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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ right-handed man with history of
generalized epilepsy, well controlled on lamotrigine
monotherapy,
followed by ___ neurology, hypertension, who presents
for
multiple breakthrough seizures in the past 2 days. History is
obtained from girlfriend at bedside. CHEST (PA AND LAT) showed No definite focal consolidation. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Seizure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ right-handed man with history of
generalized epilepsy, well controlled on lamotrigine
monotherapy,
followed by ___ neurology, hypertension, who presented
for
multiple events consistent with breakthrough seizures in the
past
2 days. He underwent cvEEG which showed initial slowing but
quick improved without any epileptiform activity. The etiology
of his breakthrough seizures is not entirely clear at this time;
there is no evidence of medication noncompliance or decreased
absorption, metabolic derangements, or underlying infection. In
addition, pt denied any changes in alcohol intake. He does
endorse a hx of seizure during the ___, which he attributes
to seasonal allergies. His outpatient neurologist confirmed that
his last seizure was in the ___ and was attributed to
allergies in addition to maybe missed medication dose.
Furthermore, on exam pt was noted to have significant cognitive
problems, including persistent attentional problems, substantial
encoding difficulties, retrieval memory problems, as well as
phonemic paraphrases error. This is concerning for possible
bilateral mesotemporal problems with left lateralization. He
needs close follow up with his outpatient neurologist for
further w/u, starting with revaluation in about a week to assess
possible post-ictal contribution that may clear. If he continues
to have persistent cognitive problems he would benefit from MRI
brain. He has follow up with his outpatient neurologist next
week. He also has an appointment with cognitive neurology here
at ___. He was discharged home in stable condition. No changes
to his medications were made. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a patient well known to the ACS surgery team. He
is a ___ year old male who has had multiple operations related to
a GSW to the abdomen in ___ (please see PSH). Most
recently, he has had abdominal wall reconstructive surgery in
the ___ of this year. His wound now currently has a known
entero-atmospheric fistula (EAF). CT ABD AND PELVIS WITH CONTRAST showed 1. Concern intussusception near level of anastomosis, underlying surgical
defect, without definite evidence of high-grade bowel obstruction. No
drainable fluid collection.
2. Small hiatal hernia.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:25 pm. The patient was diagnosed with Other complications of enterostomy, Unspecified abdominal pain. At the time of discharge, the patient had prolapsed fistula s/p reduction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Pt is a ___ year old male who has had multiple operations related
to a GSW to the abdomen in ___ (please see PSH). Most
recently, he has had abdominal wall reconstructive surgery in
the ___ of this year. His wound now currently has a known
entero-atmospheric fistula (EAF). He presented to the ED with
prolapse of his EAF. It was significantly engorged and tender,
however, appeared viable. We sprinkled sugar on it and then
reduced the prolapse successfully. We placed a pressure dressing
to keep the bowel in place. Subsequently, a CTAP showed that the
bowel was perfused but perhaps intussuscepted. The patient was
admitted for monitoring. On HD2, the patient's diet was advanced
to regular, which he tolerated. On HD3, the patient was doing
well, and was ready for discharge with appropriate follow up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o gentleman transferred from an OSH with a
diagnosis of L frontal SAH, SDH, and intraparenchymal bleeds on
CT scan. Patient presented to OSH with father who reported falls
in the last week. ___ father brought
him to OSH for slurred speech and sleepiness. Patient reports
headache. Denies numbness, weakness, tingling, blurred vision,
double vision, nausea or vomiting. Patient also denies falling
but it is clear from the history he is not fully oriented. Pt
was not loaded with AED at OSH. Upon arrival patient is slightly
lethargic, but interacts readily and is appropriate.
Neurosurgery was consulted to evaluate him in the setting of his
intracranial bleeding. Radiology showed Stable left frontal subdural hematoma, hemorrhagic contusions and small focus
of right parafalcine subarachnoid hemorrhage as well as subdural hematoma
along the right tentorium cerebelli, follow-up head CT is recommended to
evalute evolution. The patient was diagnosed with SUBDURAL HEMORRHAGE, SUBARACHNOID HEMORRHAGE, OTHER SPEECH DISTURBANCE, OTHER MALAISE AND FATIGUE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. At the time of discharge, the patient had Left frontal SDH, hemorrhagic contusions, and SAH. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the Neurosurgery service on ___
after being transferred from an outside hospital with a
diagnosis of left subdural hematoma, hemorrhagic contusions, and
subarachnoid hemorrhage. He was loaded with Dilantin in the ED
and transferred to the floor for further observation and
management. A repeat Head CT performed on the morning of ___
was stable from the previous CT scan. The patient had presented
on ___ with a creatinine of 2.2 and was started on IV fluids;
the creatinine had decreased to 1.9 by the morning of ___ and
1.7 on ___. Sodium levels were decreased at 131 on admission
and slowly normalized. On ___, patient was cleared by ___ to be
discharged home. He was ambulating and eating appropriately. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man with a history of complex partial
epilepsy followed by Dr. ___ presents with
lightheadedness and anxiety. CT HEAD W/O CONTRAST showed No acute intracranial process. The patient was diagnosed with Dizziness and giddiness, Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Lightheadedness, ?medication side effect. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo man with a history of intractable complex
partial epilepsy (foci of onset in both temporal lobes based on
Phase II evaluation) who presented with frequent lightheadedness
and anxiety, with concern from his outpatient epileptologist for
unwitnessed seizures leading to post-ictal anxiety.
Orthostatic vital signs in ED and on floor were negative. Work
up for infectious etiologies was negative. A non-contrast CT of
the head revealed no acute abnormalities. On EEG, there were no
electrographic seizures, but he did have left mid-temporal
interictal sharp-and-slow-wave discharges. Patient indicated
strong preference to be discharged with follow up with primary
epileptologist - therefore, we did not make any changes to his
AEDs.
Transitional Issues
#Neurology
[ ] Follow up with Dr. ___ in ___
[ ] Continue current AEDs</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with h/o T4___, Stage III, urothelial carcinoma
of the bladder, cycle 2 day 9 of gemcitabine/cisplatin
(gemcitabine ___, presents with fever and acute renal
failure. Radiology showed No opacification concerning for pneumonia. No pulmonary edema.
Bronchial cuffing suggests small airways disease. Radiology showed 1. Left pyelonephritis and ureteritis as well as partial obstruction at the
left UVJ from tumor/therapy.
2. Irregular thickening of the left posterior lateral bladder wall with
enhancement which appears to be somewhat improved from prior exam compatible
with patient's known bladder cancer. No evidence of metastatic disease.
3. Stranding of the subcutaneous soft tissues overlying the pubic symphysis
which may represent cellulitis.
4. Bilateral apical scarring along with multiple calcified granulomas
compatible with prior granulomatous disease.
Results discussed with Dr. ___ over the telephone by Dr. ___
at 4:20PM on ___. The patient was diagnosed with PYELONEPHRITIS NOS, RENAL & URETERAL DIS NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Locally invasive bladder cancer
urinary tract infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with history of T4aN0M0, Stage III,
urothelial carcinoma of the bladder on C2D13 (___) of
gemcitabine/cisplatin who presented with fever and acute kidney
injury. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male with a history of
central cord, resulting in paraplegia that has gradually
improved, but complicated by a bowel traction or tarry
surgery, who is transferred from ___ with abdominal
pain, and concern for cholecystitis. The patient repeatedly
falls asleep while in trying to interview him, and is not
able to give a significant history. He apparently had
several days of abdominal pain in the right upper quadrant
and left upper quadrant, he had nausea, but did not vomit
and was taken to the ___. A CT scan there was
suggestive of possible cholecystitis, LFTs and lipase were
negative, the patient was seen by surgery there, who
recommended transfer to ___ given his multiple
comorbidities and complicated surgical history. Of note,
labs there also included a troponin that was mildly
elevated. The patient does deny chest pain to me.
Timing: Gradual
Duration: Days
Context/Circumstances: CT scan of possible
cholecystitis
Associated Signs/Symptoms: Nausea Radiology showed No acute intracranial abnormality. Radiology showed Right heart failure or volume overload. The patient was diagnosed with ABDOMINAL PAIN GENERALIZED. At the time of discharge, the patient had urinary tract infection
troponin leak
acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the acute care service with
abdominal pain. On initial examination in the emergency room,
he was also found to have unequal pupils. Upon admission, he
was made NPO, given intravenous fluids, and underwent imaging.
Because of the pupillary finding, a head cat scan was done
which showed no acute intracranial abnormality. On ultrasound
of the abdomen, he was found to have multiple gallstones and
sludge. Further work-up with a cat scan demonstrated findings
concerning for cholecystitis. In addition to these findings, he
was found on initial lab work to have a mild elevation in the
bilirubin and a mild troponin leak without EKG changes. Routine
urinalysis was suggestive of a urinary tract infection. He was
started on unasyn which provided coverage for both the urinary
tract infection and cholecystitis. His abdominal pain gradually
subsided. His troponins were cycled because of the troponin
leak.
During his hospitalization, his mental status improved and he
became alert, oriented, and conversant. His vital signs and
electrolytes were closely monitored and his electrolytes were
repleted. There was a mild decrease in the tropnin level to
0.02 from 0.03, but the current level has stabilzed at 0.03.
Cardiology was informed of these findings and recommended
resumption of his home medications, along with aspirin, and a
out-patient echocardiogram.
His vital signs have been stable and he has been afebrile. He
has been tolerating a regular diet and has a indwelling foley
catheter. His total bilirubin has decreased to 1.4 and his
white blood cell count has decreased to 12.5.
On HD #3, he was discharged to a ___ facility in
stable condition on a 2 week course of augmentin. He has an
appointment scheduled for an out-patient echocardiogram and a
follow-up visit with a cardiologist. The rehabilitation
facility has been informed of the date and time of the
appointment. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ h/o newly diagnosed locally advanced HCC,
HCV, cirrhosis decompensated by ascites, grade I varices and
right-->PV thrombus (not on AC) and acute anemia who was
referred
to the ED for abnormal labs. Patient was recently admitted in
___ for acute anemia to 5.5, at which time he underwent
EGD
which did not show any source of bleeding. He did not undergo a
colonoscopy because he wanted to leave the hospital; he was in
distress over his new cancer diagnosis. Patient was transfused
while in-house and at discharge on ___ his hemoglobin was 7.5.
Today he presented to liver clinic where vital signs were stable
and he was only reporting fatigue. He denied any BRBPR, melena,
hematuria, dizziness, presyncope, chest pain, or dyspnea; he
otherwise feels well. In the ED, initial vital signs were: 97.6,
HR88, BP130/80, RR16,
100% RA Radiology showed 1. Redemonstration of multifocal hepatocellular carcinoma with slight interval
enlargement of several of the lesions. No definite evidence of extrahepatic
disease. Persistent occlusion of the right Portal venous system with the
probable tumor thrombosis, likely unchanged.
2. Mild irregular enhanc thin patchy peritoneal enhancement elsewhere that
appears unchanged. Pelvis was not imaged before, however. Ement and
thickening along the peritoneum in the deep pelvic cul de sac. Versus drop
metastases to the pelvic cul-de-sac. Although this may be due to peritoneal
inflammation possibility of drop metastases to the pelvic cul de sac should be
considered, particularly given the irregular appearance.
3. Underlying cirrhosis with large volume ascites and extensive esophageal and
paraesophageal varices. These Findings are similar to the prior study.
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 convincing evidence of intrathoracic malignancy.
2. Mild to moderate apical predominant centrilobular emphysema.
3. Please see separately submitted Abdomen and Pelvis CT report for
subdiaphragmatic findings. CHEST (AP AND LAT) showed Limited, negative. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Intermittent main portal vein flow, which is suspicious for progression of
thrombosis or slow flow and worse on today's exam when compared to ___ and ___.
2. Persistently thrombosed right portal vein. Left portal vein remains
patent.
3. Large volume complex ascites.
4. Cirrhotic liver with a dominant mass measuring up to 9.7 cm, consistent
with known HCC.
5. Cholelithiasis without evidence of cholecystitis. Diagnostic and therapeutic paracentesis showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 5 L of bloody fluid were removed. The patient was diagnosed with Anemia, unspecified. The patient was treated with ___ Colonoscopy
___ Paracentesis. At the time of discharge, the patient had PRIMARY DIAGNOSES
===================
Acute on chronic microcytic anemia
Decompensated cirrhosis
___
SECONDARY DIAGNOSES
====================
Hyponatremia
Severe Malnutrition. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ h/o newly diagnosed locally advanced HCC,
HCV, cirrhosis (decompensated by ascites, grade I varices and
right PV thrombus, not on AC) and acute anemia who was referred
to the ED for low Hb. He was given blood transfusions and
underwent a paracentesis and colonoscopy.
ACUTE ISSUES ADDRESSED
========================
# ACUTE ON CHRONIC MICROCYTIC ANEMIA
# IRON DEFICIENCY ANEMIA: The patient presented with hgb of 5.5
from baseline of 9.2 and was transfused 2u pRBCs. Recent EGD w/o
signs of bleeding. Colonoscopy on ___ found 4 cm non-bleeding
polypoid lesion of multilobular in the appendix. Biopsies
performed. In addition, his diagnostic/therapeutic paracentesis
had high RBCs, raising suspicion for intraluminal bleed related
to his HCC. The patient was transfused 2u pRBCs with adequate
response, given IV iron infusion x2. Hemolysis labs negative.
# DECOMPENSATED CIRRHOSIS
Cirrhosis see on ___ RUQUS. MELD 30 CHILDS B (MELD 16 in
___. Presumed EtOH + HCV cirrhosis, decompensated by
ascites, portal vein thrombus (not on anticoagulation) and
esophageal varices. Currently decompensated with worsening
transaminitis and complex ascites. Negative for SBP on
paracentesis.
EGD on ___ showed chronic portal HTN, grade 1 varices.
Portal vein thrombus present likely tumor thrombus and not on
anticoagulation given anemia and blood loss. Home furosemide and
spironolactone initially held and restarted.
# HCC
Triphasic CT A/P scan on ___ consistent with multifocal HCC.
___ RUQUS was concerning for portal vein thrombosis, likely
tumor thrombus. Patient was discussed at tumor board on ___,
saw Dr. ___ and then Dr. ___ here.
They have not yet decided on next steps but per wife, quality
over
quantity is valued but patient seems to prefer more aggressive
options. CT Chest/Abd/Pelvis w/ and w/o contrast ___ - no
thoracic
mets, interval enlargement of liver tumors, possible pelvic
mets. There were no plans for biopsy due to c/f intraluminal
bleeding, Dr ___ he may be candidate for nivolumab
(bleeding risk from sorafenib). If appropriate, Dr. ___ plans
on referral to ___ for local treatment. Patient and
wife plans on meeting with ___ care as outpatient to
discuss goals of care.
# HYPONATREMIA
Patient was hyponatremic. On this admission UNa <20 and UOsm 365
making SIADH less likely. Hyponatremia likely secondary to poor
PO intake and hypovolemia
from ascites. Hyponatremia was monitored, persistent and stable.
# SEVERE MALNUTRITION
Patient had temporal wasting and is cachectic on examination.
Nutrition followed and recommended supplementation and tube
feeds if within goals of care.
===============</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male in the emergency department for evaluation of
lower abdominal pain. Patient had pain for the past 5 or so days
worse over the past few hours. Associated with nausea and one
episode of nonbloody nonbilious vomiting.
Describes the pain as baseline cramping with occasional episodes
sharp pain. No fevers or chills. Patient has had normal small
hard bowel movements during this time. He does have a history of
diverticulosis. Radiology showed 1. Sigmoid diverticulitis with a contained perforation in association with an
intramural abscess. This fluid collection is not amenable to percutaneous
drainage due to location and small size.
2. Extensive small bowel dilation without evidence of high grade obstruction
at this time. Findings may represent an ileus, but is not classic given the
adjacent fluid and distance from primary large bowel pathology. There is
moderate mesenteric stranding and fluid which may suggest an infectious or
inflammatory ileitis. Close clinical follow-up and repeat imaging as
necessary is recommended as partial obstruction is also possible.
3. Bilateral upper pole nonobstructing renal calculi. The patient was diagnosed with DIVERTICULITIS OF COLON. At the time of discharge, the patient had Complicated diverticultitis. The patient was given written instructions concerning 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 male who presented to the
emergency room with abdominal pain. He was admitted to the Acute
Care Surgery service after CT Scan imaging revealed "Sigmoid
diverticulitis with a contained perforation in association with
an intramural abscess." The patient had a white blood cell count
of 15.5 on admission. The patient was initiated on Intravenous
fluids, Intravenous antibiotics and strict bowel rest. He was
kept NPO until his diet was advanced to clear liquids on HD 3,
which he tolerated well. His pain was well controlled with IV
pain medications, however after receiving IV Antibiotics, pain
did improve. On the day of discharge, the patient was able to
tolerate a regular diet without experiencing nausea or vomiting.
Blood cultures were drawn on admission and they are still
pending. The patient was seen by gastroenterology prior to
discharge in light of his diverticulitis. They recommended he
followup as an outpatient with a colonoscopy. On HD 4, the
patient denied abdominal pain and was transitioned to oral
antibiotics. He was discharged home with instructions to finish
a two week course of Cipro/Flagyl. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ woman presenting with fever and
dysuria. The patient reports that one month ago she began to
have cloudy urine, urinary frequency and dysuria. She was seen
by a physician at urgent care and prescribed an antibiotic that
began with a C but she is unsure of what it was. She was taking
it twice daily. She states that she took the full course with
improvement in symptoms but the day after she stopped
antibiotics her symptoms immediately returned. Her symptoms have
progressively worsened over the last few weeks and now she is
having left-sided lower quadrant abdominal cramping and
drenching sweats and fevers at home. She is sexually active with
one male partner; she is not on oral contraceptives or any other
contraceptives; she occasionally does not use protection. She
denies any vaginal discharge or bleeding. She took Tylenol
approximately 1 hour prior to arrival. PELVIS U.S., TRANSVAGINAL showed 1. Normal pelvic ultrasound. No evidence of PID or pelvic fluid collections.
2. Normal appearance of the right lower quadrant however the appendix could
not be specifically identified. RENAL U.S. showed No evidence of hydronephrosis bilaterally. A trace amount of perinephric
fluid is identified adjacent to the upper pole of the right kidney, which
could be associated with pyelonephritis. No perinephric abscess or drainable
fluid collections are identified. The patient was diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic. At the time of discharge, the patient had PRIMARY: Pyelonephritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old woman p/w fevers and dysuria,
clinical picture most consistent with pyelonephritis. A
transvaginal ultrasound ruled out PID. Renal ultrasound revealed
a trace amount of perinephric fluid adjacent to the upper pole
of the right kidney, which could be associated with
pyelonephritis. No perinephric abscess was seen. Ultimately the
clinical picture was most consistent with pyelonephritis, with
urine cx growing E.Coli sensitive to both ceftriaxone and
ciprofloxacin.
TRANSITIONAL ISSUES:
====================
CODE STATUS: Full Code
CONTACT: Father (___) ___
- Patient will complete antibiotics for pyelonephritis with IV
ceftriaxone with transition to oral ciprofloxacin for 7 days
total (___).
- Urine Chlamydia and Gonorrhoeae pending on discharge
- Given her extensive maternal family history of cancer at early
ages and multiple types of cancer, please discuss genetic
counseling with the patient. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ w/ RA who presents s/p bicycle crash w/ pelvic
fractures. She was bicycling in a course when she crashed. No
LOC. She was initially seen at an OSH and transferred to ___
for further management of her pelvic fractures. Chest radiograph showed As above. SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA RIGHT showed Minimally displaced right distal clavicle fracture. PELVIS (AP, INLET AND OUTLET) showed Minimally displaced comminuted right iliac, right superior and inferior pubic
rami fractures, grossly unchanged in alignment as compared to the recent prior
CT examination. PELVIS (AP, INLET AND OUTLET) showed Fractures of the right superior and inferior pubic ramus as well as the right
iliac bone appear overall similar to prior exam. The patient was diagnosed with Unsp fracture of right ilium, init for clos fx, Pedl cyclst (driver) (passenger) injured in unsp traf, init. At the time of discharge, the patient had Right superior pubic rami, Right comminuted ilium fx, right
clavicle 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 superior pubic rami fracture, right comminuted
ilium fracture, right distal minimally displaced clavicle
fracture and was admitted to the acute care surgery service. She
was transferred to the orthopedic surgery service where it was
determined that her fractures were non-operative at the time.
The patient was given anticoagulation per routine. The patient's
home medications were continued throughout this hospitalization.
The patient worked with ___ who determined that discharge to
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications and the patient was voiding/moving bowels
spontaneously. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with high-grade activated B-cell like diffuse
large B cell lymphoma s/p 6 cycles R-CHOP (last was about 1 mo
ago) who presents with severe LUQ pain and LL chest pain.
Patient's PET scan recently showed recurrence of her lymphoma.
The patient was due to come to clinic this morning for a regular
follow-up appointment to discuss the PET findings. Prior to
that appointment she woke overnight with sharp left-sided pain
and presented to the ED. CT scan showed possible splenic infart
and EKG was negative for ischemic changes. Patient was admitted
to the ___ service for evaluation and treatment. CT abdomen and pelvis. showed 1. Splenic mass, decrease in size.
2. Chronic splenic infarct. No definite signs of acute splenic infarct though
difficult to assess given heterogeneous perfusion.
3. Possible small urachal cyst with mild adjacent bladder wall thickening.
Attention on follow up exam. Consider non-urgent ultrasound for further
information. CHEST (PORTABLE AP) showed Heart size top-normal. Lungs clear. No pleural abnormality or evidence of
central lymph node enlargement. Right supraclavicular central venous infusion
port catheter ends in the mid SVC. No pneumothorax. US ABD LIMIT, SINGLE ORGAN showed Grossly patent splenic artery and vein demonstrating normal waveforms.
Hypoechoic splenic mass consistent with treated lymphoma. ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. The patient was diagnosed with ABDOMINAL PAIN LUQ. At the time of discharge, the patient had PRIMARY: Chest pain; High Grade, diffuse large B-Cell Lymphoma
SECONDARY: Hepatitis B, Anemia, Thrombocytopenia. The patient was given written instructions concerning 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 high-grade activated B-cell like diffuse
large B cell lymphoma s/p 6 cycles R-CHOP (last was about 1 mo
ago) who presents with severe LUQ pain and LL chest pain.
Patient's PET scan recently showed recurrence of her lymphoma
and relapse despite chemotherapy.
The patient presented with acute onset of left lower chest pain
and left upper abdominal pain. In the ED there was concern for
splenic infarct based on CT with contrast. Given acute onset of
presentation and recent hospitalization for chemotherapy and
high tumor burden, PE was high on the differential.
V/Q scan showed no signs of PE on ___. Trop, BNP, MB, CK were
all normal. Chest xray to evaluate for acute pulmonary process
was normal. LENIs were negative. Splenic US showed no signs of
infarct and patent splenic artery and vein. The most likely
cause was ___ to costochondritis. Patient's pain improved after
initiation of ICE and dexamethasone. Patient was on no pain
medications and her symptoms were significantly improved on day
of discharge.
Recent PET CT showed relapse of the disease. Patient's
outpatient oncology team (Dr. ___ Dr. ___ held a
family meeting to inform the family. Patient initiating on ICE
salvage therapy and will likely undergo an Auto BMT. Patient was
C1D4 of ICE on day of discharge. She tolerated the chemotherapy
without complication. The patient received her home dose of
Neulasta on day of discharge. She will f/u with Dr. ___
___ Dr. ___ in clinic for Rituxan on ___.
ACUTE ISSUES
#Left Lower Chest Pain/RUQ Abdominal Pain: The patient presented
with acute onset of left lower chest pain and left upper
abdominal pain. In the ED there was concern for splenic infarct
based on CT with contrast. Given acute onset of presentation and
recent hospitalization for chemotherapy and high tumor burden,
PE is high on the differential. The patient describes pleuritic
chest pain that is consistent with PE versus chostocondritis.
The patient's VS are normal making PE unlikely but possible. ACS
is unlikely given no changes on EKG.
V/Q scan showed no signs of PE on ___. Trop, BNP, MB, CK were
all normal. Chest xray to evaluate for acute pulmonary process
was normal. LENIs were negative. Splenic US showed no signs of
infarct and patent splenic artery and vein. No anticoagulation
at this time given stability in vitals. The most likely
diagnosis is costochondritis or inflammatory pain of the ribs.
Pain significantly improved by day of discharge. Patient
required no medications to control her pain on day of discharge.
# high-grade activated large B-cell lymphoma s/p 6 cycles R-CHOP
(last was about 1 mo ago). Recent PET CT showed relapse of the
disease; patient's outpatient oncology team (Dr. ___ Dr.
___ held a family meeting to inform the family. Patient
initiating on ICE salvage therapy and will likely undergo an
Auto BMT. Patient tolerated ICE without complication. Patient
received home dose of neulasta on day of discharge.
# Hypotension: Resolved with IVF in the ED. Patient taking good
PO. asymptomatic.
CHRONIC ISSUES
# Hepatitis B: Patient was continued on her pre-admission
Entecavir. She is being followed by Hepatology as an outpatient.
# Anemia: chemotherapy induced, stable.
# Thrombocytopenia: chemotherapy induced, Stable.
# Infectious prophylaxis:
- PCP: ___
- HSV/VZV: acyclovir
TRANSITIONAL ISSUES
============================
-patient will f/u with her oncology team in clinic on ___
___
-patient will receive rituxan in clinic on ___
-patient was started on allopurinol ___ PO Daily
-ciprofloxacin was stopped at discharge; can be restarted
pending instructions from outpatient oncology team if needed
-patient given dose of Neulasta on day of discharge (patient
family brought home medication in to hospital from pharmacy)
-patient will have all other doses per outpatient oncology team</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 was the restrained
driver in ___ around 7pm, + airbag deployment, no LOC. She
reports she was going at low-speed when another car directly hit
her from the driver side. She was evaluated at ___
where workup reveals L clavicle fracture. She was then
transferred to ___ ED for further care. Here, she was also
found to have L patella fracture & R ___ MC fracture. Ortho was
c/s for further evaluation. In ED, she endorses L clavicular
pain, R hand pain & L knee pain but denies paresthesias or
sensory deficits in any extremity. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute cervical spine fracture or traumatic malalignment.
2. Acute displaced proximal left clavicular fracture seen only on scout
images.
3. Partially visualized left pneumothorax. Consider dedicated chest imaging
for further evaluation.
4. Bilateral hyperdense thyroid nodules measuring up to 7 mm. thyroid lobe
nodule. The ___ College of Radiology guidelines suggest that in the
absence of risk factors for thyroid cancer, no further evaluation is
recommended.
5. Biapical pleural-parenchymal opacities may represent scarring.
NOTIFICATION: The finding of small left apical pneumothorax was discussed
with ___, M.D. by ___, M.D. on the telephone on ___
at 3:15 ___, 5 minutes after discovery of the findings. CLAVICLE LEFT showed Acute fracture of the proximal left clavicular shaft with foreshortening and
displacement. CHEST (PA AND LAT) showed Compared to chest radiograph ___.
Minimal left apical pneumothorax, projecting over the second posterior
interspace, is not clinically significant. There is no pleural effusion.
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
are normal. Minimal scoliosis mid thoracic spine, concave left, has no
corresponding abnormality of the vertebral bodies on the lateral view or
paraspinal hematoma to suggest that it is an indication of trauma. Right hand was done. The patient was diagnosed with Displaced comminuted fracture of left patella, init, Disp fx of shaft of fifth metacarpal bone, right hand, init, Fracture of unsp part of left clavicle, init for clos fx, Car driver injured in collision w car in traf, init. The patient was treated with ORIF left patella fracture. At the time of discharge, the patient had Left patella fracture
Left clavicle fracture
Right fifth metacarpal 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 clavicle fracture, left patella fracture and
right fifth finger metacarpal fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction/internal fixation
of her patella 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. Nonoperative
management was recommended for her left clavicle fracture and
outpatient follow up in Hand clinic in one week (with Dr. ___
___ recommended for her right fifth metacarpal
fracture. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
moderate risk for DVT will be discharged on 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: Per admitting resident: Pt is a ___ M s/p lap sleeve
gastrectomy in ___ ___ which per patient was uncomplicated.
He presented ___ to ___ with
c/o 4 days progressive "dagger-like" ___ abd pain, n/v, -BM,
fevers to 101. He endorses still passing flatus. He denies sick
contacts, diarrhea, blood in stool, cough, chest pain, SOB. CT
AP at ___ was read as "significant for free air at
anastomosis site, suggestive of breakdown." CHEST PORT. LINE PLACEMENT showed There is a new right-sided PICC line with tip at least at the cavoatrial
junction. There is another catheter that overlies a similar location of the
right atrium. The heart and therefore it is difficult to see the exact end of
the PICC line. There continues to be dense retrocardiac opacity compatible
with volume loss/infiltrate/effusion. There is no pneumothorax Radiology showed The right-sided PICC is within the right atrium. The nasogastric tube needs
to be advanced approximately 4 cm.
Increasing subsegmental atelectasis, persistent left retrocardiac opacity with
small left-sided effusion. Radiology showed Nasogastric tube ends in the upper esophagus, approximately 18 cm from the GE
junction. This should be advanced prior to use.
RECOMMENDATION(S): Nasogastric tube ends in the upper esophagus,
approximately 18 cm from the GE junction. This should be advanced prior to
use.
NOTIFICATION: Wetread findings and recommendations were discussed with Dr.
___ by Dr. ___ telephone at 12:30 on ___, 2 minutes after
discovery. CHEST (PA AND LAT)
Chest radiograph showed Moderate left pleural effusion.
Rounded left retrocardiac opacity may reflect loculated pleural fluid or a
rapidly developing lung abscess.
RECOMMENDATION(S):
Chest CT if there is concern for left lung or pleural abscess.
NOTIFICATION: Pertinent critical findings were posted by Dr. ___ on
___ at 08:18 to the Department of Radiology online critical
communications system for direct communication to the referring provider. Upper GI series. showed Irregularity of the gastric wall near the gastrectomy site, but no leakage
with Optiray and thin barium administered orally.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 10:00 AM, 5 minutes after discovery of the
findings. Upper GI series with water-soluble contrast showed 4.3 cm area of free leakage along the proximal aspect of the sleeve
gastrectomy, as seen on the reference CT from ___. No defined
collection.
NOTIFICATION: The findings were discussed by Dr. ___ Dr. ___ with
Dr. ___ on the telephone on ___ at 3:40 ___, 15 minutes after discovery
of the findings. Ultrasound-guided thoracentesis showed Thoracentesis with removal of 350 mL of left pleural fluid. Microbiology is
pending.
RECOMMENDATION(S): Followup microbiology from left pleural fluid.
NOTIFICATION: Findings discussed by Dr. ___ with Dr. ___
in person on ___ at 7:00 ___, upon procedure study completion. Radiology showed Fluoroscopic guidance provided for ___ tube placement, placed by
the surgical fellow. The tip is in the distal esophagus. CHEST (SINGLE VIEW) showed NG tube tip is in the lower esophagus, as placed by the surgical team there is
dense retrocardiac opacification secondary to volume loss/infiltrate/effusion
as seen on the prior CT. There is no new infiltrate CHEST (PA AND LAT) showed No significant chain The patient was diagnosed with OTHER COMPLICATIONS OF OTHER BARIATRIC PROCEDURE. The patient was treated with ___: ___ placement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was transferred to the ___ Emergency Department on
___ after developing worsening abdominal pain and
dyspnea after eating steak four days earlier. The CT scan
obtained at the outside hospital was suggestive of staple line
breakdown at the site of the patient's previous sleeve
gastrectomy performed in ___ the previous month. Given these
findings, he was placed on bowel rest, given intravneous
imipenem and vancomycin and transferred to our ED for further
management. Upon arrival to ___, the patient underwent an UGI
series which confirmed a 4.3 cm defect along the staple line
with active extravasation of contrast. Given hemodynamic
stability, he was managed conservatively with bowel rest with
TPN, an intravenous pantoprazole gtt, meropenem/ vancomycin/
fluconazole, an NGT placed via fluoroscopy and left pleural
effusion drainage via thoracentesis .
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with intravenous
acetaminophen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: As noted above, the patient underwent thoracentesis
with drainage of 350 mL pleural fluid dt dyspnea and findings of
a large left sided pleural effusion. An UGI obtained upon
arrival did not suggest any communication of leak with the
thoracic space. He continued to improve from respiratory
standpoint throughout his hospitalization, which was wihtin
normal limits at the time of discharge.
Good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization.
GI/GU/FEN: The patient was placed on bowel rest with TPN and an
NGT placed under fluoroscopy for decompression. On HD5, the
patient self-d/c'd his NGT and declined replacement. He then
underwent an EGD which was within normal limits. On HD8, the
patient underwent a repeat UGI which did not show active
contrast extravasation. On HD9, the patient began a gradual
diet advancement to a bariatric stage III; which was well
tolerated. Patient's intake and output were closely monitored.
The PICC and TPN were discontinued on HD11 per patient's request
to leave the hospital.
ID: Infectious disease was consulted on HD2 and recommended
transition to ceftriaxone and metronidazole. This was continued
throughout the hospitalization. Of note, the patient did
decline antibiotics on HD11 and was discharged without oral
antibiotics.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
On HD11, the patient requested to leave the hospital as
insurance was no longer covering the admission. He was
hemodynamically stable at this time and was without pain. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan and was encouraged to follow-up with Dr. ___ in clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y.o. male with PMH of T2DM, COPD w/ DOE, HTN,
recent dx of IgA Vasculitis w/ leg rash & angioedema requiring
intubation x3d & pT1bN0M0 glottic SCC w/ involvement of
bilateral
TVC s/p XRT (completed ___, followed by Dr. ___
presenting as a transfer from OSH via med flight due to
respiratory distress x12 hours. Venous duplex of bilateral lower extremities. showed 1. No evidence of deep venous thrombosis in the left lower extremity.
2. No significant venous reflux throughout the bilateral deep or superficial
venous systems apart from mild reflux of the left small saphenous vein
measuring 1.5 seconds. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Abnormality left true vocal cord, laryngeal ventricle, worrisome for tumor
recurrence, NIRADS 4.
2. Abnormal left paralaryngeal space, may represent posttreatment change or
tumor.
3. Low-density abnormality left aryepiglottic fold, likely reactive, see
above.
4. Indeterminate cluster of left level 3 subcentimeter lymph nodes, may be
reactive or metastatic, see above.
5. Stable tiny lung nodules. CHEST (PORTABLE AP) showed A tracheostomy tube is present. The tip of the feeding tube extends below the
level the diaphragm but beyond the field of view of this radiograph.
Known ground-glass infiltrate in the right middle lobe is not as
radiographically evident. NON-INVASIVE PERIPHERAL ARTERIAL STUDY showed 1. Limited exam however toe brachial indices indicate there is likely
peripheral vascular disease in the left lower extremity. Radiology showed Penetration and aspiration as above.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services). The patient was diagnosed with Other pneumonia, unspecified organism, Shortness of breath, Acute pharyngitis, unspecified, Dyspnea, unspecified. The patient was treated with ___: emergent TRACHEOSTOMY, MICROLARYNGOSCOPY WITH BIOPSY,
FLEXIBLE ESOPHAGOSCOPY
___: PEG. At the time of discharge, the patient had PRIMARY DIAGNOSES:
===================
- Glottic squamous cell carcinoma
- Acute necrotizing cutaneous vasculitis
- Post-radiation laryngeal edema
SECONDARY DIAGNOSES:
====================
- Type 2 Diabetes
- Asthma
- Chronic Obstructive Pulmonary Disease
- 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 ___ yoM with PMHx of DMII, COPD, HTN, recent acute
necrotizing vasculitis of lower extremities and pT1bN0M0 glottis
squamous cell carcinoma with involvement of bilateral true vocal
cord s/p XRT(last in ___, presenting with respiratory
distress, s/p fiberoptic intubation w/ trach placement ___,
now found to have invasive SCC of the vocal cord in the setting
of laryngeal edema and lower extremity vasculitis. PEG was
placed pending decision of treatment for invasive SCC.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male who complains of GSW.
Healthy patient who was the back seat passenger behind the
driver when he was shot at close range by someone standing
next to the car (window was down). Bullet was through and
through the L arm and into the chest cavity. Seen at OSH
where he was hemodynamically stable and had a CT torso
showing a L hemothorax without pneumothorax. Transferred via
medlight. Got about 750 cc of NS, supplemental oxygen as
well as analgesics Radiology showed Stable-appearing opacity at the left base. Radiology showed AP chest compared to ___ through ___, 10:40 a.m.:
There is no pneumothorax or increase in the possible small residual left
pleural effusion since ___ a.m. following removal of the left pleural tube.
Consolidation at the base of the left lung is presumably contusion or
hematoma, also unchanged. Lungs are otherwise clear. Fragments of fractured
left lower lateral ribs noted. Normal cardiomediastinal silhouette. Right
lung clear. The patient was diagnosed with TRAUM HEMOTHORAX-CLOSED, OPEN WOUND CHEST-COMPL, OPEN WOUND OF UPPER ARM, OTHER SPECIFIED RETAINED FOREIGN BODY, ASSAULT-FIREARM NEC, TETANUS-DIPHT. TD DT. The patient was treated with left chest tube placed ___
left chest tube removed ___. At the time of discharge, the patient had Trauma: gunshot wound
Left hemothorax
GSW Left arm
Left 8th rib fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the hospital after he sustained a
gunshot wound to his left arm and chest. He underwent a cat scan
of the torso at an outside hospital where he remained
hemodynamically stable. On review of the cat scan he was
reported to have a left hemothorax without pneumothorax. FAST
examination was negative. A chest tube was inserted with about
170 cc of frank blood. His vital signs remained stable. As a
result of the injury, he sustained an ___ left rib fracture. The
patient was neuro-vascularly intact in the left upper extremity
despite the through and through wound. Because of the nature of
the injury, the trauma service was consulted. The whole bullet
was removed from his back and the wound was packed. The patient
was started on a course of antibiotics. The patient underwent
serial hematocrits and his vital signs were closely monitored.
The patient received intravenous analgesia for management of his
pain. After tolerating a regular diet, the patient was
transitioned to oral analgesia. The chest tube drainage was
closely monitored. On HD #2, the chest tube was placed to water
seal. The patient continued to have minimal drainage and the
chest tube was removed on HD # 3. The social worker met with
the patient to address his fears and concerns. The patient was
discharged home on HD #4 in stable condition. He was encouraged
to follow-up with the acute care service in 2 weeks. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with new onset weakness at 2 pm and nausea vomiting at 10
pm. Was taken to ___ OSH that showed right cerebellar bleed.
In ED here he is somnolent. Chest radiograph. showed 1. Endotracheal tube at the level of the thoracic inlet and the upper airway.
Consider advancing 1.5 cm for better positioning.
2. Aerated lung extending inferiorly down the left costophrenic angle.
Although this is not a deep sulcus sign if clinical concern for pneumothorax
consider upright or decubitus radiograph for further evaluation. CTA HEAD WANDW/O C AND RECONS showed 1. Postoperative changes suboccipital craniectomy for right cerebellar
hematoma evacuation with overall decreased size of hematoma and decreased
ventricular size though with persistent edema and cerebellar sulcal
effacement.
2. No evidence of new intracranial hemorrhage.
3. No evidence of aneurysm, vascular malformation, or occlusion within the
intracranial vasculature.
4. Focal, fusiform dilatation of the distal right vertebral artery which is of
uncertain significance and dissection is not entirely excluded. CT HEAD W/O CONTRAST showed 1. Stable postsurgical changes status post occipital craniectomy with
herniation of brain parenchyma through the craniectomy site with decrease in
pneumocephalus since previous examination.
2. Stable 3.2 cm right cerebellar hemisphere intraparenchymal hemorrhage in
comparison to study performed 23 hr prior. No new hemorrhage. The following vessels were selectively catheterize injected:
Right common carotid artery: Cervical biplane, intracranial biplane, magnified
biplane oblique
Left common carotid artery: Cervical biplane, intracranial biplane, magnified
biplane oblique
Right vertebral artery: Cervical biplane, intracranial biplane, magnified
biplane oblique, Three dimensional rotational angiography and postprocessing
on separate work station with concurrent physician supervision with images
being used for final interpretation.
Left vertebral artery: Cervical biplane, intracranial biplane, magnified
biplane oblique, Three dimensional rotational angiography and postprocessing
on separate work station with concurrent physician supervision with images
being used for final interpretation.
Right femoral artery: ___
ANESTHESIA: ANESTHESIA: Moderate sedation was provided by administrating
divided doses of 100 mcg of fentanyl and 2 mg of midazolam throughout the
total intra-service time of 80 min during which the patient's hemodynamic
parameters were continuously monitored by an independent trained radiology
nurse. 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site
TECHNIQUE: OPERATORS: Dr. ___ Dr. ___ physician performed
the procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
PROCEDURE: The patient was brought from is room directly down to the
angiography suite. ___ language interpreter was available per the
patient's request and remained to train slight instructions throughout the
entirety of the procedure. The patient was laid supine on the fluoroscopy
table. Bilateral groins were prepped and draped in the usual sterile manner. A
separate radiology nurse provided conscious sedation throughout the entirety
of the procedure, an monitor the patient's hemodynamic and respiratory
parameters. Institutional time-out procedure was performed per guidelines.
Next the patient's right mid femoral head was located using anatomic and
radiographic landmarks. A 10 cc of 1% lidocaine was infused into the
subcutaneous tissue. A micropuncture kit was used to gain access to the right
femoral artery, serial dilation was undertaken until a long 6 ___ groin
sheath to be placed under direct fluoroscopic visualization. This was
connected to a continuous heparinized saline flush. Next the ___ 2
catheter was connected to an RHV in the continuous heparinized saline drip and
also to the power injector. The catheter was advanced over the 0.038
glidewire, reformatted in the left subclavian artery, and used to select the
right common carotid artery. Road mapping cervical biplane imaging was
undertaken. Followed by intracranial biplane and magnified biplane oblique
imaging. Next the catheter was reformatted in used to select the left common
carotid artery. Road map cervical biplane imaging was undertaken. Next imaging
of the intracranial biplane and magnified biplane oblique views were taken
from the left common carotid artery. Next the catheter was reformatted in used
to select the right innominate artery followed by the right subclavian artery
and finally the right vertebral artery. Cervical biplane, ___ and lateral,
magnified biplane oblique and 3D angiography with separate processing on a
separate 3D workstation for physician interpretation results for final
diagnosis was undertaken. Under direct fluoroscopy, gentle puffs of contrast
was administered in demonstrated no damage to the right vertebral artery, the
catheter was pulled back into the subclavian artery and then reformatted in
then used to select the left subclavian artery followed by the left vertebral
artery. Next cervical biplane, ___ and lateral, magnified biplane oblique,
3D rotational angiography with separate processing on a separate 3D
workstation for physician interpretation of results of imaging was undertaken.
Next under direct fluoroscopic visualization, gentle puffs of contrast were
administered as the catheter was pulled out of the left vertebral artery, this
does not demonstrate evidence of dissection or thrombus. Finally the catheter
was fully removed from the patient's body. AP projection of the right femoral
artery demonstrated the level the groin puncture to be suitable for closure
device utilization. A 6 ___ Angio-Seal device was deployed which results in
excellent hemostasis. At the conclusion of the procedure, the patient was that
is neurologic baseline. ___ was subsequently transferred to his hospital bed
and brought back up to term for convalescence. There is no evidence of
thromboembolic complication at the conclusion of the case.
FINDINGS:
In the right common carotid artery injections: The carotid bifurcations
well-visualized, there is no significant atherosclerosis or carotid stenosis.
In the intracranial projections, the distal right ICA, proximal and distal ACA
and MCA branches are well-visualized. Vessel caliber is smooth and tapering.
There is no evidence of aneurysm, abnormal arteriovenous shunting, or early
venous drainage. Of the ECA vessels visualized, there is no evidence of
abnormal extracranial to intracranial anastomosis or fistula.
In the left common carotid artery injections: The carotid bifurcations are
well-visualized, there is no evidence of significant atherosclerosis carotid
bulb disease. In the intracranial projections, the distal left ICA, proximal
distal ACA and MCA branches are well-visualized. Vessel caliber smooth and
tapering. There is no evidence of aneurysm, abnormal arteriovenous shunting,
or early venous drainage. Of the ECA vessels visualized, there is no evidence
of an abnormal extracranial to intracranial anastomosis or fistula.
In the right vertebral artery injections: The cervical portion vertebral
artery does not demonstrate any significant stenosis or tortuosity. The right
vertebral artery, right ___, basilar artery, bilateral SCA and PCA vessels
are well-visualized. In the region of the distal right SCA, there is a small
bleb on the AP projection, there appears to be a vessel loop when correlated
with 3D imaging and also with the lateral projections. Vessel caliber is
otherwise smooth and tapering, there is no evidence of vertebral artery
dissection. There is also some reflux into the left vertebral artery just
proximal to the ___, there appears to be irregularity within this
segment of the vessel. Followup angiography if from the left vertebral artery
was subsequently undertaken.
In the left vertebral artery injections: The cervical portion of the vertebral
artery does not demonstrate any significant stenosis or tortuosity. The left
vertebral artery, left ___, basilar artery, bilateral SCA and PCA vessels are
well-visualized. Just distal to the left ___ takeoff, there is a string on
bead appearance of the vertebral artery concerning for potential dissection.
Multiple views were undertaken of this along with 3D rotational angiography,
there is no evidence of flow limitation, are dissection flap, there is also no
contrast stasis. When correlated with the patient's initial CT scan, the
intercerebral hemorrhage was all parenchymal without evidence of subarachnoid
component in clearly also in the right cerebellar hemisphere. Is unclear the
exact significance of this left vertebral artery irregularity finding.
Although a it seems unlikely that it is directly related the patient's
intercerebral hemorrhage. However given this finding with concern for
potential dissection, this area will need to be continually watch with
followup imaging in the near future.
In the right femoral artery injections: The level of the groin puncture is
distal to the inferior epigastrics and proximal to the bifurcation, there is
good distal run-off.
IMPRESSION:
1. Focal string on bead appearance of the left vertebral artery just distal
to the ___ takeoff. This likely represents an area of dissection. Its exact
correlation and significance the with the patient's known right cerebellar
hemorrhage is unclear. We will need to follow this region of dissection
carefully with serial followup imaging.
2. No other aneurysms, or abnormal arteriovenous, or fistulous connection was
identified that could be causative of the patient's right cerebellar
hemorrhage.
I, Dr. ___ was personally present, supervised, and participated in
the key portions of the procedure. ___ is also reviewed the above images and
agrees with the interpretation. showed 1. Focal string on bead appearance of the left vertebral artery just distal
to the ___ takeoff. This likely represents an area of dissection. Its exact
correlation and significance the with the patient's known right cerebellar
hemorrhage is unclear. We will need to follow this region of dissection
carefully with serial followup imaging.
2. No other aneurysms, or abnormal arteriovenous, or fistulous connection was
identified that could be causative of the patient's right cerebellar
hemorrhage.
I, Dr. ___ was personally present, supervised, and participated in
the key portions of the procedure. ___ is also reviewed the above images and
agrees with the interpretation. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. The patient was diagnosed with INTRACEREBRAL HEMORRHAGE. The patient was treated with ___ Sub-occipital crani for evacuation of cerebellar
hemorrhage.
___ Cerebral Angiogram for right Vert Dissection. At the time of discharge, the patient had Cerebellar Hemorrhage
Right verterbral dissection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was brought to the OR on ___ from the ED for an
emergent sub-occipital craniotomy for evacuation of his
cerebellar hemorrhage. His intraoperative course was uneventful.
However, intraoperatively, his hemorrhage was thought to be from
an AVM. A CT/CTA of the head was obtained post op and showed
expected post operative changes and did not show AVM or
aneurysm. The plan is to obtain a repeat head CT in the morning
and an Angiogram on ___. Please refer to the operative for
further information. The patient was transferred intubated to
the ICU for close monitoring.
On ___, the patient was stable over night. He was extubated and
other than some mild confusion and a ___ nerve palsy on the
right, was stable neurologically. CT showed no evidence of
hydro. A diagnostic angiogram was planned for the following
day.
On ___, the patient's exam improved somewhat. His
nausea/vomitting was controlled.
On ___ Stable exam. Complained of GERD. EKG normal.
On ___ Ambulatory to bathroom. ___ eval recommending rehab.
On ___ He went for a diagnostic angiogram which showed fusiform
dilitation of the right distal vertebral artery.
On ___: He was workign with ___ and will need rehab. Overnight he
required 20mg of hydralazine and a 500cc fluid bolus.
On ___: he was stable and awaiting rehab palcement which was
complicated by his lack of insurance.
On ___ he was neurologically stable, was working with ___, and
was awaiting rehab placement and resolution of his insurance
issues.
Mr. ___ continued to recover well on ___. Physical Therapy
was asked to re-evaluate the patient because he was ambulating
with the nurse, versus previous evaluation where he needed
assistances with two people.
On ___ the patient was stable neurologically and there were
no significant events. He was pending rehab placement.
On ___, the patient remained neurologically and hemodynamically
intact. His staples were removed without any difficulty. The
inferior portion of his incision was red and warm to touch with
no drainage, he was starated on Keflex TID.
On ___, rehab placement was denied. ___ continued working with
the patient. Discussion was had with the family yesterday about
planning for 24hr care at home. Case manangement continued to
look for accessible benefits. On ___ patient was cleared for
home with 24hr supervision and teaching was done with the
family. He was discharged home with family.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male who presents to ___ with
approximately 36 hours of right-sided abdominal pain, radiating
to the back, and associated nausea with report of 2 bouts of
emesis. He reports subjective fevers and chills, and generalized
malaise. He reports feeling a similar but less intense episode
of
such pain approximately one week prior, attributed to food
poisoning, which resolved spontaneously within 1 day. He has had
no change in bowel habits. Radiology showed 1. Dilated common bile duct along with slight gallbladder wall thickening and
gallstones raises concern for choledocholithiasis, although none are seen on
this study. The distal CBD is not visualized.
2. No evidence of gallbladder distention or sonographic ___ sign to suggest
cholecystitis, however if clinical concern persists, a HIDA scan could be
performed. Radiology showed No acute cardiopulmonary process or evidence of free
intra-abdominal air. Radiology showed Persistent elevation of the right hemidiaphragm and mildly
increased right basilar atelectasis. The patient was diagnosed with CHOLEDOCHOLITHIASIS NOS. The patient was treated with ERCP with sphincterotomy
laparoscopic cholecystectomy. At the time of discharge, the patient had Cholangitis
Choledocholithiaisis
Cholecystolithiasis
Atelectasis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted and made NPO, started on IV ceftriaxone
and flagyl. ERCP was done, sphincterotomy performed, sludge and
pus found consistent with cholecystitis and cholangitis. Started
clears, then made NPO for operation. Underwent lap chole, which
he tolerated well. On POD1, was advanced to regular diet, had no
N/V, passing flatus, ambulating, discharged home doing well. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of CAD, pulmonary embolism, HTN,
GERD who presents with SOB for several days. She notes she has
been breathing rapidly and has had increasing dyspnea on
exertion, but has otherwise been able to tolerate her usual
level of activity (at baseline uses walker, unable to ambulate
one block without dyspnea or fatigue). She does endorse mildly
worsening lower extremity edema, which she had attributed to
shin trauma she experienced while getting on a bus. She
experiences chronic orthopnea, requiring a "wedge" and a pillow,
but this has not worsened recently. She lives in an ALF
___ in ___. Review of records sent with
her on transport indicates she desaturated to 85% on room air.
She has not adjusted her fluid intake or had dietary
indiscretions. She denies recent chest pain, palpitations,
pleuritic pain, subjective fevers, chills, night sweats. As
mentioned, she lives in a group home, in which she states
several people are usually sick, but she denies a recent
personal history of URI or malaise. Radiology showed 1. New mild interstitial pulmonary edema. Chronic mild cardiomegaly.
2. New right middle lobe atelectasis. Radiology showed 1. No pulmonary embolism or aortic pathology.
2. Enlarged main pulmonary artery suggests pulmonary arterial hypertension.
3. Thickened bronchial walls with innumerable millimetric predominantly
subpleural centrilobular nodules, likely reflecting a bronchiolitis picture.
Largest individual nodule measures 4 mm but likely reflects an
inflammatory/infectious response.
4. Bilateral small nonhemorrhagic pleural effusions.
5. Stable lobulated hypodensity in the right hepatic lobe, likely a cyst
versus biliary hamartoma.
6. Gastric diverticulum.
7. Stable gallbladder wall calcification. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC. At the time of discharge, the patient had PRIMARY:
- acute diastolic congestive heart failure exacerbation
SECONDARY:
- bronchitis/bronchiolitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was admitted to ___ on ___ for management
of acute respiratory distress. She was determined to be in mild
heart failure and diuresed with bolus IV furosemide. Of note,
she had a TTE on ___ which identified new wall motion
abnormalities. She did not undergo catheterization during this
admission due to her advanced age and poor risk:benefit ratio. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year old femal with a history of donor
hepatectomy for liver transplant ___ years ago and no intervening
medical issues presents with one day
of nausea and crampy abdominal pain. She reports the pain
started last evening at around 10:30 ___ - it was crampy and
diffuse and has continued until presentation to ___
this morning where she received pain medication. She reports
feeling better after NGT insertion though reports persistent
pain when she does not have pain medication. Radiology showed 1. Small bowel obstruction.
2. NG tube projects over the stomach. Radiology showed Worsening high-grade small-bowel obstruction now with peritoneal fluid.
Transition point is in the vicinity of the more superior surgical clip in the
mid abdomen. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. At the time of discharge, the patient had Small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was admitted to the Acute Care Surgery service for
management of her acute abdominal pain. CT scanning revealed
signs of a small bowel obstruction with a transition point
visible in the vicinity of the more superior surgical clip in
the mid abdomen. The patient was kept NPO, given IV fluids and
a ___ tube was inserted for gastric decompression. Her
WBC as normal on admission, but she did have an elevated
neutrophil count of 88%. She was transferred to the inpatient
ward for further management and observation.
Mrs. ___ was observed over the following days for return of
bowel function and improvement of her clinical symptoms. During
this time, she was given intermittent non-narcotic and narcotic
analgesics for pain. Serial abdominal exams were conducted.
While NPO, her electrolytes were checked daily and repleted as
necessary. As her initial nausea improved and her NGT output
decreased, her NGT was removed on ___ (HD 5). Her diet was
slowly advanced thereafter. She has tolerated her diet fairly
well, but had some frequent episodes of diarrhea. The frequency
has now decreased at the time of discharge. She had no fever,
nausea during this time. Consideration of c. difficile was
suggested, but due to lack of recent antibiotic use, the
diarrhea was likely due to her post-obstructive intestinal
motility. The patient has voided without issue and was
ambulating independently.
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable and in no acute distress. Follow-up was
scheduled with her PCP.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH HCC (s/p TACE in ___ and on ___ for recurrence),
CAD
(s/p stent and pacemaker placement), HFrEF (EF ___, chronic
pancreatitis, NASH/HCV Cirrhosis, CKD, and GERD who presents
with
abdominal pain after recent TACE procedure (discharged on ___.
Starting 3 days ago he began having mid to lower mid abdominal
pain. Pain is constant and crampy, ___ in severity that becomes
a ___ after eating. Associated with nausea, vomiting and
diarrhea. Patient also endorses nonbloody diarrhea and increased
flatulence.
He denies fevers, chills, chest pain, or worsening shortness of
breath (patient has this at baseline ___ CHF). Denies history of
DVT or PE. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Very limited exam. Cirrhotic liver. Stable splenomegaly. Patent portal
vein, with hepatofugal flow, new from prior. Chest radiographs, PA and lateral. showed No evidence of acute cardiopulmonary disease. Radiology showed 1. Post treatment changes in the right hepatic lobe status post TACE, not
further characterized on a single contrast CT, however amenable to
reassessment on routine liver CT/MR.
2. No additional acute findings to explain abdominal pain. Specifically, no
bowel obstruction or evidence of schema.. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
==================
viral gastroenteritis
SECONDARY DIAGNOSIS:
====================
hepatocellular carcinoma s/p TACE in ___ and on ___ for
recurrence
NASH/HCV cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY STATEMENT:
==================
___ M with hx HCC (s/p TACE in ___ and on ___ for
recurrence), CAD(s/p stent and pacemaker placement), HFrEF (EF
___, chronic pancreatitis, NASH/HCV Cirrhosis, CKD, and GERD
who presents with abdominal pain after recent TACE procedure on
___ (discharged on ___ and diarrhea.
ACTIVE ISSUES:
==============
#Abdominal pain
#Diarrhea
Patient presenting with abdominal pain after recent TACE
procedure on ___ with 3 days of diarrhea that resolved day
prior to presentation and no nausea/vomiting. He denied any
dietary changes, medication changes, recent travel or sick
contacts. Given his recent TACE he was advised to go to the ED
for further workup. In the ED, ultrasound and CT abdomen showed
no acute abnormalities including no signs of infection,
obstruction or ischemia. Lipase of 5 lowered suspicion of
recurrent pancreatitis. Given no acute intraabdominal processes
seen on imaging and self-resolution of patient's diarrhea, we
felt that this was most consistent with viral gastroenteritis
with abdominal pain from post-infectious IBS. An infectious work
up including blood culture and urine culture were negative, and
stool cultures were pending on discharge. Patient was discharged
given resolution of his diarrhea, and he was advised to continue
dicyclomine for his abdominal pain and to follow up for his
scheduled EGD on ___.
#NASH/HCV cirrhosis c/b esophageal varices
#___ s/p TACE (___)
Patient with a hx of NASH/HCV cirrhosis complicated by ___ s/p
TACE in ___ and again recently on ___ for recurrence. Last
EGD in ___ showed 4 grade I cords of distal esophageal varices
with no bleeding. No known history of ascites, SPB, or HE. MELD
on admission 14. Abdominal ultrasound on admission though
limited showed reversal of portal flow most likely due to portal
HTN, though may also suggest a portosystemic shunt. Patient did
not demonstrate any signs of HE throughout admission.
#Myelodysplastic syndrome
#moderate neutropenia
Patient with a hx of MDS with baseline leukopenia to ~2,
admitted with WBC 1.8 with ANC 880 (normally baseline >1500).
This may be in setting of dilution as he had received 25g of 25%
albumin vs. viral infection vs worsening MDS. On discharge, his
WBC was 2.3 and ANC 1060. He was advised to have close follow up
with his outpatient hematologist/oncologist.
CHRONIC ISSUES:
===============
#CKD
Baseline Cr ~1.4-1.5; on admission Cr 1.6 with improvement to
___ s/p 25g albumin.
#CAD
History of prior MI with known 1 vessel CAD s/p stenting and hx
of pacemaker placement. Continued on home aspirin and statin
#Chronic pancreatitis
Continued on creon 2 caps with meals as home medication was not
available.
#BPH: continued home finasteride
#Depression: continued home citalopram
#Hypothyroidism: continue home levothyroxine
#GERD: switched home omeprazole to pantoprazole given known
interaction of citalopram with omeprazole
TRANSITIONAL ISSUES:
====================
[]Continued abdominal pain that improved with dicyclomine on
discharge - likely postinfectious IBS. Discharged with
dicyclomine for symptomatic relief and will have scheduled EGD
on ___ ___.
[]Home omeprazole switched to pantoprazole as there is a
drug-drug interaction between citalopram and omeprazole
[]Continue to follow neutropenia in setting of known MDS, ANC on
discharge 1060
#CODE: FULL
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
Cell phone: ___
Date on form: ___
Proxy form in chart: ___
Filed on Date: ___
Comments: alternate daughter ___ ___
___ on date: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/pAfib presents with shortness of breath. Pt was seen by
her PCP ___. She was given nebs in the office but had
persistent shortness of breath with peak flow of 135 and so was
referred her to emergency department. Pt reports also with
cough, generalized aches and chest pain. Reports that the pain
started when she was outside in the cold. She denies any recent
travel, leg swelling, fevers. Denies abdominal pain, nausea or
vomiting. Chest radiograph showed Mild pulmonary edema. The patient was diagnosed with Shortness of breath. At the time of discharge, the patient had Viral upper respiratory infection
Acute kidney injury
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>___ w/pAfib presents with cough and shortness of breath due to
viral infection.
Viral Upper Respiratory Infection: CXR without pneumonia. Flu
negative.
She was treated symptomatically with nebs, tessalon,
guaifenicin. Ambulatory O2 sat was over 95%.
Pulmonary Edema: no hypoxia. no history of heart failure but
echo ___ ago with LVH and Borderline pulmonary hypertension.
Outpatient ECHO could be considered.
Acute dehydration
Acute kidney injury
Mild hyponatremia
She was noted to have acute kidney injury and hyponatremia.
Lactate was elevated. HCTZ and ___ were held during
hospitalization and at discharge. She was rehydrated in the ED.
She will have lab recheck on ___ to determine need to
restart these agents.
Paroxysmal atrial fibrillation: currently in sinus. Her arixtra
was held due to acute kidney injury, and was held at discharge.
Risk of stroke was discussed, but she did not want to consider
other agents. She will have lab recheck in 4 days, and likely
restart arixtra at that point. If her ___ is persists Coumadin
therapy should be considered.
Hypertension. She was normotensive, or slightly low during
hospitalization. As above, HCTZ and ___ were held. Amlodipine
low dose was restarted (may not have been taking at home)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of OA, obesity, remote CCY presenting with
progressive low back pain, referred to ED after MRI demonstrated
diffuse vertebral lytic lesions. Pt describes initial symptom as
L sided chest wall pain after leaning against her car in ___
to scrap snow and ice off the roof of the car. Ultimately a CXR
revealed a rib fracture. She also describes a long history of
sciatica, starting in ___, which has consistently responded
immediately to a short course of physical therapy. ULTRASOUND-GUIDED TARGETED LIVER BIOPSY showed Uncomplicated 18-gauge targeted liver biopsy x two, with specimens sent to
pathology. CT CHEST W/CONTRAST; CT ABD AND PELVIS W AND W/O CONTRAST, ADDL
SECTIONS showed 1. An irregular, hyperenhancing left breast mass measuring up to 2.4 cm is
concerning for primary breast cancer. Consider dedicated breast imaging.
2. An abnormally enhancing left axillary lymph node could reflect a nodal
metastasis.
3. Innumerable hepatic and osseous lesions reflect metastases.
4. Known pathologic compression fractures, including a severe compression
fracture at T10 resulting in severe spinal canal narrowing, are not
significantly changed since recent imaging.
5. There are multiple nondisplaced pathologic rib fractures.
6. Multiple vertebral and pelvic metastases are particularly large and place
the patient at significant risk of additional pathologic fractures.
7. Abnormal appearing uterine hypoattenuation may be at least partially
artifactual. Consider nonemergent pelvic ultrasound. PELVIS U.S., TRANSVAGINAL showed 1. There is a 6 mm vascular lesion in the superior aspect of the cervix,
probably a polyp. There is trace adjacent endocervical fluid. If clinically
indicated, consider biopsy.
2. There is a 5 mm uterine fibroid.
RECOMMENDATION(S): There is a 6 mm vascular lesion in the superior aspect of
the cervix, probably a polyp. There is trace adjacent endocervical fluid. If
clinically indicated, consider biopsy. BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM
INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND showed There is a highly suspicious 3.3 cm retroareolar left breast mass and left
axillary lymphadenopathy.
RECOMMENDATION(S): Suspicious left breast mass is amenable to
ultrasound-guided core needle biopsy if clinically indicated, however no
needed biopsy is requested given that ultrasound-guided core needle biopsy of
a liver mass revealed breast cancer. Further management will be directed by
the clinical team.
NOTIFICATION: Findings reviewed with the patient at the completion of the
study. Dr. ___ was notified by Dr. ___ on the phone at 10:30 on ___.
BI-RADS: 5 Highly Suggestive of Malignancy. BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM
INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND showed There is a highly suspicious 3.3 cm retroareolar left breast mass and left
axillary lymphadenopathy.
RECOMMENDATION(S): Suspicious left breast mass is amenable to
ultrasound-guided core needle biopsy if clinically indicated, however no
needed biopsy is requested given that ultrasound-guided core needle biopsy of
a liver mass revealed breast cancer. Further management will be directed by
the clinical team.
NOTIFICATION: Findings reviewed with the patient at the completion of the
study. Dr. ___ was notified by Dr. ___ on the phone at 10:30 on ___.
BI-RADS: 5 Highly Suggestive of Malignancy. The patient was diagnosed with Low back pain. The patient was treated with Liver biopsy
Radiation to T10 pathologic fracture. At the time of discharge, the patient had Metastatic breast cancer
Bony and liver metastatic lesions
Abnormal liver function tests. The patient was given written instructions concerning 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 admission, a CT torso was ordered, which showed a large liver
metastasis, an endometrial mass, and a mass in her left breast.
A biopsy was performed over the liver mass, which returned with
ER/PR + breast cancer; mammogram confirmed that the breast mass
(felt on exam) was likely malignant. Pelvis ultrasound suggested
a polyp. Atrius oncology was consulted, who will see her on
___ in clinic to discuss treatment options. For
her ___ and hypercalcemia, she initially received IV fluids,
then received a single dose of pamidronate. Her calcium
normalized. Radiation oncology was consulted for her spinal
metastases, and she finished 5 days of radiation therapy. She
was seen by NSGY in the ED, who recommended TLSO for comfort
though pt found the brace very uncomfortable. Pt was evaluated
by ___, and will discharge to a skilled nursing facility for
rehab.
HOSPITAL COURSE BY PROBLEM
1. Metastatic breast cancer: newly diagnosed and would benefit
from palliative care while pursuing oncologic treatment given
large burden of disease and symptoms. Outpatient follow up with
___ oncologist Dr. ___ oncology on ___.
2. ___ of malignancy: Resolved after pamidronate
and aggressive IVF. Repeat Calcium was normal while inpt but
should be monitored in the next ___ weeks.
4. T-10 metastasis with cord compression: Pt received palliative
radiation therapy to spine and has a TLSO for comfort as needed.
She will need ongoing ___ at SNF
5. Diffuse bony cancer-related pain. Pt is very sensitive to
pain meds including NSAIDs and would benefit from pall care in
conjunction with Oncology care. Pt was treated with Tylenol,
Lidoderm patch, Ibuprofen 800mg TID x 10 days with H2 blocker
and Oxycodone 2.5-5mg q4hr as needed for pain with aggressive
bowel regimen.
>30 minutes on day of discharge including time spent on
coordination of care in transition.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ yo woman, pmh of HTN, HLD and recent
admission for gallstone pancreatitis (see notes for ___
___
___, presents from OSH s/p tpa given at 1646 for Right
side weakness and global aphasia. CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK CT perfusion showed 1. Study is moderately degraded by motion.
2. No evidence acute intracranial hemorrhage. No definite large territorial
infarction. Please note MRI of the brain is more sensitive for the detection
of acute infarct.
3. Within limits of study, no definite CT perfusion abnormality identified.
4. No aneurysm greater than 3 mm, dissection, or luminal narrowing.
5. Small bilateral pleural effusions.
6. Multiple subcentimeter thyroid nodules as described. The ___ College
of Radiology guidelines suggest that in the absence of risk factors for
thyroid cancer, no further evaluation is recommended. CHEST (PORTABLE AP) showed Mild pulmonary vascular congestion with patchy opacities within the lung
bases, likely atelectasis, but infection is not completely excluded. Probable
layering bilateral pleural effusions. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. No evidence of intracranial hemorrhage or acute infarction.
2. Diffuse parenchymal volume loss with probable chronic small vessel
microangiopathy. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. On motion degraded examination, no definitive evidence for acute large
territory infarct. No evidence of intracranial hemorrhage.
2. MRI would be more sensitive for subtle acute infarcts if there are no
contraindications. CT HEAD W/O CONTRAST showed 1. No evidence of intracranial hemorrhage, as clinically questioned.
2. No evidence of large territorial infarct.
3. Involutional changes and likely chronic microvascular ischemic changes. WRIST(3 + VIEWS) LEFT showed Degenerative changes as described. CHEST (PORTABLE AP) showed COMPARED TO CHEST RADIOGRAPHS SINCE ___, MOST RECENTLY ___.
SEVERE CARDIOMEGALY HAS WORSENED, MILD PULMONARY EDEMA IS MORE SEVERE,
PARTICULARLY LOWER LUNGS AND THERE ARE NEW SMALL PLEURAL EFFUSIONS.
OPACIFICATION IN THE LEFT LOWER LOBE IS SUFFICIENT TO OBSCURE THE
DIAPHRAGMATIC PLEURAL SURFACE, COULD BE DUE TO CONCURRENT ATELECTASIS OR EVEN
PNEUMONIA. BILAT LOWER EXT VEINS showed 1. The bilateral peroneal veins were not well visualized. Otherwise no
evidence of deep venous thrombosis in the right or left lower extremity veins.
2. 3.0 cm left ___ cyst. The patient was diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac. The patient was treated with TPA. At the time of discharge, the patient had Acute Ischemic Stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with past medical history of
HTN, HLD, and recent UTI and recent hospital admission for
gallstone pancreatitis, who presents with global aphasia and RSW
s/p TPA at 1646 at OSH. Patient was admitted to the stroke
neurology team for further monitoring and work up.
# Likely L MCA stroke Stroke
-Throughout her hospitalization, exam was notable for increased
responsiveness to light touch and voice with eye opening, fluent
speech in response to questions (with paucity of language in
response) without paraphasic errors or dysarthria, and ability
to move all extremities anti-gravity with BLE withdrawal to
noxious stimuli. -Patient had MRI which was negative for any
evidence of ischemic stroke, hemorrhage, or tumor. However, she
did have extensive atrophy and periventricular white matter
disease. Echocardiogram was negative for any mural thrombus,
however it showed stage II diastolic heart failure.
-Bilateral lenis were done for leg swelling and low grade
temperature which was negative for DVT's.
-Vessel imaging showed minimal atherosclerosis with open patent
vessels.
-On discussing with the family, they stated that she has been
lethargic and not at her baseline since she received a flu shot
in ___. After this, she became ill due to gallstone
pancreatitis and was admitted to ___ in ___ and received
an ERCP. Since this time she has needed assistance with walking,
moving, and transferring positions.
-Patient was switched from aspirin (considered aspirin failure)
to Plavix after hemorrhage was rule out on post TPA CT scans.
After this time, patient noted to be in paroxysmal afib and
after discussion with the family was switched to apixaban to
prevent further cardioembolic events.
-Patient also started on PO metoprolol 12.5mg bId. Patient only
had one episode of afib during hospitalization.
-Her initial NIHSS score at the OSH likely was due to deficits
in language and lethargy/in attention rather than significant
deficits.
-Patient recovered well and worked with ___. She was
recommended to be discharged to rehab.
#Pneumonia:
-Patient spiked fevers between 100-101.5. Mild leukocytosis.
Started on IV vancomycin, ceftriaxone. Blood, urine, cultures
and sputum did not grow anything. Patient treated with IV
antibiotics for 5 days and transitioned to PO augmentin for last
two days of treatment. Patient recovered without any fevers or
infectious signs on discharge.
#Sleep disturbances:
-Patient noted to be very somnolent during the day , which
family has endorsed , neuro checks were suspended during night
once her examination had stabilized. This helped the patient
stay awake during the day time. One consideration was to start
modafinil however patient improved after she slept through the
night with minimal interruptions.
#New onset afib:
-See above. Patient started on eliquis and PO metoprolol. Had
one episode of captured paroxysmal afib on telemetry and EKG
during hospitalization otherwise remained in sinus rhythm.
Transitions of care:
1. Patient to follow up with stroke Neurologist on scheduled
appointment date
2. Patient to stop taking aspirin, and to take apixaban
3. Patient to stop taking atenolol, as she was switched to
metoprolol 12.5mg BID for better heart rate control given her
new onset afib
4. Patient to follow up with her PCP ___ ___ weeks.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? () Yes - (X) No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL =95 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No - () N/A </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ yo M w h/o papillary RCC s/p L nephrectomy,
bladder cancer, DM, CKD (Cr 1.2), presenting for evaluation of
recurrent UTI. CHEST (PA AND LAT) showed Emphysema is severe. Elevation of the left hemidiaphragm is chronic, and may
be related to the chest trauma responsible for multiple healed left rib
fractures. Patient may have had wedge resection from the left upper lobe as
well.
There is no evidence of current cardiac decompensation or pneumonia. No
pleural effusion. RENAL U.S. showed 1. No hydronephrosis in the right kidney. The patient is status post left
nephrectomy.
2. Markedly abnormal appearance of the bladder with multiple mass-like
protrusions from the bladder wall. These areas could be consistent with post
resection changes versus recurrent tumor, correlation with cystoscopy is
recommended as clinically indicated. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had Primary:
UTI
Secondary:
- papillary RCC, incidentally discovered on left
nephroureterectomy for bladder TCC, 9 mm in size, early stage
- bladder TCC s/p multiple resections - most recently TUR
___
- COPD, s/p left lobectomy per ___ and ___ records
- Perioperative Afib
- ___ DVT
- DM
- Hypertension
- BPH
- CKD - Cr baseline 1.2
- Urinary retention (straight caths). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ yo M w h/o papillary RCC s/p L nephrectomy,
bladder cancer, DM, CKD (Cr 1.2), presenting for evaluation of
recurrent UTI.
# Recurrent UTI: Has been treated for UTI at least 3 times in
past 1 month without resolution and with cultured organism.
Given leukocytosis and UA with positive WBC/bacteria/nitrates,
as well as leukocytosis there was a strong suspicion that this
represented infection. Patient underwent renal US shows bladder
wall changes (possible CA), but no signs of pyelonephritis or
renal dysfunction. Was started on CTX. Patient was discussed
case with ___, who recommend treating UTI, without
indication for continuous bladder irrigation or further
investigation. Speciated urine cultures, but only grew mixed
flora with gram + cocci concerning for skin flora. Patient was
transitioned to Cefepime given history of re-current UTIs with
no identified species. Straight cath UA was sent and grew no
colonies. Given recurrent history and lack of speciation, the
decision was made for the patient to complete a 7 day course of
cefepime. At discharge, the patient no longer had pain or
difficulty with urination, and no longer complained of
suprapubic pain. He was discharged with plans to follow up with
his PCP and ___ appointment.
# ___ on CKD: Cr baseline around 1.2, Cr 1.6 on admission.
Patient was given 1L IV and had improvement to 1.3 suggesting
pre-renal disorder. Given patients history of weak urine stream,
performed post void residuals to ensure no post-renal
dysfunction. Did not require straight catheterization.
Underlying CKD likely ___ DM, HTN, and only having one kidney.
Cr at discharge was 1.4.
# Bladder TCC: Patient with bladder cancer for several years. He
is s/p cystoscopy and TUR of bladder tumor ___. Renal US
earlier this month showing bladder wall irregularity concerning
for tumor recurrence. Inpatient Renal US showed no signs of
hydronephrosis, but did reveal markedly abnormal appearance of
the bladder with multiple mass-like
protrusions from the bladder wall. These areas could be
consistent with post
resection changes versus recurrent tumor. Urology was alerted,
patient has planned follow up with outpatient Urologist, Dr.
___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with PMHx of cardiomyopathy likely
secondary to cardiac amyloidosis, sCHF (EF30%; ___ II-III; on
supplemental ___ NC), sp PPM (?CHB), chronic afib, AS (valve
0.6cm2), HLD, CKD (Baseline Cr ___, and HTN, who presents after
a fall with R hip pain and inability to ambulate s/p a
mechanical fall. Radiology showed Right intertrochanteric hip fracture.
NOTIFICATION: Dr. ___ is aware of the above findings. CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormality.
2. Fracture of the left nasal bone is of unknown chronicity. Please correlate
with site of pain. Radiology showed 1. New large bilateral pleural effusions, left greater than right. Underlying
infection cannot be excluded.
2. New opacity at the right apex may reflect pleural fluid. Followup
radiographs are recommended after diuresis and resolution of the pleural
effusions. If opacity at the right apex persists a CT should be obtained. Radiology showed 1. Stomach distention and small bowel dilatation, with air and stool seen
throughout the colon, probably due to mild ileus. 2. Free air cannot be
excluded at this point, recommend repeating study including upper abdomen and
left lateral decubitus if clinically indicated
Findings and recommendations communicated with Dr. ___ by Dr. ___ at 3:30PM
on ___. Radiology showed 1. Moderate stomach distention. 2. Interval resolution of small bowel
dilatation. HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R. showed Intraoperative images from IM nailing of a right intertrochanteric femoral
fracture. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the patient has been intubated. The
tip of the endotracheal tube projects 6 cm above the carina. No evidence of
complications, notably no pneumothorax. Unchanged appearance of the right
pectoral pacemaker. Unchanged extent of the bilateral pleural effusions with
the subsequent areas of atelectasis. No new focal parenchymal opacities. CHEST PORT. LINE PLACEMENT showed As compared to the previous radiograph, the patient has received the new left
internal jugular vein catheter. The catheter projects over the confluence of
the brachiocephalic vein and the superior vena cava. No evidence of
complications, notably no pneumothorax. The bilateral pleural effusions, the
endotracheal tube and the right pectoral pacemaker are constant in appearance. Portable chest x-ray showed Slight improvement in mild interstitial pulmonary edema and bilateral pleural
effusions. Radiology showed Distended stomach with NG tube in appropriate position. Otherwise, bowel gas
pattern unchanged compared to prior study. CHEST PORT. LINE PLACEMENT showed As compared to the previous radiograph, the left internal jugular vein
catheter has been advanced. The tip of the catheter now projects over the mid
SVC. The position of the endotracheal tube is constant. There is a new
nasogastric tube, with the tip projecting over the middle parts of the
stomach. The stomach, however, is still slightly overinflated. No
complications, notably no pneumothorax. Unchanged bilateral pleural effusions
with subsequent atelectasis and mild fluid overload. Unchanged right pectoral
pacemaker. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen with
respect to the position of the monitoring and support devices. The lung
volumes have minimally decreased. The extent of the bilateral pleural
effusions is constant. Constant subsequent areas of atelectasis at both the
left and the right lung base. Unchanged mild cardiomegaly without overt
pulmonary edema. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Large bilateral pleural effusion, left greater than right, both increased
since ___. To some extent this may be a function of extubation. Upper
lungs clear. Lower lungs atelectatic as expected. Heart size obscured by
pleural effusion. Left internal jugular line ends in the mid SVC, transvenous
right atrioventricular pacer leads in standard placements. No pneumothorax CHEST (PORTABLE AP) showed No change. No new line identified CHEST (PORTABLE AP) showed No change. PORTABLE ABDOMEN showed Ileus versus SBO similar compared to prior The patient was diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL, URIN TRACT INFECTION NOS. The patient was treated with ___ Right TFN. At the time of discharge, the patient had Cardiomyopathy likely secondary to cardiac amyloidosis;
depressed ejection fraction
Congestive heart failure, ___ Class
II-III Permanent pacemaker placement for presumably due to heart
block ___)
Chronic atrial fibrillation
Aortic stenosis (valve area: *0.6 cm2)
OTHER PAST MEDICAL HISTORY:
Hyperlipidemia
CKD (baseline Cr ___
Hypertension
Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with PMHx of cardiomyopathy likely
secondary to cardiac amyloidosis, sCHF (EF30%; on supplemental
___ NC), sp PPM (?CHB), chronic afib, AS (valve 0.6cm2),
HLD, CKD (Baseline Cr ___, and HTN, who presents with R hip
fracture after a mechanical fall.
#) Right Greater Trochanter Fracture:
Repaired ___ by orthopedic service.
#) Congestive Heart Failure secondary to suspected cardiac
amyloidosis:
He was transferred from ortho service to heart failure for
diuresis/optimization for orthopedic surgery, and he continued
to be hypotensive to SBP's of ___'s (although able to mentate
normally at these pressures) with cool limbs. He was
transferred to the CCU for inotropes to allow for diuresis.
Post-surgery he was unable to be weaned from pressors. Mr. ___
and his family sat down for a family meeting with the primary
CCU team and palliative care team and he was transitioned to
CMO. Pressors were weaned at that time, and his blood pressures
returned to ___ of 70's. Monitoring was stopped, aside
from RR and manual HR. He initially mentated well, but then
experiened increasing confusion and decreased responsiveness as
the narcotic dosing required to control his pain.
#) Urinary Tract Infection:
He had a UA positive for infection, initially on ceftriaxone,
later transitioned to cipro.
#) Ileus/Nausea/Vomiting:
On ___, he developed severe abd pain, with decreased bowel
sounds. KUB was unable to exclude free air but ileus was
suspected, repeat abdominal film later was concerning for SBO vs
ileus, but that afternoon he was transitioned to CMO and he was
treated symptomatically with ondansetron and enemas.
#) CMO: Patient made CMO after being unable to be weaned from
pressures, worsening nausea/vomiting symptoms, and a family
meeting with palliative care. He expressed more despondent
feelings and was refusing all care. Levophed and tele
discontinued. No further lab draws. SubQ narcotics for pain
control. Ativan PRN for anxiety, glycopyrolate PRN for
secretions.
- If he appears to decompensate: call sons cell at ___
or family line at ___ at night
#) Other Chronic Medical Issues: holding therapy given CMO</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with h/o ischemic cardiomyopathy LVEF
of 20% ___ BMS to LCX, DES to LAD,
mitral valve repair/three vessel CABG (LIMA to LAD, SVG to OM,
SVG to PDA)on Plavix, pAF on amiodarone, ___ biventricular ICD
implant in ___, RA thrombus on apixaban, drug induced liver
cirrhosis, T2DM with recent admission dc'd ___ for acute CHF
exacerbation presented from OSH for acute abd pain and concern
for choledocholithiasis or cholecystitis. CHEST (AP AND LAT) showed Mild cardiomegaly with mild pulmonary vascular congestion and bibasilar
atelectasis. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. Stones and sludge within a mildly distended gallbladder without specific
signs of acute cholecystitis. Please note that acute cholecystitis is not
excluded in the correct clinical setting and if clinical concern remains high,
MRCP with hepatobiliary agent or HIDA scan may be obtained.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study. The presence of
what appear to be Gamna Gandy bodies in the spleen suggests congestive
hepatopathy in addition to fatty liver disease, as noted previously.
RECOMMENDATION(S): Please note that acute cholecystitis is not excluded in
the correct clinical setting and if clinical concern remains high, MRCP with
hepatobiliary agent or HIDA scan may be obtained. The patient was diagnosed with Calculus of GB and bile duct w/o cholecyst w/o obstruction. At the time of discharge, the patient had 1. Abdominal Pain
2. Choledocholithiasis without cholangitis or cholecystitis
3. Chronic systolic heart failure - ICM EF 20%
4. Paroxysmal atrial fibrillation ___ ABJ on anticoagulation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with h/o ischemic cardiomyopathy LVEF
of 20% ___ BMS to LCX, DES to LAD, mitral valve repair/three
vessel CABG (LIMA to LAD, SVG to OM, SVG to PDA)on Plavix, pAF
on amiodarone, ___ biventricular ICD implant in ___, RA
thrombus on apixaban, drug induced liver cirrhosis, T2DM with
recent admission dc'd ___ for acute CHF exacerbation presented
from OSH for acute abd pain and concern for choledocholithiasis
or cholecystitis.
# Abdominal Pain -resolved RUQ on admission, sudden onset and
offset x3 hr.
Relieved with pain medication. No nausea, vomiting, diarrhea,
icterus. LFTs WNL which is improved from previously. CT outside
hospital with ?cystic duct stone. Imaging ?cholecystitis but the
patient has no RUQ pain, benign abd exam, eating, and no
wBc/fever. We monitored for 24 hours without any abd pain or LFT
elevation at time of discharge
- imaging second opinion by radiology however there were no
images sent from ___. Discussed with patient and due to no
further complaints would like to d/c today
- ERCP/Cards involved and no further intervention. MRI is not
FDA approved/compatible for MRCP and without any further LFT
elevation or pain it benefits to not outweigh risks for ERCP
with his heart status. He did have a recent clean cath in the
last 3 months so if euvolemic and emergent situation arises this
may be reconsidered.
___ on CKD stabe III0 resolved. - baseline 1.5-1.7. Cr 2.2 at
OSH wth Cr
1.9 then baseline 1.6 on discharge.
# CORONARIES: ___ 3v CABG (LIMA to LAD, SVG to OM, SVG to PDA)
# PUMP: EF 20%
# RHYTHM: NSR/bi-V paced
#Chronic Systolic CHF Exacerbation:
HFrEF with LVEF 20% on last TTE. Extensively followd by
Cardiology. Appreciate their evaluation.
- Metop succ 6.25 XL qd, spironolactone 12.5 qd, Lasix 120 BID
- no ACE-I/hydral as does not tolerate afterload reduction
#Cirrhosis:
Patient has liver biopsy consistent with cirrhosis with features
of drug induced injury. No encephalopathy.
- f/u with ___ for liver/heart transplant eval.
#Paroxysmal Afib/atrial tachycardia:
Patient has known paroxysmal atrial fibrillation and is ___ BiV
pacemaker placement, cardioversion on ___. ___ EP ablation.
Doing well. No indication for telemetry. Continue apixiban
# CAD ___ CABG:
LIMA to LAD, SVG to OM, SVG to PDA. LHC demonstrated stable CAD
with patent grafts in ___. No CP. Continued Plavix and
pravastatin 40mg daily.
# H/o Right Atrial Thrombus: Continued apixaban as above.
# Type II Diabetes Mellitus:
Previously discharged on glargine 25U qHS, novolog 16U
# Anemia:
Likley ___ CKD. Hgb at baseline of ___ throughout the admission.
# Back pain:
Continue oxycodone 5 q4
# DVT ppx: on apixiban
# Diet: Regular , 3g salt restriction
# Precautions: None
# Code status: DNR per patient request, extensively discussed
with
patient how he does not want any CPR and/or intubation. This may
be disagreement with his wife but was verbalized with me without
hesitation by the patient.
# Contact Wife ___ number: ___
Cell phone: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ transferred from OSH s/p ATV rollover p/w right proximal
tibia fracture. No numbness, intermittent tingling but no
definite paresthesias. Denies injury elsewhere. TIB/FIB (AP AND LAT) RIGHT showed 1. Comminuted and displaced fracture of the right proximal tibia with the
fracture line extending superiorly towards the tibial plateau, but no definite
evidence of intra-articular extension
2. An oblique lucent line overlying the lateral articular surface of the
tibia is nonspecific. However, a second fracture involving the articular
surface cannot be ruled out. CT right lower extremity. showed 1. Comminuted fracture of the proximal right tibia involving the lateral and
medial tibial plateaus with intra-articular extension.
2. Significant associated soft tissue edema and stranding, in addition to a
large joint effusion demonstrating a lipohemarthrosis. TIB/FIB (AP AND LAT) RIGHT showed Fluoroscopic images show placement of a fixation device about the fracture of
the proximal tibia. Further information can be gathered from the operative
report. The patient was diagnosed with Displaced comminuted fracture of shaft of right tibia, init, Occupant (driver) of 3-whl mv injured in unsp nontraf, init. The patient was treated with ORIF R tibial plateau fx with anterior compartment release. At the time of discharge, the patient had right Shatzker VI tibial plateau fracture s/p ORIF with anterior
compartment release. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right tibial plateau fx and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF right tibia with anterior
compartment release, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI distally in the right lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ female with history of metastatic pancreatic cancer
on protocol ___ and recurrent cholangitis s/p stent placement
who presented on ___ with fever ongoing for several days
prior to admission. She was also complaining of
abdominal pain. Initial labs were remarkable for normal WBC,
elevated LFTs LFTs, UA with moderate leukocytosis and WBCs.
Right upper quadrant ultrasound no biliary obstruction. She was
started on Cipro and Flagyl IV. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Evaluation limited by bowel gas and poor sonographic penetration.
2. No evidence of biliary obstruction.
3. Hepatic steatosis. Scattered hypoechoic areas cannot be distinguished
between fatty sparing versus metastatic disease. If there is concern for
progression of metastatic disease, further evaluation with CT or MRI is
recommended. The patient was diagnosed with Fever, unspecified. The patient was treated with ERCP findings:
Cholangiogram: The CBD was mildly dilated. The left and right
hepatic ducts and intrahepatic branches were evaluated and
appeared slightly dilated. The gallbladder is not well
visualized. No obvious filling defects were seen. Despite the
absence of visible strictures, given recurrent presentations
with cholangitis, a covered metallic stent followed by a double
pigtail plastic stent within the metallic stent to reduce risk
of migration.
Impressions: Accessible ERCP with metallic stent removal
followed by fully covered metal stent placement and double
pigtail stent placement with a metallic stent as described
above.
Recommendations: Follow-up with gastroenterologist.
Continue home medications unless specified differently by her
doctor.
Continue your current diet unless specified differently.
If any abdominal pain, fever, jaundice, GI bleeding, please call
advanced endoscopy fellow on-call ___.. At the time of discharge, the patient had # Presumed cholangitis, in the setting of biliary stent and
elevated liver function tests. Does not meet sepsis criteria.
# Leukopenia, mild, may be secondary to oncology therapy.
# Metastatic Pancreatic Cancer, mets to liver and lungs.
# Recurrent Cholangitis
# Transaminitis, with associated elevated alkaline phosphatase.
# Mild coagulopathy (elevated INR)
# Diabetes, adequate control.
# Hypertension, controlled. Holding home lisinopril for now,
plan to resume this at discharge.
# Anxiety
# Normocytic anemia, appears to be chronic and and baseline.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with history of metastatic pancreatic cancer
on protocol ___ and recurrent cholangitis s/p stent placement
who presents with fever.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ YOM with a PMH significant for MDS on
recombinant erythropoietin with increasing transfusion
requirement, ITP, lupus anticoagulant, and CAD s/p 3v-CABG in
___, s/p pacer insertion ___ and ___ who presented to his
oncologist today and complained of increasing episodes of throat
burning, concerning for unstable angina, fatigue, and worsening
anemia so he was referred to the ED for admission for
transfusion and cardiology evaluation. Radiology showed Right middle lobe mass which is new since ___.
Otherwise, no change since prior, without acute cardiopulmonary process. Radiology showed Prominent rounded mass in the right middle lobe, stable since the previous
study. The patient was diagnosed with CHEST PAIN NOS, ANEMIA NOS, MYELODYSPLASTIC SYNDROME, UNSPECIFIED. The patient was treated with Cardiac Catheterization ___
BMS #1 - graft to SVG-OM (90% lesion)
BMS #2 - jump diag graft: SVG-diag-LAD (90% lesion). At the time of discharge, the patient had Primary Diagnosis: Unstable Angina,CAD
Secondary Diagnosis:
Lung mass
MDS
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>___ M with transfusion dependent MDS and CAD s/p CABG who
presents with unstable angina in setting of anemia.
# Unstable angina: Symptoms correlate with ST depressions on EKG
that resolve with SL nitroglycerin and resolution of chest pain.
After discussion with cardiology, patient was started on IV
heparin and underwent cardiac catheterization which showed 90%
lesion of the graft to SVG-OM (90% lesion) and 90% lesion of the
jump diag graft (SVG-diag-LAD), both areas of which was stented
with BMSs. Patient was noted to have some distal embolization
during cardiac catheterization. CKMB were trended and decreased
as expected in the day s/p catheterization. Transfusions of pRBC
were administered with a goal hematocrit of >30% (patient
received 3 transfusions during admission). His aspirin was
increased from 81mg to 325 mg daily, and he was started on
plavix 75mg daily. He was not placed on a statin or ACEI given
his age and comorbidities/prognosis (MDS, likely has lung cancer
and also has a history of allergy to several statins).
# Low-grade temperature: Patient developed low-grade temperature
of 100.2 one evening 2 days prior to discharge. On infectious
review of symptoms, the patient denied SOB, abdominal pain, n/v,
diarrhea. Has had a persistent cough for months, not worse. He
was experiencing some pleuritic left shoulder pain with deep
inspiration and leaning on his left side (not associated with
exertion), however CXR was unrevealing. His exam does not reveal
source of infection (lungs are clear). Given his neutropenia and
concern for infection, he was monitored for an additional day
and was afebrile x24hrs prior to discharge. UA was negative.
Urine and blood cultures were pending/NGTD on discharge. No
sources of fever became apparent. Low grade fever may be due to
suspected malignancy. Outpatient CBC was planned to monitor this
closely.
# Anemia: Known to be tranfusion dependent MDS, but has required
more frequent transfusions lately. Total bilirubin was increased
in the setting of known Gilberts. Haptoglobin normal.
Reticulocyte count elevated at 4.9%. Patient received 3 units of
PRBCs with a goal hct in the high ___, given CAD and chest pain.
Given low grade fever, he was not transfused prior to discharge,
but outpatient CBC was planned to monitor hct level closely.
# Thrombocytopenia: Likely from MDS vs ITP. Stable at baseline
and no evidence of bleeding.
# Leukopenia: WBC ranged from 1.7-2.7. Neutrophils on the day
prior to discharge were 63%. Grnaulocyte count was 1360 this
admission, so patient was kept on neutropenic precautions.
# Lung mass: Presumed to be lung malignancy given smoking
history. ___ be contributing to worsening fatigue. Patient was
scheduled with ___ f/u on ___ (4 days from discharge).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old male with recurrent minimal change disease, h/o
laryngeal CA s/p laryngectomy, DMII, and HTN who was referred to
the ED by his outpatient nephrologist due to rising creatinine
in the setting of recurrent nephrotic syndrome despite high dose
prednisone.
.
In late ___ he noted increased lower extremity edema and
increasing proteinuria with prot/cr > 5 gram/day. He was started
on 60 mg prednisone daily on ___ and 40 mg of lasix daily.
Despite this treatment he continued to have worsening edema and
increased his lasix to bid. His baseline creatinine usually is
0.7. On ___ he was found to have a creatinine rise to
2.4 and repeat labs have shown continued elevation of creatinine
on ___ up to 4.3 and on ___ up to 6.5.
.
He states he feels poorly. He has had increasing abdominal
distension and feels like there is a hardness near his
umbilicus. He denies nausea or vomiting. No itching, confusion,
or dyspena. He does admit to a 20 pound weight gain and lower
extremity edema. His wife accompanies him and states he has had
relapsing episodes of minimal change disease every year or two
since ___ when he was first diagnosed. He states he was briefly
on dialysis in ___, but during recurrences he has not had as
severe renal injury and usually responds to steroids quickly and
is back to his baseline within a month. No recent NSAID use. He
does report his po intake has been a little less then usual.
.
In the ED his BUN was 159 and his creatinine was 5.8. Potassium
was midly elevated at 5.6. Albumin was 2.0. A foley was placed
and he had 150 cc urine output.
.
On The floor he continues to complian of abdominal distension as
well as being hungry from being NPO. Radiology showed Small bilateral pleural effusions. Hyperinflation. Otherwise,
unremarkable exam. Radiology showed 1. Minimally elevated resistive indices in the bilateral renal parenchymal
arteries, otherwise normal renal ultrasound and Doppler.
2. Tiny left lower pole simple renal cyst. Radiology showed Uncomplicated placement of a 23-cm tip-to-cuff tunneled dialysis
line with the distal tip at the right atrium. The line is ready to use. Radiology showed No evidence of small bowel obstruction. Radiology showed Patchy retrocardiac opacity and left base atelectasis, new compared with
___. The possibility of an associated pneumonic infiltrate cannot be
excluded. Color Doppler and spectral waveform analysis was
performed. The main renal vein is patent bilaterally. Normal arterial
waveforms with sharp upstrokes are seen in the main renal artery bilaterally.
Resistive indices are again noted to be minimally elevated measuring 76 to 77
in the right kidney and 73 to 77 in the left kidney.
IMPRESSION:
1. No hydronephrosis. Stable simple left renal cyst.
2. No evidence of renal artery stenosis bilaterally. The main renal vein is
patent bilaterally. Resistive indices of the intraparenchymal arteries are
again noted to be minimally elevated. showed 1. No hydronephrosis. Stable simple left renal cyst.
2. No evidence of renal artery stenosis bilaterally. The main renal vein is
patent bilaterally. Resistive indices of the intraparenchymal arteries are
again noted to be minimally elevated. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Tunneled dialysis line placement
initiation of dialysis followed by six dialysis sessions
EGD. At the time of discharge, the patient had Primary:
Nephrotic syndrome/acute kidney injury
Urinary tract infection
Bacteremia
Anemia
.
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>___ year-old male with recurrent minimal change disease, diabetes
Type II, and hypertension here with nephrotic syndrome and
worsening ___ despite high dose prednisone therapy with minimal
response to IV solumedrol now on dialysis. Hospitalization
complicated by anemia, thrombocytopenia, UTI, bacteremia.
.
# Acute renal failure/Recurrent nephrotic syndrome: The patient
has had 2 or 3 prior episodes of nephrotic syndrome, caused by
minimal change disease, which had previously been responsive to
steroids. During this relapse of nephrotic syndrome, he was on
PO prednisone 60 mg daily for 14 days prior to being admitted,
yet he was not responding to the PO prednisone. Upon admission,
he was transitioned from PO prednisone 60 mg daily to IV
solumedrol 125 mg daily. His creatinine initially trended down
with IV solumedrol but it then reached a plateau that was
elevated at baseline at ~5 up from baseline of ~1 in ___.
Mild ATN may have contributed to ___. Because patient failed to
regain renal function on solumedrol, hemodialysis was initiated
with plans to continue on discharge. He was transitioned from
Solumedrol IV to Prednisone 60mg which he will likely require
for several months with no taper. Patient was started on
nephrocaps and low K diet. He was also treated with PPI, and
Bactrim was started for prevention of Pneumocystis pneumonia.
.
#Anemia: On admission, hct was 36.8. The patient has a history
of iron-deficiency anemia, on iron supplementation. He also has
a history of gastritis which was previously evaluated by
endoscopy. The patient had an MCV of 74 which is consistent with
microcytic anemia with a possible iron-deficient etiology. Fe
studies showed anemia of chronic disease possibly from a renal
etiology. Retic count was 0.6, indicating that a component of
the patient's anemia is caused by his kidneys not producing
enough EPO in the setting of CKD or his bone marrow not
responding to the EPO. GNR bacteremia (see below) may have also
contributed to anemia. During admission, hct trended down.
Transfusion threshold was hct 25 and he required 2 units of
pRBCs over the admission. He had guaiac positive stool x1. Given
history of gastritis, there was concern for possible UGIB. An
EGD showed that the patient has mild gastritis but no active
source of bleeding. Gastric biopsy results pending at time of
discharge. He will f/u with GI as outpatient for possible
colonoscopy and EUS to evaluate the possible lipoma in the
second part of his duodenum.
.
#Thrombocytopenia: Platelets trended down from baseline 200 to
nadir of 89. The dx included infection, HIT, hemodialysis, DIC,
TTP-HUS, and post-transfusion purpura. In setting of GNR
bacteremia and low reticulocyte count, it is likely that his
bone marrow was being suppressed. Initially, heparin sq was
held, but HIT type 2 antibody test was negative. At that time,
heparin SQ and for dialysis line were re-started. No extensive
bruising, has no hematuria, has no bloody diarrhea and normal
hemolysis labs. Normal FDP fibrinogen coagulation panel. On
d/c, platelets were 167.
.
#UTI, bacterial: U/A was indicative of infection. Urine culture
showed Klebsiella pneumoniae which was pan sensitive. At this
time, the foley was pulled. Patient was initially treated with
Cipro, but was then transitioned to cepfepime --> ceftriaxone
given bacteremia (see below).
.
#Bacteremia: On ___, blood cultures grew out GNRs, found to be
klebsiella, pan sensitive as organism in the urine. Thus,
source of bacteremia was UTI. First neg blood culture on ___.
The patient has been on ceftriaxone 1 g Q24h to treat this
infection. The patient will need to be on antibiotics to treat
his bacteremia until ___ for a 2 week course. On d/c, he will
switch from ceftriaxone to Ceftazadime per HD protocol (1g after
HD).
.
#Hypertension, benign: The patient has a history of essential
Hypertension. His increase in volume status was likely
contributing to his elevated BP as SBPs were better controlled
after dialysis sessions. Patient was well controlled on
hydralazine 25mg q6h in house, but was transitioned to
amlodipine 5mg qd as it is more feasible for him to take a daily
drug at home. Will need to continue to titrate amlodipine as
needed.
.
#Diabetes, type II, uncontrolled, without complications: Blood
glucose was difficult to control in the setting of high dose
steroids as above. Initially, he was managed with Lantus in the
morning in addition to insulin sliding scale. However, sugars
were still elevated and ___ was consulted--recommended
changing to NPH and helped with sliding scale. He will need to
f/u with ___ as outpatient as glucose will be particularly
difficult to control when prednisone is tapered.
.
#Hypercholesterolemia: Continued home simvastatin 40 mg PO
daily.
.
#GERD: Temporarily on IV PPI when ?UGIB, then transitioned back
to home omeprazole 20mg qd.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with DM, HTN, stage III
chronic kidney disease, mitral regurgitation, who is presenting
for 3 days of dizziness and lightheadedness. Patient was
lightheadned for a few days approximately two weeks ago, saw her
PCP, was found to have low sodium. She was advised to increase
her fluid intake, so she drank gatorade and fluids with
improvement of her symptoms. Her symptoms worsened over the last
3 days, and is most notable when looking up and moving her head.
She feels unsteady when standing up. CTA HEAD AND CTA NECK showed Atherosclerotic calcification of the internal carotid arteries bilaterally
without significant stenosis. No occlusion or aneurysm formation. The patient was diagnosed with ABNORMALITY OF GAIT, VERTIGO/DIZZINESS, OTHER MALAISE AND FATIGUE, URIN TRACT INFECTION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS
1. Benign Paroxysmal Posistional Vertigo
SECONDARY DIAGNOSES
1. Hyponatremia
2. Chronic urinary tract infections
3. Hypertension
4. Diabetes Mellitus
5. Chronic Kidney Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to the ED with 7 days of intermittent and
worsening positional dizziness and lightheadedness. Her exam was
notable for positive ___ to the right which, along with
history was highly suggestive of BPPV.
ACUTE ISSUES
# Dizziness: The patient relayed a history of positional
dizziness despite fluid resuscitation as an outpatient. This was
thought to be BPPV given positional nature and ability to elicit
symptoms with ___ maneuver (by neurology). She was seen
by Neurology who recommended vestibular ___. She was seen by
physical therapy who performed an Epley Manuever with
improvement of symptoms. Posterior circulation hypoperfusion was
ruled out with a negative CTA head/neck. She was able to
tolerate PO and ambulate with a walker.
# Hyponatremia: The patient presented with a mild hyponatremia
of 131, which was thought unlikely to contribute to current
symptoms. Patient has had significant hyponatremia before and
relayed that she is on a 2L/day fluid restriction. Her current
presentation was likely hypovolemic hyponatremia as patient has
no hx of heart failure to suggest hypervolemic, and patient is
on two diuretics. Lasix was held given history that patient is
decreasing lasix as an outpatient and that her leg swelling is
improved with compression stockings. She was discharged with a
script for these. Her sodium was 133 on discharge.
# Chronic suppressive therapy for UTI: The patient is on
ciprofloxacin for chronic suppressive therapy for UTI (hx of
frequent UTIs). Patient had no current symptoms of dysuria, no
elevated wbc, or evidence of SIRS. UA only showed leuks and few
bacteria. Therefore this was deemed as asymptomatic bacteruria
and not treated with treatment doses of antibiotics, but instead
prophylactic doses were continued. Her final urine culture
resulted after discharge which showed >100K Citrobacter Koseri,
which was resistant to ciprofloxacin. Outpatient follow-up is
needed.
CHRONIC ISSUES
# DM: Stable. Outpatient glimiperide and saxagliptin held in the
inpatient setting in exchange for insulin sliding scale.
# HTN: Normotensive currently. Lasix held as above.
# CKD: Creatinine 1.0 today. Can be followed as outpatient
TRANSITIONAL ISSUES
- Please assess urinary symptoms as an outpatient given positive
culture with organisms resistant to ciprofloxacin (her current
treatment) to determine if she needs to be treated for a UTI
- consider altering prophylactic antibiotic choice since her
isolate, CItrobacter Koseri, was resistant to ciprofloxacin
- please consider avoiding fluoroquinolones in this patient as
they are more likely to cause delirium in the elderly
- please consider using an ___ for this patient with
diabetes if not contraindicated</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ yo female presenting with mechanical fall and
landed with left hip on curve and landed on left wrist. Denies
head strike or loss of conciousness. Patient's injuries occurred
at 11:05 this morning. Patient was unable to bear weight on left
lower extremity. Was taken to ___ wherein a
femur fracture and left DRF fracture was discovered. She was
transferred to the ___ for operative fixation. Radiology showed Status post cast placement for comminuted intra-articular
fractures of the distal radius and ulna with improved alignment of the distal
radius and distal ulna. The patient was diagnosed with INTERTROCHANTERIC FX-CL, FX DISTAL RADIUS NEC-CL, UNSPECIFIED FALL. The patient was treated with ___: ORIF L distal radius, L hip. At the time of discharge, the patient had L distal radius and L 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 orthopedic surgery team. The patient was found
to have left distal radius and left hip fractures and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF of the left
distal radius and L hip, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LLE and NWB in LUE,
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: Mr. ___ is a ___ right handed man with a past
medical history of well controlled epilepsy, CAD s/p DES, HTN,
HLD who presents following onset of Right weakness last night. Chest: Frontal and lateral views showed No focal consolidation. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Dental amalgam and spinal fusion hardware streak artifact, as well as
motion limits study.
2. Nonspecific left corona radiata and left occipital lobe hypodensities,
which may represent acute to subacute infarcts. Please note MRI of the brain
is more sensitive for the detection of acute infarct.
3. No evidence of acute intracranial hemorrhage.
4. Mild nonocclusive focal luminal narrowing of the mid V4 segment of the left
vertebral artery, and bilateral supraclinoid internal carotid arteries and
M1/2 segments are likely atherosclerotic. Otherwise, the circle of ___ is
patent.
5. Atherosclerotic disease at the carotid bifurcations without internal
carotid artery stenosis by NASCET criteria.
6. Hypodense left thyroid and isthmic nodules measuring up to 2 cm. The
___ College of Radiology guidelines suggest thyroid ultrasound for
further evaluation.
7. Nonspecific patchy opacities within the lung apices. Differential
considerations include infectious, inflammatory, neoplastic etiologies. If
clinically indicated, consider correlation with dedicated chest imaging. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Acute to subacute infarctions are seen involving the left corona radiata
and left occipital lobe.
2. Chronic microangiopathy. THYROID U.S. showed 1. 2.6 cm spongiform nodule in the lower pole of the left lobe of the
thyroid.
2. Similar appearing 2.4 cm nodule in the isthmus.
RECOMMENDATION(S): Fine-needle aspiration could be performed for further
evaluation the above thyroid nodules, or alternatively, a six-month follow-up
ultrasound could be obtained.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 15:32 into the Department of Radiology critical
communications system for direct communication to the referring provider. The patient was diagnosed with Cerebral infarction, 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 a ___ year old R-handed man with well-controlled
epilepsy, CAD s/p DES 3 months ago, HTN, HLD who presented with
acute onset right-sided weakness. Initial exam was notable for
right-sided arm/leg weakness and mild ataxia. Initial labs were
normal. ___ was negative for acute intracranial process. CTA
was notable for possible mild short segment narrowing proximal
to left MCA bifurcation, but negative for stenosis, occlusion or
aneurysm of the major vessels of the neck. Two thyroid nodules
were also identified incidentally. Thyroid ultrasound showed two
2.5 cm nodules. TSH normal at 2.3. Recommendation was for
outpatient FNA vs. 6 month repeat ultrasound.
Mr. ___ was admitted to the Neurology stroke service for a
suspected ischemic stroke. MRI head w/o contrast revealed acute
to subacute infarctions involving the left corona radiata and
left occipital lobe as well as chronic microangiopathy. Stroke
risk factors were checked, indicating HbA1c of 4.5 and LDL of
49. Echocardiogram was significant for LVH and left atrial
dilatation. Mr. ___ was evaluated by ___ who recommended
discharge to acute rehab facility given difficulties with
mobility and coordination. Neurologic exam before discharge was
significant for improved motor strength but persistent right
dysmetria.
Mr. ___ was told to continue taking his home medication,
including dual anti-platelet therapy (aspirin and Plavix) as
well as atorvastatin. He was prescribed a heart monitor for 30
days to assess for atrial fibrillation. He will follow up with
his neurologist (Dr. ___ and PCP (Dr. ___, both at ___.
---------------</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/DM, psoriaisis presents with fever, leukocytosis and
pustular dermatitis of palms. Pt reports that sx began 6 days
ago with back/hip pain and rash on hands. Rash has gotten
progressively worse, is painful, has associated edema of hands.
She has never had a similar rash. Reports psoriasis and excema
of feet. No recent travel, no new sexual partners. Radiology showed 1. Soft tissue swelling along the dorsum of the left hand in this patient
with an IV in place. Clinical correlation is requested.
2. Bilateral osteoarthritis.
3. No findings conclusive for psoriatic arthritis. The patient was diagnosed with NONSPECIF SKIN ERUPT NEC, FEVER, UNSPECIFIED. At the time of discharge, the patient had 1. Inflammatory arthritis and rash. The patient was given written instructions concerning 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 ___ year old female with a questionable history of psoriasis
(no psoriatic lesions were noted) presenting with polyarthritis
and palm and sole rash that was characterized as eruptive and
pustular. Dermatology saw Ms ___ and ___ that the rash
could be consistent with pustular psoriasis even though she had
no risk factors (did not start using steroids previously and has
unclear history of psoriasis). Biopsy was consistent with this
diagnosis. However, biopsy cannot distinguish between this and
keratoderma blenorrhagicum which is associated with HLA B27
seronegative spondyloarthropathies, especially reactive
arthritis. G/C and chylamydia were negative, however she did
describe a preceeding sore throat and sick contacts with fever
and sore throat and her ASO titers returned mildly positive.
Given increasing joint swelling in wrists bilaterally with no
improvement with NSAIDs, we started her on PO prednisone taper.
She will see Rheumatology as an outpatient. Plain films were
obtained of the left hand with no acute changes. She was
discharged on prednisone with significant improvement in
arthritic symptoms and synovitis and stable rash. Syphilis and
parvovirus titers returned negative. A single blood culture of
6 showed gram + organisms in clusters later identified as
coag-negative Staphylococcal species (contaminant).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old male known to Neurosurgery for
recent diagnosis of unruptured left ICA ophthalmic segment
aneurysm, currently ___ s/p pipeline stent-mediated
embolization. Hospital course was significant only for anxiety,
and he was discharged home in stable condition on POD#2. The
aneurysm was originally identified on MRI at an OSH in early
___ performed for a variety of complaints, including
headache, speech hesitancy and word-finding difficulties,
myalgias, cognitive slowing, and fatigue. EEG and LP were also
performed during this workup. CT HEAD W/O CONTRAST showed 1. No evidence of infarction or hemorrhage.
2. 6 mm hyperdensity abutting the supraclinoid left ICA, compatible with known
aneurysm with increased density suggesting thrombosis and no evidence of
enlargement or bleeding.
3. Sinus disease, as described above. The patient was diagnosed with HEADACHE. At the time of discharge, the patient had Headaches
Left ICA aneurysm s/p pipeline 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>Mr. ___ was admitted to the Neurosurgery service for further
management of his headaches. A CT head was performed while the
patient was in the ED and showed no acute hemorrhage. He was
started on steroids and gabapentin to reduce his headache pain
and left facial tingling.
On the following morning, Mr. ___ continued to have his
headache, but it was much better controlled. He was discharged
home with prescriptions for a Medrol dosepack and gabapentin.
As advised by Neurology, he was instructed to not take more than
three doses (per week) of Fioricet or Tylenol for his headaches
due to concerns of rebound headaches.
Per his discharge instructions, Mr. ___ should follow up with
Dr. ___ Dr. ___ previously
scheduled.
At the time of discharge, Mr. ___ was afebrile,
hemodynamically and neurologically intact.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of anxiety, depression, EtOH cirrhosis, benzo abuse
and OSA who is presenting as a transfer from ___
___ with right femur fracture after a fall. She denies
prodromal chest pain, shortness of breath, dizziness, vision
changes, numbness, weakness or tingling. After the fall she was
unable to ambulate due to pain and EMS was called. She was found
to have a femur fracture and transferred here for ortho surgery. CT HEAD W/O CONTRAST showed No acute intracranial hemorrhage. CT C-SPINE W/O CONTRAST showed No fracture or alignment abnormality. Reversal of cervical lordosis with
degenerative changes most pronounced at C6-7. FEMUR (AP AND LAT) RIGHT showed Re-demonstration of the spiral right femoral diaphyseal fracture with anterior
displacement and 14.5 cm overlap of the distal fracture fragment. PELVIS AP ___ VIEWS showed No hip dislocation. Please refer to the report of the femur from the same
day. FEMUR (AP AND LAT) RIGHT showed Correlation with real-time findings and, when appropriate, conventional
radiographs is recommended for further assessment. The patient was diagnosed with Oth fracture of shaft of right femur, init for clos fx, Fall on same level, unspecified, initial encounter. The patient was treated with R retrograde intramedullary femoral nail. At the time of discharge, the patient had regular. The patient was given written instructions concerning 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 R femur fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for R retrograde femoral nail, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with home ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right 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: This is an ___ with history of Htn, HLD, rheumatic heart
disease,
osteoporosis, and remote history of breast cancer who was
brought
to ___ by her family because of inability to get up and
confusion. The patient is not a reliable historian and her son
___ provided most of the history. He reports that he visits her
every day and noticed she had been a bit weaker over the last
few
days, and had difficulty getting up today for which he brought
her to the ED. He states she has not had any focal complaints
but
her diet has been poor recently. CHEST (PA AND LAT) showed 1. No focal consolidation.
2. Compression fracture of a low thoracic vertebral body of indeterminate age.
Likely anterior wedging of multiple other vertebral bodies which are not well
visualized. CT HEAD W/O CONTRAST showed No acute hemorrhage or infarction. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had Encephalopathy
Urinary tract infection
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>___ hx Htn, HLD, OP, rheumatic heart disease and remote hx
breast
ca presents with confusion and inability to get up, found to
have
a UTI as well as new onset AFib with RVR.
#Encephalopathy, poor mobility
#Urinary Tract Infection - Coagulase negative Staph
: Patient admitted with altered mental status thought to be
secondary to progressive, chronic dementia and cognitive
impairment with an acute encephalopathy secondary to her urinary
tract infection. She lives at home alone and has had a poor PO
intake lately
-Treated with ceftriaxone (___)
-Grew staph coagulase negative bacteria in her UA
-d/c on Augmentin (___) to complete a 7 day course
-plan to discharge patient to rehab facility to improve her
functional mobility
#New onset AFib with RVR: In the ED, patient had HRs in the 160s
and an EKG with ischemic changes. Her troponins were negative
and her HR improved to the 100s-110s with fluids. Initially, son
and family reluctant to start anticoagulation in the setting of
altered mental status but anticoagulation with Coumadin was
started on ___. CHADSVASC 4. Coumadin was used as patient with
valvular atrial fibrillation. Patient with difficult to control
HRs in the 130s-150s intermittently and metoprolol was
uptitrated until she was discharged with metoprolol 37.5 mg
every 6 hours.
-transition to 75 mg PO every 12 hours if BP>110/60
-patient has been asymptomatic with her high HRs.
-held ASA 81 mg daily in the setting of starting AC, but can be
restarted with primary care physician
-___ further evidence of a myocardial infarction
-TTE done that showed thickened mitral valves, EF>65%
-Lipids, A1C, and TSH normal.
******Please check INR three times a week on: ___
to titrate Coumadin. Patient currently taking 2.5 mg daily with
an INR of 1.1; goal INR ___
#Hypoxia - Patient with lower oxygen saturations between 92-94%
on RA. Patient carries no formal diagnosis of COPD however her
smoking history and lung exam are consistent with what seems to
be COPD. XRAY did not show any consolidation to suggest
pneumonia. Oxygen saturations remained stable.. Doubt any acute
CHF,
although she has some trace ___ swelling clinically she looks
euvolemic presently
#Hypertension/HLD
-continued losartan 50 mg PO daily
-continued Atorvastatin 10 mg daily at bedtime
#Osteoporosis - reportedly Rx forteo (teriperatide) and has been
non compliant with this, not sure if she is taking it.
Compression fracture in thoracic spine noticed as indicental
finding on CXR and related to pain with movement
- Vitamin D deficiency is new Dx, replace with 50K units q
___
- PTH
#Anxiety/depression - not formally listed in her history and son
does not confirm these, but she takes sertraline and Xanax at
home. C/w sertraline 50 mg daily. Hold Xanax ___ some confusion.
#Question of urinary incontinence - takes oxybuytynin at home,
held in the hospital secondary to concern of anticholinergic
effects.
#Code Status: Full
#Communication - patient's son ___ ___.
DISCONTINUED MEDICATIONS:
Alprazolam 0.25 mg PO TID PRN anxiety
NEW MEDICATIONS
Acetaminophen 1000 mg PO TID PRN for mild-moderate pain, fevers
Albuterol Neb q6h PRN for wheezing/shortness of breath
Amoxicillin-Clavulanic Acid ___ mg every 12 hours x 3 more doses
- end on ___
Metoprolol tartrate 37.5 mg every 6 hours - CAN CHANGE TO 75 mg
every 12 hours if blood pressure is greater than 110/60
Vitamin D 50,000 units PO once a week
Warfarin 2.5 mg daily at 4PM
HELD MEDICATIONS - follow up with your primary care physician
-___ 81 mg daily
-oxybutynin chloride 5 mg daily
CONTINUE THESE MEDICATIONS:
Atorvastatin 10 mg at bedtime
Losartan 50 mg daily
Sertraline 50 mg daily
Clobetasol 0.05% solution BID to scalp</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History of Presenting Illness:
___ yo F with PMH CAD/NSTEMI, FSGN s/p renal txp in ___ (acute
rejection ___, CAD with non-ST elevation myocardial infarction
status post CABG, DVT/PE on Coumadin until ___ (stopped ___
hemarthrosis), TIA and 2 lacunar strokes, HTN, HL presents with
chest pain. CHEST (PORTABLE AP) showed No evidence of pneumonia. No pulmonary edema. CTA chest showed 1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Lobulated predominantly fatty appearing tissue seen in bilateral breasts,
can be correlated with prior breast imaging and/or history of surgery. The patient was diagnosed with Chest pain, unspecified, Acute kidney failure, unspecified. At the time of discharge, the patient had Primary diagnosis
-Atypical chest pain
Secondary diagnosis
- Acute kidney injury
- End stage renal disease status point kidney transplant
- 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>HOSPITAL COURSE
===============
___ yo F with PMH CAD/NSTEMI, FSGN s/p renal txp in ___ (acute
rejection ___, DVT/PE on Coumadin until ___ (stopped ___
hemarthrosis), TIA and 2 lacunar strokes, HTN, HL presented as
OSH transfer from OSH with chest pain and dyspnea on exertion.
Was empirically started on heparin, but V/Q scan and CTA
negative for PE or dissection. Troponin negative x3 with no EKG
changes. Pain decreased but still present at time of discharge,
patient advised to follow up outpatient with cardiologist for
possible echo or stress test. Creatinine bumped from 1.8 to 2.3
on discharge in setting of CTA; patient to have labs checked
___ or ___ with results followed up by transplant
nephrology.
ACTIVE ISSUES
=============
# Chest pain
Patient presenting with chest pain consistent with previous PE.
Low clinical suspicion for dissection. Patient with history of
MIs but pain not consistent, trops negative x 2, and no EKG
changes. Both V/Q scan and CTA negative for PE, so stopped
empiric heparin gtt on ___. Will f/u with cardiology
outpatient for possible stress test.
# Acute kidney injury
Creatinine 2.3 on ___ from 1.8 day prior, likely in response
to contrast on ___ CTA. 1L NS on ___ to hydrate; patient to
have labs checked ___ or ___ with results followed up by
transplant nephrology.
# ESRD s/p renal transplant: Admission Cr of 1.8 from a baseline
of 1.8-2.0. Patient took double dose of immunosuppression on
___, so pending levels readjusted doses as below.
- Prograf was decreased from 2mg twice a day to 1.5 mg twice a
day based on levels.
- Continued sirolimus 1 mg PO daily
CHRONIC ISSUES
==============
# CHF: Patient w/new CHF last admission (TTE with ejection
fraction 51% and wall motion abnormalities). Continued
furosemide 40 mg daily.
# HTN: Continued home amlodipine.
# CAD with h/o NSTEMI: Continued home metoprolol, ASA,
clopidogrel, atorvastatin.
# GERD: Continued PPI.
# GOUT: Continued febuxostat
TRANSITIONAL ISSUES
===================
[] Prograf was decreased from 2mg twice a day to 1.5 mg twice a
day based on levels.
[] Patient to call cardiologist ___ and make an
appointment in the next few weeks for an echocardiogram or
stress test.
[] Patient to get usual kidney labs checked on ___ or ___
due to Cr 2.3 on discharge, to be followed up by transplant
nephrologist</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ without significant medical history who
presents with abdominal pain. She was in her usual state of
health until the day of admission, when she developed epigastric
and left lower quadrant abdominal pain, resolved after 2 hours,
without associated fevers, nausea, vomiting, cough, shortness of
breath, chest pain, loose stools, urinary symptoms, or new rash.
She lives with her family and has not experienced similar pain
in the past. Radiology showed Small nodular opacity in left upper lobe could potentially be due to an early
focus of pneumonia, but lung cancer is an additional consideration. Short-term
followup radiograph after antibiotic therapy may be helpful to assess for
resolution. Alternatively, chest CT could be considered for further
characterization, particularly the patient has risk factors for lung cancer
Moderate cardiomegaly. CT ABD AND PELVIS WITH CONTRAST showed 1. Large hiatal hernia.
2. Large ventral hernia containing small bowel and mesentery, with no evidence
of incarceration.
3. Enlarged uterus containing a partially calcified mass, likely a fibroid.
4. Heterogeneous right adnexal mass measuring 3.2 x 2.4 cm. In a patient this
age, an enlarged ovary would be abnormal, and ovarian mass should be
considered. This can be further evaluated with ultrasound or MRI.
5. Sub 5mm right middle lobe nodule can be further evaluated at time of the
Chest CT to follow up the left upper lung density seen on chest radiograph. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had 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>___ with hx. severe AS, DM, stage III CKD, HTN,
hyperthyroidism, anemia who presents with c/o abdominal pain,
found to have urinary tract infection. Chart review revealed
patient clearly expressed DNR/DNI and outpatient notes have
documented desire to not pursue surgery for known severe AS. She
was treated for UTI, and blood and urine cultures were followed.
Hospice care was introduced to the patient and her family (since
she has refused care for severe AS and thus has a life-limiting
illness); however, they ultimately declined and she was
discharged home.
--ACUTE--
# Urinary tract infection:
P/w abd pain, found to have grossly positive UA, likely
representing urinary tract infection. She was treated with
ceftriaxone; blood and urine cultures were sent. She was
transitioned to cefpodoxime for a total 7d course. BCX are
pending; urine cultures grew E.coli (resistant only to cipro)
and Klebsiella (intermediate resistance to nitrofurantoin).
# Abdominal pain:
Pt presented with epigastric and left lower quadrant abdominal
pain, resolved after 2 hours, without associated fevers, nausea,
vomiting, cough, shortness of breath, chest pain, loose stools,
urinary symptoms, or new rash. She describes the pain as a
'twinge' in her belly after eating that resolved on its own.
Denies constipation or diarrhea. CT abdomen pelvis showed Large
hiatal hernia, large ventral hernia containing small bowel and
mesentery, with no evidence of incarceration, enlarged uterus
containing a partially calcified mass, likely a fibroid, and a
heterogeneous right adnexal mass measuring 3.2 x 2.4 cm
concerning for possible ovarian mass. However, none of these
findings could explain her new discomfort, which was ultimately
attributed to her UTI and resolved with abx as above.
# Fever:
Maximal temperature in the ED was 102.6 rectally, likely
reflecting urinary tract infection in the absence of other
localizing signs or symptoms of infection. In the hospital, she
had the occasional temperature of 100.4 but continued to improve
on abx for UTI. No fevers at time of discharge.
--CHRONIC--
# critical AS:
S/p admission at ___ ___ for respiratory failure thought due
to AS. TTE ___ showed ___ 0.9. Per outpatient record,
patient declined transcuaneous valve and/or surgical
intervention and would rather 'die at home' where she is happy.
Did not appear volume overloaded during hospitalization. Volume
status was closely monitored and home
antihypertensives/diuretics held.
# HTN: continue metoprolol, hold lisinopril
# CKD: patient with Cr 1.3 on admission, last value in OMR is
1.3 ___, up from 1.0 in ___. ACEI/diuretic held.
Meds renally dosed.
# Normocytic anemia: Hct of 29 on admission which per OMR as it
recent baseline, etiology possibly due to CKD vs nutrient
deficiency. Hct was trended but given goals of care was not
investigated further, as active bleeding not suspected.
# DM: diet controlled, ISS in house
# Graves disease: continue methimazole
--TRANSITIONAL--
1. Radiographic findings - can consider workup but this should
be judiciously pursued given clearly stated goals of care
# Incidentalomas: Large hiatal hernia; large ventral hernia
containing small bowel and mesentery, with no evidence of
incarceration; enlarged uterus containing a partially calcified
mass, likely a fibroid; heterogeneous right adnexal mass
measuring 3.2 x 2.4 cm concerning for ovarian mass.
# LUL nodule: noted on CXR, recommending CT scan for further
investigation
- CT chest as outpatient (transitional issue)
2. Final blood cultures can be followed up in OMR.
3. patient's lisinopril and furosemide were held on admission,
she remained normotensive and euvolemic, recommend considering
restarting per PCP ___
4. consider referral to home hospice again once patient ready
5. to complete a 7d course antibiotics for complicated UTI
(cefpodoxime) </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ s/p distal pancreatectomy, splenectomy,
and segmental splenic flexure colectomy on ___ for
pancreatic
adenocarcinoma. Patient's post-op course was relatively
uncomplicated and he was discharged on ___ with his JP drain
(amylase level >100,000) draining minimal but consistent amounts
daily (now down to ___ cc/day). Radiology showed 1. No acute intrathoracic process.
2. Subcentimeter right lower lobe pulmonary nodular opacity, also seen on the
prior radiograph, which may represnt a pulmonary nodule. Further workup can
be obtained with non-contrast CT examination on an outpatient basis, if prior
outside hospital studies are not already available. The patient was diagnosed with SYNCOPE AND COLLAPSE, MALIG NEO PANCREAS NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. At the time of discharge, the patient had syncopal episode secondary to dehydration and medication. The patient was given written instructions concerning 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 being admitted to the ___ surgical service, Mr. ___
was appropriately resuscitated and had labs drawn which were
notable for a crit of 28.6. His other laboratory values were
within normal limits. He had blood and urine cultures taken
which are negative to date and an EKG which was unchanged from
previous. His terazosin was held but was continued on other
home meds. He did not have any further episodes of syncope or
near syncope while an inpatient. He tolerated a regular diet
during his stay. His vital signs were routinely monitored. He
was started on flomax for urinary difficulty (to replace the
terazosin). He was voiding without difficulty on discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p auto vs peds at approx 10 mph at a crosswalk. No
headstrike/LOC. Unable to ambulate and brought to ___ ED. On
arrival isolated complaint of R thigh pain. No
numbness/tingling. No other complaints. Radiology showed Incompletely imaged spiral fracture of the right mid and distal
femur.
Findings and limitations were discussed with ___ by ___
by telephone at 11:08 a.m. on ___ at the time of discovery of these
findings. Radiology showed No evidence of acute intracranial hemorrhage or mass effect or obvious
fracture. Radiology showed 1. No evidence of acute fracture; levoscoliosis. Degenerative changes at C4/5
level with moderate foraminal narrowing. Correlate clinically to decide on
the need for further workup.
2. Small locules of subcutaneous gas in left supraclavicular region. No
overlying bony injury is noted, however, there is mild asymmetry of clavicular
heads. Correlate clinically and with dedicated imaging.
Study is limited due to motion. Radiology showed Comminuted predominantly spiral fracture of the right distal
femur with displacement, impaction, and angulation.
Findings and limitations were discussed with ___ by ___
by telephone at 11:10 a.m. on ___ at the time of discovery of these
findings. Radiology showed Comminuted spiral fracture of the mid and distal femur without
intra-articular extension. The patient was diagnosed with HEAD INJURY UNSPECIFIED, FX NECK OF FEMUR NOS-CL, MV COLL W PEDEST-PEDEST. The patient was treated with Open reduction, internal fixation of right distal femur fracture. At the time of discharge, the patient had Right distal femur fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the Orthopaedic Trauma Service for
repair of a right distal femur fracture. The patient was taken
to the OR and underwent an uncomplicated ORIF. The patient
tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: partial weight bearing RLE.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old right-handed woman with hx of Atrial fibrillation on
Eliquis (only once daily), hypertension, hyperlipidemia, CHF
presents as transfer from OSH after she had acute onset
dysarthria and CTA showed possible partial thrombus or stenosis
in superior division of L MCA. Transferred here for closer
monitoring and possible thrombectomy if her exam acutely
worsens. MR HEAD W/O CONTRAST T___ MR HEAD. showed 1. No acute intracranial abnormality. Specifically, no large territory
infarction or hemorrhage.
2. Scattered foci of T2/high-signal intensity in the subcortical and
periventricular white matter are nonspecific and may reflect changes due to
chronic small vessel disease. CT ANGIOGRAPHY HEAD AND NECK showed 1. Segmental left vertebral artery occlusion of indeterminate chronicity. No
evidence of ischemia.
2. Somewhat small caliber attenuated left M2 inferior branch, without
evidence of focal occlusion.
3. No acute intracranial abnormality on noncontrast CT head. The patient was diagnosed with Cerebral infarction, unspecified. At the time of discharge, the patient had transient dysarthria not secondary to TIA or stroke
Mild Vitamin B12 deficiency. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with AFib on Eliquis, CHF,
HLD, HTN who presented w/ sudden onset dysarthria, abnormal arm
movements, and poor balance (walker at baseline). NIHSS 1 for
slurred speech at OSH. There, a CTA head and neck was completed,
and there was concern for left M2 branch attenuation concerning
for stenosis or occlusion, and she was subsequently transferred
for consideration of thrombectomy but NIHSS 0 on arrival so she
was not deemed a candidate. She was admitted to the Neurology
stroke service for further evaluation of possible TIA vs stroke.
No further symptoms noted during admission. MRI head w/o
contrast were without evidence of stroke. Reports recent
echocardiogram per outpatient PCP/cardiologist, reported as no
acute findings and so this was not repeated. She mentioned
concern about worsening memory, but able to perform ADLs w/
meals/cleaning provided by ALF (moved 10 months ago); it appears
there has been no acute change. She was taking apixiban 2.5mg
once daily (unclear why as this is a BID medication), and so her
dose was increased to 2.5mg BID (she was not a candidate for 5mg
BID due to her age and weight). She was started on atorvastatin
for her hyperlipidemia (LDL 126). EP cardiology was consulted
for frequent sinus pauses noted on telemetry that persisted
despite holding home atenolol, recommending discontinuing home
digoxin and close cardiology ___. Discharged to home w/
___ & ___ and close PCP ___.
#Transient slurred speech and instability, c/f TIA
- ___ consult - cleared for home with home services
- Started on atorvastatin for HLD and increased home apixaban to
therapeutic level
- ___ with stroke neurology after discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a history of type 1 diabetes complicated
by nephropathy, followed at ___. Reports she was at a
6 week visit yesterday for routine labs and was called today to
come to the emergency department for a GFR less than 9. The
patient did have a brachiocephalic fistula creation in ___ of
this year, but has not had this evaluated for maturity. Her
symptoms at home included weakness with difficulty breathing
upon walking further than 10 steps at a time, pruritus over the
past one to 2 weeks, and significantly increased bilateral lower
extremit swelling over the past several days. Denies any
confusion, chest pain, decrease in urine output. Radiology showed 1. Retrocardiac left base opacitiy could represent a small Bochdalek hernia,
suggest confirmation with comparison with prior studies or CT to exclude an
underlying consolidation.
2. Costophrenic angles are indistinct and could represent small pleural
effusions. Radiology showed Patent left upper extremity surgical AV fistula with elevated
velocity at the anastomosis, consistent with a stenosis. Flow volumes as
described. For more information, evaluate scan worksheet. The patient was diagnosed with END STAGE RENAL DISEASE, DIABETES UNCOMPL JUVEN. The patient was treated with Hemodialysis initiation on ___ and ___. At the time of discharge, the patient had Primary Diagnoses:
1. End Stage Renal Disease
2. Hypocalcemia
3. Hypertension
Secondary Diagnosis:
1. Diabetes, Type I. The patient was given written instructions concerning 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/ DM1 and worsening kidney disease now presenting with GFR
and symptoms (pruritis, swelling, SOB) consistent with ESRD here
for initiation of dialyis.
#ESRD: Patient with CKD likely ___ diabetes here with GFR of 9,
leg swelling, dyspnea on exertion and symptoms of pruritis
suggestive of uremia. Patient evaluated by transplant surgery
who gave the ok to use left upper extremity fistula. Patient
started on dialysis on ___ with additional sessions on ___
and ___. Given concern that fistula was difficult to access at
___ session, LUE ultrasound performed on ___ with read
pending at discharge. Hepatitis serologies showed patient was
not hepatitis B immune and patient was given first immunization
in Hep B series on day of discharge and PPD was planted and was
negative. Patient was continued on home sevelamer and started on
nephrocaps as well as 3 days of aluminum hydroxide. Calcitriol
was stopped as patient on doxercalciferon with dialysis.
# Hypocalcemia: Patient admitted with calcium of 6.2 (corrected
to about 6.5 with albumin). Patient was asymptomatic without
Chvostek's sign and with normal Qtc on EKG. Attempted to correct
with HD however without good effect and patient treated with
calcium gluconate with improvement of calcium to 7.5 on ___
(corrected to 7.8). Patient continued on calcitriol during
hospitalization and this was stopped prior to discharge with
plan for correction of calcium and vitamin D via HD.
# Hypertension: Patient hypertensive on arrival to 180s,
improved with home carvedilol, HCTZ, losartan, doxazosin and
lasix. Patient with recurrent hypertension to 203/64 on ___
with improved to systolic pressures of 140s with evening
carvedilol. Patient with recurrent hypertension to SBP of 200s
thought to be due to volume overload and ineffectiveness of HCTZ
with ESRD. HCTZ stopped and doxazosin increased to 4mg BID on
___. With increased doxazosin and 1.5L off at HD on day of
discharge, blood pressures improved to 130s-160s/60s prior to
discharge. Patient may need down titration of blood pressure
meds as fluid status improves with HD.
#Anemia: Patient with hematocrit ranging ___ (just below
previous baseline in ___ of this year. Normocytic anemia likely
related to low erythropoetin in setting of end stage renal
disease. Patient started on epo with HD on ___ along with iron
supplementation through dialysate. Anemia stable during
admission and patient asymptomatic.
#Petechial rash: Patient developed petechial rash over bilateral
arms to just above elbows bilaterally without any itching or
pain. Rash did not spread, and was slowly improving after
initiation of HD. Rash was thought to be due to uremic platelets
in the setting of ESRD.
# Diabetes, Type I: Patient was initially continued on home
lantus with an insulin sliding scale however, sugars poorly
controlled on initial insulin sliding scale with sugars ranging
170s-340s. On hospital day 4, patient returned to ___ counting
with carb ratio 10:1 and lower dose of sliding scale insulin
with improvement in sugars to 150s-250s prior to discharge.
# Hyperlipidemia: Patient continued on home simvastatin while
inpatient.
# Dysthymic Disorder: Continued on home bupropion and sertraline
while admitted.
# Code Status: Full Code
# Health Care Proxy: ___, sister,
--</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with history of hypertension presents with
postural dizziness. On the night prior to admission, he at some
corn tortillas made by his wife. The next morning, he developed
about 30 minutes of diffuse abdominal discomfort, and while
trying to force a bowel movement he became lightheaded and dizzy
and felt as though he was going to pass out. He did not have
palpitations, SOB, chest pain or other symptoms. Of note, the
patient typically takes hctz-lisinopril and pravastatin, however
at ~9pm day PTA he took an extra dose of anti-hypertensives
accidently in lieu of his statin. He states this had not
happened recently, however he has taken incorrect medications in
the distant past. He does not have a pill-box. Radiology showed 1. No acute process of the abdomen and pelvis.
2. Significantly enlarged prostate gland.
3. 5 mm left pulmonary nodule. Follow-up CT in 6 months is recommended. Radiology showed No acute cardiothoracic process. The patient was diagnosed with POIS-CARDIOVASC AGT NEC, POISONING-SALURETICS, SYNCOPE AND COLLAPSE, ABDOMINAL PAIN OTHER SPECIED, HYPOTENSION NOS, ACC POISN-CARDIOVASC AGT, ACC POISN-METABOL AGNT. At the time of discharge, the patient had Orthostatic hypotension secondary to medication error at home. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ___ year old man with history of hypertension presents
with postural dizziness and orthostatic hypotension in the
emergency room.
.
# Orthostatic hypotension: Secondary to taking additional doses
of anti-hypertensives by accident. His initial episode of
dizziness at home developed in setting of high vagal tone while
attempting to force a bowel movement. Was given 2.5L of normal
saline IV, and instructed to obtain a pill-box for medications,
counseled on the dangers of excess medication use, and
discharged after orthostasis and symptoms resolved.
.
# ___: From hypoperfusion and extra dose of ACE-I/diuretic,
improved back to baseline creatinine of 1.1-1.2 with IVF.
.
# Depression: Citalopram was continued, this medication was felt
to be unlikely cause of his orthostasis.
# Hyperlipidemia: continued statin
# Pulmonary nodule: Follow-up CT in 6 months is recommended
.
====</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with diverting loop colostomy in ___ s/p rectal
injury from fleets enema, ___ notable for cerebral palsy,
currently living in group home, presents from group home with
bowel prolapsed from colostomy for indeterminate amount of time.
Pt unable to participate in interview ___ discomfort and
baseline
mental status, per report was having acutely worsening abdominal
discomfort, inability to tolerate PO. ACS consulted due to
significant bowel prolapsing from stoma, concern for acute
intra-abdominal process causing pt to be tachycardic,
hypotensive, febrile. CHEST (PORTABLE AP) showed As above. Radiology showed Mildly dilated bowel loops consistent with ileus. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently in on ___.
Lung volumes remain quite low. Mild edema in the right lung is probably
positional, improved since ___. Although there are no focal
abnormalities to suggest pneumonia, lower lobes are partially obscured.
Cardiomegaly is mild. Pleural effusions small if any. No pneumothorax. Radiology showed Dilated loops of small and large bowel, likely increased given differences in
technique. Radiology showed 1. NG tube terminates in the stomach.
2. Interval improvement of the ileus. Radiology showed Persistent ileus with interval distension of the stomach with gas.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 2:32 ___, 2 minutes after discovery of the
findings. The patient was diagnosed with Supraventricular tachycardia. The patient was treated with ___: Exploratory laparotomy, reduction of intussuscepted
sigmoid colon, sigmoid resection, and ___- type end
colostomy
___: Reopening of recent laparotomy, and closure of
abdominal wall. At the time of discharge, the patient had [] Intussusception of sigmoid colon at the stoma site
[] Postoperative fascial dehiscence with evisceration
[] Bacteremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>On ___ ACS was consulted for prolapsed bowel on Mr. ___.
He was taken to the operating room for exploratory laparotomy,
LOA, sigmoidectomy and end-colostomy formation. After a brief
stay in the PACU, he was re-admitted to the surgical floor.
His post-operative course was complicated by sustained
tachycardia greater than 140, for which he received valium. His
abdomen was distended and a foley catheter was placed. He
continued to have a distended abdomen, and on POD#4 he was noted
to be dry heaving. He was found to be febrile to 102.3, and
blood and urine cultures were taken. After three failed
attempts to straight cath the patient, an 18 ___ Coude
catheter was placed. After foley placement, he vomited one time
and remained distended.
On POD#5 he eviscerated on the floor, and was taken back to the
OR for repair of fascial dehiscence. An NG tube was placed in
the OR, and his blood cultures grew GNRs, so he was started on
Meropenem.
On ___, his bowel function returned and the NG tube was
removed.
On ___, significant sanguineous drainage was noted from the
middle aspect of the wound, and two staples were removed. The
underlying fascia was noted to be intact, and an old hematoma
was evacuated. After a few more episodes of emesis, the patient
began tolerating full liquids, and final a regular diet. His
pain was well controlled. He was discharged back to his group
home with ___ for foley care and wound care. He will be seen in
clinic for follow up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ h/o CAD s/p stenting, AAA s/p open repair ___ who
presented with sudden onset chest pain this afternoon. He
presented to an OSH where troponin was negative and EKG was
sinus. CTA of the torso was concerning for a new type B
dissection. He was transferred to ___ for further care. He has
no current complaints and denies current chest pain, nausea,
vomiting, abdominal pain, lower extremity pain or shortness of
breath. Radiology showed 1. Severe atherosclerotic, ulcerative plaque in the descending aorta, with a
possible small area of intramural hematoma between the levels of the left
subclavian artery origin and diaphragm.
2. Left pleural effusion with associated compressive atelectasis.
3. Sludge in the gallbladder. Radiology showed 1. Thoracic aortic irregularity and dilation consistent with severe
ulcerative plaque and intramural hematoma extending from the origin of the
left subclavian artery to the diaphragmatic hiatus. The extent is stable from
the prior exam but there is worsening plaque ulceration and/or undermining of
hematoma described above. Differential would also included embolized soft
plaque.
2. There is a new right middle and lower lobe ground-glass airspace disease
suspicious for aspiration or multifocal pneumonia.
4. The heart is enlarged. There coronary artery vascular calcifications.
These findings were discussed by Dr. ___ with Dr. ___ within 15
minutes of discovery. The patient was diagnosed with THORACIC AORTIC ANEURYSM. The patient was treated with No surgical or invasive procedures during this hospitalization.. At the time of discharge, the patient had intramural 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 presented to ___ ___ 11:45pm from outside hospital
for suspected aortic dissection. Imaging from outside hospital
revealed a type B aortic dissection. Patient was stable on
admission and was admitted to CVICU for strict BP monitoring,
placed on IV labetolol/nitro for SBP goal of <120, DBP<90.
___: patient denies any chest pain; however, reports left
shoulder pain that resolved within next few hours. Patient
downgraded from CVICU to floor for observation
___: increased omeprazole for presumed ulcer
___: pt stable in CVICU, sent back to VICU
___: CP improved
___: CP correlating with BP increasing
___: hydralazine prn often, labetolol increased to 200TID
___: Cards Consult, CP non cardiac, rather d/t aortic IMH
___: minimal chest pain
___: Cr stablized at 1.2, baseline 1.2, CTa done, no change,
sent home with specific instructions with dosing and adherance
to BP medications. Visiting nurse for ___ few days for BP checks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with history of HTN,
hypothyroidism, anemia, CKD, recent mechanical fall with left
hip fracture s/p ORIF (___) on enoxaparin presenting from rehab
with anemia noted on routine lab work. CT PELVIS ORTHO W/O C showed 1. 8 x 11 cm soft tissue hematoma lateral to the left gluteus maximus, with
associated surrounding soft tissue edema and possible intramuscular extension.
2. Status post ORIF of a comminuted left intertrochanteric femoral fracture
with residual mild displacement of the lesser trochanter and
impaction/foreshortening.
3. Extensive atherosclerotic disease. The patient was diagnosed with Anemia, unspecified. At the time of discharge, the patient had acute blood loss anemia
left hip hematoma
___ on CKD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with history of HTN,
hypothyroidism, anemia, CKD, recent mechanical fall with left
hip fracture s/p ORIF (___) on enoxaparin presenting from rehab
with anemia noted on routine lab work.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ lives in a nursing home fell from standing while near a
refrigerator onto a chair with her right chest striking the arm
rest. No head strike or loss of consciousness. She had immediate
pain and send to the hospital for evaluation. She was sent to
___ where pan scan revealed right rib fractures ___
and a (very) small pneumothorax. She was transferred to ___
for
further evaluation Radiology showed Small persistent right apical pneumothorax. Radiology showed Suboptimal radiograph as the patient is rotated. There is probably no
significant interval change in size of the small right apical pneumothorax.
Small left pleural effusion. Chest AP and lateral showed No appreciable change in right apical pneumothorax.Right-sided effusion has
increased when compared to ___, and must be followed up to ensure
stability as there is concern for hemothorax in the setting of trauma.
RECOMMENDATION(S): Follow-up radiograph is recommended to ensure stability of
right sided a fusion, as there is concern for hemothorax. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. There is no change apical thickening.
There is left basal the shin. Overall the findings are similar to previous
examination. SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT showed Left shoulder prosthesis without evidence for periprostatic fracture or
dislocation. KNEE (AP, LAT AND OBLIQUE) LEFT showed No acute osseous injury of the left knee. Radiology showed Right apical pneumothorax not clearly delineated and certainly not enlarged
since priors. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is again scarring at the
apices with no definite pneumothorax. Continued low lung volumes. Blunting
of the costophrenic angles is consistent with small effusions and underlying
compressive atelectasis.
Multiple vertebroplasties and bilateral shoulder prostheses are again seen.
The multiple right rib fractures were better seen on a prior CT examination. The patient was diagnosed with Traumatic pneumothorax, initial encounter, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Trauma: mechanical fall
right sided rib fractures, ___
small right apical pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female admitted to the hospital after a mechanical
fall in which she sustained right sided ___ rib fractures and a
small right pneumothorax. She was transferred here for medical
management. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging. Cat scan imaging of
the head and c-spine showed no acute fractures. Additional
imaging of the chest and pelvis showed a small right apical
pneumothorax, 13x8 mm nodule left lower lobe and a 0.7 cm lesion
in left hepatic lobe. These findings will need further
investigation.
During the patient's hospitalization, her vital signs remained
stable and she was afebrile. She was instructed in the use of
the incentive spirometer. Her rib pain was controlled with oral
analgesia. She was tolerating a regular diet and voiding without
difficulty. She was evaluated by physical therapy and
recommendations made for discharge to a rehabilitation facility.
The patient was discharged on HD #5 in stable condition.
(telephone conversation with NP at facility for need to review
current medications) </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___, ___ woman
with a history of ESRD (possibly due to SLE) who is s/p
cadaveric renal transplant, performed in ___ in ___.
She was sent to the ED from an outpatient appointment for
elevated creatinine.
The patient denies any recent fevers/chills, though does endorse
some intermittent RLQ cramping for the past week associated with
fatigue. No dysuria/frequency/urgency/hematuria. Her baseline
creatinine is not entirely clear, as she has not followed up
here in some time. She has been taking her immunosuppression as
prescribed.
While in the ED, intial VS: 98 72 155/65 18 100% RA. Cr was 2.1.
UA was positive and she was given ceftriaxone for possible UTI.
Ultrasound of the transplanted kidney that was normal.
On the floor, initial vitals were 98.1 157/66 71 18 99 RA.
Patient confirms the above history.
Review of Systems: As above The main renal vein is patent with normal flow. The
main renal artery is patent showing normal flow direction and a sharp upstroke
with a peak systolic velocity of 122 cm/second compared to 219 cm/second .
The upper, mid, lower pole intrarenal arteries show normal spectral wave forms
and stable resistive indices ranging from 0.74-0.83, previously 0.82-0.87.
IMPRESSION:
1. Stable mild fullness in the pelvis of the transplant kidney with no
evidence of hydronephrosis, stones, or perinephric fluid collections.
2. Patent main renal artery and vein with normal waveforms and an interval
decrease of the peak systolic velocity within transplanted kidney which now
measures measures 122 cm/s compared to 200 cm/s previously.
3. Slightly improved resistive indices. showed 1. Stable mild fullness in the pelvis of the transplant kidney with no
evidence of hydronephrosis, stones, or perinephric fluid collections.
2. Patent main renal artery and vein with normal waveforms and an interval
decrease of the peak systolic velocity within transplanted kidney which now
measures measures 122 cm/s compared to 200 cm/s previously.
3. Slightly improved resistive indices. Radiology showed No evidence of pneumonia. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had 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>PRIMARY REASON FOR HOSPITALIZATION:
============================================
___ y/o ___ only female with history of renal
transplant (cadaveric, thought to be due to SLE nephritis, done
in ___ ___ who presents with RLQ pain and SCr mildly
elevated above baseline.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with history of MCTD
with features of inflammatory muscle disease and scleroderma
(raynaud's, sclerodactyly, abnormal nailfolds, telangiectasia)--
on cellcept and prednisone-- and hypothyroidism who was referred
in by her out-patient Rheumatologist for 1 day history of
generalized weakness, myalgias, difficulty ambulating, DOE and
generalized, non-exertional chest pain x1 day c/f myositis
flare.
The patient called her rheumatologist (followed at ___ on
___ with worsening weakness, myalgias and difficulty ambulating
after recent viral infection similar to prior polymyositis
flares. She states her symptoms were similar to those that she
experienced during her recent hospitalization in ___ when she
was diagnosed with a polymyositis flare in the setting of
transitioning to cellcept and tapering her prednisone. During
that hospitalization, her prednisone was increased and she
received IVIG and she was ultimately discharged on prednisone
20mg and cellcept 1000mg BID.
Regarding her MCTD, she has had polymyositis for about ___ years
although has never had muscle biopsy or EMG. She has a history
of longstanding MCTD (myositis, Raynaud's, telangiectasia,
sclerodactyly, positive ___, U1 RNP and CCP antibodies) with no
internal organ involvement refractory to methotrexate,
Plaquenil, and Imuran. She is followed by ___ rheumatology with
most recent visit on ___. Currently, her immunosuppressant
regimen includes cellcept 1000mg BID and prednisone 15mg daily.
She was doing well from a symptom stand-point until 1 day ago as
detailed above and she is now admitted to ___ for further
management.
Upon arrival to the floor, patient reports improvement of her
pain following the administration of morphine and steroids in
the ED. She recounts the above history and states that her
symptoms were relatively controlled until about one week ago
when she was diagnosed with a URI and prescribed a course of
azithromycin. Since then she's experienced her typical flare
symptoms marked by increased generalized fatigue, significant
myalgias, and worsening weakness (particularly noticed when
climbing stairs). CHEST (PA AND LAT) showed No acute cardiopulmonary process. UNILAT LOWER EXT VEINS RIGHT showed 1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. 4 cm ___ cyst. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT showed Moderate to severe degenerative changes around both hips, progressed since
prior. No acute osseous injury. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Coarsened hepatic parenchyma. No focal lesions. No biliary dilation.
2. Cholelithiasis. CHEST (PORTABLE AP) showed In comparison with the study of ___, there are lower lung volumes.
Cardiomediastinal silhouette is stable. There is mild indistinctness of
pulmonary vessels, which reflect some elevation of pulmonary venous pressure.
Nevertheless, some of this apparent increase may merely reflect the supine
portable rather than upright PA view.
No acute pneumonia.
Evidence prior fracture of the midshaft of the left clavicle. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS
=============================
# MIXED CONNECTIVE TISSUE DISORDER FLARE / MYOSITIS
SECONDARY DIAGNOSES
=============================
# ELEVATED TROPONIN
# ELEVATED TRANSAMINASES
# VOLUME OVERLOAD
# DIAPHORETIC EPISODES
# ORAL CANDIDIASIS
# MACROCYTIC ANEMIA
# BORDERLINE QTc
# LIKELY MILD SCLERODERMA ASSOCIATED LUNG DISSEASE
# DYSPHAGIA
# LEFT HIP BURSITIS
# STEROID INDUCED HYPERGLYCEMIA
# FIBROMYALGIA
# BONE HEALTH
# HYPOTHYROIDISM
# ANXIETY. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with history of mixed connective tissue
disorder and scleroderma overlap (myositis, Raynaud's,
telangiectasia, sclerodactyly, positive ___, U1 RNP and CCP
antibodies), and hypothyroidism who presented with myalgia and
generalized weakness most consistent with mixed connective
tissue disorder flare / myositis.
# MIXED CONNECTIVE TISSUE DISORDER FLARE / MYOSITIS
Initially presented for worsening weakness, myalgias and
difficulty ambulating after recent viral infection most
consistent with MCTD / myositis flare. Previously treated with
MTX, plaquenil, azathioprine, most recently on MMF and
prednisone 20 mg. During this admission she was treated with
high dose Solumedrol (1000 mg x3 days) after which was
transitioned to prednisone 60 mg. Further received IVIG 2g x2
(split doses). Symptoms of weakness and myalgias did not
immediately improve, however labs were notable for steady
downtrend of CK. She was discharged with plan to continue higher
dose prednisone and MMF with close outpatient rheumatology
follow up for further management.
# ELEVATED TROPONIN
Initial workup notable for elevated troponin (peak 0.29) with
CK-MB index >5%. No ischemic EKG changes or symptoms concerning
for ACS. Overall thought most likely due to be related to
myositis flare. TTE unchanged from prior. Obtained pMIBI which
demonstrated normal myocardial perfusion.
# ELEVATED TRANSAMINASES
Lab workup notable for mild though persistently abnormal LFTs,
ongoing for several months prior to this admission. RUQUS
without obvious pathology. Prior hepatitis serologies negative,
negative anti-smooth and AMA antibodies. Currently on MMF though
abnormal LFTs predate this medication. No other obvious
hepatotoxic medications. Overall thought most likely related to
connective tissue disorder. Anti-LK pending at time of
discharge.
# VOLUME OVERLOAD
Mildly hypoxic with evidence of volume overload following IVIG
administration. Improved with intermittent diuresis and was
euvolemic by time of discharge. No need for home maintenance
diuretic.
# DIAPHORETIC EPISODES
Reported intermittent episodes of diaphoresis. Unclear etiology
though temporal association with MMF points towards medication
side effect. Immunosuppressed but no other focal signs of
infection. Blood cultures negative.
# ORAL CANDIDIASIS
Noted on exam in setting of chronic steroids. No odynophagia and
so unlikely to have esophageal involvement. Started 14-day
course oral nystatin.
# MACROCYTIC ANEMIA
Most likely due to MMF. B12/folate were normal.
# BORDERLINE QTc
In setting of chronic amitryptilin and fluoxetine. QTc prior to
discharge was 415.
# LIKELY MILD SCLERODERMA ASSOCIATED LUNG DISSEASE
Per prior records has mild PHTN based on right heart cath. Prior
PFTs notable for reduced FVC and DLCO. No acute respiratory
symptoms and with stable O2. Rheumatology planning for regular
monitoring of PFTs with annual CT chest.
# DYSPHAGIA
Noted to have mild-moderate symptoms of dysphagia which
typically worsen with myositis flares. Normal endoscopy and
biopsy ___. Per speech/swallow, she may benefit from a repeat
video swallow study and esophagram to evaluate for
MCTD-associated esophageal dysmotility if not improved with
flare treatment.
# LEFT HIP BURSITIS
Reports ongoing left hip pain ever since a mechanical fall ___
months prior to admission. X-ray with evidence of degenerative
changes. Clinically most consistent with bursitis. Consider
outpatient steroid injection if persistent pain.
# STEROID INDUCED HYPERGLYCEMIA:
Patient was kept on insulin sliding scale while inpatient. Did
not require insulin on discharge
# FIBROMYALGIA
Continued on amitriptyline 10 mg PO/NG QHS and fluoxetine 40 mg
PO/NG DAILY
# BONE HEALTH
Continuing alendronate 70 mg for prophylaxis of steroid induced
osteoporosis. Continued vitamin D.
# HYPOTHYROIDISM
Continued levothyroxine Sodium 100 mcg PO/NG DAILY
# ANXIETY
Continued alprazolam 0.25 mg PO/NG TID:PRN</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with a history of stage IV clear cell renal carcinoma
who complains of increasing fatigue. The patient has known
metastases to the liver. The patient was diagnosed with a renal
cell carcinoma 9 months ago and is status post left nephrectomy.
He has lost a large amount of weight since that time. The
patient has low appetite and has recently started taking Marinol
for this. Recently, he has become much more fatigued. He is so
fatigued today that he could not walk and was slumping over. His
eyes continued close and he was falling asleep at the kitchen
table so his wife called EMS. His mental status is much more
fatigued, but he is able to recount his history. He has had high
calcium levels and gotten "a shot" for treatment. The patient
also complains of some abdominal pain and the sensation of a new
mass on the left side of his abdomen. Additionally, he reports
some neck pain. He has baseline nausea but no recent vomiting.
The patient has been stooling normally. No fevers or chills. No
urinary symptoms. Radiology showed No definite enhancing lesions identified. No acute intracranial
hemorrhage. Radiology showed 1. Stable pulmonary nodules at bilateral lung bases. Bilateral pleural
effusions.
2. Interval progression of extensive hepatic metastases.
3. Anasarca, mild ascites, and mesenteric edema likely secondary to hepatic
dysfunction in the setting of diffuse hepatic metastases.
4. Splenomegaly likely secondary to increasing portal hypertension in the
setting of widespread hepatic metastasis.
Findings discussed with Dr. ___ at 1:40am on ___ via telephone. Radiology showed 1. No acute intracranial process or acute infarction.
2. No evidence of intracranial metastasis.
3. Normal MRA head. Radiology showed Left PICC terminates in the mid SVC. The patient was diagnosed with OTHER MALAISE AND FATIGUE, MALIG NEOPL KIDNEY. At the time of discharge, the patient had Hypercalcemia (elevated calcium level).
Weakness/fatigue.
Altered mental status (confusion).
Metastatic kidney cancer.
Hyponatremia (low sodium level).. The patient was given written instructions concerning 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 HTN and metastatic renal cell CA admitted for
weakness, altered mental status, and hypercalcemia. Mental
status and calcium improved with IV hydration.
.
# Weakness/metabolic encephalopathy: Likely due to hypercalcemia
given history of waxing and waning course coinciding with
calcium correction. Calcium and mental status have improved
during this admission and he and his wife feel that he is ready
and would be safe for discharge. Lactulose started, but no
evidence of hepatic encephalopathy - no asterixis, normal
ammonia level. AM cortisol normal. Corrected calcium as
outlined below.
- Blood cultures PENDING.
.
# Hypercalcemia: Due to renal cell carcinoma mets. PTH <6.
Allergic to bisphosphonates. IV fluids given with plan to
continue this at home. Denosumab will be given as an
outpatient, due to insurance issues limiting in-patient use.
Started calcitonin PRN, but not continuous consider
tachyphylaxis.
.
# Renal cell carcinoma: Continued axitinib until everolimus
(Afinitor) arrives (already ordered, but can take a week to come
in). Progressed through gemcitabine/sunitinib and now axitinib.
Anti-emetics PRN.
.
# Anemia: Chronic, mild, stable.
.
# Leukocytosis: No evidence for infection. Likely due to
malignancy. U/A negative.
- Blood cultures PENDING.
.
# Abnormal LFTs: Due to liver mets. Hepatitis serologies
negative. Stable.
.
# Hypothyroidism: Normal T4. TSH mildly elevated 4.6, low T3,
normal free T4. Started low-dose levothyroxine.
.
# Hyponatremia: High Una 116 consistent with SIADH, probably
exacerbated by poor PO intake. Stable on IV normal saline.
.
# FEN: Regular diet. Continued outpatient dronabinol for
anorexia/wght loss. IV fluids; continued IV fluids at home.
Repleted hypophosphatemia.
.
# DVT PPx: Heparin SC.
.
# GI PPx: H2 blocker. Bowel regimen.
.
# Pain (neck/chest/abdomen): Due to cancer. Acetaminophen
(limited doses considering LFT abnormalities). Tramadol PRN.
.
# IV access: Peripheral IV. ___ placed ___ for home IV
hydration.
.
# Precautions: None.
.
# CODE: FULL.
.
TRANSITIONAL ISSUES:
- F/U BLOOD CULTURES.
- Denosumab to be given as outpatient.
- Chemotherapy to be changed from axitinib to everolimus as
outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M w/ recently diagnosed cholecystitis (___) and
elective cholecystectomy in ___ at ___ who presents
with blocked JP drain and GNR in abscess fluid. After patient
underwent cholecystectomy, he developed anorexia, intermittent
fevers, and persistence of acute on chronic abdominal pain. He
also notes 40 pound weight loss. He underwent CT scan for
evaluation and was found to have a 10 cm hepatic cyst on CT scan
thought to be consistent with infectious abscess or cyst. He was
admitted for this cystic lesion to ___ ___.
Echinococcal and entamoebal antibodies were negative. The lesion
was drained in ___ on ___ with JP drain placement and he now
notes that the drainage has stopped and he suspects a blood clot
is blocking the drain. After ___ drainage patient was prescribed
augmentin. Cytology was negative for malignant cells. Subsequent
gram stain of abscess fluid showed GNRs and Dr. ___
the patient to come to the hospital for IV antibiotics and
admission.
Of note, over the past several months, the patient has had 40lb
unintentional weight loss. He has had decreased appetite, poor
energy, mild subj fevers, and persistent R sided abdominal pain.
He denies jaundice, nausea, vomiting, diarrhea. He reports that
he has had a known lesion in his liver ___ years ago found
incidentally on CT at ___ and was evaluated
by ___ and was told that it is likely a benign lesion.
In the ED, initial vitals were: 8 98.1 81 151/73 16 100% RA
- Labs were significant for WBC 5.2, H/H 8.5/27.1
In the ED, JP was flushed and now draining.
- The patient was given 4.6g zosyn
Upon arrival to the floor, patient states that he continues to
have anorexia. He notes that his RUQ pain has significantly
improved after ___ drainage. CHEST PORT. LINE PLACEMENT showed The right subclavian PICC line terminates in the distal SVC. Lungs are well
inflated without evidence of focal airspace consolidation, pulmonary edema or
pneumothorax. No right pleural effusion is seen. The left costophrenic angle
is not entirely included. Overall cardiac and mediastinal contours are within
normal limits. CT abdomen with contrast. showed 1. Status post placement of a pigtail catheter with decrease in size of an 6.5
cm right hepatic lobe collection with rim of surrounding edema. No new
lesion.
2. Status post cholecystectomy with stable small choledochal cyst and mild
central and extrahepatic biliary duct dilatation which is likely postsurgical
in nature. Correlation with laboratory data is recommended, and if concern a
dedicated MRCP/ERCP can be obtained for further evaluation. The patient was diagnosed with Abscess of liver. The patient was treated with ___ PLACEMENT. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Liver 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>Patient is a ___ with a PMHx of cholecystitis s/p
cholecystectomy and liver lesion s/p ___ drainage and JP drain
placement ___, admitted for IV antibiotics for GNRs growing in
drainage fluid.
#Hepatic abscess: Unclear etiology of abscess. Given prior
presence of hepatic cyst and recent instrumentation, likely
superinfection as a complication of cholecystectomy. Fluid from
JP drain grew Pan-sensitive E coli. He was initially started on
zosyn then transitioned to IV CTX via ___, which should be
continued for at least 3 weeks. He will be followed by the ___
___ clinic and should have a repeat liver Ultrasound in 3
weeks. JP drain should remain in place until repeat imaging. CT
abdomen on ___ showed drain in good position with decreased
size of fluid collection.
# Pain control: Spinal stimulator in place. Continued on home
pain regimen and started on bowel regimen for opiate induced
constipation
# Anemia: Patient had new diagnosis of anemia at last
hospitalization. No prior labs available for comparison. He had
no evidence of active bleed and Hgb within range of prior
hospitalization. Fe studies from prior admission consistent with
AOCD. H/H stable this admission.
# COPD: Continued home spiriva </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with a past medical history of DM, PVD, HLD,
and chronic right foot ulceration. She was instructed to
present to the ED on ___ due to her reports of worsening of her
right foot wound. She had not been taking her antibiotics as
scheduled. She was sent in for IV antibiotics, ID consult, and
possible bedside vs operative I & D. She was admitted at the
end of ___ as well as mid ___ due to a right foot
infection where she has undergone debridements for OM. She had
reports of chills prior to presentation to the ED. Radiology showed Soft tissue ulcer medial to the base of the first metatarsal bone. No
definite radiographic evidence for osteomyelitis. DX CHEST PORTABLE PICC LINE PLACEMENT showed There to prior chest radiographs ___.
Heart size normal. Lungs clear. No pleural abnormality.
New left PIC line ends in the low SVC. The patient was diagnosed with Non-prs chronic ulcer oth prt right foot w unsp severity. At the time of discharge, the patient had Right Foot Infection
Osteomyelitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the podiatric surgery service from
the ED on ___ for a R foot infection. Bedside micro obtained
and sent for evaluation. On ___ bedside deep bone and tissue
samples were taken and sent.
The patient remained afebrile with stable vital signs; pain was
well controlled oral pain medication on a PRN basis. The
patient remained stable from both a cardiovascular and pulmonary
standpoint. She was placed on vancomycin, ciprofloxacin, and
flagyl while hospitalized and discharged home on the same. Her
intake and output were closely monitored and noted to be
adequtae. The patient received subcutaneous heparin throughout
admission; early and frequent ambulation were strongly
encouraged. She was evaluated by ___ who determined she was ok to
go home and did not require rehab.
The patient was subsequently discharged to home on HD 7 with 6
weeks of IV antibiotics. 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: The patient is a ___ PMHx anxiety and irritable bowel
syndrome who presents with transient gait instability with
headache, nausea and vomiting. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No acute hemorrhage. At the time of final dictation, subsequent same date
brain MRI demonstrates a small acute infarction in the left cerebellar
hemisphere, which is not detectable on the present exam.
2. High-grade stenosis of the V2 segment of the right vertebral artery distal
to C6-C7 with occlusion distal to C4. Reconstitution of the V4 segment,
presumably retrograde from the basilar artery. Right ___ is not seen;
right ___ complex appears present.
3. Bilateral internal carotid artery origin atherosclerosis with less than 40%
stenosis by NASCET criteria.
4. Aneurysm of the partially visualized ascending aorta measuring at least 4.0
cm.
NOTIFICATION: The right vertebral artery abnormality was discussed with Dr.
___. by ___, M.D. on ___ at 18:15 hours. CHEST (PA AND LAT) showed COPD/ emphysema, top-normal heart size, otherwise unremarkable. MRI AND MRA BRAIN, W/O CONTRAST T715 MR HEAD showed 1. Likely tiny subacute infarction in the left cerebellar hemisphere.
2. No other evidence of infarction.
3. No antegrade flow demonstrated in the far right vertebral artery. This may
be a combination of slow and retrograde flow, rather than complete occlusion
since the CTA of several hr earlier.
4. No other intracranial vascular abnormalities detected. The patient was diagnosed with Headache. The patient was treated with TTE Echo ___
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension.. At the time of discharge, the patient had Left cerebellar infarct. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the Neurology service for headache,
nausea and gait instability. MRI showed a left cerebellar
infarct.
CTA head and neck showed: 1. No right internal carotid stenosis
by NASCET criteria. Mild calcified plaque at the right external
artery origin.
2. Mild mixed plaque in the proximal left internal carotid
artery with approximately 15 percent stenosis by NASCET
criteria.
3. Occlusion of the right vertebral artery distal to the C4-C5
level.
4. No evidence for left vertebral artery stenosis.
_________________________________
Transitional Issues
- Begin Atorvastatin
__________________________________
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No
4. LDL documented? (x) Yes (LDL =166) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for follow-up) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - () N/A </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ (speaks ___ but conversational in
___ with PMH HTN, DMII, hx ETOH abuse, recent diagnosis of
pancreatic adenocarcinoma (CT ___, not yet on chemo), and
newly diagnosed alcoholic cirrhosis with ascites s/p therapeutic
para on ___ who presents from the PACU after experiencing
shortness of breath and abdominal distention after extubation
after an EGD on ___. Of note, he already has a metal
biliary stent placed that was patent on EGD and so he did not
require ERCP. He desatted to 87% on ra and had diffuse abdominal
discomfort after extubation. Given his large ascites and
significant edema, he was sent to the ED for a therapeutic
paracentesis. Radiology showed Small left-sided pleural effusion with adjacent atelectasis. Right basilar
atelectasis. The patient was diagnosed with OTHER ASCITES, CIRRHOSIS OF LIVER NOS, MALIG NEO PANCREAS NOS, HYPERTENSION NOS. The patient was treated with (had EGD just prior to admission on ___. At the time of discharge, the patient had Primary diagnoses:
# Shortness of breath
# Alcoholic cirrhosis complicated by ascites and edema
Secondary diagnoses:
# Hypertension
# Dyslipidemia
# Diabetes mellitus, type 2
# Pancreatic adenocarcinoma. The patient was given written instructions concerning 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 ___ (speaks ___ but conversational in
___ with PMH HTN, DMII, hx ETOH abuse, recent diagnosis of
pancreatic ca (not yet on chemo), and newly diagnosed cirrhosis
with ascites s/p therapeutic para on ___ who presents from
the PACU after experiencing shortness of breath and abdominal
distention after extubation after an EGD. Transferred to ED and
then to medicine.
#Shortness of breath: patient experienced shortness of breath
after extubation. Likely hypoxia in the setting of anesthesia
with significant edema/ascites as a contributing factor. Patient
received a 4-L paracentesis in the ED and was admitted for
further diuresis. Upon arrival to the floor, asymptomatic and
satting 96% on ra with no evidence of crackles on exam. CXR did
show a small pleural effusion. Patient began diuresis on ___:
as he strongly wished to return home that day, he received po
lasix 40 mg and 100 mg spironolactone to begin diuresis and was
discharged on these medications.
#Alcoholic cirrhosis complicated by ascites and edema:
___ class C, MELD 6 at admission. Received a 4L tap upon
arrival in the ED. Had 3+ pitting edema in ___. EGD on ___
did not show any varices. No evidence of SBP from peritoneal
fluid analysis. Diuresed per above.
# Hypertension: held home Hctz pending more aggressive diuresis.
Continued metoprolol.
# Dyslipidemia: continued home ezetimibe
# Diabetes mellitus, type 2: on home metformin. Held while in
house, ISS
#Pancreatic adenocarcinoma: Diagnosed via CT on ___,
underwent MRCP in ___ on ___ at which time a common
bile duct stricture was identified within the pancreatic head.
Dr. ___ ERCP and identified portal gastropathy. A
plastic stent was deployed across the 2.5 cm stricture within
the pancreatic head. Brushings demonstrated adenocarcinoma. Not
yet on treatment, has an initial appointment with Dr. ___ in
Heme-onc on ___.
#CODE: Full
#CONTACT: Sister ___: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PER ___ Record
Patient is a ___ male hx of SCC to the L tibia now s/p L knee
disarticulation by Dr. ___ on ___ with Pelvic
Lymphadenectomy with Dr. ___ at the same time, who fell today
while walking on a new prothesis and suffered a left displaced
femoral neck fracture. Patient just got a new prothesis to
replace his old one 2 days ago and was not used to ambulating
with it. He tripped and suffered a mechanical fall onto his
left
side with no head strike no LOC. He was taken to ___ for
further care. Radiology showed Acute left femoral neck fracture. Radiology showed No acute osseous abnormalities. Radiology showed 1. Displaced fracture of the left femoral neck. No obvious lytic or sclerotic
lesion to raise concern for a focal proximal femoral metastasis. The mottled
appearance of the proximal left femur appears to represent diffuse osteopenia,
presumably due to disuse osteopenia or osteoporosis with intracortical
tunneling.
2. Scarring from prior surgery in the left inguinal region.
s Radiology showed No evidence of acute cardiopulmonary process. Radiology showed No radiographic evidence for acute cardiopulmonary process. CTA CHEST showed 1. No evidence of pulmonary embolism.
2. Bronchial wall thickening and mucous plugging at the lung bases compatible
small airways disease. Radiology showed No radiographic evidence for acute cardiopulmonary process. The patient was diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL. The patient was treated with L hip hemiarthroplasty. At the time of discharge, the patient had L 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 was taken to the operating room on ___ for L hip
hemiarthroplasty, which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
The Medicine Team was consulted for persistent, asymptomatic
tachycardia, which resolved with blood transfusion.
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 WBAT in the affected 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: Ms. ___ is a ___ female with history of ER/PR+
metastatic breast adenocarcinoma to the liver, vertebrae, lung,
pleural fluid, calvarium, and palate s/p recent XRT to C1-T2 and
palliative taxol now on capecitabine as well as Lupron/AI who
presents with headache and nausea/vomiting. CHEST (PA AND LAT) showed Stable appearance of bilateral pleural effusions and compressive lower lobe
atelectasis. Known bony metastasis better assessed on prior CT. CT HEAD W/O CONTRAST showed No acute intracranial process. Sclerotic calvarial metastases. If there is
concern for intracranial metastases MRI is recommended. MR HEAD W AND W/O CONTRAST T___ MR HEAD. showed 1. New areas of right frontal and left frontoparietal sulcal FLAIR
hyperintensity, suspicious for leptomeningeal metastasis. Correlation with
CSF studies can be obtained for further evaluation.
2. Multiple stable calvarial metastatic lesions, measuring up to 1.5 cm in the
right occipital bone with destruction of the inner table, with probable
underlying dural involvement.
3. No parenchymal enhancing mass.
4. Enhancing mass arising from the left palate with infiltration of the
pterygoid plate and adjacent musculature is overall unchanged.
5. Partial assessment of enhancing metastatic lesions in the C3, C4 and C5
vertebral bodies.
6. No infarct or hemorrhage. The patient was diagnosed with Headache. The patient was treated with Lumbar Puncture ___. At the time of discharge, the patient had Metastatic Breast Cancer
Headaches. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with history of ER/PR+
metastatic breast adenocarcinoma to the liver, vertebrae, lung,
pleural fluid, calvarium, and palate s/p recent XRT to C1-T2 and
palliative taxol now on capecitabine as well as
Lupron/AI who presents with headache and nausea.
# Headache/Nausea
Pt presented with severe headache and nausea after bending down.
Her MRI brain showed new areas of right frontal and left
frontoparietal hyperintensity suspicious for leptomeningeal
metastasis, multiple stable calvarial mets measuring up to 1.5cm
in the right occipital bone with destruction of the inner table,
with probably underlying dural involvement. Her CSF cytology
however was negative for malignant cells. Radiation oncology
felt that in the context of negative cytology WBRT was not
indicated and that there was no one skull based lesion that
merited targeted radiation, though she does have right sided
lesion which is larger than the other which could be considered
for radiation should her headaches fail to improve further in
the next 2 weeks. Dr. ___ neuro oncology was following and
also felt that in absence of positive cytology intrathecal
chemotherapy was not indicated. It was his opinion that likely
her skull based mets were causing her headaches. Overall her
headaches improved but remained an issue at the time of
discharge. She was initially started on high dose steroids but
when CSF came back negative these were tapered.
She will continue her home methadone and gabapentin as she was
taking. Celebrex was started inpatient but this was not covered
by her insurance and was discontinued at time of discharge. She
did well with hydromorphone combined with ___ for control
of her headaches that allowed her to be functional without
oversedation. Continue home prn reglan for nausea and Ativan
if needed though cautious using Ativan and dilaudid together as
pt had a reaction "was loopy" earlier this year when using both
at once though we did not see this during this admission. We
also minimized Zofran as she had bradycardia during this
admission. The differential includes spontaneous CSF
rupture/leak which would be expected to self-resolve however
opening pressure was not low (26) which argues against this.
There was nothing to suggest bacterial/infectious etiology such
as meningitis as she never had fever or leukocytosis or
meningismus. Her CSF had 0 WBC and 0 polys. There was a report
of GPR on CSF which was felt to be corynebacteria and given
absence of any clinical sx/signs of bacterial meningitis, this
was felt to be skin contaminant. Discussed w/ micro lab and they
were in agreement.
She was concerned about recurrence of severe nausea and pain at
home preventing her from taking pills in an acute situation, so
she was sent home with some liquid dilaudid and prn ODT Zofran
to be reserved for these rare situations.
# Metastatic ER/PR+ Breast adenocarcinoma: Mets to liver,
vertebrae, pleural fluid, calavarium, palate. She had initial
ER+/PR+/EGFR- left breast cancer in ___, then recurrence on
right breast ___. She is currently on capecitabine. cont
letrozole but holding capecitabine per Dr. ___ she
___ likely resume this as outpatient.
# Shortness of Breath/Pleural effusions: Stable. Denies dyspnea
at this time and comfortable off oxygen during conversations and
ambulating the floor frequently. S/p right sided pleurodesis
earlier this year. Supplemental O2 prn comfort but she is
ambulating without it and comfortable
# PICC-Associated Right Upper Extremity DVT - Recently finished
course of apixiban
# Bradycardia - HR 45-70s, pt asymptomatic, but did have
prolonged periods with HR in ___ which was new for her.
Bradycardia likely vasovagally mediated w/
headache and nausea or from some element of ICP, vs from
narcotics. Lytes
WNL, EKG and CEs reassuring, no chest pain, no e/o heart block,
and serial EKGs without prolonged QTC (mid ___, stable)
despite multiple QTC prolonging meds. Ultimately Zofran was
discontinued with some mild improvement in her bradycardia. Her
methadone was continued with prn reglan for nausea but no other
QTc prolonging meds.
# H/o ___ White - reported per pt. No
SVT/tachyarrhytymia this admit, at home intermittently
occurs(last in ___ w/ post LP headache) uses vagal maneuvers
EMERGENCY CONTACT HCP: ___ (husband/HCP) ___
Greater than 30 minutes were spent in planning and execution of
this discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo women with HTN, COPD, CAD, CKD who developed severe left
groin/lower abdominal pain beginning last night at about ___
with nausea and vomiting. She presented to ___ where a
CT revealed LLL pna versus aspiration and small stones,
hydronephrosis, hydroureter, and possible caliceal rupture. The
pt was subsequently transferred to ___ for urology
consultation. Prior to transfer given CTX and azithromycin and
dilaudid for pain. CHEST (PA AND LAT) showed Volume loss versus infiltrate in the lower lobes right greater RENAL U.S. showed Normal renal ultrasound. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, CALCULUS OF KIDNEY. At the time of discharge, the patient had Proteus bacteremia
Occlusive nephrolithiasis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo women with HTN, COPD, CAD, CKD who developed severe left
groin/lower abdominal pain beginning ___ at about ___ with
nausea and vomiting most likely ___ movement of small kidney
stone through urinary system now bacteremic with proteus
#Proteus blood stream infection: Likely ___ acute urinary
obstruction from small kidney stone. Pt was not septic, did not
spike a fever. She appeared extremely healthy for having GNR
blood stream infection. She was initially started on CTX.
Sensitivities returned demonstrating sensitivity to
ciprofloxacin. The pt has a documented cipro allergy but on
futher discussion, it was determined this was not a true allergy
and she was monitored while on this medication with no incident.
She will complete a 2 week course.
#Left hydronephrosis, hydroureter, and calcyceal rupture: Pt
presented with left groin and abdominal pain. The etiology of
her intial presentation is unclear but is consistent with
passage of a small calculus that was not seen on intial CT. The
fact that the patient's pain resolved quickly is c/w spontaneous
stone passage. Given the
patient's long time smoking hx, interval imaging is needed to
ensure resolution of left hydronephrosis given that intial CT
was done without IV contrast. Urology saw the pt and recommended
urine cytology as an outpt (given smoking history). She will
have urology follow up.
# ? Aspiration: CT scan demonstrated left base airspace opacity.
She had no symptoms of pneumonia. This finding may be from
aspiration when she vomited.
# CAD s/p stent x 3: Continued home regimen of daily aspirin,
QOD plavix, statin, losartan.
# ___ on CKD: Likely from being dry in the setting of infection.
Possible from left sided obstruction in the setting of CKD.
Improvement after gentle IVF and presumed passing of stone.
Given improving renal function at the time of discharge, she was
instructed to have repeat Cr checked 2 days after discharge to
determine if cipro dosing will need to be change (results will
be sent to her PCPs office).
# COPD: Not active. Not on inhalers
# Hypertension off meds now per son
# ___
# Hypothyroidism: Levothyroxine
# Moderate AS: Asymptomatic. Avoided aggressive IVF</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed Possible small airway obstruction. No evidence of pneumonia or cardiac
decompensation. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. No evidence of cholelithiasis or acute cholecystitis.
2. Normal hepatic parenchyma. No intrahepatic or extrahepatic biliary
dilatation. The patient was diagnosed with Weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with HTN/HLD, DMII, CKD,
dementia, and COPD who presented to the ED with four days of
back and lower extremity pain with ambulation, found to have
rhabdomyolysis thought secondary to statin, as well as ___ and
___ in setting of rhabdomyolysis.
# Acute on Chronic Renal insufficiency
# Rhabdomyolysis
# Concern for statin-induced myopathy
Patient presents with several days of leg and lower back pain
and noted to have ___, CK > 8K, and moderate "blood" on dipstick
urinalysis (but only 1 RBC on microscopic exam). Overall
consistent with rhabdomyolysis. Patient without any recent
excessive activity and while carries a history of dementia,
lives at home with several family members and has not had any
prolonged periods of being down. Treated with aggressive IVF
with improvement of renal function to baseline (Cr from peak 2.6
to 1.8-1.9 on discharge, on review of prior labs appears recent
baseline around 1.8-1.9 per PCP ___ as well as improvement of
CK from ___ to 1769. Statin discontinued indefinitely.
# ___: Both AST/ALT elevated in 100-200 range, suspect
in setting of rhabdomylosis and muscle release of AST/ALT. On
discharge ALT 141, AST 144, AP 89, Tbili 0.6. RUQ U/S obtained
___ with no evidence of cholelithiasis or acute cholecystitis,
normal hepatic parenchyma, no intrahepatic or extrahepatic
biliary dilatation. Consider recheck at PCP follow up.
# Back pain:
# Leg pain:
Suspect related to rhabdo as above. Patient notes a history of
"arthritis" that is likely OA as no documentation of
rheumatologic condition in chart. Patient seen by ___ who
recommended rehab.
# HTN: Lisinopril initially held in setting of ___, later held
as had borderline K up to 5.4, was 5.0 at time of discharge.
Upon review appears that patient was eating many bananas which
may have contributed. Would recheck ___ and if still stable,
consider restart of home lisinopril.
# HLD: Discontinued statin as above.
# hx of DM2: Diet controlled. SSI while inpatient.
# COPD: Continued home Spiriva, received albuterol PRN while in
patient.
# Positive ___: Patient with 1:80 ___ titer, which can be seen
in
20% of healthy individuals, currently without other complaints
such as joint pains, rash, systemic symptoms.
TRANSITIONAL ISSUES:
====================
[] Statin discontinued indefinitely given rhabdomyolysis
[] Cr on discharge 1.9, K 5.0 (baseline Cr around 1.8-1.9 per
PCP ___ lisinopril on hold at this time given fluctuating K
in setting of possible dietary choices. Please recheck by ___,
and consider resume lisinopril should repeat labs be stable. At
this time please also CK and LFT to ensure continued downtrend.
[] Note patient still with daily coughing episodes in setting of
known COPD, no PFTs available, may consider as outpatient +/-
uptitration of inhaler regimen pending GOLD staging
[] Due for 2nd dose of shingles vaccine (presumably received
shingrix, last ___ per OMR)
#CODE: Full
#CONTACT: Daughter ___ ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with metastatic melanoma on ipilimumab with 5 days of
worsening diarrhea since second infusion of ipilimumab on ___
(first infusion on ___ without any adverse effects). Since
then,
diarrhea has been increasing in frequency (up to ___ times a
day), watery, non bloody, no mucous. Only intermittent RLQ
abdominal cramps, but none now (in the past patient has had RLQ
pain with constipation). Nausea started 3 days prior with one
episode of NBNB vomiting enroute to hospital. She has been
taking
Imodium with no relief of diarrhea. Denies any fevers, chills,
recent antibiotics, orthostatic dizziness. Radiology showed Evidence of known metastatic disease including left apical,
paramediastinal, left paraspinal masess as seen on prior CT. No pulmonary
edema or definite new focal consolidation. The patient was diagnosed with DIARRHEA. The patient was treated with Flexible sigmoidoscopy ___. At the time of discharge, the patient had Primary diagnosis: Ipilimumab-associated colitis
Secondary diagnosis: Malignant Melanoma, Hypovolemic
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>___ with metastatic melanoma on ipilimumab with 5 days of
worsening diarrhea.
#diarrhea: Ddx ipilimumab-related colitis (started on prednisone
in ED), infectious etiology (e.g. cdiff, though no recent abx,
abd exam benign, lactate wnl). Patient was started empirically
on PO steroids for presumed ipilimumab colitis in the emergency
room. Stool cultures and C Diff negative. ___ Flex sig with
erythema of the rectum, sigmoid and distal descending colon.
Biopsies consistent with colilitis, CMV negative, likely
ipilimumab-associated. Had episode of possible BRBPR ___ which
appeared more like orange-red tinged stool, no blood upon
wiping, no recurrent episodes. Hct stable, with no associated
symptoms. Unable to recall any red-orange colored foods. Unable
to obtain stool guiaic prior to discharge home. Patient was
started on PRN loperimide and continued on steroids. She had
improvement of her symptoms on this regimen and was able to
tolerate PO without any nausea or cramping. She is to continue
prednisione 60mg until seen by her oncologist for follow up.
#dyspnea: Reported subacutely worsening DOE on admission,
thought to be related to known metastatic disease, possibly
exacerbated by poor PO intake/dehydration due to her diarrhea.
Her symptoms improved on admission and the patient was able to
ambulate without difficulty at the time of discharge.
#hyponatremia: thought to be secondary to hypovolemia, improved
with IVF.
#Onc: outpatient oncology team notified of admission and updated
on daily events.
#BPAD: cont home meds seroquel and valproic acid
#h/o anxiety: continued on home clonazepam
#HL: continued home statin
Transitional issues
# f/u final blood cultures.
# Discharged on 60mg prednisone daily, to continue on this
regimen until seen by her oncologist
# Given PRN loperamide for diarrhea
# Had red-tinged stools on ___, unable to obtain stool guiaic
prior to discharge. No further episodes in the hospital. If
bloody BM do not improve, consider performing complete
colonoscopy as an outpatient</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In brief, Mrs. ___ is a ___ year-old-female who has
history of right breast cancer with lymph node spread s/p right
total mastectomy in ___, previously on tamoxifen, HTN, HLD,
HFrEF (40% in ___, and poorly controlled DM2 (A1c 13.3%), who
presented with right arm cellulitis c/b sepsis and DKA now
resolved, BCx with GPCs in pairs and clusters, on vancomycin and
ceftriaxone. UNILAT UP EXT VEINS US RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. The patient was diagnosed with Type 2 diabetes mellitus with ketoacidosis without coma. At the time of discharge, the patient had PRIMARY
=======
CELLULITIS
DIABETIC KETOACIDOSIS
THROMBOCYTOPENIA
SECONDARY
=========
BACTEREMIA - Coagulase negative staph
OBESITY
HYPERLIPIDEMIA
HYPERTENSION
HEART FAILURE WITH REDUCED EJECTION FRACTION
BREAST CANCER
TYPE 2 DIABETES MELLITUS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old-female with hx R-sided breast cancer metastatic to
nodes s/p total mastectomy (tamoxifen currently on hold), HTN,
HLD, HFrEF (EF 40% in ___, poorly-controlled DM presenting
with R forearm cellulitis, sepsis, and DKA, with course c/b CoNS
in blood, likely contaminant.
# R forearm cellulitis:
# CoNS in 1 of 2 bottles:
# Sepsis:
P/w sepsis ___ to R forearm cellulitis without purulence with
low suspicion for osteomyelitis or necrotizing fasciitis given
unremarkable Xray of humerus, forearm, hand and RUE U/s with no
e/o DVT. Improved with Vanc/Zosyn and then transition to PO
antibx, subsequently
re-broadened to Vanc/CTX prior to MICU callout given GPCs in 1
of 2 bottles drawn in ED. BCx speciated to CoNS, likely a
contaminant, with subsequent BCx NGTD. Given improvement in her
cellulitis, she was transitioned to PO Keflex/doxycycline on ___
to complete a 10-day course through ___.
# Diabetic ketoacidosis:
# Uncontrolled diabetes mellitus:
A1c 7.2% ___, up to 13.3% on admission for DKA, likely in
setting of infection and metformin non-adherence (had confused
metoprolol and metformin). DKA resolved, and sugars improved on
lantus 35u qAM/15u qPM with Humalog 8u qAC + SS. Ms. ___ is
reluctant to start insulin, hoping for improvement in her
diabetes with metformin alone. In discussion with ___, she
has agreed to discharge on metformin 500mg BID, along with
lantus and humalog insulin pens. She will check her fingersticks
before meals. If sugar is >200, she has agreed to administer
lantus 35u qAM with a humalog sliding scale beginning with 8u
for fingerstick >200. She was provided a glucometer, lancets,
and test strips prior to discharge and received teaching from
the ___, nursing, and nutrition. She was instructed
on identifying and managing hypoglycemia as well. She will f/u
with ___ endocrinology and with her PCP ___ ___.
# Acute on chronic thrombocytopenia:
Plt have ___ slowly downtrending over the last year or so. Was
recently seen by heme/onc (Dr. ___ on ___ who attributed
thrombocytopenia to tamoxifen (now on hold since ___ in setting
of likely initiation of aromastase inhibitor). W/u notable for
CMV IgM/IgG positivity, but CMV VL was negative. HIV negative.
No e/o DIC. Plt were uptrending at discharge (from 106 on ___ to
132 on ___ with no e/o bleeding.
# HFrEF (EF 40% in ___:
# HTN:
# Risk factors for CAD:
EF 40% on stress echo ___ with e/o prior inferior MI without
inducible ischemia. Received IVF iso sepsis and DKA, but no e/o
volume overload during admission. Continued home Toprol and half
dose of home losartan (25mg daily in place of home 50mg daily).
___ benefit from outpatient cardiology f/u and addition of
low-dose ASA and a statin, which were deferred to PCP.
# R-sided breast cancer metastatic to nodes s/p total
mastectomy:
Tamoxifen on hold since ___, with plan for initiation of AI.
She will f/u with her outpatient oncologist, Dr. ___,
___ discharge.
TRANSITIONAL ISSUES
===================
[ ] F/u BCx, pending at discharge
[ ] ___ diabetes management and insulin titration
[ ] Insulin plan as above: discharged on metformin 500mg BID
with plan to dose lantus 35u qAM for AM fingerstick >200 and
humalog SS beginning with 8u for pre-prandial fingerstick >200
[ ] ABx with cephalexin/doxycycline x 10 days to complete ___
[ ] Reduced losartan to 25mg qd from 50mg. Titrate as needed
[ ] Consider starting moderate intensity statin and ASA for
primary prevention given ASCVD risk >10%. ___ benefit from
outpatient cardiology f/u.
[ ] Further ___ deferred to outpatient
hematology/oncology</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with a PMH of asthma and
crohn's disease which has been usually affecting her ilium. Pt's
first line of treatment was Pentasa but she continued to have
symptoms so she was switched to Humira in ___. She
developed skin lesions and Humira was stopped ___. Pt was
started on ustekinumab (Stelara) in ___, which was
initially given via injection every 8 weeks. She had improvement
on Stelara but continued to have some mild ileitis so her
Stelara was increased to every 6 weeks. SECOND OPINION CT TORSO showed 1. Active Crohn's disease involving an approximately 25 cm contiguous segment
of mid and distal ileum, similar in extent and appearance when compared to the
prior MR enterography from ___. No evidence of bowel
obstruction, abscess, or fistulizing disease. No new sites of inflammatory
bowel disease identified.
2. Normal appendix. The patient was diagnosed with Periumbilical pain. At the time of discharge, the patient had Crohn's disease
Acute abdominal pain
Chronic 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>SUMMARY/ASSESSMENT: Ms. ___ is a ___ female with the
past medical history and findings noted above who presented with
abdominal pain, likely related to dietary indiscretion, but on a
background of likely persistently active Crohn's disease.
#Abdominal pain
#Crohn's disease with proximal terminal ileitis
The pt p/w ___ pain, quite rapid onset, no
nausea/vomiting/diarrhea/melena/hematochezia. CT shows her known
Crohn's disease which is active in the terminal ileum. Her
acute symptoms resolved with bowel rest, and antibiotics were
stopped. Her acute symptoms were not felt to represent a flare
of her Crohn's disease, but rather a reaction to the dietary
indiscretions.
In regards to her Crohn's disease, her imaging remains unchanged
since ___ despite treatment with stellara at increasing
dose, so the GI consult advised start of budesonide and follow
up regarding changes in her chronic treatment for Crohn's.
#Asthma
Currently asymptomatic, usually seasonal.
- she was treated with Duonebs PRN
# GYN
OCPs continued</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ with a PMH of ___
disease, dementia, NIDDM, CVA, meningioma who p/w sub-acute
weight loss and increased lethargy. Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST showed Re-demonstration of the left frontotemporal en plaque meningioma with
increased left cerebral vasogenic edema and increased rightward midline shift
now measuring 6 mm with associated effacement of the left lateral ventricle,
and left cerebral sulci. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Interval worsening of mass effect, enlargement of the gyri and worsening
shift of midline structures due to increasing, extensive left frontal,
temporal and parietal white matter vasogenic edema, worrisome for infiltrative
process. The determination whether this is due to extra-axial or intra-axial
mass is limited due to lack of intravenous contrast. However, given the
associated findings, findings may represent atypical meningioma or
hemangiopericytoma arising from the inner table of the left greater wing of
the sphenoid. If clinically indicated, contrast enhanced exam would be
helpful.
2. No evidence of large territorial infarct or hemorrhage.
3. Additional findings described above.
NOTIFICATION: The findings were discussed with ___ , M.D. by
___, M.D. on the telephone on ___ at 11:59 am, 10 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed Possible bronchitis right lung base. Radiology showed No evidence of obstruction. No supine radiographic evidence of free air. The patient was diagnosed with Anorexia, Abnormal weight loss. At the time of discharge, the patient had Primary:
Meningioma
Cerebral Edema with Midline Shift
Secondary:
HTN
Dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a PMH of ___ disease,dementia, NIDDM, CVA,
meningioma who p/w sub-acute weight loss and increased lethargy,
found on imaging to have significant edema with evidence of
midline shift secondary to expanding meningioma.
ACTIVE ISSUES
=============
# Encephalopathy
# Meningioma
Patient initially presented with failure to thrive and weight
loss with altered mental status. She had CT in the ED which
showed a new 6 mm mid-line shift as compared with imaging done
___. Per family discussion at the time of admission no
neurosurgical intervention was indicated, nor was it within the
patient's goals of care. Patient was started on Dexamethasone
4mg BID and was subsequently increased to 4mg QID the second day
of admission. Neuro onc consulted and recommended MRI which
showed worsening likely infiltrative process causing edema and
midline shift, no evidence of an acute stroke. Patient was also
started on Keppra for seizure prophylaxis given history of
unresponsive episodes at her nursing facility. Given location of
her meningioma, it was felt very likely that patient would have
some element of seizure activity on EEG. No e/o infection on
labs, no significant electrolyte/LFT/BMP abnormalities from
baseline. Per neuro-onc, given already present cerebral edema,
radiation therapy was not an option for treatment. Given the
patient's poor prognosis, progressive cerebral edema and midline
shift, and limited medical therapies, GOC conversion with family
on ___ led to decision to transition the patient to comfort
measures while still continuing on dexamethasone and Keppra for
comfort. Patient was discharged to inpatient hospice.
#HTN
Blood pressure progressively increased throughout her admission,
as high as 202/68 on ___. Started on hydralazine 10 TID with
some improvement in BP to SBPs 140s-160s. Concerning for early
signs of herniation with associated bradycardia to HR ___.
#Nutrition
Initially started on diet as patient presented with failure to
thrive and significant sub-acute weight loss. Speech and swallow
consulted and recommended NPO due to aspiration risk. Per goals
of care discussion with the family, diet was liberalized to food
for comfort on ___.
#Hypoxia
Patient had O2 requirement of 2L on first day of admission and
was noted to be intermittently tachypneic to as high as the ___.
She needed up to 4L during her admission but CXR revealed no
acute findings. Speech and swallow team evaluated for concern
for aspiration risk, made NPO, but per above restarted comfort
feeding on ___. She continued to be tachypneic at the time of
discharge but was saturating well on room air.
Transitional Issues
======================
[]Continue on PO Dexamethasone 4mg q6 hr, Keppra 500mg BID as
able if patient swallowing and able to take PO.
[]Continue IV dilaudid PRN for pain. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with history including
seizure disorder and nephrolithiasis who presented with left
flank pain and was admitted for management of left UVJ stone. RENAL U.S. PORT showed Mild fullness of the left renal collecting system of unclear etiology. The
urinary bladder was moderately distended at time of examination. Bilateral
ureteral jets are seen within the bladder, right greater than left. CT ABD AND PELVIS W/O CONTRAST showed 1. 5 mm left UVJ stone with mild left hydronephrosis.
2. Small amount of air is seen in the endometrium, significantly decreased
compared to the prior CT. The patient was diagnosed with Calculus of kidney, Urinary tract infection, site not specified. At the time of discharge, the patient had Primary Diagnosis:
====================
Ureterovesicular Stone
Urinary Tract Infection
Seizure Disorder
Secondary Diagnosis:
=====================
History of Roux en y procedure
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>PATIENT SUMMARY FOR ADMISSION:
Ms. ___ is a ___ year old female with history including
seizure disorder and nephrolithiasis who presented with left
flank pain and was admitted for management of left UVJ stone who
was discharged once symptomatically improved.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year-old Female with a PMH significant for temporal
arteritis (biopsy-proven ___, three episodes of transient
right eye blindness, previously on Prednisone - but not in the
last 6-months), osteopenia, HTN, HLD, hypothyroidism,
hyperparathyroidism, sciatica, peripheral neuropathy, s/p
cholecystectomy (with bile salt diarrhea) who presents as a
direct admission from her PCP office given concerns for
unintentional 15-lbs weight loss, persistent nausea and anorexia
found to have acute renal insufficiency.
.
Of note, she recently saw her PCP ___ ___ for concerns
regarding unintentional weight loss (one year prior she was
142-lbs and weighed 126-lbs on ___ with associated
anorexia, nausea and heightened anxiety symptoms with
unidentifiable source (previously poor response to Ativan -
recently started on Celexa 10 mg PO daily). Her nausea was
worsened with PO intake, but she denied early satiety or
abdominal pain, rather poor appetite. She has been treated for
bile salt diarrhea following her cholecystectomy with minimal
benefit. She also reported peripheral neuropathy and worsening
of her sciatica. Her PCP performed ___ laboratory evaluation
showing a WBC 14.2, HCT 35.9%, hypokalemic and hypochloremic
metabolic alkalosis with acute renal failure to 2.2 (baseline
0.9-1.0).
.
On the floor, she is accompanied by her daughters. Upon
questioning, the patient has had at least 2-weeks of persisent
nausea and decreased appetite. She denies early satiety, but has
a decreased interest in food. She also has had episodic food
particulate emesis in the last few days that is non-bloody. She
notes her weight loss has been on-going for several months and
that she has experienced generalized fatigue and malaise. She
also notes several weeks of loose, watery and non-bloody stools.
They are not pale, greasy, voluminous, or foul-smelling stools.
She denies fevers, chills or nightsweats. She has no chest pain
or trouble breathing. She denies headaches or vision changes.
She denies URI symptoms or sick contacts. She has not recently
traveled, has no rashes and has not used antibiotics recently.
She denies numbness or tingling. She has no weakness.
.
Of note, her ___ year-old grandson grandson was recently diagnosed
with tonsillar or oropharyngeal cancer which has precipitated a
fair amount of anxiety in the family. The patient's daughters
note that she seems 'out of it' lately and more somnolent than
usual in the last few days.
.
In the ED, vitals 96.1 107/57 65 18 96%RA. The patient received
1L NS x 1. A CXR showed no acute process. Her labs were
remarkable for a WBC 14.2 (N 83.2), HCT 32.9, INR 1.0, potassium
of 3.0, metabolic alkalosis with bicarbonate of 34, and
creatinine 2.3. She received 40 mEq of PO KCl. An EKG was NSR
with no acute ST-changes noted. U/A was negative. A Foley
catheter was placed for UOP monitoring.
.
On the floor, she has no complaints of note, other than
generalized fatigue. Radiology showed No acute intrathoracic process. Radiology showed 1. Subcentimeter right upper lobe lung nodule could be an early bronchogenic
carcinoma, with no evidence that it has metastasized to regional lymph nodes.
2. Handful of punctate nodules in the left lung could be inflammatory or
early metastases.
3. Small bilateral pleural effusions and right pleural thickening are of
uncertain significance. Radiology showed Several prominent retroperitoneal nodes, the largest measures 11
x 24 mm. No other evidence of intra-abdominal malignancy. The patient was diagnosed with FAILURE TO THRIVE,ADULT, DEHYDRATION, HYPOKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED. The patient was treated with ___ - Esophagoduodenoscopy and Colonoscopy. At the time of discharge, the patient had Primary Diagnoses:
1. Severe hypercalcemia
2. Unintentional weight loss
3. Generalized malaise and fatigue
4. Chronic, persistent diarrhea with microscopic colitis
5. Right-sided upper lobe lung nodule concerning for early
bronchogenic carcinoma
.
Secondary Diagnoses:
1. Temporal arteritis
2. Osteopenia
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Hyperparathyroidism (per report). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a PMH significant for temporal arteritis (biopsy-proven
___, three episodes of transient right eye blindness,
previously on Prednisone), Osteopenia, HTN, HLD, hypothyroidism,
hyperparathyroidism, sciatica, peripheral neuropathy, s/p
cholecystectomy (with bile salt diarrhea) who presents as a
direct admission from her PCP office given concerns for
unintentional 15-lbs weight loss, persistent nausea and anorexia
found to have acute renal insufficiency
.
# UNINTENTIONAL WEIGHT LOSS, POOR PO INTAKE - The patient
presented with a vague constellation of symptoms, specifically
an unintentional weight loss of roughly 15-lbs over the course
of ___ years (146 to 125-lbs) with decreased interest in food
and poor PO intake rather than early satiety. She denied
abdominal pain. She has persistent nausea and some emesis
episodes that are non-bloody. She denies fevers or chills, has
had no sick contacts and or recent URI symptoms. Possible
etiologies included: endocrinopathy (hyperthyroidism, diabetes,
adrenal insufficiency) vs. gastrointestinal disorders (anorexia,
without abdominal pain, denies early satiety; no dysphagia,
odynophagia or dysmotility - consider malabsorption or chronic
infectious diarrhea given leukocytosis; unlikely obstruction)
vs. inflammatory bowel disease (no history of UC or Crohn, no
bloody diarrhea, no abdominal pain) vs. occult malignancy
(reassuring age-appropriate screening and negative stool guaiac,
but significant hypercalcemia makes this more likely) vs.
substance abuse concerns (denied by patient; daughters note
prior heavy alcohol use) vs. medication-effect.
.
We consulted Gastroenterology and, along with serologic studies,
they recommended EGD and colonoscopy which was performed on
___ and showed only grade I internal hemorrhoids and scoped
to the hepatic flexure; otherwise normal colon. There was
microscopic evidence of microscopic colitis (lymphocytic
variant) and she was started on Budenoside 3 mg PO daily and
will follow-up with her GI physician. Her EGD showed a small
hiatal hernia, but no other abnormality. She has also had
age-appropriate screening - normal colonoscopy (___),
mammography in ___ BI-RADS 1 and negative for malignancy. Her
TSH was 4.0, random cortisol level was reassuring. We sent stool
studies which were negative and reassuring (including Giardia,
C.diff toxin negative). Fecal fat assessment was ordered to rule
out a malabsorptive picture of diarrhea and was pending at
discharge. A urine and serum toxicology screen was negative. Her
nutritional status was impaired - her albumin 3.2 and iron
studies compatible with a mild component of anemia of chronic
disease. We asked the Nutritionists to evaluate her and we
supplemented her diet with oral Ensure shakes with meals and she
steadily improved. Her weight was closely monitored.
.
The unintentional weight loss and anorexia with nausea was all
attributed to her severe hypercalcemia and likely underlying
malignancy (see below). Her chronic diarrhea was attributed to
her microscopic colitis.
.
# HYPERCALCEMIA - On the patient's initial evaluation her serum
calcium was 8.8-8.9 in ___, with hypocalcemia in the 7.7 range
in ___ and was last checked at 7.4 in ___ - this admission her
calcium was initially drawn at 17.9 (correction for albumin of
3.2 would be 18.4) with phosphorus of 2.6. Her creatinine
baseline was 0.8-0.9 (and has trended upward from 1.1 to 1.7 and
on presentation was in the 2.2-2.3 range). She initially
presentated with fatigue, weight loss (anorexia and nausea),
mild abdominal discomfort, mental clouding and neuropsychiatric
complaints all fitting with the serum calcium measurement; no
PTH had been measured previously. Possible etiologies included:
primary hyperparathyroidism vs. hypervitaminosis with vitamin D
vs. malignancy (most probable) vs. milk-alkali syndrome vs. bone
resorptive issues (Paget disease, immobilization, vitamin A
overuse); with that said, serum calcium values > 13 mg/dL are
more concerning for malignancy and her serum calcium was > 18
mg/dL this admission. Nephrology was consulted early and
assisted with management of her acute renal failure and
hypercalcemia. She was initially treated with aggressive IV
fluid resuscitation - a goal of 6L (received 1L NS x 1 in the
ED, ran NS @ 200 cc/hr for goal UOP 100-150 cc/hr) was achieved.
Following these fluids, we switched her to maintenance fluid
with Lasix 20 mg IV BID to follow. She also received Calcitonin
100 units SC Q12 hours for 2-days and was dosed a
bisphosphonate, specifically Pamidronate 60 mg IV (received
___. The IV bisphosphonate medication should be dosed every
___ months. Her labs revealed a PTH ___, a TSH of 4.0, vitamin
D-25 and 1,25 levels were pending, UPEP was negative and SPEP
was negative. We serially trended her calcium and phosphorus
levels and monitored her electrolytes. She was maintained on
telemetry and her electrolytes were optimized. Her Foley
catheter was removed without issue following her re-hydration;
it had been placed for urine output monitoring. We also stopped
Lasix and allowed her to maintain PO hydration for 24-hours
prior to discharge, with good effect. We discontinued her
Calcium, Vitamin D and Hydrochlorothiazide medication given her
hypercalcemia. Her calcium maintained in the ___ mg/dL range
prior to discharge and will be followed as an outpatient.
.
We began the work-up for a malignancy this admission, given her
extreme hypercalcemia (milk alkali syndrome and
hypervitaminosis-D were considered) - the most likely etiologies
being multiple myeloma vs. lymphoma vs. solid tumor malignancy
with production of PTHrp. Her work-up for myeloma was
unrevealing with a negative UPEP and SPEP, and her free kappa
and gamma light chain analysis was pending at the time of
discharge. A CT of the chest showed a right lung nodule which
was suspicious for malignancy with a left-sided smaller lesion
as well (see radiology read). She will likely need biopsy of one
of these lesions for tissue diagnosis, given the concern for a
bronchogenic carcinoma. Given her smoking history and
unintentional weight loss, this was the most likely diagnosis,
but her recombinant PTH was still pending at discharge. A CT
abdomen and pelvis was also obtained for staging, and the final
read was pending at the time of discharge - but this
preliminarily showed a non-obstructing renal stone and some
retroperitoneal nodes.
.
# PERSISTENT DIARRHEA - The patient has had persistent diarrhea
for several days to weeks that has been watery, occasionally
formed and non-bloody with no abdominal pain or features of
early satiety. She has a remote history of bile salt diarrhea
reported following cholecystectomy without relief after
cholestyramine therapy. She was admitted with leukocytosis to 14
(neutrophilia), and was afebrile nonetheless. She denied recent
sick contacts, had no recent URI symptoms, and no recent travel
or antibiotics. Possible etiologies included inflammatory bowel
disease (stools were non-bloody) vs. irritable bowel syndrome
vs. functional diarrhea (possible given no abdominal pain but
exclusionary diagnosis) vs. microscopic colitis vs.
malabsorption (denied pale, greasy, voluminous, foul-smelling
stools; we considered lactose intolerance or chronic pancreatic
insufficiency, as well as celiac disease) vs.
post-cholecystectomy diarrhea (performed ___ vs. chronic
infections (C. difficile, Aeromonas, Plesiomonas, Campylobacter,
Giardia, Amebae, Cryptosporidium, Whipple's disease, and
Cyclospora) vs. medication effects. Gastroenterology was
consulted and recommended an extensive work-up. The patient had
negative ova & parasite culture, a negative C.diff toxin,
negative stool studies for bacteria and Giardia. Immune-mediated
work-up showed no immunoglobulin deficits and tTG-IgA for celiac
was negative. An EGD and colonoscopy was performed and did show
evidence of microscopic colitis which was treated with
Budenoside 3 mg PO daily and this should be monitored by her GI
physician. Her fecal fat qualitative assessment was pending at
the time of discharge.
.
# ACUTE RENAL FAILURE - She presented with acute renal
insufficiency with a creatinine of 2.2-2.3 with a baseline of
0.9-1.0 and with no prior chronic renal insuffiency. The patient
also presented with an acute hypokalemic, hypochloremic
metabolic alkalosis, attributed to contraction from volume
depletion. On exam, she was noted to have volume depletion and
dehydration given her nutritional status. A U/A showed trace
protein (although her protein/creatinine ratio was elevated at
34.3) and she received 1L NS x 1 in the ED. Her FeNA was 1% on
admission. We consulted Nephrology given her hypercalcemia and
acute renal insufficiency. Her UPEP and SPEP were negative for
___ proteins or M-spike, respectively. Her creatinine
dramatically improved with hydration from 2.2 to 1.7-1.8 prior
to discharge. This will be monitored as an outpatient. A Foley
catheter had been placed initially and was discontinued when she
tolerated oral hydration. She voided without issues. A urine
culture was negative for growth this admission. Lastly, we
avoided all nephrotoxins (discontinued her Gabapentin) and
renally dosed all medications.
.
# LEUKOCYTOSIS - She presented with a WBC to ___ with a
neutrophil predominance (N83.2 L13.1 M3.2 E0.3 B0.2, no
bandemia); without fevers or chills and without systemic
symptoms of infection (no dysuria, no URI or cough symptoms)
with the exception of chronic diarrheal concerns. Of note, she
stopped oral systemic steroids in ___ and during her treatment
period had a leukocytosis in the ___ range. Other etiologies
considered included: hematologic or solid malignancy vs.
medication-induced (not on steroids) vs. hypercalcemia. There
were no indications for antibiotics and in the end, an
exhaustive infectious work-up only revealed microscopic colitis.
The colitis, along with a potential malignancy, was the most
likely etiology of her leukocytosis. A CXR was negative, U/A was
reassuring, and urine and blood cultures along with stools
studies were all negative and reassuring. She remained afebrile
and her leukocytosis improved to 14 prior to discharge.
.
# TEMPORAL ARTERITIS, POLYMYALGIA RHEUMATICA - Has a history of
biopsy-proven giant cell arteritis in ___, with three
episodes of transient right eye blindness; previously on
Prednisone, but not within the last 6-months. No recurrence of
symptoms and managed by Dr. ___ from ___
with last follow-up in ___. This admission, she had no evidence
of vision changes or PMR flare.
.
# OSTEOPENIA, BONE METABOLISM - She was diagnosed on BMD imaging
in ___ with no vertebral or pathologic fractures of note; and
had been maintained on Calcium carbonate-Vitamin D3 500 (1250
mg/200 units) PO daily - no longer on chronic steroids for
temporal arteritis - had left partial hip arthroplasty for left
hip OA in ___. Given her above issues with hypercalcemia, we
discontinued her Vitamin D and calcium supplementation.
.
# PERIPHERAL NEUROPATHY - The patient has a chronic diagnosis
with evidence of peripheral neuropathy in the lower extremities;
etiologies included vitamin B12 vs. folate deficiency vs.
alcohol-induced (prior heavy history of abuse, denies current
use) vs. medications vs. chronic malnutrition vs. diabetic
neuropathy (HbA1c 5.9% in ___ vs. hypercalcemia issues.
This admission her HbA1c was normal, her vitamin-B12 - 1352,
folate - > 10 and she was maintained on a Multivitamin 1 tab PO
daily, Thiamine 100 mg PO daily and Folate 1 mg PO daily. Again,
we discontinued Gabapentin for now given renal insufficiency and
concern for mental status changes and recent somnolence, per her
daughters. We did not resume this medication.
.
# HYPERTENSION - The patient is normotensive and she has been
well-controlled on Triamterene-Hydrochlorothiazide 37.5-25 mg PO
daily; prior PCP visits note systolic BP in the 100-120 mmHg
range. We discontinued her potassium-sparring diuretic and
thiazide diuretic given her renal insufficiency and electrolyte
abnormalities.
.
# HYPERLIPIDEMIA - in ___, FLP showing cholesterol was 127,
Trig 99, HDL 65, LDL 42 - she has been maintained on Simvastatin
20 mg PO daily and we continued this medication.
.
# SCIATICA - She had no evidence of active back pain complaints;
not currently on narcotic medications; Tylenol ___ mg PO Q6H
PRN pain was administered as needed and we monitored her
neurologic exam.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: This is a ___ year old right handed man with a history of
metastatic melanoma with metastasis to the brain, vertebra as
well as intra-abdominal mets who presents with 3 days of
progressive leg weakness and loss of sensation. History is
obtained from the neurology note as well as the patient.
.
Mr. ___ reports that on ___ he was moving belongings
out of his trailer and as he reached the last step he tripped
and fell on his right side, also striking his left shoulder as
he went down. He was able to get up with the help of a neighbor
and was just sore for the rest of the day. The next morning he
noticed that he had difficulty getting out of bed and needed a
cane to walk around (which is not typical) due to weakness. He
also noticed decreased sensation of the legs but can't be more
specific as to where. These symptoms all worsened over the last
few days. Yesterday he went shopping with his wife but had to
lean on the cart the whole time and was not able to help bring
packages in the house. This morning at 3am he had to urinate but
could not get off the couch. His wife called EMS who took him to
___ who then transferred him to ___. The patient
denies urinary retention or ncontinence. No bowel changes. No
saddle anesthesia. He denies back pain.
.
Vitals in the ER: 99 100 143/83 16 98% RA. He received Ativan
2mg IV,l Morphine 4mg IV, and Dexamethasone 10mg IV. An MRI was
complicated by motion artifact. On arrival to the floor, he
states that his pain is not significant enouth to require
medication at this time. He is very tired from being awake for
such a long period of time.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies chest pain or tightness,
palpitations, lower extremity edema. Denies cough, shortness of
breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
All other systems negative. Radiology showed Extremely limited evaluation for metastatic disease. There
appears to spinal canal stenosis at C2-3, C4-5, C5-6, and C6-7 with
indentation on the cord, most likely degenerative. High-grade spinal stenosis
also seen in the lumbar region from L2-3 to L4-5 level which also appears
degenerative in nature. Bony metastasis seen at T10 level. Evaluation for
bony metastasis at other levels is limited on T2-weighted images. Consider
repeat study with sedation or anesthesia if clinically indicated. Radiology showed 1. Mixed lytic and sclerotic lesion within T10, the posterior portion of
which appears to have slightly increased in size. This lesion does abut the
vertebral canal, however, the effects upon the spinal cord are not
characterized. MRI would be recommended if further characterization is
necessary.
2. Slight increase in size of the innumerable pulmonary metastatic foci.
3. No fracture.
4. Partially visualized abdominal masses. Radiology showed 1. No acute intracranial process.
2. Bilateral metastatic disease as seen on previous MRI. No obvious change is
seen but MRI can help for better assessment. Radiology showed No acute fracture or dislocation. Severe tricompartmental osteoarthritis. Radiology showed No acute fracture or dislocation. The patient was diagnosed with BACKACHE NOS, MUSCSKEL SYMPT LIMB NEC, SECONDARY MALIG NEO BONE, SECONDARY MALIG NEO LUNG, SEC MAL NEO BRAIN/SPINE, HX-MALIG SKIN MELANOMA. At the time of discharge, the patient had Primary diagnosis:
Spinal cord compression from metastatic disease
Secondary diagnoses:
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>Pt admitted for progressive leg weakness and loss of sensation
following a fall. In the ED pt tachycardic to 99, VS otherwise
stable. Pt received ativan, morphine, and also empiric
dexamethasone for concern for compression. Pt denied urinary
symptoms. CT head and C-spine negative for fracture or bleed.
MRI performed due to concern for spinal compression, imaging
complicated by motion artifact. Pt was seen by neuro-oncology
who did felt that pt's exam was reassuring, no additional
imaging under anaesthesia necessary. Pt did display a metastasic
lesion at T10, but w/ little evidence that this was the cause of
his symptoms, more likely osteoarthritis or musculoskeletal
pain. Per outpatient oncology notes, pt is undergoing evaluation
for cyberknife therapy, and recent scans show little disease
progression -- no systemic therapy indicated. Pt was treated w/
ibuprofen, and also w/ oxycodone and morphine for breakthrough
pain. His symptoms resolved w/ little intervention, and he was
discharged in improved condition to follow up with his PCP and
primary oncologist.</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 CAD s/p
multiple PCI, PVD s/p R BKA/L ___ toe amputation, stroke, HTN,
HLD, T2DM, chronic pain, who presents with chest pain. He
presented to the ED yesterday evening with three hours of
crushing substernal chest pain, without radiation. He reported
that it was similar to his prior MI pain but more sever. It was
worse with lying down and better when sitting up. Of note, he
had also been experiencing erythema and pain of his left foot
and was febrile to ___ shortnly before arrival.
In the ED initial vitals were: T 99.8F BP 113/59 mmHg P ___ RR
20 O2 98% NC
EKG: NSR, rate of 105, ST depressions in V4/V5, with TWI in
V1/V2, Q-wave in III
Exam was notable for diaphoresis, tachycardia, and skin findings
consistent with L foot cellulitis.
Labs/studies notable for normal Chem 7, including Cr of 1.2
(though from a baseline of ~0.9), WBC 15,700, with 89.6%N, no
bands, H/H 13.9/42.9, PLT 273, trop-T of 0.02 rising to 0.40,
lactate 2.3, bland UA. CXR was notable for stable
cardiomediastinal silhouette, without evidence of pneumonia,
large effusion, or pneumothorax. A foot radiograph demonstrated
no evidence of erosion or radiographic evidence of
osteomyelitis. FOOT AP,LAT AND OBL LEFT showed 1. No evidence of erosion or radiographic evidence of osteomyelitis
2. No fracture or dislocation. The patient was diagnosed with Non-ST elevation (NSTEMI) myocardial infarction. The patient was treated with Cardiac catheterization ___
Cardiac catheterization ___ with drug eluting stent. At the time of discharge, the patient had Primary:
Non-ST elevation myocardial infarction requiring stent placement
Severe sepsis secondary to cellulitis
Secondary:
Coronary artery disease
Peripheral vascular disease
Diabetes mellitus
Hypertension
Hyperlipidemia
Chronic 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>Mr. ___ is a ___ y/o man with a PMH of CAD s/p
multiple PCI, PVD s/p R BKA/L ___ toe amputation, stroke, HTN,
HLD, T2DM, chronic pain who has been admitted with NSTEMI in the
setting of sepsis from skin and soft tissue infection.
# CORONARIES: Diffuse 3VD, L dominant, complex lesions in ___
LAD
(bifurcation lesion with a diffusely diseased restenotic diag),
distal LAD, ostial ramus intermedius and moderate disease in the
dominant AV groove CX into the LPDA. Underwent PCA to LAD this
admission (see below)
# PUMP: LVEF >55%
# RHYTHM: NSR
# NSTEMI: Patient presented with chest pain in the setting of
sepsis. EKG showed NSR, rate of 105, ST depressions in V4/V5,
with TWI in V1/V2, Q-wave in III. Trops initially 0.13 with CKMB
21. Patient initially underwent cardiac catheterization on
hospital day 1 which showed diffuse multivessel CAD. No
intervention was performed due to diffuse disease and ongoing
fevers (see below). He was planned for medical management with
nitro gtt for chest pain symptom relief as well as Plavix,
metoprolol, aspirin 81, atorvastatin 80 mg qHS. ACEi was
initially held due to hypotension (although ultimately resumed
over hospital course). However, troponins continued to rise and
patient again developed chest pain on ___ that was responsive
to SL nitro. He was placed on heparin gtt and isordil for chest
pain control. He was taken back to the cath lab on ___, and
received a drug-eluting stent to proximal LAD, and balloon
angioplasty of D1 ostium and lower pole branch of ramus
intermedius. Please review OMR for the catheterization reports.
# Severe sepsis secondary to cellulitis: Patient initially
febrile, with leukocytosis, borderline hypotension and
tachycardia. Source appears to be left foot with warmth and
erythema. No evident ulceration or erosion. Dopplerable DP
pulses. No evidence of trauma, though neuropathy and severe
peripheral vascular disease does place him at high risk for
SSTI. Given his recent hospitalizations and diabetes, patient
was initially covered broadly, including with MRSA and
Pseudomonal coverage. He does not have any cough or evidence of
PNA on CXR or evidence of UTI. He was initiated on vancomycin
1000 mg IV q8h and zosyn with panculture. Given concern for
osteomyelitis of foot, case discussed with vascular, podiatry,
and infectious diseases and decision was made that there was low
suspicion for osteomyelitis, and no MRI was necessary.
Ultimately, he defervesced and improved clinically in <24 hours
and it was felt that the source of infection was cellulitis. He
was narrowed to cephalexin and will complete a course ending
___.
#HEART FAILURE WITH PRESERVED EJECTION FRACTION. Noted to have
elevated LVEDP on catheterization. No dyspnea, PND, orthopnea at
this time to suggest significant decompensation. Given concern
for sepsis, he did not undergo diuresis initially. TTE this
admission showed mild regional left ventricular systolic
dysfunction c/w CAD in mid to distal LAD territory. EF 45-50%.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p MVC belted driver, head-on collision with another
vehicle at 50mph, prolonged extraction, med-flight to ___.
ATLS protocol followed on arrival, GCS 15. Hemodynamically
stable. Pt complaining of bilateral hip pain. Fast negative.
Found to have left posterior hip dislocation on XR, now s/p left
hip closed reduction in ED trauma bay. CT scan subsequently
showed left hip reduced without evidence of acetabular fracture
or other pelvic fx.
CT head and abdomen negative. TRAUMA #2 (AP CXR AND PELVIS PORT) showed No acute cardiopulmonary abnormality. Superior/posterior dislocation of the
left hip without evidence of fracture. CT HEAD W/O CONTRAST showed No acute intracranial process. Left posterior parietal scalp laceration. CT C-SPINE W/O CONTRAST showed Normal study. CT CHEST W/CONTRAST showed 1. Horizontal, overlapping fracture of the midshaft of the right femur with
internal rotation of the distal fracture fragment, seen on the scout view.
2. Minimal fat stranding adjacent to the right common femoral vein is most
likely related to recent femoral vein intravenous line placement.
3. No evidence of intra-abdominal or intrapelvic injury. No additional
fractures are identified. PELVIS (AP ONLY) showed No fractures or dislocations identified. eval for fx showed Horizontal fracture through the midshaft of the right femur with 5.2 cm of
bony overlap, 1 shaft with posterior displacement, and moderate internal
rotation of the distal fracture component.
Recommend dedicated right knee radiographs for further evaluation if
clinically indicated. DX FEMUR AND TIB/FIB showed Horizontal fracture through the midshaft of the right femur with approximately
3 cm of_ overlap. HIP NAILING IN OR W/FILMS AND FLUORO LEFT IN O.R. showed Nine intraoperative images obtained without a radiologist present demonstrate
the left hip and knee joint. Please see the operative report in OMR for
procedure details. FEMUR (AP AND LAT) RIGHT IN O.R. showed Images from the operating suite show placement of an intra medullary rod
across a fracture of the midshaft of the femur. Further information can be
gathered from the operative report. The patient was diagnosed with POSTERIOR DISLOC HIP-CL, FX FEMUR SHAFT-CLOSED, OPEN WOUND OF SCALP, OPEN WND KNEE/LEG/ANKLE, MV COLLISION NOS-DRIVER. The patient was treated with left hip closed reduction in ED
right retrograde femoral IMN - ___. At the time of discharge, the patient had right femur fracture
left hip dislocation, s/p closed reduction in ED. The patient was given written instructions concerning 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 hip dislocation (and underwent closed reduction
in the ED, please see note for full details) and a right femoral
shaft fracture and was admitted to the orthopedic surgery
service.
The patient was seen and evaluated by ACS who continued to
follow for a tertiary survey. Please see their note for full
details.
The patient was taken to the operating room on ___ for
right femoral shaft retrograde IMN , which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to <<>> 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
RLE WBAT and LLE WBAT w/ posterior hip precautions, 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: ___ is a ___ female who presents to ___ on
___ with a mild TBI. Patient was transferred from OSH to
___. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Essentially unchanged 8 mm parafalcine subdural hematoma. No new areas of
intracranial hemorrhage or infarction.
2. Large left frontal subgaleal hematoma. The patient was diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall same lev from slip/trip w strike agnst oth object, init. At the time of discharge, the patient had Mild traumatic brain injury
Traumatic acute subdural 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>#TBI; Acute SDH
___ female on ___ admitted in the early morning of
___ s/p a mechanical fall overnight. NCHCT at OSH showed an
acute parafalcine SDH for which she was transferred to ___ for
Neurosurgical evaluation. At OSH, her INR was 1.8 and she
received K-Centra. Upon presentation to the ___ ED, her
___ was held with plans to hold for one month. She received
Vitamin K for a repeat INR of 1.5, after which her INR was 1.3.
She was found to be neurologically intact, and was admitted to
the floor for observation. She was started on Keppra 500mg BID
for one-week for seizure prophylaxis. Repeat NCHCT 6-hours after
her original scan was stable. She remained neurologically intact
and her pain well-controlled with oral medications, oxycodone
was added to medication regimen due to complaints of headaches
worse with movement. Patient's INR was 1.1 on ___. Patient
continued to remain neurologically intact. ___ evaluated the
patient on ___ and recommended discharge home without services.
On ___ patient without complaints of increased headaches,
lightheadedness, dizziness, or any other neurological
complaints. Patient ambulating without difficulty to a from the
restroom.
#Trauma
Upon admission, her left knee was found to be edematous. XR at
OSH had been negative. ACS was consulted for tertiary survey and
stated full traumatic workup was negative without additional
injuries.
#Diabetes
The patient was ordered for her home diabetes medications upon
admission and she was covered with an Insulin sliding scale
AC/HS PRN.
#BRPPR
In the ED, the patient was noted to have one episode of a small
amount of BRBPR. A CBC was repeated and was stable. Her CBC was
monitored daily and she was ordered for stool guaiacs. Patient
reports history of hemorrhoids for which she notes BRBPR
occasionally, she states she has a scheduled appointment with
her PCP regarding this issue as well as complaints of diarrhea.
Patient without diarrhea while inpatient.
#Disposition
Patient was evaluated by physical therapy on ___ and
recommended for home discharge without services. Patient was
discharged to home on ___. Patient given all follow up
instructions and prescriptions. Patient to follow up with PCP
next week regarding left forehead laceration as well as her
complaints of diarrhea and BRBPR. Patient to follow up with Dr.
___ in ___ weeks with CTH, patient will continue to hold
___ until this appointment with Dr. ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx of CHF, DM, HTN, Hep C cirrhosis s/p TIPS (___)
during recent admission ___ who presents with chest pain
and chest fluttering. Patient states that he was in his usual
state of health after his last discharge on ___. However, for
the past few days he has felt a "fluttering" in his chest. This
AM, he states he started to have sharper, epigastric pain,
unrelated to position or exertion. Pain was associated with SOB,
lasted for a few seconds, and resolved spontaneously. He did
report 1x emesis this AM which was clear. (Questionable history
of coffee ground emesis per report although pt denies). Per
report patient has also had dark stools, although he currently
does not recall how many. CHEST (PORTABLE AP) showed Probable slight increase in CHF.
Partial interval improvement of left lung base collapse/consolidation and
effusion. Residual atelectasis and small residual amount of left pleural
fluid remain present.
No frank consolidation or gross effusion at right base, though atelectasis and
vascular engorgement have probably increased. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Patent TIPS. Relative to prior examination dated ___, velocities
within the mid and distal tips are decreased and similar to ___
examinations. There remains elevated velocities within the proximal TIPS.
RECOMMENDATION(S): Continued close monitoring in setting of elevated proximal
TIPS velocities for concern of stenosis at this location. CTA ABD AND PELVIS showed 1. No evidence of acute bleeding, intra-abdominal or retroperitoneal
hemorrhage.
2. Moderate bilateral effusions and adjacent atelectasis.
3. Cirrhotic liver with extensive esophageal and gastric varices despite
patent TIPS and Coronary in gastric vein sclerosis/embolization. Splenomegaly
measuring up to 17.6 cm. Moderate simple ascites. Radiology showed Increased airspace opacities, worsening pulmonary vascular congestion, and new
small bilateral pleural effusions suggest worsening pulmonary edema. A
superimposed consolidation, particular within the right lung base, cannot be
entirely excluded.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:47 AM, 2 minutes after
discovery of the findings. Radiology showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Diffuse ground-glass opacities are likely secondary to pulmonary edema.
Infectious process cannot be ruled out.
3. Moderate right greater than left pleural effusions. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently ___.
Moderately severe pulmonary edema has worsened. Bibasilar consolidation is
usually combination of dependent edema and atelectasis. Pleural effusions are
presumed, but not large. Moderate cardiomegaly stable. No pneumothorax. CHEST (PORTABLE AP) showed All compared to chest radiographs ___ through ___.
Mild pulmonary edema has changed in distribution, improved minimally, still
accompanied by moderate right pleural effusion moderate cardiomegaly and
consolidation or atelectasis at least at the left lung base. No pneumothorax. Radiology showed Three gastric and esophageal varices embolized with ethanol and coils with
good angiographic result. Completion portosystemic gradient measured at 7 mm
Hg. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified, Non-ST elevation (NSTEMI) myocardial infarction. The patient was treated with alcohol embolization of varices by interventional radiology. At the time of discharge, the patient had decompensated heart failure
NSTEMI
anemia likely secondary to bleed
HepC cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY
=============
___ year old male with history of Hep C cirrhosis s/p Harvoni c/b
varices s/p TIPS ___ after admission for variceal bleed,
presenting with anemia, NSTEMI, and decompensated CHF.
ACTIVE ISSUES
=============
#Acute on chronic CHF exacerbation:
The patient was recently admitted with NSTEMI in the setting of
GIB. At that time, he was initiated on statin, but ASA was held
in the setting of GIB. No beta blocker due to history of severe
bradycardia from them. He was scheduled to follow-up with
cardiology for further work-up (stress vs. cath), however he
represented with anemia and a NSTEMI. Cardiology was consulted
as an inpatient and the patient was managed in a similar
fashion. He was started on ASA 81mg, heparin gtt was held due to
concern for risk of variceal hemorrhage pending EGD, and beta
blocker held due to risk of bradycardia. He was continued on
high dose statin. On ___ due to worsening tachypnea, shortness
of breath, patient transferred to the MICU for nitro gtt, TTE,
further diuresis and possible BIPAP. In the MICU, he was started
on captopril and uptitrated to lisinopril 40 mg. Home
hydralazine was started. He was diuresed with IV Lasix boluses
up to 60 mg BID with good effect. Repeat TTE showed mildly
depressed EF 45-50%.
# Type II NSTEMI/Chest Discomfort: Likely ___ hypertensive
emergency with some EKG changes with ST depressions and TWI.
Repeat EKGs have improved. CTA negative for PE. We continued
aspirin 81, atorva 80. We held his beta blocker in the setting
of bradycardia to ___. It was deemed that he not need his
metoprolol. Patient was also not candidate a for cath lab given
bleeding.
#Anemia: The patient presented with subacute to acute H/H drop
since prior admission. Given history of GIB and questionable
history of coffee ground emesis, there was a concern for UGIB.
However, clinical history does not support GIB as the sole
etiology of his anemia; TIPS should have decompressed gastric
varices, which are grade I and should not be bleeding at any
rate. Luminal GI bleed unlikely to cause this degree of Hgb drop
given no significant bloody output. CTA negative for RP bleed,
however notable for persistent esophageal and gastric varices as
well as ascites. Given concern for variceal hemorrhage he was
started on PPI and octreotide gtt as well as Ceftriaxone for GIB
in a cirrhotic patient. His H/H stabilized and he was
transferred to the floor. Due to concern for coronary ischemia
in the context of anemia, he was transfused 2 units of blood on
___, 1 on ___ and 1 on ___. His octreotide was stopped
given that he was hemodynamically stable and he completed 7 days
of ceftriaxone. Pt underwent ___ embolectomy without
complications, incisino site was clean/dry with stabilizing H/H
after procedure.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with recently diagnosed
alcoholic hepatitis and cirrhosis, DMII who presents as transfer
from ___ for possible liver transplant
evaluation. Patient notes being in relatively good health until
a
few months ago when ___ noticed ___ was getting more swollen. ___
was diagnosed with cirrhosis but never followed up with a doctor
___ went to ___ 3 times, for ___
weeks at a time to receive care. ___ was told ___ does not have
hepatitis. Records are unavailable at this time. Per report, ___
received steroids for alcoholic hepatitis without improvement.
His MELD-NA scores have been >30. ___ also had ERCP with
sphincterotomy in attempt to improve bilirubin. Unfortunately,
his LFTs and status did not improve. ___ had been getting
diuresed
with now apparent ___. Radiology showed Combined partial right upper and lower lobe collapse.
RECOMMENDATION(S): Physical therapy for respiratory exercises.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:52 pm, 10 minutes after
discovery of the findings. Chest radiograph showed No acute cardiopulmonary abnormality. Improved aeration compared the prior
study with improving right basal atelectasis. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver, without evidence of focal lesion.
2. Patent main portal vein with normal hepatopetal flow.
3. Sequela of portal hypertension including splenomegaly and moderate ascites. CHEST (AP AND LAT) showed No pulmonary edema or focal consolidation to suggest pneumonia. Elevation of
the right hemidiaphragm, of indeterminate age, with subsegmental atelectasis
in the right middle lobe. RENAL U.S. showed 1. No hydronephrosis or evidence of renal atrophy..
2. The bladder is only minimally distended and can not be fully assessed on
the current study.
3. Large volume ascites. CT abdomen pelvis without contrast showed 1. Cirrhotic liver with sequela of portal hypertension including splenomegaly,
small varices and moderate to large volume ascites.
2. No gross infectious source in the abdomen or pelvis given confines of a
noncontrast examination. The patient was diagnosed with Unspecified jaundice. The patient was treated with Diagnostic paracentesis ___
Therapeutic/Diagnostic paracentesis ___. At the time of discharge, the patient had Alcoholic cirrhosis
Acute kidney injury
Macrocytic anemia
Thrombocytopenia
Hyponatremia
Type II Diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with alcoholic cirrhosis and DMII presented with
decompensated liver failure and MELDNa36, referred from ___
for evaluation of liver transplant.
ACUTE ISSUES:
==============
# Goals of care
# Liver transplantation need due to Alcoholic cirrhosis
Since patient refused blood transfusions, it is unlikely that
any surgeon would agree to perform a liver transplant. ___ was
discussed by our transplant committee, who felt ___ was not an
appropriate candidate to be transplanted here due to his refusal
to take blood products. ___ understands that ___ would likely die
without a transplant, but expresses the preference to go home.
___ was not interested in further management of his acute
decompensated hepatitis given there was limited further
intervention to change his overall course without transplant- ___
reports ___ would rather spend the remaining time ___ has left at
home.
# Alcoholic Cirrhosis
Patient presented in liver failure with MELDNa36 and Child Class
C. ___ had failed to improve with steroids and sphincterotomy for
alleged cholodocholithiasis at OSH. Sober x 2.5 months. Used to
drink ___ gallon of rum daily. Complicated situation as patient
is a Jehovah's Witness and refuses blood products. Workup
initiated included ___, AMA, SMA, hepatitis A IgM, hepatitis A
Ab, hepatitis B SAg, hepatitis B cAb, hepatitis B SAb, hepatitis
B viral load, hepatitis C Ab, hepatitis C viral load, IgG, IgA,
IgM, iron, ferritin, TIBC, CMV, EBV, HSV, HIV, A1c, utox,
ethanol. RUQUS showed cirrhosis. Diagnostic paracentesis showed
no SBP. Nutrition was consulted to teach patient about low
sodium, high protein diet. ___ was treated with lactulose and
rifaximin. Results of workup were largely negative for non-EtOH
etiologies and comorbidities.
___ 01:25AM BLOOD calTIBC-153* ___ Ferritn-1273*
TRF-118*
___ 01:25AM BLOOD %HbA1c-5.9 eAG-123
___ 01:25AM BLOOD TSH-4.2
___ 01:25AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HBc-NEG IgM HAV-NEG
___ 01:25AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 01:25AM BLOOD ___
___ 01:25AM BLOOD IgG-982 IgA-679* IgM-160
___ 01:25AM BLOOD HIV Ab-NEG
___ 01:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:25AM BLOOD HCV Ab-NEG
___ 01:25AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 10:19PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ Blood (EBV) ___ VIRUS VCA-IgG
AB-NEGATIVE; ___ VIRUS EBNA IgG AB-NEGATIVE;
___ VIRUS VCA-IgM AB-NEGATIVE
___ Blood (CMV AB) CMV IgG ANTIBODY-NEGATIVE;
CMV IgM ANTIBODY-NEGATIVE
The patient was informed that a liver transplant would require
blood transfusions. However, ___ stated that as a ___s
Witness, ___ refuses blood transfusions. ___ expresses
understanding that ___ would likely die without a liver
transplant. States that ___ wants to go home to live out the
remainder of his days.
# ___: Patient presented with creatinine elevated to 2.7. This
was suspected due to HRS, with a possible component of ATN as
well. ___ received albumin challenge 100g x3 days with some
improvement in creatinine to 2.1.
# Ascites
Underwent therapeutic paracentesis, draining 4.5L of ascitic
fluid on ___. No evidence of SBP on tap x2.
# Nutrition
Nutrition was consulted to educate patient on low salt diet;
however, nutrition team expressed concern that patient does not
want to follow low salt diet even though ___ has received such
education in the past. ___ was offered a tube placement for tube
feeds; however, ___ declined, preferring to go home and eat what
___ likes in his remaining time.
# Macrocytic Anemia: Likely ___ alcohol. Retic elevated 5.4, TSH
normal, B12 elevated.
# Thrombocytopenia: I/s/o cirrhosis, splenomegaly. Continued to
monitor.
# Hyponatremia: suspected to be related to ___.
Improved with albumin.
#DMII
Continued lantus, ISS
#CODE: Full with limited trial
#CONTACT:
Name of health care proxy: ___
Phone number: ___
TRANSITIONAL ISSUES
[ ] Furosemide and spironolactone held in the setting of
improving ___. Would revisit utility of these medications for
symptomatic relief moving forward in discussion with hospice
services.
[ ] Patient reports ___ has hospice services set up. ___ is being
discharged with visiting nurse as ___ bridge to hospice.
[ ] Patient is advised to go to regular appointments with his
primary care doctor (___) and gastroenterologist (Dr
___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of CAD s/p LCx stent ___, prostate CA managed w/
active surveillance, HLD p/w back/chest pain & weakness,
equivocal stress test being admitted for unwitnessed syncopal
episode. Radiology showed No acute cardiopulmonary process. Radiology showed No evidence of pulmonary embolism. The patient was diagnosed with CHEST PAIN NOS, OTHER MALAISE AND FATIGUE, SYNCOPE AND COLLAPSE. At the time of discharge, the patient had Primary: Vasovagal presyncope
Secondary: CAD, HLD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ hx of CAD s/p LCx stent ___, prostate CA managed w/
active surveillance, HLD p/w back/chest pain & weakness,
equivocal stress test being admitted for unwitnessed syncopal
episode.
#SYNCOPAL EPISODE: Patient did not lose consciousness.
Unwitnessed. No events on tele. Patient likely had vasovagal
event after exercising in stress test. No hx of urinary
incontinence or confusion to suggest seizure. No diuresis/bleed
to suggest orthostasis. Normal fingertsick glucose levels and
TSH 2.6. Patient was asymptomatic throughout hospital stay on
floor.
#CHEST PAIN: Patient originally came in for chest pain.
Equivocal stress test in ED. Ruled out for MI. EKG shows no
ischemic changes. Plavix was discontinued as it has been a year
since stensts placed. Pain actually around top of shoulder
blade and reproducible on palpation. Labetalol was added to
medical regimen given very high heart rate during stress test.
Patient was continued on aspirin and atorvastatin.
#HLD:
-continued atorvastatin </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ gentleman currently working in an ___ office as a ___, with a distant history of kidney
stones (20+ years ago) who presents today with acute onset of
right flank pain this am at approximately 730. He reports the
pain as right sided and was associated with multiple episodes of
emesis. He has been having some pain with urination but has not
noted any blood in his urine. CT ABDOMEN AND PELVIS showed 8 mm obstructing stone in the area of the right UVJ with associated moderate
hydroureter and moderate hydronephrosis. No other acute findings. The patient was diagnosed with Calculus of kidney. The patient was treated with ___: Cystoscopy, right ureteroscopy, laser lithotripsy,
biopsy of left bladder tumor and bilateral ureteric stent
placement (___). At the time of discharge, the patient had Right sided kidney stone
Left sided bladder tumor. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ was admitted to Dr ___ for nephrolithiasis
management with a known right ureteral stone and acute kidney
injury, he subsequently underwent cystoscopy, right
ureteroscopy, laser litrhotripsy of right UVJ stone, right
ureteric stent placement, biopsy of incidental bladder tumor at
left ureteric orifice, left ureteric stent palcement and left
retrograde pyelogram
He tolerated the procedure well and recovered in the PACU before
transfer to the general surgical floor. See the dictated
operative note for full details. Overnight, the patient was
hydrated with intravenous fluids and received appropriate
perioperative prophylactic antibiotics. On POD1, BMP was checked
and revealed creatinine down to 1.5.
Intravenous fluids and Flomax were given to help facilitate
passage of stones. At discharge on POD1, patients pain was
controlled with oral pain medications, tolerating regular diet,
ambulating without assistance, and voiding without difficulty.
Patient was explicitly advised to follow up as directed as the
indwelling ureteral stent must be removed and or exchanged and
he</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo F s/p spinal fusion for back pain on
___ p/w constipation and inability to tolerate POs. She
had posterior thoracolumbar fusion T3-S1 on ___, discharged
___, for scoliosis.
Pt reports that she has had no bowel movements since discharge.
She was discharged on bisacodyl and dulcolax. Since discharge,
under the direction of her doctors, she increased both
medications, added mag citrate, bisacodyl suppositories, and
miralax and still has not had a bowel movement. On ___ she
had worsening nausea and inability tolerate POs. Vomitted with
PO intake, non-bloody, non-bilious and severe nausea.
Post-surgical back pain then became uncontrolable due to
inability to tolerate PO pain meds and the stress from vomiting.
Denies urinary incontinence, weakness, or numbness.
Seen by ___ on AM of presentation and told to go to hospital.
Went to hospital in ___, where she was found to have good
rectal tone and no stool in the rectal vault.
Initial VS in the ED: 97.6 98 127/77 16 99% ra Exam notable for
vitals WNL, volume depleted, CTAB, RRR no m/r/g, well healing
surgical incisions on back, weak but palpable DP pulses bilat.
Nl strength and sensation in ___. Labs notable for neg UA
and UCG, unremarkable chem 7 and LFTs, Hct 28.3 and plts of 879.
Patient was given dilaudid and zofran in the ED. VS prior to
transfer:98.6 97 123/71 18 98%
On the floor, the patient is tachycardic, in severe pain and
recently nauseaus. She thought she needed to have a BM, but just
had gas. Has been passing gas the whole time. The patient denies
abd pain, fevers, chills. Denies pain aside from surgical
incision pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied abdominal pain. No dysuria.
Denied arthralgias or myalgias. Radiology showed No bowel obstruction or free air. Moderate colonic fecal
loading. The patient was diagnosed with DEHYDRATION, UNSPECIFIED CONSTIPATION. At the time of discharge, the patient had Primary diagnosis:
Constipation ___ narcotic use for pain control
Secondary diagnosis:
s/p thoracolumbar fusion ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is a ___ F s/p spinanl fusion ___ p/w
constipation and inability to tolerate POs who had bowel
movements after aggressive bowel regimen and then able to
tolerate oral diet.
# Constipation: Attributed to narcotic use for post-operative
pain control as well as iron supplementation for anemia. Patient
was given a soaps-suds enema as well as aggressive bowel regimen
with resultant bowel movement. Patient had 2 bowel movements
through the admission and was tolerating POs through day
___. In her discharge paper work she was instructed to
take a daily bowel regimen of senna, colace, and fiber
supplement daily. If she had not had a bowel movement in 2 days
then she was instructed to use magnesium citrate or bisacodyl,
and if still no bowel movement, then to try a Fleets enema. The
patient was instructed to seek medical attention if she did not
have a bowel movement in 4 days or if she had symptoms secondary
to constipation.
# Post-operative pain control: Patient's home pain medication
regimen of MS ___ and PRN dilaudid were discontinued on
admission. She was swithced to scheduled tramadol, increased
gabapentin dosing, and cyclobenzaprine TID: PRN. IV morphine was
available as needed for breakthrough pain. Upon discharge,
patient was instructed to continue MS ___ 15mg BID with
scheduled Ultram as well as increased gabapentin as an
outpatient as well as continuing Flexril PRN as an outpatient.
She was instructed to stop taking dialudid for breakthrough
pain.
# Nausea/vomiting: Prior to presentation and upon presentation,
patient was unable to tolerate orals which was attributed to
constipation. IV ativan was available as needed for nausea; IV
zofran was avoided as medication could also cause constipation.
Patient was able to tolerate oral diet upon discharge.
# Anemia: Patient attributes anemia to blood donation;
supplemented as an outpatient. Hematocrit remained stable
through hospital admission. Discharged patient with instructions
to decrease frequency of ferrous sulfate
# Thrombocytosis: Likely reactive. Trended through the
admission.
# s/p spinal surgery: Orthopaedic surgery evaluated the patient
in the ED. Per patient report, ortho stated that the incision
site looked good. Orthopaedic surgery followed the patient
through the hospital course with plan to keep outpatient
surgical follow-up as previously scheduled. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo. ___ female with unknown handedness and unknown
medical history hx AFib, DM,
dyslipidemia, HTN, dementia), transferred from nursing home
after
developing respiratory distress and fever. Pt returned to
nursing
home after a recent admit for stroke from ___ yesterday. It was unclear what her clinical status at
the time of discharge was, although the presence of a fresh PEG
suggests that she probably had a prolonged stay and failed
speech/swallow there. I called the nursing home, and spoke to
the
nurse who saw her today but she was not able to provide me with
any insight regarding her clinical status and level of
functioning before this. It appears that yesterday (___) in pm,
pt developed a fever to 100.6 F axillary. She was noted to be
nonverbal, have heavy oral secretions, and to be in respiratory
distress. RNs initially paged an NP on call, who prescribed a
scopolamine patch. However, her distress persisted despite the
patch and vigorous suctioning, and eventually decision was made
to transfer pt back to ___. ___. However, for unclear reasons,
EMS
brought pt here. In transit, pt developed hypoxia and required
NRM. She was quickly seen by respiratory therapy here, who noted
"an intermittent but strong cough" and ability to partially
clear
airway. They suctioned "a large amount of thick, yellow sputum
from upper oropharynx, after which pt resumed quiet breathing".
Neurology was then consulted emergently. Radiology showed Pulmonary vascular engorgement. Radiology showed 1. Large late acute or subacute infarct in the right middle cerebral artery
territory with lateral occipital involvement; the latter may be related to a
fetal PCA or other arterial variation. MRI could help date the infart.
2. No acute hemorrhage.
3. Chronic infarcts in bilateral frontal and medial right occipital lobes.
Findings discussed with ___ by ___ by telephone at 01:30 on
___ at the time of discovery of these findings. Evaluation of the patient with CVA, shortness of
breath.
Portable AP radiograph of the chest was reviewed in comparison to prior study
obtained the same day earlier.
Cardiomegaly, mediastinal contour and appearance of the lungs is unchanged.
Minimal pulmonary vascular engorgement is redemonstrated. No pleural effusion
or pneumothorax seen. was done. Radiology showed 1. New right PICC line terminates 7 cm below the carina, withdrawal of 3 cm
is recommended to ensure adequate positioning. No pneumothorax.
2. Right atrial lead terminates lower than expected, proximal to the
tricuspid valve.
These findings were discussed with ___ by ___ via
telephone on ___ at 12:45 ___, time of discovery and with ___, IV
team nurse via telephone on ___ at 1 ___. The patient was diagnosed with ALTERED MENTAL STATUS , URIN TRACT INFECTION NOS, PNEUMONIA,ORGANISM UNSPECIFIED. The patient was treated with Placement of a PICC Line. At the time of discharge, the patient had Urinary tract infections
Recent acute ischemic stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the ___ Neurology Wards for new onset
fever and breathing difficulties. She lives in an elderly home
and was to at first be transferred to ___ (from where
she had originally been discharged few days prior following the
discovery of a large new stroke). In the ED, she received some
gentle suctioning which relieved her tachypnea in the ED. Labs
showed a WBC of 9.5 and a urinary tract infection, and she
received one dose of treatment with ceftriaxone. She sustained
an allergic reaction to this medication, with stridor, facial
and tongue swelling. A repeat CXR was no different from the
admission CXR, and simply showed "pulmonary vascular
engorgement". Her presumed anaphylactic reaction was addressed
aggressively with the administration of nebulizer treatments and
one dose of methylprednisolone and diphenhydramine.
She was switched to bactrim DS for a few days, but then her
urine culture sensitivities identified the growth of Proteus
that was resistant to multiple agents including bactrim and
cephalosporins. Given her allergy and the sensitivity results,
we discussed with ID team and she was switched to AZTREONAM. A
repeat UA was checked while on this medication and showed little
by way of signs of UTI. The last dose of this medication should
be on ___. For the delivery of long term antibiotics, a
PICC line was placed. Of note, blood cultures drawn at the time
of ED visit grew out GPCs, and so she was initiated on
vancomycin. However, these returned as coagulase negative staph,
and so the patient's vancomycin was discontinued.
A NCHCT done in the ED showed no new hemorrhage, but a
combination of old strokes of various ages. While in the
hospital, she was maintained on the remainder of her
medications. We obtained further history from her son that she
had been previously on warfarin and aspirin, but this caused
difficulties with epistaxis and serious cutaneous bruising. She
had been actually off of aspirin prior to her most recent
stroke, and had recently been started. From the neurological
perspective, given her recent stroke, active atrial fibrillation
and previous history of bleeding, we decided on continuing an
antiplatelet agent. Her son, ___, was updated on the day of
discharge and he agreed with this plan.
While in house, she sustained no further allergic reactions. She
had one episode of AF RVR which improved with beta blockade. Her
HR on discharge was in the 90-110 range, and so she was started
on a low dose of metoprolol for rate control. Her blood sugars
remained on the higher side (200-270) while in house, likely
related to the administration of dextrose containing agents
(aztreonam), her current infection (UTI) and non-diabetic TF
administration. The latter was switched to Glucerna 1.0 one day
prior to discharge.
Transitional issues:
- Please have the patient follow up with Dr. ___ the
___ of Stroke Neurology. We defer the remainder of her
medical care to the physicians at her facility. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ CAD, dCHF (EF 55% in ___, Gold Stage IV COPD (3L home O2
with sats in low ___ at baseline), DMII presents with AMS.
Nursing notes from facility said she refused morning meds today
and wasn't herself this morning, becoming increasingly agitated.
Sent to ED for concern for recurrent UTI. Radiology showed Mild-to-moderate pulmonary edema. CT HEAD W/O CONTRAST showed No evidence of acute intracranial abnormality. Chronic deformity of the left
orbital floor with inferior displacement of the inferior rectus muscle. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. The
monitoring and support devices are constant. Low lung volumes. Moderate
cardiomegaly. Mild to moderate pulmonary edema. No larger pleural effusions.
Retrocardiac atelectasis. No new focal parenchymal opacities. The patient was diagnosed with ALTERED MENTAL STATUS , ACUTE RESPIRATORY FAILURE, URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN. The patient was treated with Endotracheal intubation (___). At the time of discharge, the patient had Primary:
Encephalopathy
Hypoxemic respiratory failure
Acute kidney injury
Secondary:
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Diastolic heart failure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with severe COPD, diastolic heart failure, obstructive sleep
apnea, obesity hypoventilation syndrome who was transferred to
the hospital from rehab facility for altered mental status,
found to be in respiratory acidosis and hypoxemia with profound
agitation requiring sedation and intubation. She was extubated
on ___ (HD#1) w/o complication. She refused to wear her CPAP
mask at night. Initial UA consistent with UTI, for which she was
started on empiric meropenem. ___ of 3.0 on admission rapidly
resolved to baseline of 1.3 on ___.
Active Issues
# Hypoxic respiratory failure
Multifactorial in nature. Has COPD, chronic diastolic CHF, and
OSA. Likely contributions from exacerbation of ___ w/ mild
pulmonary edema in setting of reduced torsemide dose upon last
discharge, as well as accumulation of opioid metabolites in
setting of reduced CrCl. Her pre-intubation gas reflected
acute-on-chronic respiratory acidosis, and her post-intubation
gas was much improved. Additionally, she was agitated and
non-complaint with home O2, worsening her hypoxia. She was
extubated ___ without complication. Post-extubation she was
intermittently confused but at her baseline per collateral
conversations. Per conversation with ___ staff, Mrs
___ is extremely ___ with oxygen at her facility, and
refuses to wear her CPAP at night. She was subsequently
transferred to the medicine ward where hypoxia continued to
improve and she was titrated to home O2 (2L NC). She did refuse
CPAP on the floor but had no recurrent hypoxia.
# Encephalopathy
Likely secondary hypercarbia with pre-intubation ABG reflecting
acute respiratoy acidosis. Other contributors include
accumulation of opioid metabolites in setting of acute kidney
injury which is all exacerbated by baseline dementia. Negative
CT Head in ED. Opioids were held during hospitalization and
mental status improved to baseline. She was ultimately
discharged on a reduced dose and frequency of opioids.
# Recent UTI
She has a history of MDR E.coli UTI treated with ertapenam,
course ended ___. Urinalysis on admission had 98 WBCs for
which she was started on empiric meropenem. However, UA
difficult to interpret in setting of recent UTI and UCx grew
yeast. Antibiotics were stopped on ___. Patient remained
asymptomatic, afebrile, and with no leukocytosis. PICC line from
previous admission removed ___.
# Acute Kidney Injury
Cr 3.3 on admission (baseline 1.0-1.2). Likely due to
exacerbation of diastolic CHF in setting of reduced torsemide
dose from last admission (from 80 to 40mg qday at last
admission). CXR on admission revealed mild increase in pulmonary
edema / pulmonary vascular markings. FeUrea consistent with
pre-renal etiology. ___ also be exacerbated by dehydration
secondary to decreased PO intake in the setting of AMS. Improved
with one time furosemide administation and careful IVF.
Lisinopril initially held and Cr downtrended. Cr 0.9 on ___.
Lisinopril restarted on ___. Toresmide restarted on ___.
# Acute on chronic diastolic heart failure
As described above, she has mild pulmonary edema concerning for
exacerbation of CHF. She was diuresed and restarted on home
torsemide.
# Right shin ulcer
She has a 7x8cm ulcer s/p skin graft earlier in ___. Patient is
on MS contin at nursing home due to pain from ulcer. During
hospitalization, pain was controlled on acetaminophen alone.
Narcotics held for reasons described above (concern for
accumulation in setting of decreased CrCl leading to AMS). Wound
care was consulted who recommended applying Soothe and Cool skin
conditioner to intact dry skin, covering wound with melgisorb ag
sheet followed by softsorb. Secure with Kling and change daily.
CHRONIC ISSUES
# COPD, OSA, obesity hypoventilation syndrome
Patient not on home CPAP and refused several offerings during
hospitalization. Patient was maintained on home
Fluticasone-Salmeterol, Tiatroprium, standing albuterol inhaler,
and albuterol neb PRN, ipratropium-albuterol PRN.
# Persistent Atrial Fibrillation
Patient with afib not on home anticoagulation, without clear
documentation why. Home metoprolol 25mg BID continued.
# History of bradycardia
Patient had intermittent episodes of bradycardia while
sleeping, likely due to OSA. She was not symptomatic.
TRANSITIONAL ISSUES
- Consider change in pain regimen. Buildup for morphine
metabolites may have contributed to presentation. Pain was
managed with acetaminophen during hospitalization, and therefore
would suggest pain control with non-opiate medications or
judicious use of opiate medication. She was discharged on lower
dose of oxycodone. MS ___ was discontinued.
- Patient with atrial fibrillation, but not on anticoagulation
for unclear reasons. Please address the need as an outpatient.
- Please have daily wound care for RLE ulcer.
- Please encourage CPAP at night and supplemental O2 use. Given
her severe COPD it is important that her SaO2 be maintained at
90-92%. She does not need to be higher than this.
- EMERGENCY CONTACT: From ___ records ___ Healthcare:
___, contact ___ (friend) ___,
___ (?Granddaughter, unclear relation) ___,
___ (brother) ___, ___ (?Sister
in law): ___
- CODE STATUS: FULL (Confirmed)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of cataracts, anxiety, who presents after a
fall and decreased vision in her left eye. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Minimally displaced fracture of the left lateral orbital wall. Please
refer to the dedicated facial bone CT for further details. Radiology showed 1. No acute fracture of the cervical spine. Multilevel degenerative disease
with disc space narrowing and small endplate osteophytes.
2. Left lateral orbital wall fracture as seen on same-day CT facial bones. CT ORBIT, SELLA AND IAC W/O CONTRAST showed 1. Minimally displaced fracture involving the left lateral orbital wall. No
retro-bulbar hematoma.
2. Subtle loss of the normal spherical shape of the left globe with
flattening along the lateral aspect. Small amounts of high density material
within the posterior chamber of the left globe is compatible with vitreous
hemorrhage. The patient was diagnosed with VISUAL DISTURBANCES NEC. The patient was treated with repair of globe laceration. At the time of discharge, the patient had globe laceration s/p repair. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ s/p mechanical fall with truama resulting in OS globe
rupture. She was admitted for observation following emergent
surgical repair.
# Globe Rupture:
She underwent emergent surgery with ophthalmology to repair
ruptured globe. She tolerated the surgery well. She was seen in
___ clinic the following morning and it was recommended that
she did not need further systemic antibiotics and she was
discharged on topical antibiotics, topical prednisolone, and
atropine drops to the L eye. She will see Dr ___ day
following discharge to be re-evaluated. Her pain was managed
with tylenol and tramadol prn.
# Anxiety/Hypertension:
She will continue to take her home propranolol on discharge.
# Constipation:
Senna/Colace</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o HTN, HLD, and IPH in ___ (no residual deficits),
presenting with one week of progressive exertional dyspnea and
two days of orthopnea and PND. She was feeling well until she
developed a cold about three weeks ago. Last weekend (1 week
PTA)
she first noticed new shortness of breath while walking which
she
initially attributed to her cold. However, her dyspnea worsened
on ___ (2 days PTA) and noticed new orthopnea and PND. No
edema or weight gain. She developed palpitations and noticed her
pulse was irregular and decided to seek evaluation. No chest
pain, diaphoresis, nausea, or syncope/presyncope. +Cough, no
fever or chills. CHEST (PA AND LAT) showed Moderate cardiomegaly and pulmonary vascular congestion. The patient was diagnosed with Unspecified atrial fibrillation. The patient was treated with cardioversion. The patient was given written instructions concerning 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 HTN, HLD, IPH in ___, presenting with new onset AF
and heart failure, started on pradaxa, diltiazem and underwent
TEE cardioversion ___, which was uncomplicated but did place
her in an atrial tachycardia rhythm with HR in the ___.
-CORONARIES: unknown
-PUMP: EF 67%
-RHYTHM: AFib
#Atrial Fibrillation s/p Cardioversion
Presented with rapid rates to 160s, hemodynamically stable but
symptomatic. No evidence of infection, ischemia, or PE. TSH WNL.
TTE with normal systolic function, mild MR, mild pulm HTN. She
was initially placed on a dilt gtt then transitioned to
diltiazem long acting with good rate control. Given her history
of IPH, Neurology consulted, her images from ___ from ___ were
obtained and reviewed, and they agreed with anticoagulation. She
was started on pradaxa for the possibility of using a reversal
agent if ever necessary. She underwent TEE CV ___, found to go
into atrial tachycardia with HR in low 90-100s. She should
continue her diltiazem 120 mg ER and pradaxa 150 mg BID until
follow up with Dr. ___
#HFpEF
Patient presented with PND, orthopnea, and elevated JVP and
proBNP 1625 consistent with new heart failure. Potential
etiologies include tachycardiomyopathy, alcohol (drank heavily
the weekend prior to symptoms developing), HTN (well controlled
but ran out of BP meds several days PTA). Likely also triggered
by onset of AFib
as above. TTE showed EF 67% with mild/mod MR. ___ was given IV
Lasix up to 40 mg, diuresed from 208.1 lbs to 204.6 lbs on
discharge.
-discharge weight 204.6 lbs.
#HISTORY OF INTRAPARENCHYMAL HEMORRHAGE
#HYPERTENSION
No residual deficits. BP well controlled per ___ notes on
current regimen. She ran out of antihypertensives several days
prior to admission. Her home BP meds were initially held and
resumed as tolerated. She remained normotensive during her
admission with some BP measurements in the 140s.
-resume home HCTZ and lisinopril</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ w/ COPD and asthma who presents with several
day history of fevers, nausea/vomiting, and myalgias. Patient
reports she began having nausea, vomiting, and diffuse myalgias
on ___ morning when she woke up. Symptoms became worse over
the past few days despite Tylenol. She had fever to 100.7 and
chills. She also reports headache, dizziness, and cloudy urine
over the same time period. She denies dysuria, urinary
frequency, diarrhea, constipation. She has no history or past
UTIs. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. Emphysema. Radiology showed 1. Bilateral pyelonephritis. No renal abscess.
2. Gallbladder not visualized. Normal appendix.
3. Colonic diverticulosis. The patient was diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic. At the time of discharge, the patient had PRIMARY DIAGNOSES:
=================
-Bilateral pyelonephritis, E. coli pansensitive
-Bacteremia, Gram negative rods, pansensitive
-Diabetes Mellitus Type 2
SECONDARY DIAGNOSES:
====================
-None. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ COPD and asthma who presents with several day history of
fevers, chills, nausea/vomiting/myalgias and was found to have
bilateral pyelonephritis on CT. Patient was placed on
ceftriazone empirically and urine cultures came back with E.
coli, sensitive to ceftriaxone and ciprofloxacin. One blood
culture on ___ revealed E coli, also sensitive to
ceftriaxone and ciprofloxacin, likely a translocation from her
pyelonephritis. Her symptoms continued to improve with
antibiotic therapy.
She was constipated but began having bowel movements with a
bowel regimen. She initially had an elevated glucose and was
found to be diabetic (a1c 6.5%). Patient's glucose trended down
as her infection was treated. On day of discharge, patient was
transitioned to PO ciprofloxacin to complete a 14 day antibiotic
course to cover both her pyelonephritis and bacteremia (presumed
first day of negative blood culture ___ while antibiotic
therapy). She will complete antibiotic therapy on ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old right-handed man with PMH of migraines
and traumatic head injury with concussion in ___ with
subsequent
progressive seizure disorder who presents with recurrent
seizures. Radiology showed Normal heart, lungs, hila, mediastinum and pleural surfaces. Radiology showed No seizure focus identified. The patient was diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY. The patient was treated with Nil. At the time of discharge, the patient had Post traumatic Epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ was admitted to the ___ neurology service under the
supervision of Dr. ___. We obtained further
history. He explained that he had two types of spells: one where
he is staring and difficult to "snap out of" for ___ minutes at
times, and the second is where he has a generalized convulsion.
He had been more of the latter events recently. His only risk
factor for epilepsy is the recent head trauma, and prior work up
at another neurologist's office had identified a normal MRI and
EEG (PER REPORT of patient). He also explained that he initially
started LEV 500mg BID, which was then uptitrated to 750mg BID.
He was admitted and we repeated an extended routine EEG and
obtained our own MRI with and without contrast under epilepsy
protocols, and neither identified any obvious foci of
epileptogenicity. His MRI did not identify any changes
concerning for significant prior head trauma, such as focal
encephalomalacia, prior contusions or extensive FLAIR changes.
We empirically increased his LEV to 1500mg BID in order to
obtain better seizure control. He refused his second dose of
1500mg LEV because he felt that he would be quite sleepy on this
higher dose. He claimed to have quite a bit of knowledge
regarding anticonvulsant medications given his job as a ___
___, but later he reported to us that he WAS in school
for that temporarily, but now currently lives at home as he is
trying to transfer from one ___ branch to another.
On his second hospital night, he did report an event where in
the middle of the night, he woke up and "didn't know what just
happened". He couldn't clarify further. He just felt weird.
We ultimately provided him a choice. He could either remain in
the hospital for another ___ hours of continuous EEG
monitoring to better clarify these events. OR, we could attempt
to add a third medication with the understanding that LEV could
eventually come off. He preferred this plan, and we agreed that
an ambulatory EEG would be sufficient. We started oxcarbazepine
at 150mg BID, and he agreed to continue his current dose of
levetiracetam and topiramate. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a lovely, ___- old female, who was diagnosed
by her primary care doctor, ___, together with
Dr. ___ of GI with a
mass in the head of the pancreas. Brushings were suspicious for
adenocarcinoma. She subsequently developed evidence of biliary
obstruction and had a stent placed. The risks and benefits of
operation were discussed with the patient who understood and
elected to proceed. Radiology showed 1. Mildly distended gallbladder, however no specific signs of acute
cholecystitis.
2. The pancreatic head mass is partially evaluated measuring up to 2.6 cm,
better evaluated on the recent CTA. Stable mild intrahepatic biliary ductal
dilatation with a new CBD stent. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, PANCREATIC DISEASE NOS. The patient was treated with ___:
1. Diagnostic laparoscopy.
2. Pancreaticoduodenectomy with antrectomy and standard
gastrojejunostomy.
3. Harvest of pedicled omental and falciform ligament flaps for
protection of anastomoses.
4. Placement of gold fiducials for possible CyberKnife therapy.. At the time of discharge, the patient had Pancreatic ductal adenocarcinoma. The patient was given written instructions concerning 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 newly diagnosed pancreatic head mass was
admitted to the Surgical Oncology Service on ___ for
elective Whipple procedure. On ___, the patient underwent
classic pancreaticoduodenectomy (Whipple) and open
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
NPO with an NG tube, on IV fluids, with a foley catheter and a
JP drain in place, and epidural catheter for pain control. The
patient was hemodynamically stable.
The ___ hospital course was uneventful and followed the
___ Clinical Pathway without deviation. Post-operative pain
was initially well controlled with epidural catheter, which was
converted to oral pain medication when tolerating clear liquids.
The NG tube was discontinued on POD# 2, and the foley catheter
discontinued at midnight of POD#4. The patient subsequently
voided without problem. The patient was started on sips of
clears on POD# 2, which was progressively advanced as tolerated
to a regular diet by POD# 6. JP amylase was sent in the evening
of POD#6; the JP was discontinued on POD#7 as the output and
amylase level were low.
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.
At the time of discharge on ___, the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old woman with a PMH significant for COPD and
asthma, as well as recent admission to ___ at the end of
___ for left-sided hydropneumothorax, who presents with ___
days of dyspnea and left sided chest pain.
She endorses ___ days of progressively worsening dyspnea and
left-sided chest pain, but no fever or cough. The dyspnea is
exertional in nature and similar to prior, but not as severe.
She presented to urgent care in ___, where she had a CXR
showing small left sided pleural effusion. She was sent here for
further evaluation.
During her last hospitalization, she had 400 cc of fluid
(non-malignant) drained, and a pig-tail catheter placed (which
has since been removed).
She presents requesting clearance for an air flight on ___. CHEST (PA AND LAT) showed Compared to chest radiographs ___ through ___.
Very small volume of air persists at the apex of the left hemi thorax due to
previous hydro pneumothorax. There is no appreciable layering pleural
effusion. Left hemidiaphragm is moderately elevated. Large volume of stomach
traversing a hiatus hernia, probably unchanged. Cardiac silhouette normal
size. Upper lungs clear. The patient was diagnosed with Pleural effusion, not elsewhere classified. At the time of discharge, the patient had Primary:
- Dyspnea NOS
- Chronic systolic heart failure (EF 40-50%)
Secondary:
- COPD (50 pack/year tobacco)
- Pulmonary nodules
- Iron deficiency anemia
- Left sided pleural effusion
- Hiatal hernia
- Obesity
- Hypothyroidism
- Hypertension
- Hyperlipidemia
- Carotid Stenosis
- 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 woman with a PMH significant for COPD and
asthma, as well as recent admission to ___ at the end of
___ for left-sided hydropneumothorax, who presents with
recurrence of left-sided pleural effusion.
ACTIVE ISSUES
# Left pleural hydropneumothroax: Patient with known left sided
pleural effusion. Previously admitted at the end of ___, where work up showed pleural fluid consistent with
nonspecific exudate; microbiology showed 1 colony of coagulase-
negative Staph, which is likely a contaminant. Cytology was
negative for malignancy. Underwent thoracentesis on ___ in ___
clinic with drainage of 600 cc of serous fluid, again negative
for malignancy. Presents with mild reaccumulation of pleural
effusion and small pneumothorax on this admission. Evaluated by
interventional pulmonology on this admission and they decided
that there was no need for further intervention at this time.
Patient safe to fly 2 weeks after thoracentesis, per last IP
note (___). Continued tiotropium and albuterol. Ambulatory
saturation was >95% during admission. Discharged on her home
tiotropium and albuterol.
# Heart failure with preserved ejection fraction: Patient
presented with chest pain and SOB over the last few days.
Unclear if it was associated with exertion or other triggers but
likely multifactorial but given reaccumulating pleural effusion
underwent cardic work up. Trponin was negative x2, and EKG
without ischemic changes. ECHO showed wall motion abnormality
and EF 40% but pharmacologic nuclear stress test with EF 56% and
normal wall motion. Cardiology was consulted and recommended
metoprolol succinate 25 XL daily and lisinopril 5mg daily both
of which were started during admission. Her home ASA 81 was
continued and she was discharged with plan for cardiology
referral as she was leaving for 1 month on vacation ___ with
children and ___). Given discrepancy between EFs on ECHO and
nuclear stress would recommend repeat ECHO after cardiology
follow up. Discharged with lasix prescription to be used as
instructed by MD if weight greater than 3 lbs and increasingly
SOB. Received 20mg IV lasix during admission.
CHRONIC ISSUES
# HYPOTHYROIDISM: Patient's TSH was elevated but Free T4 was
normal. Home levothyroxine, 125 mcg daily was continued.
Recommend repeat TSH and T4 in 6 weeks.
# ASTHMA: continued home albuterol inhaler PRN
# HYPERTENSION: stopped home triamterene/HCTZ, 37.5/25 mg,
replaced with metop and lisinopril as above.
# GERD: continued home pantoprazole, 40 mg daily
# HYPERLIPIDEMIA: continued home simvastatin, 20 mg every
evening
# CAROTID STENOSIS: home aspirin 325 reduced to 81</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of HTN, NIDDM2, hypothyroidism, s/p CCY ___ (Dr.
___ for gallstone pancreatitis who now presents with 3
days of abdominal pain, nausea and vomiting. The patient reports
that after ___ cholecystectomy three months ago, she continued
to have intermittent epigastric abdominal pain, lasts 45 mins,
resolves with belching. She lives in ___, and was
visiting ___ daughter and new grandchild in ___, then
planning to come to ___ to visit ___ elderly mother. At the
airport in ___ on ___ way to ___ on ___, she
developed worsening epigastric pain with associated fever,
nausea and vomiting; EMTs were called, she was evaluated and
allowed to travel to ___. ___ GI MD called in a lab
requisition to a local ___, and labs sent on
___ apparently resulted with elevated lipase (2539 per
notes) on ___. ___ GI in ___ advised ___ to present to a
local ED for further care. She also reports that she had a fever
of 102-103 on ___, and noticed a change in ___ urine color. She
denies any dysuria, hematemesis, black stools, BRBPR, chest
pain, or dyspnea. MRCP showed 1. Cholecystectomy. Mild dilatation of the central intrahepatic biliary
tree. Moderate to severe dilatation of the CBD with persistent narrowing of
the intersphincteric segment of the CBD throughout the study. This can be seen
in the context of stricture or sphincter of Oddi dysfunction. No evidence of
mass lesion in this location. No evidence of choledocholithiasis/retained
calculus. No findings of cholangitis.
2. Mild liver steatosis. No morphologic features of cirrhosis. The patient was diagnosed with Acute pancreatitis without necrosis or infection, unsp. The patient was treated with Endoscopic ultrasound ___. At the time of discharge, the patient had pancreatitis
biliary colic
abnormal LFTs
anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with hx of HTN, NIDDM2,
hypothyroidism, s/p CCY ___ (Dr. ___ for gallstone
pancreatitis who presented with 3 days of abdominal pain, nausea
and vomiting, found to have likely recurrent gallstone
pancreatitis. She underwent EUS ___ after MRCP showed moderate
to severe dilatation of the CBD with persistent narrowing of the
intersphincteric segment of the CBD. EUS was normal appearing,
did not show any stones or sludge. Differential included passed
biliary stone vs SOD Type 1 dysfunction, less likely biliary
stricture. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M with h/o HFpEF, asthma, pleural effusion s/p
thoracentesis c/b PTX s/p TPC, CAD s/p DES to RCA, HTN, HLD,
a-fib on Eliquis, nephrolithiasis s/p several lithotripsies
presents to ED with nausea and vomiting for 2 weeks. He
initially had non-bloody diarrhea but it has resolved. Was seen
in ED on ___ for similar complaints, also with hematuria,
diarrhea and abdominal pain. His symptoms at that time were
thought to be due to viral gastroenteritis and treated with IV
Zofran and was discharged from the ED once he was able to pass
PO challenge. Radiology showed Interval development of moderate left pleural effusion and left basilar patchy
opacity, likely atelectasis. Unchanged right pleural effusion with chronic
elevation of the right hemidiaphragm and similar patchy basilar opacity likely
reflective of chronic aspiration. Mild pulmonary vascular congestion. Radiology showed 1. Fat stranding surrounding the right renal pelvis and proximal right ureter
is nonspecific but could reflect an infectious, inflammatory, or infiltrative
process. No hydroureteronephrosis. Correlation with urinalysis is
recommended.
2. Chronic right loculated pleural effusion with smooth enhancing pleura and
complex fluid, which could represent empyema in the correct clinical setting,
as seen on the previous CT. New moderate left pleural effusion.
3. Ground-glass opacities with hyperdense material in the right lower lobe,
improved compared to ___, most likely representing chronic
aspiration.
4. 1.5 x 0.9 cm hypoattenuating lesion in the neck and uncinate process of the
pancreas, possibly side-branch IPMN, unchanged.
5. Cholelithiasis without cholecystitis. The patient was diagnosed with Nausea with vomiting, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o HFpEF, asthma, pleural effusions s/p thoracentesis
c/b PTX s/p TPC, CAD s/p DES to RCA, HTN, HLD, a-fib on eliquis,
nephrolithiasis s/p several lithotripsies, presents to ED with
nausea and dry heaving for 3 weeks.
ACTIVE ISSUES
=============
# Nausea: Etiology unclear, most likely psychosomatic ___
anxiety. Patient confirms feeling generalized anxiety, though
this seems chronic, thus unclear why there would be an acute
exacerbation in the last 3 weeks. Less likely gastroenteritis
(no leukocytosis as well as course unchanged over 3 weeks),
biliary colic (no post-prandial sx), gastroparesis (no DM),
nephrolithiasis (no urinary sx, flank pain, or hydronephrosis),
esophageal spasm/Zenker's (no dysphagia). CT A/P ___ did show
IPMN new since CT A/P ___, and IPMNs can present with
nonspecific sx such as nausea, vomiting, and abdominal pain
however, GI was consulted and felt it was too small to be
causing sx and denied need for MRCP. As Zofran seemed not to
help in the past, reglan was trialed with good effect. Blood and
urine cultures were pending on discharge. We got in touch with
the patient's PCP, who recommended EGD as an outpatient to
exonerate esophagitis/PUD as his last EGD was ___ year ago.
# Pleural effusions: Pt has known recurrent pleural effusions,
previously exudative ISO chronic aspiration. CXR ___ shows
interval development of left pleural effusion and unchanged
right effusion. Given that pt has no leukocytosis, fever or
worsening respiratory symptoms, IP consult was deferred to outpt
(he has f/u appts scheduled). Given possibility that worsening
of left effusion is transudative ISO known HFpEF, home Lasix
dose was increased from 20 mg QD to 20 mg BID. Patient should
follow up with his PCP regarding his respiratory status, and if
needed, PCP can coordinate an IP appointment.
# HFpEF: Patient denied any acute worsening of SOB, however had
interval increase in left pleural effusion and appeared mildly
volume overloaded on exam. Given that he was saturating well on
room air, no active diuresis was pursued. We did however
increase his home Lasix to 20 mg BID, as above.
# HTN: Patient was hypertensive to 160s-170s. He had recently
been started on amlodipine 5 mg daily by PCP. In-house, patient
was increased to 10 mg amlodipine daily and started on labetolol
100 mg BID: PRN. Discharge BP was still in the 160s, thus
consider adding additional agent as an outpatient.
# Fat stranding on R. renal pelvis and R. ureter: Seen
incidentally on abdomen/pelvis CT ___. Given that no
hydronephrosis was seen and the patient denied any dysuria,
suspicion low for large obstructive nephrolithiasis. Patient is
followed by ___ urology and should follow up with them at the
next appointment. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with a h/o HTN and SS anemia c/b iron overload and DCMP
(EF 50%, ___ who p/w exertional CP.
Pt previously seen by ___ with cath in ___
showing no CAD. Today he notes that he was rushing to his PCP
___ ("power walking") and developed dull CP, ___,
nonradiating, a/w dyspnea and sweating. This resolved after
___ min of rest with ECG at PCP showing ___ V4-V6. He was
given ASA 325mg and sent to the ED where ECG now shows upright
Tw V4-V6/resolution of ___. On further history, he notes having
a similar CP infrequently with heavy exertion for several years,
dating back prior to ___, without any change in frequency or
severity with no prolonged rest sx. He also notes NYHA FC II
dyspnea climbing stairs that is unchanged recently.
In the ED, initial vitals were: 98.0, 74, 115/84, 16, 99% RA
On exam, JVP is elevated to 12 with bibasilar rales with CXR
showing mild vascular congestion and pulmonary edema. ECG with
LVH and likely repolarization changes V4-V6. Labs were notable
for trop<0.01, BNP 454. Cardiology was consulted who felt that
the EKG showed LVH with likely repolarization changes in V4-V6.
Given the dynamic nature of his changes and ongoing stable chest
pain since ___, it was felt that this represents strain in the
setting of HF and possible microvascular dysfunction. It was
recommended to admit to the CHF service for gentle diuresis.
Vitals prior to transfer were: 98, 118, 173/82, 18, 98% RA
Upon arrival to the floor, patient feels comfortable and denies
any chest pain, palpitations, sob, n/v. CHEST (PA AND LAT) showed Cardiomegaly, mild pulmonary vascular congestion, and mild pulmonary edema. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, CHEST PAIN NOS, ABNORM ELECTROCARDIOGRAM. The patient was treated with Stress Test and ECHO ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS
SICKLE CELL ANEMIA
chronic dilated cardiomyopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with a h/o HTN and SS anemia c/b iron overload and DCMP
(EF 50%, ___ who p/w exertional CP. Patient of note had pain
while power waking, and has had off and on pain for years,
thought to be ___ dilated cardiomyopathy and possible heart
strain. He had two negative troponins, EKG indicative of stable
LVH, and a stress echo that showed: "average functional exercise
capacity. Equivocal ECG changes with possible 2D
echocardiographic evidence of inducible ishemia at achieved
workload (single vessel CAD). Normal hemodynamic response to
exercise. Mild mitral regurgitation at rest." He was treated
medically for optimization of his coronary artery disease.
BRIEF HOSPITAL COURSE BY ISSUES
=================================
CHEST PAIN: Patient presented with exertional chest pain,
resolved with rest and EKG notable for LVH and ___ in V4-V6 that
are likely repolarization changes. By time he arrived to floor
chest pain da resolved at rest and exertiob. Given the dynamic
nature of these changes and the ongoing stable CP since prior to
___, team felt this likely represented strain related changes
in the setting of HF and possible microvascular dysfunction
(given absence of epicardial CAD in ___. Last cath in ___
without CAD. His risk factors is HTN. Lipid panel checked in
___ was appropriate. Since chest pain has been off and non,
now EKG changes concderning for ischemia, negative trop, and
lack of fevers, low of hypovolemia on exam. ACS, acute chest
were considered less likely. He had ECHO stress that showed
possible echocardiographic evidence of inducible ishemia at
achieved workload (single vessel CAD). AS a result he was d/ced
with medical management of CAD with aspirin and atorvastatin.
TRANSITIONAL ISSUES
================================
-Patient d/ced with medical management of his CAD seen on ECHO
with 81 mg ASA, metoprolol 25 XL and atorvastatin 40 mg
-Pt instructed to d/c upcoming ECHO appointment as he had one
done in hospital </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ pmh ADHD p/w chest pain and elevated troponin. Earlier this
week, the patient had an episode of syncope with reported
shaking. It was followed by vomiting. Vomit green in color, no
blood. The next day he continued to vomit. Also developed viral
type symptoms: fever, chills, nonproductive cough, sore throat.
No futher episodes of syncope. Denies diarrhea, constipation.
Went to his PCP on ___, who did blood tests and STD
testing, and told him to come back in 1 month. Symptoms improved
on ___, and the patient was able to play basketball yesterday
without symptoms. This morning, he woke up with substernal chest
pain that is worse when lying back and deep breaths, improves
slightly with sitting forward. The pain was constant. Not
associated with SOB. It did not improve and he went to the
hospital. CHEST (PA AND LAT) showed 1. Heart size normal. No acute pulmonary process identified.
2. Note made of mild pectus excavatum and slight left convex curvature of the
thoracic spine. The patient was diagnosed with ACUTE PERICARDITIS NOS. At the time of discharge, the patient had Perimyocarditis. The patient was given written instructions concerning 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 w/ ADHD p/w chest pain and elevated troponin,
diagnosed with myopericarditis.
# Myopericarditis: Patient presented with substernal chest pain,
elevated troponin to 1.24 and CK-MB of 87, and EKG changes (ST
elevations in II, III, aVF, IV-VI). Endorses recent viral
illness. No risk factors for STEMI. No CXR findings. ECHO
negative for effusion or wall motion abnormalities. Diagnosed
with myopericarditis secondary to viral infection. Repeat
troponin 10 hours later was 1.08 and CK-MB was 83. No arrhythmia
identified on telemetry overnight. Denies illicit drug use with
the exception of frequent marijuana use, and serum toxicology
screen was negative. Treated with ibuprofen 600mg q8h and
colchicine 0.6 BID. He will continue these medications as an
outpatient for 2 weeks and 3 months respectively. Patient
cautioned not to resume strenuous exercise until advised by
cardiology in follow up.
# Elevated AST and Lipase: Pt has elevated AST>ALT, lipase.
Denies heavy drinking. Elevation may be secondary to
perimyocarditis rather than liver source. Would recommend
repeating LFTs in 3 months to ensure resolution.
=== TRANSITIONAL ISSUES ===
# Myopericarditis:
- Follow up with Dr. ___ in 3 weeks.
- PCP follow up within 10 days.
- 2 weeks of ibuprofen for symptomatic relief.
- 3 months of colchicine to reduce risk of disease recurrence.
- He is discharged with a Rx for 1 month of colchicine. He will
require refills to complete his 3 month course when he sees his
PCP
# ___ AST and lipase:
- Recommend repeating these labs in 3 months to ensure
resolution</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ woman with a PMH of DM II,
stage 3 CKD, atrial fibrillation on warfarin, diastolic HF,
gout, HTN, HL, HIT, and recurrent C.difficile colitis who is
admitted to ___ with SOB, hypoglycemia and altered mental
status. She was found to have pulmonary edema on chest X-ray. Radiology showed Progression of pulmonary edema and persistent left effusion. Superimposed
infection would be difficult to exclude. Radiology showed Significant improvement of pulmonary edema from ___.
Persistence of left lower lung opacification and pleural effusion makes
infection most likely, given this patient's history. Radiology showed AP chest compared to ___ through ___:
Pulmonary edema had improved substantially between ___ and ___,
but there is substantially worse consolidation in the right lower and left
upper lobes today than on ___. Whether this is recurrence of pulmonary
edema or concurrent pneumonia is radiographically indeterminate. At least
small bilateral pleural effusion is presumed. Moderate-to-severe cardiomegaly
is longstanding. Left PIC line ends in the upper SVC. Findings were
discussed by telephone with Dr. ___ at 12:45 p.m. The patient was diagnosed with HEART FAILURE NOS, OTHER PULMONARY INSUFF, HYPOXEMIA, PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Primary Diagnoses:
Influenza
Acute on chronic diastolic congestive heart failure
Secondary Diangoses:
Type 2 Diabetes ___
Recurrent C.difficile
Chronic kidney disease
Atrial fibrillation
Normocytic 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>___ woman with a PMH of DM II, stage 3 CKD, afib on
warfarin, gout, HTN, HL, HIT, and recurrent c.diff who was
admitted to ___ with SOB, hypoglycemia and altered mental
status. She was found to have pulmonary edema and influenza.
#Acute decompensated diastolic CHF. She had respiratory distress
upon arrival and was given positive pressure ventilation which
helped her significantly. Her BNP was extremely elevated
consistent with a heart failure exacerbation. She was diuresed
with increasing doses of lasix and her O2 requirement was
weaned. She required Lasix 200mg BID with metolazone to achieve
adequate diuresis. An echocardiogram was performed on ___ and
showed: Normal left ventricular cavity size with low normal
global systolic function, moderate pulmonary artery systolic
hypertension, right ventricular cavity enlargement with free
wall hypokinesis, mild mitral regurgitation and increased PCWP.
She was below her dry weight on discharge and was discharged on
a slightly higher dose of Torsemide. Discharge weight 150.4lbs.
#Influenza pneumonia- Influenza A returned positive on her
second hospital day. She was treated with a 5 day course of
Tamiflu.
# Acute renal failure on CKD: Admission Cr 2.2 (baseline of 2.4
but fluctuates). Her Creatinine peaked at 3.6 and improved with
diuresis. Creatnine 2.0 at discharge.
# RECURRENT C.DIFF: Recently on imipenem for a urinary tract
infection. Fever and elevated WBC count could be contributing.
Patient was started on an oral vancomycin taper as outlined
below:
vanco 125 Q8H for 7 days (changeover ___
vanco 125 Q12H for 7 days
vanco 125 Q24H for 7 days
vanco 125 Q48H for 4 doses
vanco 125 Q72H for 3 doses then stop</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o woman w/ afib on xarelto, SSS s/p PPM ___, GPA on
AZA, and M. Kansasii infection s/p tx, admitted to OSH with
increasing SOB and malaise, transferred to ___ with
pericardial effusion/tamponade. CHEST (PORTABLE AP) showed Small left basal pneumothorax.
Globular, enlarged heart consistent with pericardial effusion. Minimal
pericardial air consistent with recent pericardiocentesis. Radiology showed The left-sided pacemaker and wires are unchanged. Drain device over the left
heart border is unchanged. The loculated left basilar pneumothorax mentioned
previously has resolved. Heart size is enlarged and stable. There is minimal
pulmonary edema. CT CHEST W/CONTRAST showed 1. Interval improvement of pericardial effusion.
2. Interval increased pleural effusions, small left, moderate right, with
associated basal atelectasis.
3. Upper lobe predominant centrilobular emphysema.
4. Unchanged right middle lobe nodules. Radiology showed Left-sided pacemaker and pericardial drain are unchanged in position. There
is unchanged cardiomegaly. There has been development of a left retrocardiac
opacity. There are small bilateral pleural effusions. There is no overt
pulmonary edema. No pneumothoraces are seen. Radiology showed There has been placement of an endotracheal tube whose tip is 3.7 cm above the
carina, appropriately sited. The left-sided pacemaker and pericardial drain
are unchanged position. There is unchanged cardiomegaly. There are no
pneumothoraces. There is an unchanged left retrocardiac opacity and small
bilateral pleural effusions. No overt pulmonary edema is seen. CT HEAD W/O CONTRAST showed No acute intracranial process. CT with contrast or preferably MRI would be
more sensitive for assessment of an intracranial infectious process. Radiology showed There has been placement of a new right IJ central line with the distal lead
tip at the cavoatrial junction. Endotracheal tube, pericardial drain,
left-sided pacemaker are unchanged position. There is a nasogastric tube
whose tip and side port are below the GE junction. There is unchanged
cardiomegaly. There is a persistent left retrocardiac opacity and small
bilateral effusions. No pneumothoraces are seen. Radiology showed Evaluation of location of the endotracheal tube is difficult to assess due to
the overlying catheters. There is a new catheter projecting over the neck,
likely external to the patient, which limits evaluation. However the tip of
the endotracheal tube appears to be 4 cm above the carina. If there is high
concern, repeat imaging could be obtained with displacement of externa
catheters around the expected location the endotracheal tube. The pacemaker,
right IJ central line, and feeding tube appear unchanged position. Heart size
is upper limits of normal. There is a persistent left retrocardiac opacity
and left-sided pleural effusion. There are no pneumothoraces. CHEST (PORTABLE AP) showed As compared to ___ chest radiograph, the patient has apparently been
extubated and a nasogastric tube is been removed. Cardiomediastinal contours
are stable. Worsening pulmonary vascular congestion is accompanied by
enlarging right pleural effusion, now moderate in size. Moderate left pleural
effusion is a persistent finding, accompanied by a retrocardiac atelectasis. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little overall change.
Cardiomediastinal contours are stable. The degree of pulmonary edema may be
improved, though there again are bilateral pleural effusions with compressive
basilar atelectasis. Some of the apparent improvement in the bilateral of
opacification is may reflect a more upright position of the patient. The patient was diagnosed with CARDIAC TAMPONADE. The patient was treated with Pericardiocentesis (___). At the time of discharge, the patient had Primary diagnoses:
-Cardiac tamponade
-Toxic metabolic encephalopathy
Secondary diagnoses:
-Hyponatremia
-Anemia
-Lung nodule
-Atrial fibrillation
-Granulomatous polyangitis
-Sick sinus syndrome s/p pacemaker placement
-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>___ y/o woman w/ afib on xarelto, bradyarrhythmia s/p PPM
___, GPA s/p tx, admitted with tamponade s/p drainage in ED.
#)Cardiac Tamponade: Patient admitted with pericardial effusion
and tamponade physiology. She responded well to emergent
pericardiocentesis in ED. A drain was placed with bloody output
(Hct 12). Cultures and cytology were negative. Etiology of
tamponade was unclear given patient's complex medical history
but ultimately thought to be secondary to viral infection.
Drain was pulled two days after admission and follow up TTEs
showed trace pericardial effusion. Patient continued to have
pleuritic chest pain and colchicine 0.6 mg daily was started, to
be continued for 6 monthes.
#) Altered Mental Status: The day following admission, patient
had hallucinations and was extremely agitated. She recently had
VZV infection so HSV encephalitis considered as possible cause
for acute onset mental status change. Patient given haldol PRN
as needed for agitation but was still combative and psychotic.
Patient needed to be sedated and intubated in order to obtain
LP. CT scan w/o acute changes of signs of ICP. LP was
ultimately unremarkable. The patient was extubated the following
day. Over the next two days, she returned to baseline mental
status.
#)Afib: Patient with history of pAfib on rivaroxaban, also with
rhythm and fate
control on Fleicanide and metoprolol. She was continued on
flecainide, rivoroxaban initially held in setting of
coagulopathy, metoprolol initially held due to tamponade and
hypotension. Patient was monitored on telemetry and was in
atrial fibrillation during this admission (NSR prior to
admission). Cardioversion planned for week after discharge.
Rivoroxaban restarted when stabilized and transferred out of
CCU.
#)Coagulopathy: Patient came in with elevated INR/coagulapathy
of unknown etiology. She was not on warfarin and did not appear
to have clinical signs of hepatic dysfunction. Rivaroxaban was
held initially due to ongoing bloody pericardial fluid output.
#)SSS s/p pacemaker placement: PPM placed 4 months PTA for SSS.
Pacer was interrogated and appeared to be functioning properly.
#)Lung nodule: Pt had incidental finding of new LLL nodule on
OSH CT abd/pelv. She does not have any recent weight loss but
does have risk factors such as smoking and chronic inflammation
of her lungs ___ infection and GPA. CT at ___ showed nodule
consistent with granulomatous process.
#)Hyponatremia: Patient with hyponatremia on admission, which is
new compared to prior data in system from ___. Urine sodium
and osmolarity not consistent with SIADH. Ultimately, her
hyponatremia was thought likely due to poor nutrition.
Electrolytes were followed with hyponatremia improving during
admission.
#)Anemia: Low Hgb of 8.9 appeared new compared to recent H&H on
___. CBCs trended with stable Hgb. Hemolysis panel was
unremarkable. TIBC normal, ferritin elevated c/w anemia of
chronic disease.
#)GPA: Patient with GPA, well managed on AZA. Recent labs did
not show elevated inflammatory markers. GPA was not an active
issue during admission.
#)HTN: In the setting of tamponade, antihypertensives initially
held. Patient restarted on home metoprolol and HCTZ with good
control of BP.
TRANSITIONAL ISSUES
-proteinuria- patient with urine protein:Ct of 0.3. This will
need to be followed up by her PCP.
-patient started on colchicine 0.6 daily for pericarditis which
will need to be continued for 6 months
-patient with agitation and hallucinations while in CCU with CT
showing frontal lobe atrophy. She will need neurocognitive
testing as an outpatient. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with a h/o Crohn's disease who present with
2.5 weeks of right sided abdominal pain and diarrhea, consistent
with his past Crohn's flares. Patient said current flare
started shortly before the ___ - had intermittent
stabbing right sided abdominal pain and 5BMs/day which were
non-bloody and mucousy. He was seen in ___ on ___
where a CT showed ilial inflammation with a phlegmanous
collection surrounding it. They sent him home with 4 days of PO
prednisone of unknown dose. He made an appt. with a new
gastroenterologist who he saw on the ___. Dr. ___ him on
60mg PO prednisone daily as well as PO flagyl. The patient did
not fill the flagyl prescription becuase he was going to a party
that weekend and wanted to be able to drink alcohol. In
contrast he has been compliant with the PO prednisone, without
relief of symptoms. Over the weekend his symptoms changed to
become a midline squeezing feelig in addition to the stabbing
right sided pain. He started the PO flagyl the day PTA, without
relief of symptoms, and came to the ___ due to worsening of his
pain and encouragement by the nurses at his gastroenterologist's
office. Radiology showed Findings suggesting acute on chronic Crohn's disease including
findings suggesting mild inflammatory activity at two narrowed sites of distal
ileum with suspected mild functional obstruction and complex ileocolic
fistula. No evidence of abscess or perforation.
Correlation with outside imaging is recommended. MR can be more sensitive for
acute inflammation of the bowel if needed clinically.
Dr. ___ the final report with Dr. ___ at 2:15 pm on ___ by telephone. The patient was diagnosed with REGIONAL ENTERITIS NOS. At the time of discharge, the patient had Crohn's Flare. The patient was given written instructions concerning 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 Crohn's disease, here with Crohn's flare
refractory to 2 weeks of PO prednisone. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with a history of squamous cell carcinoma of the
tongue base who is admitted with throat pain. The patient states
that she has had severe pain but inside and outside of her
throat
and mouth throughout radiation but it has been getting worse
recently. She also had an issue with getting her oxycontin over
the weekend. She has also had thrush and has been taking
nystatin
but it has persisted. She states she had been able to maintain
some nutrition with boost supplements and hydration but has not
had anything in the last day. She also reports intermittent
nausea. She is constipation and has not had a bowel movement in
5
days. She denies any shortness of breath, abdominal pain,
diarrhea, or dysuria. Of note she received her last radiation
treatment today and last received cisplatin on ___. Chest: Frontal and lateral views showed Left lower lung pneumonia. Recommend follow-up radiograph after completion of
treatment.
RECOMMENDATION(S): Follow-up radiograph after completion of treatment.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ On the telephoneon ___ at 4:43 ___, 10 minutes after
discovery of the findings. CHEST (PA AND LAT) showed Slight improvement an heterogeneous left perihilar and basilar opacities,
likely due to an acute infectious process. The patient was diagnosed with Other esophagitis. At the time of discharge, the patient had Pneumonia
Esophagitis/mucositis
Thrush
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>___ yo female with a history of squamous cell carcinoma of the
tongue base who is admitted with odynophagia, PO intolerance due
to mucositis/radiation esophagitis, course complicated by
progressive anemia and development of pneumonia.
#Mucositis/Radiation esophagitis: Decreased PO intake due to
odynophagia. improving, taking pills better, but still liquids
and soft solids. Contd supportive care w/ MM, topical lidocaine
added Carafate QID. Prn Zofran/Compazine for nausea. Contd
adaptic dressing daily for external neck radiation burns +
aquaphor. IVF DCd and pt was tolerating PO somewhat better at
the time of discharge.
#Pneumonia - ___ noted she had worsening cough, CXR consistent
with pneumonia and pt had fever, LL infiltrate. possible
aspiration of oral secretion in setting of
odynophagia/esophagitis. resp status stable on RA. started
ceftriaxone ___. narrowed to PO levoflox ___ but pt reported
no significant improvement so broadened to cefepime (no longer
febrile but developed neutropenia). was given 1x neupogen w/
improvement in WBC count. She was narrowed to CTX while in house
but due to copays insurance it was cheaper to finish course of
cefepime at home, she will complete course through ___. Sputum
grew sparse MSSA pan sensitive, and it was felt cefepime/CTX had
good enough MSSA coverage but also important to cover gram
negatives commonly seen w/ HCAP in her case, and MSSA growth
only sparse.
#Anemia - stable. no overt clinical symptoms, gradually
declining ___ chemorads/inflammatory block, nothing to suggest
bleeding though drop is quite significant over the past month.
Received 1u on ___ with appropriate
bump. INR was 1.2 on ___. No melena/hematochezia, ferritin
elevated c/w inflammatory block.
# Thrombocytopenia - stable. also like ly ___ marrow suppression
from cchemo/rads, trend mirrors that of anemia. Low suspicion
for HIT as drop a bit rapid for such, and not convincingly
consistently <50% of baseline. No e/o bleeding. Plts improving
by DC.
# Hypokalemia - repleted, stable. No diarrhea/vomiting, likely
due to poor po intake
#Candidiasis - thrush and possible ___ esophagitis given
odynophagia. Cont empiric fluc and hold statin to avoid
interaction. QTC trended and remained WNL. Extended fluc course
to go through the end of antibiotic course (through ___ given
pt reported yeast infections every time on antibiotics in the
past.
#Acute on chronic pain - ___ fibromyalgia/RA exacerbated due to
above issues. Continued home lyrica, escitalopram, oxycontin
(reduced to 20 q8) and PRN oxycodone.
# Depression/decreased appetite - likely ___ situational illness
and diagnoses, SW following. Started low dose mirtazapine pt
reports she has card for medical marijuana she uses at home.
#Squamous Cell Carcinoma of Tongue Base: Recently completed
radiation and chemotherapy with cisplatin. F/u w/ RT and
oncology as ___. The node in her right neck remains firm, her
___ oncologist was notified. In the future salvage surgical
removal could be considered.
#DM: Held home metformin. Due to decreased PO intake pt may no
longer need for now, but should resume when po intake improves.
#HTN/HLD: BP elevated SBP up to 180. Increased home lisinopril
from 10mg to 20mg daily. held aspirin for now given
thrombocytopenia, pt will f/u with pcp and ___ providers about
restart pending PLT trend
#Insomnia/Anxiety - contd home nortriptyline, held temazepam </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS:
___ is a ___ man with a history of Atrial
Fibrillation, Depression, COPD and squamous cell carcinoma of
the scalp who was discharged from plastic surgery service on
___ where he was admitted for a rotational flap surgery. He now
presents in referral from ___, transferred from ___
for cough and fever.
He reports that he was discharged on ___ to home with home ___
for wound care and generally has been feeling well until
yesterday. Yesterday he reports, "over doing it", pushed himself
to far and walked 4 miles. Therafter he started feeling unwell
with weakness, generalized malaise and started having chills.
His ___ evaluated him today for routine wound care changes and
found him febrile to 101. She called ___ office who referred him
to ___ who then transferred him to ___ given recent
plastic surgery.
In the ___, Initial VS: 5 97.1 48 97/44 20 98% RA. Exam was
notable for a Left frontal rotational flap which is
well-perfused, R basilar crackles and left radial flap
well-healing. Plastic surgery was consulted who indicated wounds
appear well and not infected. CXR showed atelectasis without
pneumonia. Labs with leukocytosis. He was diagnosed with RLL
pneumonia and started on Vanc and cefepime and admitted to
medicine.
On the floor, he appears well though seems slightly weak and
tired. He is using oxygen but is breathing comfortably,
non-labored breaths, talking full sentences. He does report a
cough for the last ___ days productive of brownish colored
sputum with significant volume when he does produce. He reports
shortness of breath with exertion new the last 2 days but denies
chest pain.
Of note, during last admission he had several episodes of
bradycardia and hypotension, discharged without Verapamil or
Lisinopril.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Otherwise ROS is negative. Radiology showed The tip of the new right PICC line projects over the mid SVC. No
pneumothorax.
Interval increase in diffuse interstitial prominence. This may be reflective
of increasing pulmonary edema or an infectious process. CHEST (PORTABLE AP) showed Mild pulmonary edema has improved. There is no pneumothorax or pleural
effusion. Cardiac size is top-normal. Right PICC tip is in the lower SVC.
Sternal wires are CHEST (PA AND LAT) showed Comparison to ___. No relevant change. Both leads of the
dual-chamber pacemaker are in correct position. The alignment of the sternal
wires is stable and correct. No change in appearance of the cardiac
silhouette. No pneumothorax, no pulmonary edema. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, there is an placement of a dual
channel pacer via right subclavian approach with leads extending to the right
atrium and apex of the right ventricle. No evidence of post procedure
pneumothorax.
Little change in the appearance of the heart and lungs. The patient was diagnosed with Pneumonia, unspecified organism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with a history of AF, depression, COPD, SCC scalp s/p
recent flap, presents with HAP.
# Sepsis: resolving
# Hospital acquired pneumonia
# hypoxemic respiratory failure:
Pulmonary infiltrate and findings, started on vancomycin
(___), cefepime (___), azithromycin
(___), narrowed to levofloxacin on ___. Received IVF for
sepsis. Microbiology of sputum was invalid due to extensive
contamination with upper respiratory secretions however finished
5 day course of levofloxacin (ends ___
# RUE infiltration: with fluid resuscitation, patient had
infiltration of RUE. Mildly symptomatic, resolved with
elevation. Had PICC placed given inability to use LUE, pulled
prior to discharge.
# Squamous cell carcinoma s/p resection and rotator flap
surgery. Evaluated by plastics who found no issues. Per their
recommendation, left scalp flap open to air, and daily
xeroform/4x4 gauze/kerlex/ACE wrap to L forearm graft, splint
for left forearm. He was continued on home ASA 121.5mg x4
weeks(ends around ___.
# LUE flap: unfortunately patient had a blood draw on RUE, which
is contraindicated post operatively. An incident report was
filed and apologies were expressed to patient and wife.
# AF: resumed anticoagulation as outpatient just prior to
admission with ok from plastics. His verapamil was fractionated,
and when one dose was held once for hypotension he had a brief
asymptomatic episode of RVR. He was noted to be symptomatic from
the fibrillation, so consideration can be made for a rhythm
control strategy.
# r/o SSS: had episodes during last admission that were
questionable for sick sinus syndrome, and during this admission
was noted to have symptomatic 4s pauses, for which he was
transferred to EP and received a pacemaker on ___.
# episode of chest pressure: morning of ___ had 15 minutes of
non-exertional chest pressure. Ruled out for MI, was able to
exert himself thereafter without any symptoms. Patient noted
that he had DOE recently. Received gentle diuresis with
improvement using furosemide 20mg IV x1. Can consider stress
test as outpatient.
# Aortic Stenosis: s/p tissue valve
# TIA v CVA: residual mild L weakness/numbness
- cont ASA, atorvastatin as above
- BP control as below
# HTN: held home chlorthalidone given sepsis, but continued home
lisinopril and verapamil. Had asymptomatic BPs in ___ on HD 1,
so lisinopril was stopped and he received IVF as above with
resolution. He is discharged on lisinopril and verapamil.
Chlorthalidone was held on discharge due to rise in creatinine
# Chronic Obstructive Pulmonary Disease: continued home meds
(with Advair in place of non-formulary ___.
# Depression: continued home venlafaxine, mirtazapine.
Add on creatinine was elevated at 1.7 (from 1.2 the day before.)
Results were reviewed with wife over the phone who is a ___.
Told to make sure ___ gets INR, sodium and repeat creatinine
tomorrow and to send results to PCP</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ otherwise healthy who was jogging when he was struck by a
car and sustained a left open tibia fracture. He did not see the
car coming, was thrown onto the windshield and then off of the
car. He was HD stable at the scene and was brought by ambulance
to the ___ ED where he remained HD stable. He was complaining
of pain only in his head, neck, and left leg. Hevdenied loss of
consciousness. No headache, no blurry vision. No numbness or
paresthesias in the extremities. Radiology showed Lung volumes are low, accentuating the cardiac silhouette and bronchovascular
structures. Multifocal linear opacities in the mid and lower lungs are
suggestive of atelectasis. A patchy opacity in the left retrocardiac region
has slightly improved since recent thoracic spine radiograph of earlier the
same date and may reflect atelectasis or spinal aspiration. Possible small
pleural effusions are evident on the lateral view. L-SPINE (AP AND LAT) showed Stable alignment. Radiology showed No acute cardiopulmonary abnormality. No acute fracture or dislocation within
the pelvis. CT HEAD W/O CONTRAST showed No acute intracranial process. No fracture. Radiology showed No evidence of acute fracture or traumatic malalignment
Tiny radioopaque densities adjacent to a right facial laceration may represent
foreign bodies. TIB/FIB (AP AND LAT) LEFT IN O.R. was done. DX THORACIC AND LUMBAR SPINES showed 1. Compression fracture of L2 with mild retropulsion.
2. Posterior loss of vertebral height at L5 that is not typical of trauma, for
which cross-sectional imaging is recommended. This more likely represents a
chronic appearance, possibly related to background spondylolysis.
Spondylolysis is not definitively visualized on the current radiographs
however.
3. Incompletely evaluated left lower lobe infiltrate, recommend chest x-ray.
NOTIFICATION: These findings were discussed by Dr. ___ over the
telephone with Dr. ___ at 16:15, 15 minutes after the findings were
made. The patient was diagnosed with OPEN WOUND OF SCALP, OPEN WOUND OF CHEEK, MV COLL W PEDEST-PEDEST, TETANUS-DIPHT. TD DT. The patient was treated with Left tibia irrigation and debridement, open reduction, internal
fixation left tibia. At the time of discharge, the patient had Left open tibia/fibula fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open left tibia/fibular fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for irrigation and debridement and
fixation of the left tibia with an intramedullary nail, 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.
On the morning of POD#1, the patient was complaining of back
pain. He reported that he has chronic back pain, but the back
pain appeared to be worse since the accident. At that time,
L-spine plain films were ordered and showed a L2 compression
fracture. The orthopaedic spine team was consulted and
recommended a TLSO brace to be worn at all times while out of
bed. The patient will follow-up in the ___ in 2 weeks.
The patient worked with ___ who determined that discharge with
home ___ was appropriate.
The patient was also seen by the neurology team as an inpatient
for concerns of post-concussive syndrome. It was unclear whether
the patient had a concussion following his accident, but he was
experiencing an intermittent headache, nausea, and confusion at
times. These symptoms were thought to likely be secondary to his
recent trauma, surgery, and use of heavy pain medications and
less likely due to a concussion. The symptoms were monitored and
improved over the hospitalization. He will follow-up with the
neurology team as needed as an outpatient. 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 weight bearing as tolerated 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: Ms. ___ is a ___ s/p OLT in ___ for HCV Cirrhosis now
complicated by recurrent HCV infection s/p TIPS in ___ for
refractory ascites who presents for concern of abnormal labs
(low HCT and elevated Cr) in setting of recent spinal surgery on
___. She was discharged on ___ after L4-S1 laminectomy,
L4-5 fusion which she tolerated well. Her hospital course was
uncomplicated. She was seen by the liver consult team in
regards to her LFTs and Tacro level all of which were near
baseline.
She has been following up with PCP who is monitoring her Hgb w/
latest one being 8.9 ___s elevated Cr 1.6. Pt was notified
of her low Hgb and told she may need a transfusion so she
presented to the ED. At home she has noted poor PO intake she
thinks is secondary to her back pain. When her pain is under
control she is able to eat. Otherwise she has minimal appetite
and reports significant fatigue. She denies any fevers/chills.
She has had no abdominal pain/N/V. Her back pain is responsive
to Oxycodone/Oxycontin. She has had a ___ who last changed the
dressing on her back.
In the ED initial vitals were: 98.9 77 140/93 20 100%. Labs were
significant for Cr 1.6. Patient was going to get IV fluid
challenge but lost access and took in POs. Patient reports
getting no IVF in the ED despite signout that she received 1L. US ABD LIMIT, SINGLE ORGAN showed No ascites identified. Splenomegaly incidentally noted. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had Primary: Acute Kidney Injury
Anemia
Secondary: S/p OLT for HCV Cirrhosis
HCV. The patient was given written instructions concerning 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 ___ s/p OLT in ___ for HCV Cirrhosis now
complicated by recurrent HCV infection s/p TIPS in ___ for
refractory ascites who presents for concern of abnormal labs
(low HCT and elevated Cr) in setting of recent spinal surgery on
___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with a history of gastric
volvulus s/p repair in ___ complicated by gastroparesis and
G-J tube placement in ___ who presents with acute on chronic
abdominal pain. She reports constant chronic pain in her
mid-abdomen which worsened last ___ when she presented
to the ER and was found to have her G-J tube displaced,
scheduled to be replaced on ___. Over the weekend she was
apparently instructed to have one can of tube feed and jello
only. She reports minimal PO intake of popsicles and ice chips
over this period secondary to abdominal pain. On ___ she had
her GJ tube successfully replaced and its position was verified
then and today. However her abdominal pain has failed to
improve, and she complains of discharge from her GJ tube
insertion site when infusing tube feeds, so she presented today
to the ___ ED for evaluation. Radiology showed Appropriate location of GJ tube within jejunum, with balloon
appearing to not be embedded within the abdominal wall. No evidence of leak. Radiology showed 1. No acute intra-abdominal process.
2. Properly positioned GJ tube which is in concordance with the findings from
the previous fluoroscopic study.
3. Small hiatal hernia containing debris. The patient was diagnosed with URIN TRACT INFECTION NOS, DEHYDRATION, GASTROPARESIS, TOX DIF GOITER NO CRISIS. At the time of discharge, the patient had Primary: abdominal pain, urinary tract infection, hypernatremia
Secondary: gastroesophageal reflux disease, Grave's disease,
neurogenic bladder, gastroparesis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#) ABDOMINAL PAIN: Appears to be acute on chronic. Likely
multifactorial. Differential includes discomfort related to her
GJ tube placement, her periumbilical hernia, vs. some infectious
process. Does not appear to be an overlying cellulitis given
lack of erythema, but patient is tender at the GJ tube site.
Given history of diarrhea x 2, could also be gastroenteritis.
However, patient chronically complains of this type of pain
since her GJ tube placement in ___, which has especially
worsened and persisted since her tube was found to be dislodged
last ___ and was re-placed this ___ PTA. Pain is also
apparently unrelated to tube feed rate, but becomes acutely
worse upon movement. PUD confirmed on recent EGD likely
contributing to her abdominal pain. CT abdomen negative for
acute intraabdominal process and verified correct placement of
GJ tube. Amylase and lipase negative. C. diff negative. Stool
cultures ordered but patient did not have a stool before
leaving.
Patient urgently requests to go home on Day 4 of admission.
Despite encouragement to stay and explanation of the risks of
discharge, pt adamant that she needs to go home for professional
reasons. ___ with pt's PCP ___ for tomorrow AM
and pt given prescriptions for new tube feeds and bactrim.
#) ENTEROBACVTER URINARY TRACT INFECTION: Urine culture positive
for enterobacter sensitive to bactrim. Less concerned for
pyelonephritis given lack of fever, leukocytosis. DC'd vanco on
___
- Gave 7d bactrim course.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ G0 presents with LLQ pain. She reports that her pain
started 2 nights ago. This pain has never happened to her
before. The pain started as sharp pain and was acute in onset.
She cannot recall if she was doing any particular activity. She
then presented to ___ where CT abd/pel demonstrated a rim
enhancing left ovarian cyst with internal septations measuring
5.7 x 3.6 cm. Her pain then subsequently improved and became
dull in quality. She states that her pain nearly disappeared.
Today, her pain returned and was ___ at its worst. She
therefore presented to ___ for evaluation. PELVIS U.S., TRANSVAGINAL showed 1. Enlarged left ovary with 3.7 and 2.2 cm septated left ovarian cysts.
While arterial and venous waveforms were demonstrated, ovarian torsion cannot
be excluded. Recommend GYN consultation. If no acute intervention, suggest
close GYN consultation with possible followup MRI.
2. No right ovarian torsion.
3. 0.6 cm small uterine fibroid. Otherwise normal uterus.
4. Trace trace amount of physiologic free fluid. The patient was diagnosed with Other ovarian cysts. The patient was treated with N/A. At the time of discharge, the patient had epigastric pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo woman who presented with LLQ pain most
suggestive of left ovarian cyst rupture. However, given the
patient's history of intermittent pain and enlarged left ovary
on pelvic ultrasound concerning for intermittent ovarian
torsion, she was admitted for observation with plan for
diagnostic laparoscopy if pain returned.
Upon admission she was made NPO and started on IVF. Her serial
exams were repeatedly negative and her pain did not return
overnight. She was subseqeuntly started on a regular diet the
following morning. Shortly after she developed epigastric pain,
which resolved upon starting pepcid and tums with instruction to
continue use on discharge.
*) Papulomacular rash: Patient devevloped a rash shortly after
her presentation to the ___, likely due to IV morphine. She was
treated with benadryl and hydrocortisone cream for symptomatic
releif. Her rash remained stable on day on discharge with
instruction to continue use of benadryl and hydrocortisone cream
and to avoid morphine in the future.
By hospital day #2, patient's pain had resolved, she was
voiding, ambulating and tolerating a regular diet. She was
discharged home in a stable condition with instruction to
follow-up in the gynecology clinic. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old lady with complex past medical history of breast/
uterine/ ovarian cancer (+BRCA 1) s/p chemoradiation ___,
bilateral salpingo-oophorectomy and a hysterectomy in ___ with
history of radiation colitis, multiple psychiatric diagnoses
including PTSD, ADHD, delusional disorder, depression,
borderline
personality disorder, and dissociative identity disorder who
presents to the emergency department as a transfer from urgent
care for colitis in the setting of abdominal pain. Radiology showed Mild constipation. No radiographic evidence of free intraperitoneal air. The patient was diagnosed with Noninfective gastroenteritis and colitis, unspecified. At the time of discharge, the patient had Primary Diagnoses
#Radiation induced Ischemic Colitis
#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>ADMISSION
=========
___ year old lady with complex past medical history of
breast/uterine/ ovarian cancer (+BRCA 1) s/p chemoradiation
___, bilateral salpingo-oophorectomy and a hysterectomy in ___
with history of radiation colitis, multiple psychiatric
diagnoses including PTSD, ADHD, delusional disorder, depression,
borderline personality disorder, and dissociative identity
disorder who resented to the emergency department as a transfer
from urgent care for concern for colitis in the setting of
abdominal pain.
ACUTE ISSUES
============
#Ischemic Colitis
#Concern for Infectious Colitis
#Opiate Induced Constipation
Patient has previous history of biopsy proven ischmemic colitis.
She was admitted due to several weeks of constipation, after
failing Senna and a tap water enema at home. A CT of the abdomen
showed prominent fecal loading throughout the ascending and
transverse colon, likely secondary to colitis in the distal
descending colon and sigmoid colon, most likely reflecting
infectious or inflammatory colitis. Mesenteric vessels were well
opacified. She was admitted with a leukocytosis concerning for
infectious colitis initially treated with Ciprofloxacin/Flagyl
which was transitioned to Augmentin with resolution of
leukocytosis. Stool cultures were pending at time of discharge.
She was given Magnesium Citrate and responded with a large
volume bowel movement on her second hospital day, reassuring
that she did not have a mechanical obstruction. GI was
consulted, and felt this was likely multifactorial due to
history of radiation colitis and narcotic induced constipation.
She had ___ further episodes of BRBPR or hematemesis, her abdomen
remained distended and tender but not peritoneal. She likely was
missing/skipping doses of laxative, compounded by her methadone
use, leading to her recent constipation and hospitalization. Per
discussion with GI, she will not require outpatient mu
antagonist as she was able to stool with Magnesium Citrate.
However, she should be on a stable bowel regimen with a rescue
plan of Magnesium Citrate for >2 days without bowel movements as
outpatient. She will follow up with a motility specialist.
# ___
Patient had ___ that was likely pre-renal due to diarrhea,
which resolved with IV Fluids
# Hematemesis
She reported an episode of hematochezia prior to
hospitalization. Her EGD from prior admission showed evidence of
gastritis. This was felt to be likely due to ___ tear,
nausea and abdominal pain. She had ___ further episodes of
hematemesis and her hemoglobin/hematocrit was stable at
discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ED Consult Note - Dr. ___: PELVIS (AP ONLY) showed Reduction of dislocated left total hip arthroplasty. HIP UNILAT MIN 2 VIEWS LEFT showed Reduction of dislocated left total hip arthroplasty. DX PELVIS AND HIP UNILATERAL showed The alignment of the left hip is preserved and there is no evidence of
dislocation. Degenerative changes of the right hip are noted The patient was diagnosed with DISLOCATION OF PROSTHETIC JOINT, ABN REACT-PROCEDURE NOS, JOINT REPLACEMENT-HIP. The patient was treated with closed reduction of left total hip dislocation. At the time of discharge, the patient had left total hip arthroplasty dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the Orthopaedic Arthroplasty
surgical service on ___ following closed reduction in the ED of
dislocated L total hip arthroplasty. Patient admitted for pain
control and Physical Therapy; uneventful hospital coruse.
N: Pain appropriately controlled with PO pain medications.
CV: Vital signs were routinely monitored; the patient remained
hemodynamically stable.
P: There were no pulmonary issues.
GI: The patient tolerated a regular diet.
GU: Foley catheter was removed once admitted; voided without
issues postoperatively. Home lisinopril continued.
ID: No issues.
Heme: The patient received lovenox for DVT prophylaxis; she will
complete the 4 week lovenox course started after her initial
arthroplasty surgeyr.
MSk: The patient was made weight-bearing as tolerated on the
operative extremity with posterior precautions; she will remain
in a knee immobilizer at all times for 4 weeks, only to come out
for showers and range of motion with Physical Therapy.
At the time of discharge, the patient was afebrile with stable
vital signs and good pain control; the operative extremity was
neurovascularly intact. The patient will follow-up in
___ clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y M with mass in the pancreas concerning for pancreatic
cancer as well as recently diagnosed squamous lung cancer who
was febrile, tachycardic, and hypotensive during ERCP stent
exchange procedure today. He had a CBD plastic stent placed
___, and a planned replacement with a metal stent today. The
ERCP procedure went well with good flow through the CBD
post-procedure, however he became hypotensive into 80's
systolic, afib with HR in the 140s, no ST changes per report,
and with elevated temperature to 100.3. He was given 5 IV metop
and transferred to the ED. He has had afib with RVR in past in
the setting of sepsis, and was started on betablockade on prior
admission in ___. Per patient, he has had fevers at home for
the last ___ days. Also of note, his Tbili is more elevated
today. CHEST (PORTABLE AP) showed Right basal atelectasis. No evidence of pneumonia or edema. The patient was diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, ATRIAL FIBRILLATION. The patient was treated with CBD stent exchange (plastic exchanged with ___. At the time of discharge, the patient had Cholangitis
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>___ y M with new diagnosis of pancreatic mass as well as new
diagnosis of squamous cell carcinoma, admitted from ERCP with
fever, hypotension, tachycardia concerning for cholangitis.
# Cholangitis: 1 day of fever/chills at home several days prior
to presentation, elevated Tbili, puss seen draining for CBD
during procedure today. Good flow through CBD after stent
replacement. He remained hemodynamically stable upon arrival to
___. His LFTs improved throughout his course. Initially
received zosyn, which was then narrowed to unasyn. He was
transitioned to augmenten for a total antibiotic course of 10
days. He will follow-up with ERCP as an outpatient.
# Afib with RVR: first occured during a prior admission for
sepsis, recurred during admission in ___ for ERCP/stent
placement. At that time, he was discharged home on 200 metop.
CHADs score 2, anticoagulation had been discussed but pt
declined during admission in ___. Non-elevated troponin. He
was discharged on 300 metop succ daily, as well as diltiazem 120
daily. He was also started on aspirin 81 daily, and will discuss
anticoagulation with outpt providers.
# Squamous cell cancer: metastatic including to pancreas.
Diagnosed ___. Followed by thoracic team in conjunction
with Dr. ___ now following with oncology in
___. Had planned to start chemo on ___, which will be
delayed in setting of acute infection. Has follow-up in place.
# COPD: continued on home meds</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a pleasant female who was
involved in a motor vehicle accident in ___ where she was
struck by a vehicle, suffering a severe pelvic fracture. She
was taken to ___ where an external fixator
was placed as was an SI screw by Dr. ___. She has had
the external fixator on now for almost 4 weeks and has had
some increased drainage from the right pin site. Given the
concerns for infection, a decision was made to proceed with
removal of the ex fix and assessed the pelvis for stability. Radiology showed Multiple pelvic fractures status post ORIF with no evidence ___ hardware
lucency to suggest hardware related complications. Radiology showed Multiple pelvic fractures with appropriate placement of hardware
with no evidence of hardware failure. The patient was diagnosed with JOINT PAIN-PELVIS. The patient was treated with ___ Removal of pelvic exfix. At the time of discharge, the patient had Pelvic ex-fix pin site infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented as a direct admit to the orthopedic
surgery service after experiencing some fevers, chills, and
noting some increasing drainage from her right ex-fix pin site
while at ___ for rehab. The patient was taken to the
operating room on ___ for removal of pelvic ex-fix, 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
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 with services 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 weight bearing as tolerated in the
right lower extremity, and touch down weight bearing in the left
lower extremity. 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: ___ with COPD, anxiety, history of descending aortic aneurysm
s/p recent repair transferred from ___ after CT scan
showed thoracic AAA showed ?extravesation transferred for
vascular w/u and eval of hypoxia.
___ saw patient "didn't look good this AM," pt felt slight SOB.
Went to ___ had CXR with showed basilar atelectasis and
US followed by CTA which demonstrated possible endoleak. Also
found to have UTI and given 500 mg levaquin. She was then
transferred to ___. Reported left upper abdominal pain which
she has for many years every day.
In the ___ ED, initial vitals were: 99.3 80 142/70 18 95% RA CHEST (PORTABLE AP) showed No acute intrathoracic process The patient was diagnosed with HYPOXEMIA. At the time of discharge, the patient had Primary: Shortness of breath, COPD, AAA s/p repair
Secondary: Anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with COPD, anxiety, and descending aortic aneurysm s/p
recent repair who was transferred from ___ for vascular
w/u after CT scan c/f possible extravasation from thoracic AAA.
Once transferred and imaging reviewed by the vascular team, it
was determined that there was no endoleak, however, patient was
noted to be hypoxic to 89% in the ED and was therefore admitted
overnight for evaluation of dyspnea.
#Hypoxia:
Upon transfer to ___, the patient was feeling SOB with O2 sat
89%. No increased cough, sputum production, fevers, chills, or
chest pain. CTA from OSH showed no evidence of PE. CXR showed
hyperinflated lungs consistent with COPD, but no evidence of
intrathoracic process. The patient was given a nebulizer in ED,
with improvement of O2 sats to 98% on RA. She was transferred to
the floor for observation overnight. She remained on room air
and was breathing comfortably without wheezes on exam. No
evidence of desaturation with ambulation. She was continued on
her home COPD inhalers (Albuterol and Spiriva) with plans to
follow-up with her out-patient pulmonologist.
#AAA s/p repair in ___:
Patient was initially transferred to ___ when CTA imaging from
OSH concerning for possible extravasation from thoracic AAA. Per
vascular team, there is no evidence of leak on CTA and patient
was HD stable with no signs/symptoms of bleeding on exam
(baseline anemia stable, no leukocytosis or fever, abdominal
incision and examination reassuring). There was no indication
for intervention and the patient will follow-up with the
vascular team as an out-patient.
#Anemia:
The patient has baseline anemia with HgB ___. Her H/H remained
stable during her hospitalization (HgB=10.6) with no evidence of
bleeding.
#?UTI
UA at outside hospital was concerning for UTI. She received
Levaquin 500mg once prior to transfer. Repeat UA at ___
benign. Patient denied urinary symptoms and UCx showed <10,000
bacteria. Therefore, antibiotics were discontinued.
#HTN
Continued home metoprolol and lisinopril.
#Anxiety
Continued home buproprion and ativan
#HLD
Continued home statin</s> |