effusions. Radiology showed Mild pulmonary venous congestion. Possible small right effusion. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with TEE and Ablation on ___. At the time of discharge, the patient had PRIMARY
========
Heart failure with preserved ejection fraction
Pleural effusion
Right lung collapse
Atrial flutter
Coronary artery disease
Thrombocytopenia
End stage renal disease
Hypertension
SECONDARY
==========
Diabetes Mellitus
Anemia
Hyperlipidemia
Gastroesophageal reflux disease
Hypothyroidism
Depression
Anxiety
Gout
Back spasm
Constipation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ yo M with history of aortic stenosis s/p AVR
(tissue), CAD s/p CABGx2 on ___, DM, ESRD on HD (MWF), HLD,
HTN, who presented with progressively worsening dyspnea for ___
days despite regularly scheduled dialysis sessions found to have
collapsed RLL, bilateral pleural effusions.
ACTIVE ISSUES:
==============
#Dyspnea
#RLL collapse
#Bilateral pleural effusions
#HFpEF
Dypsnea likely multifactorial, likely secondary to volume
overload from HFpEF exacerbation iso elevated BNP, JVP and leg
swelling. Repeat TTE showed normal LV systolic function but RV
pressure/volume overload. Infection unlikely as patient denied
fever, chills, localizing symptoms, and urine/blood cultures
were negative. Also considered bradycardia as trigger, but HRs
have been higher than previous. Dietary indiscretion unlikely as
patient's appetite has decreased. Unlikely due to ischemia given
absence of EKG findings and stable troponin iso ESRD. TEE showed
well seated aortic valve without AR on ___. Notably, has RLL
collapse and bilateral atelectasis, pleural effusions, which
likely contributed to hypoxia. Repeat CXR after dialysis on
___ showed mild improvement in right effusion. IP was
consulted, who recommended aggressive volume removal with
dialysis and no thoracentesis. Patient should follow-up with IP
as outpatient. In coordination with hemodialysis, patient was
dialyzed to a new dry weight of 88.8kg. Patient's dyspnea
improved to where he was ambulating at 96% RA. However, patient
continued to have episodes of air hunger without documented
desaturations while sleeping. Given patient's weight had
improved and patient looked more euvolemic, negative cardiac
work up, negative CTA, these episodes thought to be mainly due
to anxiety. Patient agreed with this assessment and did feel
improvement with Lorazepam 0.5mg QHS PRN in addition to his home
1mg TID (on this for many years). Patient also has a history of
OSA and was on CPAP ___ years ago, however discontinued using
this. Recommended repeat Sleep study and evaluation.
Patient's home torsemide was stopped given minimal urine output
- Nephrology in agreement with this. He was continued on
isosorbide mononitrate and hydralazine was uptitrated for
hypertension to 100mg TID.
#CAD s/p CABG
#Sternotomy wound dehiscence
On exam, appears dry without discharge, but signs of possible
inflammation/infection on CTA. Evaluated by cardiac surgery who
did not believe wound was infected. ESR (55) and CRP initially
elevated, but CRP trended down during admission (27.7 -> 19.9).
Wound care consulted. Patient continued on aspirin, tylenol,
tramadol and oxycodone. Patient's chest pain was tender to
palpation and there were no EKG changes or CKMB elevations (trop
high due to ablation procedure and ESRD), and so thought to be
musculoskeletal in origin.
#Aflutter
#History of AV Block
Patient had advanced AV block with junctional escape in the ___,
immediately followed by 2:1 AV conduction on previous admission.
Has hx of AV Wenckeback and 2:1 AV block. EP consulted then and
decision was potential pacemaker in the future if conduction
abnormalities worsened or symptomatic. HRs have been 50-60s on
admission. Patient denies lightheadedness at rest and no
syncope. EKG on admission showed aflutter with 3:1. EP was
reconsulted and patient underwent TEE and ablation for aflutter
on ___. Findings from the procedure were notable for "high grade
AV block in AVN." Afterwards, his HRs remained in ___
degree AV delay and 2:1 conduction on serial EKGs. He was
heparin bridged and continued on warfarin. Final dose at
discharge was 5mg daily for goal INR ___. Should recheck INR on
___ by ___ and results faxed to PCP, ___.
#Thrombocytopenia
Platelet count trended down from 188 to 110 during admission
possibly in the setting of procedure. 4T score calculated to be
___ (low to moderate risk of HIT). Blood smear showed occasional
schistocytes, though haptoglobin and LDH were unremarkable.
Platelets rebounded without intervention several days prior to
discharge.
#DM
Patient on lantus 55U in morning and novolin sliding scale at
home. He was managed with lantus 35U QAM and HISS while
inpatient. Restarted home insulin on discharge.
#ESRD on hemodialysis
Patient continued on dialysis with aggressive UF to remove fluid
to lower dry weight according to hemodynamics. Continued on
nephrocaps and calcium.
#Anemia
Hgb stable at baseline Hb ___ in recent months. Likely due to
ESRD.
#HTN
Patient was consistently hypertensive during this admission.
Uptitrated hydralazine to 100 mg TID and continued amlodipine 10
mg daily.
#Anxiety
Patient noted to be subjectively short of breath at night,
though no clear oxygen desaturation. Patient reported missing
wife and art at home and stating the hospital was too "sterile."
PCP has been considering increasing Ativan dosing. Continued on
home seroquel and provided Ativan 0.5 mg QHS, in addition to his
home lorazepam 1mg TID. Patient felt improved. PCP was notified
of these changes.
CHRONIC ISSUES:
==============
#HLD
On ___, patient developed whole body myalgias similar to
symptoms he had on simvastatin and pravastatin. CK and LFTs were
normal. Held home rosuvastatin 5 mg qpm. Of note, at this point
patient has been tried on three statins and has not tolerated
these. Started on ezetimibe 10 mg daily.
#GERD
Continued home pantoprazole.
#Hypothyroid
Continued home levothyroxine.
#Depression/Anxiety/Agitation
Continued home quietiapine (dose reduced per patient request),
duloxetine and lorazepam. Added lorazepam 0.5mg QHS:PRN.
#Gout
Continued home allopurinol.
#Back spasms
Continued home baclofen.
#Constipation
Continued home lactulose.
=======================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F h/o COPD p/w SOB. Pt had onset of worsening SOB 3 wks
ago. Reports "bad cold" at that time, which she could not get
ride of. She got Z-pack and prednisone. Both "definitely"
helped. However, SOB recurred and got worse. Has SOB with
walking. SOB was at its worst yesterday, prompting her to
present to ED. Has sensation of chest heaviness but denies frank
chest pain. She reports cough x 2 weeks, but just today she
started coughing up green mucous, no hemoptysis. Getting mucous
out has led to subjective improvement in symptoms. She reports
sweating at night but denies fever/chills. Also reports sore
throat x 1 day and runny nose x 2 day. Today, the right eye
"closed over" with crust. It is sore, "annoying," no burning. Radiology showed 1. No pulmonary embolus.
2. Diffuse bronchial wall thickening compatible with bronchitis.
3. ___ opacities within the right middle lobe may reflect early small
airways infection.
4. Severe changes of centrilobular emphysema. The patient was diagnosed with SHORTNESS OF BREATH, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION. At the time of discharge, the patient had Primary diagnosis: COPD exacerbation, bronchitis, small airway
infection
Secondary diagnosis: 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>___ F h/o COPD p/w worsening SOB x 3 wks, now with cough
productive of green sputum and CTA indicating bronchitis and
small airway infection. Ms. ___ was seen in ED and had
CTA chest negative for PE as well as negative troponins in the
setting of chest heaviness. She was admitted due to persistent
SOB and treated with PO prednisone for a COPD exacerbation. She
was also started on a five-day course of azithromycin for
bronchitis/small airway infection.
ACTIVE DIAGNOSES
# Acute bronchitis and small airway infection: Pt endorsed
infectious symptoms including cough productive of green sputum,
sore throat and rhinorrhea. CTA chest in the ED revealed
diffuse bronchial wall thickening compatible with bronchitis and
___ opacities within the right middle lobe, possibly
reflecting early small
airways infection. Differential diagnosis included viral
(coronavirus, adenovirus, rhinorvirus, less likely influenza A
or B given lack of systemic symptoms) versus bacterial
(Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella
pertussis) bronchitis/small airways infection. There was a low
threshold for treatment with antibiotics in the setting of COPD
exacerbation. She was started on azithromycin 500mg PO x 1 and
then 250mg PO x 4 days. (In combination with psychotropic
medications including quetiapine, QTc prolongation was
considered, and QTc was within normal limits at 422 msec.)
Supportive care was provided with acetaminophen PRN and
albuterol/ipratropium nebs.
Sputum was collected in efforts to test for MAC via AFB smear
and culture, but the sample was not processed as expected.
Sputum cytology was negative for malignant cells (although the
yield is low). On CTA chest, there was an opacity in the
periphery of the right middle lobe which was not specifically
commented upon in the radiology report. Repeat CT chest imaging
in ___ weeks is advised. If lungs have not cleared in the
interim, further evaluation for MAC pulmonary infection ("Lady
___ syndrome") and malignancy is advised. Patient was
scheduled for outpatient follow-up with Pulmonary Medicine.
# COPD exacerbation: Pt had decreased aeration in all lung
fields. She reported symptomatic improvement after
administration of steroids in the ED, and PO prednisone was
continued on the floor. She saturated normally on room air and
had non-labored breathing at rest. She passed ambulatory O2
monitoring on hospital day 2 with SpO2>/=92% throughout, but she
was not able to walk far and had purse-lipped breathing with
exertion. She was treated with standing albuterol/ipratropium
nebulizers and continued on fluticasone-salmeterol diskus. By
hospital day 3, there was additional subjective improvement in
SOB. She was discharged with a ten-day prednisone taper and her
usual home COPD medications. ___ was arranged for outpatient
oxygen monitoring, and she should be referred for pulmonary
rehabilitation. She was also scheduled to follow-up with
Pulmonary Medicine as an outpatient. CTA chest showed severe
changes of centrilobular emphysema. She should have repeat
chest CT imaging in ___ weeks after discharge, as described
above.
# Conjunctivitis: Pt developed erythema and soreness of right
eye, which progressed to involve both eyes. Cream-colored
opaque discharge was visualized in the medial canthus of right
eye on admission, and there was yellow crust on both eyelids in
the morning of hospital day 2. Ddx includes viral versus
bacterial or allergic conjunctivitis. Most common causes of
bacterial conjunctivitis include Staphylococcus aureus,
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis. She was prescribed erythromycin ophthalmic
ointment to apply to both eyes.
# Smoking cessation: Pt started on a nicotine patch and was
given a prescription for nicotine replacement therapy to
continue as an outpatient. Smoking cessation was encouraged.
CHRONIC DIAGNOSES
# Psych: Pt has h/o depression for which she takes a variety of
other psych meds. Topiramate 350mg daily, quetiapine 200mg PO
BID, bupropion SR 200mg PO q AM, and venlafaxine 75mg PO daily
were continued in order to maintain stable regimen compared to
home. However, this combination of medications increases risk
for serotonin syndrome. Optimization/simplification of
psychiatric medication regimen as an outpatient is advised, in
part to reduce risk of serotonin syndrome.
# Menopause: Pt takes estradiol and progesterone at home for
menopausal symptoms. She had a CTA chest in the ED which was
negative for PE, given her SOB and increased risk for blood clot
while on estradiol. Pt reported feeling like these medications
were not necessary. Estradiol and progesterone were held during
hospitalization so as to minimize risk for PE while monitoring
for improvement in shortness of breath. Duration of treatment
with these medications should be reassessed as an outpatient.
# HLD: Continued home simvastatin.
TRANSITIONAL ISSUES
* Pt will be discharged with home ___ services. Please do oxygen
saturation monitoring as an outpatient and refer to pulmonary
rehab as appropriate.
* Pt should follow-up with Pulmonary Medicine as an outpatient.
Please repeat chest CT in ___ weeks as an outpatient to assess
interval change. If lung findings have not cleared in the
interim, further evaluation for MAC pulmonary infection ("Lady
___ syndrome") and malignancy is advised (see below).
* Sputum was collected to test for AFB smear/culture, but the
specimen did not get processed as expected. If repeat chest CT
is abnormal, consider testing sputum for AFB smear and culture
to assess for MAC pulmonary infection ("___
syndrome").
* Given history of smoking and COPD, family history of lung
cancer, and finding of peripheral opacity in right lung on CTA,
sputum cytology was tested and returned negative for malignant
cells. Please note that sputum cytology has a low yield for
abnormal cells, and further work-up would be necessary to
definitively rule out malignancy if repeat chest CT remains
abnormal after pulmonary/small airway infection clears.
* Also of note, pt is on a variety of psychiatric medications at
home, including bupropion, quetiapine, venlafaxine, and
topiramate. This combination of medications increases risk of
serotonin syndrome. Optimization/simplification of psychiatric
medication regimen as an outpatient is encouraged.
* Please consider whether estradiol and progesterone remain
necessary and, if so, determine their expected duration.
Discontinue when possible so as to avoid risk for blood clot and
other complications.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed Mild pulmonary vascular congestion. No edema. CHEST (PORTABLE AP) showed There are postsurgical changes from CABG. There is no focal consolidation,
pleural effusion or pneumothorax. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities are identified. There is a
vascular stent in the left subclavian/axillary region. The patient was diagnosed with Hyperkalemia. The patient was treated with EGD ___. At the time of discharge, the patient had PRIMARY DIAGNOSES
=================
Acute Gastrointestinal Bleed
SECONDARY DIAGNOSES
===================
Gastroparesis
Atrial Fibrillation with RVR
ESRD on HD
Hypoxemic respiratory failure, Resolved. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES
===================
[ ] Discharge HGB 8.0
[ ] Please complete repeat labs in 1 week by ___ to
follow-up his anemia.
[ ] Patient left AMA before receiving repeat endoscopy to
evaluate suspected ___ tear. Therefore, would greatly
benefit from repeat endoscopy within the next week to ensure
healing. We did not feel comfortable restarted his apixaban
without this re-evaluation. His CHADs2VASc is ___ so we felt it
was reasonable to hold apixaban on discharge, but he will need
to be restarted on this medication when repeat EGD shows
healing.
[ ] Patient likely with ___ tear in setting of
nausea/vomiting due to gastroparesis flare and missed HD
session. Patient should continue PPI as well as prn reglan for
nausea and to help with motility. Patient reports that he has
infrequent gastroparesis flares (yearly) but would benefit from
outpatient gastroparesis management.
BRIEF HOSPITAL COURSE
======================
Mr ___ is a ___ man with history of IDDM, ESRD on
HD (MWF), CAD s/p CABG in ___, Afib w/ RVR history of
gastroparesis on reglan, presented with nausea/vomiting,
initially admitted to ICU in setting of respiratory distress
after missing dialysis, then re-admitted to ICU in setting of
hematemesis found to have possible ___ tear on EGD.
Patient was treated with IV PPI and standing Zofran. Apixaban
was held during this time in setting of bleeding. Course was
also complicated by Afib with RVR resolved with addition of
standing metoprolol. Patient left AMA right as he was been
called for repeat EGD to assess healing of his ___
tear. Patient became belligerent and hostile to medical staff.
He is fully aware that his apixaban is being held until he has a
repeat EGD and therefore has a risk of stroke, and he is willing
to take this risk. Hemoglobin has been stable with no further
bleeding on discharge.
ACUTE ISSUES
===============
#Discharged AMA
Patient left AMA right as he was been called for repeat EGD to
assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Acute upper GI bleed
Patient developed hematemesis after multiple episodes of emesis.
EGD on ___ showed esophagitis and a clot with possible
___ tear. Patient was kept on IV PPI, standing Zofran
until nausea resolved and stable. Apixaban was held in the
setting of active bleeding. Patient has been hemodynamically
stable with stable hemoglobin. No further nausea/vomiting or
melena. Patient left AMA right as he was been called for repeat
EGD to assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Nausea and Vomiting
# Gastroparesis
Patient presented with nausea/vomiting likely in the setting of
known gastroparesis as well as uremia from missed HD session.
Patient was on standing anti-emetics given ___ tear.
Zofran and reglan were made prn. He has been tolerating oral
intake with no N/v. Mild epigastric pain with belching.
# Paroxysmal Afib/flutter
Discharged ___ from ___ on metop, apixaban, amiodarone
but recently switched to carvedilol. His fill history however
does not reflect this, and it appears he has not filled these
meds which his story collaborates. On ___, patient had elevated
HRs in 150s with 2:1 block requiring IV metop with conversion to
NSR. Standing metoprolol tartrate 6.25mg QID was added with
patient continuing in NSR until left AMA. As above, holding
apixaban in setting of bleeding. Unable to get repeat EGD before
left and medical team not comfortable sending him on apixaban
without visualizing his esophagus.
# HTN
Had held home amlodipine, losartan iso GI bleed. Started
metoprolol as above. Restarted home amlodipine as blood
pressures have tolerated.
#Likely OSA
Concern for apneic periods during sleep throughout admission.
Would benefit from outpatient sleep study.
CHRONIC ISSUES
===============
# ESRD
Continued HD per renal
# IDDM
Continued insulin 50 units glargine daily, sliding scale
# HLD
Continued atorvastatin
#CODE STATUS: FULL
>30 min spent on discharge planning including face to face time.
Pt was deemed to have capacity at time of AMA and understood the
risks of leaving prematurely. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ y/o woman with PMH of EtOH cirrhosis
c/b EV, PHG, GAVE who p/w hematemesis. CHEST (PORTABLE AP) was done. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with ___ EGD with variceal ligation
___ intubation for EGD s/p extubation ___. At the time of discharge, the patient had #Acute decompensated alcohol cirrhosis
#Upper gastrointestinal bleeding
#Acute blood loss anemia
#Hyponatremia. The patient was given written instructions concerning 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 ___ with PMH of alcoholic liver
cirrhosis, PHT in the form of EV (on NSBB for primary
prophylaxis), PHG, ascites on diuretics (well controlled),
jaundice, overt obscure GI bleeding and chronic anemia (baseline
___, and ongoing alcohol use who presented with hematemesis
and hemorrhagic shock. She had an EGD ___ showing esophageal
varices and GOV (oozing) s/p banding after which her bleeding
and HgB stabilized, without recurrence of hematemesis or melena.
ACUTE ISSUES:
=============
#UGIB
#Hemorrhagic shock, improving
Ms. ___ initially presented with hematemesis and
hemorrhagic shock (hypotensive to SBP in the ___, lactate 3.0)
to ___. Her initial HgB there was noted to be 7.1
(from baseline ___. She required 2 U pRBCs and 1L IVF with
improvement in hemodynamics, and was started on octreotide gtt,
IV PPI, and IV CTX. She was subsequently transferred to ___
for further management. On arrival, she underwent EGD (___)
showing 4 cords of grade II varices in the distal esophagus, as
well as one cord of varices below the gastroesophageal junction
(most likely representing GOV) which was oozing. Three bands
were applied for hemostasis successfully. Since admission, she
has required an additional 3u pRBCs (last transfusion ___ for
resuscitation, after which her HgB has stabilized without
recurrent hematemesis/melena. She was continued on an octreotide
drip (___), then transitioned to home nadolol on day of
discharge. She finished a course of ceftriaxone for SBP
prophylaxis also on ___, and will continue on daily PPI and
sucralfate on discharge. Discharge HgB 7.7.
# EtOH cirrhosis:
Followed by Dr. ___. MELDNa 19. Decompensated this admission
by variceal bleed s/p banding as above. As of his
hospitalization, the patient was noted to be actively using
alcohol with positive alcohol level. She was seen by social work
and provided relapse prevention resources. She otherwise will
continue on home nadolol for bleeding prophylaxis. Home
diuretics were temporarily held given bleed, but restarted prior
to discharge. She will continue on furosemide
40mg/spironolactone 100mg. She has no history of SBP and
completed 5 day course of CTX for SBP prophylaxis given GIB. She
also has no history of hepatic encephalopathy and no evidence of
encephalopathy this admission. She will follow up with Dr. ___
in liver clinic ___ as scheduled.
# Alcohol use disorder
Serum EtOH 138 on admission. She was continued on thiamine,
folate, multivitamin. Social work was consulted for relapse
prevention, and patient accepted resources for this.
CHRONIC ISSUES
===============
#T2DM
Home metformin 500 BID was held in setting of acute illness.
Hyperglycemia managed with ISS while inpatient. Metformin
restarted on discharge.
#Pruritus
Continued home hydroxyzine 25 TID PRN.
#GERD
Will continue home omeprazole daily.
#Hypothyroidism
Continued home levothyroxine 175mcg daily.
#Depression
Continued home duloxetine 90 daily, home trazodone 150 QHS PRN
for sleep.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male w/ history diabetes type 1, ESRD on HD, multiple
hospitalizations for DKA/hyperglycemia, and recent ER visit ___
for hypoglycemic seizure presents for critically high blood
sugar at ___ center. Noted to be sweating, tired, and vomited x2
so he did not get HD. His fasting glucose was 287 on the morning
of admission before breakfast, took 10u Humalog. His blood sugar
was running in the 300s yesterday with recent systolic blood
pressures in the 150s. He reports compliance with insulin and
home blood pressure medications.
Recently he has felt generally fatigued, but at dialysis
center he was sweating and more tired. He denies recent lows
other than the hypoglycemic seizure he had ___ while at HD,
which resulted in a tounge laceration but no other
complications. He denies any prior history of seizures. He
denies recent illness, cough, dysuria, rash, HA, diarrhea, CP,
or vomiting prior to today.
Of note he has had multiple complications of Type1DM and
HTN, including total blindness in L eye secondary to retinopathy
and nephropathy requiring dialysis. He has no known coronary
disease or peripheral vascular disease though head MRI in ___
was found to be consistent with multiple hypertensive infarcts. Radiology showed No acute cardiopulmonary process. Diabetes mellitus, hemodialysis, fever.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The central vein catheter tip terminates at the level of the right atrium.
Heart size and mediastinum are unremarkable. Lungs are essentially clear. No
pleural effusion or pneumothorax is seen. was done. The patient was diagnosed with DIAB KETOACIDOSIS IDDM. The patient was treated with 1) Hemodialysis ___ and ___. At the time of discharge, the patient had Primary diagnoses:
1. DKA
2. Malignant hypertension
3. ESRD on HD
Secondary diagnoses:
1. DM type I
2. Anemia
3. Hyperlipidemia
4. Duodenal ulcer s/p bleed and cauterization
5. Diabetic retinopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with severe type 1 diabetes with multiple
complications, malignant hypertension, and ESRD who presents
from HD center with DKA and hypertensive urgency without
neurologic compromise or obtundation.
# DKA/Type1DM: Multiple prior episodes of DKA (see OMR). Unclear
provocating factor given history of no recent illness, reported
medication adherence, and no CP to suggest MI, though
hypertensive urgency may have been significant stressor. His
glucose management is complicated by ESRD. He had breakfast and
sliding scale 10u Humalog ___ AM per patient. On admission
glucose >700 and anion gap ~34. In the ER he was bolused 2L IVF
and given 8 units bolus insulin, then insulin gtt at 7units/hr.
When he arrived in the MICU his glucose was >700 still. He
received additional IV bolus insulin in the evening of ___ and
rapidly dropped down to 200s during the night, at which point
the insulin gtt was turned down and D5W gtt was started. On ___
he was switched from from an insulin gtt to sliding scale after
his anion gap closed. His sugars remained in the 100-200 range
on ___ and he was tolerating a diet. Long acting glargine was
started at his home dose of 25u qHS and Humalog sliding scale
insulin was continued. Electrolytes were repleted aggresively.
___ was consulted and followed patient throughout his
admission. Blood glucose ranged between 100-400 over the next
several days despite regular monitoring. Sliding scale was
increased with limited effect.
Given multiple complications from T1DM (L eye blindness,
ESRD) he is at risk for signficant morbidity and even death
given dangerous episodes of DKA and now hypoglycemic seizure in
recent history (___). He has follow up with his NP at ___
scheduled for ___.
# Malignant HTN: Developed in ___ around the time of
dialysis initiation. Presents with BPs in 210s systolic on
multiple medications for BP at home. Required IV nitroglycerine
and hydralazine in ICU to obtain good control. On admission to
the floor BP controlled at 110/68 and remained controlled
w/systolic BP <140 throughout remainder of inpatient admission
on home BP medications.
As outpatient BPs noted to be 150-180s on amlodipine,
minoxidil, torsemide, ACEI, and clonidine. These were continued
in house, though lisinopril was held initially given
hyperkalemia, and then restarted ___ after dialysis. His long
term BP goal is <130/80, though this has been very difficult to
achieve despite aggressive BP regimen. Patiet reports
understanding of how and when to take his medications, although
he admits to sometimes forgetting his evening doses. He also
reports that taking the pills on an empty stomach makes him
throw up, and that he has also thrown up a few times recently
because of hypoglycemia. He thinks this may have contributed to
the very high pressures noted on admission.
# Unexplained fevers: Patient became febrile to 101.5 early AM
on ___ and 99.6 on ___. No inciting event for the fever could
be determined. Patient denied nausea, vomiting, abdominal pain,
flank pain, cough, SOB, sinus congestion. He had a negative CXR
and negative blood and PD fluid cultures from ___ and ___.
Repeat blood cultures from both the HD line and peripheral blood
were sent and are pending at the time of discharge. Given that
the patient had no identifying symptoms, antibiotics were not
started. Will follow up with Mr. ___, Dr. ___
nephrologist), and ___ if cultures return positive
as in transitional issues below.
# Elevated trops/EKG changes: TropT to 0.89 on admission and EKG
w/ peaked T waves and possible small ST elevations in V2/V3.
Baseline trop 0.6-0.8, consistent w/ poorly controled htn and
ESRD preventing effective renal clearance. No known hx MI
although past EKG w/changes c/w anteroseptal infarct. Last ECHO
___ showed LVH w/out valvular pathology or focal wall motion
abnormalities. Presentation initially concerning for ACS but
CK-MBs were serially negative and EKG changes resolved to
baseline with nitroglycerin gtt overnight and BP control to
<160.
Trop leak most likely due to hypertensive urgency w/SBP elevated
above 200. Repeat EKG on ___ again consistant with baseline EKG
prior to admission.
# ESRD: TTS. Secondary to diabetic nephropathy. PD catheter
placed ___, but developed a metabolic encephalopathy and was
switched to HD on ___ via tunnelled catheter. Currently
undergoing repeat PD training so he can attempt to swtich back.
Has residual kidney function, on torsemide. Continued
nephrocaps. Low K, low Phos diet. K was repleted gently during
DKA given ESRD. He received HD ___, ___ and ___ without
complications.
# Elevated Transaminases: ALT/AST in ___ on admission.
Negative for HBV and HCV in ___ be related to
hypertensive urgency. Resolved by ___.
# Hx CVA: Discovered ___ in the setting of "altered mental
status" thought most likely due to metabolic encephalopathy in
the setting of failed PD dialysis. MR at the time showed
multiple foci of restricted diffusion identified in the pons,
right occipital lobe, bilateral basal ganglia involving the
internal capsule, genu of the corpus callosum and both centrum
semiovale. CTA of neck showed no carotid atherosclerosis. This
suggests hypertensive infarcts. Long term blood pressure conrol
130/80, but this has been difficult for the patient to achieve
as above. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ M w/ COPD, alcohol induced chronic
pancreatitis w/ pseudocyst s/p Whipple, and chronic pain
presenting with tachypnea. CHEST (PORTABLE AP) showed No acute cardiopulmonary process. COPD. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
===================
COPD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman with COPD on chronic PO
prednisone, alcohol induced chronic pancreatitis w/ pseudocyst
s/p Whipple, and chronic pain presenting with tachypnea and SOB
admitted to the ICU for COPD exacerbation requiring BiPAP. He
was treated for the following issues during this
hospitalization:
ACTIVE ISSUES
==============
# COPD EXACERBATION:
Patient has known COPD, on chronic prednisone 10 mg daily. He is
not on home O2, but reports that he had been on it many years
ago. He was afebrile without concern for infection per CXR and
was treated with azithromycin, prednisone 40 mg, and standing
nebulizers. He was admitted to ICU given need for BIPAP,
although he was only used it intermittently. He was transferred
to the general medicine floor on HD3, where he was quickly
weaned off of oxygen. Plan was to keep patient for one more day
for frequent nebs/monitoring, but patient was very intent on
leaving. His ambulatory O2 sat and O2 sat on room air were both
>90 prior to discharge, and he was able to ambulate with mild
SOB. As such, he was discharged on a prednisone taper,
nebulizers, and azithromycin. For his cough, he was treated
with guaifenesin-codeine and Tessalon Perles.
# CHEST PAIN:
Patient noted to have chest pain in the ED with prior stress
test in ___ negative for coronary disease. Patient did have
nitro prescribed as medication though unclear indication as he
was without known history of cardiovascular disease documented.
EKG was without changes suggestive of ischemia, trops negative
x3, and normal heart rate raised low suspicion for ACS or PE.
Per patient, this chest pain is a chronic pain and he is managed
on a narcotics contract by his PCP.
# PANCREATIC INSUFFICIENCY:
Patient with known pancreatic insufficiency likely secondary to
Whipple and chronic alcohol use. He is on home creon, which was
continued during this hospital stay.
# CHRONIC ABDOMINAL PAIN:
The patient has had chronic abdominal pain since his Whipple
approximately ___ years ago. As above, he has a narcotics
contract with his PCP, the terms of which were followed during
this hospitalization to manage his symptoms.
INACTIVE ISSUES
===============
# GERD:
Continued omeprazole 40 mg PO DAILY
# Insomnia:
Continued Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
# Appetite stimulant:
Dronabinol 5 mg PO BID
# Depression:
He was continued on his home dose of sertraline this admission.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old Female who presented to the ___ in
the setting of an MVC. She was initially intubated at the OSH,
and was found on pan-scan imaging to have small bilateral
pneumothoraces, multiple rib fractures, a splenic laceration, L5
transverse process fracture, and pelvic fractures. Radiology showed 1. Uncomplicated proximal and selective distal splenic embolization.
2. Delayed right nephrogram consistent with renal insufficiency.
Findings were discussed by phone with Dr. ___ at the completion of the
procedure at approximately 8:20 p.m. on ___. Radiology showed Left mid and lower lung opacity likely represents combination of
pleural hemothorax and atelectasis and contusion. Multiple rib fractures on
the left. No pneumothorax is identified. Radiology showed No evidence of free air. No significant change compared to
___ at 5:33 a.m. Enteric tube ends in the stomach; however the
last side port is likely above the GE junction. Recommend advancement.
These findings were discussed with Dr. ___ by Dr. ___ at 940am on
___ by phone at time of discovery. CYSTOGRAM showed No evidence of bladder leak. Radiology showed Enteric tube with the tip in the stomach. Otherwise, no
significant change from the prior exam. UNILAT UP EXT VEINS US showed 1. No evidence of deep vein thrombosis.
2. Occlusive thrombus seen within a segment of the right cephalic vein at the
level of the antecubital fossa. Radiology showed 1. Resolved left upper lobe collapse but worsened left lower lobe atelectasis
from ___.
2. Small bilateral pleural effusions, left greater than right.
3. ET tube tip abuts the tracheal wall. Radiology showed 1. Unchanged position of support devices.
2. Persistent low lung volumes and bibasilar atelectasis. Possible small
right pleural effusion. Radiology showed 1. Endotracheal tube continues to have its tip approximately 5 cm above the
carina. A nasogastric tube is seen coursing below the diaphragm with the tip
just below the esophageal gastric junction. Advancement of the tube by
approximately 5 cm would be recommended to ensure that the side port is
subdiaphragmatic. The cardiac and mediastinal contours are stable. Lung
volumes remain low with improved aeration at the right base but interval
appearance of retrocardiac opacity suggestive of atelectasis, although
pneumonia cannot be entirely excluded. Possible layering left effusion. No
evidence of pulmonary edema although the vasculature is crowded. No
pneumothorax. Results were communicated to the patient's nurse, ___, by
phone on ___ at 11:38 a.m. at the time of discovery. Radiology showed 1. Left PICC ending at the upper SVC.
2. Improved aeration of the right lung base.
NOTIFICATION: Finding #1 was communicated by Dr. ___ to IV nurse, ___,
via pager at 1:45 p.m. on ___. Radiology showed 1. Status-post splenectomy with post-surgical changes in the splenectomy bed.
2. No intra-abdominal or pelvic collection noted.
3. Small residual right lower lobe pneumothorax.
4. Bilateral small-to-moderate pleural effusions.
5. Indeterminate left adnexal mass for which an elective ultrasound is
recommended when the patient is stabilized. Radiology showed Cholelithiasis. On some images the gallbladder wall appears mildly edematous,
but without other signs specific for cholecystitis. MR HEAD W/O CONTRAST showed No acute infarct, hemorrhage or mass effect.
Extensive nonspecific white matter abnormalities, likely sequela of chronic
small vessel ischemic disease. Radiology showed AP chest compared to ___:
Three serial chest radiographs show initial positioning of the Dobbhoff tube
in the distal right lower lobe bronchial tree, then at the gastroesophageal
junction, finally in the upper stomach. None of the chest radiographs shows
right pneumothorax, or evidence of bleeding in the right lung. Presumed right
pleural effusion is small. Previous consolidation in the right lung laterally
has improved since ___. Left lower lobe, however, is more consolidated
today with greater volume loss, indicating worsening of a component of
atelectasis, despite at least a small left pleural effusion. Followup for
possible complications of the bronchial intubation and possible left lower
lobe pneumonia.
No pneumothorax. Tracheostomy tube in standard placement. Left PIC line ends
in the upper SVC. Radiology showed AP chest compared to ___:
Feeding tube with a wire stylet initially placed in the lower esophagus is on
the second image advanced into the upper stomach. Moderate left pleural
effusion changed in distribution but not in overall size. Pulmonary vascular
congestion, more readily assessed in the right lung, has progressed. Heart
size top normal. Tracheostomy tube in standard placement. Left PIC line ends
at the origin of the SVC. No pneumothorax. Radiology showed 8 ___ ___ catheter left within the stomach. Despite repeated
attempts, unable to be advanced past the gastrojejunostomy.
Please note when ordering this study in the future with instructions to
bridle, only 8 and 10 ___ tubes can be successfully bridled. Radiology showed AP chest compared to ___ through ___:
Mild pulmonary edema has improved, moderate left pleural effusion has
increased. Mild-to-moderate cardiomegaly stable. Feeding tube ends in the
stomach. Tracheostomy tube in standard placement. Left PICC line ends in the
upper-to-mid SVC. No pneumothorax. CHEST (PORTABLE AP) showed Worsened fluid status. An underlying infectious infiltrate can't be excluded Radiology showed 1. Numerous left rib fractures with left hemothorax and possible left
pneumothorax. Other known right rib fractures and right pneumothorax are
better seen on concurrent CT of the chest.
2. Left superior and inferior pubic rami fractures and comminuted left sacral
alar fracture Radiology showed 1. Splenic lacerations (AAST grade 3) with several pseudoaneurysms, the
largest measuring 1.6 cm. The small inferior-most pseudoaneurysm may have a
tiny component of active extravasation.
2. Moderate left hemothorax with small bilateral pneumothoraces.
3. Small left lung contusion at the lingula.
4. Small hemoperitoneum with hemorrhage also in the left retroperitoneum and
pelvis.
5. Comminuted left acetabular column and left inferior pubic ramus fracture.
Comminuted left sacral alar fracture.
6. Fracture of the left L5 transverse process. Numerous left segmental rib
fractures as detailed above and several nonsegmental right rib fractures.
7. Cholelithiasis and adenomyomatosis of the gallbladder fundus.
8. Left adrenal myelolipoma.
These results were communicated to the surgery team immediately at the time of
discovery in person by ___, approximately 3:30 p.m., ___. The patient was diagnosed with SPLEEN PARENCHYMA LACER, FRACTURE OF PUBIS-CLOSED, FX SACRUM/COCCYX-CLOSED, FX LUMBAR VERTEBRA-CLOSE, TRAUM HEMOTHORAX-CLOSED, FX MULT RIBS NOS-CLOSED, MV COLLISION NOS-DRIVER. The patient was treated with ___ - open splenectomy
___ - L S1 screw, ant column screw
___ - bedside tracheostomy. At the time of discharge, the patient had Polytrauma following MVC. The patient was given written instructions concerning 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 the restrained driver in an ___, and was intubated
at an outside hospital and transferred to ___. After being
examined in the trauma bay, she was admitted to the ICU.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of multiple GI surgeries, now
presenting with persistent abdominal pain s/p ERCP with stent
placement. She has had recurrent abdominal pain and "issues"
over the past year. She went to ___ for initial
evaluation of abdominal pain and was found to have a UTI. She
had a subsequent evaluation with EGD/ERCP with stent placement.
She was reportedly found to have pancreatitis and treated with
bowel rest. She had minimal improvement during this
hospitalization. She was eventually discharged yesterday but
pain has persisted and she is unable to care for her children at
home, so she is presenting now for further evaluation.
In the ED, initial VS were: 98.2 87 125/85 18 97%. Exam notable
for moderate tenderness to palpation to RUQ. LFTs and lipase
normal with only mild ALT elevation. Given recent stent
placement, CT abd/pelvis done and only showed lymphandenopathy
with stent in place. She was given 1L NS, ondansetron, and
morphine with minimal improvement. With her persistent pain and
intolerance to PO, she is being admitted for pain control and
observation.
On arrival to the floor, pt feels well. She has no complaints
aside from constipation and decreased po intake. Radiology showed 1. No acute intrapelvic process.
2. Post-operative anatomy compatible with history of heterotaxy and
malrotation.
3. Several nodular enhancing soft tissue densities at the celiac axis
measuring up to 1.5 cm in short axis. These may represent lymph nodes of
unknown significance. In addition, thes could represent an atypical location
of splenosis. Given the patient's altered anatomy, the celiac axis is
adjacent to the splenic tail. No normal spleen is visualized. The patient was diagnosed with ABDOMINAL PAIN RUQ, NAUSEA WITH VOMITING. At the time of discharge, the patient had Post procedural 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>BRIEF HOSPITAL COURSE + ACTIVE ISSUES
___ year old female with history of multiple abdominal surgeries
and recent ERCP with stent placement, presenting with worsening,
persistent RUQ abdominal pain.
Patient with normal CT scan and reassuring labs. She is
hemodynamically stable and her exam is not concerning for an
acute abdomen. Exam negative for any discomfort. Lipase is
normal. Counseled about gradual relief of pain as pancreatitis
resolves. She was monitored over course of morning and afternoon
of ___ with improving abdominal pain. Was continued on home
medications in-house, and we ensured bowel movement and regular
diet prior to discharge.
INACTIVE ISSUES
# Continued on outpatient psychiatric medications. Medications
reconcilled with pharmacy.
TRANSITIONAL ISSUES
- f/u ERCP in 8 weeks for stent removal </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx CVAs (relatively nonverbal), HTN, HLD, AFib, G-tube,
and atonic colon with several recent admissions for concern of
obstruction who presented from rehab after pulling out G-tube
and with significant abdominal distention. Radiology showed Prominent colonic distention to a maximum of 11 cm, increased
compared to prior examination. This is fairly similar in appearance to some
of the patient's prior examinations including one dated from ___ and
is most likely chronic, secondary to dysmotility. Radiology showed AP chest compared to ___:
Previous large pneumoperitoneum no longer visible. New opacification in the
right upper lung with volume loss could be largely atelectasis but raises
concern for pneumonia. ET tube is in standard position, with the chin flexed.
Upper enteric drainage tube passes into a non-distended stomach. The gut in
the upper abdomen remains moderately to severely distended. Heart is
moderately enlarged, unchanged, but there is no vascular congestion, edema or
appreciable effusion. Radiology showed AP chest compared to ___, 8:47 p.m.:
ET tube in standard placement, nasogastric tube passes into non-distended
stomach. Right internal jugular line ends in the right atrium, approximately
9 cm below the level of the carina, would need to be withdrawn 5 cm to
reposition it in the low SVC. Opacification in the right upper lobe has
improved suggesting it was due in large part to atelectasis. Followup
advised. Moderate cardiomegaly has improved. Left lung is clear. No
pneumothorax or pleural effusion. The intestines in the upper abdomen remain
moderately-to-severely distended. Radiology showed Right IJ line has been withdrawn, probably ends in the upper
atrium since it is still 7 cm below the level of the carina, and would need to
be further withdrawn 3 cm to reposition it low in the SVC. No pneumothorax or
pleural effusion. Right upper lobe atelectasis has almost entirely cleared.
Mild cardiomegaly is stable. ET tube in standard placement. Upper enteric
drainage tube passes into a non-distended stomach. Intestinal segments in the
upper abdomen are still moderately-to-severely distended. Radiology showed Successful replacement of 20 ___ MIC G-tube. Radiology showed Persistent colonic dilatation, substantially increased, now with a maximal
dilatation of 14 cm. This is compatible with known pseudoobstruction, but
volvulus is not excluded in this current study. If clinical concern for
obstruction persists, a gastrograffin enema or CT may be considered.
Otherwise, short-term follow-up radiographs are recommended. The degree of
dilatation may pose a risk of perforation and close follow-up is suggested. Radiology showed Gas throughout the colon largely unchanged since 1 day prior consistent with
excessive ileus. No evidence of obstruction. Radiology showed Uncomplicated ultrasound and fluoroscopically guided single-lumen
PICC via the right basilic vein. The final internal length is 35 cm with its
tip positioned in the low superior vena cava. The line is ready for use. The patient was diagnosed with FLATUL/ERUCTAT/GAS PAIN. The patient was treated with G-tube placement ___
PICC line placement ___. At the time of discharge, the patient had Primary: Abdominal distention to to atony, pulled G-tube, UTI,
atrial fibrillation with aberrancy, respiratory failure
Secondary: CVA, myleoproliferative 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>___ with hx CVAs (relatively nonverbal), HTN, HLD, AFib, G-tube,
and atonic colon with several recent admissions for concern of
obstruction who presented from rehab after pulling out G-tube
and with significant abdominal distention.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Female sent from her SNF for concern that her JP
drain fell out the morning of admission. There is concern for a
surgical site infection. In brief she underwent a ___
laminectomy for spinal stenosis in ___ which was complicated
by wound dehiscence and a spinal leak, and was admitted in
___ for debridement and irrigation, with subsequent planned
debridement and paraspinus muscle flaps by PRS recently
(discharged ___ who was discharged with a JP-drain in place
which apparently became discharged the morning, and this
prompted transfer to ___ ED. Of note she also was noted with
a pneumonia at her SNF 2 days prior to transfer for which she
was placed on augmentin. The SNF notes purulent drainage in the
JP drain output. Radiology showed Cardiomegaly with pulmonary edema though improved since prior and persistent
bilateral pleural effusions. CT L-SPINE W/ CONTRAST showed 1. Status post L3-4 and L4-5 hemilaminectomies as well as recent paraspinous
muscle flap repair of dehisced lumbar surgical wound. Expected postsurgical
changes are seen within the midline soft tissues extending from the L1-L5
levels. Specifically, ill-defined enhancement throughout the surgical bed may
be postsurgical, but early developing phlegmon would be difficult to exclude.
Additionally, a 2.9 cm region of air within the midline wound at the L1-2
level may also be postsurgical, although abscess formation would be difficult
to exclude.
2. Sigmoid diverticulosis. Small volume pelvic free fluid surrounding the
sigmoid colon is nonspecific but limits evaluation for acute diverticulitis.
3. Bilateral pleural effusions. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with JP drain removal. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY:
___ yo F PMHx HFpEF, HTN, T2DM, CKD, prior ischemic CVA,
hypothyroidism, and spinal stenosis s/p L3-4/L4-5
hemilaminectomy/ foraminotomy (___) c/b wound dehiscence and
spinal leak requiring debridement, ___ followed by
lumbar wound debridement and muscle flap closure s/p wound vac
placement with JP in ___, who presents from ___ after
JP drain became dislodged. PRS Surgery consulted. JP drain was
removed. There was no concern for surgical site infection per
PRS. Patient will follow-up with Plastic Surgery as an
outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female medical history of hypertension presents
with the above injury s/p mechanical fall. Patient denies
numbness, tingling, weakness, head strike, LOC, or other
injuries. She is accompanied by her sister who she lives with.
She is reportedly very active and still works. Outside hospital
obtained CT of the head which did not show any acute cerebral
hemorrhage. HIP 1 VIEW was done. The patient was diagnosed with Fracture of unsp part of neck of right femur, init, Fall on same level, unspecified, initial encounter. The patient was treated with Right hip hemiarthroplasty ___, ___. At the time of discharge, the patient had Right femoral neck 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 right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing 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: ___ presents to ED with abdominal pain. PELVIS, NON-OBSTETRIC showed 1. No substantial change in findings likely reflecting left hematosalpinx.
2. Unchanged hyperemia of the normal size left ovary. Normal arterial and
venous flow without evidence of torsion.
3. Moderate volume complex pelvic free fluid.
NOTIFICATION: The findings were discussed with Dr. ___ by ___,
M.D. on the telephone on ___ at 3:29 pm, 1 minutes after discovery of the
findings. The patient was diagnosed with Torsion of left ovary and ovarian pedicle. At the time of discharge, the patient had Hematosalpinx. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to the ED with abdominal pain since the
afternoon of ___. She had CT scan showing no evidence of
appendicitis but questionable torsion. She then had a PUS which
showed a dilated fallopian tube and complex material with
possible torsion. Pain improved to ___ at time of OB/GYN
consult, without requirement for pain medication. Given imaging
reassuring against torsion, plan made for admission for
observation overnight.
The next morning, labs were stable without concern for infection
or bleeding. She remained stable without further pain medication
requirement overnight, so plan was made for discharge home with
outpatient followup.</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 a PMH of alcoholic cirrhosis c/b ascites, esophageal
varices
(s/p banding ___ HCC (s/p TACE), who presents with
abdominal pain. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with large volume ascites and multiple hypoechoic masses,
as better seen on prior MR.
2. Edematous gallbladder wall likely secondary to chronic liver disease.
3. The spleen is top-normal in size. Chest: Frontal and lateral views showed Interval progression of probable atelectasis of the right lung base. Left
lung opacity appears improved compared to most recent chest radiograph from ___. CT ABDOMEN AND PELVIS WITHOUT CONTRAST showed 1. Cirrhotic liver morphology with increasing large volume ascites.
2. Lipiodol in segments VIII and V post recent TACE.
3. No intra-abdominal fluid collections.
4. Unremarkable non-contrast appearance of the small and large bowel. Radiology showed Low bilateral lung volumes. New pulmonary vascular congestion without overt
pulmonary edema. Bibasilar atelectasis is noted, right greater than left. No
pleural effusion or pneumothorax. The size of the cardiac silhouette is
within normal limits. Degenerative changes are present around the left
shoulder. Ultrasound-guided paracentesis showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3 L of fluid were removed. CT HEAD W/O CONTRAST Q111 showed No evidence of an intracranial mass within the limitations of noncontrast CT.
No evidence of an acute intracranial abnormality. ULTRASOUND-GUIDED PARACENTESIS showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3 L of fluid were removed. ULTRASOUND-GUIDED PARACENTESIS showed 1. Technically successful ultrasound guided diagnostic paracentesis.
2. 22 cc of fluid were removed. Radiology showed Increased hazy opacity of bilateral lungs, right greater than left, could
represent worsening moderate pulmonary edema. Infection cannot be excluded.
This could be followed on subsequent exams.
Likely small right pleural effusion. Cardiac silhouette appears unchanged.
Degenerative changes of bilateral shoulders. Ultrasound paracentesis showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 2.5 L of fluid were removed. Radiology showed 1. Small amount of hyperdense blood layering in ascites in the posterior right
abdomen, measuring approximately 5.3 x 3.6 x 5.4 cm.
2. Similar volume large ascites, now measures slightly higher than simple
fluid density, likely due to mixture with blood products.
3. Colonic diverticulosis.
4. Bilateral gynecomastia.
5. Cirrhotic liver morphology with post treatment changes. Ultrasound-guided paracentesis showed 1. Successful therapeutic paracentesis, with the patient being hemodynamically
stable at the end of the procedure.
2. 3 L of serosanguineous fluid were removed. No samples were sent. The patient was diagnosed with Alcoholic cirrhosis of liver with ascites. The patient was treated with Diagnostic/therapeutic paracentesis ___
Diagnostic paracentesis ___
Diagnostic/therapeutic paracentesis ___ with ___
Therapeutic paracentesis ___ with ___. At the time of discharge, the patient had Alcoholic cirrhosis
Hepatocellular carcinoma
Post-TACE decompensation of cirrhosis
Acute kidney injury
Hepatorenal syndrome
C difficile infection
Chronic neuropathy
QT Prolongation
Hyponatremia. The patient was given written instructions concerning 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 man with a PMH of alcoholic
cirrhosis c/b ascites, esophageal varices (s/p banding
___ HCC (s/p TACE), who presented with abdominal pain,
worsening ascites, ___ consistent with hepatorenal syndrome.
ACTIVE ISSUES
=============
# ACUTE KIDNEY INJURY / Hepatorenal Syndrome:
Creatinine 2.1 on admission from recent discharge Cr 1.1.
Differential included pre-renal in the setting of decreased
intravascular volume given third spacing and poor nutritional
status, as well as poor PO intake, and resumption of diuretics
upon last discharge, ATN (ischemic vs. nephrotoxic), and CIN,
though less likely given lack of recent contrast administration
(though did undergo TACE ___. Patient underwent treatment and
monitoring for hepatorenal syndrome with octreotide and
midodrine, and this diagnosis seemed increasingly likely given
his persistent sodium-avid urine studies and lack of improvement
with daily albumin. Creatinine peaked at 4.5. Nephrology was
consulted for consideration of hemodialysis. There was no urgent
need for HD and question of whether he would tolerate it if
needed given his soft blood pressures. Ultimately he was weaned
off of octreotide. Creatinine overall downtrended and at time of
discharge Cr was 1.8. He was discharged with 15 mg PO TID
midodrine and preferred to not have renal followup. Labs will be
monitored by outpatient hepatologist.
# ALCOHOLIC CIRRHOSIS C/B ASCITES, ESOPHAGEAL VARICES
___ B cirrhosis, with MELD score of 24 on admission.
Complicated by esophageal varices (Banded ___, last EGD
___. Decompensated by mild hyponatremia and worsening
ascites, which were thought related to ischemia post-TACE vs.
progression of HCC. He was continued on Lactulose 30 mL PO TID.
Diuretics were held in setting of acute renal failure.
Management of ascites through therapeutic paracentesis (x3 over
course of hospitalization). Patient will have outpatient
paracentesis after discharge starting ___.
#Goals of care
Discussion held with treatment team, palliative care, patient
and wife regarding goals of care on ___. Patient prioritizes
independence, increased quality of life, and spending time at
home with family. Discussion was held about options of
tubefeeding, hemodialysis and pleurx catheter placement and that
some options may not be best aligned with his goals. Will plan
to continue ongoing discussion outpatient. Patient elected for
DNR/DNI on ___. He has palliative care followup scheduled
outpatient.
#Megaloblastic anemia
#Pancytopenia
#Acute blood loss anemia
Patient with anemia likely multifactorial due to chronic
megaloblatic anemia likely nutritional, with concern for
concurrent acute blood loss anemia in setting of acute Hgb/Hct
drop and CT imaging suggestive of bleed likely ___ paracentesis
on ___. He received 2u pRBCs and Hgb remained stable. Discharge
Hb 10.3.
# Neuropathy
Etiology of paresthesias in distal fingers and toes is unclear,
possibly related to alcohol use. Gabapentin was initially held
given concern for worsening of tremors, however patient felt
that the neuropathy was his most debilitating symptom. Restarted
gabapentin renally dosed, 300 mg BID with some improvement.
Please monitor renal function outpatient and titrate
accordingly.
#QT Prolongation
Patient alarming on tele for a few beats of Vtach/Vfib. Patient
was asymptomatic. EKG showed QT prolonged at 534. Patient was on
standing Zofran, prn Compazine, quetiapine qhs, mirtazapine qhs,
all of which were discontinued.
# ABDOMINAL PAIN:
# NAUSEA:
On admission had acute on chronic abdominal pain, accompanied by
ongoing nausea. Diagnostic paracentesis was not concerning for
SBP. Pain likely multifactorial from large volume ascites and
capsular distension from cirrhosis/HCC. Pain was adequately
managed with PRN Tylenol. Fentanyl patch and Tramadol had been
started in rehab, were discontinued on discharge as they were
not needed.
# TREMOR AND HALLUCINATIONS
The patient developed a new intention tremor and visual
hallucinations during his recent admission. This was thought to
be adverse effect of one of his pain medications (top contenders
were felt to be oxycodone and gabapentin). Neurology saw him on
last admission and agreed with this assessment. Unfortunately,
the tremors have persisted. CT head without contrast showed no
e/o acute intracranial process and gabapentin was restarted
without exacerbation of these symptoms.
CHRONIC ISSUES
==============
# HEPATOCELLULAR CARCINOMA
The patient was diagnosed with hepatocellular carcinoma in
___. Enlargement of previously identified liver lesion
(2.1cm->2.3cm) seen during ___ admission with multiple new
lesions (4 total). He underwent TACE on ___ and will followup
outpatient with hepatology.
# HCV
The patient had a weakly positive (less than 1.50E+01 IU/mL) HCV
viral load in ___, but the patient's last negative HCV antibody
was in ___. HCV antibody and viral load were repeated during
___ admission and both were negative.
# MODERATE MALNUTRITION
Patient presents with moderate malnutrition in the setting of
chronic alcoholic cirrhosis. He continued MVI, Thiamine. Started
megestrol for poor appetite with some improvement.
# DEPRESSION:
Sertraline 50 mg daily was held on discharge on ___ for
unclear reason. Patient was not receiving at rehab. Can consider
restarting.
# GERD:
Decreased omeprazole to 20 mg daily.
# C. DIFF COLITIS:
Diagnosed during ___ admission. The patient received a
course of Flagyl started ___, ultimately a 2 week course from
end date of ceftriaxone (course: ___. Repeat C diff
stool study negative on ___.
CORE MEASURES
=============
# CODE: DNR/DNI
# CONTACT: ___, wife, ___
TRANSITIONAL ISSUES
==================
[ ] Restarted gabapentin renally dosed, 300 mg BID (decreased
from 300 TID). Please monitor renal function outpatient and
titrate accordingly.
[ ] Discharged with 15 mg Midodrine TID.
[ ] Decreased omeprazole to 20 mg daily.
[ ] Started megestrol for poor appetite.
[ ] Held spironolactone on discharge due to worsening renal
function and managing volume with paracentesis.
[ ] DNR form signed upon discharge. Consider filling out MOLST
form at outpatient followup as goals of care are further
elucidated.
[ ] Discharged with ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with past medical history of central-line
associated aortic valve endocarditis (s/p porcine aortic valve
replacement with course c/b periprocedural stroke and residual
left-sided deficits), MI (on aspirin), and gastric lap banding
(___) who presents with two separate episodes of syncope
and pre-syncope. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No evidence of hemorrhage or infarction.
2. No evidence of dissection, occlusion, or stenosis. Incidentally noted 1-2
mm aneurysm at the left paraclinoid internal carotid artery.
3. Interstitial micronodules in the lung apices and a calcified mediastinal
lymph node, which may be suggestive of sarcoidosis.
4. 5 mm nodule and 3 mm nodule incidentally noted within the right upper lobe.
Please see ___ society guidelines as outlined below.
5. Incidentally noted 5 mm left thyroid nodule, which does not require
follow-up by ___ guidelines unless there is additional clinical concern given
the size and patient's age.
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 Syncope and collapse. At the time of discharge, the patient had PRIMARY DIAGNOSES:
- Syncope
SECONDARY DIAGNOSIS:
- Elevated blood pressure without diagnosis of hypertension
- Pulmonary nodules and micronodules
- Thyroid nodule. The patient was given written instructions concerning 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 patient is a ___ year old female with a past medical history
of a central line associated aortic valve endocarditis (with a
porcine aortic valve replacement complicated by a
___ CVA with left sided deficits), MI (on aspirin),
and gastric lap banding (___) who presents with two
episodes of recent falls.
ACTIVE ISSUES
# Falls/Syncope:
Pt with two syncope-like episodes. One episode occurred a week
prior to arrival (without prodrome and true loss of
consciousness); the second episode seemed to be more vertiginous
in nature, with room-spinning dizziness and weakness that
resolved upon sitting down. Given patient's complicated cardiac
history, she was evaluated for ischemic/arrhythmic etiology of
her falls. Troponins were negative x2, an EKG showed a right
bundle branch block and T wave inversions (stable compared to
previous EKGs). An Echocardiogram was done, without new drop in
EF/wall motion abnormalities/valvular defects since the earlier
study from ___. Overnight telemetry did not show any
arrhythmias. CT head and CTA that did not reveal any acute
processes or issues with cranial perfusion. Possible
contributors to Pt's syncopal/near-syncopal episodes include
transient cardiac arrhythmia (not observed on 24hrs of
telemetry), poor PO intake (Pt hydrating well but not eating
much). She was discharged home with an order placed for an
event monitor (no monitors available at ___ at time of
discharge), and encouraged to follow up with her PCP and primary
cardiologist.
# Elevated blood pressures without diagnosis of hypertension:
Pt with SBP's into the 170-180's while in the ED. These
resolved spontaneously to SBP < 140 on arrival to the floor.
Not started on antihypertensives given no clear diagnosis prior
to arrival.
- f/u pressures in office.
# Incidental pulmonary nodules and
# Pulmonary micronodules:
5mm and 3mm RUL nodules noted incidentally on wet read of CTA
head/neck; also with calcified mediastinal lymph node and
interstitial/perifissural micronodules in the apices, possibly
consistent with sarcoidosis. Per ___ Society Guidelines,
no follow-up recommended in a low-risk patient with low-risk
history. Given the possible consistency with sarcoidosis,
further evaluation with repeat chest CT - or rheumatology
referral - could be considered.
- Consider rheumatology evaluation as outpatient
- Follow up on final read of CTA head/neck
# Incidental thyroid nodule:
Also noted on wet read CTA head/neck. 5mm L thyroid nodule,
which by ___ recommendations does not require follow-up unless
there is additional clinical concern.
- Follow up final read of CTA head/neck.
# Incidental 1-2 mm L paraclinoid internal carotid
artery/aneurysm:
Noted on wet read CTA head/neck.
- Follow up final read CTA head/neck. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx DM, HTN, Depression, Gastric bypass, and ___
tylenol overdose presents from ___ with oliguria. Per the pt
and her son, on ___ she had a tylenol overdose, for which she
was taken to ___, and found to have a tylenol level of
>400, and DKA. Presumably she was treated with NAC and insulin
gtt. During her stay she was started on HCTZ and cymbalta. She
was discharged on ___ to ___. Since ___ of this week,
the pt felt like she couldn't urinate much, just small trickles
that were cloudy and occasionally pink. She endorsed some
chronic lower back pain, chronic n/v, and new suprapubic pain.
She denied fevers/chills. Her facility was concerned re: urinary
retention and so sent her into the ED.
In the ED, initial vs were: T 96.4 P 67 BP 116/49 R18 O2 sat 97%
RA. Given history thought c/w UTI, the pt was given Bactrim DS
x1.
Cr noted to be 6.0 from 0.7 on d/c from ___ 3.0 on ___
Foley flushed but still no urine draining, US showed collapsed
bladder. Glucose 53, given ___ amp D5. Pt received 3L ns.
On the floor, she was 98.2 120/60 72 18 98%RA. She complained of
some chronic LBP, and increased subprapubic pain with the foley.
She denied taking any non-prescribed medications, denied NSAIDs,
denied current SI. Radiology showed Normal kidney ultrasound. Echogenic liver. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had Acute Kidney Injury
Urinary Tract Infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with DM, HTN, Depression, ___ Tylenol overdose presents
from ___ with oliguria and ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old gentleman with a history of HTN, DM, lumbar
microdisectomy s/p spinal stimulator, and chronic pain on
narcotics contract presenting with fevers, headaches, and
confusion. Patient reports four days of headache and fever to
102. His headache is frontal, throbbing. He denies neck pain or
stiffness. He reports photophobia and nausea associated. Mild
nonproductive cough as well. He initially presented to ___
___ on ___ with these symptoms. Review of records from
outside hospital indicates patient had negative flu swab,
negative UA. At the OSH, he had a leukocytosis to 16 and was
treated empirically for meningitis/encephalitis with IV
Vancomycin/CTX/Acyclovir. NCHCT did not have any acute
abnormalities. LP was not performed was he had a spinal cord
device implanted. He eventually left AMA. He presented to the
___ on ___ for further management given ongoing symptoms. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. Hepatic cysts. The patient was diagnosed with Pneumonia, unspecified organism, Headache, Dehydration. At the time of discharge, the patient had Primary:
Community Acquired Pneumonia
Transaminitis
Secondary:
Hypertension
Diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman with a history of HTN, DM, lumbar
microdisectomy s/p spinal stimulator, and chronic pain on
narcotics contract who presented with fevers, headaches, and
confusion. Found to have CAP and treated with 5 days of
CTX/Azithromycin. Discharged in stable condition.
# Concern for Meningitis:
The patient presented after leaving AMA from OSH with concern
for meningitis due to headaches, fever, and confusion. He had
been empirically started on Vancomycin, CTX, and acyclovir and
these were continued. His symptoms resolved with the exception
of mild residual headache. He underwent delayed LP which showed
unremarkable cellular composition of CSF. HSV PCR was negative.
Antibiotics were stopped with the exception of CAP treatment
(see below). CSF and blood cultures were pending on discharge
and should be followed-up in the outpatient setting.
# Community Acquired Pneumonia:
Patient presented with fevers and productive cough. He was found
to have a right middle lobe consolidation consistent with CAP.
Treated with 5 days of CTX and Azithromycin (ENDED ___.
Symptoms improved on discharge.
# Transaminitis:
Patient found to have mild to moderate hepatocellular
transaminitis. RUQ US revealed steatosis. This should be further
followed-up in clinic. Consider HCV screening if not already
performed. Recommend repeat LFTs.
# Chronic Pain: Continued home regimen: Quetiapine Fumarate 50
mg PO QAM and 100 mg PO QHS, Pregabalin 300 mg pO TID, Baclofen
10 mg PO TID PRN pain, Lidocaine patch. Narcan script provided.
# Hypertension: Continued home Trandolapril 2 mg PO BID
# Diabetes Mellitus: Patient maintained on inuslin sliding scale
during hospitalization. Discharged on home regimen.
# Gout: Continued home Allopurinol ___ mg PO QDaily
# Insomnia: Continued home Mirtazapine 45 mg PO QHS and
Trazadone 100 mg PO QHS
TRANSITIONAL ISSUES:
- CSF and blood cultures were pending on discharge and should be
followed-up in the outpatient setting.
- Treated with 5 days of CTX and Azithromycin (ENDED ___
for CAP
- Transaminitis should be further followed-up in clinic.
Consider HCV screening if not already performed.
- Recommend repeat LFTs.
- Recommend continued downtitration of opioid regimen as
possible in the outpatient setting
- Patient prescribed naloxone in case of opioid overdose
- Patient on multiple seratonergic medications, please reassess
- Would recommend verification of allopurinol dosage which is
above usual dose
# CODE: Full (confirmed)
# CONTACT: ___ (___)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presents for bilateral knee pain after she played
tennis for ___ hours . Pt has some developmental delay and
participates in sports and recently flew to ___ for a tennis
tournament. She felt her both ankles were swollen after the long
plane ride. She also complains of cough which started last
___
for which she took a 8 day course of doxycycline which ended
yesterday. CHEST (PA AND LAT) showed 1. Numerous pulmonary metastatic lesions bilaterally. Given the size and
number of these lesions, it is difficult to exclude an underlying pneumonia.
2. No evidence of pulmonary edema. BILAT LOWER EXT VEINS showed 1. Completely occlusive clot within a right posterior tibial vein.
2. Nonvisualized right peroneal vein. CTA CHEST WITH CONTRAST showed 1. Limited examination due to the patient's body habitus and motion artifact.
2. Within these limitations, no evidence of large central pulmonary embolism.
3. Extensive hilar lymphadenopathy, which has progressed compared to ___. Numerous pulmonary metastatic lesions bilaterally, which seem to have
increased. Right chest wall involvement, which has also progressed.
4. New peribronchial ground-glass opacities and consolidations within the
lower lobes bilaterally, which raise concern for superimposed multifocal
pneumonia in the appropriate clinical setting. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Right posterior Tibial Vein clot
Community acquired pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ y F with Malignant peripheral nerve sheath
tumor,
metastatic to the lung despite Pazopanib treatment.
Pt has developmental disability , obesity and T2DM. She
recently had a flight to ___ and despite being active found
herself having leg swelling bilaterally.
US ___ showed R posterior tibial clot. Since it was
symptomatic for pt, decision was made to start pt on Lovenox
1mg\kg bid. Pt tolerated this without complicatinos and was
discharged in a stable condition</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of Diarrhea predominant IBS, Oropharyngeal dysphagia
(c/b aspiration now s/p GTube for nutrition), Stage IV
pancreatic cancer (c/b malignant ascites on protocol ___,
presents with vomiting. Chest radiograph showed 1. No pneumonia.
2. Small pleural effusions. CT abdomen and pelvis showed 1. Pancreatic body mass with upstream dilation and tail atrophy, similar to
prior.
2. Interval increase in now moderate sized right nonhemorrhagic pleural
effusion.
3. No dilated loops of bowel or free air.
4. Position of the G tube balloon appears slightly retracted and is not
definitively within the stomach lumen; this could be positioning or incomplete
distension of the stomach on this exam. Correlate with clinical assessment
and consider imaging after injecting G-tube with enteric contrast.
5. 7 x 3.3 cm collection along the left lateral lobe of the liver with mild
mass effect on the stomach is new or more conspicuous compared to the prior
exam. Multiple other intraperitoneal and pelvic fluid collections persist,
some overall unchanged, others perhaps slightly smaller.
6. Multiple hepatic hypodensities and extensive omental caking, consistent
with metastases are overall unchanged.
RECOMMENDATION(S): Correlate with clinical assessment and consider imaging
radiograph after injecting G-tube with sufficient oral contrast.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:33 pm, 20 minutes after discovery
of the findings. Radiology showed Enteric contrast administered via patient's PEG is noted within the stomach.
No extraluminal contrast identified. PARACENTESIS DIAGNOSTIC/THERAPEUTIC WITH IMAGING GUIDANCE showed -Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
-3.1 L of fluid were removed. Radiology showed Successful exchange of a gastrostomy tube for a new 12 ___ MIC gastrostomy
tube. The tube is ready to use. Video oropharyngeal swallow showed Intermittent aspiration with thin liquids. Penetration with nectar thick
consistency liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services). The patient was diagnosed with Unspecified abdominal pain. The patient was treated with Paracentesis - ___
G-Tube Replacement - ___. At the time of discharge, the patient had Primary Diagnosis:
- Nausea/Vomiting
- Malignant Ascites
- Bacterial Peritonitis
- Diarrhea
- Cough
- Oropharyngeal Dysphagia with Aspiration
- Severe Protein-Calorie Malnutrition
- Metastatic Pancreatic Cancer
- Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with a history of
diarrhea-predominant IBS, oropharyngeal dysphagia (c/b
aspiration now s/p G-Tube for nutrition), metastatic pancreatic
cancer (c/b malignant ascites) on protocol ___ who presents
with
nausea/vomiting and recurrent ascites.
# Nausea/Vomiting: Given temporal association to chemotherapy,
this is most likely chemotherapy induced nausea/vomiting, which
was insufficiently treated with PO medications at home.
Alternatively, may be due to mass effect of increased abdominal
fluid collection pushing on stomach. As well could be related to
bolus tube feeds. Obstruction unlikely as CT negative for it.
Much improved now and no further nausea or vomiting. Now
tolerating feeds with standing metoclopramide as needed.
# Diarrhea: Patient with increased diarrhea. Was briefly
constipated on admission but returned to diarrhea after
bisacodyl PR x1. Does have history of diarrhea predominant IBS
but large volume liquid diarrhea with nocturnal component is
suggestive of other etiology. He takes pancreatic enzyme
supplementation at appropriate dose (3 caps w/meals, 1 cap with
snack) so unlikely. At risk for SIBO or bile acid malabsorption.
Per patient, can handle at home with loperamide.
# Malignant Ascites:
# Bacterial Peritonitis: Patient s/p paracentesis on ___ with
PMN count 5,702. Possibly reactive from malignancy, procedures,
G-tube, but PMN count much higher than prior paras. ___ be
secondary from pulled back G-tube. Received CTX, remained
afebrile and stable, discharged on ciprofloxacin to complete 7
days.
# Cough: Patient with increased cough which is unlikely due to
PNA as CXR negative, but could be ___ increased aspiration of
oropharyngeal contents, post-nasal drip, viral process,
increased pleural effusion. Respiratory viral culture negative.
# Oropharyngeal Dysphagia with Aspiration:
# Severe Protein-Calorie Malnutrition: Patient is s/p G-tube and
typically receives Jevity 1.5 (7 cartons daily over 5 feedings)
with reglan to minimize vomiting, and loperamide to minimize
diarrhea. CT in ED had question of malposition of G-Tube but
contrast study showed appropriate filling of contrast in stomach
suggesting was in position however it needs upsizing and there
is still a question of proper location so patient underwent
replacement on ___. Patient was seen by nutrition and had
repeat video swallow which showed continued aspiration and
continued to
recommend NPO as diet. Switched =tube feeds to Jevity 1.5,
cycling over 16
hours which he tolerated.
# Metastatic Pancreatic Cancer: Metastatic to liver and omentum.
He is on clinical trial Protocol ___. Discussed with his
oncologist Dr. ___. Continued enoxaparin 80mg daily (study
drug)
# Anemia: Downtrending likely from IVF/albumin. Also due to bone
marrow suppression from chemotherapy and malignancy. He received
1 unit PRBC on ___.
====================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of polysubstance abuse, sciatica, and
psychiatric disorder who presents with chest pain, back pain,
and inability to ambulate s/p fall.
.
The patient states that he got into a fight at a club last
night, and was hit in the right eye with a pistol. He
experienced tearing chest pain that began in his left shoulder,
and radiated to his right hip and across his back. He states
that he was unable to ambulate, and was taken to the hospital in
an ambulence. Of note, the patient states that he used cocaine,
marijuana, and over 1 pint of vodka yesterday. He drinks at
least a pint of vodka daily.
.
In the ED, initial VS: 98.4 103 ___ 99% ra. Labs were
notable for Hct of 28.4 (baseline 36-38), Guaiac was negative.
CT head and sinuses were negative. CT abd without RP bleed. EKG
was reported to be sinus 98, NA/NI, TWF laterally. He received 2
L NS, percocet and 0.5 mg Dilaudid for the chest and back pain.
VS upon transfer 97.8, 84, 18, 125/89, 100%RA.
.
Currently, the patient is complaining of pain in his right eye
and lower back. Back pain is radiating down his right leg. He
states that he did have maroon stools 2 days ago, but has not
had a bowel movement since. No fevers, chills, N/V.
Occasionally has lower abdominal cramping, chronic since gunshot
wound to abdomen.
.
REVIEW OF SYSTEMS: Patient endorses urinary retention. Denies
fever, chills, night sweats, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Radiology showed No acute fracture. Stable degenerative changes. Radiology showed 1. No acute intracranial process.
2. No evidence of fracture. Radiology showed No acute cardiopulmonary process. Radiology showed 1. No evidence of fracture.
2. Paranasal sinus disease.
3. Unchanged asymmetric soft tissue in the left piriform sinus, as noted on
___, to be correlated with direct visualization. Radiology showed 1. No retroperitoneal hematoma.
2. No acute intra-abdominal or intrapelvic process allowing for non-contrast
technique. Radiology showed Stable multifactorial degenerative changes of the lumbar spine
without significant spinal canal stenosis and multilevel mild-to-moderate
neural foraminal narrowing. The patient was diagnosed with ANEMIA NOS, CHEST PAIN NOS, COCAINE ABUSE-UNSPEC. At the time of discharge, the patient had Anemia, Back pain, s/p eye trauma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old man with antisocial personality disorder admitted
for left eye pain and back pain s/p trauma with blunt object,
found to have diminished lower extremity sensation and
significant hematocrit drop from baseline.
.
# Normocytic anemia: The patient was admitted with a 10 point
hematocrit drop from baseline of 36-38 to 27.1. On admission,
he endorsed 4 episodes of maroon stool prior to admission.
Guaiac in the ED was negative. The patient had several
documented bowel movements during admission, but refused to save
stools to visualize or guaiac. He denied hematemesis or coffee
ground emesis. No evidence of RP bleed on CT. No evidence of
hemolysis on laboratory testing. On day 2 of admission, the
patient began refusing labs, so hematocrit could no longer be
followed. The patient was continued on folate, as he likely has
folate deficiency from chronic alcohol abuse (despite lack of
macrocytosis).
.
# Back pain/Inability to walk: On admission, the patient
endorsed acute inability to walk following trauma to lower back.
He described associated symptoms of decreased lower extremity
sensation bilaterally and urinary retention. He refused to
participate in lower extremity motor exam. He underwent
lumbosacral spine x-ray that was without evidence of fracture.
Given associated symptoms, the patient underwent lumbar spine
MRI that showed chronic degenerative disease (unchanged from
___ with mild chronic multilevel foraminal narrowing, but no
evidence of cord compression. The patient was continued on
tizanidine, acetaminophen, ibuprofen, and a lidocaine patch for
pain. He was not provided narcotics per psychiatry
recommendations. With stable MRI findings, the patient was
discharged to home. On discharge, he was able to stand, dress
himself, and ambulate with a cane. He was recommended to
continue ibuprofen for pain.
.
# Eye trauma: Patient with trauma to right eye from blunt end
of pistol. Right eyelid swollen closed. Appearance unchanged
over the course of admission. The patient was seen by
ophthalmology, who determined that there was no direct trauma to
the eye. He was found to have cotton wool spots from chronic
disease.
.
# Threatening behavior: On admission, the patient endorsed
intent to "kill the people out to get him" when he is
discharged. However, he did not specifically name anyone. He
also endorsed hearing voices, but was unable to report the
gender of the voices or what they were telling him. He demanded
Seroquel and Celexa throughout admission, stating that these
were chronic medications. However, he did not have a primary
provider and had only filled one prescription for short supply
written by the emergency department in the last year. The
patient was seen by psychiatry, who determined the patient has
antisocial personality disorder, and is without indication for
acute psychiatric admission or psychiatric medications. On the
day of discharge, the patient required security supervision, as
he was threatening staff. He was escorted from the building by
security at discharge.
.
# Polysubstance abuse: The patient reported cocaine and
marijuana use prior to admission. He also endorsed drinking a
pint of vodka a day. CIWA scale discontinued on second day of
admission, as patient consistently did not score. He was
continued on thiamine, folate, and B12 throughout admission.
.
# ___: On admission, creatinine elevated to 1.4 from baseline
of 1.1. ___ likely prerenal in the setting of blood loss, as it
resolved with IF fluids in the emergency department. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of recurrent episodes of abdominal pain
and bloating of unclear etiology, presenting with RLQ pain since
yesterday at 8 ___. Patient started having some right flank pain Radiology showed 1. No hydronephrosis or renal stone.
2. 8 mm appendix which is at the upper limits of normal for size without
definite signs of acute appendicitis. Radiology showed Left renal cyst. The patient was diagnosed with ABDOMINAL PAIN RLQ. At the time of discharge, the patient had Abdominal Pain, etiology unclear. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with history trichotillomania, OCD and
chronic abdominal bloating who presented with right-sided
abdominal pain distinct from bloating pains of unclear etiology.
# ABDOMINAL PAIN: Patient with long hx of bloating, but
describes current pain as very different. Pancreatitis,
nephrolithiasis, obstruction, UTI, appendicitis ruled out with
imaging and labs, no ovarian mass on CT or torsion or gallstones
on abdominal-pelvic US. No CMT on pelvic exam and denies recent
sexual activity (husband passed in ___. Functional (gas,
constipation, pre-menstrual cramps) remain on differential as
well as endometriosis. Hx of trichotillomania raises concern for
bezoar/obstruction, but patient passing stool and flatus, no SBO
noted on CT, not distended. Pain was well controlled with
ibuprofen at time of discharge
-Patient instructed to follow with PCP ___ 1 week of
discharge.
# ENLARGED APPENDIX: CT abdomen showed an enlarged appendix with
no signs of inflammation. Patient had no pain over Mc___'s
site, no fevers or leukocytosis. Surgery evaluated the imaging
and did not feel findings were consistent with acute
appendicitis. Most likely normal variant. Patient aware.
# VAGINAL DISCHARGE: likely physiologic.
- GC/Chlamydia PCR were pending at time of discharge</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 ___ year old female with a history of severe
eating disorder, anxiety, and hypothyroidism with a recent
admission for intentional overdose of psychiatric medication now
transferred from ___ for evaluation of SI and failure to
follow their eating disorder protocol as well as medical
clearance for bradycardia. CHEST (PORTABLE AP) showed Comparison to ___. The patient is extubated and the nasogastric
tube was removed. Otherwise the chest radiograph is stable and normal.
Normal size of the cardiac silhouette. Mild scoliosis. No pneumonia, no
pulmonary edema, no pleural effusions. The patient was diagnosed with Anorexia nervosa, unspecified. At the time of discharge, the patient had Primary Diagnosis
- Anorexia nervosa
- Malnutrition
- Bradycardia. The patient was given written instructions concerning 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 for continued weight loss and concern
for bradycardia at ___ Inpatient Eating disorder unit. She
arrived in stable condition, and has remained stable throughout
her admission. She was on the ___ eating disorder protocol and
did not fail any meals. She has gained about 4 lbs during
admission.
# Malnutrition secondary to anorexia nervosa
Ms. ___ was admitted on the eating disorder protocol which
is a multi-team protocol involving nutritionists, physicians,
social workers, psychiatrists, and nursing staff. Though she has
frequently complained about the restrictions and demands of the
protocol, she ultimately cooperated eating all meals in 30
minutes and being observed for one hour following. She has been
given a regimen of supplementation with nutriphos, a
multivitamin with minerals, thiamine, and folate. Basic
electrolytes have been evaluated daily and remained within
normal limits throughout her stay. She has gained weight during
her stay from 67% to 70% of ideal.
Behaviorally, she has been found in the kitchen on several
occasions after being told she could not be there. She attempted
and may have succeed in making caffeinated beverages and
sneaking sugar packets to her room to induce purging. Of note,
despite continuous complaints of hard small stools, no bowel
movements have been observed by nursing staff. Patient continued
to report constipation but none documented, frequently asked for
laxatives. With history of abuse none were given, especially
since she did report some BMs.
#Bradycardia: Initially transferred with concerns about extent
of bradycardia. At baseline, patient has sinus bradycardia at
rest. She was monitored on tele with rates as low as high ___
while sleeping, however during the day rates were ___ at
rest and rose appropriately with exercise. She had no
symptomatic bradycardia.
# Depression
Currently reports depressive symptoms that are likely
multifactorial from malnutrition and possible true depression.
She wants inpatient psychiatry at this time. She endorses
passive suicidal ideation and reports "holding back desires to
harm herself. During her stay she has been started on zyprexa
2.5mg TID with meals in addition to her normal 5mg qhs. QTC ___
was 382. She was not found to need a ___ or to need a 1:1
sitter.
Chronic Problems
================
# Anxiety
- clonazepam PRN
# Insomnia
- Diphenhydramine PRN
# Hypothyroidism
- continue levothyroxine 25mcg daily
# Anemia and leukopenia
Likely secondary to malnutrition, chronic and stable. HGB 10.4
on admission and 10.9 on ___. Leukopenia resolved prior to
discharge at 4.3 on ___
TRANSITIONAL ISSUES
===================
[] Despite gaining weight, she is still severely malnourished.
Additional inpatient treatment is needed with careful monitoring
of her diet and meals as she returns to a healthy weight.
[] She has made repeated attempts to obtain sugar or other
laxative substances. She still needs to be closely monitored at
all times.
[] She continues to endorse significant depressive symptoms
including thoughts of self harm. These might improve with
increased weight, however she has needed and will continue to
need close psychiatric care for both her eating disorder and
depression.
[] She has recently been started on zyprexa 2.5mg TID with meals
in addition to her long standing 5mg QHS. She may additional
dose adjustments.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with history of benign
neutropenia, psoriasis and recently diagnosed Crohn's disease
(in
___ of this year) on humira and chronic prednisone who presents
with high grade fevers and new petechial rash x2 days. US EXTREMITY LIMITED SOFT TISSUE RIGHT showed Subcutaneous edema and hyperemia without a drainable fluid collection. The patient was diagnosed with Fever, unspecified. The patient was treated with skin punch biopsy. At the time of discharge, the patient had arm abscess and soft tissue skin infection, cellulitis
pancytopenia. The patient was given written instructions concerning 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 lady with history of crohn's disease on adalimumab
who was admitted with pancytopenia and fevers and rash in
context
of travel to ___ and use of Bactrim for 10 days
prior to admission.
#Soft tissue infection/cellulitis/right antecubital fossa arm
abscess
-Underwent bedside biopsy by dermatology which produced 20 cc
purulence
on drainage. Biopsy prelim shows CoNS and no fungus seen or AFB
at time of discharge.
-initially on IV vancomycin, then transitioned to PO
doxycycline on ___ for 10 day course. This was recommended by
ID consult.
-patient will follow up with dermatology on ___ as scheduled.
#Pancytopenia
-Not suspecting tickborne illness. Anaplasma PCR negative.
Parvovirus IgG positive but IgM negative. Parasite smears
negative. Lyme serology negative.
-Heme onc consult suspect thus far that the cytopenias are
largely due to Bactrim bone marrow suppression She did require
1uPRBC on ___. Subsequent daily H/H demonstrates stability in
counts.
-Patient will have repeat CBC drawn a week from discharge for
follow up with her hematologist, Dr. ___.
#Crohn's disease
-Holding off on adalimumab due to
acute infection and neutropenia. Will remain on home
dose of prednisone on discharge.
-She will need to follow up with her primary GI, Dr. ___, on
discharge, to determine future re-introduction of humira as
outpatient.
Ms. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was 35
minutes.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI:
Mr. ___ is a ___ yo man with hx multiple vascular risk factors
including afib on Coumadin who presents from ___ with
RLE weakness, found to have IPH. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Unchanged acute left putaminal hematoma, measuring up to 1.4 cm allowing
for differences in imaging modalities. No definite underlying putaminal
lesion allowing for lack of intravenous contrast.
2. Findings compatible with an old right parietal infarct with associated
volume loss and gliosis.
3. Confluent white matter chronic small vessel ischemic disease given the
patient's age
___. Parenchymal involutional changes, likely age-related. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed Hemorrhage centered on left basal ganglia, stable, mild edema. There is mild
hyperemia, typical of early subacute hemorrhage, no evidence of underlying
mass or vascular malformation. Consider follow-up imaging when hemorrhage
resolves, if indicated.
Chronic infarcts. Severe chronic small vessel ischemic changes. Advanced
generalized brain parenchymal atrophy. Radiology showed Successful balloon angioplasty of mild in stent stenosis due to intimal
hyperplasia, with no residual stenosis seen post angioplasty.
RECOMMENDATION(S): The fistula may be used for dialysis immediately.
Case was discussed with Dr. ___ by telephone on ___ at 10:55 AM. The patient was diagnosed with Anesthesia of skin. At the time of discharge, the patient had Left putamen hemorrhagic stroke
Urinary tract infection
ESRD. The patient was given written instructions concerning 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 hx multiple vascular risk factors
including afib on Coumadin who presents from ___ with
RLE weakness, found to have L putamen IPH. His exam is notable
for asterixis, inattention, frontal release signs, mild anomia,
R facial droop and mild weakness of the RLE. NCHCT notable for
severe global atrophy, chronic R inferior division R MCA
infarct, vascular calcifications and small (0.6 cc) acute L
putamen IPH. Etiology likely hypertensive given SBP to 200s on
presentation to OSH.
MRI confirmed acute hemorrhage of the L putamen. His symptoms of
weakness resolved completely by the time of discharge. In
consultation with our nephrology colleagues, we controlled his
BP initially on labetolol and transitioned him to once daily
amlodipine prior to discharge. Given his multiple risk factors
for having another stroke (HTN with cerebrovascular disease on
imaging), A-fib, and diabetes, we restarted his Coumadin prior
to discharge with an Aspirin bridge. He was also diagnosed with
a UTI and was discharged to complete a 7-day course of oral
Bactrim.
Transitional issues:
- BP control: He is being discharged on Amlodipine 5mg PO daily.
He should wait until several (___) hours after dialysis to take
his amlodipine on HD days, and ideally try to take as close to
the same time every day as possible. Monitor carefully for
post-dialysis hypotension as this was an issue previously, and
he may require further adjustments of his regimen.
- Anti-coagulation: He is being discharged on Coumadin 2.5mg PO
daily, with an INR goal of ___. This is half his usual dose of
5mg PO daily while he is on Bactrim for his UTI. His Coumadin
will need to be increased again after this course is completed.
He is also taking Aspirin 81mg daily while restarting Coumadin.
This should be discontinued once his Coumadin is therapeutic.
- UTI: He is being discharged on a 7-day course of PO Bactrim
DS, beginning ___, to finish on ___.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
35 minutes were spent on discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PKD s/p LRRT ___ on tacro/MMF/prednisone, prostate
cancer, htn/hl, presents from ___ with fever/chills, and
shakes.
Pt is from ___, and get his care at ___ normally.
Pt is in town to visit this grandson.
Of note, pt was admitted to ___ in ___ for e
coli urosepsis. He completex ___ x 3 weeks - he did not remember
the name of the ___.
On morning of admission (___), pt reports onset of fever,
chills and rigor. He also noted urinary frequency w/o dysuria or
hematuria. He had clear emesis x 1. He otherwise denies cough,
diarrhea, new skin rash, or abdominal pain.
He presented initially to ___. He was noted to have T
100.8 HR 99, BP 132/84 RR 18 O2 97%RA.
At ___, lactate was 2.2, WBC 3.8. UA was +leuks, neg
nitrite. Tbili 1.36 Per record, UCx and blood cx was drawn.
CTU reportedly showed non-obstructing stone, transplanted
kidney did not show hydronephrosis.
Pt received vanc 1g, zosyn 2.25mg prior to transfer to ___.
In the ___ ED, vitals were: 100.7 ___ 12 94% RA
Labs were notable for: Cr 2.5 (baseline unknown), WBC 2.4 1 10%
bands, Hgb 12.3, lactate 1.3
Patient was given:
___ 00:29 IVF 1000 mL NS 1000 mL
Transplanted kidney ultrasound: Normal on prelim.
On the floor, pt reports feeling better. Though he reports that
he had loose stool x 1 since being in the hospital - he himself
attributed it to ___. On arrival to floor, nursing staff
received report that BCx grew GNB ___. DX CHEST PORTABLE PICC LINE PLACEMENT showed There is a new left-sided PICC line with tip in the mid SVC. There is no
pneumothorax. The lungs are clear. RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. ABDOMEN US (COMPLETE STUDY) showed 1. The patient is status post cholecystectomy.
2. Splenomegaly.
3. No sonographic evidence of abscess or other intraabdominal infectious
source. CHEST (PORTABLE AP) showed There no prior chest radiographs available for review. Lungs clear. Heart
size normal. No pleural abnormality. MRI of the Abdomen showed 1. Innumerable cysts in the liver and left kidney, as well as several small
cysts in the pancreas, in keeping with the history of polycystic kidney
disease. Many of them have hemorrhagic or proteinaceous material, though none
have overtly concerning features or evidence of an obvious infection on this
limited noncontrast exam.
2. Status post right nephrectomy. No abnormality in the surgical bed.
3. Splenomegaly. MR HEAD W/O CONTRAST PORT showed 1. No evidence for parenchymal abnormalities on noncontrast MRI. No
extra-axial collection. No evidence for meningitis on FLAIR images; however,
CSF studies would be more sensitive for meningitis.
2. Paranasal sinus abnormalities and trace fluid in bilateral mastoid air
cells may be secondary to prolonged supine positioning in the inpatient
setting. However, please correlate clinically whether there may be associated
infectious symptoms. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Sepsis
Gram-negative rod bacteremia
Acute kidney injury
Neutropenia
SECONDARY DIAGNOSES:
Autosomal dominant polycystic kidney disease
Status-post kidney transplant (___)
Hypertension
Hyperlipidemia
Prostate cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMHx PKD s/p LRRT ___ on tacro/MMF/prednisone, prostate
cancer, HTN/HLD, presenting with sepsis and GNB bacteremia
thought to be ___ infected intraabdominal cyst vs UTI.
# Severe Sepsis: following transfer from OSH, blood cultures at
OSH were notable for ___ bottles with (+) GNR. Initial concern
was for urinary source, given patient's recent admission for E.
coli UTI and bacteremia and concern for increased urinary
frequency. However urinalysis was unrevealing for infection,
given only 1WBC, negative nitrites, and trace leukocytes.
Infectious work-up was initiated, including blood, urine, stool,
and viral studies. He was initially hemodynamically unstable and
received a x1 dose of amikacin and aggressive IVF resuscitation.
With continued IVF, his blood pressure stabilized. Due to
ongoing fevers, he was transitioned from Zosyn to cefepime.
Blood cultures were repeated with fevers and were (+) for GNRs
x3 days, urine culture was negative. Due to persistence of
bacteremia and concern for poor source control, Infectious
Disease was consulted. In the setting of PKD, a MRI abdomen was
performed to assess for infected cysts which was unrevealing.
Due to patient's headaches, an MRI brain was performed which was
negative for intracranial process. An echo was obtained which
showed no vegetation. Following speciation of blood cultures and
improved stability of the patient, he was transitioned from
cefepime to CTX. Blood cultures after ___ were notable for no
growth. A PICC was placed to allow for completion a x4 week
course of antibiotics.
# ___ on CKD in the setting of PKD s/p LRRT (___): Cr 2.5 on
arrival, baseline creatinine 1.5 - 2.1. In addition, patient was
noted to have low urine output. A renal transplant ultrasound
was obtained which was normal. He received aggressive IVF
resuscitation and his MMF was held in the setting of sepsis. His
urine was spun and was notable for mild ATN. CMV was checked and
no viral load was detected. Urine BK was negative. He was
continued on tacrolimus and prednisone for immunosuppression.
Due to leukopenia (discussed below) his Bactrim ppx was held and
he was transitioned to dapsone. His creatinine was trended and
continued to improve; discharged with creatinine of 1.5. His MMF
was restarted day prior to discharge at a dose of 500mg BID;
outpatient provider should ___ as appropriate.
# Leukopenia/Neutropenia: during admission, patient was noted to
be neutropenic. Concern for marrow suppression in the setting of
persistent bacteremia vs EtOH use given patient reported daily
EtOH use vs splenic sequestration given splenomegaly on
exam/imaging vs medication-induced. His home bactrim was held
and he was transitioned to atovaquone for PCP ___. Heme-Onc was
consulted who recommended treatment with G-CSF, with resultant
resolution of his neutropenia. Of note, patient's imaging was
concerning for new splenomegaly; he should be monitored closely
and repeat imaging considered.
# HTN: on admission, his home anti-hypertensives were in setting
of sepsis. They were restarted in the hospital after his sepsis
resolved.
# HLD: he was continued on his home ezetimibe/simvastatin.
# Question of pre-diabetes: he was monitored on the insulin
sliding scale while in house and did not require insulin.
# GERD: he was continued on his home omeprazole
# Gout: his home colchicine was originally held in the setting
of ___ this was restarted prior to discharge
Transitional Issues:
[] D1 of clear blood cultures ___ plan for 4 week course of
CTX 2gm IV q24hr (last day ___
[] Given neutropenia, Bactrim was stopped and patient was
started on Dapsone 1500mg qd for PJP ppx
[] Tacrolimus trough was elevated on admission; discharged on
dose of 1.5mg BID. Plan to recheck level on ___
[] MMF was held on admission ___ sepsis; restarted at dose of
500mg BID, please ___ to home dose if needed (750mg BID)
[] Cinalcet was held ___ hypocalcemia during admission; please
continue to monitor
[] Physical exam and abd MRI notable for splenomegaly (measured
at 16.6 cm, no focal lesions) with previous obtained imaging
reports without mention of splenomegaly, please continue to
monitor
Code: FULL
Contact: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Two weeks prior to admission, Ms. ___ was in her usual state
and had noticed wide-based blisters developing on her right
lower extremity (RLE). While she was using a washcloth on her
right leg, she noted the removal of skin from a blister with
immediate drainage of clear fluid. Given her body habitus, she
cannot directly visualize her lower extremities. However, she
noted continued leakage based on the wetness on her clothes. She
believes the leakage rate increased over time, and 4 days prior
to admission noted the leakage of milky white fluid from the
lesions. That day, she was seen by her PCP who believed the
lesions to be venous stasis ulcers. She denies fevers and
endorses feeling chilly. On ___ she presented to the
___ ED due to concern about possible cellulitis. Radiology showed No radiographic evidence for osteomyelitis. Diffuse soft tissue swelling. VENOUS DUP EXT UNI (MAP/DVT) RIGHT showed Extremely limited examination secondary to patient's known right lower
extremity cellulitis. No evidence of deep venous thrombosis in the rightlower
extremity veins. The patient was diagnosed with Cellulitis of right lower limb. At the time of discharge, the patient had Primary:
Cellulitis
Venous stasis dermatitis. The patient was given written instructions concerning 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 T2DM, COPD, and prior cellulitis who
presents with RLE lesions most consistent with cellulitis ___
venous stasis dermatitis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of chronic anemia (Hct 30) who p/w fatigue and
palpitations x 3 months. She has also been having nonradiating,
exertional chest pain, ___ in intensity. She went to outpt
provider and was found to have Hct 18 and referred here for
further evaluation. She denies hemoptysis, hematemesis,
hematochezia, melena. She was guiac negative in the ED. She
does however endorse heavy periods, sometimes requiring ___ pads
per day. She denies sob, f/c, night sweats, rash, abd pain. Radiology showed Cardiomegaly with mild edema. Radiology showed 1. Echogenic kidneys, compatible with chronic renal disease.
2. 1.2 cm right upper pole renal cyst contains a single thin septation. No
dedicated followp necessary.
3. No splenomegaly. The patient was diagnosed with ANEMIA NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had Chronic kidney disease
iron deficiency anemia
symptomatic anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of chronic anemia (Hct 30) who p/w several months of
feeling dizzy and tachycardic as well as new onset CP, now with
acute on chronic anemia and chronic renal failure.
# Iron deficiency anemia, beta thalassemia, menorrhagia: This is
consistent with severe iron deficient anemia. Her CKD may also
contribute. She was treated with 2u PRBC with improvement of her
tachycardia, chest pain and shortness of breath. She continued
to feel palpitations. She was started on ferrous gluconate TID
(has not tolerated ferrous sulfate in the past due to pruritis).
She did not have any side effects. She was treated with colace
and senna as well. She will need to follow up with her PCP to
get repeat lab draws. She will follow up with nephrology where
she may require epo injections.
# Chronic kidney disease stage IV: Based on GFR she is nearly
stage V. Nephrology was consulted and think this is chronic
renal failure. She has protein in her urine but was not started
on an ACE inhibitor due to dizziness. She should be started on
one in the near future if she tolerates. She will follow up with
nephrology. This appointment will be scheduled by the nephrology
department with an interpreter and she will be contacted about
the appointment.
# Palpitations: Likely due to PVCs as seen on EKG. No evidence
of arrhythmia. Possibly exacerbated by anemia. She will need
further monitoring as an outpatient.
# Menorrhagia: She should receive further evaluation as an
outpatient to determine if further management is necessary.
Of note, she was warned not to take any more ___ herbs.
TRANSITIONAL ISSUES
- f/u pcp for labs and symptoms evaluation
- f/u nephrology for evaluation and treatment of CKD
- consider ACEi and epo (epo after iron repletion)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man with h/o Down syndrome who presents with cough for one
week and concern for PNA on CXR.
Per patients group leader, patient is minimally communicative at
baseline, but has had cough for approximately 1 week. He thinks
it may have been productive at first, but now appears to be dry.
His group leader denies associated symptoms including fever or
noticable shortness of breath. No one else in his group home is
sick, and patient is without recent hospitalization or abx
therapy. After group activities today, he developed a large
coughing fit and was incontinent of urine and refused to get up
off the floor, prompting the trip to the ED.
Initial VS in the ED: T 99.0, HR 100, BP 105/p, RR 20. Patient
triggered for O2 sat of 86% on room air. Initial labs were
notable for lactate 3.3, Cr 1.3, BUN 25, and leukocytosis to
12.2 with 95% N. Patient was given 750mg levofloxacin and 1L NS
prior to being admitted to medicine for furhter management. VS
prior to transfer: Temperature 99.4 °F (37.4 °C). Pulse 77.
Respiratory Rate 22. Blood Pressure 105/. O2 Saturation 98. O2
Flow ___ np. Pain Level 0.
On the floor, patient appears well. He intermittently nods yes
or no to questions, but appears very shy. He denies pain at this
time. Radiology showed Opacities in the lower lungs concerning for pneumonia. Radiology showed Resolving opacities in the lower lung. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ Male with down's syndrome with pneumonia.
# Cough: Likely PNA given CXR findings. Patient also hypoxic at
triage, but appears comfortable with normal O2 sat currently on
RA. Lactate mildly elevated at 3.3, decreased to 1.4 the
following morning after fluids. Given 750 Levo in the ED, and
continued daily on the floor. Will send home with 5 days of
levo. Repeat chest xray showed resolving opacities. Pt sent
home afebrile with O2 sats >90 on RA. Has appt for PCP follow
up.
# Incontinence: Not normally incontinent of urine. Likely due to
coughing fit and acute illness. UA was negative.
# Down syndrome: Will continue home meds for now including bowel
reg and Paxil.
# FEN: 500cc bolus, replete electrolytes, regular diet
# Prophylaxis: boots, bowel regimen
# Access: peripherals
# Code: Full (confirmed)
# Communication: Patient's Sister (HCP) </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with history of psychiatric illness (?ADHD,
anxiety, bipolar disorder) recently admitted and discharged from
___ who re-presents with disorientation. She reported to
the emergency department that she lost her medications. She
complains that her backpack was stolen and she is also concerned
her charger was stolen when she was in the emergency department. CHEST (PA AND LAT) showed 1. Bilateral streaky and patchy opacities likely represent atelectasis, but in
the appropriate clinical setting, patchy retrocardiac opacity could represent
very early pneumonia.
2. Compression deformity of L1 is age-indeterminate. The patient was diagnosed with Schizoaffective disorder, unspecified, Encounter for issue of repeat prescription. At the time of discharge, the patient had Schizoaffective disorder
COPD without acute exacerbation
R 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>This is a ___ with history of psychiatric disease who presented
with disorganized thinking. She was seen by psychiatry who
recommended inpatient psychiatric admission. She was
subsequently admitted to medicine for management of COPD
exacerbation.
#Chronic COPD without exacerbation
The patient was noted to have wheezing in the emergency
department and was treated for a COPD exacerbation with
Solumedrol and Azithromycin. Her lung exam was without wheezing
on admission to the medical floor, she was able to speak in full
sentences, she was afebrile and not short of breath on
ambulation making both COPD and Pneumonia unlikely. The patient
was monitored for a number of days in the ___ medical
setting on her home inhalers with good control of her
respiratory symptoms. Smoking cessation was advised.
#Schizoaffective disorder with decompensation.
The patient presented with delusions and disorganization after
her medications were stolen. She was seen by psychiatry who
placed a ___ and recommended inpatient admission. The
patient was intermittently agitated, requiring IM Haldol 5mg
IM/Ativan 2mg IV/Cogentin 1mg and a security sitter. She
continued to be agitated requiring a security sitter and doses
of the above medications. Attempts were made to place her in an
inpatient psych facility but no beds were available for several
days. She was continually evaluated by psych daily until it was
felt that she was no longer a harm to herself or others and
close to her baseline on ___. Her home abilify was
increased from 15 to 20 mg and she received an injection of
long-acting abilify prior to discharge. Arrangements with the
SW at ___ to assist pt in finding psychiatrist locally.
#Right humerus fracture
Missed outpatient follow up. Discussed with orthopedics who
reviewed X-ray. Patient can begin ROM. She should remain
non-weight bearing but can begin pendulum swings and follow up
in clinic after discharge. pain was managed with ibuprofen,
acetaminophen and oxycodone.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F w/ hx BRCA mutation, endometrial ca s/p TAH/
chemo/radiation, large bowel obstruction, radiation enteritis
p/w acute onset b/l lower abd pain and nausea/ emesis starting
at 1700 last night. Radiology showed No evidence of obstruction. No free air. Radiology showed No evidence of bowel obstruction. Chronic radiation fibrosis of the sigmoid
and rectum.
Hepatic steatosis. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormalities The patient was diagnosed with RECTAL & ANAL HEMORRHAGE, ABDOMINAL PAIN GENERALIZED. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
viral gastroenteritis
SECONDARY DIAGNOSIS:
radiation enteritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F with hx of radiation enteritis presenting with acute
onset nausea, vomiting, and crampy abdominal pain. Reports BRBPR
which she has had in the past. CT scan shows radiation enteritis
without obstruction. Believed to have viral gastroenteritis on
top of chronic radiation enteritis.
On day of admission pt complained of ___ chest pain, sharp,
pleuritic, reproducible, non-radiating with no
SOB/diaphoresis/palpitations. EKG similar to previous. Later
that day pt had episode of hypotension to 72 systolic,
asymptomatic, that prompted 2L fluid bolus, trops x 2
(negative), stat H/H (decrease from previous hemoconcentration
but recheck stable), and CXR (normal). This episode was
attributed to hypotension. Pt had not received any IVF since
admission so maintenance fluids were continued and blood
pressure responded appropriately.
On last day of admission patient complained of the medical team
not giving her meds as prescribed (her reported 300 mg colace
BID was changed to 200 mg BID and her home 0.3 mg clonidine TID
was held after hypotensive episode- pt was normotensive at the
time). Pt had taken home clonazepam and clonidine in the ED when
first admitted and was asking nursing for opiates for a headache
despite being on methadone. Her neuro exam was non-focal. Pt
eventually left AMA, despite counseling from medicine team, but
beforehand was informed to make f/u appointment with PCP and
discuss GI f/u. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M recently admitted to ___ surgery service on for
management of a cystic duct stump leak following lap CCY at an
OSH presents with abd pain and low grade temperatures. Pt and
wife report pain has been present for 3 days. Continuous, dull,
associated with nausea but no emesis. Pt is tolerating PO but
has had a decreased appetite. Some associated chills and fevers
to
102 at home.
During recent admission pt has an ___ guided drain placed in his
biloma. He had already had one in place from the OSH. He also
underwent ERCP and is s/p sphincterotomy and stent placement. He
was discharged to home on a 6 day course of C/F which he
finished. Radiology showed 1. Pain with scanning along the surgical drain over the mid
abdomen/periumbilical region. No fluid collection is identified along this
drain to suggest abscess formation, however.
2. Likely interval resolution of the previously seen biloma in the
gallbladder resection bed with a pigtail catheter remaining in place.
3. Stable liver cyst. Radiology showed 1. Interval decrease in size of the fluid collection within the gallbladder
resection bed compared to CT from ___, although the collection
has not completely drained. The pigtail catheter is seen along the edge of
the collection and correlation with catheter output is recommended to ensure
proper positioning.
2. Likely subcapsular 6.5 cm collection along the inferior aspect of the
right hepatic lobe appears more organized on the current study, now with a
thick surrounding rind.
3. Reactive changes, without evidence of abscess formation, along the distal
portion of the surgical drain that ends near the hepatic flexure. Of note,
this drain does not end within either of the intra-abdominal collections. The patient was diagnosed with OTHER SPEC COMPL S/P SURGERY, ACCIDENT NOS. At the time of discharge, the patient had Cystic duct stump leak and biloma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient with history of cystic duct stump leak and biloma
s/p percutaneous drainage was admitted to the General Surgical
Service with increased abdominal pain and fever. The patient
completed the course with Cipro/Flagyl at home. On admission,
the patient underwent abdominal CT, which demonstrated interval
decrease in size of the fluid collection within the gallbladder
and new undrainable right hepatic lobe fluid collection. The
patient was started on IV Unasyn, IV fluids and his Coumadin was
held. The patient was hemodynamically stable.
On HD # 2, patient was afebrile with stable vital signs, his
abdominal pain resolved. On HD # 3, patient was advanced to
regular diet with good tolerance, IV fluid were discontinued and
antibiotics were changed to PO Augmentin. Patient's percutaneous
drain was removed and he was restarted on home dose of Coumadin.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old gentleman with a PMH of
hyperlipidemia and obesity, now admitted s/p VF arrest. Radiology showed Satisfactory positioning of ET tube. Pulmonary edema. No
pneumothorax. Radiology showed 1. Support and monitoring devices are in satisfactory position. There is
improving mild pulmonary and interstitial edema. In addition, there is
retrocardiac opacity with probable associated layering left effusion which
likely reflects patchy atelectasis and is slightly worse when compared to the
prior study. No large pneumothorax is seen, although the sensitivity to
detect a pneumothorax is diminished given supine technique. Overall, cardiac
and mediastinal contours are unchanged. Radiology showed 1. Interval increase in mild pulmonary edema.
2. Minimal improvement in lung volumes. The patient was diagnosed with VENTRICULAR FIBRILLATION, CARDIAC ARREST. The patient was treated with - ___ - Cardiac catheterization
- ___ - 1. Simple extraction, teeth numbers 30 and 29. 2.
Surgical extraction, tooth number 19.
- ___ - CABG X 4 (LIMA-> LAD, SVG-> OM1, OM2, R PDA). At the time of discharge, the patient had Ventricular fibrillation arrest in the setting of 3 vessel
coronary disease
Hyperlipidemia since age ___ (has a history of being on Lipitor
and Crestor but stopped for the past year b/c he was concerned
about myalgias)
Benign Prostatic Hyperplasia
Restless leg syndrome
Gastroesophageal Reflux Disease
Asthma (in his ___
Tinnitus
Cardiomyopathy
Postoperative, 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>___ year old male past medical history only significant for
hyperlipidemia who was admitted on ___ following ventricular
fibrillation arrest.
Given the lenght of his inpatient stay, his preoperative course
will be divided into systems.
# VF arrest: Patient had a witnessed VF arrest while at a gas
station that happened to have an ambulance there at the same
time. CPR was started immediately. On presentation to ___,
cardiac cath was performed demonstrating severe RCA and LAD
disease and moderate LCX disease with normal flow. None of the
lesions were intervened upon. TTE was performed which
demonstrated mild symmetric left ventricular hypertrophy with
mild left ventricular cavity dilation and severely depressed
biventricular systolic function (LVEF ___ with 2+ mitral
regurgitation. LV thrombus was unable to be ruled out, and
patient was started on heparin. Pt's Vfib was thought most
likely to be due to global ischemia in the setting of three
vessel disease. Non-ischemic causes such as electrolyte
abnormality, a hereditary channelopathy or old MI scar
initiating a focus of arrhythmia were also considered in the
differential. Post cardiac catheterization, patient was cooled
per cooling protocol and rewarmed. On being rewarmed, patient
was found to be neurologically intact, and was extubated.
Repeat TTE demonstrated severe global left ventricular
hypokinesis (LVEF = ___ with relatively better wall motion
in the basal inferolateral wall. No masses or thrombi are seen
in the left ventricle. Pt was also noted to have possibly
worsened mitral regurgitation. While in the CCU, patient was
loaded with amiodarone given his vfib arrest of unclear
etiology, and continued on amiodarone PO. He was also treated
with aspirin 325 mg daily, metoprolol tartrate 25 mg q6 hours,
and captopril 3.125 mg q8 hours. Heparin gtt was started due to
concern for possible LV thrombus on initial TTE. On transfer to
the floor, pt's captopril was discontinued and lisinopril 5 mg
daily was started. In addition, metoprolol was titrated to
metoprolol XL 125 mg daily. Atorvastatin was started at 10 mg
daily given pt's known history of myalgias with other statins.
Lisinopril was changed to Losartan 25 mg daily after pt
developed a cough. On the floor, pt underwent a thallium
viability study which showed extensive myocardial viability in
all coronary artery territories. In addition, TTE ___
demonstrated continued LV dysfuncttion with LVEF = 20% and
improved MR from previous study. It was determined that pt would
undergo CABG with cardiac surgery. As part of pre-op work up,
pt underwent extraction of 3 teeth (19, 29, 30) with extensive
decay.
# CAD: As discussed above, cath on arrival showed severe RCA and
LAD disease with normal flow. No PCI were performed, and
further interventions held off while undergoing cooling. Seen
by cardiac surgery and underwent CABG x4 with Dr. ___ on
___. Atorvastatin was initially held during the cooling and
low dose atorvastatin at 10 mg daily was started once patient
was transferred to the floor. Aspirin was started while
hospitalized.
# Heart Failure: Initial TTE post-arrest demonstrated severe
systolic diyfunction with and EF ___ and 2+ mitral
regurgitation. Repeat echo demonstrated severe global left
ventricular hypokinesis (LVEF = ___ with relatively better
wall motion in the basal inferolateral wall. No masses or
thrombi are seen in the left ventricle. Pt was also noted to
have possibly worsened mitral regurgitation. Pt was started on
an ACEi and metoprolol as described above, and lasix 40 mg
daily. Lasix was changed to 20 mg daily, and the ACEi was
changed to losartan after pt developed a cough. Post-CABG, he
was followed by Dr. ___ recommended that he be discharged
home with Life Vest for 3 months.
# Superficial thrombophlebitis: On the floor, pt developed a
superficial thrombophlebitis of his right forearm. Pt was
already anticoagulated with heparin as described above, and warm
compresses combined with elevation were instituted which were
effective.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Primary Care Physician: ___. MD
.
___ with new dx of nodular vasculitis is here with upper and
lower extremity pain not relieved by morphine or ibuprofen at
home. He has been undergoing W/U as outpt for fevers x 5 weeks.
He then developed pain and stiffness in his hands, wrists,
elbows, ankles and feet then developed small tender erythematous
subcutaneous nodules over his upper and lower extremities. ID
saw pt and felt this was not infectious. He was seen by Rheum
and had nodule biopsy which revealed nodular vasculitis. Plan
was to start IV steroids next week but b/c of pain pt came to
the ER. Extensive work up revealed elevated ESR, WBC count, and
LFTs. Pt reports abdominal CT and MRI of lower extremities was
WNL. At this point in time pt is in so much pain he lays on the
couch all day long and needs to use a wheelchair to get to the
bathroom.
.
ROS: some dry mouth "I think this is from the AC" denies cough,
hemoptysis, dysuria, hematuria, headache, n/v/d, chest pain,
palpitations, shortness of breath, no rashes, no nausea
vomittign diarrhea, no dry eyes, no vision changes
.
In the ED, initial vital signs were 98.9, 133, 105/91, 18, 100%.
WBC 13K, CRP 163, ALT 124, AST 58, Alk P ___. Exam was notable
for multiple SQ nodules in extremities and diffuse joint
tenderness. Triggered for HR of 130's. 2 L IVF, 2 mg IV
morphine, 30 mg IV ketorolac. Improved to 120's. Patient was
given 2 L NS, 3 mg dilaudid and ketorolac.
. Radiology showed Normal abdominal ultrasound. Radiology showed No acute abnormalities. The patient was diagnosed with JOINT PAIN-MULT JTS, ERYTHEMA NODOSUM. The patient was treated with skin biopsy ___. At the time of discharge, the patient had Primary:
1. Painful subcutaneous nodules, arthralgias
2. Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with 6 wks of myalgias/arthralgias, 15 lb weight loss, and
tender subcutaneous nodules on all extremities has started
workup for rheum vs ID vaculitis vs erythema nodosum was
admitted for pain control and further workup.
.
#fever/arthralgias/subcutaneous nodules, likely c/w NODULAR
VASCULITIS: Pt had already undergone extensive outpt w/u, with
skin biopsy most c/w nodular vasculitis with plan to initiate
systemic steroids. However, due to severe pain, pt presented to
the hospital for pain control. Rheum, ID and Derm Consults were
involved in his care. The following workup has been done: Smear
negative for parasites, Lyme antibody negative, Erhlichia
IgG/IgM negative, CMV neg, Anaplasma IgG/IgM negative, Quant
gold neg, Blood culture negative x 2, Hep panel neg, HCV neg,
HIV neg, ASO neg. ___ neg, ANCA neg, normal SPEP, normal
Complement levels, antiphospholipid Ab neg, cryoglobulin neg.
Further infectious w/u at ___ was done to r/o fungal
infection, which was negative. He had one positive blood
culture from ___ which grew GRAM POSITIVE COCCI IN CLUSTERS,
however, another set from the same day was negative for growth,
and he had 4 more additional sets of blood cultures, so the
positive blood culture was felt to represent contaminant. He
had a TTE that did not show evidence of vegetations / infective
endocarditis.
He underwent repeat skin biopsy at ___, with dermatopathology
result showed: lots of hemorrhage, c/w acute and chronic
inflammation, but otherwise non-diagnostic. HIs outpt path
slides were obtained and were reviewed by ___ Pathology, and
based on their review, the findings are c/w nodular vasculitis.
Pending return of Quantaferon gold, if TB is ruled out,
Rheumatology Consult plans to coordinate with his outpt
Rheumatologist and recommend the initiation of systemic steroids
for treatment of nodular vasculitis.
.
#Sinus tachycardia: HR iniitally in the 120s and before d/c in
the low 100s. Tachycardia felt to likely be related to pain and
improved with pain control.
.
#Microcytic anemia: Ht ___ MVC 78 then after IVF was
___ anemia with iron low at 25, TIBC 286 ferritin
312. Haptoglobin and LDH both WNL, not suggestive of hemolysis.
Guaiac negative. On d/c Ht was 27..
.
#Elevated LFTs: ALT 124, AST 58 Alk P ___, then started trending
down and on day before d/c AST 39 ALT 87 Alk P ___. Per pt he
has frequently had elevated LFTs whenever he is sick even in
college. It is possible that either infections of systemic
inflammation could explain this. RUQ u/s was unremarkable. Hep
C serology was negative. Hep B serologies were c/w prior
immunization.
.
.
TRANSITIONAL ISSUES
[]per rheum, they will discuss w/ outpatient rheum the plan to
be started on prednisone assuming quant gold neg </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx HIV (last CD4 ___, last VL undetectable in
___ and extensive joint history including b/l steroid wrist
injection for chronic carpal tunnel on ___ and right knee
arthritis w/ tap and steroid injection on ___ presents with ___
days fevers, chills, night sweats, and exquisite tenderness
worst in left wrist but notable in numerous PIP, DIP, MCP (left
___ digit worst), ?L elbow, right knee (though the latter is
improving since ___. The left wrist pain has gotten worse
since injection (which have helped in the past). Her right knee
feels "tense."
At At___, labs drawn ___ as below:
- PENDING: ___ prev negative ___
- uric acid 2.9
- RF<30
- CRP 141
- ESR 90
Right knee tap showed 33K cells, gram stain with 4 PMNs but no
organisms.
No new sexual partners and ___ w/i marriage (20+ years),
though per records does have history of gonoccocal proctitis a
few years ago. No ocular symptoms.
Bilateral steroid injections of hands for carpal tunnel
___.
Knee tap of 81cc fluid + steroid injection ___.
In the ED, initial vitals were: 100.6 97 144/92 18 100% RA
- Exam notable for:
Left wrist with erythema, edema, warm to touch, more swollen
than right wrist. Tender per pt. All MCP tender, majority of
PIP/DIP as well, left ___ PIP most visibly swollen. Pt yells out
when most of these are touched. Also endorsing tenderness of
right elbow though this has full ROM. Right knee also tender w/o
frank erythema, edema, no ballottment. No restriction on ROM.
- Labs notable for:
WBC 8.7
Joint fluid with ___ WBC's, 79% PMN's and no crystals (GST
PND)
- Imaging was notable for: none obtained
- Orthopedics, Hand surgery were consulted:
-Please process synovial fluids for analysis.
-Please elevate LUE as much as possible with IV pole.
-Suggest NSAIDS.
-NPO at midnight, please.
-will plan for serial examinations.
-please obtain hand and wrist films
-Advise rheumatologic workup as well
- Patient was given:
Vanc/CTX
Tylenol ___ mg
Oxycodone 5
Dilaudid 0.5 IV x 2
- Vitals prior to transfer: 100.2 86 140/86 18 99% RA
Upon arrival to the floor, patient reports severe debilitation
in her L arm and hand. The pain has been getting worse and
worse. She can barely use her L arm now. Endorses some
occasional night sweats over the past month. Otherwise, denies
fevers at home, weight changes, diarrhea, dysuria, abdominal
pain, cough. DX HAND AND WRIST showed 1. Pronounced soft tissue swelling extending from the base of the proximal
phalanx to the distal forearm without acute bony abnormality or osseous
erosions makes osteomyelitis less likely. However, fine osseous detail is
obscured by the overlying cast. RENAL U.S. showed Limited evaluation of the left kidney. However, no hydronephrosis
bilaterally. The patient was diagnosed with Fever, unspecified. The patient was treated with SURGICAL WASHOUT OF L ELBOW, L WRIST, R KNEE ___. At the time of discharge, the patient had Primary:
Septic Arthritis due to gonorrhea
Acute Kidney Injury
Vaginal Bleeding
Secondary:
HIV. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of HIV, bilateral carpal tunnel syndrome, and
OA of knee who presents with oligoarthritis. She was found to
have septic arthritis due to gonorrhea and treated with surgical
washouts and doxycycline. Hospital course complicated by acute
renal failure of unclear etiology which improved prior to
discharge. Also found to have vaginal bleeding.
#Gonococcal Arthritis:
The patient presented with fever and severe joint pain. She had
tap of R knee prior to ED presentation which showed ___ WBC.
Tap of left wrist with ___ WBC, which was thought to be
concerning for septic arthritis. She was continued on
Vancomycin/CTX. The patient went for surgical washout of left
elbow, left wrist, and right knee with purulent fluid in the OR.
Her clinic knee culture subsequently grew rare staph which was
thought to be contaminant. Urine gonorrhea came back positive
which was likely cause of septic arthritis. The patient was
continued on CTX for gonococcal arthritis, which was
subsequently narrowed to doxycycline due to concern for AIN (see
below). The patient should continue a 2 week course of
doxycycline (___). She received one-time dose of 1g
azithromycin. Joint fluid cultures were pending at discharge and
should be followed-up in the clinic. She should follow-up with
___ clinic, orthopedic surgery, and hand surgery after discharge.
She was discharged on Tylenol for pain. Her partner was notified
with intent to seek partner treatment with his provider.
#Acute renal failure:
The patient's course was complicated by acute renal failure,
with creatinine peaking at 5.6 from baseline ~0.6. Unclear
etiology of this ___ but creatinine trended towards normal prior
to discharge. It should be noted that WBC casts were seen in the
urine, so the patient's CTX was changed to doxycycline due to
concern for AIN. This may have contributed to the cause.
Discharge Cr 2.0. Recommend repeat Cr and BMP in clinic.
Medications adjusted for renal failure should be re-adjusted
when creatinine returns to normal: ranitidine and lamivudine.
#Vaginal Bleeding:
The patient was found to have slowly downtrending Hb in the
setting of vaginal bleeding between periods. She remained
hemodynamically stable. She received 2U of pRBCs during
hospitalization for Hb 7.1 with slow downtrend. Her Hb was
subsequently stable and her bleeding stopped. UHCG negative. She
should follow-up in clinic with OB/GYN for further workup and
consideration of ultrasound and endometrial biopsy. She should
also have repeat CBC in clinic.
#HIV: Continued abacavir 600, lamivudine (dose adjusted for
renal dysfunction to 150 daily), and etravirine 400. CD4: 787.
HIV VL: NOT DETECTABLE.
#GERD: Continued ranitidine
#History of sleeve gastrectomy: Vit D, MV, B12
TRANSITIONAL ISSUES:
- Continue a 2 week course of doxycycline (___).
- She received one-time dose of 1g azithromycin.
- Joint fluid cultures were pending at discharge and should be
followed-up in the clinic.
- She should follow-up with ___ clinic, orthopedic surgery, and
hand surgery after discharge.
- She was discharged on Tylenol for pain and miralax for
constipation.
- Her partner was notified with intent to seek partner treatment
with his provider.
- Recommend repeat Cr and BMP in clinic. WHEN CREATININE RETURNS
TO NORMAL WILL NEED DOSES OF RANITIDINE AND LAMIVUDINE INCREASED
TO HOME-DOSE.
- Medications adjusted for renal failure should be re-adjusted
when creatinine returns to normal: ranitidine and lamivudine.
- She should follow-up with OB/GYN for continued workup of
vaginal bleeding between periods.
- Recommend repeat CBC in clinic for slow vaginal bleeding.
- Discharged with limited PO Zofran for nausea likely due to
doxycycline
# DISCHARGE CR: 2.0
# CODE: Full (confirmed)
# CONTACT: ___: ___ Daughter (*please note patient
does not want updates to go to anyone else besides her daughter)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with hx remote paroxysmal afib presenting as
transfer from OSH with c/o cough, n/diarrhea, and chest pain.
Patient reports onset of cough/congestion 4d ago. Cough
productive of green sputum. Had progressive fatigue, and
yesterday had 6 episodes watery diarrhea with nonbloody emesis
x1. Denies fevers/chills although did not take temp at home, no
recent travel or sick contacts Radiology showed Short interval development of bibasilar opacities, which are concerning for a
rapidly developing pneumonia versus alveolar hemorrhage. Radiology showed AP chest compared to ___:
Large scale consolidation in both lower lungs developed between ___, most likely severe pneumonia or pulmonary hemorrhage. Aspiration is most
likely scenario. Mild-to-moderate cardiomegaly unchanged. Pulmonary vascular
congestion is probably a function of volume resuscitation. Small left pleural
effusion is larger, small right pleural effusion, presumed. No pneumothorax. Radiology showed Mild gaseous distention of loops of small and large bowel with air seen within
the rectum. No evidence of obstruction. Radiology showed There is persistent opacification within the left lower lobe and to a somewhat
lesser extent at the right lung base. These findings would be consistent with
aspiration or pneumonia. The heart remains enlarged. No pulmonary edema.
Probable small layering left effusion. No evidence of pneumothorax. Marked
thoracolumbar curvature. Radiology showed 1. Bilateral pleural effusions, moderate on the left side without evidence of
empyema.
2. Multifocal airspace disease which is predominant at the lung bases and is
likely in keeping with multifocal pneumonia. Multiple mediastinal and hilar
reactive lymph nodes are noted.
3. Incidental finding of a 6 mm non-obstructing stone in the upper pole of
the left kidney. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Primary: Pneumonia
Secondary: Ileus. The patient was given written instructions concerning 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 ___ year old male with
no significant medical history presenting as transfer from OSH
with c/o cough, n/d/diarrhea, and chest pain found to have fever
and hypoxia. On further work-up, pt. was found to have a
multifocal pneumonia. Culture data was unrevealing. Pt. was
placed on antibiotics and continued to improve. His O2
requirement resolved and he was discharged with close follow-up.
ACTIVE ISSUES
=============
# Sepsis and Community Acquired Pneumonia: Mr. ___
presented with tachycardia, temp to 104, and multifocal
opacities seen on CXR. He was started on ceftriaxone and
levofloxacin in accordance to ___ guidelines for community
acquired pneumonia. Respiratory viral panel negative,
legionella negative, strep pneumo antigen negative, and cultures
were unrevealing. Pt. grew GPCs in clusters in blood ___
bottles) which raised concern for possible MRSA bacteremia from
MRSA pneumonia. Pt. has negative MRSA swab and without known
MRSA risk factors. TTE was negative for evidence of
endocarditis and surveillance blood cultures were negative.
Oxygen requirement had resolved by day 2 of admission and he was
transferred to the floor. He was transitioned to levofloxacin
to complete his course of antibiotics.
# Chest Pain: Pt. complained of left sided sharp chest pain
made worse with coughing and deep breathing. Most likely
pleuritic chest pain from underlying inflammatory pleuritis from
pneumonia. Cardiac enzymes neg x2 making cardiac ischemia less
likely. No ischemic changes or other notable changes seen on
ECG. TTE done on ___ and was grossly normal with LVEF 60-65%.
# Abdominal Distension: Initially, pt. presented with diarrhea,
CDiff negative. Continued to complain of abdominal distension.
KUB showed multiple air filled loops of bowel without air fluid
levels consistent with possible ileus. Pt. continued to
complain of minimal flatus, abdominal distension made worse with
consuming POs, and minimal BMs. Slowly, he began to tolerate PO
intake. At time of discharge, pt. was tolerating full liquids
without issue. He was encouraged to advance his diet as
tolerated.
# Anemia: Patient with downtrending Hct throughout this
admission. Initial and repeat DIC labs returned negative. Most
likely etiology ___ bone marrow suppression due to acute illness
with possible suppression ___ medication effect. No signs of
active bleeding.
# ___: Pt. with evidence ___ on admission. Likely pre-renal
etiology in the setting of pneumonia and sepsis. With IVF, pt's
creatinine returned to baseline and ___ resolved.
CHRONIC ISSUES
==============
# BPH: Stable. Continued on flomax
TRANSITIONAL ISSUES
===================
# Antibiotics: Pt. should continue levofloxacin for an
additional 4 days to complete a 10 day course.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a PMH of HepC, arthritis on a narcotics contract, and
multiple admission for ___ who presents with four days of
malaise, fatigue, polyuria, and polydipsia. She called EMS and
was found to have a FSBG >500 by EMS and brought into the ED.
The patient is a poor historian, but notes subjective fevers,
chills, cough, dysuria, and genital rash. She denied a history
of diabetes or insulin use. She states that she eats
significant amounts of sugar in the form of Koolaid, ice cream,
and cookies.
In the ED, initial vitals were: 98.7 78 155/97 16 94% RA
Her glucose was >1000 and and AG of 26. She was given 10U of
insulin and 3L of IV fluids. Her AG fell to 16 and her
fingerstick fell to 513. Radiology showed No acute intrathoracic process. Trace fluid on the minor fissure. The patient was diagnosed with NIDDM UNCONTROLLED. The patient was treated with PATIENT LEFT AMA. She did not wait for her paperwork, but was
given a prescription for Metformin and instructed to follow up
with her PCP.. At the time of discharge, the patient had primary diagnosis:
hyperglycemia
secondary diagnosis:
chronic pain, opiate use
vaginal yeast 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># Hyperglycemia - appeared HHS > DKA and was treated with SC
insulin and 4L of IV fluids to good effect in ED and
normalization of her serum osms. Her K and Phos were repleted.
A search for infectious causes of her presentation including UA
and CXR was unrevealing and the patient was afebrile. On
admission the patient was refusing further insulin. She
repeatedly stated she wished to manage her blood sugars with
diet and oral medications. She understood that this was a
dangerous therapy for her acute condition and that there were
risks including death. She was started on metformin 500 BID and
her sugars on the floor ranged between 300 to 400. She left
against medical advice with a prescription for oral metformin
and stated that she would follow up with her PCP. She
understood the risks of leaving and that she may have to return
in an ambulance or die as a result. An A1c was pending at
discharge.
# thick vaginal discharge - treated empirically with one dose of
fluconazole
# HTN - continued home amlodipine and atenolol
# HL - held simvastatin due to increased risk of rhabdo with
fluc
# Chronic pain - continued gabapentin, oxycodone, oxycontin.
Doses and refills confirmed with ___.
# Vertigo - continued home meclizine
# GERD - continued home omeprazole</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female past medical history significant for smoking,
COPD presented to the emergency department with a 3-day history
of worsening of shortness of breath with exertion as well as
intermittent lower extremity edema. Patient states that she has
for the past few months had dyspnea walking up stairs, but no
associated chest pain. Patient denies any fevers, chills but
endorses significant coughing with some green/brown sputum the
past few days. Patient states that this feels consistent with
her
prior COPD episodes but feels worse. If she attempts to ambulate
for father than a few steps, she has a coughing fit and feels
like she cannot breath. No lightheadedness or falls. CHEST (PA AND LAT) showed Persistent mild pulmonary edema. CTA CHEST showed 1. No evidence of pulmonary embolism or acute pulmonary parenchymal process. The patient was diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation. At the time of discharge, the patient had Primary diagnoses:
Acute hypoxemic respiratory failure
COPD exacerbation
Pulmonary edema
Secondary diagnosis:
Benign paroxysmal positional vertigo
Panic attacks
GERD
Tobacco abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman w hx COPD (last PFTs "normal" per ___ pulm note
___, ongoing smoker, presented w acute on chronic SOB and DOE,
symptoms and findings concerning for both COPD exacerbation as
well as potential congestive heart failure. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: At work, around 9:45 am, the patient reported the acute onset of
a headache, along with chest pain and a right facial droop. The
headache came on suddenly and remained in the front of his head.
He experienced nausea, but no vomiting, photophobia, or vision
changes. The chest pain was located substernally and was sharp.
The patient reported that it felt "like food was stuck in my
throat". The pain did not radiate and was constant. He felt
that the right side of his face had drooped, but was not sure if
it involved his forehead. He was able to comprehend speech but
was non-fluent. He knew what he wanted to say and thought he
was speaking clearly, but others noted that his speech was
slurred but could be understood. A friend drove him home where
his wife was returning from work, at which time she noted his
right face was drooping. She activated EMS for transport to
___ ED for further evaluation. On arrival, his symptoms per
the wife and clinical evaluation by the ED were gone (around
1200hrs). CTA HEAD AND CTA NECK showed 1. No acute intracranial process. Please note, MRI is more sensitive for
detecting acute ischemia.
2. No thrombosis, aneurysm or dissection within the principal arteries of the
head and neck.
3. This report is provided without 3D and curved reformats. When these
images are available, and if additional information is obtained, then an
addendum may be given to this report. Radiology showed 1. Bibasilar opacities are likely atelectasis with low lung volumes, however,
pneumonia could be considered in the correct clinical setting.
2. Mild pulmonary edema. MR HEAD W/O CONTRAST showed 1. No acute infarct.
2. Extensive supratentorial white matter signal abnormalities, nonspecific
but likely sequela of chronic small vessel ischemic disease in a patient of
this age. The patient was diagnosed with TRANS CEREB ISCHEMIA NOS. At the time of discharge, the patient had 1. Right facial droop and difficulty with language concerning
for stroke.
2. Stroke work up
3. Alcohol dependency
4. Tobacco dependency
5. Hypertension
6. Hyperlipidemia
7. Headache
8. Diabetes
9. Obesity. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with multiple cerebrovascular
risk factors including hypertension, hyperlipidemia, diabetes,
obesity and smoking presenting with multiple episodes of right
facial droop and dysarthria concerning for TIA v. new ischemia
v. migraine. On initial examination, the patient demonstrated
right facial droop with good activation. Otherwise his
sensorimotor examination was unremarkable. He was admitted to
rule out stroke, rule out MI, and to asses for stroke risk
factors.
# NEURO: In the Emergency department, a CT/CTA Head/Neck showed
no thrombosis, aneurysm or dissection within the principal
arteries of the head and neck, but did show atherosclerosis.
MRI showed "No intracranial hemorrhage or acute infarct.
Numerous foci of patchy and confluent FLAIR hyperintensity in
the white matter, nonspecific but consistent with severe chronic
small vessel ischemic disease". Mr. ___ stroke risk factors
were assesed with fasting lipid panel and HbA1c (see labs
section for details). During his hospitalization, home
pravastatin 10mg daily was increased to atorvastatin 40mg daily
and home aspirin was increased from 81mg daily to 325mg daily.
At discharge, both medications were returned to ___
medications and doses. Mr. ___ was seen by physical therapy
and speech pathology. He was assesed to be back at his baseline
with resolution of the facial droop and no residual symptoms.
He was determined to have a complex migraine as the cause of his
symptoms.
# ___: EKG and troponin-T x1 normal. Echo: "Mild symmetric left
ventricular hypertrophy with a normal LVEF and biatrial
enlargement. Mildly dilated ascending aorta. No ASD/PFO
demonstrasted on saline contrast injection." He was monitored on
telemetry and no concerning findings were recorded. His home
dose of atenolol was halved from 100mg to 50mg daily to allow
his blood pressure to autoregulate. His more norvasc was held
during his hospitalization. Both medications were returned to
home doses at discharge.
# PULM: Chest radiograph from the emergency department revealed
possible pneumonia vs COPD flare. Mr. ___ was started on
azithromycin 250mg for a five day course. He was also provided
with his home dose of atrovent and albuterol.
# ENDO: HbA1c result was pending at the time of discharge.
Blood sugars were monitored with finger sticks QID and Insulin
sliding scale with a goal of normoglycemia.
# Toxic/Metabolic: Slight transaminitis (ALT 66, AST 63),
consistent with HCV history.
# ID: UA negative for UTI. Chest radiograph concerning for PNA
and patient was started on azithromycin x 5day . </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old man with history of history
?afib/WPW on A/C, HTN, CHF, cirrhosis/EtOH, and 2wks ago wide
exision of sarcoma resection bed (RLE). He was in his USOH until
he underwent skin grafting on his RLE last ___. Following
this, he has been complaining frequently of pain in that
leg/ankle, and while taking several sedating medications, he
developed drowsiness and mild behavioral changes.
.
His behavior was normal until ___ morning. At that time,
his wife noticed that he was falling asleep at the breakfast
table. He said he wanted to walk downstairs to put up his leg
and watch TV. She argued against this (due to concern for
falling on the stairs given his drowsy state and gait
instability since the surgeries), but he went anyway. He had to
catch himself on the wall near the bottom few stairs and sat on
the staircase while she helped him up (no fall/trauma). He
watched TV and dozed in his chair. His daughter says that he
looked "fine" in the afternoon when she visited. His wife said
that he would close his eyes and keep talking or mumbling
sometimes, and that all his extremities would twitch or jerk
briefly when he closed his eyes sometimes (I witnessed this in
the ED room, see below). That night (___), he went to bed early,
around 7:30pm, which is very out of character for him. His
daughter checked on him, and he told her, "I'm fine, I just need
rest." His wife says he arose at least 6x during the night to
use his bedside urine container. This morning, he told his wife
that he was speaking with his sister (in ___ on the phone,
but there was no one there and no phone. She called the
orthopedics office to discuss -- nurse there recommended 911,
ED.
.
His wife and ___ say that he has no history of stroke or
seizure. Never, at any time, was his speech slurred or garbled.
Never was his comprehension abnormal. He never complained of
weakness or numbness. A couple days ago, he mentioned blurry
vision to his wife, in passing, but this resolved. No sustained
or rhythmic jerking movements at any time.
.
His wife says he was prescribed a bottle of 40 tabs of oxycodone
5mg (q4h PRN). This was adequate for pain control for the first
week, but this past ___, he said 5mg q4hrs was not cutting it
for his pain. She says it is unusual for him to want to take
medications of any kind. ___, she spoke with a nurse from
the orthopedist's office, who suggested increasing to two tabs
(10mg q4hrs). She gave him 10mg ___ night around 11pm. He
got another 5mg and 5mg ___ morning and afternoon (none ___
evening), and the last dose of oxycodone was 5mg yesterday
morning with breakfast (___). A visiting nurse
suggested stopping the oxycodone at that point (started Tylenol)
due to behavioral changes, as described above. Radiology showed No evidence of acute intracranial process. No fracture
identified. Radiology showed No acute cardiopulmonary process. Mild cardiomegaly. Radiology showed Slightly prominent ventricles and sulci, likely age related and
involutional in nature.
Few scattered areas of high signal intensity are demonstrated on T2 and FLAIR
sequences, distributed in the subcortical white matter and periventricular
regions, which are nonspecific and may reflect chronic microvascular ischemic
disease. No diffusion abnormalities or areas with abnormal enhancement are
identified.
MRA OF THE HEAD:
There is evidence of vascular flow in both internal carotid arteries as well
as the vertebrobasilar system, no flow stenotic lesions or aneurysms larger
than 2 mm in size are seen. The anterior, middle and posterior cerebral
arteries are grossly unremarkable. Both vertebral arteries and the basilar
artery are patent.
IMPRESSION: Essentially normal MRA of the head with no evidence of flow
stenotic lesions or aneurysms.
MRA OF THE NECK:
The origin of the supra-aortic vessels appears normal, the common carotid
arteries are patent and the bifurcations are widely patent with no stenotic
lesions. Both vertebral arteries are patent and appear unremarkable as well
as the visualized intracranial structures.
IMPRESSION: Normal MRA of the neck with no evidence of flow stenotic lesions
or major vascular abnormalities. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old right/left-handed man with a past
medical history including Afib/WPW on A/C, HTN, CHF,
cirrhosis/EtOH, 2wks ago wide exision of sarcoma resection bed
(RLE) with multiple recent psychoactive and sedating medications
(Ambien, Oxycodone, Benadryl) who presented to the ___ with
behavioral issues and sleep disturbances. He was admitted to
the stroke service from ___ to ___.
.
On initial evaluation his neurologic examination was not
remarkable for any gross
sensory or motor deficits. Likewise, there are no speech or
language or visual deficits by history or on exam. HOWEVER, the
exam did reveal a few unexpected findings -- First, was a subtle
sensory loss in the LEFT arm (patchy pinprickassymetry); Second,
there may be a subtle LEFT neglect (line bisection neglected on
the left side; VF testing intermittently abnormal on the left);
Third, he had a constructional/visual-spatial deficit manifest
as inability to copy a cube. These subtle deficits all localize
to a potential Right-parietal (cortical) deficit; the lack of
motor findings implied that any such lesion avoids the frontal
(precentral) motor cortex. Of note patient had several risk
factors for stroke
(primarily afib, but also HTN, age, positive smoking history).
.
A CT of the head showed no evidence of hemorrhage, masses, or
obvious signs of ischemia. There did not appear to be evidence
of stenosis, dissection, or aneurysm on angiography. As the
patient's symptoms were considered concerning for stroke, an MRI
of the brain was performed. The study revealed no signs of
acute ischmic stroke.
.
The patient most likely had an issue with polypharmacy which
accounted for his presentation. We recommended to stop taking
oxycodone, ambine, benadryll.
For his atrial fibrillation, the patient continued his home
medications and anticoagulation without any issues. He was
monitored on continuous telemetry without any significant
events.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year-old woman in her USOH until this afternoon
when she sutained a mechanical fall from a chair. She was
transferred from an OSH with a splint in place.She denies
headstrike and LOC. She also denies, neck or chest pain. She
presented to ___ ED with films demonstrating a tibia shaft
fracture. Radiology showed Hyperinflated lungs without superimposed acute pathology. Radiology showed Unchanged alignment of displaced proximal tibial shaft fracture.
Minimally displcated segmental fracture of the proximal fibula. The patient was diagnosed with FX SHAFT TIBIA-CLOSED, FALL FROM CHAIR OR BED. The patient was treated with IM nail insertion left tibia.. At the time of discharge, the patient had Left tibial shaft 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 tibial shaft fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibia IM nail insertion, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to 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 PWB in the left lower 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: HISTORY OF PRESENT ILLNESS:
___ is a ___ yo ___ speaking man with h/o BPH with
urinary retention c/b recurrent UTIs and dementia who presents
with fevers, and confusion x 1 day.
This is his third admission for identical symptoms within the
last 2 months.
___ is unable to provide history given mental status so
history obtained from his daughter who is his primary care
taker.
Per daughter, patient has been fine, at his baseline mental and
functional status all week until yesterday. In fact, yesterday
morning he walked with a walker, ate breakast as he typically
does and was doing well. She returned from her afternoon walk
and found him laying in his bed, confused, not answer questions
and shivering. He also had abdominal distension and pain with
palpation of his abdomen. She took his temperature and it was
101, she gave him 500mg PO Tylenol and watched him, he was no
better and mounted another fever 4 hours later for which she
gave him another 650mg tylenol. He had an "extra large" bowel
movement and his abdomen pain resolved but by morning he was
still shivering and confused so she brought him to the ED. CHEST (PORTABLE AP) showed 1. Bilateral medial lung base atelectasis or pneumonia.
2. Lucency under the right hemidiaphragm may be related to distended bowel
loops. The possibility of pneumoperitoneum will be resolved on the pending
abdominal CT. CT HEAD W/O CONTRAST showed No acute intracranial process. CT abdomen and pelvis with IV contrast. showed 1. Multiple dilated fluid and air-filled loops of small and large bowel. The
sigmoid is markedly dilated compared to ___, but there is no
transition point to suggest an obstruction. No bowel wall thickening. Again
this may reflect ___ syndrome.
2. Other incidental findings include cholelithiasis and prostatomegaly. The patient was diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic. At the time of discharge, the patient had Urosepsis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT AND PLAN:
___ with history of BPH, HLD, dementia (alert and oriented x 1
at baseline), BPH with urinary retention and recurrent urinary
tract infections, who presents with confusion and abdominal pain
with positive urinalysis all consistent with recurrent sepsis
from UTI including MDR GNR (susceptible to penems) similar to
two recent hospitalizations.
# Sepsis, severe, without shock:
# Bacterial Urinary tract infection:
# Acute Renal Failure
Profound leukocytosis with neutrophilia and bands, with fever to
101, hypotension and elevated lactate, acute renal failure and
source clearly UTI. Patient has history of multi-drug resistant
urinary tract infections, last two cultures only overlap with
Meropenem sensitivity. Patient has underlying BPH and retention
which is likely contributing to increased risk of recurrent
UTI's. He initially received Cefepime in ED, however, his most
recent urine culture was resistant to Cefepime. ARF and lactic
acidosis both related to hypovolumia and sepsis most likely. He
was evaluated by ID who knew him well. They agreed with
Meropenem. His urine culture grew MDR Klebseilla sensitive to
penems. In house, he was treated with Meropenem. He had a
midline placed. He received and test dose of Ertapenem and
tolerated this well. He will complete a 7 day course of
Ertapenem (starting: ___. Per ID, reasonable to continue
fosfomycin 4g PO q10d. Unfortunately, given his BPH as noted
below, these UTIs will likely recur. The family is aware of
this.
# Acute Metabolic Encephalopathy:
# Dementia:
Patient has baseline dementia and is alert and oriented x 1, can
ambulate with aid of walker and can use a cup to drink but needs
assist to eat, can communicate and answer questions generally.
Presents altered, non-responsive to questions, unable to follow
commands consistent with. Encephalopathy was most likely
toxic-metabolic related to sepsis. CT head negative for acute
intracranial process. His mental status improved by to baseline
upon treatment.
# BPH/Urinary Retention:
Chronic history with prior admission requiring foley catheters,
difficult placements and urology following. No foley placed
during this admission. However, BPH is likely the underlying
trigger for his recurrent UTI. He was continued on Tamsulosin
and Finasteride.
# Sigmoid Distention: Concern for Ogilve
This is a chronic problem with several prior CT Torso performed
in the ED showing similar findings of "persistent dilation of
the sigmoid colon without bowel
obstruction." This CT is showing more dilatation than the prior
CT and again concern for ___ syndrome. His
abdominal exam, however, is completely benign, soft, non-tender,
no peritoneal signs and he had a large BM last evening. Given
increased dilation and notable leukocytosis, ACS was consulted
to opine on possibility of toxic megacolon. However, his C. diff
was negative and ACS thought this was acute worsening of
___ and no further intervention was needed. His exam
remained benign and he continued to pass gas and have bowel
movements.
# Elevated Troponin:
Likely demand related in setting of sepsis. During prior
admissions for similar symptoms he developed ST Depressions in
V4-5 on admission EKG with a similar Trop elevation of 0.05 with
MB 3. Not a candidate for cath or anticoagulation anyway, highly
unlikely to be acute plaque rupture
# Hypokalemia: had mild hypokalemia during his stay, which
corrected with oral repletion and had resolved as of discharge.
Should have a repeat BMP early next week to follow up on this</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman who presents after leaving ___
___ AMA this morning for further evaluation and
treatment of lower abdominal pain and diarrhea.
Patient reports having ongoing diarrhea and abdominal pain now
for the past 8 weeks. Her diarrhea was as frequent as ___ a day
in the beginning, mostly during the day. At times she would have
incontinence of stool. On ___, she presented to the ED for
these symptoms and was prescribed a week of Flagyl, which she
says made the diarrhea and pain worse. During this time she had
blood stools as well. She then presented to the ED again and was
admitted. She had a colonoscopy by Dr. ___ at ___ and
pathology returned for colitis with skip lesions, concerning for
Crohn's disease vs c.diff. Repeat c.diff studies were negative.
She was discharged. She represented to ___ on ___ with
persistent diarrhea and abdominal pain and fevers to 102. She
was started on solumedrol 40mg q8h per GI recommendations
yesterday. She was planned to have an upper GI series but it was
rescheduled and she became unsatisfied with her care there and
thus left AMA.
She continues to have ___ lower abdominal pain, mouth ulcers
and diarrhea. Denies fever/chills at this time and denies blood
in stool. Denies stools being dark or tarry. Reports
odynophagia. Denies reflux, chest pain, shortness of breath.
Reports hemorrhoids and rectal pain.
She has had several similar episodes of abdominal pain and
diarrhea over the last ___ years. She has had episodes of
abdominal pain and diarrhea lasting as long as a week. They
occur monthly or so. She was originally diagnosed with Celiac's
disease although never had any blood work or biopsy. She has
lost 17 pounds since end of ___. She also has had
increases in her mouth ulcers. Initially started with ___ ulcers
8 weeks ago but then increased significantly. She endorses knee
and angle swelling and pain as well. She denies any hip pain.
She also has a rash on her thighs that she describes as
appearing like pimples but then scabs over.
In the ED, initial vital signs were: 98.3 88 134/83 16 100%RA
- Exam was notable for: ulcers noted on uvula, gums and roof of
mouth, all hemostatic, mildly tender to palpation in LLQ and
RLQ, LLQ>RLQ
- Labs were notable for: wbc 15.1, plts 428
- The patient was given: IV morphine
- Consults: none
Vitals prior to transfer were: 97.6 66 120/90 18 100% RA
Upon arrival to the floor, patient feeling well. Continues to
have some abdominal pain and diarrhea. Sores in her mouth are
very painful as well. MR ___ showed No definite MR features of inflammatory bowel disease. Apparent wall
thickening and hyperemia of the cecum and ascending colon may be secondary to
nondistended bowel. No extra intestinal manifestations of inflammatory bowel
disease. No fluid collections. The patient was diagnosed with Unspecified abdominal pain, Diarrhea, unspecified. The patient was treated with EGD/colonoscopy with biopsy ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with h/o recently diagnosed Crohn's
disease who presents after leaving ___ AMA
for further evaluation and treatment of lower abdominal pain and
diarrhea.
# Abdominal pain, diarrhea:
# Severe malnutrition:
Possibly IBD however per GI, pathology results atypical for
Crohn's disease. Patient also with significant other IBD-related
symptoms such as oral ulcers, lower extremity arthritis, and
skin manifestations which could be consistent with Behcet's
disease though she does not meet clinical criteria for
diagnosis. Her stool studies were largely unrevealing and
serologies for parasites were pending at time of discharge. Her
symptoms improved and CRP downtrended to 6 after IV
methylprednisolone x 4 days (___). She was
tolerating a low-residue diet by day prior to discharge. She was
transitioned to PO prednisone 40mg daily on ___ with plan
for prolonged steroid course and ___. She was started on
calcium/vitamin D supplementation, a PPI, and Bactrim for PCP
___.
TRANSITIONAL ISSUES
====================================
-Patient had PPD placement and quantiferon in house which were
negative
-Patient was discharged on prednisone ___ with calcium/vitamin
D, PPI, and Bactrim for PCP prophylaxis
___: 40mg x1 week, 30mg x1 week, 20mg x1 week, 10mg x1 week,
5mg x1 week, then stop.
-Patient was started on escitalopram for anxiety, which was
exacerbated by steroids. She was also given a small amount of
lorazepam in case of panic attacks, which she has had in the
past prior to this hospitalization.
-Patient to continue low residue diet
-Patient to F/U with GI at ___
-Patient will require outpatient hepatitis B vaccine
-Patient reports she was previously misdiagnosed with Celiac
disease; please discuss at GI followup whether she can resume
gluten in her diet
-Entamoeba histolytica, Yersinia enterocolitica, Schistosoma,
and Strongyloides antibodies were pending at the time of
discharge
-Final HSV culture from swabs of oral ulcers were pending at
time of discharge (prelim negative)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ year-old woman with a history of HTN,
spinal stenosis, vertigo, and anxiety who presents with a week
of general malaise and low-grade fevers found to have new L
upper lung opacity concerning for infection. Per the patient,
she began feeling unwell last ___ with nausea, abdominal
discomfort, decreased PO intake, dizziness and measured
temperatures to ___ F. She describes the dizziness as
occuring when walking and worse with sudden movement but not
present if she is sitting/lying still. Radiology showed 1. No acute focal consolidation.
2. 7-mm rounded opacity in the left upper lung new since 2 days prior and may
be focus of infection; attention to this region on follow up imaging. Radiology showed 1. No definite acute abdominal pathology to explain patient's symptoms.
2. Descending colon and sigmoid diverticulosis without evidence of acute
diverticulitis.
3. Mildly prominent pancreatic duct, but improved from ___. No definite
acute intra-abdominal pathology. The patient was diagnosed with NAUSEA, OTHER MALAISE AND FATIGUE, FEVER, UNSPECIFIED. At the time of discharge, the patient had Primary diagnoses: Pneumonia, C. difficile infection
Secondary diagnoses: Hypertension, spinal stenosis, vertigo,
anxiety, sarcoid. The patient was given written instructions concerning 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 hx of HTN, spinal stenosis, vertigo, and anxiety who
presents for nausea, abdominal pain, and dry cough found to have
new opacity concerning for community acquired pneumonia and to
be Cdiff positive.
# Community acquired pnumonia: The patient was found to have a
new R upper lobe opacity compared to a CXR from 2 days prior,
with concerns of possible pneumonia. Clinically, this could be
consistent with her general malaise, low-grade fevers, and
abdominal discomfort. She was administered one dose of IV
ceftriaxone and azithromycin, and switched to PO Levofloxacin on
second day of admission. Throughout this hospitalization, she
remained afebrile without shortness of breath and oxygenating
well on room air. She was discharged with plans to complete a 7
day course of antibiotics.
# Clostridium Difficile: The patient had an episode of soft
stool at home prior to admission, which she brought into the
hospital and was sent for stool studies (C. diff, culture, O&P).
Her C. diff ___ came back positive though the patient
remained afebrile, without abdominal pain/discomfort, and a
normal white blood cell count. Her bowel movements were
infrequent. She was started on PO Flagyl with plans to complete
a 14 day course.
# Hypertension: The patient was maintained on her home dose of
Losartan 100mg PO QD, and her blood pressures remained
well-controlled in 130-140s throughout the hospitalization. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: REASON FOR MICU ADMISSION: hypoxemia, tachycardia
HISTORY OF PRESENT ILLNESS:
___ is a ___ female with PMH significant for relapsed
Hodgkin's lymphoma currently receiving Brentuximab/Bendamustine
(C2D1 = ___ who presents with one day of fevers, rigors and
N/V. Chest radiograph showed No acute cardiopulmonary abnormality. Radiology showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Prominence of soft tissue in the anterior mediastinum most likely reflect
thymic hyperplasia/rebound and can be reassessed at followup imaging.
3. Slight interval improvement in mediastinal lymphadenopathy.
4. Minimal subsegmental atelectasis and/or superimposed inflammatory/atypical
infectious changes at the left base and left apex. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had Drug reaction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH of relapsed Hodgkin's lymphoma who is one day s/p
Bendamustine and Brentuximab who presents with fevers, nausea,
vomiting, rash concerning for acute infection vs. drug side
effect.
#Drug Reaction: Patient presented with fever, tachycardia,
tachypnea, with an elevated lactate, which in setting of
infection would be consistent with severe sepsis. She had some
nasal congestion and infected contacts so may have had a viral
illness. She had no evidence of pneumonia or UTI and no other
localizing symptoms. Flu negative. Port appeared uninfected. The
rash and her symptoms resolved quickly however after hydration
and sympotmatic management of sympotms, making this more likely
to be drug side effect, likely from bendamustine. She had no
respiratory compromise or drop in pressure to suggest an
anaphylactic reaction. CTA showed no evidence of PE.
#Respiratory alkalosis - Secondary to tachypnea likely from
reaction to medication
#Elevated lactate - Unlikely from hypoperfusion. Lactic acidosis
is known to occur in lymphoma from anaerobic metabolism.
#Nausea/vomiting -symptomatic control with Zofran, ativan
#Hodgkin's lymphoma - Recurrence now s/p C2 of bendamustine and
brentuximab prior to BEAM auto SCT. She may be able to get
bendamustine again in the future with more
premedication since no anaphylaxis was noted.
Transitional
===========
-follow up with oncology, they will contact you about an
appointment</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ y/o M with several months of BLE pain
and muscle fasciculations of unclear etiology. He was recently
admitted here with extensive work-up largely unrevealing (please
refer to that discharge summary for further details). He
presented to clinic today for ___ and experienced and
acute
pain episode in the waiting room with associated diaphoresis.
While he stated that he would not have gone to the ED for this,
clinic staff were concerned and referred him to the ED for
evaluation. Neuro saw the patient in the ED and felt that exam
was at baseline, recommended outpatient ___. In the ED, he
also endorsed lightheadedness with standing as well as an
episode
of syncope several weeks ago. Orthostatics were checked and were
positive. He was admitted to medicine for evaluation. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Orthostatic hypotension. At the time of discharge, the patient had # Orthostatic Hypotension / Neuropathy / Lower Extremity Pain
# Delirium
# Depression
# 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>This is a ___ year old male with past medical history of venous
insufficiency, recent workup for bilateral lower extremity pain
thought to relate to potential peripheral neuropathy of unknown
etiology, admitted ___ w orthostatic hypotension,
resolving with IV fluids, course complicated by episode of
delirium though to have been precipitated by recent increased
stress and decreased sleep, subsequently ambulating safely, able
to be discharged home with PCP and neurology ___.
# Orthostatic Hypotension / Neuropathy / Lower Extremity Pain -
as documented in prior discharge summary and neurology notes,
patient with peripheral neuropathy of unclear etiology; he
presented with episode of orthostatic hypotension and reported
recent syncopal episode; suspected etiology of syncope was
orthostatic hypotension; he received IV fluids with subsequent
normal orthostatic vital signs. He subsequently revealed
increased stress at home related to marital discord and that he
had only been sleeping < 2 hours per night as a result. He
continued to report ongoing pain and tingling in his lower
extremities, unchanged from his recent admission. He was seen
by the neurology service who recommended outpatient ___
for additional workup and repeat EMG. Stress and lack of sleep
were felt to be a major driver regarding his ongoing symptoms,
and recent reported decreased PO intake (likely the etiology of
his hypovolemia / episode of orthostatic hypotension). At time
of discharge he was able to safely ambulate in the hall today
without issue. Continued home gabapentin, prn Tylenol,
methocarbamol. Trialed on lidocaine cream.
# Delirium - On evaluation by social work and neurology patient
appeared to be responding to internal stimuli and making bizarre
and disorganized statements
clearly awake. Given concern for a primary psychiatric process,
he was seen by psychiatry who felt he had acute encephalopathy
as a result of intense stress and sleep deprivation with
underlying major depressive disorder and anxiety disorder. Case
discussed with neurology who did not believe this was related to
a primary neurologic issue. Psychiatry recommended increasing
duloxetine dose to 90mg daily.
# GERD - continued ranitidine
Transitional Issues
- Discharged home with prescription for increased dose of
duloxetine and trial of lidocaine cream.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b
(RAS and HTN) w/ recent admission at ___ for angioplasty of
right renal artery c/b by RP bleed (embolized ___ @___)
presented to ___ for right flank and abd pain.
ED course at ___ w/CT showing ?enlarged hematoma
and a large right sided effusion. Patient refused transfer back
to ___, thus transferred to ___ for further evaluation by
___ and thoracic surgery.
In further discussion with patient predominant symptoms of
dyspnea and R sided chest pain, RLQ abd pain. First noted ___
days ago and have progressively worsened. Endorses worsening
pain, occasional lightheadedness w/o syncope, chest pain,
palpitaitons. Denies fever/chills/n/v/myalgias.
ED course also significant for consultations by both thoracic
surgery and ___. Given no active extravasation on in house CT-A,
a multidisciplinary plan was made to hold on ___ intervention,
trend h/h and plan to have thoracics place pigtail cath early am
for symptomatic relief non-urgently. CTA Torso showed 1. Nonhemorrhagic large right pleural effusion causing near completely
collapse of the right lung with moderate leftward mediastinal shift.
2. A large right perinephric hematoma encompasses the right kidney. There is
no evidence of active arterial extravasation. Renal arteries are patent. No
pseudoaneurysm. Metallic devices, likely related to coil embolization seen in
the medial aspect of the right kidney. There are wedge-shaped infarcts within
the posterior cortex of the right renal interpolar region.
3. The left kidney is severely atrophic with severe thinning of the cortical
parenchyma and hydronephrosis with foci of calcification within the dependent
portion of the lower pole calyces. Stranding of fat surrounding the left
proximal ureter as well as ill-defined soft tissue stranding within the
ipsilateral psoas muscle adjacent to the proximal ureter and enhancing lymph
nodes in the left para-aortic region measuring up to 1 cm in short axis raise
suspicion for chronic infection as an etiology for the above described
findings. Comparison with any prior imaging if available is recommended to
ascertain the exact cause for chronic renal atrophy on the left.
4. The liver demonstrates heterogeneous attenuation however without delayed
phase imaging unable to distinguish between perfusional variant versus
ischemic changes.
5. Mild splenomegaly. CHEST (PORTABLE AP) showed Right pigtail catheter is in place. Large pleural effusion on the right has
decreased since the prior study. There is small to moderate pneumothorax.
Left lung is clear. Heart size is top-normal. CHEST (PA AND LAT) showed Comparison to ___. Minimal decrease in extent of the known right
pleural effusion. An air-fluid level at the right lung apex confirms the
presence of intrapleural air. Mild leftward mediastinal shift. Normal size
of the heart. Normal appearance of the left lung. CTA CHEST WITH CONTRAST showed Interval placement of a right-sided pleural drain. The right-sided pleural
effusion has significantly decreased in size with decreased mediastinal shift
and re-expansion of the right upper and middle lobes. However, a large
right-sided effusion persists, with collapse of the right lower lobe. Radiology showed Interval placement of 2 right-sided chest tubes. No discrete pneumothorax
identified.
Interval decrease in size of the right pleural effusion. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
After pleural drainage procedure, auto before ___, moderate right
pleural effusion persists common despite 2 right thoracostomy tubes. No
pneumothorax. . Right lower lobe atelectasis is severe. Left lung is clear.
Heart size is mildly enlarged. Mediastinum is midline. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change.
Bilateral chest tubes are seen on the right following with surgery with no
evidence of pneumothorax. Combination of pleural fluid and volume loss is
seen at the right base.
The left lung is clear. There is mild enlargement of the cardiac silhouette
without appreciable pulmonary vascular congestion. Radiology showed 1. Interval removal of right-sided chest tubes without evidence of
pneumothorax. Small right pleural effusion.
2. Consolidative opacities in the right lower lung field are consistent with
expected atelectasis although could represent pneumonia. Follow-up x-ray is
recommended to follow these opacities.
RECOMMENDATION(S): Follow-up x-ray to follow right lower lung field
opacities. The patient was diagnosed with Pleural effusion, not elsewhere classified. The patient was treated with ___
Right pleural pigtail catheter placement
___
Right VATS decortication, evacuation of effusion. At the time of discharge, the patient had Right pleural effusion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b
(RAS and HTN) w/ recent admission at ___ for angioplasty of
right renal artery c/b by RP bleed (embolized ___ @___)
presented to ___ for right flank and abd pain. She
was found to have recurrent RP bleed w/o active bleeding on
___ imaging and right pleural effusion. She was dyspneic and
underwent initial pig tail catheter placement.
Acute issues
#RP Bleed, Right Pleural Effusion: Course began with initial
admission to ___ for balloon angioplasty of right renal
artery stenosis ___ fibromuscular dysplasia. Course complicated
by RP bleed from wire injury(pt reported) then s/p emobolization
___. Presented to ___ ED and eventually transferred to
___ given recurrent bleed w/o active extravasation. No ___
intervention at this time. However, given effusion, she
underwent pigtail catheter placement but her right lung did not
fully reexpand and she was taken to the Operating Room on
___ where she underwent a right VATS decortication. She
tolerated the procedure well and returned to the PACU in stable
condition. She maintained stable hemodynamics and her pain was
controlled with a Dilaudid PCA. Her chest tubes remained on
suction for 48 hours and her chest xray showed almost full
reexpansion of the right lung. Her oxygen saturation on room air
was 97% and her port sites were healing well. Following removal
of her tunes on ___ her post pull chest xray revealed
almost full expansion of the right lung except for a tiny
basilar space. She was converted to oral Oxycodone and Tylenol
and had adequate pain control. Her chest tube sutures remain in
place and will be removed at her post op visit next week and she
was reminded to continue to use her incentive spirometer.
Chronic issues
#Hx IVDU/Substance Abuse Disorder: Per patient at bedside stated
no IVDU for 6 months, however told thoracics fellow most recent
use was 3 months. Patient finished 7 day course of oxycontin and
oxycodone recently and denies any current use. Hep C positive.
HIV negative, RPR negative.
#Hypertension: Secondary to fibromuscular dysplasia
- HydrALAZINE 100 mg PO TID
- Carvedilol 25 mg PO BID
- amLODIPine 10 mg PO DAILY
#Polycystic Kidney Disease: Pt w/known PCKD. Patient has not had
imaging of head to look for berry/sacular aneurysms. No current
headaches or visual symptoms.
- obtain pcp ___ records
- will need MR-A head/neck.
#Insomnia, Anxiety
- TraZODone 50 mg PO QHS:PRN insomnia
- ClonazePAM 0.5 mg PO BID
#Iron Def Anemia
-Ferrous Sulfate 325 mg PO DAILY
TRANSITIONAL ISSUES
=================
- will need MR-A head/neck to look for brain aneurysm given
polycystic kidney disease
Ms. ___ was discharged to home on ___ and will follow
up with Dr. ___ week in the Thoracic Clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH bladder CA s/p pelvic exenteration & ileal conduit c/b
SBO w/ exlap x2, recent C. diff, who presents with abdominal
pain, nausea, vomiting, and diarrhea since ___. She states that
her symptoms changes yesterday evening, when she stopped passing
stool or flatus, and her abdominal pain and nausea worsened. She
presented to the ___ ED for further care. A CT A/P showed a
closed loop small bowel obstruction. ACS was consulted for
surgical management. Radiology showed The tip of a new right internal jugular central venous catheter projects over
the upper right atrium, approximately 1 cm beyond the cavoatrial junction.
The tip of the endotracheal tube projects 2.1 cm from the carina. The enteric
tube extends to the stomach. A drainage catheter is noted over the right
upper quadrant.
Ill-defined opacities in both lung apices may reflect underlying emphysematous
change. No focal consolidation, pleural effusion or pneumothorax is
identified. The size of the cardiomediastinal silhouette is within normal
limits. CHEST (PORTABLE AP) showed NG tube tip isin the stomach. ET tube is in standard position. Right IJ
catheter tip is at the cavoatrial junction.
Cardiomediastinal contours are stable. There is no pneumothorax or enlarging
pleural effusions. There is mild vascular congestion. Radiology showed 1. No evidence of pulmonary embolism.
2. Large bilateral pleural effusions with bibasilar atelectasis.
3. Colonic wall edema with mucosal hyperenhancement and loss of normal
haustra. There is also wall edema and mucosal enhancement involving multiple
small bowel loops. Findings in the colon are compatible with pseudomembranous
colitis. Abnormal findings in the small bowel may also indicate enteritis.
4. Peripheral areas of hypoenhancement in the right kidney, some of which are
new from prior exam suggestive of renal infarcts. Portable chest radiograph showed 1. Right pigtail catheter tip projects over the posterior ninth rib; there is
no evidence of pneumothorax.
2. Bilateral low lung volumes with small left layering pleural effusion. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, this and placement of an
endotracheal tube with its tip approximately 3.3 cm above the carina.
Nasogastric tube is now in place with the tip coiled within the upper fundus
of the stomach.
Otherwise, little change in the appearance of the heart and lungs. CT ABDOMEN AND PELVIS WITHOUT CONTRAST. showed 1. Status post right lower quadrant ileostomy. No evidence of leak. No
evidence of small-bowel obstruction.
2. Re-demonstration of diffuse, pancolonic wall thickening, most likely
infectious. No pneumoperitoneum. Transverse colon measures 5.0 cm in
diameter.
3. Status post right chest tube placement with near complete resolution of
right pleural effusion.
4. Unchanged moderate left pleural effusion and left lower lobe consolidation.
5. Previously seen areas of decreased enhancement of renal parenchyma are
again seen, which may represent renal infarcts, consider pyelonephritis if
clinically indicated. Radiology showed Successful US-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation. CHEST (PORTABLE AP) showed Comparison to ___. Stable small left pleural effusion with left
basilar atelectasis and retrocardiac atelectasis. Stable correct position of
the monitoring and support devices, including the right-sided chest tube. New
introduction of a feeding tube, the tip projects over the proximal parts of
the stomach, the tube is coiled in the fundus. No new focal parenchymal
changes. Stable appearance of the cardiac silhouette. CHEST (PORTABLE AP) showed Cardiomediastinal contours are normal. Right IJ catheter tip is in the lower
SVC. There are low lung volumes. Left apical parenchyma opacities have not
improved. Moderate left pleural effusion and adjacent atelectasis are stable.
Minimal opacities in the right base have improved. There is no evident
pneumothorax. Catheter in the right pleura, catheters in the right upper
quadrant are in place. NG tube tip is in the stomach. DX CHEST PORTABLE PICC LINE PLACEMENT showed The right PICC terminates in the cavoatrial junction and the enteric tube is
curled in the upper abdomen with tip terminating over the region of the
gastroesophageal junction. Otherwise, the study is unchanged compared to the
prior. Radiology showed 1. No evidence of active hemorrhage or hematoma in the abdomen and pelvis.
2. Small increase in right pneumothorax. Right pleural catheter in stable
position.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:18 pm, 5 minutes after
discovery of the findings. Radiology showed Technically successful Right 8 ___ nephroureteral stent replacement. CHEST (PORTABLE AP) showed Small right pneumothorax is probably unchanged. Cardiac size normal. Small
to moderate left pleural effusion and adjacent atelectasis is stable.
Opacities in the right base have minimally increased could be atelectasis or
pneumonia. Right PICC tip is at the cavoatrial junction. Right basal pigtail
catheter is in place. NG tube tip is out of view below the diaphragm UNILAT UP EXT VEINS US showed No evidence of deep vein thrombosis in the left upper extremity.
Moderate subcutaneous edema within the left upper extremity as well as a large
heterogeneous fluid collection tracking along the medial left arm which may
reflect a hematoma. CHEST (PA AND LAT) showed Small to moderate left pleural effusion is minimally increased with increasing
adjacent atelectasis. Right lower lobe atelectasis have improved. Cardiac
size is normal. NG tube is coiled in the stomach. Right PICC tip is at the
cavoatrial junction. Right pigtail catheter and catheters in the right upper
abdomen are in place. Chest Radiograph showed 1. No radiographic evidence of pneumothorax. Notably, pneumothorax seen on
prior abdominal and pelvic CT was not visible radiographically.
2. Enlarging left pleural effusion. Radiology showed Interval removal of the right chest tube. No discrete pneumothorax is
identified. UNILAT UP EXT VEINS US LEFT showed Of note, there is severely limited visualization of the left brachial and
basilic veins due to a large known hematoma. Otherwise, no definite evidence
of deep vein thrombosis in the left upper extremity. Radiology showed Dilated air-filled loops of small and large bowel consistent with ileus. CT ABD AND PELVIS WITH CONTRAST showed 1. Dilation of the small and large bowel is consistent with ileus.
2. Anasarca.
3. Bilateral pleural effusions with associated atelectasis. Radiology showed Slight interval improvement in dilated loops of small and large bowel. CHEST (PORTABLE AP) showed In comparison with the study of ___, there has been placement of a
nasogastric tube that coils in the upper fundus of the stomach. Right
subclavian catheter again extends to the region of the cavoatrial junction.
The left hemidiaphragm is now sharply seen, consistent with improvement in the
left pleural effusion and atelectatic changes. However, there are increasing
atelectatic changes at the right base.
No evidence of appreciable vascular congestion or acute focal pneumonia.
Significant dilatation of gas filled loops of bowel are again seen in the
abdomen. Radiology showed NG tube terminates in the gastroesophageal junction and should be advanced
further. Re-demonstration of dilated loops of small and large bowel, slightly
improved compared to the day prior.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 8:57 am, 5 minutes after discovery of
the findings. VENOUS DUP UPPER EXT UNILATERAL LEFT showed 1. No DVT identified in the left arm.
2. Large hematoma extending in the medial left upper arm from the axilla to
the antecubital fossa. CHEST (PORTABLE AP) showed No acute findings in the chest. PORTABLE ABDOMEN showed No evidence of bowel obstruction. T-TUBE CHOLANGIO (POST-OP) showed Patent cystic duct with contrast passing into the small bowel. CT abdomen pelvis with contrast. showed 1. No acute intra-abdominal process identified.
2. Persistent prominence both ureters in this patient with known ileal
conduit. No focal drainable fluid collection is identified.
3. Post cystectomy, with postsurgical changes in the lower pelvis. The patient was diagnosed with Unspecified intestinal obstruction. The patient was treated with ___ ___ percutaneous nephrostomy tube
___ ___ for percutaneous cholecystoscopy tube
___ ex-lap, lysis of adhesions, enteroenterostomy. At the time of discharge, the patient had Small bowel obstruction
clostridium difficile infection
Urinary tract infection
Pleural effusion
acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female s/p anterior pelvic exenteration, ileal
ureteral conduit
for poorly differentiated carcinoma of unknown primary on
___. This was complicated by a right ureteral obstruction
resulting in a right PCN. The patient underwent salvage
radiation and subsequent small bowel obstructions requiring
exploratory laparotomy, and recent c. diff infection. She
presented to the hospital on ___ with nausea, vomiting and
abdominal pain. On cat scan imaging she was reported to have a
closed loop bowel obstruction. The Acute care surgery service
was consulted.
Based on the cat scan findings, the patient was taken to the
operating room where she underwent an exploratory laparotomy,
LOA, and entero-enterotomy. For details regarding this
procedure, please refer to the operative report. The patient was
taken to the intensive care unit after the procedure. She
remained intubated. She was noted to have labile pressures
requiring levophed and intravenous fluids. She was started on
flagyl for the reported c.diff.
On ___ she was extubated and resumed home Advair to augment her
pulmonary status. The fentanyl drip was weaned to intermittent
doses of intravenous Dilaudid and the levophed was weaned off.
She reported right upper quadrant pain and right flank pain.
The patient continued with serial abdominal examinations and the
white blood cell count was monitored. To assist with pain
management, the patient resumed her home fentanyl patch. The
Acute pain service was consulted for consideration of an
epidural catheter. Because of her mental status and elevated
INR of 1.6, the pain service were reluctant to place an epidural
catheter and she continued on oral and intravenous home pain
regimen.
After return of bowel function, the ___ tube was
removed and she was advanced to clear liquids. Her vital signs
were stable and she was transferred to the surgical floor.
Over the next two days, her respiratory status declined in the
context of her difficult to control post-operative pain. She was
transferred back to the intensive care unit secondary to
increased O2 requirement. Radiographic imaging of her chest
showed bilateral pleural effusions and a pigtail catheter was
placed in her right chest. On ___, the patient's hematocrit
drifted down and she was transfused 2 units PRBCs, with an
appropriate response. She continued to report abdominal pain.
Cat scan imaging was negative for a post-operative abnormality
but it did show a distended gallbladder. A percutaneous
cholecystostomy tube was placed on ___ to treat presumed
acalculus cholecystitis. The patient's LFT were monitored. The
patient was started on a course of meropenum and cefepime.
On ___, while attempting to remove the right sided pigtail
catheter, the patient's percutaneous nephrostomy tube was
removed. On ___, the patient was taken to ___ for replacement
of the nephrostomy tube. The chest tube remained in place, and
was placed on water-seal. Her antibiotics were narrowed to cipro
for pseudomonas UTI, and tube feedings were restarted, and her
central line access was removed. The patient was again
transferred to the surgical floor for continue management.
The right sided chest tube was placed on water-seal and removed
on ___.
The patient was reported to have purulent material draining from
her abdominal wound and the lower wound staples were removed.
The wound was lightly packed with a dry dressing. The white
blood cell count was monitored. At this time, the patient was
noted have a swelling of the left upper extremity and a
ultrasound was done. No DVT was reported.
The nutritional status of the patient continued to be
sub-optimal. She was evaluated by Speech and Swallow and cleared
for a soft diet. Her oral intake was poor and a PICC line was
placed for TPN. Despite her limited intake, she developed
abdominal distention and vomiting. She was reported to have an
ileus on imaging and was started on a bowel regimen. A
___ tube was placed for bowel decompression and she
was made NPO. After return of bowel function, the ___
tube was removed and the patient's diet was slowly advanced.
Because of caloric depletion, TPN continued along with calorie
counts.
On ___ she had a temperature of ___ F, tachycardic to
130's, and hypotensive with a systolic BP 60's and therefore
transferred to the intensive care unit. PICC line was removed in
setting of sepsis and therefor TPN was discontinued. Patient was
found to have bacteremia with gram negative rods and a e. coli
infection in percutaneous nephrostomy. She was treated initially
with cefepime and flagyl. Once cultures sensitivities were
obtained, she was transitioned to ceftriaxone and a midline was
placed. On ___ she was hemodynamically stable and transferred
back to the surgical floor.
Infectious disease recommended 2 weeks of antibiotic treatment
for bacteremia and an additional week of oral vancomycin for
chronic clostridium difficile infection.
At this point in hospitalization, her remaining issue was
nutritional intake. She was given Dronabinol to stimulate
appetite and family was encourage to bring foods of from. The
patient appetite and caloric intake improved with these
interventions.
In preparation for discharge, the patient was evaluated by
physical therapy who recommended discharge to rehab.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
making adequate urine, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Rehab stay anticipated <30 days.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ old with CAD s/p anterior MI ___ s/p
CABG (LIMA-LAD, SVG-RPDA, SVG-D1), iCM (LVEF 25%), afib on
warfarin, VT s/p ICD in ___, CML, and hx of prostate cancer s/p
brachytherapy, who presented with hematuria following
cystoscopy,
developed afib w/ RVR and hypotension requiring ICU admission. RENAL U.S. PORT showed 1. The bladder is only minimally distended and cannot be fully assessed on the
current study. Within this limitation, there is no sonographic evidence of
clot within the bladder.
2. No hydronephrosis.
3. There is trace perihepatic free fluid.
4. Prostate is suboptimally evaluated, but appears markedly heterogeneous in
echogenicity. Clinical correlation is recommended. CHEST (PORTABLE AP) showed 1. Stable cardiomegaly without evidence of pulmonary vascular congestion.
2. No evidence of focal consolidation. CT ABD AND PELVIS WITH CONTRAST showed 1. Foley catheter in place within a partially decompressed urinary bladder,
which contains slightly increased density consistent with blood products.
2. Small to moderate fluid within the pelvis, as well as trace perihepatic and
perisplenic ascites. No rim enhancing fluid collections identified.
3. Small right pleural effusion and trace left pleural effusion with adjacent
bibasilar atelectasis.
4. Minimally complex cyst in the left upper renal pole measuring 3.3 cm and
containing a thin internal septation, compatible with Bosniak II.
5. Cholelithiasis without evidence of acute cholecystitis.
6. Diverticulosis without evidence for acute diverticulitis. CHEST (PORTABLE AP) showed 1. Interval placement of a right internal jugular central venous catheter,
with tip extending to the mid SVC.
2. No evidence of pneumothorax. The patient was diagnosed with Hematuria, unspecified, Anemia, unspecified, Tachycardia, unspecified. The patient was treated with Extraction of retained foley catheter (___)
RIJ placement and removal. At the time of discharge, the patient had Urinary tract infection
Gross hematuria
Sepsis with septic shock
Chronic systolic heart failure
Atrial fibrillation
Coronary artery disease
CML. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with history of CAD s/p CABG, ischemic
cardiomyopathy (LVEF 25%), VT s/p ICD, atrial fibrillation on
warfarin, prostate cancer s/p brachytherapy, CML on nilotinib
who presented with gross hematuria after routine outpatient
cystoscopy s/p traumatic foley placement with retained urethral
foreign body s/p extraction and CBI initiation, with course c/b
shock, suspected septic due to UTI, and atrial fibrillation with
RVR, called out of FICU ___, s/p successful voiding trial with
improvement in hematuria treated with IV Vanc/Cefepime from
___ transitioned to Ceftriaxone until discharge and
continued on Cefpodoxime to complete course of antibiotics
ending on ___. He will follow-up with urology for outpatient
evaluation and continue on Coumadin for atrial fibrillation.
# Shock, presumed septic, now resolved, due to
# Urinary tract infection:
Developed shock in setting of gross hematuria, traumatic foley
placement, and retained urethral foreign body s/p extraction.
Suspect urinary source with UCx growing pan-S E.coli. CXR
without pneumonia, and blood cultures without growth to date.
Likely some component from baseline systolic heart failure, but
no compelling evidence for cardiogenic shock. Briefly required
phenylephrine in the FICU via RIJ, weaned off with IVFs. He was
treated broadly with Vancomycin/Cefepime initially (___),
transitioned CTX based on culture results with plan to complete
course of antibiotics until ___, continued on Ceftriaxone
IV while hospitalized and transitioned to Cefpodoxime on
discharge.
# Gross hematuria:
# Prostate cancer s/p brachytherapy:
P/w gross hematuria after routine outpatient cystoscopy.
Underwent traumatic Foley placement in the ED c/b retained
catheter and clots (extracted by urology) and development of
UTI/sepsis as above. Two way coude was placed with initiation of
CBI, with improvement in hematuria. Underwent a successful
voiding trial on ___. Monitored in house until INR therapeutic
on coumadin with no further episodes of frank hematuria with
clots. He will f/u with outpatient urology (scheduled for ___.
# Anemia:
Chronic anemia likely multifactorial due to CKD, AoCD,
nilotinib. Acute component secondary to gross hematuria in
setting of anticoagulation. Transfused 1 unit pBRC on ___ and
Hb subsequently stable. Hgb 8.8 on discharge.
# Thrombocytopenia:
Chronic, stable, suspect secondary to nilotinib, continued this
admission. Plt wnl on d/c.
# Transaminitis/hyperbilirubinemia:
Developed mild transaminitis and hyperbilirubinemia on ___,
likely secondary to shock, which downtrended with management as
above.
# Atrial fibrillation:
CHADs2vasc = 4. Developed RVR in setting of suspected septic
shock as above, improved with treatment of infection. Warfarin
initially held for hematuria (did not require reversal), resumed
at home dosing on ___ without bridging. Home metoprolol and
digoxin were continued.
INR 1.8 on discharge on the 1 mg of warfarin 4 times a week, and
2 mg the other three days. Will need INR check ___.
# Ischemic cardiomyopathy (LVEF 25%):
# VT S/p ICD:
As above, developed shock that was presumed septic in setting of
UTI, without evidence of frank cardiogenic shock. Home torsemide
and ACE were initially held in setting of volume resuscitation
and subsequently resumed. Home metoprolol was continued.
Torsemide was restarted and on discharge, ACE was resumed on
discharge. He will f/u with his outpatient cardiologist, Dr.
___. Dry weight on discharge 70.67 kg (155.8 lb)
# CAD s/p anterior MI s/p CABG:
# NSTEMI, type II:
Patient with elevated troponin on admission in setting of CKD.
Suspect mild demand in setting of sepsis and atrial fibrillation
as above. Downtrended. Home statin was continued. Of note,
patient is not on an ASA in setting of warfarin use. Deferred
consideration of ASA to outpatient cardiologist Dr. ___.
# Chronic kidney disease stage III:
Recent baseline around 1.8-2.2, now stable at baseline. Renal
ultrasound on ___ without hydronephrosis. Home calcitriol and
vitamin D were continued. Cr 1.8 on discharge.
- continue calcitriol and vitamin D
# Hypertension:
As above, initially required pressor for shock, weaned off with
fluids and treatment of infection. Home metoprolol was continued
and home torsemide subsequently resumed.
# Hyperlipidemia:
Continued home statin.
# CML:
Continued home nilotinib. F/u with Dr. ___ on ___
# Gout:
Continued home allopurinol, renally dosed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ with chronic HCV presents as a
transfer from an OSH in ___ for evaluation for a splenic
laceration s/p coil embolization. She presented to a hospital in
___ on ___ due to syncope in the bathroom, one week
after tripping and falling while attempting to catch a bus. She
reports she fell on her left side injuring her left rib cage and
hitting her head. She felt well overall and decided not to seek
medical care. She thereafter left to go ___ for vacation
(Hepatitis C support convention, also to visit a friend with
liver transplant) and had a syncopalepisode in the bathroom,
prompting her admission. While there, undergone splenic ___
embolization after a hematoma was discovered on a CT of her
abdomen. She then decided to come here for further care, got on
a plane, and was even upgraded to business class.
Also, of note The patient was discharged to rehab on nafcillin
after having a bacteremia and a reaction to vancomycin, and was
discharged home after she completed that course. Her last
injection was on ___.
In the ED, initial VS were:5 99.7 98 146/77 18 96%
-Patient was seen by transplant team in the ED, who recommended
to obtain OSH records especially discharge summary to determine
need for admission. If requires admission, recommend admission
to medicine/hepatology (Hep C cirrhosis). No active surgical
issues at this time. Discussed with Dr. ___
attending.
- Labwork was significant for
136 103 7
---------<115
4.2 25 0.5
ALT/AST ___ AP 108 Tbili 0.9 Alb 3.1
WBC 10.3
HCT 37.7
VS prior to transfer were:99.3 70 18 140/70 98% ra
On arrival to the floor,98.6 145/87 HR 90 RR 18 97%RA. She felt
well, other than pain in her abdomen over her spleen.
REVIEW OF SYSTEMS:
reprted having some fevers up to 102 recently, but not in the
past day,Denies headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. Radiology showed 1. Splenic enlargement compared to prior likely secondary to an intracapsular
hematoma and liquification status post embolization. Minimal amount of
residual enhancing splenic tissue is noted. Superinfection is not excluded,
although lack of a thickened and enhancing rim would make this less likely.
There is no evidence of extracapsular extension.
2. Cirrhosis with a mild amount of ascites.
3. Bilateral pleural effusions, small on the right and moderate on the left,
with lobar collapse in the left lower lung.
4. Gastric band. The patient was diagnosed with SPLEEN PARENCHYMA LACER, UNSPECIFIED FALL. At the time of discharge, the patient had splenic laceration status post splenic artery embolization. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Assessment/Plan: ___ ___ witness with PMHx s/p HCV
cirrhosis completed full treatment, in Afib now presenting with
abd s/p splenic embolisation
#Abdominal Pain - Pt recently sustained a traumatic splenic
laceration in early ___ s/p mechanical fall in trying
to catch a bus. She was unaware of the laceration until she
became lightheaded and passed out a few weeks later. She was
brought to an OSH in ___ where she was found to be anemic and
the splenic lacerations were identified on CT. She underwent
splenic embolization at OSH on ___. Of note, she did
not receive any blood products, because she is a ___
witness. Even though she was anemic s/p bleed from splenic lac
at ___, when she was admitted to ___ her HCTs were stable at
38.4. Per pt, decision was made to undergo splenic embolization
over surgery bc of her religous reasons for not getting blood.
Pain was controlled with acetaminophen 650mg Q8h standing and
oxycodone 5mg PO q6h prn pain. Repeat CT was performed to assess
for evidence of phlegmon that could rupture and leading to
bleeding. CT results revealed a stable hematoma around the
spleen. Transplant surgery was consulted in the event there were
findings requiring repeat intervention. Pt was hemodynamically
stable throughout stay, with pain control improving. Pt was
discharged with close follow-up with her PCP and hematologist.
To prevent constipation with pain medications, pt was discharged
on an aggressive bowel regimen.
# Splenic artery embolization: Pt was continued on
flagyl/ciprofloxacin which was started at OSH for a total course
of 28d to prevent splenic abscess. Patient should also be
assessed for vaccinations against encapsulated organisms once
she is a spleniC (e.g. pneumovax, HIB vaccination, and N.
meningitides vaccine).
#S/P multiple Falls - First fall sounds like it was
purelymechanical as she denies chest pain, sob, palpitations,
lightheadedness. The subsequent falls were likely ___ to anemia
and lightheadedness. While at ___ her hct has been stable. ___
worked with her to ensure that she was steady on her feet.
#Elevated alk pos: Alk phos was marginally elevated at 108,
which was trending down from a month prior. It was likely
elevated for multiple reasons including her recent splenic
embolization and HCV cirrhosis.
# HEP C cirrhosis - Pt completed her therapy for HCV and her
most recent viral load undetectable. While she was hospitalized,
we limited acetaminophen for pain control to <2g/day. Pt had
grade 4 cirrhosis by biopsy from ___. She completed a total
of 48 weeks of treatment which included telepavir completed on
___, interferon, and ribavarin. Per prior notes, most recent
HCV viral load in ___ was undetectable.
# Afib: currently irregularly irregular. CHADS risk score = 0,
thus does not need anticoagulation and not symptomatic per
patient
# Hypothyroidism - stable and continued on home levothyroxine
per endocrinology note from labs on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ gentleman with past medical history
significant for hypertension and CLL in remission recently
completed chemo, history of prior hypertensive stroke ___ years
ago with residual right foot drop who presents as an outside
hospital transfer for further evaluation of IPH. CHEST (PORTABLE AP) showed Mild bibasilar atelectasis. No focal consolidations or pneumothorax. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Slight increase in moderate amount of intraventricular blood described
above. Of note, on CTA there is evidence a potential spot sign in the region
of the right lateral ventricle occipital horn raising concern for potential
active bleeding.
2. Redemonstrated evidence of intraparenchymal extension blood just superior
to right lateral ventricle temporal horn in the region of the basal ganglia
where there is mild surrounding vasogenic edema.
3. Evidence of mild-to-moderate white matter small vessel disease.
4. Small old infarct abutting the body of the right caudate nucleus.
5. Extensive cervical lymphadenopathy likely correlates with the patient's
history of CLL.
6. A 2 mm left upper lobe pulmonary nodule for which no imaging follow-up is
recommended in low risk patients. High-risk patients may receive an optional
follow-up CT in 12 months per the ___ ___ criteria.
7. Couple thyroid nodules measuring up to 1.4 cm for which no follow-up
imaging is recommended.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or older.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:32 pm, 10 minutes after
discovery of the findings. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Stable hematoma in the right basal ganglia and medial temporal lobe with
stable surrounding edema and stable intraventricular extension.
2. Several small foci of contrast enhancement within the basal ganglia and
medial temporal lobe portions of the hematoma, without peripheral masslike
enhancement outside the margins of the hematoma, are of uncertain clinical
significance. Follow-up imaging is needed to exclude an underlying mass.
3. Extensive supratentorial white matter and pontine signal abnormalities,
nonspecific but likely sequela of small vessel disease. Small chronic
infarcts within bilateral corona radiata, left centrum semiovale, and left
pons.
RECOMMENDATION(S): Follow up MRI with and without contrast to assess for
resolution of contrast enhancement at the site of the right basal
ganglia/medial temporal lobe hematoma. CT HEAD W/O CONTRAST Q111 CT HEAD showed Essentially unchanged intraparenchymal hemorrhage with only minimal
redistribution in the region of the right basal ganglia with breakthrough and
layering into the temporal and occipital horns of the right lateral ventricle
and occipital horn left lateral ventricle. Similar surrounding vasogenic
edema. No discernible midline shift. Basal cisterns remain patent. Radiology showed There has been interval placement of a Dobhoff tube with the last image
demonstrating the tip in the proximal gastric body, satisfactory. Right-sided
port is unchanged, satisfactory. There is mild cardiomegaly and unfolding of
the thoracic aorta. Hilar contours are preserved. There is minimal bibasilar
atelectasis. The visualized lung fields are otherwise clear. There is no
large effusion or appreciable pneumothorax. Radiology showed 1. The enteric tube tip projects over the left upper quadrant presumably
within the stomach.
2. The right chest wall Port-A-Cath tip projects over the distal right atrium.
3. Nonspecific and nonobstructive bowel gas pattern. Radiology showed Penetration with thin liquids and nectar thick liquids without aspiration.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services). The patient was diagnosed with Traum hemor right cerebrum w/o loss of consciousness, init, Other fall on same level, initial encounter. The patient was treated with ___ Percutaneous endoscopic gastrostomy tube placement. At the time of discharge, the patient had 1. Right basal ganglia intraparenchymal hemorrhage
2. Dysphagia s/p PEG placement
3. Hypertension
4. E. faecalis 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>___ man with history notable for HTN, prior hypertensive
infarct, and CLL s/p ___ transferred from OSH after
presenting with left-sided weakness, found to have right basal
ganglia IPH on CT. Follow-up MRI did not demonstrate
microhemorrhages suggestive of underlying CAA as etiology of
hemorrhage, raising suspicion for hypertension (particularly in
light of persistent hypertension noted during the admission)
rather than trauma as the proximal cause of the IPH. Note was
made on MRI, however, of several small foci of contrast
enhancement within the basal ganglia and medial temporal lobe
portions of the hematoma potentially concerning for an
associated mass, for which repeat MRI with and without contrast
is recommended for further evaluation.
Subsequent course complicated by dysphagia s/p uncomplicated PEG
placement as well as E. faecalis UTI treated with a seven-day
course of ampicillin. HTN managed with captopril (transitioned
to lisinopril prior to discharge) as well as home metoprolol and
spironolactone. Chronic thrombocytopenia again noted during the
admission, with subcutaneous heparin held for platelet levels <
50,000.
TRANSITIONAL ISSUES
1. Ongoing blood pressure monitoring and titration of
antihypertensives.
2. Follow up MRI brain with and without contrast as above within
the next three months.
3. Ongoing speech therapy and assessment of swallow function.
4. Periodic monitoring of platelet counts.
5. Optional follow-up chest CT in 12 months for incidental
pulmonary nodule noted on CTA.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (X) Yes - () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? (X) Yes - () No </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/PMHx COPD, dCHF/sCHF (EF ___ ___ CRT ___, presents
with shortness of breath x several days, much worse today. Said
at baseline, she is ually able to walk around the house and get
chores done all day without feeling short of breath. However,
today she had a very difficult time breathing.
She denies any recent illnesses, or associated fevers or cough.
Also denies any sick contact.
Of note, patient's lisinopril dose was increased from 5 to 10mg
a few months ago. Otherwise, no recent change in medications.
In the ED initial vitals were: 97.6 88 115/78 22 100% 15L. She
initially triggered for a desat into 70's.
- Labs were significant for K 5.5, creatinine 1.5, BNP 1765,
trop <.01.
- Patient was given albuterol, ipratropium and prednisone
Vitals prior to transfer were: 97.5 77 94/60 18 94% RA
On the floor, patient reports she pretty much feels back to her
baseline. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is noted. The size
of the cardiac silhouette has slightly increased, caused by LS a inspiratory
air Ford. There is no evidence of pneumonia, pulmonary edema or pleural
effusions. The pacemaker leads are constant in position. CHEST (PORTABLE AP) showed FINDINGS:
As compared to the previous radiograph, the size of the cardiac silhouette has
minimally decreased and the lung volumes have minimally increased, likely
reflecting a stronger inspiratory effort Ford. There is no evidence of
pneumonia. No pulmonary edema. No pleural effusions. Unchanged course of the
pacemaker leads. On the current radiograph. There is no evidence for
nasogastric tube placement. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION. At the time of discharge, the patient had ACUTE DIAGNOSES:
1. COPD exacerbation
2. CHF 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>___ w/PMHx COPD, dCHF/sCHF (EF ___ ___ CRT ___, presents
with shortness of breath x several days consistent with COPD
___ CHF exacerbation.
#COPD Exacerbation: Precipitating factor unclear but most likely
cardiac given report of palpitation by pt and crackles on exam.
Infectious cause less likely as no systemic systems such as
fever, cold symptoms, or CXR findings. Pt was treated with
prednisone 40mg x5 days, last dose ___, in addition to nebulizer
treatments. Advair and tiotropium were added to her home
regimen.
#Palpitations: Pt reported palpitations x1 month, raising
concern for ICD malfunction. She has been self dosing carvedilol
for such symptoms. EP was consulted for device interrogation.
Her Device battery is at RRT (recommended replacement time).
However, pt expressed reluctance in replacing the battery. She
has an appointment with Dr. ___ on ___ and this will be
discussed further during that visit.
#Systolic (EF 15%) and Diastolic CHF ___ CRT: Pt presented with
worsening dyspnea and dry cough. She has been self dosing
torsemide at home. She reports non-compliance with her diet and
Na use x1 month. Exam was notable for crackles in the lungs but
no JVD or peripheral edema. Diuresis regimen included additional
torsemide doses (___), lasix 60mg IV, and metolazone 2.5mg.
-Continue home beta blocker, digoxin
- torsemide dose may be adjusted as appropriate in discretion of
PCP ___ cardiologist </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with CAD, asthma, metastatic colon cancer undergoing
chemotherapy, who presented to the ED with abdominal pain 2 days
prior and was found to have a 2 mm UVJ stone on CT scan. Pain
was controlled and she was discharged with pain medications and
flomax. She presented to the ED today with cough and weakness.
CXR was negative for pneumonia. She was afebrile and
hemodynamically stable, without leukocytosis or evidence of ___,
dirty UA. In this setting urology was consulted and the patient
was admitted for observation in the ED for IVF and pain control. Radiology showed Mild bibasilar atelectasis. Known bilateral lower lobe pulmonary nodules are
better depicted on the prior CT. The patient was diagnosed with CALCULUS OF KIDNEY. The patient was treated with 1. Cystoscopy.
2. Left ureteroscopy.
3. Left ureteral stent placement.
4. Basket extraction of stone. At the time of discharge, the patient had Left 2 mm ureterovesical junction 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 service after ED observation
and in anticipation of going to the OR for surgical intervention
for her uteral stone. She was taken from the ED to the
preoperative holding area and subsequently to the cystoscopy
suite after consent obtained with ___ interpreter. No
concerning intraoperative events occurred; please see dictated
operative note for details.
The patient received perioperative antibiotic prophylaxis. The
patient was transferred to the floor from the PACU in stable
condition. On POD0, pain was well controlled post-operatively
and she was provided with pneumoboots and incentive spirometry
for prophylaxis and home medications were resumed. On POD1, the
patient ambulated, basic metabolic panel and complete blood
count were checked and heart healthy diet was advanced as
tolerated. The remainder of the hospital course was relatively
unremarkable. The patient was discharged in stable condition,
eating well, ambulating independently, voiding without
difficulty, and
with pain control on oral analgesics. The patient was given
explicit instructions to follow-up in clinic in approximately
one week for ureteral stent removal. Urine cultures at time of
discharge were negative but with mixed flora suggestive of
contamination. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with medical history of CAD ___ RCA stent ___, HFpEF ___
porcine MVR (___), anti-cardiolipin antibody and paroxysmal
atrial fibrillation ___ MAZE and PVI on warfarin and flecainide,
mild aortic stenosis, broncho-alveolar carcinoma, seizures, CKD,
and prior stroke, who presents with substernal chest pain
radiating to the left that woke her up from sleep. Radiology showed 1. No definite acute cardiopulmonary process.
2. Grossly stable bibasilar interstitial markings and calcified pleural
plaques. The patient was diagnosed with Other chest pain. At the time of discharge, the patient had Primary:
Unstable angina
Anticardiolipin antibody syndrome
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>___ with CAD, HFpEF, pAF on Coumadin for anti-cardiolipin (INR
goal 2.5-3.5), MR ___ porcine valve replacement ___, known
multifocal lung adenocarcinoma, seizure disorder, gout who
presents with chest pressure/dyspnea at rest and aborted stress
test due to atrial irritability and dyspnea. She underwent
persantine MIBI test inpatient which showed no perfusion
defects.
While awaiting P-MIBI she was maintained on heparin gtt given
anti-phospholipid syndrome and prior stroke. After perfusion
study complete and determined no plan for cardiac
catheterization she was restarted on coumadin. She was kept
inpatient while her Coumadin was restarted on heparin bridge
given her anticardiolipid syndrome with prior TIA. She was not a
candidate for lovenox bridge given her renal function. She is
being discharged on a dose of 7.5mg daily with plan for INR
check ___
Electrophysiology saw her regarding her paroxysmal atrial
fibrillation and her antiarrhythmic plan. Flecainide carries a
mortality risk in patients with CAD and therefore she was
transitioned to amiodarone. Her baseline TSH/FT4 were normal
(4.9/1.1). LFTs normal.
She is being discharged with ___ of hearts monitor for
further characterization of her paroxysmal afib versus other
arrhythmias.
# Orthostatic hypotension
- positive orthostats; pt states this is chronic
- consider this problem prior to starting nitrates
- fall precautions
# Hyperlipidemia- She was continued on rosuvastatin 40mg qHS
# Gout- She was continued on allopurinol ___ daily
# Seizures- she was continued on home Keppra 750mg BID
# Anti-cardiolipin antibody
-INR goal 2.5-3.5 with Coumadin as per above
-bridge heparin gtt as per above
# Lung adenocarcinoma
-stable, undergoing outpatient 6 month surveillance
======================
TRANSITIONAL ISSUES
======================
-STOPPED flecainide
-STARTED amiodarone 200mg BID
-DECREASED aspirin to 81mg daily (to reduce risk of bleeding)
-NEEDS TO F/U with primary care doctor and cardiology as
scheduled
-DISCHARGED WITH ___ cardiac monitoring for 30 days
-discharge weight: 62kgs
-full code
-HCP: ___ (husband) ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo M with recently diagnosed neuroendocrine
tumor of the lung, stage IV with mets to skin and brain who is
admitted with increasing shortness of breath and chest pain.
Describes the chest pain as a constant dull ache in his chest
since last night at 10 pm. He took his morphine ___ at home
which relieved the pain enough for him to sleep but it recurred
this am so he called the ambulance. He says that the pain is
not worse with activity or eating, although he has not been
having much of an appetite and has lost weight. He does have
paroxsymal nocturnal dyspnea and orthopnea. His EKG shows
diffuse ST elevations, not in a vascular territory and his
troponins are negative x 1. Radiology showed Right lower lobe opacity is likely a combination of tumor
infiltration, atelectasis, and infection cannot be rule out. This area will
be further evaluated on the subsequent CT angiogram. Radiology showed 1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Large infiltrative right hilar lung mass with extension into the
mediastinum, much progressed from the prior study.
3. The mass causes compression of the right pulmonary artery, obliteration of
the right pulmonary veins, narrowing of the right mainstem and lobar bronchial
branches, and likely endobronchial invasion at these locations.
4. Diffuse infiltration of the right lower lobe with probable malignant
effusion.
5. Extensive mediastinal and bilateral axillary lymph node metastases.
6. Lytic metastases of the right fifth and sixth anterior ribs. The patient was diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH, SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES. At the time of discharge, the patient had metastatic large cell neuroendocrine carcinoma of the lung. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M with newly diagnosed neuroendocrine
tumor of the lung which is metastatic to brain and skin who
presented with chest pain and was found to have progression of
his cancer encasing the pulm artery, pulm veins, SVC, and left
atrium.
# Chest pain and SOB: These symptoms are likely from the
progression of his lung cancer which is very aggressive and
invasive to the medastinal structures including bronchi and
vasculature. Per oncology, increased symptoms may also be
secondary to inflammation from recent initiation of
chemotherapy. CTA was negative for PE and there is no clinical
evidence of pneumonia. Negative troponins and pattern on EKG
more consistent with diffuse myocarditis or pericarditis from
the tumor invasion rather than a vascular territory. Outpatient
oncologist (Drs ___ documented very clear
discussion with the patient and family that his cancer was
aggressive and life expectancy was on the order of weeks on
___. Per radiation oncology, no benefit to chest or whole
brain XRT at this time. Palliative care was consulted. Morphine
dosing increased to help with pain and dyspnea. Per discussions
with the patient and his family, code status was changed to
DNR/DNI and decision made to send him home with hospice.
# Hyponatremia: Na 128-130 during hospitalization, did not
improve with IV fluids. Urine electrolytes suggestive of SIADH
with urine Na 199, urine osmolality 645, likely secondary to his
malignancy.
# Chronic pain: from prior falls and accident. Used morphine ___
at home. The patient was transitioned to home with hospice.
# H/o depression and EtOH use: social work and pall care
involved.
# Code status: DNR/DNI, home with hospice
# HCP: daughter, ___ ___ cell, ___
Transitional issues
- blood cultures pending at time of DC, no growth to date</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ with h/o COPD/asthma, not on home O2, HTN,
who p/w COPD/asthma exacerbation. For the last 2 days, she has
had symptoms of a URI including subjective fever and a cough.
Her grandchildren have recently been sick. She was seen at ___
today and given a Z-pack and 60mg prednisone. A CXR showed mild
hyperinflation of the lungs, without consolidation. These
interventions did not improve her symptoms and she presented to
the ED.
.
PFTs per Atrius records last done ___, show FEV1 65%
predicted, FVC 83% predicted, FEV1/FVC 64% (Gold stage II COPD). Radiology showed Increased lung hyperinflation.
Reported to ___ by ___ by phone at 7:36 a.m. on
___ after attending radiologist review. The patient was diagnosed with RESPIRATORY ABNORM NEC. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with history of COPD and reactive airway disease
(asthma), hypertension who presented with impending hypercarbic
respiratory failure attributed to influenza infection causing an
asthma vs. COPD exacerbation.
.
#) Influenza, COPD/asthma exacerbation: Patient presented in
moderate respiratory distress with accessory muscle use and poor
air entry on exam. She required non-invasive positive pressure
ventilation initially but weaned to supplemental oxygen over the
course of her ICU stay. The trigger for this exacerbation was
most certainly influenza A (she had no been vaccinated this
year) and she was started on oseltamavir on admission (___) for
a planned 10-day course given her severe presentation. She also
received standing nebulizer treatments, corticosteroids and
azithromycin for a component of COPD and asthma exacerbation.
Given her youth, relatively low pack-year for smoking, we
obtained an alpha-1 antitrypsin level, which was reassuring. Her
PFTs in ___ documented an obstrutive ventilatory deficit with
severe asthma. She remained dyspnea with exertion following
transfer to the floor, but overall was much improved. She was
weaned off supplemental O2 successfully. She requested a
nebulizer machine, which we were able to obtain. She will
complete a short steroid taper on discharge.
.
#) Elevated hematocrit: Hematocrit 54.8 on admission. As high as
45% back in ___. Polycythemia ___ should be considered in
women with this hematocrit, though secondary polycythemia is
also a possibility given her pulmonary disease. However, her
lack of oxygenation issues supports a primary cause. Epo level
was low. LFTs were reassuring. She should be referred to
Hematology for further work-up.
.
#) HTN: Held her home carvedilol initially given her
bronchospastic airway disease and risk of beta-blocker induced
bronchospasm. Resumed her amlodipine for BP control once she
clinically stabilized. Carvedilol is being re-started on
discharge.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with RCA stenosis on medical management, hypothyroidism, and
bipolar disorder presenting with chest tightness and dizziness. Chest: Frontal and lateral views showed No acute cardiopulmonary process. The patient was diagnosed with Unstable angina, Dizziness and giddiness, Athscl heart disease of native coronary artery w/o ang pctrs. The patient was treated with Cardiac cath ___. At the time of discharge, the patient had Primary Diagnosis:
Chest tightness, ruled out cardiac etiology
Secondary Diagnoses:
Hypothyroidism
Bipolar disease
Depression
Osteopenia. The patient was given written instructions concerning 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 ___ stress with inducible inferior/posterior
ischemia concerning for RCA stenosis, treated with medical
management, hypothyroidism, and bipolar disorder presenting with
chest tightness and dizziness, s/p cardiac cath ___
showing no CAD.
CORONARIES: No angiographically apparent coronary artery disease
PUMP: EF >55%
RHYTHM: NSR
=============
ACTIVE ISSUES:
=============
#Chest tightness
Presented with chest tightness that occurred at rest. Troponins
negative. ECG with normal sinus rhythm, global t wave
flattening, no ST elevations or depression. Given full dose
aspirin. Taken to cath lab and found to have no CAD. On
discharge, stopped patient's imdur, SL nitro and aspirin. Chest
tightness had resolved at time of discharge. Likely MSK in
origin.
#Lightheadedness, dizziness
Likely ___ to hypovolemia. On day of discharge, given 500cc IV
fluid bolus.
===============
CHRONIC ISSUES:
===============
#HYPERTENSION
Patient was taking imdur, metoprolol, and amlodipine at home
prior to admission. Discontinued imdur on discharge. Per chart
review, it looks like outpatient cardiologist had stopped
patient's amlodipine ___ concern for lower extremity swelling.
She indicates she continued to take it. On exam in the hospital,
she has no lower extremity swelling. Will discharge her out on
amlodipine 2.5mg daily which can be discontinued in outpatient
setting if she develops any lower extremity swelling or her
blood pressures normalize. BPs 100s/60s on discharge.
#BACK PAIN
- Treated with lidocaine patch and tylenol
#HYPOTHYROIDISM
- Continued levothyroxine
#BIPOLAR DISORDER
- Continued divalproex, quetiapine
#DEPRESSION
- Continued citalopram
#OSTEOPENIA
- Next alendronate dose due ___, Continued vitamin D</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with hx CAD (single vessel coronary artery
disease, LAD w/ 40% stenosis after the diagonal, proximal D1 w/
90% stenosis; s/p Cath in ___ (first PCI with BMS to D1
complicated by acute closure requiring 2 additional BMS stents),
HTN, frequent GI bleeding who prevents following acute onset CP,
SOB, and elevated blood pressures. Radiology showed Normal chest radiograph. Radiology showed 1. No acute process. Specifically, there is no pulmonary embolus or aortic
pathology.
2. Minimal bibasilar bronchiectasis evident. Radiology showed Normal examination. The patient was diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC. The patient was treated with Coronary Angiography (___) - Placement of BMS x1 to LAD. The patient was given written instructions concerning 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 ___ with hx CAD
(single vessel coronary artery disease, LAD w/ 40% stenosis
after the diagonal, proximal D1 w/ 90% stenosis; s/p Cath in
___ (first PCI with BMS to D1 complicated by acute closure
requiring 2 additional BMS stents), HTN, hx. of GI bleeding who
presents following acute onset CP and SOB found to have
hypertensive urgency and NSTEMI. Pt. had coronary angiography
which revealed 90% lesion in mid LAD, s/p placement 1 BMS. Pt.
tolerated the procedure well. She had notable bruit at femoral
access site. Preliminary read of ultrasound revealed no evidence
of AV fistula, pseudo aneurysm or other complication. She was
chest pain free at time of discharge.
ACTIVE ISSUES
================
# NSTEMI: Pt. presented with acute onset CP and SOB found to be
with significantly elevated blood pressures. Cardiac enzymes
sent which revealed troponin elevation. Given pt's known
coronary artery disease, pt. was taken for coronary angiography
where she was found to have a 90% lesion in mid LAD. One BMS
was placed across this lesion. Pt. was loaded with ticagrelor
and told to continue ticagrelor for a limited 7 day course given
her previous history of GI bleed. Pt. was then told to
transition to plavix for approximately ___ weeks given placement
of BMS. She was also initiated on crestor 5mg daily.
# Hypertensive Urgency: Pt's elevated blood pressures were self
limited and improved without medication. Given her significant
history of anti-hypertensive intolerance and allergy, initiation
of BP meds were deferred at this time. This was communicated to
pt's outpatient cardiologist. Outpatient regimen will be
considered if BPs remain elevated.
CHRONIC ISSUES
================
# GERD: Pt. was started on ranitidine for GI protection in
setting of ongoing aspirin, anti-plt therapy, and her hx. of GI
bleed.
# Mild obstructive sleep apnea (dx/ by sleep study ___: Pt.
diagnosed with OSA on ___ sleep study. Pt should be seen as
outpatient for possible CPAP.
# Hypothyroid: No current therapy. Continue monitoring as an
outpatient.
# Pernicious anemia: Continue on vitamin B12 supplementation
TRANSITIONAL ISSUES
======================
# Ticagrelor and Plavix: Pt. should continue with ticagrelor
through ___. Following termination of ticagrelor, pt. should
start on plavix on ___. This should continue for at least 4
weeks. Total duration to be discussed with ___. cardiologist
Dr ___
# Pt. started on crestor 5mg daily on this admission (unable to
tolerate higher doses)
# Pt. scheduled to have TTE as an outpatient per Dr. ___
# Began ranitidine for GI protection in setting of ongoing
anti-plt therapy and previous GI bleed
# CODE: Full, confirmed
# CONTACT: Carmalina (daughter, HCP, ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain. The patient reports that
her pain began 2 days prior to admission while placing A/C units
in the window. She noticed ___ back pain as if someone put a
fist through her back. She thought is was muscular in etiology,
but when she got home from her daughters, she developed nausea
and mid/epigastric abdominal pain consistent with her
pancreatitis flares. SHe went to bed that night and the next
morning tried to eat some toast with some tea and her pain
became ___ and she had increased nausea without vomiting. She
took some tylenol and advil without benefit and she made herself
NPO. On the morning of admission, she tried to work from home
hoping the pain would improve, but it was persistent so she came
to the ED for further evaluation. She also reports some mild
loose BM the day of admission. Not watery or bloody, just
loose. Radiology showed 1. Stranding along the second and third portions of the duodenum may be
duodenitis, however, given elevated lipase, inflammation may be secondary to
pancreatitis.
2. Splenomegaly and chronic splenic vein thrombosis.
3. Hepatic steatosis. The patient was diagnosed with ACUTE PANCREATITIS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain and recurrent pancreatitis.
.
# Acute on Chronic Pancreatitis: Patient with recurrent flare
of her pancreatitis over the last 2 days. Her last flare
requiring hospitalization was ___. There continues to
be no clear etiology of her symptoms. She last had her MRCP 4
months ago and given her acute symptoms, and is not due for
repeat MRCP so we did not perform. Patient maintained on pain
control, IVF, and NPO status initially with gradual advancing of
diet. Patient did well and was discharged home with plan to
follow up in primary care.
.
# Chronic Splenic Vein Thrombosis: Patient with known chronic
splenic vein thrombosis. Likely secondary to recurrent
inflammation from pancreatitis flares. Monitored patient for
signs/symptoms of bleeding from gastric varices.
.
# Diabetes: Held metformin while in house given poor PO intake
and risk for ___ and possible need for further contrast studies.
Maintained on ISS. Discharged back on home metformin.
.
# Yeast infection: Patient noted to have UA with 12 WBC but
asymptomatic. Thereafter on history/physical noted to have
signs/symptoms of vulvovaginal candidiasis. It is likely this
may have contributed to WBC in urine. Treated patient with
fluconazole IV (given NPO status).
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with HIV (on ART, last CD4 1200) presenting
with acute onset vomiting and right sided abdominal pain that
woke him up from sleep on the day of admission at 12AM ___.
The patient endorses copious yellow vomiting. He has also been
experiencing diarrhea. He experiences nausea, vomiting and
abdominal pain on a nearly daily basis (4 out of 7 days of the
week). He takes Zofran for nausea and oxycodone for pain. He
also takes and herbal supplement buscapina for nausea. His
symptoms acutely worsened over the last 24 hours. He denies
fevers or sick contacts. Of note, he is s/p cholecystectomy and
appendectomy. No history of kidney stones. He denies recent
travel. He own 2 dogs, 1 cat and 1 parakeet.
Regarding his GI history the patient has known NAFLD. He has a
history of acute hepatitis (secondary acetaminophen/viral
illness), pancreatitis and chronic RUQ abd pain/n/v/d. He smokes
marijuana daily for nausea. He is s/p cholecystectomy and
appendectomy. An EGD in ___ showed mild mucosal abnormalities
in the stomach and duodenum, biospies were normal. He underwent
a liver biopsy in ___ which showed evidence of toxic
metabolic injury and stage I fibrosis. tTg negative, quant gold
negative (___) and ___ negative in the past.
In the ED intial vitals were: 96.6 68 136/79 18 95% RA
- Labs were significant for: WBC 15 (75%N), Hct 45, plt 429
- Patient was given: Zofran, IVFs, morphine
- CTU: no acute abdominal process
- RUQ: unremarkable
- Admit for abdominal pain
- Vitals prior to transfer were: 97.9 68 113/75 14 97% RA
On the floor, pt reports continued abdominal pain in the RUQ,
which has not improved. Nausea which is somewhat improved.
Review of Systems:
(+) per HPI Radiology showed No evidence of acute cardiopulmonary process. Radiology showed Unremarkable right upper quadrant ultrasound. No evidence of biliary
dilatation. Radiology showed 1. No evidence of acute intra-abdominal process
2. Fatty liver, diverticulosis, bilateral fat containing inguinal hernias. Radiology showed No pneumonia. Radiology showed Unremarkable bowel gas pattern without evidence of obstruction.
Moderate amount of stool in the right colon. Radiology showed 1. No obstructive biliary stones are noted. The patient is status post
cholecystectomy with the common bile duct measuring up to 8 mm which is within
normal limits post-cholecystectomy.
2. Fat replacement throughout the pancreas and more than expected for the
patient's age. Mild fibrosis of the pancreatic parenchyma which raises the
concern for a form of chronic pancreatitis.
3. No fat deposition within the liver. No cirrhotic changes noted within the
liver. No splenomegaly.
Findings were discussed with Dr. ___ at 11:15 a.m. on ___, two hours after discovery of the findings. The patient was diagnosed with ABDOMINAL PAIN RUQ, VOMITING, ASYMPTOMATIC HIV INFECTION. At the time of discharge, the patient had Diagnosis:
Nausea/Vomiting
Secondary diagnoses:
HIV on ART
NAFLD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman with PMH of DMII, NAFLD, anxiety, CAD
s/p MI, and HIV on HAART admitted with acute onset vomiting and
right sided abdominal pain. for one day. His LFTs and lipase
were initially normal on admission, but his LFTs gradually
uptrended on subsequent days. Abdominal imaging including CT,
RUQ U/S and MRCP were unrevealing. Viral hepatitis serologies
were negative this admission. Tox screen was also negative this
admission. He has no history of sick contacts or abnormal food
intake, though he was born in ___ and travels back to see
family on occasion. His HIV is well controlled with a CD4 count
of 1100 in ___. An opportunistic infection was felt to be
less likely due to his robust CD4 count. Of note, he is
followed by GI for NAFLD, chronic abdominal pain/nausea, and a
history of pancreatitis. An EGD in ___ showed gastritis with
normal biopsies.
Symptoms resolved with supportive care including IVF,
anti-emetics, and pain control. HIs LFTs also downtrended
without intervention. Acute complaints were felt to likely be
due to viral gastroenteritis with associated liver inflammation
as no other source of hepatobiliary pathology was identified.
Chronic symptoms may be related to post-cholecystectomy
syndrome, an IBS varient, hyperemesis variant, or possibly
gastroparesis. Pt. was advised to follow-up with his outpatient
gastroenterologist for continued management of chronic symptoms.
Throughout the admission, pt. was continued on his home HAART,
divalproex, anti-anxiety, and anti-hypertensive medications. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ without significant past medical history
who is admitted with several months of fever and sore throat
found to be neutropenic and thrombocytopenic.
Patient first developed sore throat and fever in ___,
and he was treated for Strep throat with penicillin. Since that
episode, he reports several intermittent bouts of recurrent
strep throat, fevers, and malaise that would last for several
days at a time before improving. He notes two such episodes in
___, last being two weeks ago which improved with Tylenol and
Sudafed.
Yesterday morning, patient again awoke with a markedly sore
throat. He also noted rigors/sweats, headache, sore back, and
orthostasis. He stayed in bed all day, and presented to
___ this morning. There, he was found to have
pancytopenia, with WBC 0.5 (0 neutrophils), Plt 22. He was given
Toradol, PCN, decadron, and 2L of fluid. He was transferred to
___ for further evaluation.
In the ED, initial VS were t 96.7 HR 90 BP 113/65 RR 18 O2
100%RA.
Labs were notable for WBC 0.3 (20%N, 75%L), HCT 35.7, PLT 15,
Uric acid 3.1, Na 135, K 3.9, Cr .0.8, lactate 1.6, ALT 12, AST
9, ALP 51, LDH 209, TBili 0.5, Alb 3.9, Fibrinogen 670, INR 1.2.
CT neck with contrast showed enlargement of the left palantine
tonsil without abscess. CXR showed no acute process. Bone marrow
biopsy was performed and patient was given 2g cefepime, 1mg po
Ativan, 1L NS, 1g IV vancomycin, 4mg IV morphine, and APAP prior
to transfer to ___ for further management. VS prior to transfer
were T 102.2, HR 102, BP 134/84, RR 18, O2 100%RA.
On arrival to the floor, patient reports significant anxiety.
He notes sore throat and odynophagia as above. He denies any
bleeding or significant bruising. No new rashes or joint pains.
No nausea, vomiting, or abdominal pain. He has been constipated
for a few days. No new joint pains or swelling. No travel
outside of ___, and no significant outdoor activity or
bug bites. He drinks ___ days per week, ___ beers. A few times a
month he will binge drink up to 5 beers. Reports much heavier
alcohol use several years ago. He smokes marijuana about 2x per
week, no other current illicit drugs. However, he does have a
history of daily IV heroin use, reports being clean ___ years. He
was incarcerated for almost ___ years, and was released in ___.
Sexually active with one female partner; doesn't use condoms.
About ___ female partners in the last year. Per report, he also
had a WBC at OSH of 1.7 in ___. Radiology showed No acute cardiopulmonary process. NECK CT WITH CONTRAST showed Asymmetric enlargement of the left palatine tonsil without peritonsillar
abscess.
Bilateral cervical adenopathy. DX CHEST PORTABLE PICC LINE PLACEMENT showed New right PICC line Radiology showed 1. No worrisome lymphadenopathy in the abdomen or pelvis.
2. Mild splenomegaly.
3. Moderate colonic fecal loading.
4. Please see the separately submitted report of the same day CT Chest for
findings above the diaphragm. CT CHEST W/CONTRAST showed 1. No lymphadenopathy by CT criteria. A single borderline right hilar lymph
node measures 9 mm in short axis, attention on follow-up imaging is
recommended.
2. Please see separately submitted Abdomen and Pelvis CT report for
subdiaphragmatic findings. DX CHEST PORTABLE PICC LINE PLACEMENT showed Right PICC line tip low SVC. Radiology showed Mild interval retraction of the right PICC line, the tip now projecting over
the mid SVC.
Clear lungs. Radiology showed The tip of the right PICC line projects over the mid SVC.
New haziness along the contour of the right hemidiaphragm may reflect a small
effusion or atelectasis. The patient was diagnosed with Other pancytopenia. At the time of discharge, the patient had PRIMARY DIAGNOSES
=================
Aplastic Anemia
Tonsillitis
Neutropenic fever
IgA Deficiency
Transaminitis
Steroid-induced hyperglycemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of polysubstance abuse (reportedly clean for ___
years), presented with with pharyngitis, pancytopenia found to
have newly diagnosed severe aplastic anemia. Also noted to have
IgA deficiency. He started immunosuppressive therapy with AtG
(___) and cyclosporine (___). His tonsillitis was treated
with cefepime (___) and clinda (___) until clinical
improvement and counts recovered with ANC>500. Course
complicated by methylprednisolone induced hyperglycemia, of
which ___ was consulted for management, which resolved after
cessation of steroids. Donor search was initiated for possible
bone marrow transplant in the future if patient relapses.
#Aplastic Anemia
BMBx confirming severe aplastic anemia. Vital studies negative.
Suspect immune related. Patient was started on ATG/cyclosporine
(D1: ___ and cyclosporine (___) with goal cyclosporine
level 200-250. Patient tolerated ATG without major
complications, although did experience some transaminitis (see
below). Patient was also treated with course of
methylprednisolone (Day 5: ___ to Day 14: ___. He was started
on acyclovir for prophylaxis. Voriconazole was started for
fungal prophylaxis, but was held in the setting of transaminitis
(see below). Patient's course was complicated by
thrombocytopenia, and he required platelet transfusions, which
he will likely need to continue in the outpatient setting.
Patient was discharged on cyclosporine, prednisone 3 week taper
(to end on ___, and acyclovir, with plan to restart
fluconazole as outpatient.
#Tonsillitis/Neutropenic fever
Patient with neutropenia, sore throat, and swollen exudative
tonsils. No abscess on CT of neck. Patient was treated with
Cefepime (___), Clinda (___), s/p Vancomycin
(___). Antibiotics were discontinued with evidence of
clinical improvement and when counts recovered with ANC>500.
#IgA Deficiency
Likely congenital as pt reports having frequent sinopulmonary
infections as a child. CT torso negative for lymphadenopathy,
but has mild splenomegaly of 14.4cm. Anti-IgA pending at time of
discharge.
#Steroid induced hyperglycemia
Patient with elevated FSBG in setting of methylprednisolone.
___ was consulted for further management. Hyperglycemia was
very mild and controlled with sliding scale insulin that
eventually resolved after cessation of steroids.
#Transaminitis:
Likely in the setting of voriconazole, ATG, and atovaquone, with
ALT peaking in 200s and AST in the 200s. Voriconazole and
atovaquone were discontinued, and following conclusion of ATG
therapy, ALT/AST downtrended. ALT/AST ___ on ___ at time of
discharge on ___.
#Polysubstance abuse: Reports clean from IVDU for several years.
Denies known EtOH withdrawal but has history of heavy drinking.
Also with tobacco abuse. Tox screen negative on admission.
Patient was agreeable to a sober pain management plan. Offered
patient nicotine patch/lozenge, although pt declined.
TRANSITIONAL ISSUES
========================
- Please consider starting fluconazole ppx for patient upon
discharge in the setting of his immunosuppression with recent
ATG therapy as well as ongoing cyclosporine and prednisone
therapy. Pt had been on voriconazole, but this was held in the
setting of transient transaminitis that was likely ___ to
combination of ATG therapy, voriconazole, and atovaquone.
- Patient received pentamidine for PCP ___ (Day 1:
___, in the setting of transaminitis as discussed above. His
next dose will be due on ___.
- Patient was started on cyclosporine as inpatient as discussed
above, with goal range 200-250. On day of discharge, ___,
cyclosporine level 389, and dose was decreased from 550mg daily
to 500mg daily. Please recheck cyclosporine level at outpatient
appointment on ___.
- Patient required intermittent platelet transfusions during
hospital course, and will likely need regular transfusions as an
outpatient.
- Patient was started on three week prednisone taper following
conclusion of methylprednisolone therapy, to end on ___.
- Patient has anti-IgA antibody pending at time of discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with history of cryptogenic cirrhosis s/p liver
transplant, CKD, and recurrent self-resolving febrile illnesses,
here with fever. Patient and family report that he has been
having fevers ~q6 weeks without clear source. Fever began again
yesterday, tmax of 101.2. He complains of chills and diffuse
myalgias, similar to previous episodes of fever. No focal
symptoms. Reports he has leg pains which are chronic but make it
difficult for him to walk. ROS positive for dysuria and urinary
urgency, which started yesterday.
No other focal symptoms.
In the ED, initial vitals were 100.6 115 112/61 18 98% RA
Labs notable for: negative UA; Cr 1.8 (at baseline), LFTs wnl
CXR and RUQ u/s were unremarkable. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Patent hepatic vasculature, similar to the prior exams. Evaluation of the
right hepatic artery is somewhat limited due to patient cooperation, though it
is patent with a normal waveform.
2. Normal echogenicity of the transplanted liver.
3. Pneumobilia again seen. No biliary duct dilation.
4. Limited evaluation of the common bile duct stents due to overlying bowel
gas. Stents not seen CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of posttransplant lymphoproliferative disease.
2. Transplanted liver, with pneumobilia within left lobe of the liver. Biliary
stents in appropriate position. Mild intrahepatic biliary ductal dilatation of
the left lobe of the liver. Even though there is no query biliary ductal
enhancement or thickening, possibility of cholangitis is raised. Clinical
correlation is recommended.
3. No lymphadenopathy.
4. Please refer to the CT chest from the same day for complete details on
thoracic findings. CT CHEST W/CONTRAST showed Subtle patchy areas of ground-glass changes along the peripheral aspects of
upper and lower lobes of the lung are nonspecific, and may simply relate to
atelectasis, however differential considerations would include prior scarring
given the parenchymal changes on prior study from ___ and
infectious/inflammatory etiologies including atypical organisms. Continued
followup is recommended.
Please refer to CT abdomen/pelvis from the same day for complete details on
abdominal/pelvic findings. The patient was diagnosed with FEVER, UNSPECIFIED. At the time of discharge, the patient had Fever. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with history of cryptogenic
cirrhosis s/p liver transplant, cholangitis, CKD, and recurrent
mild febrile illnesses, who presents with fevers.
# Fevers: Patient with fever to 101.2 at home. On the night of
admission his Tmax was 99.6. He did not have a recurrence of his
fevers for the rest of his hospital stay. Workup with RUQ US,
blood and urine cultures was unrevealing. CMV viral load pending
on discharge. CT scan did not reveal evidence of abscess or
PTLD. However, the radiographic possibility of cholangitis was
raised. Clinically, there was low suspicion for cholangitis with
normal LFTs, no leukocytosis, no fevers, and negative cultures.
He had mild diffuse abdominal pain, which patient stated was his
baseline. He is scheduled for close follow up in the liver
clinic for further monitoring.
# Liver transplant: S/p transplant in ___ for cryptogenic
cirrhosis. RUQ u/s on admission in the ED unremarkable. LFTs
were within normal limits during his hospital stay without
evidence of graft dysfunction. He was continued on home
Cellcept, sirolimus, ursodiol, and Bactrim. Sirolimus levels WNL
on admission, but pending on discharge.
# CKD: Thought to be ___ prior cyclosporine toxicity. Creatinine
at baseline during his stay.
# Holosystolic murmur: Consistent w/ mitral regurgitation. No
previous documentation of murmur and last TTE w/o significant
valvular disease. Unlikely to be related to current
presentation. Blood cultures negative. Consider outpatient TTE
to evaluate etiology of murmur.
# Abdominal bruit: Heard diffusely throughout abdomen. No
palpable/pulsatile mass. CT scan notable for normal caliber of
abdominal aorta. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/chronic trach ___ laryngeal cancer s/p exploration and
tracheal tube change on ___ by ENT presents from nursing
facility due to frank blood coming from the trachea tube. Pt
reports sore throat and pain at the top of the lung. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OTHER HEMOPTYSIS, TRACHEOSTOMY STATUS. At the time of discharge, the patient had bleeding from trach
chronic trach and peg 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>ASSESSMENT AND PLAN: ___ w/chronic trach ___ laryngeal cancer
s/p exploration and tracheal tube change on ___ by ENT presents
from nursing facility with trauma from too much deep suctioning
at ___ causing mild tracheitis
Tracheitis: likely due to repetitive suctioning and recent
procedure. Resolved. ENT advised no use of antibiotics and
avoidance of frequent deep suctioning, use of cough training and
pulmonary toliet. Patient only had one episode of low grade
fever in the ED and did not receive antibiotics once she was
admitted to the floor. She remained on her usual cough meds and
humidified trach mask to keep secretions wet to be able to cough
up. She should f/u with ENT, Dr. ___ in 4 weeks.
Schizophrenia/Anxiety: cont home meds
CAD: cont home meds
neurogenic bladder: maintain foley, UA negative, culture urine
grew 10k proteus, not treated
FEN: tube feeds
I communicated discharge plans on ___ Dr. ___ ___</s> |