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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with hx of afib on coumadin, CAD s/p DESx3 in ___, ___, with recent fall 4 days ago, who presents with SOB and chest pain. Radiology showed 1. Left internal jugular central venous catheter in appropriate position. 2. No pneumothorax. Stable small bilateral pleural effusions. 3. Improved pulmonary edema in right upper and lower lung opacities. Portable chest radiograph showed Interval increase in small left pleural effusion. Improvement in pulmonary edema. CHEST (PORTABLE AP) showed Bibasilar hazy opacities, which may reflect combination of atelectasis and small effusions, slightly increased. Minimal edema stable. The patient was diagnosed with Unspecified atrial fibrillation, Pneumonia, unspecified organism. At the time of discharge, the patient had PRIMARY: Atrial fibrillation with rapid ventricular rate Coronary artery disease Acute on chronic heart failure with reduced ejection fraction Urinary tract infection SECONDARY: Facial Contusions Gastroesophageal Reflux Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>================ PATIENT SUMMARY ================ Mrs. ___ is a delightful ___ yo woman with history of afib on coumadin, CAD s/p DESx3 in ___, HFpEF, with recent fall with resultant facial fractures, who presented with SOB, chest pain, and afib with RVR - initially admitted to the CCU, however with transfer to the Cardiology floor s/p Digoxin loading and improved heart rate, with course complicated by UTI. #CORONARIES: S/p stent (RCA x1, LADx2 at ___) #PUMP: EF 35% #RHYTHM: Af ============== ACUTE ISSUES ============== #CAD s/p stent (RCA x1, LADx2 at ___) #Chest Pain: Not on Plavix, but is on aspirin. Mrs. ___ developed new chest pain during her hospitalization, with new TWIs found in V4-V6. She was started on a Heparin gtt and continued for 48 hours. Her Troponins were 0.03 x3. We obtained a P-MIBI, which showed evidence of moderate fixed septal and inferolateral wall defects and normal ventricular size and systolic function. She was continued on ASA 81mg, Atorvastatin 80mg, a reduced dose of lisinopril 2.5mg, and an increased dose of fractionated Metoprolol as per below. #HFrEF (LVEF 35%): On furosemide 20 mg daily at home. Throughout her hospitalization she has not seemed fluid overloaded, and as such her home Lasix was held. She was started on an increased dose of fractionated Metoprolol, and she was continued on home Lisinopril. Of note, she will need a repeat TTE in ___ months to re-evaluate her reduced LVEF. On discharge, her home Furosemide was held. Discharge weight 60.69kg #Atrial fibrillation with RVR: At home, was on propranolol and diltiazem - both of which were discontinued during this hospitalization. On admission she was found to have HR to 130s and 140s. She initially required IV and PO Diltiazem, but then developed hypotension requiring Levophed while in the CCU (which was ultimately weaned). Of note, she had a CTA that was negative for PE. She was loaded with Digoxin, which showed improvement in her HR. She had Digoxin levels that were initially elevated, and as such her Digoxin dose was held at times. She was discharged on a Digoxin dose of 0.0625mg PO daily. She was continued on her home warfarin and started on fractionated Metoprolol. She was discharged home with the following medications: digoxin 0.0625mg PO daily, metoprolol XL 150mg, and warfarin 1mg daily. #UTI: UA showed large ___, 7 RBC, 12 WBC, few bacteria, and 1 Epi - consistent with UTI. Mrs. ___ was treated with Augmentin 500mg q8 hours (initially per Plastic Surgery for her facial contustions), as this provided good coverage. Urine culture showed no growth. Augmentin continued for 10-day course from last discharge, finished ___. #Diarrhea #Fecal incontinence: Noted upon transfer to the general cardiology floor. No saddle paresthesias or lower extremity weakness on exam, thus less likely cord compression. It seemed most likely related to diarrhea (likely in the setting of Augmentin) and difficulty ambulating to the restroom in time. We obtained a C. Difficile test, which was negative. Diarrhea improved and was resolved on discharge. #Right eye conjunctivitis Treated with erythromycin eye drops QID for 1 week ___ to ___. Resolved at discharge =============== CHRONIC ISSUES =============== #Facial sutures s/p plastics procedure: Continued Augmentin 500mg q8 hours x10 days from last discharge, finished ___ #GERD: Continued home pantoprazole 40 mg daily ==================== TRANSITIONAL ISSUES ==================== [ ] Stopped home propanolol and diltiazem and started on metoprolol XL 150mg daily and digoxin 0.0625mg daily. Would follow-up blood pressure and heart rate on these new medications and adjust accordingly [ ] Held home furosemide at discharge and patient euvolemic on discharge. Would follow-up fluid status and weight as outpatient. Restart furosemide if she gains ___ pounds above her dry weight or develops any signs of volume overload. [ ] Repeat TTE in ___ months to re-evaluate reduced LVEF [ ] Please schedule appointment with PCP ___ (___) and Cardiologist Dr. ___ ___ ___ weeks following discharge from rehab. [ ] Check INR on ___ and adjust warfarin for INR goal of ___ #CODE STATUS: Full code #CONTACT: Name of health care proxy: ___ Relationship: spouse Phone number: ___ DISCHARGE WEIGHT: 60.69 kg</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old female h/o dCHF (TTE ___ showing LVH and EF>55%) who complains of fatigue. Of relevance, pt s/p recent admission end of ___ for fatigue and weakness at which time she was noted to have diastolic CHF and ___ on CKD. troponins were 0.26 on admission and remained stable at that level x3. BNP elevated at 27,000 and pt with pulm edema. TTE similar to prior, did show LVH and dx of dCHF given. During this admission VQ scan also performed (___) which was negative for PE. Infectious workup was negative, and TSH wnl. She was effectively diuresed and discharged on furosemide QOD (which she had not been taking at home) with downtrending creatinine. . Pt recently admitted with weakness, and sent initially to rehab and then home 1 week ago. Was doing well until two days ago, when she woke up with sudden weakness of her lower extremities (on chronic baseline leg weakness requiring use of a walker). That same day she had 1 episode of vomiting, without nausea. For the last 2 days has had decreased PO intake and leg weakness. No SOB/CP/edema throughout. Called PCP who told her to go to the ED. Pt continues to take her lasix QOD as per last discharge instructions. . In the ___ ED, pt developed new chest pain described as pressure in substernal area. Non radiating. no pleuritic. no orthopnea. no dyspnea on exertion. "Just felt weak". No fevers or cough. No urinary symptoms. . In the ED, initial vitals were 96.7 102 105/53 22 97% 3L. Labs significant for MB 9, proBNP 16,000, Cr of 2.7 (last adm presented with cr 3.0, down to 2.1 at DC), K of 5.0. HCT 36.6 from 28.9 on last DC. ECG showed 1mm ST depressions V4-6 with inverted TW in these same leads, LAD, sr@75. (ST changes new from ___ Patient given aspirin 325mg and heparin gtt was started. Chest pain had resolved on its own without intervention. . On arrival to the floor, patient expresses disgust re having been admitted this time, for which she blames her son/HCP who brought her to the hospital. She is comfortable lying in bed. Denies lower extremity weakness at this time. Denies SOB/CP. Ordered dinner. . REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Radiology showed Bibasilar opacities most suggestive of atelectasis versus scarring given persistence over time. Trace bilateral pleural effusions, no evidence of acute cardiopulmonary process. Radiology showed Gaseous distention without dilatation of the small and large bowel. No free air. The patient was diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, ACUTE KIDNEY FAILURE, UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had PRIMARY non-ST elevation myocardial infarction SECONDARY gastrointestinal bleeding hypertension hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>REASON FOR HOSPITAL ADMISSION: ___ with PMH HTN/HLD and h/o diastolic CHF last EF 55% ___ presenting with lower extremity weakness x3 days, found to have elevated cardiac enzymes. . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of HTN, ILD, RA (on prednisone, MTX, Rituximab), HF with preserved EF who presents with DOE. She was scheduled to undergo PFTs as an outpatient today, however on presentation she was noted to be dyspnic with sats 88% on room air and appeared dypsnic. Sats reportedly improved while the patient was sitting, however dropped to 81% on RA with 20ft ambulation. Patient was also having trouble speaking in complete sentences. CXR reportedly showed bilateral LL infiltrates. Patient was referred to the ___ ED via ___ for further evaluation. On arrival to the ED, patient reported acute SOB which began on ___ and has been constant since. She denies CP. She has a productive cough but no leg swelling, pain or orthopnea. She reports that she always sleeps on ___ pillows CHEST (PA AND LAT) showed Diffusely increased interstitial opacities likely reflective of chronic interstitial lung disease, though a component of superimposed interstitial pulmonary edema is not excluded. More focal patchy opacity in the right upper lobe could suggest infection. Moderate size hiatal hernia. Comparison with any previous chest CT imaging is recommended, and if none are available, dedicated high-resolution chest CT is suggested. DIFFUSE LUNG DZ showed Fibrotic interstitial lung disease, most suggestive of UIP pattern. Widespread ground-glass opacification is nonspecific the differential considerations include atypical infection including PJP given history of immunosuppression, or acute exacerbation of interstitial lung disease in the appropriate clinical setting. CHEST (PA AND LAT) showed Cardiomegaly and mediastinal contour are stable. Since the prior study there is minimal improvement in diffuse interstitial opacities. No interval development of pleural effusion or pneumothorax is demonstrated. No evidence of new superimposed focal consolidation is seen. Large hiatal hernia is re- demonstrated. The patient was diagnosed with Shortness of breath. The patient was treated with ___ - Bronchoscopy with bronchoalveolar lavage. At the time of discharge, the patient had Acute issues: #Interstitial lung disease c/b hypoxia #Community-acquired pneumonia c/b hypoxia #Rheumatoid arthritis. The patient was given written instructions concerning 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 F with ILD, RA (on prednisone, MTX, Rituximab), and HF with preserved EF (~60% on ___ TTE) admitted with dyspnea on exertion and acute hypoxemia. #Hypoxemia/Dyspnea on exertion with Interstitial Lung Disease The patient was admitted with acute onset of dyspnea without evidence of antecedent viral UI, sick contacts or over aspiration. Labs on admission notable for normal WBC count and elevated pro BNP with a CXR notable for focal opacity in te right upper lobe ad diffusely increased interstitial opacities. Initially treated with furosemide and levofloxacin in the ED prior to admission to the medicine floor, requiring ___ L of O2. The patient has a history of early fibrotic lung disease consistent with RA-ILD followed with PFTS and Chest CT. Both the pulmonology and rheumatology teams were consulted. The differential was broad in the setting of underlying ILD and immunosuppression therapy, and included CHF, CAP, atypical infections in the setting of immunosuppression, acute exacerbation of ILD, and drug related pulmonary toxicity. The patient underwent a high resolution chest CT with diffuse GGO most consistent with acute exacerbation of ILD vs. atypical infection. There was likely a contribution from reflux as well given cough and sputum production in the setting of clear hiatal hernia, and the patient was treated with BID omeprazole. The patient completed a 7 day course of levofloxacin for presumed CAP. Broad infectious workup including serum fungal markers, urine strep/legionella/histo, viral respirator panel, induced sputum for Gram stain/cx, funal Gx, AFB x3 and PCP DFA was negative. Additionally the patient underwent bronchoscopy and BAL with broad infectious workup which was also negative. Given the extensive negative infectious workup, the diagnosis was most likely acute exacerbation of RA-ILD. The patient underwent a solumedrol pulse of 500 mg IV x 3 days followed by prednisone taper. Methotrexate was held indefinitely due to possibility of MTX related lung toxicity. In the setting of high dose prednisone use, the patient was started on PCP prophylaxis with ___. Patient required home O2 on discharge given ambulatory saturations <89% on RA. #Rheumatoid arthritis: The patient was evaluated by the rheumatology team in house in the setting of above concern for acute exacerbation of RA-ILD. She was determined to have decreased ROM and pain on exam indicating a mildly active flare. The patient was initially continued on prednisone 10 mg daily and then treated with solumedrol pulse and high dose prednisone tape as above. Joint pain improved. As above, MTX was held indefinitely given concern for MTX related pulmonary toxicity. The patient will follow up with outpatient rheumatologist after discharge for discussion of restarting rituximab given negative infectious workup. ===================== CHRONIC ISSUES ===================== #Hypothyroidism: Patient was continued on Levothyroxine 150mcg qD. Of note patient taking 300 mcg Q ___ at home, however tis was deferred while inpatient in setting of low TSH on admission. This will be followed as an outpatient by patient's PCP. #HTN: Patient continued home verapamil 180 q24H. #GERD: As above, increased omeprazole to BID due to concern for GERD/aspiration contributing to dyspnea and hypoxemia as above. #Chronic Diastolic CHF ===================== TRANSITIONAL ISSUES ===================== [ ] Patient discharged on prednisone taper as below: 60 mg (___) 50 mg (___) 40 mg (___) 30 mg (___) 20 mg (___) 10 mg ___ - ) [ ] Patient discharged with home O2 given ambulatory saturations <89% on RA [ ] Patient continued on levothyroxine 150 mcg daily - admitted on 150 mcg 6x/week and 300 mcg on ___. TSH 0.26 on admission. Please follow up outpatient TFTS after discharge. [ ] Hold methotrexate given possibility of MTX related lung injury [ ] Patient started on Bactrim 1 DS three times weekly [ ] Continue PPI BID [ ] Monitor BP given high dose steroids at next PCP ___ [ ] Discussion of outpatient rituximab at next rheumatology appointment</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with PMH of kidney and pancreas transplant in ___ and DM1 who p/w progressive weakness and fatigue for the past ___ weeks. Patient went to ___ who told her to go to ED which she did via EMS. Patient states her balance has been off over same period of time, and she attributes this to overall muscle weakness. She has also had headaches since ___ that have been getting worse, located "all over" her head. She describes the pain as an "explosion" which can then feel like a "nail." They occur daily, and last anywhere from a couple seconds to a few hours. Noise makes it worse but she notes no photophobia. It helps when she lays down and closes her eyes. She has not tried any medications for headache. She denies any associated nausea or vision changes. She notes that she feels the exact same way as when she has previously presented to the hospital. She has had stable dyspnea ascending 1.5 flights of stairs and stable chest pain that comes on randomly. It feels like a "poking" that goes away on its own since NSTEMI earlier this year. Radiology showed 1. Mild renal transplant collecting system fullness, similar to prior. 2. Unremarkable renal transplant vasculature with unchanged resistive indices. 3. Urinary bladder debris. Postvoid residual of 85 cc. The patient was diagnosed with URIN TRACT INFECTION NOS. At the time of discharge, the patient had Primary diagnosis: Urinary tract infection Secondary diagnosis: 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>___ yo F with PMH of renal and pancreas transplant who presents with fatigue and weakness and was found to have a UTI. ACTIVE ISSUES # Fatigue and weakness: These are likely chronic issues that have worsened in the setting of infection. Also on differential diagnosis were increasing levels of sedating medications or tacrolimus toxicity in the setting of her low GFR although these are unlikely given patient's stable GFR and normal tacrolimus levels. Hypothyroidism and statin toxicity were also considered but TSH and CK were normal. Viral screen was also negative arguing against influenza. Fatigue and weakness improved with treatment of UTI and patient was feeling energetic and ready to go home on day of discharge. # Urinary tract infection: Positive UA. Given first dose of linezolid and Bactrim in ED. Linezolid started due to recent history of ___ Enterococcus on urine culture from ___. Bactrim was subsequently discontinued due to patient's history of C. diff. Started on ceftriaxone for gram negative coverage. Given patient's long history of urinary retention requiring frequent caths and the bladder debris on renal ultrasound Urology was consulted. They determined that patient was not complying with recommended cath regimen. They recommended that she cath herself a minimum of twice per day and void at least 400 cc with each cath. Urine culture returned as contaminated on ___. Requested speciation and sensitivities given the higher likelihood of a polymicrobial infection in a transplant patient. These studies were pending on discharge. Switched patient to linezolid and cefpodoxime for outpatient therapy. Discharged her with a 2 week course of these antibiotics and with Rx for repeat urine culture in 3 weeks. CHRONIC ISSUES # Chronic kidney disease: Patient remained at her stable low GFR during admission. ___ ultrasound of renal graft. Increased bicarbonate to 1300 mg TID. Renally dosed all medications. Scheduled voiding and Urology consult as above. # Renal and pancreas transplant: Performed in ___. Renal function was at baseline and amylase and lipase were within normal limits. Renal ultrasound on ___ was reassuring. Continued immunosuppressive regimen including prednisone, tacrolimus, and MMF at home doses. # Hyperlipidemia: CK within normal limits. Continued atorvastatin. # Hypothyroidism: TSH within normal limits. Continued levothyroxine. # OSA: Patient uses a special machine at home that delivers PEEP 10 and pressure support that flexes between ___. Per Respiratory, closest machine we had was BIPAP. Managed with BiPAP per Respiratory. # Peripheral neuropathy: Continued gabapentin and Flexeril. # Depression: Continued citalopram. TRANSITIONAL ISSUES - Discharged on 14 day course of linezolid and cefpodoxime - Now on a higher dose of bicarbonate tabs - Instructed patient to HOLD Celexa and Flexeril while on linezolid - Continue weekly labs faxed to Dr. ___ at ___ - Urine culture 3 weeks after discharge - ___ with PCP scheduled - ___ with Transplant Nephrology scheduled - ___ with Urology scheduled</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w h/o asthma per chart (no PFTs apparent), never been intubated, obesity, HTN p/w 2 weeks of progressive SOB. Pt was in USOH until 2 weeks ago then developed progressive SOB with wheezing and cough. Onset was gradual. No chest pain at onset but then with all the coughing, starting having pain only with coughing. Denies ___, weight gain, ___ trauma, h/o clots. Endorses cough worse at night which limits sleeping. Some PND from this. Denies f/n/v/d/rhinorrhea/sick contacts (but works in a hospital as a ___)/recent abx/recent med changes. Has a cat. No large dust exposure or cleaning or mold exposure. Got flu shot this year (just prior to decompensation which she thinks is the cause). Cough is non-productive. Denies abd pain, diarrhea, constipation, rash, joint pain. Reports chronic LBP at baseline. Reports "chills" for ___ years. CHEST (PORTABLE AP) showed No acute intrathoracic process. The patient was diagnosed with Unspecified asthma with (acute) exacerbation. At the time of discharge, the patient had Asthma exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w likely asthma, HTN p/w subacute asthma exacerbation. # Hypoxemic respiratory failure, acute # Asthma exacerbation, acute # Steroid induced hyperglycemia # Prediabetes (A1c 6.4) Given her relatively mild smoking history as well as her mother having "bronchitis" without a smoking history, this suggests that patient actually has asthma rather than COPD. Given the lack of prominent sputum, that is another reason arguing against the need for abx (as well as her QTc prolongation which makes azithromycin a less ideal medication anyway). No other risk factors for PE, and likelihood of sick contacts makes URI induced asthma much more likely than PE induced asthma. No exam or history evidence of CHF. - Weaned O2 for goal sat >92. Satting at 94% on RA on day of discharge - prednisone burst 60mg po qd x5d, ___. Had steroid induced hyperglycemia with this (A1c 6.4) - s/p 1 dose azithromycin on ___ in ED, but as above, stopping abx - standing duonebs, prn albuterol - Started controller med on discharge - has pre-diabetes so favor LKA over ICS - recommend o/p PFTs # HTN: reports that her PCP was planning on increasing her BP meds as o/p for HTN anyway, so likely this is chronic HTN in poor control - cont home HCTZ - added amlodipine # chronic back pain: NSAIDs are a poor choice in her given her HTN. She is frustrated by lack of good options - increased home APAP to 1g TID prn for now - added lidocaine patch - may benefit from o/p ___ # QTc prolongation: has at baseline, may be worsened by azithro dose in ED - telemetry overnight - rechecking EKG in AM, stopping tele # TWFs on EKG - troponin negative Outstanding issues [ ] Started on amlodipine in addition to hydrochlorothiazide for better control of blood pressure. Some concern for nonadherence as patient was out of her medicines when she was admitted and systolics were in the 190s [ ] Added montelukast to controller medications for possible asthma. Will need pulmonary function test at outpatient appointment as well as risk-benefit discussion of inhaled corticosteroid. This was not provided on discharge due to high blood sugars in the setting of prednisone use. [ ] Patient had steroid-induced hyperglycemia. A1c was measured at 6.4. ___ need further education on management of prediabetes. [ ] Complained of shortness of breath when climbing flights of stairs. Presumption is that this is due to uncontrolled asthma. If still persists after initiation of controller medications may want to do further workup for dyspnea. [ ] Patient has QTC prolongation. Avoid prolonging meds such as azithromycin >30 minutes spent on discharge planning including >50% face to face time</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx recurrent DVT/PE on warfarin, pulmonary HTN, CKD on 4L home O2 at night who presented with 1 week of right sided pleuritic chest pain similar to previous PE. Pain is pleuritic, dull, right sided. Denies associated fever, chills, cough, leg swelling, n/v/d, abdominal pain, headache, dizziness. Does report travelling to ___ last week. BILAT LOWER EXT VEINS showed 1. Partially occlusive thrombus in the right mid superficial femoral vein, which extends to the distal right superficial femoral vein, where it becomes occlusive. 2. Partially occlusive thrombus in the left mid and distal superficial veins. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 10:46 on ___, 2 minutes after discovery. The patient was diagnosed with Other chest pain. At the time of discharge, the patient had #Primary: Pulmonary embolism #Secondary: Severe pulmonary hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of recurrent DVT/PE on warfarin s/p bilateral femoral vein ligation, pulmonary HTN, CKD who presented with pleuritic chest pain and several months of increasing oxygen requirement with ambulation, admitted due to concern for new pulmonary embolism, found to have acute on chronic pulmonary embolism, treated with lovenox. Also found to have worsening severe pulmonary hypertension, for which he was given O2 for ambulation. He will continue lovenox while bridging back to warfarin with new INR goal range 2.5-3.5. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of multiple abdominal surgeries/complications since her Roux-en-Y gastric bypass in ___, previous ___ ___ tear, iron deficiency, depression, recent c. diff infection ___ (one positive c diff in OMR, pt reports multiple recurrent infections), and ulcer noted at her anastomosis site last month (___) presents with abdominal pain. Pt reports sudden onset of LLQ pain at 1am ___ which awakened her from sleep with ___ left-sided periumbilical pain that was non-radiating, deep, cramping and sharp in quality. She reports inability to tolerate PO due to nausea, vomited x5, denies hematemesis, coffee ground emesis. She also has associated loose BM diarrhea (___), no melena or BRBPR recently (albeit reports small amount of blood in her stool 1 week ago). Reports a fever of ___ yesterday, measured with a thermometer, +chills. No dysuria or hematuria. No sick contacts. Radiology showed No CT findings to explain the symptoms. Unremarkable post gastric bypass anatomy. No evidence of obstruction, leakage or intra-abdominal abscess. The patient was diagnosed with CLOSTRIDIUM DIFFICILE. At the time of discharge, the patient had Abdominal pain of unclear etiology. The patient was given written instructions concerning 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 Roux-en-Y in ___ s/p multiple complications, and a recent c diff infection who presents with nausea, abdominal pain, and diarrhea. Pt was admitted overnight ___. On the morning of ___ patient eloped and left the hospital prior to evaluation by the day team. The day team spoke to her by phone. She reported leaving due to a personal matter that she needed to attend to. She was advised to return to the hospital if she felt unwell or if symptoms persisted or worsened. # Abdominal pain: Patient had acute LLQ abdominal pain and no obvious cause on imaging, ruling out such etiologies as SBO. Exam was also very benign making a surgical process less likely. Recent c diff infection; pt reports multiple c diff infections in the past. States that current sxs started and had not improved since she was initially diagnosed w/ c diff. This is occuring despite being treated with Vanco twice, and currently on a taper. Reports fever but no leukocytosis on labs. Other considerations for LLQ pain include diverticulitis (negative CT), IBS. Less likely are referred pain from ulcers, but pt does have a recently diagnosed anastomotic ulcer - was instructed to stop NSAIDs and smoking. Stool studies including c diff were sent. Blood and urine cultures were sent. She was given an IV PPI and oxycodone for pain control. She did not have known diarrhea after admission. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year-old lady residing at the dementia unit ___ with a history of HTN, hearing loss and eczema who presents referred by her PCP with new cellulitis. Per daughter and health aide she had a mechanical fall on her right lower extremity about a week ago that resulted in skin erosions right below her right knwee that were healing well. Last night her home health aide noticed some subtle redness in the area. This morning she was found to have edema, erythema and pain extending from the area of the wound until her ankle. Her PCP was made aware and referred her to the ED for evaluation. In the ED, initial vitals were: 97.4 66 143/48 16 100% - Labs were significant for *CBC: 7.6> 9.7/29.6 < 266 *mild hyperkalemia at 5.3, mild alkalosis at 29, BUN 25 / Cr 1.1 (b/l 0.9-1.0), normal lactate *UA: negative for leuk esterase, nitrites, ketones - Imaging revealed : *tib/fib XR negative for fractures ___ negative for DVT - The patient was given: CTX 1g iv, Vancomycin 1g iv, APAP 1g Po - Admission was discussed with geriatrics fellow Vitals prior to transfer were: 98.0 88 152/65 16 100% RA Upon arrival to the floor, the patient complained of mild pain in her right lower extremity but mostly of pruritus in the anterior surfaces of both lower extremities. UNILAT LOWER EXT VEINS RIGHT showed 1. Limited evaluation of the right peroneal veins. No evidence of deep venous thrombosis in the visualized right lower extremity veins. 2. Subcutaneous edema in the right calf. Radiology showed No acute fracture. The patient was diagnosed with CELLULITIS OF LEG. At the time of discharge, the patient had Primary Diagnosis: Cellulitis Mechanical Fall, skin abrasion Secondary Diagnosis: Eczema, prurigo nodularis. The patient was given written instructions concerning 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 a past medical history of alzheimer's dementia, HTN, eczema, prurigo nodularis presenting a week after a fall leading to RLE abrasion found to have cellulitis. # Cellulitis: The patient presented 1 week following a mechanical fall with erythema and edema on her right lower extremity surround an abrasion on her right lateral calf. The patient was evaluated with a RLE US which was negative for DVT. She was also evaluated with a RLE xray tib/fib which showed no fracture. The patient remained afebrile and hemodynamically stable. It was thought that her recent abrasion predisposed her to infection in this region. The patient also has a history of skin conditions (below) which she often scratches which may have contributed to her risk. The patient was treated with vancomycin and ceftriaxone which was transitionned to amoxicillin and tmp/smx to cover strep and MRSA given her risk factors (living in a dementia unit). The patient should continue these antibiotics for a total of 10 days (to end on ___. The patient's leg was wrapped in an ace bandage to prevent her from scratching the area. The patient should follow up with her PCP for ___ management. # Arthlagias: The patient reported pain in her knees and hips. Per report of her daughter, the patient had recenty been given a walker and schedued acetaminophen for management of her leg pain and weakness. The patient was continued on her acetaminophen TID. # Pruritus, eczema, prurigo nodularis: The patient has a history of several skin conditions and she was found to have diffuse nodules on her upper and lower extremities. The patient had significant pruritus and, as above, it was thought this may further predispose her to infection. The patient had been treated with clobetasol cream in the past with good effect. This had recently been transitionned to triamcinolone cream due to problems with insurance coverage. The patient was discharged on betasone valerate 0.1% cream BID, for equivalent steroid dosing. The patient should follow up with her PCP for further management of these medications. # Dementia: The patient's mental status was thought to be at baseline. She was continued on donepezil. # Hyperkalemia, mild elevated in Cr: The patient presented with elevated potassium to 5.3 and Cr elevated to 1.1 from baseline 0.9-1.0. This was thought to be caused by decreased PO intake and because of her albuterol being held. The patient did not have any ECG changes. Her K and Cr were monitored and returned to baseline. # COPD: The patient was found to have some wheezing while hospitalized when her albuterol 2mg PO BID was held due to difficulty with medication reconciliation. The patient was treated with an albuterol nebulizer and restarted on her home medication with improvement in her symptoms. The patient should f/u with her PCP in the future for further management of this condition. Can consider albuterol neb treatement in the future if needed as the patient tolerated this well in the hospital. # Systolic Murmur: The patient was found to have a systolic murmur at the RUSB radiating to the LUSB/LLSB and the carotids bilaterally. This was thought to represent aortic stenosis. No further imaging was ordered as it was thought that a TTE would be unlikely to change management. The patient should f/u with her PCP as needed. # HLD: Continued atorvastatin # Hypothyroidism: Continued levothyroxine</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with multiple prior abdominal operations and small bowel obstructions managed non-operatively who presented at this admission with 24 hours of abdominal pain associated with nausea. She denied flatus and had one small BM on the day of admission. She reported nausea without emesis. Review of systems notable for URI, mild lightheadedness and dizziness, and increased urinary frequency. She denies fever, chills, and dysuria. Radiology showed 1. Dilated segment of ileum demonstrating mural edema, thickening, and adjacent stranding with a transition point noted in the caliber of the lumen in the mid abdomen. Findings are worrisome for an early small bowel obstruction with ischemia. 2. No evidence of diverticulitis. Findings were discussed by Dr. ___ with Dr. ___ by phone at 8:49 p.m. on ___. 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>Ms. ___ was admitted to the ___ surgery service for conservative management of her small bowel obstruction. She was initially made NPO with IVF; as she had no episodes of emesis an NGT was not placed. Labs were monitored daily. On HD 2 she began to pass flatus and was advanced to clears, which she tolerated without difficulty. She had no further nausea and continued to pass gas. She was advanced to a regular diet on HD 3 which she tolerated. She is discharged home on HD 3 in good condition after successful conservative management of SBO. She is passing flatus, tolerating a regular diet, voiding and ambulating normally, with no abdominal pain or nausea. She will follow up with ACS surgery in clinic in ___ weeks.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ Crohn's s/p L hemicolectomy and diverting colostomy ___ and recent C. diff s/p fecal transplant on ___ who presents with abdominal pain and fevers. Patient was admitted ___ to ___ for Crohn's flare. She was initially covered with Cipro/flagyl but stool studies including CDiff were negative. She was started on prednisone 60mg daily and has been tapering as an outpatient with good improvement in her symptoms. She then underwent FMT on ___, and biopsies at that time showed severe active colitis. Following her FMT she noted some mild abdominal pain. She then developed new diarrhea and was diagnosed with CDiff colitis at ___ in ___ approximatley 10 days ago. She then restarted po vanco. Her diarrhea improved but starting approximately 5 days ago, she developed new and worsening lower abdominal pain, described as up to ___ stabbing pain radiating from her lower abdomen around to her back. She presented to urgent care and underwent an ultrasound NOS which was apparently normal. She was started on cefixime for possible UTI, which she has been taking for the last three days. Due to progressive pain and new fevers over the last few days, she then presented to the ___ ED. In the ED intial vitals were pain 10, T 98.4, HR 115, BP 120/77, RR 18, O2 99%RA. Initial labs were notable for WBC 23.3 with 93%PMN, 847 Plt, and HCT 35.4. UA was negative and remainder of chem7 and lactate were wnl. KUB showed no evidence of obstruction and CT A/P showed colitis. Patient was given flagyl, IV morphine, IV dilaudid, and IV zofran along with 2LNS and admitted to medicine for further management. Radiology showed Mucosal edema with mural thickening and surrounding inflammatory changes along the distal left colon leading to left lower quadrant diverting colostomy are consistent with colitis, likely secondary to underlying Crohn disease flare. Mild inflammatory changes are also present about the rectal stump with adjacent mild pelvic lymphadenopathy. No evidence of abscess or obstruction. Radiology showed 1.4 cm subcutaneous fluid collection medial to the stoma, which is not amenable to percutaneous drainage. Aspiration could be considered if clinically indicated. The patient was diagnosed with CLOSTRIDIUM DIFFICILE, REGIONAL ENTERITIS NOS. The patient was treated with Colonoscopy. At the time of discharge, the patient had Primary Diagnosis 1. Crohn's Colitis 2. Clostridium Difficile 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>___ is a ___ w/ Crohn's s/p L hemicolectomy and diverting colostomy ___ and recent C. diff s/p fecal transplant on ___ who presents with abdominal pain and fevers. ACUTE ISSUES #Abdominal pain, presumed Crohn's flare: Patient with marked colitis on CT and inflammation of rectal stump. Patient was recently diagnosed with CDiff at ___ and she was on a steroid taper for a Crohn's flare as well. She was continued on PO vancomycin and GI was consulted for colonoscopy to further evaluate colitis. Colonoscopy revealed mucosal ulceration without evidence of CMV infection in the colon/sigmoid, however tissue within the rectal stump was not inspected. Given that the patient's pain was lower in the pelvis than her usual Crohn's flares, there was concern for PID vs inflammation of the rectal pouch itself. A pelvic US was considered to evaluate the adnexa, however radiology felt that the CT abdomen pelvis was sufficient to evaluate the pelvis. Given her clinical picture, ovarian torsion was thought to be unlikely, and inflammation of the rectal stump observed on CT was thought to be the primary cause of her pain. Cortifoam enemas coupled with antispasmodics (dicyclomine and hyoscyamine) were attempted and the patient had significant pain with enemas. After 48 hours, and after consultation with Dr. ___ primary GI, She was started on IV methyl prednisolone 20 TID, with improvement in her pain. She was then transitioned to prednisone 30mg PO daily with instructions to continue this regimen until her follow-up appointment with GI (Dr. ___. Per the GI team, PCP prophylaxis was not needed while taking prednisone. She was discharged with instructions to take calcium and vitamin D supplements to help prevent bone demineralization in the setting of steroid treatment. - ___ virus negative #Crohn's Disease She was continued on her home dose of 20mg prednisone daily. With continued pain she was transitioned to 20 TID of IV methyl prednisolone on ___. The patient endorsed improvement in pain with IV methyl prednisolone, and was transitioned to prednisone 30mg PO daily on day of discharge (___). As above, per GI, she was instructed to continue taking prednisone 30mg daily until her follow up appointment with Dr. ___. She was also instructed to take vitamin D and calcium supplements given her steroid treatment. CHRONIC ISSUES #GERD: The patient was continued on her home regimen of BID omeprazole #Asthma- The patient has known diagnosis of asthma and was continued on her home Montelukast and prn albuterol and remained clinically stable. # Depression The patient has a history of depression and was continued on her home Celexa regimen. Transitional Issues **Pt will need DEXA scan as out-patient given long term steroids **Pt was discharged with instructions to start calcium and vitamin D to prevent bone demineralization in the setting of steroid treatment. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HMED ATTENDING ADMISSION NOTE ADMIT DATE: ___ ADMIT TIME: ___ . ___ yo F with h/o GERD and cholelithiasis, s/p lap chole ___ for gallstone pancreatitis complicated by bile leak s/p ERCP with stent placement ___ and right abdominal hematoma s/p percutaneous abdominal drain who is transferred from ___ ___ with abdominal pain, new fluid collection and dilated common bile duct. . Patient initially presented to ___ on ___ with abdominal pain, nausea and vomiting and was found to have gallstone pancreatitis (also with facial cellulitis and otitis externa). Patient underwent a lap chole on ___ complicated by a cystic duct bile leak for which she was transferred to ___. Patient underwent ERCP with stent placement on ___. Patient was discharged home on ___ however continued to have persistent abdominal pain, nausea and vomiting. She was evaluated by her PCP, found to have a bili of 2 and CT scan showed an intra-abdominal fluid collection. Patient was admitted to the hospitalist service on ___. ___ performed a CT-guided placement of drain in the fluid collection on ___ which was consistent with a hematoma. She had a HIDA scan which was negative for bile leak. Drain was pulled and patient was discharged on ___. . Patient initially felt well after hospital discharge - minimal pain and nausea (never fully resolved). Approximately one week ago, RUQ pain returned. Described as intermittent, sharp/cramping, ___ at maximum. Two days ago developed nausea and anorexia. No vomiting. No fever, + chills. No cp, sob, diarrhea, brbpr or melena. . Presented to ___ ED yesterday and found to have a dilated CBD of 1.8 cm (per ED report, no imaging in chart) with normal bilirubin. Transferred to ___ for ERCP evaluation. . ED: 97.7 73P 109/69 16 98%RA; zofran 4mg iv, unasyn 3gm, CT a/p with contrast - extruded biliary stent in duodenum, stable moderate biliary ductal dilatation, decrease in RLQ fluid collection; surgery consulted - fluid collection seen on CT scan prior to lap chole - biloma vs hematoma, no surgical intervention, consider drainage. ERCP consulted with plan for ERCP and stent replacement in the am. . ROS as per HPI, otherwise 10 pt ROS negative Radiology showed 1. Patient is status post cholecystectomy with mild central intrahepatic and extrahepatic biliary dilatation with no evidence for choledocholithiasis. Of note, the stent is noted still within the distal common bile duct and is draining freely into the third portion of the duodenum. 2. Normal hepatobiliary excretion of the contrast agent Eovist from the liver with no evidence of bile leak from the cystic duct remnant. 3. Right upper abdominal collection with imaging characteristics consistent with a liquefied hematoma. No evidence for biloma. 4. Moderate narrowing at the origin of the celiac axis with associated post-stenotic dilatation. Findings were discussed with Dr. ___ via telephone by Dr. ___ ___ at 10:30 a.m. on ___. The patient was diagnosed with DIS OF BILIARY TRACT NEC, ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had abdominal 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>___ yo F with h/o GERD and cholelithiasis, s/p lap chole ___ for gallstone pancreatitis complicated by bile leak s/p ERCP with stent placement ___ and right abdominal hematoma s/p percutaneous abdominal drain now with recurrent nausea and abdominal pain and found to have an extruded biliary stent with stable ductal dilatation. . #Abdominal pain/nausea: initial ddx included extruded biliary stent vs recurrent bile leak vs possible infected fluid collection. --following admission, the patient was made NPO, placed on IVF, given IV antiemetics and started on IV antibiotics for empiric cholangitis treatment. The ERCP and Surgical Consult services were also asked to see the patient. ___ d/w both consult services, the pt first had a HIDA scan performed to evaluated for biliary leak, which was negative. She then underwent a MRCP to further evaluate the fluid collection. Initially the MRI was read as a possible biloma, so a plan was made to have ___ place a drain into the collection. However, on further review with Radiology, it was felt that the collection was most likely a resolving hematoma. Surgery felt that the hematoma could be managed conservatively as long as the patient's symptoms improved. The pt's abdominal pain resolved quickly and her nausea was well controlled with antiemetics. Her diet was advanced and her IVF were stopped. Given that there was no evidence of cholangitis, the patiet had the IV antibiotics stopped as well. The patient was able to tolerate a full diet with no pain and nausea. She will be discharged to home with follow-up with GI as an outpatient. She was discharged with PRN oral antiemetics. She will need a follow-up KUB in approximately 2 weeks by GI to confirm passage of the biliary stent. If it remains in place, she will need a repeat ERCP to have it removed. . #GERD: --continued on ranitidine. She has not tolerated PPI in the past. . #Post-nasal drip: --continued on Singulair and PRN fluticasone. . .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M h/o of reflux nephropathy, BPH, presents with 1 week of chills, sweats, fevers, found to have pyelonephritis. Began to feel unwell 1 week prior to admission with a feeling of "wooziness," malaise that progressed over several days. He then presented to urgent care 1 day prior to admission where he was diagnosed with pyelonephritis and prescribed Ciprofloxacin. Despite taking several doses he continued to have fevers to 102 at home and felt unwell. He called urgent care the day of admission who told him to present to the ED. He was started on Ceftriaxone/Vancomycin and given 4L IVF in the ED. Lactate normal. His blood pressure briefly dipped into the mid ___ systolic without change in mental status and this quickly improved with fluids. His heart rate was in the ___ throughout. On arrival to the floor he is feeling much better. He continues to have some chills. He relays a recent history of urinary urgency with mild dysuria and flank pain. CT urogram revealed right-sided pyelo w/o abscess. Radiology showed 1. Right pyelonephritis and mild ureteritis. No perinephric abscess is identified. 2. No additional acute process within the abdomen or pelvis. 3. Mild splenomegaly. The patient was diagnosed with Fever, unspecified, Unspecified abdominal pain, Weakness. At the time of discharge, the patient had Sepsis due to 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>Mr. ___ is a ___ year-old man with a history of BPH and reflux nephropathy who presented with severe sepsis from pyelonephritis. His urine grew a sensitive enterococcus; blood cultures were negative. He was treated with IV ceftriaxone, and received a total of five liters of IV fluids. He continued to have fevers through HD#2. He was discharged on PO ciprofloxacin on HD#3 to complete a 7-day course of therapy. 1. Severe sepsis d/t enterococcal pyelonephritis - ciprofloxacin 500 mg BID x 4 additional days 2. HLD. - home atorvastatin 3. ADHD. Home Adderal 4. CV Risk. Asa 81 mg. > 35 minutes spent on discharge activities.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male history of hypertension, prostate cancer, left patella fracture status post ORIF ___, ___ who presents with left hip pain status post mechanical fall. Patient was walking home from the assisted living facility in which his wife with dementia resides, when he tripped and fell on the sidewalk today. He tried to get up and then fell again. He was unable to bear weight on his left side. EMS brought him into the hospital for evaluation. He currently complains of pain "all over". He is accompanied by his son who states that he has been recently seen by neurology for evaluation of his cognitive decline. He denies any numbness or tingling in his left lower extremity. Positive head strike, negative loss of consciousness. Patient son states that he has been prescribed some home medications, however he has not been taking any. FEMUR (AP AND LAT) LEFT showed 1. Re-demonstrated is foreshortening of the left femoral neck, consistent with a femoral neck fracture. 2. There are new fractures within the cerclage wires since the ___ study with irregularity of the anterior aspect of the patella on the lateral view. Please correlate with patellar pain to exclude an acute on chronic patellar fracture. CT HEAD W/O CONTRAST. showed 1. There is a new small subgaleal hematoma overlying the right frontal bone. 2. Re-demonstrated is a small hematoma overlying the left frontal bone with an overlying laceration, and subcutaneous emphysema. 3. No acute intracranial hemorrhage or fracture. GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT showed 1. No acute fracture. 2. Mild degenerative disease in the acromioclavicular joint. Left hip radiograph, single AP portable view, intraoperative. showed Anticipated postoperative appearance immediately status post left hip hemiarthroplasty. The patient was diagnosed with Fracture of unsp part of neck of left femur, init, Unspecified fall, initial encounter. The patient was treated with ___: Left hip hemiarthroplasty. At the time of discharge, the patient had Left femoral neck fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left hip hemiarthroplasty, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the left 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: ___ year old male w/no significant PMH who presents for 3 weeks of diarrhea and bloody stools. He endorses a baseline stool of ___ and now is stooling large, loose stools with mucus and blood approximately ___ daily for the last 3 weeks. He has had red clot and blood streaked stool but no melena. He has not traveled recently, only has eaten sushi in terms of raw/undercooked foods. He is not aware of a family history of IBD or autoimmune disease. He has cut lactose out of his diet w/out effect. He thinks he may have hemorrhoids. He has been having gradually worsening crampy abdominal pain that is exacerbated by eating and has not been able to tolerate PO for the last 24h. He describes it as sharp pain that occurs all over the abdomen 5 minutes after eating, which is not immediately resolved with defecation, as he has had tenesmus, but is unable to pass stool at times. He had a scheduled GI appointment as an outpatient but couldn't wait. He presented today for worsening pain to ___. He endorses chills, denies fevers. + NS. He endorses nausea, denies vomiting. He does note some pain when hitting a pothole while driving. CT ABD AND PELVIS WITH CONTRAST showed Proctocolitis, with wall thickening involving the entire colon, most pronounced in the cecum and ascending colon, findings which are likely infectious or inflammatory in etiology. No small bowel involvement. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, MELENA. The patient was treated with Sigmoidoscopy. At the time of discharge, the patient had Primary diagnosis: Ulcerative colitis Secondary diagnosis: History of exercise-induced asthma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old male with no significant past medical history who presents with abdominal pain, hematochezia, and diarrhea, found to have moderate to severe ulcerative colitis. # New-onset, moderate to severe ulcerative colitis: Patient presented with abdominal pain, hematochezia, and diarrhea. He was also unable to eat during the day prior to admission, but began eating on his first day in-hospital. During this admission, he remained afebrile and without peritoneal signs on abdominal exam. CT abdomen and pelvis showed proctocolitis without small bowel involvement. Sigmoidoscopy showed diffuse colitis involving the rectum with continuous involvement proximally, consistent with ulcerative colitis. Sigmoidoscopy biopsy showed moderately active colitis without granulomas or dysplasia. Infectious work-up was negative for C. difficile, salmonella, shigella, campylobacter, vibrio, yersinia, E. Coli O157:H7, and ova and parasites. Given these findings, he was diagnosed with moderate to severe ulcerative colitis. He received five days of IV methylprednisolone, and then was transitioned to oral prednisone his day of discharge. On discharge, the patient's bloody diarrhea slowed down, had minimal abdominal pain, and was tolerating PO intake without difficulty. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old R-handed woman with PMHx of partial seizures and a recent dental infection with numerous complications who presents with RLE weakness and numbness on the R foot. The patient's recent history begins on ___ when she had a cavity filled and then had air tracking into the R side of her face with eyelid swelling. This then tracked into her neck and mediastinum. She was seen at ___ where she had unequal pupils, nystagmus, blurred vision and difficulty with tandem gait. She had a NCHCT there that was read as no acute intracranial abnormalities and a CT neck that showed extensive subcutaneous emphysema throughout the bilateral cervical soft tissues extending to the right orbit superiorly and right supraclavicular fossa and superior mediatsium inferiorly. She was given IV augmentin and pain medication and was discharged on ___ on PO augmentin after her neurological sx resolved. She continued to have facial pain at home, which slowly resolved. Then on ___ around 7pm she had the sudden onset of "excruciating" abdominal pain in the middle of her abdomen. She lay upside down on the stairs and this made it feel "a little bit better". She went to the ___ where she was noted to have a temperature of 102.5. She had blood cultures done which were negative and a CXR which was also negative. She was changed from augmentin to clindamycin (which she was supposed to take until ___. She also at this time started to notice a dull chest pressure. On ___ in the morning she noticed that the tip of her R ___ finger and the tips of her L ___ and ___ R finger were dusky and dark. She saw her PCP also on the ___, and he ordered an echo for concern of endocarditis. The echo was read as normal. She also got a "spiral CT of the torso" at ___ given her chest pain and this was read as normal except for some incidentaal small granulomas, per the patient that they felt could be worked up non-urgently. The CT showed interval resolution of the cutaneous emphysema and pneumomediastinum. Then on ___ and ___ she felt "better", but still with some mild chest pressure. She went for a run on the ___ without any issues. She also flew to ___ on ___. On ___ she had "terrible diarrhea" so she stopped her clindamycin 1 day early. She returned home without incident from her trip. She saw her oral surgeon who prescribed her with an antibiotic mouthwash on ___, but that same evening she had the onset of the same mid jaw pain up to her R eardrum that she had had previously with the crepitus, but this time there was no sensation of "crackling" under her skin. She did feel feverish on that day also. She still ahd some augmentin left over from her previous Rx, so she took that BID. On ___ she no longer had jaw pain. Then today (___) she went to church, and when looking up she felt "dizzy" and "funky", but when pressed to explain the sensation more she was unable to better describe it. This went away if she looked straight or down and would return when she looked up again. This happened at 11am. Shortly after that she felt like she had difficulty paying attention. She went home and at around 1pm she went for a run. She was able to run ___ of a mile before she felt her R leg "fly out from under me". She slumped to the ground but didn't fall. She tried to "walk it off" and had no difficulty with walking. Then she tried to run again and her R leg "flew out again". She again slumped to the ground but didn't fall. She had numbness of her R foot below her ankle at this time. She was again able to walk, and then again tried to run and this time also had the same sensation and was forced to walk the rest of the distance to her car. When she got into her car, she felt unsafe driving home because she "could barely press down on the accelerator" and so she called her husband, who brought her to the ___. There, she had a ___ that was read as showing a "basilar artery issue". She was transferred to ___ for further workup as there was no MRI tech available there. In the ___ at ___, the patient reported that her numbness improved slowly. However, she had some involuntary movements that she felt were seizures in the ___. Starting at 5:30pm she had ___ seconds of bilateral leg shaking, which self-resolved. She had 4 more episodses like this between 5:30pm and 6:15pm and each time she felt that the shaking got a "little bit more severe". Then at 6:15pm she had an episode lasting 5 seconds where her bilateral arms and legs were shaking. She reports that she "looked down and thought, I can't stop these". Her husband witnessed the shaking. She had another episode with arm and leg shaking shortly after this one. She was given 2mg IV ativan. She did not have any further shaking episodes after the ativan but did feel "shaky" still. Radiology showed 1. No acute intracranial abnormality. No evidence of infarct. 2. Unremarkable MR angiography of the head and neck. 3. Nonspecific white matter signal abnormality most likely represents the sequela of chronic small vessel disease. The patient was diagnosed with MUSCSKEL SYMPT LIMB NEC, HYPOTHYROIDISM NOS. At the time of discharge, the patient had Transient neurologic event: Migraine varient vs Seizure varient vs other?. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Neuro# No further symptoms reported since admit and overnight on the neurologic unit. She had an MRI which did not demonstrate any new significant pathology. She also had a lumbar puncture and the initial CSF results were all within normal limits. Her examination in the morning was also at baseline without focal deficit. Her symptoms may have been secondary to a seizure but this is not entirely clear at this time. No changes to her medications were made and she was discharged the next day. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ no sig PMH p/w ___ weeks of abdominal pain. He states that for the past ___ weeks he's had LLQ abdominal pain, fatigue, malaise, fevers/chills, and anorexia. He does state that he typically has hard stools and chronic constipation. He denies melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency. He has never had a colonoscopy, and never had symptoms like this before. CT-GUIDED ASPIRATION showed Successful CT-guided aspiration of the 2 largest fluid pockets of the collection without drainage catheter placement due to multiple septations within the collection. Samples were sent for microbiology evaluation. CHEST (PORTABLE AP) showed No acute findings. The patient was diagnosed with Dvtrcli of lg int w perforation and abscess w/o bleeding. The patient was treated with CT guided aspiration of intraabdominal collection ___ Procedure. At the time of discharge, the patient had Diverrticular 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>Mr. ___ is a ___ yo M admitted to the Acute Care Surgery service on ___ from outside hospital with a CT scan concerning for perforated sigmoid diverticulitis with a multiseptated abscess collection. ___ aspiration was preformed. He was made NPO given IV fluids and IV antibiotics and admitted to the surgical floor for continued monitoring and management. On HD4 he was febrile with temperature of 102, white blood cell count continued to rise to 17.8 - antibiotic therapy was changed to zosyn. On HD5, due to increasing white blood cell count, the decision was made to operate. Informed consent was obtained and on ___ he underwent ___ procedure. He received 6 units of FFP intraoperatively for elevated INR of 2.0. Post operatively he was exutbated and taken to the PACU in stable condition then transferred to the surgical floor once recovered. On POD1 he was hemodynamically stable, afebrile, NPO on IV fluids and dilaudid PCA for pain control. Wound vac was applied to midline surgical incision. The patient recovered from his surgery well. His WBC trended down he had no more fever episodes and was HD stable. He began to pass gas and than BM per colostomy and his wound VAC was changed every 3 days. His Jp drain that was left in his pelvic during surgery was removed on the day of discharged. the patient was ambulating easily resumed regular diet and tolerated it well. pathology report showed Diverticular disease with peridiverticulitis and mural abscess formation. Six lymph nodes with reactive changes. The patient received ostomy teaching and was discharged home with ___ for VAC change and with the following recommendations: </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman found down by ___ after an unwitnessed fall. The patient states that she was laying in bed and accidentally rolled off the edge onto the floor striking her head and left shoulder. She does not recall feeling dizzy, lightheaded, SOB, chest pain, palpitations, or any other preceeding symptoms. However, the EMS reports state that the patient reported falling as she was returning from the bathroom when she became dizzy and fell. Unclear whether she lost consciousness. She reports pain in her head, left shoulder, lower back, and right knee. . In the ED, initial VS were 97.6, 62, 177/67/14, 96% RA. Labs notable for HCT 33.1, UA with a few bacteria and trace leuk esterase. CT head neg for acute process. CT c-spine with severe DJD and congenital non-fusion of posterior arch of C1. CXR neg for acute process. EKG showed sinus at 58, incomplete LBBB. Patient was given 4mg IV morphine. Radiology showed 1. Left anterior shoulder dislocation. 2. Pulmonary vascular congestion. Radiology showed Persistent anterior inferior displacement of the left humeral head in relation to the glenoid. Radiology showed Multilevel severe degenerative changes, difficult to assess the lumbosacral junction particularly L5. If there is high clinical concern for acute fracture, CT is more sensitive and should be considered. Radiology showed Status post right knee arthroplasty with prosthesis in anatomic alignment. On the oblique image, there is a linear lucency projecting over the lateral distal femur thought to most likely be artifactual. Not seen on the additional images. Small suprapatellar joint effusion. Radiology showed No acute intracranial process. Radiology showed 1. No evidence of fracture or traumatic malalignment. 2. Severe degenerative changes as noted above. The patient was diagnosed with SYNCOPE AND COLLAPSE, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE, HYPERTENSION NOS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman s/p mechanical fall. . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ yo male with h/o ESRD on HD, CAD, distant seizure, gout, who presents from ___ with concern for UGIB. The patient reports had black stools for ___ days and was feeling nauseous and weak, so he went to ___. There, he was found to have BP 84/51 and HCT of 22. He was given 500cc NS with improvement. His stools were guaiac positive. He was started on protonix 80mgbolus then 8mg/hr, given 1U pRBCs and transferred here. Upon arrival here, the patient had no complaints in ED. In the ED, initial VS were: 99.5 64 129/71 15 100% 2L. HCT here was 23, hgb 8, WBC 11.2 w/ neutrophil predominance CK: 38 MB: 2 Trop 0.21 @1:15am, K 5.4, Bicarb 21 with AG 12 and Lactate:0.9, BUN/creat 105/6.3. . EKG NSR 67, RBBB, LAD, ST depressions in V4 to V5. hemodynamically stable. CXR with no acute changes. He was ordered for 2 more units of PRBCs, transfused 1L NS infusing at 125cc/hr, 2 18g IVs were placed, protonix drip at 8Mg/hr. Prior to transfer the patient’s VS were 125/70 - 64 - 20 - 98% RA. Upon arrival to the MICU the patient was comfortable and denied chest pain, palpitations, shortness of breath or abdominal pain. He did reports occasional lower abdominal cramping and some loose watery stools. He denies fevers, chills, or sick contacts. The patient also reports that he has recently been taking plavix and ASA 325mg. He originally discontinued Plavix as recommended by his cardiologist and increased ASA from 81mg to 325mg. However, he resumed Plavix inadvertently and so was on plavix and ASA 325mg. In addition, he was treated last week with prednisone and indomethacin for a gout flare. Radiology showed Stable cardiomegaly. No evidence of volume overload. The patient was diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS. The patient was treated with ___ Esophagogastroduodenoscopy (EGD). At the time of discharge, the patient had Esophagitis Pyloric ulcer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ yo male with h/o ESRD on HD, CAD, distant seizure, gout, who presented from ___ with concern for UGIB, found to have HCT drop to 22 from baseline ~30. # Acute Anemia: Initially unstable at OSH, stable at ___, initially in MICU, rec'd total 3 u pRBC at ___, additional transfusions at OSH. Most likely secondary to PUD in setting of NSAID use (was recently prescribed endomethacin), platelet dysfunction, and use of plavix (was not supposed to be taking this medication any longer). He underwent EGD which revealed esophagitis with friability and erythema of the gastric mucosa with contact bleeding in the gastroesophageal junction as well as in duodenal bulb and second part of the duodenum. A single superficial non-bleeding 1.5 cm ulcer was found in the pylorus extending into the pyloric channel. Also notable was a single 4 mm nodule of benign appearance in the upper third of the esophagus. The patient was treated initially with IV PPI then transitioned to Omeprazole 40mg BID. Gastroenterology recommended outpatient repeat egd in ___ weeks for biopsies of esophageal nodule, GE junction and evaluation to ensure ulcer healing. They also requested H pylori serologies to be sent as an inpatient, and this request was carried out. He was stable, with brown stool at discharge. # CAD: The patient has a history of NSTEMI with stent in ___. Patient was supposed to be off plavix and only on ASA 325mg per his primary cardiologist, however the patient had been taking plavix because "I didn't think it would hurt and I had some extras lying around." He had some ST depressions in the absence of chest pain, so was ruled out for an MI with serial EKGs and cardiac enzymes. ASA 325mg was restarted after the patient stablized and please note he does NOT need plavix at this time. # CKD: ___ dialysis schedule, continued Renal Caps, Sensipar 60mg daily, Renagel (Sevelamer). # HTN: held amlodipine, atenolol, diazide given hypotension, instructed patient to re-start these medications as tolerated after dialysis. # Seizure d/o: continued lamotrigine and levitiracetam. ===</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 hx of CAD s/p NSTEMI, T1DM (last A1c 8.5%), ___, and multiple prior debridements for non-healing L foot ulcers recently hospitalized for cellulitis of right foot. He was discharged home and when he came back for follow up four days, he was found to have hyperkalemia and ___ from his bloodwork. For his cellulitis, he was initially treated with empiric IV vancomycin and zosyn, transitioned to PO bactrim, cipro, and flagyl per wound culture showing polymicrobial growth (notably MRSA and GNR's). FOOT AP,LAT AND OBL RIGHT showed Retained needle adjacent to the second metatarsal. NOTIFICATION: These results were discussed with The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at approximately 745 am. The patient was diagnosed with Non-prs chronic ulcer oth prt right foot w unsp severity, Acute kidney failure, unspecified. At the time of discharge, the patient had Primary Diagnosis: - Acute Kidney Injury - Hyperkalemia Secondary Diagnosis: -T1DM -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 ___ y/o man with hx of CAD s/p NSTEMI, T1DM (last A1c 8.5%), dCHF, and multiple prior debridements for non-healing L foot ulcers recently hospitalized for cellulitis of right foot, found to have hyperkalemia and ___ on most recent bloodwork, likely secondary to Bactrim and lisinopril further complicated by poor PO fluid intake prior to admission. # HYPERKALEMIA: Patient presented with a serum potassium of 6, which prompted his admission to the hospital. Hyperkalemia occurred in the setting of recent uptrend in creatinine on his prior hospitalization (at that time attributed to prerenal azotemia) in the setting of recent discharge for foot infection on Bactrim, flagyl, and ciprofloxacin. Both Bactrim and the patient's home dose of Lisinopril were thought to worsen the patient's electrolyte abnormality. Upon further review of OMR, patient was noted to often have serum potassium levels between 4.5 and 4.7, which could be suggestive of underlying renal etiology for high normal potassium at baseline. With a minor renal insult, this potassium level became supratherapeutic. Hyperkalemia was treated with multiple bouts of D50 + IV Insulin 10 units, with kayexalate, lactulose, and calcium glucose administered (for concerning T wave peaking noted). Hyperkalemia improved with improvement in renal function (see below). Patient was discharged with a stable K of 5.1, and will repeat labs at the time of his follow-up appointment with primary care on ___. # ACUTE KIDNEY INJURY (baseline Cr 1.1-1.2): Patient presented with increased Creatinine, which was noted on his discharge labs on his prior hospitalization. Uptrend at that time as attributed to a prerenal etiology, and patient was encouraged to increase his PO fluid intake. Patient's Lisinopril and Bactrim were held upon admission in the setting of acute kidney injury and hyperkalemia. Patient was initially hydrated with IV fluids, and encouraged to increase his PO fluid intake. Cr peaked at 1.7, and eventually began to downtrend. Lisinopril was held at the time of discharge; the patient will repeat a Chem-7 at the time of his outpatient follow-up appointment, with the decision to restart Lisinopril to be re-addressed at that time. # R diabetic foot diabetic ulcer complicated by recent cellulitis: Patient was recently admitted for cellulitis of his R foot, and was discharged on Cipro/Flagyl/Bactrim. On current presentation, Bactrim/Flagyl were discontinued in the setting of ___, and the patient was transitioned to PO Clindamycin and Ciprofloxacin. Admission foot X-ray remarkable for retained foreign body (insulin needle); patient was evaluated by his outpatient podiatrist while in-house, who recommended no further intervention at this time, as any procedure to remove the foreign body would likely cause more discomfort and possible infection risk in comparison to leaving it in place. The patient will follow-up with podiatry on an outpatient basis. # T1DM: Patient with hx of T1DM diagnosed at age ___, presenting with most recent A1c of 8.5 in ___. He continued his home insulin regimen while in-house. # Chronic/compensated diastolic CHF: Patient with hx of dCHF with most recent EF >55% in ___. Patient was euvolemic on examination, and was continued on his home medication regimen (with the exception of lisinopril, which was held in the setting of ___ CHRONIC/STABLE/RESOLVED PROBLEMS: # Coronary Artery Disease: Continued home regimen of ASA, carvedilol, atorva # Hypertension: Continued home hydralazine, carvedilol, and chlorthalidone. Lisinopril was held on admission, and was not restarted at the time of discharge. # Hyperlipidemia: Continued home atorvastatin. # Gastroesophageal Reflux Disease: Continued home omeprazole # Depression: Continued home sertraline. # Neuropathy: Continued home gabapentin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: THis is a ___ with significant history of tobacco use who presented with aphasia. Last known well ___ AM when his wife left him to go to work. Per wife, the patient had returned from early AM shift and she had prepared breakfast for him. He ate breakfast and was quite jovial. He then went to lie down at 08:45. Wife left to work at that time. The patient's brother randomly called throughout the day and noted that the patient wasn't making sense on the phone. Wife was alerted and EMS was called. He was taken to OSH and subsequently transferred for left M1 occlusion for evaluation of thrombectomy as he was outside tPA window on arrival to OSH. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Scattered cortical, subcortical and white matter DWI hyperintensities in the left frontal and parietal lobes are consistent with acute infarction after incomplete revascularization of a distal left M1 occlusion. 2. Punctate focus of microhemorrhage in the left parietal lobe. 3. Mild paranasal sinus disease as described above. The patient was diagnosed with Other cerebral infarction. The patient was treated with Thrombectomy. At the time of discharge, the patient had 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>In brief, Mr ___ is a ___ man with h/o tobacco use, glaucoma who presented as transfer from OSH for Left M1 occlusion. LWK ___ at 0845. He came home from work, took a nap. Spoke to his brother over the phone after his nap and was speaking word salad. His wife came home and called EMS. Sent to OSH where CT head showed L M1 occlusion. Outside the window for TPA. Transferred to ___ for thrombectomy. NIHSS at ___ 8. Thrombectomy TICI IIb, admitted to Neuro ICU post angio. Patient continued with aphasia with word finding difficulties but occasionally could be fluent. Naming deficit. Patient's speech improved. Patient has full strength throughout on motor exam. Patient started on aspirin and atorvastatin. LDL 92. Very poor vision in R eye but pt says it is chronic. Urine tox positive for cocaine but patient denies use. Patient counseled on abstaining from cocaine. Patient was monitored on telemetry; found to have asymptomatic sinus bradycardia. MRI brain showed scattered cortical, subcortical and white matter DWI hyperintensities in the left frontal and parietal lobes are consistent with acute infarction after incomplete revascularization of a distal left M1 occlusion, focus of microhemorrhage in the left parietal lobe. TTE performed, showing no intracardiac source of thromboembolism. Normal biventricular cavity sizes, regional/global systolic function. Mild mitral regurgitation. Normal estimated pulmonary artery systolic pressure. Remained stable for the remainder of the admission. Recommendation for outpatient speech therapy. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo G3P___ with several days of intermittent, colicky RLQ pain. Reports that ___ night she awoke from sleep with well localized RLQ pain, and was able to go back to sleep and go into work. Same thing happened ___ night. ___ morning she awoke from sleep with pain again, was able to drink some tea, do some yoga, and eventually had significant enough resolution to go to work. She has a one episode of diarrhea and a BM that day with worsening of her pain, and noted that it continued to come and go. She was seen at the ___ in ___ where blood tests, urine tests, and a KUB were reassuring, and she was called with these results. ___ mornign the pain came again, but resolved enough for her to go out to dinner ___ night. This morning the pain awoke her from sleep at 3am and did not abate. She felt it ___, intense pain, radiating from her RLQ down her anterior leg. During these pain episodes, she felt she could not sit still, and would instead move all around. Today she has had nausea and ___ episodes of vomitting. She has been NPO since 3am. She has never had any similar episodes prior. In the ED she has required 3 doses of morphine 4mg IV. Radiology showed 1. Right adnexal mass, likely ovarian in origin. Given the clinical history, resulting ovarian torsion cannot be excluded, and ultrasound of the pelvis is recommended for further evaluation. Trace dependent free fluid. 2. Incidentally noted partially duplicated left renal collecting system. Dr. ___ was informed by phone by Dr. ___ at 9:45 a.m. on ___. Radiology showed 1. Large right ovary, measuring up to 7.8 cm, with two lesions within. One is a simple cyst, the other may be a solid mass or a complex hemorrhagic cyst. No flow is seen within the possible mass or the ovary in general, which strongly suggests a consideration of ovarian torsion. 2. Moderate free complex fluid, likely hemorrhage. 3. Thickened endometrium measuring 9 mm, should be correlated with the patient's hormonal status. Discussed in detail with OB-GYN service by Dr ___. Operative exploration was performed. The patient was diagnosed with ABDOMINAL PAIN RLQ, ABDOM/PELV SWELL/MASS UNSP SITE. The patient was treated with right salpingo-oophorectomy via mini-laparotomy. At the time of discharge, the patient had ovarian torsion, adnexal mass (pathology pending). The patient was given written instructions concerning 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 taken from the ED to the OR for an exploratory lapartotomy via small Phannensteil incision, evacuation of hemoperitoneum, right salpingoopherectomy of torsed complex right ovary and tube. Please see operative report for full details. From the recovery room, she was transported to ___ ___, where her recovery was uncomplicated. She was discharged home on POD#1 in good condition, ambulating, voiding, tolerating a full diet and with pain well controlled on po pain medications. She will follow up at the ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ped struck by ___ green line, brought in by EMS with R leg pain and deformity. Patient was struck directly in the R leg by train. Per report, the mirror struck her on the back of her head. She reports brief LOC. Radiology showed No acute cardiopulmonary process. No pelvic fracture. DX TIB/FIB AND ANKLE showed Fractures through the mid diaphysis of the right tibia and fibula. Nondisplaced distal fibular fracture. CT HEAD W/O CONTRAST showed 1. No evidence of acute intracranial hemorrhage. 2. Large right frontoparietal subgaleal hematoma with possible calcific foreign body material versus partially calcified sebaceous cyst. No underlying displaced fracture is identified. 3. Moderate cerebral volume loss. CT C-spine without contrast. showed 1. No definitive evidence of acute fracture. 2. Mild anterolisthesis of C4 on C5 and retrolisthesis of C5 on C6, age indeterminate and likely degenerative. Recommend clinical correlation. 3. Moderate degenerative changes of the cervical spine, most notable at C5-C6. 4. Incidental, 5 mm right upper lobe solid pulmonary nodule. If the patient is at high risk for malignancy, recommend chest CT in ___ months. If at low risk, recommend chest CT in 12 months to establish stability. TIB/FIB (AP AND LAT) RIGHT showed Fluoroscopic images from the operating suite shows placement of a intramedullary rod across a fracture of the midshaft of the tibia. Adjacent fibular fracture is seen. The patient was diagnosed with FX TIBIA W FIB NOS-OPEN, MV COLL W PEDEST-PEDEST, TETANUS-DIPHT. TD DT. The patient was treated with R tibial IMN. At the time of discharge, the patient had Right tibia 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 open right tibia fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right tibial IMN which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is tdwb in the right 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: ___ F s/p lap hiatal hernia repair ___ gastroplasty by Dr ___ on ___ presented initially to ___ ___ with weakness, decreased appetite since surgery. She reports less PO intake but is tolerating what she eats. She experienced some nausea today but denies emesis. She is passing flatus and having formed regular bowel movements. Denies abd pain or drainage fro incsion. She is able to do activities around house but has experienced weakness since surgery. No fevers, chills, CP, SOB. On imaging at ___ was found to have a hemothorax and possible extravasatation from the left gastric artery. She was transferred to ___ for further work up and care. Radiology showed No evidence of acute fracture or dislocation of the left ___. The patient was diagnosed with OTHER SPEC COMPL S/P SURGERY, OTHER MALAISE AND FATIGUE, ACCIDENT NOS. At the time of discharge, the patient had s/p laparoscopic hiatal hernia repair with ___ gastroplasty. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F s/p lap hiatal hernia repair ___ gastroplasty by Dr ___ on ___ presented initially to ___ ___ with weakness and decreased appetite since surgery. Her original CT read at ___ indicated there may be active extravasation from the gastric artery so she was transferred to ___ for further workup. Here her main complaint was that she has had trouble caring for herself and she feels "weak." EKG did not show any acute changes. Labs WNL. Additionally she was complaining of left shoulder pain so left shoulder x rays were obtained which did not show acute fracture or dislocation. Upon further review of her images it does not appear that she has any active extravasation of any vessels within her abdomen and that the radiologist may have been seeing staples from her surgery. She has been completely hemodynamically stable while in house. She was started on her home medications and a regular diet. She was seen by social work, case management and Physical therapy who all agreed she was safe to d/c home with services for home health and meals on wheels. She agreed with this plan. She will follow up closely in clinic with her PCP ___ ___ and in surgery clinic later this week.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male who had a motorcycle accident 2 days before presenting to an outside hospital. At the time of presentation he was having significant shortness of breath and was noted to have a large left hemothorax. Chest tube was emergency placed. Initial placement drained 2.2 L blood. He was transferred to BID for further management. On arrival he was hemodynamically unstable and felt responded to blood and resuscitation. A chest tube continued to have significant output, which then dropped off over the course of approximately 48 hours. Chest radiograph showed Left-sided chest tube terminates over the left hemi thorax. Moderate left-sided pleural effusion with adjacent compressive atelectasis of the left lung. CHEST (PORTABLE AP) showed In comparison to prior radiograph of 1 day earlier, a left-sided chest tube remains in place with persistent moderate to large left pleural effusion and adjacent atelectasis or consolidation in the lingula and left lower lobe. New linear atelectasis is present at the right lung base and there remains a persistent linear left perihilar focus of atelectasis. ANKLE (AP, MORTISE AND LAT) LEFT was done. CHEST (PORTABLE AP) showed In comparison to ___ radiograph, a left chest tube remains in place, with an apparently new small left apical pneumothorax. Left pleural effusion and adjacent atelectasis are not appreciably changed when consideration is given to technical differences between the studies. CHEST (PA AND LAT) showed Compared to chest radiographs since ___, most recently ___. Combination of left lower lobe atelectasis and some left pleural effusion unchanged. Small left apical pneumothorax not appreciably changed since ___. Left pleural drainage tube unchanged in position in the left lower hemi thorax, precise location indeterminate. Chest CT on ___ one was equivocal regarding placement of the tube in the collapse left lower lobe. If repeat chest CT is performed for that determination,intravenous contrast agent should be administered. Right lung clear. CT CHEST W/CONTRAST showed Moderate size left hemopneumohydrothorax. Complete atelectasis of the left lower lobe and lingular segments. The tip of the left-sided ICD is inseparable from the left lower lobe pulmonary parenchyma and repositioning is advised. Peribronchial opacity in the right lower lobe may represent aspiration or pneumonia. Radiology showed As above. Radiology showed Interval placement of a second left chest tube. No discernible pneumothorax is identified. Persisting retrocardiac opacity likely reflects a combination of atelectasis and a pleural effusion. Radiology showed No significant interval change since yesterday's radiograph given slight differences in technique. No discernible pneumothorax identified. CHEST (PORTABLE AP) showed Left chest tubes are in place. There is no interval increase in pleural effusion. Heart size and mediastinum are stable. There is no pneumothorax. There is no pulmonary edema CHEST (PORTABLE AP) showed 2 left chest tubes are in place. There is no pneumothorax. There is left pleural effusion, moderate, unchanged. Minimal atelectasis at the right lung base has not changed substantially. No pulmonary edema. Cardiomediastinal silhouette is stable. Radiology showed Unchanged left pleural effusion/hemothorax and left lower lobe CT CHEST W/CONTRAST showed 1. Interval repositioning of a left-sided chest tube, with its tip terminating in the upper pleural space posteriorly. Near complete resolution of a left-sided hemothorax, with residual small left-sided hydropneumothorax. 2. Interval re- expansion of the left lower lobe, with residual subsegmental atelectasis noted. 3. Splenomegaly. Radiology showed Worsening left lung atelectasis. Unchanged left pleural effusion/hemothorax. No evidence of pneumothorax. The patient was diagnosed with Multiple fractures of ribs, left side, init for clos fx, Traumatic hemothorax, initial encounter, Mtrcy driver injured pick-up truck, pk-up/van nontraf, init. The patient was treated with ___: Left VATS washout with chest tube placement. At the time of discharge, the patient had Left posterior rib fractures ___ Left hemothorax with trapped lung. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the ICU for close hemodynamic monitoring. On admission he received 2uPRBCs-however he remained hemodynamically stable since admission. There was concern if his chest tube output remained high or if he was requiring continuous transfusions he would need a thoracotomy. However his chest tube output remained minimal and his pain was well controlled while in the ICU. On hospital day two he was then transferred to the floor Serial chest x-rays showed minimal improvement in the hemothorax. A repeat chest CT on HD4 showed a trapped collection in the left lower lobe. Given the failure to clinically progress, a discussion was had with the patient and a decision was made to proceed with a left VATS with washout of the retained hemothorax. On HD7, the patient was taken to the operating room and underwent a left VATS washout with chest tube placement, 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 tolerating sips, on IV fluids, and PCA for pain control. The patient was hemodynamically stable and had 2 chest tubes in place. POD2 the chest tubes were placed to water seal. On POD3 the left anterior chest tube was removed. POD4 a chest CT showed near complete resolution of the left hemthorax. POD5 the remaining chest tube was removed. . Chronic pain was consulted early on during the admission given the patient's history of heroin abuse and current use of suboxone. Pain was well controlled. Postoperatively, diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge on POD5, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, pulling 2500 on the IS, 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: HISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ with PMH of gout, HTN, ESRD s/p LRRT (___) c/b diabetes and CMV viremia, with multiple recent admissions for hypotension and c/f infection presents with fevers and hypotension. CHEST (PORTABLE AP) showed Status post placement of right IJ central venous catheter which terminates at the cavoatrial junction. CT abdomen and pelvis without contrast showed 1. No acute process in the abdomen or pelvis. 2. Diffuse anasarca. The previously described area of induration in the soft tissues of the right flank is less conspicuous, is felt to represent sequela of volume overload. 3. Diverticulosis, without evidence of diverticulitis. CT CHEST W/O CONTRAST showed 1. Patchy areas of ground-glass opacity in bilateral lung apices, slightly worse on the right worrisome for a multifocal infectious or inflammatory process. 2. Similar appearance of the asymmetrically enlarged left breast with skin thickening, previously evaluated by diagnostic mammography. 3. Small nonhemorrhagic pleural effusions bilaterally. The patient was diagnosed with Sepsis, unspecified organism, Hypotension, unspecified, Other cytomegaloviral diseases, Anemia, unspecified, Nonspec elev of levels of transamns & lactic acid dehydrgnse. The patient was treated with Right CVL ___. At the time of discharge, the patient had Hypotension Insulin dependent 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>**LEAVING AMA** Patient expressed understanding of the risks and consequences of leaving AMA. ___ female with a history of ESRD s/p remote LRRT c/b CMV viremia, type II diabetes, and multiple recent hospitalizations for hypotension re-admitted for fevers and hypotension presumably secondary to rapid steroid taper and adrenal crisis in that regard, though suspicious for undifferentiated systemic illness. #) Adrenal insufficiency: Initially hypotensive concerning for septic shock, though rapidly improved with stress-dose steroids in keeping with secondary adrenal insufficiency in the context of chronic exogenous corticosteroids. Definitive prednisone taper to be determined with mindfulness of supra-physiologic needs. Tapered to 15 mg prednisone daily, will need prolonged outpatient taper and close follow-up. #) Hospital acquired pneumonia: biapical ground glass opacities by CT. Initially received empiric vanc/cefepime for said opacities, which were then transitioned to levofloxacin for 7 day course for treatment of HAP. Smoldering PJP in the context of elevated LDH and prior positive B-D-glucan is conceivable, though never hypoxemic. Could alternatively be a manifestation of pulmonary edema. Evaluated by ___ with plan for bronchoscopy though patient declined and left AMA. Last day of levofloxacin ___. Repeat B-glucan pending on discharge, please refer to ___ if required. #) ESRD s/p LRRT: c/b chronic allograft nephropathy secondary to IFTA of uncertain etiology and CMV viremia, which has since cleared. Renal function at baseline. Immunosuppression lessened in the setting of probable pneumonia. Holding home azathioprine. Continued home cyclosporine, level on d/c: 69. Prednisone as above. Changed home valganciclovir 450 mg QD to Q48H for maintenance dosing. CMV-VL negative. #) Pancytopenia, dual lineage: Presence of macrocytic anemia and thrombocytopenia since at least ___ concerning for MDS or plasma cell dyscrasia in the context of abnormal SPEP of uncertain significance and elevated B2 macroglobulin. No outpatient hematology oncology follow-up due to frequent hospitalizations. Evaluated by inpatient heme-onc team with plan for inpatient bone marrow biopsy though patient decline and left AMA. #) Type II diabetes, insulin-dependent: Labile in the setting of steroids, in the 200s on d/c. Increased home insulin regimen to NPH 30U QAM and Humalog 7U, 8U, 9U standing with meals. Arranged ___ f/u on d/c. #) ___ edema: s/p 40 mg IV lasix while inpatient. Changed home regimen to 40 mg lasix daily from 20 mg BID, please uptitrate as tolerated. TRANSITIONAL ISSUES =================== - Holding home azathioprine on d/c, restart when able. - Discharge prednisone dose of 15 mg daily, please taper to physiologic dose as able. - Unable to obtain inpatient bronchoscopy and bone marrow biopsy for further evaluation as patient left AMA. Please arrange to obtain outpatient. - Pending rheumatologic w/u and b-glucan on d/c. Please follow-up. - Discharge insulin regimen: NPH 30U QAM and Humalog 7U, 8U, 9U standing with meals - Changed valganiclovir dose to Q48H for maintenance dosing. - Please uptitrate lasix as tolerated. Unable to titrate while inpatient as patient left AMA. Changed dose to 40 mg daily from 20 mg BID. - Started on Na bicarb while inpatient. Continued on d/c. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs ___ is well known to the cardiac surgery service. She originally underwent CABG x3 on ___. She was readmitted on ___ for sternal wound dehisence and on ___ underwent bilaterl pectoral flaps and plating with Dr. ___. She was discharged to rehab on ___ on a 6 week course of Vanco and Cipro despite negative OR cultures. Sternal drains placed by plastics remained in place. She was due to f/u with Dr. ___ week to have them removed. Over the past 48hrs she spiked fever and zosyn was added. Today she became acutely SOB and lethargic. She was brought to the ER and was intubated. Head CT was negative (recent hx of stroke after CABG), CTA of chest suggestive OF PE. ALabs, EKG and bedside Echo was unremarkable. During her ER stay she became mildly hypotensive. Central line was placed and she was started on levo. She was admitted cardiac surgery service for further evaluation Radiology showed No acute intracranial process. Radiology showed 1. Equivocal linear filling defects within the right lower lobar and segmental pulmonary arterial branches may represent artifact from severe patient motion vs pulmonary embolism. Consilder followup examination in 24 hours for further assessment. 2. Trace bilateral pleural effusions. 3. Post-CABG and sternal dehiscence repair surgeries. Radiology showed 1. New right internal jugular central line ends in the upper SVC. No pneumothorax. 2. Stable bibasilar atelectasis. Radiology showed 1. Evidence of bilateral pyelonephritis more pronounced on the right than the left without associated nephrolithiasis or hydronephrosis. 2. No other findings to suggest ___ infection. Radiology showed Small bilateral pleural effusions. No evidence of pneumonia. The patient was diagnosed with RESPIRATORY ABNORM NEC, FEVER, UNSPECIFIED, HYPOTENSION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS. At the time of discharge, the patient had mental status changes s/p sternal dehiscence, debridement, sternal plating Coronary artery disease s/p coronary artery bypass grafts hypertension insulin dependent Diabetes peripheral vascular disease hyperlipidemia Breast CA in ___ s/p lumpectomy (radiation therapy with recurrence in ___ s/p right breast mastectomy and reconstruction Left great toe to left shin cellulitis problem Depression Hypothyroidism s/p appendectomy Obesity. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs ___ arrived in the ER from rehab after becoming acutely short of breath, lethargic and developing a rash after receiving a one time dose of zosyn for fever. She was also mildly hypotensive and neo was started. She was intubated and sent for a CTA and head CT to r/o PE. Both were negative for acute processes. ECHO was unremarkable. She was admitted to the CVICU, weaned from the vent and extubated on HD#2. She was pan cultured and continued on Vanco, Zosyn, and Cipro. ID was consulted and recommended all antibiotics be discontinued since previous OR cultures were negative and event was thought to be related to a Zosyn reaction. She was seen by Plastic Surgery - Dr. ___- and one of two JP drains was removed. The remaining JP will be removed at subsequent follow up visit to Dr. ___. On HD #3 she was transferred to the stepdown unit. Her foley was removed but was re-inserted after failing to void. She continued to progress, remained afebrile with normal WBC. She did have large volumes of loose stool which was negative for c-diff and O+P. It was noted that due to her very poor appetite she was only consuming Glucerna whicih caused diarrhea. She was started on banana flakes with significant improvement. She was noted to have a Stage II pressure ulcer on coccyx and was seen by the wound care specialist and regimen of Criticaide and DXeroform gauze was recommended. She was discharged on ___ to ___ Rehab with appropriate follow up appointments.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ year old man with dementia, TIA, pulmonary fibrosis, ataxia with prior falls (most recently ___ who presented from his assisted living facility after a fall. He is very demented at baseline and does not recall any of the circumstances surrounding the fall. The staff at the nursing home noted scrapes on his knees and they were concerned that his mental status was "not normal." In speaking with his health care proxy, he was not as interactive as he usually is and it was difficult to get him to respond to any questions, so he was sent into the the hospital. No other trauma was noted aside from the scraped knees. In the ED, initial vitals were 97.8 95 151/120 18 98%. Exam was notable for his baseline dementia, with knee abrasions bilaterally. His labs were notable for creatinine of 1.2 (from baseline of 1.0) and BUN of 28. His WBC count was 11.5 with 92% PMNs (prior hospitalization 10.4 - 11.5). He had a CT head and C-spine which were unremarkable, CXR without pneumonia, and hip and pelvis x-rays which were unremarkable as well. He was noted to be in atrial fibrillation with RVR with rates in the 130s for approximately one hour. This resolved with 2L NS without the need for rate control medications. He also received 500 mg acetaminophen before being admitted to medicine for monitoring for a complaint of back pain. On arrival to the floor, vital signs were 98.1 119/73 82 18 95%RA. He has no specific complaints and clearly reports that he is not in any pain. In speaking with his neice who is his health care proxy, the circumstances surrounding the fall are unclear. She was worried in the Emergency Department because the patient was not speaking as much as he normally does. She also noted that they recently discontinued many of his medications in an effort to simplify his medication regimen. On review of systems, denies fever, chills, headache, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Radiology showed Similar appearance of the chest with chronic fibrotic interstitial changes most pronounced in the lung apices. These findings could reflect sarcoidosis, but considerations for coalworkers pneumocosis or silicosis should be considered with the appropriate clinical history. Radiology showed No acute fracture or dislocation. Radiology showed No evidence of acute intracranial process. Radiology showed 1. No fracture or traumatic malalignment of the cervical spine. Stable multilevel degenerative changes present. 2. Chronic fibrotic biapical opacities with small nodular opacities and bronchial wall thickening, bronchiectasis. This is concerning for small airways infection versus inflammation superimposed on a background of chronic interstitial lung disease. Chest x-ray is recommended for further evaluation. The patient was diagnosed with ATRIAL FIBRILLATION, ABRASION HIP & LEG, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE. At the time of discharge, the patient had Primary diagnosis: - Syncope with fall - Advanced dementia - Paroxysmal atrial fibrillation Secondary diagnoses: - Prior TIAs - Hyperlipidemia - Pulmonary fibrosis ___ syndrome) - Ataxia - Glaucoma - Chronic constipation - Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old man with advanced dementia, prior TIAs, pulmonary fibrosis, hyperlipidemia, and BPH who presented ___nd was found to have paroxysmal atrial fibrillation with RVR in the ED. # s/p fall: Patient has a history of falls, most recently he was admitted ___ - ___ for a fall resulting in small subarachnoid hemorrhages and an ear laceration repaired by plastics. Given lack of witnesses or history surrounding his current fall, it is difficult to elucidate the underlying etiology. Regarding the trauma, his imaging was all unremarkable (CT head, C-spine, pelvis/hip x-rays). He was noted to be in afib with RVR in the ED. Volume depletion could have caused him to be orthostatic or may have prompted his RVR, which may have contributed to his fall. Stroke or TIA is possible, but he is demented at his baseline and does not have any new focal deficits (slight facial droop and left eye ptosis noted on prior discharge). His orthostatic BPs were positive with SBP dropping from 150s supine to 120s standing. He was monitored on telemetry which revealed paroxysmal atrial fibrillation in addition to his baseline rhythm with what appears to be a first degree heart block. His mental status returned to baseline prior to arrival to the floor and he remained alert and oriented to self only and is interactive and follows commands. He was maintained on strict fall precautions with low bed height and bed alarm. # Atrial fibrillation with RVR: He was noted to be Afib with RVR to the 130s in the ED which resolved with 2L of IVF. The patient was likely volume depleted on presentation, which is supported but slight increase in Cr from 1.0 to 1.2. Patient has CHADS2 score is 4 (hypertension, age, hx of TIA) but is not anticoagulated given recent subarrachnoid hemorrhages, history of falls, and dementia patient does not seem to be a good candidate for anticoaguation at this time. In discussion with HCP, they are not interested in pursuing anticoagulation. He was started on low dose metoprolol as this could potentially decrease his frequency of falls if his atrial fibrillation is contributing. His underlying rate appears to be a first degree heart block with intermittently dropped beats. He was continued on aspirin 81 mg and discharged on new metoprolol succinate 25 mg daily. # Leukocytosis: WBC count of 11.5 on admission which is stable from prior admission. He has a left shift with 92% PMNs, but he remains afebrile without localizing signs or symptoms of infection. CT chest showed increased tree and ___ opacities and bronchial wall thickening with bronchiectasis concerning for small airway infection vs inflammation, however CXR unchanged and patient without respiratory symptoms. Urine and blood cultures were pending at the time of discharge without growth to date. His WBC count fell to 8.9 with fluids indicating that hemoconcentration was possibly playing a role. # Hematuria: Patient incontinent of pink tinged urine while on the floor. This is likely related to foley trauma in the ED. This should continue to be monitored while he is back at his assisted living facility and urology follow up can be considered if this continues and it is within the patient's goals of care. # Pulmonary fibrosis ___ syndrome): Noted on admission CXR as stable from prior. # Hypertension: Recently discontinued lisinopril in an effort to simplify medications. # Dementia/ataxia: Alzheimers vs vascular. recent TSH, RPR, B12 returned within normal limits. He was continued on Namenda 10 mg BID. # Glaucoma: Continued on timolol and travaprost eye drops BID. # Chronic constipation: He was continued on colace, senna, and miralax as needed. # Depression: Patient's mood was stable. His venlafaxine was recently discontinued in an effort to simplify his medication regimen. # Hyperlipidemia: Recently discontinued simvastatin in an effort to simplify medication regimen. # BPH: s/p laser surgery. previously on vesicare however this worsened his mental status. Not currently on medications. # Transitional issues: - Code status: DNR/DNI (confirmed with HCP ___ - Emergency contact: ___ (neice) who is HCP, ___ - Blood and urine cultures pending at the time of discharge. - Patient was started on metoprolol 25 mg PO daily given paroxysmal afib. - Patient was not anticoagulated despite CHADS2 of 4 given recent subarachnoid hemorrhages and frequent falls. - Patient's HCP interested in continued discussions regarding goals of care, specifically having a higher threshold to hospitalize the patient and possibly considering comfort focused care. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of esophageal adenocarcinoma s/p neoadjuvant treatment and then minimally invasive esophagectomy on ___, who presents with 3 weeks of regurgitation of solids and SOB. For the past 3 weeks, she has been unable to keep down any solid food; she can swallow, but a few minutes later feels as though the food is stuck, feels nauseated, she begins coughing, and will cough the food back up. No trouble with liquids. She has also felt SOB intermittently, usually when walking or working, but also occasionally at rest. The patient was seen by her PCP ___ 3 weeks ago when this started, and has since taken courses of azithromycin and levofloxacin, with subjective improvement in SOB when on antibiotics; SOB returned after completing the anitbiotics. No chest pain. No fevers, but occasional chills. Some diarrhea about a week ago. Fluoroscopic upper GI series. COMPARISONS: ___ and CTs from ___. PROCEDURE AND FINDINGS: The patient was brought to the fluoroscopic suite and placed upright on an imaging platform. The patient under fluoroscopic surveillance self-administered thin barium. Contrast was administered orally. Initial scout radiographs demonstrate the patient to be status post esophagectomy with gastric pull-through with relatively high anastomosis. The lungs are clear. There is no pleural effusion or pneumothorax. The cardiomediastinal and hilar contours are otherwise unremarkable. Pulmonary vascularity is not increased. Contrast flows freely through both the anastomosis and also the distal stomach through the pylorus. There is no evidence of outlet obstruction. IMPRESSION: Status post esophagectomy with gastric pull-through with no evidence of obstruction. showed Status post esophagectomy with gastric pull-through with no evidence of obstruction. The patient was diagnosed with RESPIRATORY ABNORM NEC, VOMITING, MAL NEO ESOPHAGUS NOS. The patient was treated with conservative management. At the time of discharge, the patient had -Esophageal adenocarcinoma s/p MIE ___ -Dysphagia -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>The patient was admitted to the thoracic surgery service for evaluation of her regurgitation and shortness of breath, after having been ruled out for PE and PNA in the emergency department. She was kept NPO overnight with IV fluids. She had a swallow study the next morning, which demonstrated contrast flowing freely through both the anastomosis and also the distal stomach through the pylorus, with no evidence of obstruction. By morning, her symptoms had also resolved; she was breathing comfortably and was tolerating solids and liquids by mouth. She never showed signs of infection, and she was hemodynamically stable. She was then discharged home in stable condition, to continue her protonix and anxiolytic medication, and to follow up with Dr ___ in clinic in 1 month. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with H/O breast cancer S/P breast reconstructive surgery, insomnia, depression, and recent hospital admission (___) for hyponatremia thought due to Effexor presenting with chest pain. Patient noticed onset of sudden, sharp left sided chest pain that radiated to the back and left arm the night prior to admission. She had just finished walking home from the ___ in her ___ building and had sat down in her residence when she noticed onset of sharp left sided chest pain. The pain occurred at rest and was not associated with exertion. She denied any nausea, vomiting, diaphoresis, palpitations, shortness of breath or lightheadedness. She took a baby aspirin but the pain persisted so she presented to the ___ emergency department. Radiology showed 1. No evidence of aortic dissection. 2. Postsurgical changes in the left breast and likely postradiation changes involving the lingula and left upper lobe lung apex. The patient was diagnosed with CHEST PAIN NOS, HX OF BREAST MALIGNANCY. At the time of discharge, the patient had Primary: costochondritis Secondary: -aortic atherosclerosis -insomnia -depression -breast cancer -radiographic pancreatic lesion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with H/O breast cancer S/P chemotherapy, radiation therapy and left breast reconstruction using a right rectus flap, insomnia, depression, and recent hospital admission (___) for hyponatremia thought due to Effexor presenting with chest pain. While awaiting a biomarker series to exclude acute coronary syndrome, she was transferred to ___ when the ___ CTA was interpreted as possibly suggestive of a small aortic dissection. # ? Aortic dissection: CTA at ___ was interpreted formally as "The assessment of the aorta demonstrates focal minimal area of calcification in the distal portion of the aortic arch with associated linear low density opacity most likely representing part of the plaque but focal minimal area of dissection cannot be excluded." Patient had limited risk factors for dissection (no HTN, no reported atherosclerosis), pulses and BPs were noted to be equal in both arms. She was admitted to the cardiology floor where blood pressures were monitored and remained in the 110s-120s systolic. Repeat CTA was done on ___ which showed no evidence of aortic dissection. The imaging finding on the other CTA was presumably an atherosclerotic plaque, perhaps slightly ulcerated. # Chest pain: Patient presented with pain in left chest reproducible with palpation on exam. Troponins were negative x3 between the outside hospital and labs done in the ___. EKG was unchanged from prior. She notably has minimal risk factors for CAD. Echocardiogram in ___ was normal without evidence of post-chemotherapy LV systolic dysfunction, and she had a stress test in ___ that was negative. Given the fact her pain was reproducible by palpation and not provoked by physical activity, a musculoskeletal cause, such as costochondritis, was deemed much more likely than ischemia. Patient was given acetaminophen overnight with good effect. On day of discharge, patient did recall that she had this problem a few years ago after reading for a long time and thought it could be due to her body position while reading. Since she presumably has a pedicled abdominal flap that was redirected to her left chest as part of her reconstructive surgery, it is conceivable that when she sits in certain positions, the circulation to part of her chest wall via the neurovascular bundle originating in her abdomen might be compromised. It was recommended to the patient that she be mindful of ergonomics and change positions often while seating for long periods of time. # Insomnia and depression: Recent admission for hyponatremia due to effexor. Mood reported as stable, currently getting ECT on an outpatient basis. Continued buproprion. # Breast cancer: on maintenance hormonal therapy, stable # Pancreatic hypodensity: CT imaging from OSH incidentally noted a hypodenisty in pancreatic uncus and recommended ___. Official interpretation commented that it could also be artifact due to shadowing. Patient was informed of this result on day of discharge and recommendation for f/u ___. TRANSITIONAL ISSUES 1. Patient remained full code 2. PCP can consider ___ for further characterization of incidental pancreatic finding on CT from ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with PMHx of DM, HTN, HLD, hypothyroidism, essential tremor, who presents with an unwitnessed fall. She reports that she has had two falls in the last week. She was found by her neighbor on the ground this morning when the neighbor came over to check on her. She denied any headache, dizziness, chest pain, shortness of breath, neck, back, or extremity pain at this time. Chest: Frontal and lateral views showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process. Specifically no intracranial hemorrhage. 2. No fracture. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes of the cervical spine most severe at C6-7 and C7-T1. The patient was diagnosed with Weakness, Urinary tract infection, site not specified, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had E coli UTI E coli bacteremia Sepsis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES: -She will need follow up regarding the carbidopa-levodopa started as an outpatient for the essential tremor. They may be causing a feeling of slower mentation that the patient has been describing. -She will finish a course of antibiotics (PO cipro) on ___. -She has a murmur on auscultation. Echo was done, but no report yet at time of discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a very pleasant ___ year old female with hx CHF w/preserved EF, and pAFib on Xarelto who presents with arm pain. Pt states she had L arm pain starting at the shoulder and radiating down the hand, which she states is worse with urination. The pain resolved in the ED however she was noted to be hypoxic to the low ___ on RA which is new for her. Of note she recently also had dysuria and was treated with fosfomycin on ___, however her dysuria symptoms have persisted x2 days. On further questioning about her respiratory status, pt states that she has had SOB and nighttime cough, which she attributes to PND, for ___ years. She notes that she used to be able to walk 3 miles but now she is only able to walk 10 min before getting SOB. She also tells me that she sleeps on 2 pillows at night. Denies CP/n/v/d/f/c/ wheezing. She states that she is currently thirsty, denies recent dietary indiscretion or increased salt intake, has been taking all her meds as prescribed. Chest: Frontal and lateral views showed Hyperinflated lungs. Increased interstitial markings are similar to slightly increased compared to the prior study from ___, concerning for moderate interstitial edema and/or chronic lung disease. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had Acute on Chronic Diastolic Heart Failure 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 very pleasant ___ year old female with hx multiple falls, CHF w/ preserved EF, and pAFib on ___ who presents with arm pain and found to be hypoxic. # Acute on Chronic dCHF: Pt presenting with hypoxia and reports of DOE and possible PND. Also with ___ edema as well as some recent weight gain. ECG reassuring, and Tn negative x 2. She was given IV diuresis on presentation and then transitioned to Lasix 40mg BID which she will continue for 2d after discharge and then continue 40mg Lasix in AM and 20mg in ___ afterwards. Her weight prior to discharge was 151.9 lb. Creat rose slightly before discharge and she declined to have labs repeated on dday of discharge. # UTI: Unclear if this is truly an ongoing infection, as she gave conflicting reports as to whether she was still having dysuria. Urine cx with mixed flora. Decided to continue CTX for 3 day course for uncomplicated UTI as unclear if pt has a true infection. # Paroxysmal atrial fibrillation: Stable, currently rate controlled. Continued home Rivaroxaban, propranolol, and amiodarone. # Hypertension: continued home meds # HLD: continued statin # CODE: confirmed full # CONTACT: Name of health care proxy: ___ Relationship: daughter Phone number: ___ Cell phone: ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with AF on Coumadin, history of digoxin use, who presented with tachypnea. In the ED, pt initially triggered for hypotension, tachypnea and tachycardia. Trachycardic to 130 in afib with RVR and was intubated shortly after. Radiology showed As above. ETT somewhat high-riding and may benefit from slight advancement. CT abdomen pelvis without contrast. showed 1. Circumferential thickening of the urinary bladder and stranding is concerning for cystitis. Correlation with UA is recommended. 2. Bladder diverticulum containing a 12 mm stone. Non-urgent urology consultation recommended. 3. Small volume intraperitoneal ascites. 4. Left nonobstructing renal calculi. No hydronephrosis. 5. Please see CT chest performed concurrently for detailed intrathoracic findings. CT chest without contrast. showed 1. Right middle lobe wedge-shaped peripheral consolidation. Infarct could be considered in the appropriate clinical setting. Follow-up in 3 months is recommended to ensure resolution. 2. Bilateral pleural effusions with overlying compressive atelectasis. 3. Extensive vascular calcifications, compatible with atherosclerotic change. 4. Please see CT abdomen pelvis that was performed concurrently for detailed intra-abdominal findings. CHEST (PORTABLE AP) showed NG tube tip is in the stomach. ET tube tip is 5.5 cm above the carinal. Heart size and mediastinum are unchanged including cardiomegaly. Bilateral pleural effusions, right more than left are substantial. Right basal more nodular opacity represents a right middle lobe lesion, better characterized on ___ chest CT. No pneumothorax. CHEST (PORTABLE AP) showed Comparison to ___. The effusion on the right. Is still moderate in extent and has not substantially changed. A minimal left effusion and a left retrocardiac atelectasis is also stable. Moderate cardiomegaly persists. In the interval, the patient has been extubated. No pulmonary edema. No pneumothorax. Video oropharyngeal swallow showed 1. Gross aspiration with thin and nectar thick liquids. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology showed Successful placement of a left 47 cm basilic approach double lumen PowerPICC with tip in the distal SVC. The line is ready to use. DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS showed Dobhoff tube is coiled in the stomach. Interval decrease in moderate right pleural effusion. Right lung lesion is concerning for possible lung mass and should be followed closely with subsequent radiographs. NOTIFICATION: The findings were discussed with Dr. ___ , M.D. by ___ ___, M.D. on the telephone on ___ at 8:16 AM, The patient was diagnosed with Sepsis, unspecified organism, Severe sepsis with septic shock, Hypokalemia. The patient was treated with arterial line- ___ CVL placement- ___. At the time of discharge, the patient had Septic shock secondary to urinary tract infection Hypoxic respiratory failure Severe metabolic acidosis ___ secondary to acute tubular necrosis Acute HFrEF Hyperkalemia 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>PATIENT Mr ___ is an ___ year old man with a history of AF on warfarin, nephrolithiasis, hypothyroidism, urinary incontinence and G6PD def admitted to the ICU ___ and with ___ (baseline Cr 1.0), refractory acidemia, hyperkalemia and septic shock. ACUTE ISSUES # Septic Shock: Initial presumed source pulmonary vs urinary. Started on vanco, cefepime, and levofloxacin for broad coverage. Lactate initially severely elevated, but resolved with volume resuscitation. Weaned off pressors ___. Small volume ascites non-tapable. GNRs in urine ultimately speciated two colonies of E. coli, antibiotics subsequently changed to IV unasyn. MRSA screen negative. The patient should continue the IV unasyn until ___ to complete a 14d course of antibiotics. # Hypoxic respiratory failure: Felt multifactorial from volume resuscitation ISO sepsis, moderate right sided pleural effusion, and possible aspiration. TTE demonstrated that new global systolic hypokinesis / LV dilation with EF of ___ and 2+ mitral regurgitation, which was felt to be in the setting of septic shock and myocardial stunting. Extubated successfully to facemask on ___ (HD #2) and was weaned to room air. # ___: Patient developed Non-oliguric ATN, likely secondary to septic shock. Baseline cr 1.0, with peak value of 2.9. After resolution of sepsis, patient began to urinate and autodiurese (post-ATN diuresis). Acidemia and hyperkalemia improved with concurrent improvement of renal function. Renal was consulted, but patient did not require RRT at any time this hospitalization. # CHF: Patient noted to have elevated BNP at admission, with hypoxia as noted above. TTE demonstrated that new global systolic hypokinesis / LV dilation with EF of ___ and 2+ mitral regurgitation. Unclear etiology at this time, unclear if chronic (from tachymyopathy) or acute (from myocardial suppression of sepsis). Started on metoprolol and uptitrated for rate control. # Severe academia: Pt admitted with pH 7.09, due to severe lactic acidosis (initial lactate 7.5) and uremia. Patient was initially treated with bicarb amps and a bicarb drip. With volume repletion and correction of underlying sepsis, academia improved. However, he continued to have a non-anion gap metabolic acidosis (with concurrent respiratory alkalosis) later during his hospitalization. # Hyperkalemia: in the setting ___ and ___ academia, patient's intial potassium (non-hemolyzed) was 7.3. EKG without concerning changes. Initially temporized with furosemide, insulin/dextrose, and calcium gluconate. Bicarbonate treatment for academia also reduced serum levels considerably. After volume repletion and treatment of sepsis, potassium levels normalized. # AFib: Previously on dig, stopped ___ PTA. On warfarin. Tachy in the setting of sepsis, but rates improved with volume resuscitation, and later initiation of metoprolol. Once coagulopathy was reversed, the patient's home warfarin was restarted. # Bladder Diverticulum: Likely ___ chronic renal stones. Outpatient f/u. TRANSITIONAL ISSUES [ ] check thigh blood pressure (BP on arms SBP 30mmHg lower than A line, thigh was congruent) [ ] TTE in 1 month to follow-up newly reduced EF [ ] CXR in ___ weeks for evaluation of pleural effusion on R sided lung mass [ ] needs ACE inhibitor restarted as an outpatient [ ] Pt will complete a 14d course of antibiotics for sepsis, end date of unasyn ___ [] Pt needs urology follow-up as an outpatient for bladder diverticula</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx DM2, dementia, HTN, HLD, who presented to the ED yesterday with complaint of right knee pain x 2 days. She reports that 2 days prior to presentation, she bent over while standing to pick up her cane and she felt a "pop" in the knee. Since this time, she's had increased difficulty bearing weight, and ranging that knee. She reports increased swelling and warmth in the knee, though denies any fevers, chills, sweats. Denies any other trauma to the knee. She does report mild pain in the left knee as well as in her right shoulder, though pain there is chronic. Radiology showed Tricompartmental degenerative changes without acute fracture. Moderate suprapatellar effusion. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the lung volumes have slightly decreased and a platelike atelectasis is seen at the right lung bases. Otherwise no relevant changes. No pneumonia, no pleural effusions, no pulmonary edema. CHEST PORT. LINE PLACEMENT TECHNIQUE: Portable Chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Right PICC terminates in upper to mid SVC. There is no consolidation, pleural effusion, or pneumothorax. Cardiomediastinal and hilar silhouettes are normal size. IMPRESSION: Right PICC terminates in mid to upper SVC. showed Right PICC terminates in mid to upper SVC. The patient was diagnosed with PYOGEN ARTHRITIS-LOWER LEG. The patient was treated with ___: Right knee irrigation & debridement. At the time of discharge, the patient had Septic right knee (native). The patient was given written instructions concerning 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 septic right native knee and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right knee irrigation and debridement, 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 infectious disease team followed her during this admission for her joint infection. She will be maintained on IV Cefepime 2g q12h for 6 weeks (end date: ___. She has been scheduled with follow-up appointments in ___ clinic for monitoring of her native knee infection. She will receive antibiotics through a PICC line that was placed during this hospitalization. Please see infectious disease instructions in the discharge paperwork for antibiotic and lab testing follow-up, and for where lab results should be faxed (OPAT note also in OMR). The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ old man with a history of idiopathic unilateral vocal cord paralysis, left paraclinoid aneurysm s/p clipping c/b visual loss, transient L ICA occlusion and asymptomatic parietooccipital stroke who presents with unsteady gait and worsening vision which started ten days ago and worsened eight days ago. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Dental streak artifact, left ophthalmic artery aneurysm clip, and left frontal craniotomy or hardware streak artifact limits examination. 2. A 5 mm aneurysm is identified at the left paraclinoid ICA slightly larger compared to ___, finding is suggestive of recanalization. 3. A 2 mm aneurysm at the superior wall of right MCA M1 segment is unchanged. 4. Likely sequela of old infarct in the left parieto-occipital regions appear similar to before. 5. Please note MRI of the brain is more sensitive for the detection of acute infarct. NOTIFICATION: The findings regarding slightly increased size of left ICA aneurysm were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 5:31 ___, 3 minutes after discovery of the findings. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. No acute intracranial hemorrhage or infarct. 2. Encephalomalacia of the left precentral gyrus, left parietal and left parietal occipital lobe likely represents sequela of interval infarcts since examination of ___. 3. A single FLAIR hyperintense focus of the left centrum semiovale likely also represent sequela prior infarct. This is not in a distribution commonly seen in setting of demyelinating process. CHEST (PORTABLE AP) showed Compared to chest radiograph ___. Aside from the new linear atelectasis or scarring in the left midlung, lungs are clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Vestibular neuronitis. The patient was given written instructions concerning 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 neurology service given concern for possible cerebellar stroke. However, upon repeat exam, it was thought his presentation was more likely consistent with a peripheral vestibular dysfunction, possibly post-infectious given a recent illness. He had L beat nystagmus on L gaze with falling/swinging to the left; nystagmus resolved and he was ambulating indepdently with ___. The rapid resolution of symptoms was also more suggestive of a post-infectious transcient peripheral process. Of note, his clipped L left paraclinoid ICA aneurysm is 5mm, from 4mm previously and may represent recanalization as seen on prior imaging. This should be followed by neurosurgery as an outpatient. His MRI revealed ___ acute/subacute infarct. LDL 102 and A1C 5.2%. Patient was continued on atorvastatin 20mg and started on aspirin 81mg upon admission. ASA 81mg was discontinued after his MRI revealed ___ infarct, and his atorvastatin 20mg home dose was continued. He was monitored on telemetry without abnormality. He will be discharged to home. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of sigmoid colectomy for colon cancer in ___, now with 1-day history of nausea and abdominal pain. She was in her usual state of health until yesterday, when she developed epigastric abdominal pain and nausea. She had 2 episodes of non-bloody, non-bilious emesis. She last passed gas and had a bowel movement yesterday. She has no history of bowel obstruction. Had a normal colonoscopy earlier this month. Radiology showed No acute cardiopulmonary process or evidence of pneumoperitoneum. Radiology showed Small bowel obstruction with two transitions at the same location, 3 cm medial and superior to the sigmoidectomy anastamosis, concerning for closed loop obstruction from a single adhesion/band. The intervening small bowel is thickened with mesenteric edema, concerning for early ischemia. No pneumatosis or free air. NOTIFICATION: The findings were discussed in person and over the phone by Dr. ___ with Dr. ___, 5 minutes after discovery, approximately ___:40 on ___. The patient was diagnosed with Epigastric pain. The patient was treated with Closed loop small bowel obstruction with periaortic mass causing the closed loop bowel obstruction. -Open exploratory laparotomy, small bowel resection. 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>Patient is a ___ year old female with a known history of colon cancer s/p resectionx2 and HBV who presented to ___ ED on ___ due to abdominal pain and several episodes of emesis. Abdominal CT was consistent with a small bowel obstruction with concern for a close-loop obstruction and early ischemia. The patient was evaluated by the surgical staff expeditiously and due to her positive exam and concerning radiological findings that patient was consented and taken to the OR for an exploratory laparotomy, please view the operative note for further details. The patient tolerated the procedure well, and transferred to the floor in stable condition. In the initial post-op period the patient was managed with NPO/IVF, PCA for pain control, and serial abd exams. The patient was kept NPO until return of bowel function, at which point her diet was sequentially advanced to a regular diet which was well tolerated. Her pain had been well controlled on a PO regimen, and the patient ambulated independently, and discharged home on hospital day 7. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a dPCA and then transitioned to oral oxycodone/tylenol once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO, the diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with diabetic neuropathy s/p right first toe amputation ___ returns with a 12 day history of right second toe pain, erythema and serosanginous discharge after stubbing his toe. He has noticed progressive redness, swelling, erythema and drainage from the nail bed extending only to the base of the toe. There has been no cellulitis extending up the foot. He has not experienced any fever, chills, shortness of breath, chest pain, nausea, vomiting or diarrhea. ROS otherwise negative. Radiology showed No radiographic evidence for osteomyelitis. No acute fracture or dislocation is identified, but please note that evaluation is slightly limited as an oblique view of the right foot was not obtained. Radiology showed Subcutaneous foci of air at the second distal phalanx. Correlate for any signs of infection, recent debridement or ulceration. Findings paged to the nurse covering for Dr. ___ on ___, who was in the OR. Radiology showed No new infiltrate. The patient was diagnosed with ULCER OF OTHER PART OF FOOT, CELLULITIS, TOE NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN. The patient was treated with Right second digit amputation ___. At the time of discharge, the patient had Right second digit 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>Pt was admitted for R second digit infection. IV antibiotics (vanc/cipro/flagyl) were started on the night of admission and pt had non-invasive vascular studies the following morning, which showed no evidence of large vessel arterial disease in the legs. Labs were drawn, which were essentially within normal limits. Foot x-rays were concerning for osteomyelitis in the distal ___ digit. On ___, pt taken to OR for digit amputation. Pt tolerated the procedure well and was discharged on a two-week course of minocycline.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: We had the pleasure of seeing Mr. ___ in the ___ Pancreas and Liver Institute today. As you know, he is a ___ year old man with a history of longstanding iron deficiency anemia and B12 deficiency with a 2.5cm mass in D2 with poorly differentiated adenocarcinoma. He underwent a pylorus sparing radical pancreaticoduodenectomy with en bloc resection of the transverse mesocolon and placement of fiducials on ___ and presents today for follow up. Radiology showed Right PICC tip over the right atrium. Improving left basilar opacity. Radiology showed Successful exchange of a gastrostomy tube for a new 18 ___ MIC gastrojejunostomy tube. The tube is ready to use. CT ABD AND PELVIS WITH CONTRAST showed 1. Small low-density lesion in the hepatic dome seem slightly larger measures 0.7 cm, previously 0.5 cm. This is incompletely characterized on this exam. 2. Interval improvement of subsegmental left lower lobe atelectasis with few areas focal hypoenhancing which could be due to retained secretions or small areas of infection. 3. Interval resolution of small right pleural effusion. RECOMMENDATION(S): Recommend further evaluation with liver MR after improvement in ___ condition, preferably in no more than 1 month. G/GJ/GI TUBE CHECK showed Multiple serial abdominal radiograph status post injection of a gastrojejunostomy tube demonstrate contrast only within the gastric lumen, consistent with proximal migration of the gastrojejunostomy tube. The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:32 am, 5 minutes after discovery of the findings. Radiology showed Continual migration of G-J tube back into the stomach. Unable to maintain G-J access with the current track access into the stomach. Therefore, G tube left in stomach currently. If a GJ tube is needed, recommend a new enteric access for better angulation and positioning. The patient was diagnosed with Dehydration, Weakness. The patient was treated with ___: EGD . ___: Exchange of a gastrostomy for an 18 ___ MIC gastrojejunostomy tube.. At the time of discharge, the patient had 1. Adenocarcinoma, intestinal type 2. Delayed gastric emptying 3. 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>Mr. ___ was sent to the ED from clinic on ___ with dehydration in the setting of not being able to get his TPN due to a nonfunctioning PICC line. Upon arrival to our ED his PICC was able to be accessed and he was given fluids. Gastroenterology was consulted for EGD and possible GJ tube exchange. Per GI they would want to wait 6 weeks from PEG tube placement so EGD was deferred to as an outpatient. ___ was consulted on ___ for placement of a GJ tube. This was successfully accomplished on ___ and he was transitioned off TPN to tube feeds. After starting tube feeds, he developed an episode of hypotension and was febrile to 100.2. Broad spectrum antibiotics including vancomycin, cefepime and flagyl were started. His PICC line was discontinued. Blood cultures eventually grew sensitive E. coli. Infectious disease was consulted and recommended a 2 week course of Bactrim from last negative blood cultures. Blood cultures were with no growth since ___. His vitals remained stable throughout his remainder hospitalization and he has been afebrile. His tube feeds were cycled on ___. Hpwever, the morning of ___, his G tube was unclamped due to nausea and 600cc of tube feeds had come out of the G tube. A drain study verified that the J tube had been dislodged and was no in the stomach. Per interventional radiology, a new site would have to be used. The patient was given a subsequent trial of PO. He was started on fulls on ___ and advanced to a soft mechanical diet on ___ with good results. However he was not taking in enough to nutritionally sustain himself and he eventually tube feeds was restarted overning to provide 50% daily calories. He continued to tolerate PO around the feeds. He was eventually discharged home on ___ with plans for outpatient follow up. The patient and family verbalized understanding and were agreeable with the plan moving forward. All questions were answered to their satisfaction. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The pt is a ___ M with history of Pancreatitis, Diabetes, HTN, Depression, Anxiety, Chronic left hip and back pain, Migraines, who presents with 6 days of severe headache, initially intermittent and now constant. Patient reports that headache started last ___. Initially pain was on left side of head and was burning and then excrutiating, radiating to ___, lasting about 1.5 hours at a time, and would come and go. On ___ around 3am he woke up from sleep from the pain, now on the right side of his head. Felt like skewer from back of head out his right eye and then from temple to temple. Headache persisted and became more and more intense and now constant. Patient tried Excedrin and Oxycodone at home without relief. Of note, he did run out of home meds recently so has not had BP meds or Gabapentin. No recent illness that he recalls. Now pain is constant, ___, stabbing and painful and hollow, and feels like it has a grip on him and won't let go. Patient also with severe photophobia, unable to open eyes secondary to pain. Denies diplopia or blurred vision. Describes burning on right side of face but no numbness or tingling elsewhere. No weakness. No positional component to headache. No gait instability. No speech changes. Radiology showed 1. No acute intracranial abnormality. 2. Opacification of the right mastoid air cells may represent mastoiditis or eustachian tube dysfunction. There is no evidence of bony remodeling. NOTE ADDED IN ATTENDING REVIEW: The fluid-opacification of many of the right mastoid air cells is not significantly changed from the non-enhanced MR study of ___, when there was no definite corresponding slow diffusion. This is unlikely to reflect eustachian tube dysfunction, as the ipsilateral middle ear cavity is completely clear. Correlate with clinical signs of mastoiditis. Radiology showed 1. There is a vein crossing the trigeminal nerve root entry zones on each side. Similar findings may be associated with trigeminal neuralgia, but may also be seen in asymptomatic patients, and clinical correlation is needed. 2. Chronic opacification of right mastoid air cells with apparent viscous material, without evidence for osseous destruction on the preceding CT scan, and without middle ear cavity involvement. Please correlate clinically with any signs of chronic infection. The patient was diagnosed with HEADACHE. At the time of discharge, the patient had Primary headache. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ M with history of Pancreatitis, Diabetes, HTN, Depression, Anxiety, Chronic left hip and back pain, Migraines, who presents with 6 days of severe headache, initially intermittent and now constant. Progressed from intermittent burning left sided headache to constant stabbing and intense right sided headache. Woke from sleep once. Differential includes migraine headache given unilateral, throbbing, with photophobia and nausea. Also prior history of migraines. However, burning sensation, on right side of face and eye and jaw, is also suspicious for trigeminal neuralgia. Other possible headaches include: primary stabbing headache, cluster headache. Neuro: Obtained NCHCT and MRI brain, both unremarkable. Restarted home Gabapentin. Started Indomethacin and initially Amitrityline, later stopped given psychiatric history. Limited opioids given on narcotic contract. Pain team consulted and after discussion with PMD, increased oxycodone dose by 50% for duration of hospitalization, although this helped with back pain, not headache. Trialed occipital nerve blocks twice and preauricular nerve block once given positive trigger points with some headache relief. Also trialed Toradol, Compazine and Magnesium per pain team recommendations. Headache improved throughout hospitalization. CV: Increased Atenolol to 100mg po daily for BP control given persistently hypertensive. Endo: Started ISS for hyperglycemia. To discharge on home Gemfibrozil and Glipizide.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Reliability: Patient with underlying dementia, AAOx1. Collateral information obtained from HCP. ___ dementia, CLL, atrial fibillation that was transferred from ___ for spine fracture evaluation. He apparently experienced an unwitnessed fall, but may have had a syncopal episode. When he was found on the floor, he was conscious and mentating well. The story is not clear given underlying dementia. CT Neck revealed a cervical spine fracture. He was hospitalized in ___ for urinary retention with a urinary tract infection with indwelling foley catheter since that time. Patient lives in assisted-living, has help with ADLs/AIDLs. He does not use any assistive devices except glasses. Patient has fallen once in the past in setting of illness about ___ years ago. He states that he remembered the whole episode this morning. He denies any associated chest pain/discomfort, shortness of breath, "black outs," warmness, seizure activity. He states that he was looking for something and "went to the ground." He denies loss of consciousness and remembers the entire event. He states that someone found him on the floor. His main concern is right posterior shoulder pain. Radiology showed 1. No definite acute traumatic findings. 2. Pagetoid disease of bone as detailed without acute fracture. Compression deformities in the spine appear chronic. 3. Trace right pleural effusion. Mild cardiomegaly. 4. Partially imaged fluid-filled distended corpora cavernosa of unclear etiology or significance. Clinical correlation and, if indicated, correlation with ultrasound recommended. 5. Fluid within the esophagus, which could predispose to aspiration. Radiology showed 1. Limited radiograph demonstrating no gross evidence of fracture or dislocation. If symptoms persist, repeat radiographs with standard positioning would be recommended when the patient's condition permits. 2. Findings suggestive of Paget's disease. The patient was diagnosed with FX C5 VERTEBRA-CLOSED, UNSPECIFIED FALL, DEHYDRATION, URIN TRACT INFECTION NOS. At the time of discharge, the patient had Primary: C5 cervical fracture, paget's disease of the bone, atrial fibrillation, advanced dementia Secondary: Hypertension, hyperlipidemia, benign prostatic hypertrophy, chronic lymphocytic leukemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ dementia, CLL, atrial fibrillation that was transferred from ___ for spine fracture evaluation, admitted for possible syncope work-up. #Orthostatic hypotension and syncope. Per report, patient did not have frank loss of consciousness, although is dry on exam. Patient does endorse remembering entire event with no associated symptoms. Of note, he has been on Bumex for at least 8 months and is dry on exam. Per report, patient has been on tamsulosin for years (according to his HCP). Cardiac history is significant for atrial fibrillation, and ? MI based on prior ECHO. Admission ECG showing ? LAFB, do not appreciate prior infarct, has negative troponin. Wells score for PE low risk (1.3 %) based on HR > 100 (CLL not under treatment). Labs are suggestive of hypovolemia (hyaline cast, mild azotemia), and exam shows notable dehydration. Overall favor that patient fell from dehydration. Tropoinins negative x2. Right shoulder without evidence of fracture, with Paget's disease evidence. Echo without WMAs and preserved EF. We volume resuscitated the patient and he was able to walk with nursing assistance and wearing his brace. We held Bumex and Flomax during the hospitalization. -Hold Bumex -Hold Flomax but can restart in rehab when patient taking better PO's and during the time when the Foley will be taken out. #C5 non-displaced fractures of bilateral C5 pedicles and lamina and right sided shoulder pain: Neuro exam non-focal. Etiology could be from ? Paget's disease based on radiological examination. Alk phos is normal at 69. Shoulder films negative although limited. Patient is to continue medium aspen hard collar at all times for 6 weeks (until early ___. Pain control with acetaminophen standing 1000mg TID and tramadol 25mg q6h PRN pain and Lidoderm patch. Spoke with neurosurgery again, no possibility for taking off collar during day to eat. -follow-up with Dr. ___ in ___ clinic in ___ervical spine (___) #Atrial fibrillation CHADS 2 of 2 for age and HTN. Patient had episode ___, likely secondary to pain versus hypovolemia versus patient being on metoprolol as an outpatient for rate control in the past, but having it stopped within the last year. Patient back in sinus rhythm now. Outside echo reassuring (EF 55%, normal wall motion). Previous EKG is similar. We continued digoxin .25mg M, W, F and started metoprolol which controlled the patient when he was taking it. We discharged the patient on 25mg metoprolol succinate daily, which he was taking in the past. Patient was not on systemic anticoagulation as outpatient given his previous history of atrial fibrillation, and with his fracture, we did not start anticoagulation in house. We will have the patient follow up with cardiology as an outpatient (patient had never seen) to determine anticoagulation. -consideration of anticoagulation as an outpatient #Fevers and positive UA. Patient asymptomatic and growing MRSA from his urine, possible explanation of fevers, although also possible is due to questionable aspiration event. Leukocytes likely secondary to long term Foley. He recently did have urinary tract infection in setting of urinary retention (E. coli - resistant to fluoroquinolones). Imaging incidental showing distended corpora cavernosa. CT Abd/pelvis also made note of circumferential wall thickening with ? bladder stone. Initial urine culture positive for ___ staph (likely contaminant). Foley replaced ___ -Follow up with Dr. ___ urology #Difficulty swallowing: patient per report able to swallow at rehab and drink thin liquids without difficulty. In hospital with ___ J collar on patient has intermittently had difficulty swallowing. ___, patient failed speech and swallow study. We discussed possibility of ___ tube with HCP and he stated that this and a PEG tube would be inconsistent with the patient's wishes. Will readdress when patient has done swallow evaluation. Per repeat speech and swallow evaluation, we were able to advance to nectar thick liquids, soft solids, 1:1 supervision, meds crushed with purees. It is likely patient was having difficulty due to the collar in place. #Thrombocytopenia: patient baseline platelet count between 80-200k per outpatient records. Currently within this range. Etiologies of thrombocytopenia since admission includes medications, dilutional, primary CLL, platelet clumping. Digoxin, Simvastatin and Tramadol associated with thrombocytopenia <1% of cases. Patient was stable at discharge and within his normal range. #Normocytic, normochromic Anemia Etiology may be from underlying CLL among other factors. Recent Hgb 7.9 on ___. No evidence of warm mediated autoimmune hemolysis from underlying CLL at this juncture. Possibly anemic due to volume resuscitation and pain/ catecholamines. Reticulocyte count 1.5, haptoglobin elevated, LDH, total and direct bilirubin are normal. Transfused ___ 1 Unit PRBC. Patient had a stable HCT at discharge, with some fluctuations from lab variation. #Leukocytosis/CLL WBC 59.6 on admission with abnormal differential. In ___, he started going above critical value (WBC ~ mid ___. Since then, he has had WBC 50-70 (last measured ___. Likely reflective of CLL given smudge cells seen on smear. We continued outpatient folate. #BPH: Patient symptomatic with chronic Foley in place which we did not remove given opioid treatment and holding Flomax for orthostasis. We continued Proscar and Foley until outpatient follow up with Dr. ___ #Dementia Patient AAOx1 on admission. Discussed baseline mental status with caretaker - does have some element of dementia, uncertain of baseline mental status. Per HCP, patient at baseline #Hyperlipidemia: We continued simvastatin; however, dose 40 mg (instead of 80 mg) given recent FDA warning #Imaging incidentals -Partially imaged fluid-filled distended corpora cavernosa of unclear etiology or significance. Clinical correlation and, if indicated, correlation with ultrasound recommended. -Fluid within the esophagus, possibly predisposing to aspiration. -will place on aspiration precautions #Transitional: -Hold Bumex -Hold Flomax but can restart in rehab when patient taking better PO and during the time when the Foley will be taken out. -Patient is to wear neck brace at all times until neurosurgery follow up -follow-up with Dr. ___ in ___ clinic in ___ervical spine (___) -consideration of anticoagulation as an outpatient for atrial fibrillation -Follow up with Dr. ___ urology</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 smoking, COPD, atrial fibrillation not on anticoagulation, DMII, HTN, HLD, gastric bypass who presented from rehab to ___ with shortness of breath, found to be hypoxic and to have multiple hematologic abnormalities, transferred to ___ for further management. CT ABD AND PELVIS WITH CONTRAST showed 1. Study is limited by increased noise and lack of oral contrast limiting evaluation of small metastases 2. Left adrenal thickening, nonspecific. Otherwise no findings to suggest metastatic disease in the abdomen pelvis. 3. Cirrhotic liver with portal hypertension, characterized by splenomegaly, upper abdominal varices and trace volume of ascites. No suspicious liver lesion on this single phase CT. 4. Left kidney small nonobstructive calculus measures 3 mm. 5. Partially included known right lower quadrant mass. 6. New subsegmental of right basilar atelectasis. 7. Stable left lower lobe ground-glass opacities, likely infectious etiology. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of an acute intracranial abnormality. C-SPINE NON-TRAUMA ___ VIEWS showed No radiopaque foreign bodies identified. Multilevel degenerative change. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Coarsened and nodular liver in keeping with cirrhosis. No focal liver lesions are identified. Main portal vein is patent. 2. Small amount of ascites. 3. Prominence of the pancreatic duct without focal lesions. In addition, prominent CHD on recent CT raises the possibility of ampullary sphincter dysfunction. The patient was diagnosed with Hypoxemia. The patient was treated with Bone marrow biopsy. At the time of discharge, the patient had Metastatic small cell carcinoma lung cancer Right lower lung mass Pancytopenia B12 deficiency Acute toxic-metabolic encephalopathy Acute on chronic intermittent agitation and confusion Cirrhosis Hepatitis C Severe protein-calorie malnutrition Chronic back and pelvic pain Depression/anxiety Hypertension: Paroxysmal Atrial fibrillation Diabetes mellitus type II Acute hypoxic respiratory failure Acute kidney injury Asymtomatic bacteriuria Seizure disorder/prior traumatic brain injury with seizure. GERD Osteoporosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with history of smoking, COPD, atrial fibrillation not on anticoagulation, DMII, HTN, HLD, gastric bypass who presented from rehab to BID-M with shortness of breath, found to be hypoxic and to have multiple hematologic abnormalities, transferred to ___ for further management. CTA was negative for PE, but notable for RLL mass concerning for malignancy and adjacent pneumonia. Attempts at sputum culture/cytology were were not successful. Patient completed 5 days of ceftriaxone/azithromycin. Patient underwent a bone marrow biopsy that revealed evidence of small cell carcinoma. Bone marrow invasion was complicated by progressive pancytopenia. Pancytopenia was likely due to infiltrative malignancy, but cirrhosis and possible ITP may be contributing. Labs also significant for elevated LDH, MMA, LFTs, INR. Thrombocytopenia was notably low with minimal response to IVIG and 2 packs platelets. Thoracic oncology and palliative care guided goals of care discussion as there were limited treatment options given her comorbidities and baseline limited functional status. Ultimately, patient was transitioned to comfort focused care. Goals are to maintain comfort. Family plans to visit the patient in ___ weeks. Patient had intermittent acute toxic-metabolic encephalopathy complicated by delirium. This may have been exacerbated by sedative medications. Workup included CT A/P that demonstrated cirrhotic liver with portal hypertension, splenomegaly, abdominal varices, and trace ascites. Cirrhosis almost definitely alcohol related, but patient was also noted to be HCV positive. Additionally, RUQ US showed Prominence of the pancreatic duct without focal lesions and in relation to prominent CHD on recent CT raises the possibility of ampullary sphincter dysfunction. No further workup was pursued given goals of care. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with a history of DM2, HTN, HLD, recurrent UTIs (on fosfomycin), recent RLE DVT (on apixaban), and schizophrenia who presented to the ED after a fall. She describes tripping over her shower chair this morning with the lights out. She fell on her left side and hit her chest and abdomen. She denied having chest pain, palpitations, shortness of breath, feeling lightheaded or nauseous prior to falling down. She also says she didn't lose consciousness or hit her head. Prior to this episode, she was feeling well although she had been hospitalized two months ago for acute liver injury ___ polypharmacy. CHEST (AP AND LAT) showed Top normal heart size, mild lower lung atelectasis, chronic compression deformity at the thoracolumbar junction. Otherwise unremarkable. CT HEAD W/O CONTRAST showed No acute intracranial process. Age-related involutional change. CT C-SPINE W/O CONTRAST showed 1. No acute fractures identified. 2. No prior imaging available for comparison, however there is no definite evidence of traumatic malalignment. There is widening of the right facet joint at C4-C5, likely degenerative. 3. Multilevel degenerative change including uncovertebral hypertrophy and facet arthropathy as described above. 4. 3 mm nodule in the right thyroid lobe for which no follow-up is recommended per ACR criteria. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. CT torso. showed 1. No evidence of acute traumatic injury in the chest abdomen or pelvis. 2. Chronic appearing deformities of the anterolateral left sixth through ninth ribs are more conspicuous from prior, clinical correlation for site of pain is recommended. 3. Subtle ground-glass opacities at the lung bases may reflect aspiration. Mild to moderate hiatal hernia. 4. Pulmonary nodule in the left lower lobe are stable from prior. 5. 3 mm right thyroid nodules. No follow-up is recommended per ACR criteria. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or older. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. The patient was diagnosed with Weakness. At the time of discharge, the patient had Primary ======= Mechanical Fall Secondary ========= Hypertension Hyperlipidemia Recurrent Urinary Tract Infections History of Deep Vein Thrombosis with Inferior Vena Cava Filter 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>SUMMARY ======= Ms. ___ is a ___ year old female with a PMH of DM2, HTN, HLD, recurrent UTIs (on fosfomycin), recent RLE DVT (on apixaban), and schizophrenia presenting w/ mechanical fall, ED course complicated by tachycardia which was felt to be a-fib, but this did not recur during her admission and limited objective records of the event are preserved. During her admission she had a 7 second pause while on metoprolol, likely vagal tone given atrial beat and quick return to NSR without junctional beats. Metoprolol was discontinued as she had been on this for hypertension only. She had some left sided abdominal pain from her fall that was well controlled with ibuprofen. ACUTE ISSUES ============ # Fall: Patient fell after tripping over her shower chair in the night without the lights on, no chest pain, SOB, palpitations, or LOC with the fall, and no shaking or seizures. Trauma workup in the ED negative for any fractures or acute processes. Physical therapy evaluated the patient and deemed her stable for home discharge without further intervention. Pain control with ibuprofen and Tylenol (2 GM max daily) as needed. # Narrow-complex irregular tachycardia, possibly a-fib # Brief hypotension: Had an episode of narrow-complex irregular tachycardia while working with ___ in the ED. No reported history of AFib, and no recurrence of a-fib during roughly 72 hours of inpatient telemetry monitoring. Unfortunately, only one EKG was obtained during her episode in the ED; on review of that EKG, clear p-waves are present for the first half of the tracing, suggesting a diagnosis of sinus rhythm with pACs. However, the second half of the tracing is potentially quite consistent with a-fib. We were nonetheless reluctant to make the diagnosis based on only three seconds of objective data. Will discharge with ziopatch to monitor for atrial fibrillation vs atrial tachycardia, and possible need for rate control initiation (possibly restarting metoprolol) and decision on whether to continue anticoagulation past DVT treatment course (due to end around ___. #Pause on tele, likely vagal Seven second pause while sleeping during her first night in the hospital. She bradyed down rapidly over maybe 20 seconds, had one non-conducted p-wave, then sped back up quickly to her usual rate. She was not otherwise bradycardic and had no other evidence of heart block. Stopped metoprolol with no further episodes on telemetry. Plan to discontinue metoprolol on discharge with outpatient uptitration of her lisinopril as needed for BP control. # Recurrent UTIs: Had UA consistent with infection in the ED, but states that she doesn't currently have any burning or stinging with urination that comes with her UTIs. Mental status was at baseline and she had no fever or systemic signs of sepsis. Urine culture showed ecoli >100,000, and was fosfomycin sensitive. Did not treat inpatient but discharged with her suppressive fosfomycin. # RLE DVT: Continued home apixaban. Has IVC filter in place from bleeding with rivaroxaban which should be removed now that she is tolerating AC without bleeding. Discussed with ___ about removing it this admission versus scheduling for outpatient, and they felt that they wouldn't be able to fit her in the inpatient schedule. Plan to have her follow up with her scheduled visit on ___. CHRONIC ISSUES ============== # Recent hospitalization for acute liver failure Due to DILI and unintentional Tylenol overdose: LFTs normal this admission # HTN: Continued home lisinopril. Stopped metoprolol as above. # DM2: Last A1C 5.3%. Held home glipizide, restarted on discharge. # HLD: Continued home atorvastatin # Schizophrenia: Continued home olanzapine TRANSITIONAL ISSUES =================== Discharge Cr: 0.8 Discharge Hgb: 8.3 Discharge INR: 1.4 Discharge LFTs: normal [ ] Has cardiology follow up with Dr. ___ NP, Ms ___, who should review the ziopatch (and the as of yet unconfirmed EKG from ___ for Atach vs afib and decide on rate control and/or extending her anticoagulation to lifelong. [ ] ID follow up scheduled for management of recurrent UTIs. Follow up UTI symptoms. Ensure she is taking her home fosfomycin treatment on the appropriate schedule. Urine culture this admission with Ecoli, but fosfomycin sensitive [ ] Atorvastatin restarted this admission, recheck LFT in ___ months to ensure that they remain stable. [ ] Follow up blood pressures; stopped metoprolol this admission due to sinus pause, but discharged on ziopatch as above; may need uptitration of lisinopril if high BPs. [ ] Consider discontinuation or reduction of her sulfonylurea. Her A1c is low enough that she is at risk for harm from hypoglycemia. [ ] ___ follow up ___ for IVC filter removal!! [ ] As per CT C/A/P: Pulmonary nodule in the left lower lobe are stable from prior. 3 mm right thyroid nodules. No follow-up is recommended per ACR criteria. [ ] CT C spine with widening of the right facet joint at C4-C5, likely degenerative, and multilevel degenerative change including uncovertebral hypertrophy and facet arthropathy [ ] Has blister packs with ___ pharmacy which was updated on discharge to not include metoprolol for the follow up packs. All changes to her medications should be made through her existing pharmacy so they can adjust her blister packs. [ ] Discharging with ___ services to help with medications #CODE: Full Code #CONTACT: HCP ___ (friend) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o male who was recently admitted to transplant surgery for concerns of gallbladder malignancy and is s/p subcostal incision and intraoperative cholangiogram who was recently admitted to transplant surgery for concerns about gallbladder malignancy and underwent subcostal incision revealing perforated gallbladder with normal filling of biliary ducts via intraoperative cholangiogram (___). Patient was placed on Cipro X 1 week (GNR, no speciation). His post-operative course was c/b ileus requiring NPO/NGT decompression. Patient was discharged on ___. He had urinary retention prior to his operation and had a legbag and f/u with an urologist. Additionally his anti-HTN medications were reduced as he was stable on low doses of metoprolol. He was seen by the urologist and failed his voiding trial. He was also seen by his PCP for dizziness and hypotension. There do not seem to be any changes to his anti-HTN meds and his hypotension was treated with IVF hydration. CHEST (PORTABLE AP) showed No acute intrathoracic process CT ABD AND PELVIS WITH CONTRAST showed 1. Nondilated loops of air/fluid small bowel with oral contrast extending to the J-pouch, overall improved from ___. 2. Improved postsurgical changes including decreased fluid in the gallbladder fossa and mild decrease in heterogeneity/stranding in right upper anterior abdominal wall musculature. 3. No evidence of intra-abdominal abscess/drainable fluid collection. 4. Bladder wall thickening, recommend correlation with urinalysis. NOTIFICATION: Changes to WET READ impression #4 were discussed with Dr. ___ by Dr. ___ on the day of the exam. Radiology showed No evidence of aspiration or penetration. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Esophagram showed Normal esophagram. CHEST (PORTABLE AP) showed The post pyloric feeding tube extends beyond the ligament of Treitz into the proximal jejunum. Otherwise little change from the study of ___. The patient was diagnosed with ANOREXIA. The patient was treated with ___ EGD with post pyloric feeding tube placement. At the time of discharge, the patient had Dehydration Failure to thrive Esophagitis/gastritis Urinary retention Incision wound s/p ccy/esophagogastroduodenostomy. The patient was given written instructions concerning 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 directly admitted from clinic with systolic blood pressures in the ___. He was admitted. He had a CT abdomen/pelvis done which showed loops of small bowel that had improved, less fluid in the gallbladder fossa, a thick bladder, and no abscess. He was given Macrobid for treatment of presumed UTI (5-day course). Blood and urine cultures eventually came back negative. Blood pressures stabilized, and he actually became somewhat hypertensive while all of his home blood pressure medications were being held. He was started on Metoprolol 12.5 mg BID. That same day, he experienced some indigestion when drinking Ensure. He subsequently passed a bedside speech and swallow evaluation, but speech therapy recommended a video and barium swallow, as he was complaining of being unable to swallow some solid foods (e.g. ___ toast). Video swallow was negative for any evidence of aspiration, and the barium swallow displayed normal esophageal anatomy. GI was also consulted and recommended an EGD, which he had the following day. Some erythematous patches were noted in the lower esophagus, but no biopsies were done, as the patient was continued on Aspirin and Plavix at the time of the procedure. He was started on Nystatin swish and swallow empirically for ___ esophagitis, and his PPI dosing was increased to Pantoprazole 40 mg IV BID in house (transitioned to 40 mg PO BID on discharge). Due to the patient's poor PO intake, he also had a post-pyloric Dobhoff tube placed at the time of the EGD. He was started on tube feeds with Gevity 1.5 at 20 cc/hr, increased to a goal of 60 cc/hr. Macrobid was d/c'ed on the ___ day of the course. Patient was monitored in house for 2 more days, and discharged home with the Dobhoff tube in place and ___ services secured for help at home with the tube and tube feeds. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F pharmacy student with recent diagnosis of sickle cell disease who presents with back pain since ___. The pain is in her mid-upper back and worse with flexion. It started out as mild pain, and she did not present for medical evaluation initially since it had coincided with the onset of menses, and she felt it could be menstrual pain. However, her pain worsened and persisted, which was inconsistent with her typical menstrual cramps, and she became concerned for a sickle cell crisis, so she came in to be evaluated. Of note, she has not had any fever, chills, dyspnea, chest pain, N/V/D, rash, bleeding (other than menses), vision changes, numbness, tingling, weakness. In the ED initial vitals were: 97.8 95 107/56 16 100% - Labs were significant for WBC 11, HCt 23.5, LDH 774 - Patient was given 3mg IV dilaudid, 30mg MS ___, 1 U pRBC Vitals prior to transfer were: 98 72 104/71 16 100% On the floor she reports feeling well, but thinks her pain is worsening since she received pain medications several hours ago. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed No acute findings in the chest. The patient was diagnosed with HB-SS DISEASE W/CRISIS. At the time of discharge, the patient had Primary Diagnosis: Sickle cell disease, acute pain episode. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH significant for sickle cell disease presents with back pain. # Acute pain episode/Sickle cell disease: Back pain secondary to sickle cell disease. Trigger for this pain episode likely multifactorial: menses, dehydration (patient reports drinking ___ per day instead of the recommended 4L), and stress. Infection was ruled out as the patient did not have any infectious symptoms, is up-to-date with vaccinations, negative CXR, and unremakable UA. The patient was treated with IV fluids and dilaudid IV PRN. When the pain was adequately controlled, she was transitioned to oxycodone 10mg. We continued her home MS ___. We talked briefly about birth control to decrease the acute pain episodes triggered by menses. We would recommend the Mirena IUD as it does not have an increase risk of thrombosis and may decrease the amount of blood loss during menses. We recommended the patient continue this discussion with her primary care phyisician and hematologist. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of ankylosing spondylitis s/p C3-T9 fusion for C7-T5-T6 fracture after fall down stairs on ___. Postoperatively he remained in TLSO brace until ___. He was seen in follow-up on ___ at that time he had a small opening in his incision with no signs of infection. The patient at that visit was noted to be cachectic and instrumentation was palpable through the skin, but there was no breakdown. He was referred for x-ray which showed hardware failure. MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE. showed 1. Chronic T6 vertebral body fracture with retropulsion associated retrolisthesis of T5 and T6, with deviation of the cord at this level but no frank evidence of cord compression, there is persistent CSF fluid surrounding the cord at the level of the retropulsion. 2. No change compared with previous, post spinal fusion. 3. Fluid collection noted in the left posterior neck posterior to C4 and C5. This may represent a postoperative seroma. Does the patient have any symptoms or signs of infection? CHEST (PRE-OP PA AND LAT) showed In comparison with the study of ___, there is little overall change and no evidence of acute pneumonia. In extensive cervical, thoracic, and lumbar hardware remain in place. CHEST (PORTABLE AP) showed Low lung volumes are noted. There are small bilateral pleural effusions. No focal consolidation or pneumothorax is identified. The cardiomediastinal silhouette is stable in appearance. There is no pulmonary edema. Spinal hardware and osseous structures are unchanged in appearance. CTA CHEST ___ showed No pulmonary embolism. Chronic pulmonary hypertension. Moderate right and small left pleural effusions stable or recurrent. Stable atelectasis, moderate, right upper and severe, right lower lobes. The patient was diagnosed with Cervicalgia. The patient was treated with ___ - Wound revision. At the time of discharge, the patient had C3-t9 fusion with interval cervical spine hardware 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># Hardware failure Mr. ___ presented to ___ on ___ after c-spine xray on ___ demonstrated hardware loosening. At clinic hardware was palpable in the cervical spine, no threatened skin, no pain with palpation. Patient admitted to floor in stable condition, CT and MRI c/t/L spine were ordered for preoperative planning. Plan for OR on ___ with Dr. ___ cervical hardware removal and wound exploration. Patient restarted on tube feeds with oral supplementation per SNF regimen and nutrition consult. Patient restarted on home medication, preoperative cxr wnl, patient went to OR on ___ for planned removal of cervical instrumentation and wound exploration. During the case, when the patient was flipped into the prone position he became acutely hypotensive requiring epinephrine and IVF boluses and to be returned to ___ position. TEE done in OR demonstrated hyperdynamic left ventricle, concerning for hypertrophic obstructive cardiomyopathy. Patient was unable to tolerate prone position and the case was aborted. Distal end of incision was revised with patient in lateral position in the OR. Please read Dr. ___ report for further details of case. Patient was brought out to the PACU intubated and was managed by the TSICU overnight. He was started on IV fluids. He was weaned off sedation, phenylephrine drip, and extubated. He remained hemodynamically and neurologically stable so patient was transferred back to the floor. Patient's surgical dressing was removed on POD #2 and his surgical incision appeared intact with sutures in place, no active drainage noted. On POD #3 patients surgical incision with slight opening at the superior portion of the incision but no active drainage. Patient remained neurologically stable. # Chest pain Overnight on ___, patient complained of sternal chest pain which was worse with inspiration. EKG was done, reviewed by the Medicine team, and felt to be grossly stable from EKGs on prior admission. Troponins were elevated at 0.04 x4. Chest pain resolved with pain management. Patient continued to complain of chest pain on ___ worsening with deep breaths and cough. A repeat EKG was obtained on ___ which was stable compared to prior EKGs. Pain was thought to be musculoskeletal in nature s/p OR positioning. On ___ patient stated that his chest pain has improved. #Hypoxia Overnight on ___ into ___ patient with tachypnea and hypoxia to the 80's. Patient was placed on supplemental O2 via NC with some improvement in O2 sat. CXR on ___ revealed low lung volumes, small bilateral pleural effusions with no consolidation. Patient also underwent a CTPE which was negative for an acute PE. # Dysphagia Patient presented from SNF with PEG tube on tube feeds. Nutrition was consulted for recommendations regarding tube feeds. Post-op, patient was restarted on tube feeds and puree diet per nutrition recommendations. SLP was consulted who recommended upgrading diet to soft food, thin liquids, meds whole or crushed in puree, 1:1 supervision with meals and to slowly decrease TF after 24 hour supervision of tolerating new diet. # Urinary retention Patient presented from ___ with foley catheter in place. Void trial was attempted on ___, but patient was unable to void and coude catheter was replaced. Urology was contacted and it was recommended that patient follow up 2 weeks from time of discharge for a void trial. Patient was found to have a UTI on ___ when the urine culture resulted as enterobacter. Patient was given 1Gm of ceftriaxone on ___ and sent to rehab with Bactrim BID for a ___nd the nursing facility can extend course to 14 days if needed. # Dispo ___ and OT evaluated the patient on ___ and ___ and recommended discharge to rehab. Patient was discharged back to his ___ on ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with no PMH who was recently seen in ED ___ for c/o fever who was discharged with diagnosis of viral illness and monospot was negative. She returns to the ED today with reported fever of 103.1. Patient reports 2 weeks of fever, chills, arthralgias, night sweats and sore throat associated with general myalgia and mild abdominal pain. Patient has been taking Tylenol and Ibuprofen with temporary resolution of most of her symptoms. Radiology showed No acute cardiopulmonary process. Q22 showed 1. Prominent cervical lymph nodes bilaterally. These may be reactive in nature however exact etiology is difficult to determine. 2. The right sternocleidomastoid muscle is enlarged and there is some stranding posteriorly, likely due to central line placement. CHEST PORT. LINE PLACEMENT showed As compared to the previous radiograph, the patient has received a right-sided internal jugular vein catheter. The course of the catheter is unremarkable, the tip of the catheter projects over the cavoatrial junction. The stomach is overinflated. Obviously reflecting the known septic shock, the patient shows bilateral parenchymal opacities, with perihilar and lower lung predominance. Given the simultaneous 0 current 's of a wide and right-sided mediastinum, the changes most likely reflect hydrostatic pulmonary edema. A coexisting right pneumonia or aspiration can not be excluded. Mild cardiomegaly. No larger pleural effusions. Radiology showed 1. Nonspecific right lower quadrant lymphadenopathy and prominent retroperitoneal lymph nodes, not amenable to biopsy. The differential is broad and includes a reactive process, lymphoma or granulomatous disease. 2. Substantial gallbladder wall edema is presumably related to volume status and hepatic dysfunction. There are no findings to suggest acute cholecystitis. 3. Bilateral pleural effusions and intrathoracic findings are reported separately. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ telephone on ___ at 11:20 AM, 30 minutes after discovery of the findings. CT Chest showed 1. Moderate nonhemorrhagic, bilateral pleural effusions with adjacent atelectasis. 2. Significant consolidations within the left and right lower lobes. Findings may represent lobar atelectasis, however, superimposed infection cannot be excluded. 3. Non-obstructing, right hilar lymphadenopathy. 4. Enlarged thymus, probably reactive. The patient was diagnosed with FEVER, UNSPECIFIED, NONSPECIF SKIN ERUPT NEC, JOINT PAIN-MULT JTS. The patient was treated with Central venous line placement (IJ) ___ Bone marrow biopsy ___ Skin biopsy over dorsum of right foot ___. At the time of discharge, the patient had Primary Diagnosis: Hemophagocytic Lymphohistiocytosis, Adult Onset Still's Disease Secondary Diagnosis: Shock, Acute Kidney Injury, Disseminated Intravascular Coagulation. The patient was given written instructions concerning 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 ___ no significant PMHx recently seen in ED ___ for c/o fever, who re-presents for fever to 103.1, with multiple physical complaints, as well as elevated CRP, transaminitis, elevated ferritin and new leukocytosis. MICU COURSE # Septic shock / FUO: Met ___ SIRS criteria at admission and required pressors briefly until ___. Received about 11L fluids. Initial differential included infectious, autoimmune, malignancy. Her hemophagocytic process (elevated LDH, ferritin) was concerning for hemophagocytic lymphohistiocytosis (HLH). Patient was seen by ID, heme/onc, and rheumatology. Bone marrow biopsy was performed, which showed hemophagocytosis. Presentation was felt to be most likely due to HLH vs macrophage activation syndrome secondary to Still's disease. CT neck/abdomen/pelvis was performed given tender lymphadenopathy and to rule out occult malignancy or abscess. CT showed nonspecific lymphadenophathy and gallbladder wall edema (likely secondary to volume overload). Echo for vegetations was negative. Infectious workup to date has been unrevealing. Beta glucan was elevated, but was felt to be a false positive given no clinical signs of fungal infection and improvement on steroids. Patient was started on broad spectrum antibiotics of ___ per ID recommendations on ___ which was d/c on ___. Patient was given 1g solumedrol daily for 3 days, followed by 60mg prednisone. She was started on Anakinra on ___. Meropenem was continued because of immunosuppression on high dose steroids. Patient was also started on bactrim for PCP prophylaxis on ___. # Coagulopathy: Patient presented to ICU with low platelets, elevated FDP, elevated ___ concerning for DIC. Labs were trended and patient did not require transfution of FFP or pRRBCs. Labs improved during MICU course and while on floor. #Transaminitis / ___: Likely multifactorial, related to inflammation from underlying process and shock. LFTs were followed and downtrended appropriately. # ___: Cr 1.3 in setting of septic shock and volume depletion. UA with bland sediment. Cr returned to baseline during MICU course and stayed at normal levels while on floor # Hypoxia: Patient had new O2 requirement in the setting of aggressive volume resuscitation. Unlikely to be PNA as she did not have any previous localizing symptoms except a sore throat. Was initially started on broad spectrum antibiotics as above, but O2 requirement decreased as patient self-diuresed and was weaned to room air on ___. GENERAL MEDICINE FLOOR COURSE 1. HLH/MACROPHAGE ACTIVATION SYNDROME: As discussed, Ms. ___ was admitted with fever without localizing signs requiring a MICU admission for hypotension, pressors and broad spectrum antibiotics. She also was found to have a transaminitis, elevated LDH, and rapid ferritin elevation to ___ concerning for hemophagocytic lymphohistiocytosis with unclear precipitant. Given the clinical suspicion for HLH, a bone marrow biopsy was performed. Aspirate smear was reviewed with heme pathology and was significant for hemophagocytosis, consistent with a diagnosis of HLH. Given the patient's clinical status with worsening ferritin and LFTs, prompt steroids were initiated. We believe that she has a form of HLH known as Macrophage activation syndrome (MAS) which is associated with juvenile idiopathic arthritis and other rheumatologic conditions. MAS is a subset of HLH in which successful therapy of the underlying condition may produce a good response and allow the patient to avoid HLH-specific therapy. Therefore, pulse dose steroids as recommended by rheumatology were continued, to which indefinite anakinra was added. 2. Fevers/Adult Stills: Ms. ___ had fevers with evanescent rash, pharyngitis, very high ferritin and questionable LAD that best fit a diagnosis of Adult Stills Disease. She responded to Stills treatment including pulse-dose steroids. It is possible that that was triggered by a viral infection, but if so, that virus had resolved by the time of her hospitalization. Infectious work-up did not reveal any infectious causes of the fevers. A quantiferon gold was indeterminate, EBV serology consistent with prior infection, CMV with no prior infection and no evidence of Parvo B19, RSF, Erlichia, Anaplama, Lyme infection. She was started on Bactrim prophylaxis and high dose IV steroids were started on ___. On ___ Anakinra ___ was initiated and she was switched to PO Pred 60mg with a plan to taper by 5mg weekly. 3. ___: As above, her Cr had initially increased to 1.2, but then restored to 0.5 with fluids as clinical symptoms improved. She was mildly dizzy without orthostatic vital signs during the several days before she was discharged and received small amounts of fluids with good effect. 4. Hypoxemia: As discussed above, Ms. ___ received large amounts of IV Fluids so this oxygen requirement was most likely related to fluid overload. No crackles or decreased breath sounds on exam, but non-productive cough present. This gradually resolved on its own and she was without an oxygen requirement and with good oxygen saturation on discharge. 5. DIC: Her fibrinogen was monitored for possible continued low grade DIC. These lab values steadily improved and did not require intervention on the floor. TRANSITIONAL ISSUES - Ms. ___ is being discharged on both steroids (Prednisone 50mg per day X 1 week with a planned 5mg per week taper thereafter) and self-administered injections of Anakinra - Ms. ___ will ___ with Rheumatology within 1 week following her discharge - Ms. ___ will also ___ with a new Primary Care doctor at ___ for management of her other medical issues - Please ___ result of IL-2 receptor test</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ year old male with PMH significant for NICM with EF 15% now recovered to >55%,HTN, COPD, AICD, CKD, and a known umbilical hernia, who is presenting today to the ED with one day of pain and swelling at the hernia site. He states that he has vomited three times this morning last one of which have been bilious. The patient underwent a CT in the ED which showed incarcerated bowel, with SBO and TP in the hernia sac. His Cr is 2.3. lactate 1.9, bicarb 24. CT ABD AND PELVIS W/O CONTRAST showed 1. Supraumbilical ventral hernia containing small bowel loops with associated small bowel obstruction. Small amount of fluid in the hernia sac. Please correlate for incarceration. 2. Severe cardiomegaly with mild interstitial pulmonary edema. Radiology showed The entire abdomen is not demonstrated on plain abdominal radiographs. Partially visualized large bowel measures up to 6.6 cm which may represent ileus. The small bowel is not well delineated suggesting fluid within the intraluminal cavity better characterized on CT abdomen and pelvis dated ___. CHEST (PORTABLE AP) showed 1. Multifocal bilateral opacities, worse on the right lung, concerning for moderate pulmonary edema. Small right pleural effusion. 2. Moderate cardiomegaly and widened mediastinum the mediastinum, likely exaggerated in current study due to positioning. CHEST (PA AND LAT) showed Comparison to ___. The extent and severity of the pre-existing multifocal parenchymal opacities is stable. Stable moderate cardiomegaly. No new opacities. No pleural effusions. The left pectoral pacemaker is in stable correct position. HEEL (AXIAL AND LATERAL) RIGHT showed Mild irregularity of a small plantar calcaneal enthesophyte may relate to prior trauma. If there is concern for acute on chronic injury MRI can be performed. CHEST (PORTABLE AP) showed Median sternotomy wires are noted. There is a left chest wall AICD with a single lead terminating in the regions of the right ventricle. There are multifocal parenchymal opacities, which are not significantly changed compared to prior study. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette stable in appearance. There are no acute osseous abnormalities. The patient was diagnosed with Periumbilical pain, Athscl heart disease of native coronary artery w/o ang pctrs. The patient was treated with ___: Small bowel resection and repair of incarcerated umbilical hernia.. At the time of discharge, the patient had Incarcerated umbilical hernia, with bowel ischemia.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M with history of non-ischemic cardiomyopathy, AICD, CKD who presented to the emergency department on ___ with abdominal pain. He underwent CT scan that was consistent with an incarcerated umbilical hernia. White blood cell count normal at 5.7 and lactate normal at 1.9. The indication and possible complications of this procedure were explained to him preoperatively and appropriate informed signed consent was obtained. On ___ the patient underwent small bowel resection and repair of incarcerated umbilical hernia. Please see operative report for details. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a IV Tylenol and then transitioned to oral Tylenol once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint. Initially post operatively he had increased work of breathing and a new supplemental oxygen requirement. He was given diuresis and was able to be weaned off oxygen. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO after surgery. He was given clears on POD3-4 and on POD5 he had return of bowel function and therefore was advanced to a regular diet which was well tolerated. Patient's intake and output were closely monitored. Foley catheter was removed on POD3 and he was able to void without difficulty. He was hypernatremic to 151 on POD4 with a resolving acute kidney injury. Nephrology was consulted and he was given D5W and sodium levels improved. IV fluids were stopped after 1 day with resolution of hypernatremia. After stopping fluids, sodium level then increased to 153 on POD8. Acute kidney injury was judiciously managed given comorbidity of heart failure with an EF of 15%. His creatinine normalized to baseline of 1.8 at time of discharge. Given his stable clinical exam and previous response to fluids, increased oral fluids were encouraged. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. The patient reported foot pain. Xrays negative for acute injury. Uric acid level elevated at 13. Recommend increased hydration and further work up for gout as needed. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. The patient was discharged to rehab to continue his recovery. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old female status post lap cholecystectomy, POD#6 who presents to the ED with abdominal pain. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patient is status post cholecystectomy. Small fluid collection in the postop bed may represent a postoperative seroma or biloma however, superimposed infection cannot be excluded. The common bile duct measures 5 mm. The distal common bile duct is not well visualized, however there is no evidence of distal obstructing stones. 2. Mild splenomegaly measuring up to 15.1 cm, was not well demonstrated on prior exam however this is likely secondary to differences in technique. CT ABD AND PELVIS WITH CONTRAST showed 1. Post cholecystectomy, with mild intrahepatic biliary dilatation and a moderate amount of gallbladder fossa, perihepatic, and perisplenic fluid tracking down the bilateral gutters and into the pelvis. In the setting of prior surgery, biliary leak is not excluded on the basis of this CT. 2. Trace right pleural effusion. NOTIFICATION: The above findings were communicated in person by Dr. ___ to Dr. ___ at 15:45 on ___, 2 minutes after discovery. MRCP showed 1. Biliary leakage status post cholecystectomy as evidenced by pooling of biliary excreted contrast within the gallbladder fossa. The exact site of leakage is not identified but likely lies between the confluence of the right and left hepatic ducts and the cystic duct insertion. 2. Large volume ascites in the setting of active biliary leakage, overall similar to most recent prior CT scan of the abdomen and pelvis. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:50 pm, 2 minutes after discovery of the findings. US INTERVENTIONAL PROCEDURE showed Decrease in size of the fluid collection in the gallbladder fossa. No drainable collection identified on today's examination. If clinically warranted, interval follow-up ultrasound or CT may be considered if clinically warranted to assess for fluid reaccumulation. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with ___ ERCP with CBD stent placement. At the time of discharge, the patient had Biliary leak s/p lap chole. The patient was given written instructions concerning 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 the ED with abdominal pain post-cholecystectomy, and MRI and CT scans were positive for bile leakage. She underwent ERCP with stent placement in CBD. Patient then experienced significant improvement in abdominal pain. Subsequent imaging by ___ showed decrease in size of fluid collection in the gallbladder fossa with no drainable collection identified. She received IV-ampicillin sulbactam during her hospital stay and transition to PO amoxicillan-clavulanic acid prior to discharge. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with IV dilaudid and then transitioned to oral tylenol once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO, then post ERCP, the diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Patient will need a Repeat ERCP with GI in 4 weeks for stent pull and re-evaluation. She was discharged on 5 day course of amoxicillan-clavulanic acid and tylenol for pain control.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of lupus, lupus nephritis with ESRD on peritoneal dialysis on transplant list, hx of PE/Antiphopholipid antibody on coumadin, mitral regurg, presents with ___ month history of cough, worse in the morning, one week of trace blood, now producing bright red blood over last couple days. Patient states that the amount of blood she has been coughing has been increasing and is now almost hourly, aprroximately 1 teaspoon bright red blood. Patient states that the cough produced primarily yellow sputum until it turned to blood. Patient denies any other symptoms such as dizziness or lightheadedness. She denies any changes in her BMs, including consistency, frequency, and color. Patient visited PCP on ___, and a CXR was negative. Her was also noted to be subtherapeutic and she took an extra day of 10 mg warfarin as instructed. . Initial vitals in the ED were: 108 138/95 18 100% RA. Her HCT was 29.6, her baseline is unclear but appears to be low ___. INR was 4.4. A CTA was done for concern of PE which showed: 1. Left lower lobe consolidation with large amount of secretions/fluid within the left lower lobe segmental bronchi. 2. Centrilobular nodules and ground glass opacities throughout both lungs, compatible with chronic collagen vascular disease, progressed since ___. Ground glass opacities could also represent hemorrhage. 3. Chronic left lower segmental pulmonary arterial PE, unchanged since ___. No new acute PE detected to the subsegmental levels. She was initially admitted to medicine but then transferred to the ICU. . On arrival to the MICU initial vitals were: 110 163/96 20 95%RA. She is breathing comfortably but complains of pain in her chest. Her EKG was reviewed which did not show changes from her prior. She also complains of a HA that she says she occasionally recieves toradol. She has had emesis in the ED that looked dark/possibly coffee ground but currently denies nausea. Radiology showed 1. Left lower lobe consolidation with large amount of secretions/fluid within the left lower lobe segmental bronchi. A small air-filled space within the left lower lobe seen on the ___ CT examination is now filled with fluid and/or blood. Findings could represent hemorrhage secondary to collagen vascular disease. Infection and abscess also have the same appearance on CT. 2. Centrilobular nodules and ground glass opacities throughout both lungs, with a basilar predominance, with associated mild bronchiectasis, compatible with chronic collagen vascular disease, progressed since ___. There is no advanced fibrosis. Superimposed infection cannot be excluded by imaging alone. Ground glass opacities could also represent hemorrhage. 3. Chronic left lower segmental pulmonary arterial PE, unchanged since ___. No new acute PE detected to the subsegmental levels. Radiology showed I Irregular dense opacity at left base, increased compared with ___, associated with an elevated left hemidiaphragm. Differential diagnosis includes alveolar processes such as infection and hemorrhage. Radiology showed 1. Internal jugular line malpositioned with its tip positioned in the right internal jugular line, persisting since prior radiograph acquired ___ hours apart. 2. Lower lung collapse and mild-to-moderate left effusion is unchanged since ___ but worsened since yesterday. Minimal right lung base atelectasis and presumed small right effusion is similar. ___ discussed findings with Dr. ___ by phone on ___, ___ at 8.46AM Radiology showed 1. Moderate ascites. Given the fluid withdrawn from the peritoneal dialysis catheter is nonhemorrhagic, and the patient underwent a contrast-enhanced CT yesterday, this is likely increased in density from the contrast administration. No evidence of retroperitoneal hematoma. 2. Vicarious excretion of contrast in the gallbladder consistent with stated history of chronic kidney disease. 3. Left basilar disease is poorly evaluated on this examination. Centrilobular nodules and ground-glass opacities are redemonstrated consistent with known chronic collagen vascular disease. Again, superimposed infection cannot be excluded by imaging. Radiology showed 1. Successful particle embolization in the left bronchial artery, as described above. 2. Successful replacement and repositioning of non-tunneled right internal jugular vein triple lumen catheter, with the tip now in distal SVC. The line is ready to use. Radiology showed Collpase of the left lung probably from bronchial plugging/clot. Size of the hemorrhage is difficult to evaluate. These findings were discussed with Dr ___ by Dr ___ telephone at 11 AM. Radiology showed 1. Diagnostic venogram demonstrating single patent IVC. 2. Successful placement of infra-renal potentially retrievable Option IVC filter. Radiology showed 1. CT features are concerning for progressive multifocal pulmonary hemorrhage, most pronounced in left lower lobe. 2. Left lower lobe bronchial tree occlusion is likely from aspirated blood. 3. Moderate ascites with attenuation ranging between 19 to 35 is probably complex fluid, unchanged since ___. Lupus and recent hemoptysis. Portable AP radiograph of the chest was reviewed in comparison to ___. The ET tube tip is 4.7 cm above the carina. The right internal jugular line tip is at the level of low SVC. There is interval improvement of the left lung aeration with still substantial collapse and left mediastinal shift. Calcifications in the right lower lobe are redemonstrated. No appreciable pneumothorax is seen. was done. Radiology showed Appropriate placement of OG tube. No significant interval change. Radiology showed 1. There is persistent opacification of the left hemithorax with some residual aeration at the left lower lobe associated with volume loss and mediastinal and cardiac shift to the left. Overall, the appearance does not appear to be significantly changed. The endotracheal tube continues to have its tip 4 cm above the carina. A right internal jugular central line has its tip in the distal SVC. Nasogastric tube is seen coursing below the diaphragm with the tip within the stomach. A portion of an inferior vena caval filter is also visualized at the edge of the film within the abdomen. The right lung is well inflated without evidence of focal airspace consolidation, pulmonary edema, or pleural effusion. There is a stable calcified nodule measuring 1.3 cm in the seventh interspace. This most likely represents a calcified granuloma. No acute bony abnormality is appreciated. Radiology showed Persistent left lower lobe atelectasis with associated elevation of the left hemidiaphragm. Radiology showed No evidence of DVT within the lower extremities bilaterally. The patient was diagnosed with HEMOPTYSIS, UNSPECIFIED, ABNORMAL COAGULATION PROFILE. The patient was treated with LEFT BRONCHIAL ARTERY EMBOLIZATION UNDER FLUOROSCOPY RIGHT INTERNAL JUGULAR LINE PLACEMENT, REPOSITIONING, AND REMOVAL IVC FILTER PLACEMENT INTUBATION AND MECHANICAL VENTILATION. At the time of discharge, the patient had LEFT BRONCHIAL ARTERY BLEED VENTILATOR-ASSOCIATED PNEUMONIA END-STAGE RENAL DISEASE, PERITONEAL DIALYSIS-DEPENDENT HISTORY OF PULMONARY EMBOLISM. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with SLE c/b lupus nephritis, w/ESRD on PD & bilateral PE on chronic coumadin p/w hemoptysis & hypoxic respiratory failure, found to have L bronchial artery bleed. # HEMOPTYSIS On admission pt was HD stable, not hypoxia, and without airway compromise. She did have significant Hct drop, from 29.6 to 20.8 within 24h of admission. Pt is on chonic coumadin for hx bilateral PE ___ ago; INR was elevated to 4.4 on admission. Explanation for acute bleed not entirely clear - initial ddx included infection (PNA vs abscess) in setting of elevated INR most likely; diffuse alveolar hemorrhage also possible, & rheumatology consult also suggested possible pulmonary vasculitis. No new PE seen on CTA. She initially received antibiotics for possible pulmonary infection (vanc/levo/flagyl, subsequently narrowed to levo/flagyl). On HD3, underwent CT-guided pulmonary angiography for question source of bleed and possible bleeding into mediastinum. Bleed localized to L bronchial artery, which was embolized. Solumedrol started for possible vasculitis. Hct stabilized and uptrended thereafter. There was discussion of possible pulmonary wedge biopsy for purpose of solidifying a tissue diagnosis to guide possible immunosuppression but this was decided against after risk/benefit analysis. Discharge Hct 35.9. Sent home w/steroid taper to be further managed in rheumatology follow-up next week. . # HYPOXIC RESPIRATORY FAILURE Pt developed respiratory failure while in the ICU, w/increasing O2 requirement. CXR showed significant left-sided infiltrate, most likely from L bronchial arterial bleed (as discussed above). Pt developed progressive respiratory distress requiring supplemental O2. She was intubated on HD4 for rigid bronchoscopy and was difficult to extubate, first because of persistent L-sided infiltrate (blood) and volume overload (retained >5L over ___ from PD), then because she developed ventilator associated pneumonia (VAP). She was already on levo/flagyl at the time (coverage for possible pulmonary infection as precipitant for hemoptysis, discussed above); aztreonam/vancomycin added briefly for VAP coverage. On repeat bronchoscopy on HD9, large mucous plug removed from LUL bronchus. Pt's respiratory status improved quickly thereafter, and she was successfully extubated the following morning. Weaned to RA within several hours, O2 sat in high ___ for >48h thereafter. . #CHRONIC PE/ANTICOAGULATION Hx indication for anticoagulation was revisited during this admission given hemoptysis and supratherapeutic INR on admission. No acute PE on CTA. Heme was consulted and agreed w/continuing to hold anticoagulation. IVC filter placed. Review of OMR records revealed that anticoagulation was started in ___ during hospitalization for lung abscess; large bilateral PEs were revealed on CTA done for unexplained persistent sinus tachycardia. She has been on anticoagulation since. OMR also include diagnosis of antiphospholipid antibody syndrome in OB/GYN notes (based upon 3 miscarriages and hx CVA age ___ but rheumatology notes/records show autoantibody panel not c/w this diagnosis ___ positive 1:320, anti-Ro/La positive, lupus anticoagulant negative x2, *anticardiolipin negative*. Rheumatology and hematology were consulted here for assistance with re-evaluation of pt's indication for chronic anticoagulation and plan to resume anticoagulation. Repeat serologies sent - lupus anticoagulation now *positive*, anticardiolipin again negative, b2glycoprotein Ab pending at time of discharge. Discharge anticoagulation plan as follows: - IVC filter to be removed in ~1 week ___ aware, procedure scheduled for ___ - Resume warfarin after IVC filter removed, with f/u INR checks at ___ clinic overseen by PCP ___. ___ require re-hospitalization to restart warfarin, TBD by PCP and heme/pulm in outpatient follow-up - PCP, ___ and Pulmonary follow-up appointments arranged - situation discussed with ___ Dr. ___ will review paper records for any OSH coagulopathy studies sent prior to initiation of coumadin in ___ and share info w/Dr. ___ . # SINUS TACHYCARDIA Pt's HR was 100 on admission and trended 100-140 during her hospital status. Always sinus tachycardia on EKG and telemetry. Given hx PE, she had bilateral LENIs and a TTE to evaluate any right heart strain. Both were wnl. No CTA was obtained because a) pt had an IVC filter placed on admission so low-likelihood and b) no anticoagulation would have been restarted as an inpatient given recent life-threatening bleed. # Hx ESRD on PD Renal failure chronic, lupus nephritis. Underwent PD throughout hospital stay. Initially there was some difficulty evacuating entire content of PD dwells, and pt became volume overloaded. Renal consult service followed closely and guided modifications to PD solution. Pt was euvolemic on PD for 4 days prior to discharge. . # Hx SLE Diagnosed in ___ and followed by Dr. ___. Complicated by nephritis, & recurrent pleural effusions, w/additional ocular and skin manifestations. Plaquenil was continued while pt able to take POs; held while intubated & restarted thereafter. Rheumatology consult service followed, suggested possibility that lupus vasculitis or other vasculitis might have contributed to her hemoptysis (see above) and recommended initiation of IV steroids. Steroid taper to be further managed by rheumatologist in follow-up. . # Hx HTN Recently stopped lisinopril for concern of exacerbation of her cough. BP meds held on admission given concern for bleeding. Used PRN IV labetolol to control BPs while intubated. After extubation, pt's BP ran . # Hx MIGRAINE HEADACHES Takes amitriptyline at home at night. Amitriptyline + PRN tylenol while here. . # Hx GERD Continued ranitidine. Pt did have some nausea and PO intolerance but was able to take small-volume POs prior to discharge. . TRANSITIONAL ISSUES 1. ANTICOAGULATION </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CT ABD AND PELVIS WITH CONTRAST showed No acute intra-abdominal or intrapelvic pathology. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with N. At the time of discharge, the patient had PRIMARY ======== Hematemesis SECONDARY ========== Hypertension Phantom limb 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>TRANSITIONAL ISSUES =================== [] Patient should follow up with GI as an outpatient within 1 week for further evaluation of his hematemesis [] Patient discharged on 1 month course of omeprazole for acute GI bleed. Continue or stop as clinically indicated. [] Discharge hgb 13.3 [] Should have Hgb checked within 1 week of discharge by primary care physician [] Patient counseled on alarming symptoms that would prompt urgent ED evaluation BRIEF SUMMARY ============== ___ HTN, polysubstance abuse, and left AKA d/t osteo, who presented with epigastric abdominal pain and vomiting 4 days prior to admission, which progressed to hematemesis concerning for upper GIB. Trigger unclear as patient denies EtOH use and has no lab abnormalities concerning for cirrhosis, no recent NSAID use, or other historical triggers for GI bleed. He was fluid resuscitated in the ED with 3L IVF, and had CT A/P which was unremarkable. Labs notable for mild anemia s/p IVF. He has a history of GIB d/t gastritis, which was the leading diagnosis. He received IV pantoprazole BID. He was scheduled for EGD, however felt better and elected to leave the hospital prior to further evaluation. As he was hemodynamically stable and with stable H/H, GI and the medicine team felt outpatient follow-up was acceptable (though not ideal), however counseled the patient about the benefits of EGD, particularly around identifying a source of bleed or identifying ongoing bleed which would require further fluid resuscitation, possible transfusions, and/or endoscopic intervention with ablation. He was instructed to schedule his own follow-up with PCP and GI for further evaluation of his upper GIB. He was discharged on omeprazole 40 BID. Discharge Hgb 13.3. ACUTE ISSUES: ============= #Hematemesis #Concern for upper GI bleed #Acute blood loss anemia Given hematemesis with dark stools, presentation is most concerning for upper GI bleed. Unclear trigger, as patient denies EtOH, no NSAIDs, no hx cirrhosis and w/o labs concerning for cirrhosis. Given his 4 days of vomiting that progressed to hematemesis, concerning for ___ tear. One prior admission in ___ for the same issue w/ gastritis on EGD; given the similarity in presentation, he may have repeat gastritis. Mild anemia likely secondary to blood loss. Treated with IV BID pantoprazole while inpatient. He was kept NPO starting ___ midnight and supposed to go for EGD. Patient vehemently declined EGD as he felt much improved and wanted to leave the hospital. As he was hemodynamically stable and with stable H/H, GI and the medicine team felt outpatient follow-up was appropriate, however counseled the patient about the benefits of EGD, particularly around identifying a source of bleed or identifying ongoing bleed which would require further fluid resuscitation, possible transfusions, and/or endoscopic intervention with ablation. He is to schedule his own follow-up with PCP and GI for further evaluation of his upper GIB. CHRONIC ISSUES: =============== #HTN Continued home losartan-HCTZ #s/p AKA #Phantom limb pain Narcotic agreement in place, most recent ___ with PCP ___ ___. Continued home pain regimen: Percocet, MS contin, gabapentin. Pt seen on the day of discharge ___, hemodynamically stable, denied any further n/v/hematemesis. He preferred not to stay in-house for EGD and was intent on leaving under a specific timeframe, not able to secure him an actual appointment time for GI clinic but we did provide the number and recommended followup >30 min spent on d/c activities</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with a history of polysubstance use disorder, alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal seizures who presented with altered mental status and hypoxia s/p a presumed seizure. According to EMS, this morning around 10am, Mr. ___ had a presumed seizure. He called his ___, who then alerted EMS. On arrival, EMS found him awake and alert. However, in transit to the hospital, Mr. ___ acutely worsened, becoming progressively somnolent and hypoxic. CHEST (SINGLE VIEW) showed Mild-to-moderate pulmonary edema. CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormality. 2. Sinus disease. ABDOMEN US (COMPLETE STUDY) showed Cirrhotic liver morphology with sequelae of portal hypertension including hepatofugal portal flow, midline varices, and splenomegaly. Evaluation for focal liver lesions is limited on this study given heterogeneity of the liver. Liver MRI or multiphasic liver CT is recommended for further screening. RECOMMENDATION(S): Liver MRI or multiphasic liver CT is recommended for further screening. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Final diagnoses: - Acute Toxic/Metabolic/Postictal/Hepatic encephalopathy - Seizure - Acute pulmonary edema c/b acute hypoxic respiratory failure - Polysubstance use disorder - ETOH intoxication/use disorder/withdrawal - ETOH cirrhosis c/b portal hypertension and coagulopathy - Pancytopenia d/t ETOH and splenomegaly - PTSD/Depression/Anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY ======== Mr. ___ is a ___ with a history of EtOH use disorder, alcoholic/HCV cirrhosis, and COPD and alcohol withdrawal seizures who presented with altered mental status and hypoxia s/p a presumed seizure.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old male with a history of asthma presenting with SOB at rest and with exertion. For the past few weeks, he has had some rhinitis, congestion with a productive cough and a mild sore throat. He notes that for the past week he has developed increasing SOB with exertion, and more recently at rest as well. He has also had associated nasal congestion and cough. He denies fevers, chills, nausea, vomiting, abd pain, dysuria, diarrhea. Chest radiograph showed No acute cardiopulmonary abnormality. The patient was diagnosed with Unspecified asthma with (acute) exacerbation. At the time of discharge, the patient had Asthma exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES ======================== - None MICU COURSE ========================= ___ with a history of asthma presenting with an acute asthma exacerbation likely triggered by a viral upper respiratory infection. #Asthma exacerbation: Most likely asthma exacerbation given history, wheezing on exam and great improvement with bronchodilator therapy. No history of heart failure, no volume overload on exam and history inconsistent with CHF. Low concern for bacterial infection given no fevers, normal CXR, no leukocytosis. Asthma exacerbation likely triggered by viral URI. Patient was treated with albuterol nebs Q4h, albuterol nebs Q2h PRN SOB, ipratropium Q6h, prednisone 40mg PO on discharge with taper based on symptoms. Flu shot was offered prior to discharge. The patient's respiration improved with these interventions and without need of supplemental oxygen. #Lactic acidosis: No documented hypotensive episodes with very low concern for end organ and tissue hypoperfusion. Lactic acidosis likely secondary to beta agonist therapy with stacked albuterol nebs in the ED. No need to trend lactate. Vital signs per ICU protocol and can trend lactate if patient develops any signs of systemic infection or hypotension. Patient did not develop these signs and no further lactate measurements were indicated.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of recurrent GI bleeds, CVAs, UTIs, Grave's disease, DMII, atrial fibrillation on apixaban, and asthma who presents with dyspnea and a CT scan from an outside facility suggestive of right lower lobe pneumonitis. CHEST (PA AND LAT) showed Comparison to ___. On today's examination, there is stable mild bilateral apical scarring and elevation of the right hemidiaphragm. Moreover, the heart is slightly enlarged and there is elongation of the descending aorta. However, there is no evidence of pneumonia, pulmonary edema or pleural effusions. No pneumothorax. Severe scoliosis with secondary degenerative vertebral changes. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Primary Viral Bronchitis Aspiration pneumonia 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>Summary ___ with history of recurrent GI bleeds, CVAs, UTIs, Grave's disease, DMII, atrial fibrillation on apixaban, and asthma who presented with dyspnea and a CT scan from an outside facility suggestive of right lower lobe pneumonitis vs PNA iso probable aspiration. Read of CT scan here was more concerning for viral bronchitis. She was also found w/ pyuria. Discharged to complete a 7 day course of augmentin/azithromycin for CAP/UTI. Transitional Issues =================== [] found w/ hypercalcemia (mild) with elevated PTH, normal vit D. [] Patient is being followed by neurology and likely does not have parkinsons disease. She is being weaned off her parkinsons medications, ensure patient has adequate neurology follow up. [] Augmentin ___, azithromycin ___ [] Recommend repeating CXR in 6 weeks to eval for resolution of bronchiolar inflammation, consider CT scan at that time Acute Issues ============ # Dysphagia, Aspiration Risk # Aspiration Pneumonia # Bronchitis, viral Outside imaging with RLL pneumonitis per report. Patient is at aspiration risk given CVA history with fluctuating mental status. CXR on presentation was without focal consolidation. BNP wnl. Started on IV unasyn and azithro. CT chest here was concerning for acute infection, likely viral bronchitis. Given the clinical setting, w/ neurologic deficits and aspiration risk, we elected to treat for CAP, unasyn transitioned to Augmentin ___ - ___, and continued azithromycin. Speech and swallow evaluated, recommended continuing nectar thick liq/pureed solids, no e/o aspiration at time of d/c. # UTI: UA w/ positive nitrites, WBCs, urine cx contaminated. As above, on IV unasyn initially, transitioned to PO augmentin at time of d/c to treat PNA and UTI concurrently. # Atrial fibrillation Continued apixaban, briefly on a heparin gtt while NPO. # Hypercalcemia Corrected calcium 11.5 on admission. PTH notably elevated. ___ be primary parathyroidism +/- some component of bone resorption due to patient's immobility. Currently asymptomatic w/o GI symptoms, nephrolithiasis, appears at neurologic baseline. Vitamin D wnl. CHRONIC ISSUES: =============== # Tremor # Concern for ___ Disease Per last neuro note, was started on amantadine and carbidopa-levodopa at rehab due to concern for ___ disease. However, per neurology, do not think patient has underlying parkinsons and think her symptoms are likely related to stroke. Per family medications have not improved symptoms much and neuro is weaning off meds currently. Continued carbidopa-levodopa ___ 0.5 tab TID, and amantadine 100mg daily for now, will continue wean w/ neuro as OP. # DMII -Discharged on metformin # History of CVA - Continued atorvastatin 80 mg PO QHS # History of GI bleeds (esophagitis and ischemic colitis) - Continued PPI # Grave's disease - Continued methimazole </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with a history of HIV, HCV, end-stage renal disease on HD, and hypertension, who was found to have a positive gram positive blood culture taken during HD yesterday. . According to Ms. ___, she began to feel unwell yesterday during HD which prompted her to ask for a blood culture. After the HD session she had up to 30 episodes of non-bloody vomiting which was followed by severe, ___, epigastric abdominal pain that felt like a gnawing dullness. "It felt like pancreatitis." This morning, her primary care physician informed her by telephone that her blood culture had come back positive and advised her to go to the emergency department. . Her vital signs on presentation to the emergency department were: T 99.6, P 90, BP 192/114, RR 18, O2 Sat 100%. She was given 1 gram of IV Vancomycin for the positive blood culture, Zofran for nausea, and morphine for pain, and acetaminophen for a new onset headache while in the ED. Her labs were significant for a BUN 55, Cr 8.5, and a lactate that was initially 3.3 but then dropped to 2.1. She also received 1L of NS. Her vital signs on transfer to the floor were T 98.0, P 89, RR 14, BP 116/70, O2 Sat 100%. . Currently, she does not complain of pain or nausea. She had no sick contacts. She attributes the nausea and vomiting to having eaten at a restaurant where she previously developed a gi illness. She endorses having had developed a headache while in the emergency department that still persists. She denies shortness of breath, cough, diarrhea and constipation, urinary changes, fevers, night sweats, and chills. Radiology showed No evidence of acute cardiopulmonary disease. The patient was diagnosed with BACTEREMIA NOS, END STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE. The patient was treated with hemodialysis session on ___. At the time of discharge, the patient had Primary Diagnosis: Gram positive, coagulase negative staph bacteremia. Secondary Diagnosis: End Stage Renal Disease on Hemodialysis HIV HCV Hypertension ITP. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman who came to the ___ because of a positive blood culture, received hemodialysis, and receieved antibiotics for line infection. . #Bacteremia: A blood culture was performed during a hemodialysis session on ___ that grew staph epi in ___ bottles of 1 set. She was then referred to the ED the next day where she received 1g of Vancomycin; 2 sets of blood cultures were taken. She remained afebrile. Her WBC was 4.7. She received a second dose of vancomycin during hemodialysis on ___. Cultures from the ED on ___ grew staph epi in 1 of 2 sets - ___ bottles. Nephrology recommended treating through the infection with vancomycin for 2 weeks per HD protocol and this was communicated to her outpt HD center - ___. Her line was not replaced. . #Abdominal Pain, Nausea, and Vomiting: Ms. ___ developed abdominal pain soon after her hemodialysis session on ___ ended. This pain was followed by nausea and emesis. She mentioned that she had eaten at a restaurant at which she formerly developed a gi illness. She received morphine and ondansetron while in the emergency department. After she was transferred to the internal medicine floor, she no longer complained of abdominal pain, nausea, and vomiting. . #Abnormal EKG/CAD: An EKG done on the internal medicine floor showed inverted T waves in leads I, II, III, and V3-V5 that were new compared to an EKG from ___. CK-MB and troponins were sent which were negative for ischemia. Continued her home medications of Lisinopril 40mg po daily and metoprolol tartrate 100mg po bid. . #Chronic Kidney Disease: Ms. ___ has stage V chronic kidney disease on hemodialysis. She received hemodialysis on ___. She had an elevated Ca level of 11.2 and an elevated PTH of 3381. Her PTH in ___ was 2913. Continude her home medications of Sevelamer 800mg with meals, Nephrocaps 1mg capsule daily, and Epoetin Alpha. . #HIV: Ms. ___ was diagnosed with HIV ___ years ago. She is followed by the infectious disease specialist, Dr. ___ ___. Continued HAART: Atazanavir 300mg po daily, Ritonavir 100mg po BID, Raltegravir 400mg po BID, Emtricitabine 200mg q96hr (has not yet filled ___ prescription). . #Hypertension: Ms. ___ was markedly hypertensive, to a systolic pressure of 198, while she was in the emergency department. Despite not having received any anti-hypertensive medications, her blood pressure fell to 116 upon admission to the floor. Her systolic pressure then rose to 170 by nighttime. She received a dose of metoprolol at that time, after which her blood pressure remained normal throughout the remainder of the hospitalization. . #Transitional issues: Follow up appointments: She will be following up with her nephrologist, Dr. ___. - management of hypertension - management of hypercalcemia and secondary hyperparathyroidism Code Status: Full (Confirmed) Contacts: Son, ___ is healthcare proxy (she does not have his phone number). Can contact other son, ___, in case of emergencies, (___).</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of AVR s/p redo, CAD s/p CABG, CHB s/p pacer placement, CKD baseline cre 1.3, HTN p/w complaints of b/l ___ edema x 2 wks in the setting of now resolved upper respiratory symptoms (nonproductive cough, congestion). She wears stockings that she is now unable to pullup her thigh (only able to get up to mid calf now). However, she reports stable wt of 130. She states that she has minimal nocturia now despite taking nighttime lasix. She has been drinking less since noticing the swelling. She denies orthopnea, pnd. Does complain of some DOE. Feels that her legs are heavy and gets fatigued with walking short distances. No BRBPR, melena. No f/c/n/v/d/chest pain/baseline sob/flank pain. In the ED, initial VS were 98.6 59 132/44 16 99% ra. Exam was significant for 1+ pitting edema to mid shin. There was no stool present on rectal exam. Labs significant for Cr of 1.7 from baseline of 1.3 and HCT of 24 from normal baseline (although last value in our system from ___. BNP was in the 900s (no prior in our system). LDH elevated but normal tbili. Iron studies were suggestive of iron deficiency anemia. INR of 4.1. She had a CTAP which showed no evidence of bleed and a CXR. She was given no medications. Transfer VS were 98.5 64 104/38 16 96% On arrival to the floor, patient reports no pain, no change in bowel habits, a colonoscopy done by Dr. ___ in ___ which was "normal", a remote history of anemia that she takes folate/B12 for, no easy brusing, neuropahties or pain. She does note that for the last 2 months she has been chewing on ice which is not normal for her. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed No evidence of acute disease. Radiology showed 1. No evidence of retroperitoneal hematoma. 2. Indeterminant renal cysts. Evaluation with ultrasound is recommended when clinically appropriate. 3. Moderate to large hiatal hernia. The patient was diagnosed with ANEMIA NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, CARDIAC PACEMAKER STATUS. At the time of discharge, the patient had Primary: Iron deficiency anemia Secondary: Chronic kidney disease, hypertension, coronary artery disease s/p stent placement, pacemaker, aortic valve repair x2. The patient was given written instructions concerning 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 significant cardiac history including PPM placement, CABG, AVR x2 and CKD p/w worsening ___ edema and increasing dyspnea on exertion found to have significant hematocrit drop from 31 to 24 over the past several days. . # Anemia - Unclear etiology of acute worsening of anemia but found to be severely iron deficient, guaiac negative, and without systemic signs of active bleeding. Imaging was also reassuring- without occult hematoma. Hematocrit increased almost appropriately to 2 u PRBCs and remained stable. INR was slightly supratherapeutic but corrected and remained therapeutic thereafter. She will need close follow up for management of anemia, given that she probably has persistent low grade intravascular hemlysis from her mechanical valve which has been documented in the past. She was started on iron supplementation and given instructions to relieve constipation as needed. She may require outpatient IV iron repletion and should discuss this with her PCP and nephrologist. . . # Acute on chronic kidney injury: Chronic stage IV CKD followed by Dr. ___ felt to be from hypertensive disease which has been well controlled. Acute injury due to hypoperfusion and resolved ___. Ace inhibitor was held on admission and restarted upon discharge. Patient was encouraged to drink water as she had been restricting ALL fluid intake prior to admission. Follow up with PCP and nephrology as outpatient. . . # CAD and CHB s/p PPM, AVR x2: Stable during this admission. Continued home clopidogrel and furosemide. Initially held warfarin for elevated INR and restarted on normal dosing schedule prior to discharge. Changed ezetimibe and simvastatin to atovastatin. . . # Gout: Stable and inactive during this admission, held colchicine during admission for ___ and restarted upon discharge. Allopurinol continued throughout admission. . . # Leg Swelling: continue home lasix for now and monitor . . Transitional Issues: - Full code - ___ with PCP - ___ with nephrology - ___ with cardiology and device clinic</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old male who presents with outpatient MRI revealing a 3cm R cerebellar mass with mass effect on the ___ ventricle. Patient reports about a year ago he began to feel very fatigued and had difficult with short term memory as well as word finding difficulty. He was referred by his PCP at that time to a neurologist. He was started on CPAP machine with no improvement of symptoms. Subsequently he was trialed on a number of antidepressants with no improvement in symptoms. He was sent for an outpatient MRI with and without contrast of the brain by his PCP. Patient denies headache, weakness, numbness or tingling. He does report word finding difficulty and intermittent double vision. MR HEAD W/ CONTRAST showed No significant interval change in enhancing right cerebellar lesion. No new enhancing lesions. Radiology showed No acute cardiopulmonary process. MR HEAD W AND W/O CONTRAST showed 1. Postsurgical changes, with interval resection of the previously noted right tentorial dural-based lesion. Foci of negative susceptibility in the right cerebellar hemisphere can relate to blood products. Surrounding edema and mass effect on the fourth ventricle, as before. Foci of increased DWI signal intensity in the medial aspect of the right cerebellar hemisphere can relate to blood products or ischemic/infarction related changes. Limited assessment on diffusion sequences for ischemic changes due to the confounding effects of blood products. Attention on close followup 2. Linear, slightly irregular enhancement in the right cerebellar hemisphere and tentorium, can relate to postoperative changes. No obvious nodular component of enhancement to suggest obvious residual tumor. Assessment can be limited due to the postoperative changes. 3. Postsurgical changes are noted in the overlying soft tissues of the right occipital and upper cervical regions. Increased signal intensity in the left more than right parietal and temporal subcutaneous soft tissues of the scalp with swelling with a focal area of heterogeneous enhancement, can be correlated clinically. (se 11, im 14; se 13, im 16). This can relate to edema or inflammation with focal contusion/hematoma. CT HEAD W/O CONTRAST showed Postoperative changes from right tentorial mass lesion resection, within expected limits. No acute findings. The patient was diagnosed with BRAIN CONDITION NOS. The patient was treated with ___ Right occipital craniotomy for tumor resection. At the time of discharge, the patient had Right cerebellar mass. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to ___ Neurosurgery service on ___ for further work-up of his word-finding difficulties and new right cerebellar lesion. He was started on Decadron due to noted vasogenic edema noted on his outside hospital MRI. The patient was admitted to the inpatient ward for close neurologic monitoring. Neurology was asked to see the patient due to his word-finding difficulties. Mr. ___ was consented for surgical resection of his brain mass on ___. A chest x-ray and pre-operative labs were ordered, in addition to a MRI wand study. On ___, The patient went to the operating room for a R suboccipital craniotomy for tumor resection by Dr ___. The procedure was tolerated well. The patient was recovered in the PACU and stayed there overnight. A post operative head Ct was performed which was consistent with expected post operative change. On ___, The patient was in the PACU in the morning. He was found to be neurologically intact. The patient denies headache however stated that he had ___ neck pain. The patient was started on a low dose of muscle relaxant ROBAXIN. Given the patients excellent neurological exam, the patient was transferred to the floor. The patient had his post operative MRI which was consistent with post op changes, and small foci of blood and edema. In the morning the patient complained of objects in his vision field moving downward- this occurred ___ days prior to his surgery but went away, the patient's peripheral vision was intact and the patient remained neurologically intact on exam. The patient Foley catheter was discontinued. On ___, the patient remained neurologically and hemodynamically intact. He voided without difficulty. He was mobilizing with nursing and was evaluated by physical therapy who recommended outpatient ___. His dressing was removed and his incision was clean dry and intact with sutures. His pain was well managed on his current pain regimen. ___: cleared by ___, OT says home with direct supervision for IADLs, dispo planning, re-eval, home OT and outpatient ___ with ___. ___: neuro intact, no dysmetria. d/c home ___, home OT, outpt ___, dex taper.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular pacer, COPD on 2L at home (at night), CKD, asbestosis with known pleural plaques, AAA s/p repair who presented to the ED with a 4 day history of myalgia, SOB, and dull chest pain. He was in his usual state of health until ___ day, when he started to feel tired and achy all over. Per daughter, he began to sleep a lot and lost his appetite. He states that his cough worsened as well. He described the cough as productive of white phlegm, about a tablespoon a day. He says that he was around "a lot of people" during ___ and might have sat across from someone who had a cold. Denies nausea, vomiting, diarrhea. Chest radiograph showed 1. Interval increased retrocardiac opacity could be left lower lobe focal pneumonia in the appropriate clinical situation versus atelectasis. 2. Increased peribronchial wall thickening can be seen with small airways disease and chronic inflammation. 3. Extensive bilateral pleural plaques. 4. Cardiomegaly without edema or pleural effusion. No evidence of pneumothorax. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Primary: Pneumonia COPD exacerbation Claudication Aortic Stenosis Secondary: CKD Chronic diastolic HF CAD Angina. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular pacer, COPD on 2L at home, CKD, asbestosis with known pleural plaques, AAA s/p repair who presented to the ED with a 4 day history of myalgia, SOB, and cough.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with h/o hypertension and herniated lumbar disc with sciatica x 6 months presents with worsening low back pain radiating down left leg similar to previous sciatica. Pt reports overnight was turning in bed and felt "pop" and sudden onset pain left low back/buttock radiating down lateral leg. Has had intermittent numbness in left toe but otherwise no paresthesias or loss of bowel or bladder. Worse with movement. Has difficulty weight bearing but doesn't feel he has focal weakness. No fevers or chills. No difficulty urinating, subjective perianla anesthsia. No trauma. Oxycodone at home gave minimal relief. Has gotten cortisol injections x2, last one 3 weeks ago. Has trialed NSAIDs, flexiril, and oxycodone at home. Has not see a specialist yet. Radiology showed Multilevel degenerative change, worst in lower lumbar spine. Radiology showed Underlying dextroscoliosis with associated alignment abnormalities, as well as congenitally abnormal spinal canal geometry and prominent epidural lipomatosis, result in: 1. L4-L5: Most severe spinal canal and left more than right subarticular zone stenosis with traversing L5 neural impingement; bilateral neural foraminal stenosis with exiting L4 neural impingement. 2. L3-L4: Multifactorial moderate canal stenosis with central crowding of the traversing nerve roots; right more than left neural foraminal stenosis with possible impingement upon the exiting right L3 nerve root. 3. L5-S1: Grade 1 anterolisthesis, likely spondylolytic, with bilateral neural foraminal narrowing and possible exiting L5 neural impingement, left more than right. 4. T11-T12: Disc degeneration with right paracentral/proximal foraminal protrusion which may impinge upon the exiting right T11 nerve root, incompletely imaged. COMMENT: Given the numerous findings, close correlation should be made with the nature, level and side of the patient's symptoms. In addition, comparison with any previous (outside) MR imaging study would be helpful. The patient was diagnosed with SCIATICA. At the time of discharge, the patient had Primary diagnosis: L5 lumbar radiculopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with h/o hypertension and herniated lumbar disc with sciatica x 6 months presents with worsening low back pain radiating down left leg similar to previous sciatica. # Lumbar radiculopathy: History and exam consistent with exacerbation of known herniated disc leading to worsening radicular pain down left leg. No evidence of cord compression or cauda equina on exam. Xray did not show any bony deformities. MRI confirmed severe degenerative disc disease with lumbar disc herniation resulting in multilevel moderate to severe spinal stenosis and nerve impingement, worst at left L5 (consistent with symptoms). His pain was fairly well-controlled with standing tylenol and ibuprofen with PRN oxycodone, so he was discharged on this regimen for pain control. He was encouraged to continue physical therapy and establish care with an orthopedic spine specialist for further evaluation and care. # Hypertension: increased lisinopril to 20mg daily </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 past medical history significant for Hodgkin's lymphoma diagnosed in ___ with recurrences later that year in ___ and ___. He is status post full body radiation in ___ and a bone marrow transplant in ___ followed by another round of radiation. He then developed squamous cell carcinoma of the left mandible requiring modified radical neck dissection with resection of the left posterior mandible followed by a third radiation treatment. He presented to neurology clinic last week after CT earlier this year showed evidence of a frontal stroke. Radiology showed 1. Small cortical acute to early subacute infarction in the inferior left parietal lobe extending to the parieto-occipital sulcus. 2. Confluent elevated T2 signal in the deep and periventricular white matter of the cerebral hemispheres is compatible with sequela of chronic small vessel ischemic disease, prior medication toxicity, or prior brain radiation. 3. Linear foci of mildly high signal on the diffusion tracer sequence in the posterior frontal centrum semiovale, more conspicuous on the right than left, without associated signal abnormality on the ADC map, most likely represent T2 shine through, and less likely subacute infarcts. 4. Small area of encephalomalacia and gliosis in the superior left frontal lobe at the site of a prior hematoma, with several prominent adjacent superficial veins. Diagnostic considerations include prior hemorrhage which may be secondary to amyloid angiopathy or an underlying vascular malformation. No clear evidence for an underlying cavernous malformation is seen. This area is not included in the field of view of the MRA. 5. Left greater than right internal carotid artery origin atherosclerosis without evidence for flow-limiting stenosis by NASCET criteria. 6. No evidence for occlusion or flow-limiting stenosis of the major intracranial arteries. 7. 7 mm fusiform dilatation of the cavernous right internal carotid artery. No evidence for a saccular aneurysm. RECOMMENDATION(S): Recommend CTA of the head to exclude an arteriovenous malformation in the superior left frontal lobe. NOTIFICATION: The findings and recommendations were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:21. MRI CERVICAL SPINE WITHOUT CONTRAST showed Mild cervical degenerative disease. Mild to moderate left C2-3 neural foraminal narrowing. No spinal canal narrowing. Normal appearance of the spinal cord. Carotid Doppler Ultrasound showed Bilateral mild heterogeneous atherosclerotic plaque in the ICAs resulting in less than 40% stenosis on both sides. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No acute intracranial pathology. 2. 8 mm fusiform aneurysm of the right ICA cavernous segment. 6 mm fusiform aneurysm of the left ICA cavernous segment. No saccular aneurysms. 3. No significant stenosis of the extracranial circulation. 4. Post radiation changes the right lung with small bilateral pleural effusions. Multiple biapical lung nodules, better visualized on the prior dedicated CT chest. 5. A 1 cm left thyroid nodule for which a dedicated thyroid ultrasound can be performed. RECOMMENDATION(S): Nonurgent thyroid ultrasound. The patient was diagnosed with TRANS CEREB ISCHEMIA NOS. 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>He was admitted for dysarthria and Right hand numbness. His MRI notable for a punctate infarct in L parietal lobe, small vessel ischemic changes. CTA and US notable for atherosclerosis, <40% stenosis. His stroke risk factors were evaluated and notable for history of radiation, A1c (5.3%)/LDL (117)/ Echo: no PFO/ASD, normal EF. He was started on ASA 81, Atorvastatin and Norvasc for BP control. Renal following for PD. ___ cleared for home no services. He was set up with a holter to monitor for pAFIb. He was discharged home. Transitional issues: - ___ of ___ Holter ======================================================== AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 117) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o dementia on asa 81, no other anticoagulation, transferred with questionable traumatic SAH s/p unwitnessed fall today. Pt is delirious and cannot provide history. Per ___ note, pt lives with family, found down. Initial eval showed normal EKG, troponins negative. Vitals benign exam non focal Labs notable for cr 2.0 (unk baseline), negative troponin. CT head with bilateral frontal intraparenchymal calcifications but negative for hemorrhage. KNEE (AP, LAT AND OBLIQUE) LEFT showed No acute fracture or dislocation. Moderate tricompartmental osteoarthritis. CHEST (PORTABLE AP) showed No acute intrathoracic process The patient was diagnosed with ALTERED MENTAL STATUS , FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had Primary: - Toxic-metabolic encephalopathy - Acute renal failure - Recurrent falls - Elevated LFTs NOS Secondary: - Dementia NOS - Bifrontal subcortical calcifications secondary to traumatic frontal ICH (___) - Hypertension - Anxiety and Depression - Osteoarthritis w/ chronic pain - GERD - Vertigo - S/P hysterectomy - S/P L cataract 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>___ w/ h/o dementia, poorly controlled HTN, on ASA 81 presents s/p fall in the setting of declining mental status of unknown etiology with CT showing no acute intracranial hemorrhage but labs concerning for ___. Cuase of the fall thought to be 2'/2 orthostatic hypotension in the setting of decreased PO intake. Although her mental status improved with holding of delirium inducing medications and hydration to treat her pre-renal azotemia, she was seen by geriatrics who thought her presentation was most likely related to worsening dementia.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Overall patient is an ___ yo man with h/o ESRD on HD, Afib on coumadin, HTN, CHF with EF 48% p/w generalized weakness. Patient reports 3 days of generalized fatigue and weakness on morning of admission esp in LEs with inability to get out of bed to walk short distence. Some concern for left sided weakness initially, although patient now states that at baseline uses LUE less due to old injury and LLE w/ heel ulcer, thus less concern for left sided weakness. Patient recently admitted with UTI for which completed course of ceftaz on ___ and he continues to get neomycin bladder flush and dwell q2 days. Denies any change in quality of urine. Patient denies chest pain, palpiations, orthostasis, cough, fever, chills, abdominal pain, nausea, vomiting, diarrhea, shortness of breath, orhopnea, PND, leg swelling, parestesias, dysathria, dysphagia. Radiology showed 1. Moderate size right pleural effusion, similar compared to the prior exam, with trace left pleural effusion. 2. Bibasilar airspace opacities could reflect compressive atelectasis but infection is not excluded. 3. Interval improvement in mild pulmonary edema. The patient was diagnosed with OTHER MALAISE AND FATIGUE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM NOS. The patient was treated with Hemodialysis. At the time of discharge, the patient had Generalized weakness Volume depletion Hypothyroidism ESRD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with PMH ESRD on HD, afib on coumadin, HTN, CHF with EF 48% p/w generalized weakness. ACTIVE ISSUES # Weakness Unclear etiology at presentation. One possibility included a UTI so initially started on antibioitics, however U/A was not convincing and no leukocytosis so antibiotics were discontinued. No cardiac symptoms suggesting ACS or focal symptoms to suggest infection. No neuro findings to suggest CVA or neuropathic. He had signs of volume depletion so he was given IVF with some improvement in weakness. Also the possibility that neomycin bladder dwells could have been causing the weakness so the volume of neomycin was decreased. At discharge patient felt back to his baseline strength and was safe for discharge. # Hyperkalemia Patient presented with K of 7.1 and EKG showed peaked T waves. He was given one dose of kayexelate and had two rounds of HD. On discharge his K normalized and his EKG was at baseline. # ESRD: On HD ___, Th, Sa. Missed Th HD so got HD ___ and had a repeat HD on ___ for ___ schedule. Continued cinacalcet, nephrocaps, and sevelemer. CHRONIC ISSUES # Anemia This is a chronic, but at presentation he is above baseline and most likely hemoconcentrated. There was no concern for active bleeding at this time. His hematocrit was stable throughout the hospitalization. # Atrial fibrillation Continued his home dose of coumadin and metoprolol XL. No issues during hospitalization and he was discharged hemodynamically stable. # Hypertension Continued home dose of metoprolol. # CHF Continued lasix and metoprolol per home regimen. # Gout Continue home dose allopurinol. # Hypothyroidism: Contine home dose Levothyroxine. TRANSITIONAL ISSUES - Please follow-up at your regularly scheduled Dialysis center - Please follow-up Free T4 and T4 - Follow up blood cultures, urine culture. - Please follow-up with your primary care physician, ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with history of anorexia nervosa presenting from Radius LTS with nausea. ___ staff concerned that pt pt's J-tube had migrated into stomach, and that pt needs higher level of care so transferred her back to ___ with all of her belongings. Of note, pt was recently discharged on ___ from ___ to ___. Last hospital course was notable for prolonged stay secondary to anorexia nervosa. Initial VS in the ED:97.8 74 113/75 15 100%. Labs notable for unremarkable lytes accept slightly elevated phos. CBC shows crit of 34.9 at baseline Imaging notable for KUB dobhoff is clearly still in the right place. VS prior to transfer: 97.8 74 113/75 15 100% Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, Denies sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, ANOREXIA NERVOSA. At the time of discharge, the patient had Primary: - anorexia Secondary: - Anxiety - Chronic abdominal pain - Orthostatic hypotension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with pmhx of anorexia, osteoporosis, chronic anemia and migraines presenting from ___ with nausea and concern for migration of Dobhoff. # r/o Dobhoff migration - Dobhoff has not migrated, it is in proper place. However a new Dobhoff was placed in the stomach on ___, as ___ (where she is being discharged to) does not take post-pyloric tubes. This was verified by chest-xray on the day of discharge. # Nausea - pt complains of nausea with emesis, and abdominal pain. Nausea is a chronic problem, perhaps secondary to gastroparesis from life long anorexia, could also be secondary to celiac sprue or somatization. She was treated with Zofran and ativan PRN. We discontinued her bentyl and started amitiza for possible irritable bowel syndrome and bloating. At the time of discharge her abdominal pain and nausea was moderately improved. We increased her ativan from 0.5mg to 1mg TID as needed for anxiety and nausea. # Anorexia: The patient had normal electrolytes with exception of slightly elevated phos. Eating disorder was not initiated as patient was tolerating tube feeds. She was allowed to order and eat food for pleasure. Her weight was recorded daily, and at the time of discharge she weighed 93.2 lbs or 42.3 kg from 41kg on admission. # GERD: continued Ranitidine, Maalox. # CELIAC DISEASE: Maintained gluten-free diet. # DEPRESSION, ANXIETY: continued Venlafaxine, Abilify, Clonazepam. She was started on olanzapine 2.5mg QHS on ___, which she tolerated well. QTc was not elevated. We increased her ativan from 0.5mg to 1mg TID as needed for anxiety and nausea. # MIGRAINES: continued sumatriptan and Fiorocet as needed for headache. # OSTEOPOROSIS: we continued Calcium, Vitamin D. # CODE STATUS: Full Code # EMERGENCY CONTACT: ___, sister ___ ___, sister, ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with PMH of MRSA infections (notably left knee PJI, T6-T7 discitis requiring T4-T9 fusion in ___, also hx of L3-L5 fusion laminectomy in ___ who is referred to ED for after abnormal MRI (available through ATRIUS) with right L2-L3 paracentral fluid collection concerning for abscess. Per PMD, patient has had longstanding back pain, which is currently unchanged. She is being referred for admission for biopsy, spine surgery and ID consults. SHOULDER ___ VIEWS NON TRAUMA LEFT showed Moderate left glenohumeral joint degenerative changes and joint space narrowing. Mild AC joint degenerative changes. US EXTREMITY LIMITED SOFT TISSUE LEFT showed No evidence of fluid collection within the left shoulder. SECOND OPINION MR NEURO PSO4 MR showed 1. Study is degraded by motion and spinal fusion hardware artifact. 2. Postsurgical changes from L3-5 laminectomy and posterior fusion. 3. Approximately 5 mm T2 hyperintense, rim enhancing lesion in the right lateral recess at L2. While findings suggestive of suggestive of a discal cyst, differential considerations of infectious or inflammatory etiologies are not excluded on the basis examination. Recommend follow-up imaging to resolution. 4. Nonspecific paraspinal soft tissue edema centered at L4-5 persists, though is decreased from prior. 5. Multilevel lumbar spondylosis as described, most pronounced at L2-3, where there is moderate vertebral canal, mild left and moderate right neural foraminal narrowing. 6. Limited imaging of the kidneys demonstrate right at least partially cystic structures, incompletely characterized. RECOMMENDATION(S): Approximately 5 mm T2 hyperintense, rim enhancing lesion in the right lateral recess at L2. While findings suggestive of suggestive of a discal cyst, differential considerations of infectious or inflammatory etiologies are not excluded on the basis examination. Recommend follow-up imaging to resolution. The patient was diagnosed with Intraspinal abscess and granuloma. At the time of discharge, the patient had Primary diagnosis ================= Suspected spinal abscess Acute kidney injury Secondary diagnosis =================== Osteoarthritis Diabetes Hypertension Peripheral vascular 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>TRANSITIONAL ISSUES =================== [] Minocycline dose increased to 100mg q12h, she should continue on this dose after completing antibiotics for her current infection [] Blood cultures from ___ with coag negative Staph (preliminary), follow up final culture results [] Discussed with patient risks of leaving the hospital prior to speciation of cultures and prior to set up of antibiotics for home infusions. Attempted to coordinate home antibiotics but were unable to coordinate this on a ___ with her insurance. She understood the risks (death, septic shock, recurrent bacteremia) and chose to leave the hospital against medical advice. She will have an appointment with ID at 10 am on ___ and is agreeable to this and we will email them about the need to set up PICC placement and home infusions of Vancomycin 1250 mg IV Q 12H pending follow-up with ID regarding course. [] Held home irbesartan at time of discharge. Follow up BPs and consider restarting as outpatient. BRIEF SUMMARY ============= Ms ___ is a ___ year old woman with history of MRSA infections (notably left knee PJI, T6-T7 discitis requiring T4-T9 fusion in ___, hx of L3-L5 fusion laminectomy in ___, IDDM, HTN, CKD, hypothyroidism who was admitted for evaluation and treatment of suspected spinal abscess on MRI. This was evaluated by ID and ___ and determined that it was not accessible for biopsy or drainage. She was started on IV vancomycin with final antibiotic course pending blood culture speciation. She left against medical advice prior to determination of final antibiotic course. ACUTE ISSUES ============ #Suspect spinal abscess #GPCs in blood #Recurrent discitis Found to have rim-enhancing fluid collection near L2 on recent outpatient MRI, along with increasing CRP, concerning for abscess and potential discitis despite chronic minocycline. ___ BCx from ___ grew coag negative Staph (preliminary). ID was consulted and recommended IV vancomycin with final antibiotics pending speciation; however, the patient left against medical advice prior to determination of final antibiotic course. She was discharged on her home minocycline 100mg q12h (she had previously been on 50mg q12h but clarified dose should be 100mg q12h). #Left shoulder pain History of OA of shoulder, s/p cortisone injection ___. She had pain on moving her L shoulder this admission. She was evaluated by orthopedics who recommended ___ guided aspiration to rule out infection (low suspicion), which she declined. Shoulder pain improved the following day. #Diabetes, insulin dependent On Tresiba 46 units in AM at home, treated with insulin glargine and ISS while inpatient. ___ Baseline renal function with Cr of 1.0, elevated to 1.9 on admission, suspected pre-renal I/s/o worsening infection and dehydration. Cr downtrended after IVF and was 0.8 at time of discharge. #Hypertension Held home irbesartan in setting ___ and normotensive at time of discharge. Initially held furosemide in setting of ___, restarted after Cr improved. #Depression Continued sertraline #Peripheral vascular disease Continued rosuvastatin and aspirin #Chronic pain On methadone and hydromorphone as an outpatient which were continued. She reported her home dose of hydromorphone 4mg q4h prn despite Atrius records stating hydromorphone 2mg q4h prn so was continued on hydromorphone 4mg q4h prn this admission. This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ M with a h/o multiple spinal surgeries following spinal cord accident in early ___, s/p cervical spine fusion, lumbar spinal fusion, cauda equine syndrome s/p decompression/fusion (___) with chronic lumbar spinal pain (on fentanyl and hydrocodone), h/o multiple MRSA infection incl. bacteremia, chronic diverticulitis, Crohn's and RA (on immunosuppression), and CVL who p/w acute on chronic back pain with b/l lateral lower extremity pain, saddle paranesthesias, inability to void, and bilateral lower extremity weakness following a minor fall at 14:30 on ___. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormalities. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Postoperative changes spine. 2. No fractures. 3. Degenerative changes. CT abdomen and pelvis with contrast showed 1. No acute CT findings in the abdomen or pelvis to correlate with patient's reported symptoms. Specifically, no evidence of fracture in the lumbosacral spine. 2. Hepatic steatosis. The patient was diagnosed with Low back pain, Fall on same level, unspecified, initial encounter, Crohn's disease, unspecified, without complications. At the time of discharge, the patient had left lower extremity weakness urinary retention. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ M with a h/o multiple spinal surgeries following spinal cord accident in early ___, s/p cervical spine fusion, lumbar spinal fusion, cauda equine syndrome s/p decompression/fusion (___) with chronic lumbar spinal pain (on fentanyl and hydrocodone), h/o multiple MRSA infection incl. bacteremia, chronic diverticulitis, Crohn's and RA (on immunosuppression), and CVL who p/w acute on chronic back pain with b/l lateral lower extremity pain, saddle paranesthesias, inability to void, and bilateral lower extremity weakness following a minor fall at 14:30 on ___. CT head, abdomen/pelvis, C-spine were unremarkable. He chose to leave AMA shortly after his admission prior to completion of Neurologic workup, despite counseling regarding dangers of leaving. He was offered his home medications and additional nonnarcotic neuropathic pain medications in-house. Final radiologic reads of MRI lumbar and thoracic spine were pending at time of discharge. MRI brain and C spine were scheduled but not yet performed; ESR and CRP pending.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old male with a PMHx of metastatic RCC (papillary vs clear cell) to lungs & L pleural effusions s/p multiple chemo regimens (most recently cycle 10 of bevacizumab + erlotinib on ___, presents after a recent admission to ___ for PNA now with fevers, hypotension. Radiology showed 1. Improvement in right lower lobe aeration with resolution of previously seen opacity. 1. Persistent left mid and lower lung opacification. 2. Multiple pulmonary nodules, consistent with known history of metastatic renal cell carcinoma. This is a ___ man with metastatic RCC with elevated liver enzymes and epigastric pain; the request is to perform right upper quadrant examination with Dopplers to evaluate for source of elevated liver enzymes. COMPARISON: CT torso from ___. FINDINGS: The liver shows no focal or textual abnormalities. The gallbladder is normal, without evidence of stones. No intra- or extra-hepatic biliary duct dilatation. The CBD measures 0.4 cm. Normal appearance of the pancreas. Note is made to multiple lymph nodes around the celiac axis. Both right and left kidneys are normal without hydronephrosis or stones. The right kidney measures 13.2 cm and the left kidney measures 14.5 cm. Spleen is unremarkable measuring 12.2 cm. The aorta is of normal caliber throughout. The visualized portion of the inferior vena cava appears normal. No ascites is detected. COLOR DOPPLER AND SPECTRAL WAVEFORM ANALYSIS: The RHV, MHV, and LHV are patent, showing normal flow direction. The MPV, RPV, and LPV are patent, showing normal flow direction and normal spectral waveform. The hepatic artery is patent, showing normal spectral waveforms with RI of 0.7. Normal flow is seen in the splenic vein. IMPRESSION: 1. Normal appearance of the liver with no focal or textural abnormalities. 2. The bile ducts are not dilated. 3. Normal liver vasculature. 3. Enlarged lymph nodes around the celiac axis consistent with the patient's known lymphadenopathy. showed 1. Normal appearance of the liver with no focal or textural abnormalities. 2. The bile ducts are not dilated. 3. Normal liver vasculature. 3. Enlarged lymph nodes around the celiac axis consistent with the patient's known lymphadenopathy. The patient was diagnosed with PALPITATIONS, HYPOTENSION NOS, VERTIGO/DIZZINESS, SEPTICEMIA NOS, SEPTIC SHOCK, SEVERE SEPSIS , ACCIDENT NOS. The patient was treated with Esophagogastroduodenoscopy. At the time of discharge, the patient had Primary Diagnosis: Metastatic renal cell carcinoma Fevers Hypotension Abdominal Pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ M w metastatic RCC (papillary vs clear cell) to lungs & L pleural effusions s/p multiple chemo regimens (most recently cycle 10 of bevacizumab + erlotinib on ___, presents after a recent admission to ___ for PNA, presented with fevers and hypotension, which was managed with IVFs and antibiotics in the FICU, but managed with steroids (stopped antibiotics) on the floor, given that the fever and hypotension were likley related to his underlying progressing malignancy and adrenal insuffiency. # Hypotension: The patient presented with hypotenstion that resolved with IVF. The hypotension was likely due to dehydration; the patient reported poor PO intake of fluid for a few days prior to presenting to the hospital, partly due to abdominal pain. The patient also reported a fever prior admission. He was initially started on vanco/zosyn/azithromycin out of concern for possible sepsis (given patient has recent pneumonia requiring intubation). These antibiotics were stopped due to 1)CXR demonstrating radiographic improvement of his pneumonia, 2) recent completion of adequate antibiotics for that pneumonia, and 3) rapid improvement of his hypotension and fever. The patient's hypotension/fever was felt to be related to underlying RCC and immulogical response by his primary outpatient oncologist. The patient was started on Prednisone 40mg daily on HD#2, which was continued through discharge. The patient will continue steroids, until his f/u with his medical oncologist. The patient remained afebrile and normotensive while on steroid (and off antibiotics) for the remained of his hospital stay. . # Abdominal Pain: Intermittent sharp epigastric pain may represent gas or gastritis, as symptoms improved with simethicone. Given transaminitis, also concern for pain from capsular swelling or obstruction. Given the persistent pain, GI was consulted. He was taken for EGD which demonstrated normal mucosa in the whole stomach (biopsy) and otherwise normal EGD to third part of the duodenum. A gastric mucosal biopsies was taken was within normal limits per histopathological examination. He was continued on his home dose of omeprazole 20 mg daily. He was also started on gabapentin 300mg TID given that he had enlarge ___ lymph that could be potentially cause neuropathic pain. He was started on oxycodone 10mg Extended Release with oxycodone 5mg for breakthrough pain. # Transaminitis: Possibly a sign of progressive disease. However, may also consider iatrogenic, as patient started erlotinib last week - listed common side effects of transaminitis and abdominal pain. A RUQ ultrasound was negative. # Renal Cell CA: metastatic disease. S/P cycle 10 erlotinib and bevacizumab on ___. He was continued on erlotinib and axitinib while inpatient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old ___ man with CAD s/p PCI with chronic anginal symptoms, symptomatic bradycardia status post pacer placement at ___ several months prior, malignant melanoma and other skin cancers s/p multiple resections and CLL Radiology showed 1. No acute aortic abnormality or pulmonary embolus. 2. A 3.2 x 2.3 cm anterior mediastinal mass with internal calcifications the upper portion of which was partially visualized on prior CTA neck. Differential includes lymphoma, thymoma, thyroid lesion or germ cell tumor. Scattered prominent but nonenlarged mediastinal lymph nodes. 3. 1-cm left lower lobe nodule and 6-mm right lower lobe nodule. Given size, short-term followup is recommended as these lesions are suspicious for metastases. 4. 1 cm intermediate density lesion in the right interpolar kidney which may represent a cyst or solid lesion. Consider ultrasound to further characterize. 5. Top normal caliber of large bowel with air-fluid levels without wall thickening or pericolonic fat stranding is nonspecific, it could be suggestive of a mild enteritis. 6. Trace ascites. 7. Small-to-moderate hiatal hernia. 8. Enlarged prostate. 9. Cholelithiasis without evidence for cholecystitis. The patient was diagnosed with BACKACHE NOS, HYPERTENSION NOS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRIMARY REASON FOR ADMISSION: ___ year old male with CAD s/p PCI with chronic anginal symptoms, symptomatic bradycardia s/p PPM, malignant melanoma and other skin cancers s/p multiple resections and CLL with mid thoracic back pain, found to have no osseous lesions but with CT scan revealing new mediastinal mass as well as pulmonary nodules.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with history significant for obesity s/p Roux-en-Y gastric bypass done (___) who presents to the ED as a transfer from ___ for concern of abdominal abscess versus pancreatic pseudocyst. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Borderline dilated common hepatic duct. On outside hospital CT, the common hepatic duct and common bile duct taper gradually toward the ampulla without evidence of obstruction. 2. Peripancreatic fluid collections as assessed on outside hospital CT 1 day prior. 3. No cholelithiasis. SECOND OPINION OF CT ABDOMEN AND PELVIS showed 1. Large complex peripancreatic collection most likely a pancreatic pseudocyst. Difficult to exclude a component of pancreatic necrosis though overall volume of the pancreas appears preserved. 2. Segmental colitis along the mid transverse and splenic flexure likely reactive with, given contact by adjacent pancreatic pseudocyst. 3. Nonspecific peritoneal nodularity along the anterolateral right abdominal wall, attention on follow-up. 4. Hepatic steatosis 5. Postsurgical changes from Roux-en-Y gastric bypass without evidence of obstruction. 6. The appendix is normal. MRCP showed 1. Findings in keeping with acute pancreatitis involving the body and tail of the pancreas. No pancreas non enhancement to suggest pancreatic necrosis. 2. Extensive peripancreatic fluid collections as described above. Appearing well circumscribed, they may represent acute necrotizing collections vs walled-off necrosis, the former more likely given the reported ___ weeks of symptoms. 3. No gallstones or CBD stones to suggest gallstone pancreatitis. 4. The major vessels surrounding the pancreas appears patent. 5. Severe hepatic steatosis. No suspicious focal hepatic lesions. 6. Please note that the previously described right anterior omental soft tissue nodules is not included in the MRI scan volume and reference is made to prior CT report dated ___. The patient was diagnosed with Acute pancreatitis without necrosis or infection, unsp, Left lower quadrant pain. At the time of discharge, the patient had # Acute alcohol pancreatitis # Pancreatic pseudocyst # Transaminitis # Alcohol abuse complicated by withdrawal # Peripheral neuropathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old female with past medical history of obesity status post Roux-en-Y gastric bypass, alcohol abuse, admitted ___ with 2 weeks of persistent abdominal pain found to acute pancreatitis with pancreatic pseudocyst, course complicated by alcohol withdrawal, treated conservatively with subsequent improvement, able to tolerate Bariatric 4 diet, being discharged home # Generalized Abdominal pain secondary to # Acute alcohol pancreatitis # Pancreatic pseudocyst # Transaminitis Patient with history of roux-en-y who presented with 2 weeks of abdominal pain in setting of ongoing heavy alcohol use, found to have elevated lipase, OSH imaging with suspected pancreatic psuedocyst. She was seen by pancreas consult and bariatric surgery consult, was made NPO, started on IV fluids and prn pain and nausea medications. Given question of abnormal material seen in gallbladder on CT scan by surgical service, patient underwent MRCP to rule out biliary stone or anatomic abnormality. MRCP showed findings consistent with acute pancreatitis with extensive peripancreatic fluid collections". No gallstones or CBD stones were seen to suggest gallstone pancreatitis. She was recommended for ongoing conservative management. Patient symptoms rapidly improved and she was able to rapidly advance her diet. She subsequently tolerated a bariatric 4 diet without issue and demonstrated ability to maintain her hydration and nutritional status. She was weaned off pain medications without issue. Patient able to be discharged home. # Alcohol abuse complicated by withdrawal Demonstrated signs of withdrawal on presentation. Initially reported drinking a small amount each day, but later revealed it was closer to 5L box of wine over ___ days. Treated for alcohol withdrawal with valium CIWA. Gave IV thiamin, PO folate, multivitamin. CIWA subsequently able to be discontinued and patient remained stable x 1 day. She received counseling from social work input, was contemplating quitting and was given potential information re; resources for assistance. # Peripheral neuropathy Reported chronic numbness in feet. Given her history, suspected to be alcohol-related. Would consider additional workup an management of this. Zinc level pending at discharge. # Abnormal MRI Liver MRCP incidentally showed "Severe hepatic steatosis.". Would consider hepatology referral as outpatient. Counseled on alcohol cessation as above. # History of roux-en-y gastric bypass As surgery was done in ___, patient does not have local bariatric provider. Patient was recommended to establish with one. Patient reported that once her ___ gets approved, she will establish with a bariatric ___ local to her in ___. # Abnormal CT Abdomen OSH CT incidentally showed "Nonspecific peritoneal nodularity along the anterolateral right abdominal wall." ___ radiology recommended "attention on follow-up." Would consider discussion re: utility of repeat imaging in the future and/or additional workup as outpatient. Transitional issues - Discharged home - Recommended to continue Bariatric 4 diet - Received alcohol cessation counseling - Patient reports history of B12 deficiency; would consider outpatient evaluation and therapy for this - Discharged with ___ application pending--patient plans to establish with local PCP and ___ in/near ___ > 30 minutes spent on this discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of AFib (on Xarelto), OA, Metastatic Prostate cancer (c/b bone mets, s/p chemotherapy now on clinical trial pembrolizumab/radium) who presented to the ED with R shoulder pain and lightheadedness UNILAT UP EXT VEINS US RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. CHEST (PORTABLE AP) showed Left costophrenic angle not fully included on the image. Given this, no large pleural effusion or focal consolidation. Likely mild basilar atelectasis. Right shoulder CT with contrast. showed 1. Fluid collection with peripheral hyper enhancement in the right subscapularis muscle is likely tracking from the joint space into the subscapularis recess consistent with a moderately large effusion. Similar appearing fluid in the subacromial subdeltoid bursa is likely tracking volar via a full-thickness rotator cuff tear however this would be better evaluated with an MRI of the shoulder. Tiny locules of air within the fluid collection are presumed related to prior intervention. 2. Moderate degenerative changes at the right glenohumeral joint. 3. Multiple sclerotic foci involving the right distal clavicle, several vertebral bodies, and second right rib. Appearances are highly concerning for metastatic disease, given the patient's history of prostate cancer, recommend further evaluation with bone scan if it will alter clinical management.. 4. Replacement of the normal fatty marrow in the right humerus is nonspecific in appearance on CT imaging and could reflect red marrow reconversion, particularly in a patient receiving chemotherapy. This could also be better evaluated with a shoulder MRI. 5. Nonvisualization of the proximal portion of the long head of the biceps tendon and fluid within at the level of the myotendinous junction suspicious for a tear. 6. New enlarged right paratracheal lymph node, recommend dedicated chest imaging to better evaluate. 7. Multiple small pulmonary nodules, likely unchanged when compared to the prior study allowing for slight differences in imaging technique. Continued attention on followup recommended. RECOMMENDATION(S): 1. Evaluation of the fluid around the right shoulder region could be better performed with an MRI of the right shoulder, including assessment of any full-thickness rotator cuff tear and the biceps tendon. NOTIFICATION: Findings and recommendations discussed with Dr. ___ by telephone at 18:20 on ___ by Dr. ___, approximately 6 hours after discovery of the findings INJ/ASP MAJOR JT W/FLUORO showed 1. Imaging Findings- as above. 2. Procedure - Technically successful reaspiration of right glenohumeral joint. I Dr. ___ ___ supervised the Resident/Fellow during the key components of the above procedure and I have reviewed and agree with the Resident/Fellow findings/dictation. UNILAT UP EXT VEINS US RIGHT showed No evidence of deep vein thrombosis in the right upper extremity, however portions of the subclavian vein are not visualized. The patient was diagnosed with Anemia, unspecified. The patient was treated with ___ I&D SHOULDER RIGHT ARTHROSCOPY. At the time of discharge, the patient had Primary Diagnosis: ================== Infectious Arthritis Secondary Diagnosis: =================== Prostate Cancer Hypothyroidism 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>Mr. ___ is a ___ y.o. male with atrial fibrillation (on Xarelto), osteoarthritis, metastatic Prostate cancer (c/b bone mets, s/p chemotherapy now on clinical trial pembrolizumab/radium) who presented to the ED with lightheadedness and R shoulder pain that was found to be a septic R. shoulder joint growing MSSA. He is s/p I&D of R. shoulder joint on ___ and on cefazolin for 6 week course of therapy. His hospital course was complicated by pancytopenia and acute on chronic pain requiring titration of his medications. ===================== ACUTE ISSUES ===================== #R. septic shoulder joint Mr. ___ presented with R. shoulder pain and a documented fever of 101.1F on ___. Orthopedics was consulted and a R. shoulder CT was obtained. R. shoulder CT was notable for multiple sclerotic foci involving right distal clavicle, several vertebral bodies, and second right rib, though was thought not to be contributing to his R. shoulder pain. It was also notable for biceps tendon tear, degenerative changes at R. ___ joint, fluid collection ___ R. subscapularis muscle tracking from joint space into subscap recess + fluid collection ___ subacromial subdeltoid bursa. ___ performed an aspiration of this fluid on ___, and the aspirate was found to grow MSSA. He was initially started on vanc (___) + ceftriaxone (___) and switched to cefazolin based on sensitivities. He had an I&D of his septic R. shoulder joint on ___. ID was consulted regarding antibiotic use and duration, as well as OPAT coordination. Per ID, he should continue IV cefazolin 2g q8h until ___ for his R. septic shoulder joint (___). A duplex U/S of his tunneled line was obtained to rule out possible infected subclavian clot that may have seeded his R. shoulder joint; however, U/S was largely negative for DVT. The subclavian could not be fully appreciated due to overlying dressings from his I&D, however ID did not recommend repeat U/S. #MSSA R Shoulder Infection He presented with several weeks of worsening shoulder pain and weakness on the right. He underwent CT of the R shulder on ___ which demonstrated an enhancing fluid collection extending into the subcapsularis muscle tracking from glenohumeral joint space with large joint effusion. Orthopedic surgery was consulted and performed R shoulder arthrocentesis on ___ which demonstrated 87,895 WBC (97% polys) and ultimately grew MSSA. He underwent I&D on ___ with orthopedic surgery. ID was consulted for antibiotic management and he was transitioned to cefazolin for planned 6 week course. He had no positive blood cultures. His course is as follows: Start date: ___. Stop date: ___. #Right shoulder pain He denied any history of prior trauma to the shuolder. Due to severe uncontrolled pain over the admission his pain medications were uptitrated. Oxycontin was uptitrated from 10mg BID to 20mg BID. His oxycodone breakthrough pain dose was increased to ___ q4h. Regarding the etiology of his pain, which persisted even after I&D, orthopedic surgery felt the patient's CT was also notable for possible adhesive capsulitis vs. rotator cuff tea vs. biceps tendonitis. Per Ortho, shoulder MRI was not necessary at the time of his hospitalization and was more appropriate for outpatient follow-up. He was scheduled for orthopedics follow up ___ 2 weeks time. #RUE Edema This was likely ___ immobility from painful shoulder, as DVT study was negative at admission and edema improved gradually, prior to discharge. #Metastatic Prostate Cancer: #Pancytopenia During his hospitalization, he was on a study regimen of radium + pembrolizumab and presented with severe anemia/thrombocytopenia/leukopenia. He continued to be pancytopenic. PF-4 Ab was obtained, but was negative sp HIT was ruled out. The differential for this included prolonged myelosuppresion from radium treatment or progression/bone marrow infiltration of his malignancy. He was disenrolled from the clinical trial. He received pRBC and platelet transfusions to goal of Hgb 7 and platelet 20 prior to discharge. His anticoagulation was discontinued due to thrombocytopenia. Bone marrow biopsy was not seen as an urgent procedure that needed to be performed during this admission, but could be considered as an outpatient. #Hyponatremia He was thought to have chronic hyponatremia. Given that he was asymptomatic, we monitored his sodium. He continued to be asymptomatic at discharge. #Delirium He reported 2 prior episodes of delirium the week prior to admission, once at home and once ___ the ED. He became agitated after starting a trial of high dose prednisone at night to help with inflammation + appetite/fatigue on ___. This was discontinued the following day and he was placed on delirium precautions; he did not have any further episodes of delirium while hospitalized. #Fever He reportedly had a fever of T101.1F while receiving his blood transfusion on ___. CXR/UA + UCx neg/BCx neg. Transfusion reaction work-up was neg. He was afebrile since ___. His fever was thought to have been caused by his septic R. shoulder joint. #Lightheadedness He presented with orthostatic symptoms which are likely ___ hypovolemia from diuretics + anemia. He received IVF and pRBC while hospialized. He appeared euvolemic on exam prior to discharge. CTH from ___ negative for acute process. ===================== CHRONIC ISSUES ===================== # Hypothyroidism He was continued on his home levothyroxine. # Lower extremity edema This was thought to be secondary to his disastolic heart failure vs. docetaxol, which can cause lower extremity edema. We initially held his home torsemide at admission, as he complained of lightheadedness and there was concern for hypovolemia. He was restarted on his torsemide on ___, but at a lower dose of 20mg qd (regular home dose is 40mg qd), given his initial complaint of lightheadedness. He was discharged on this lower dose. # Peripheral neuropathy He was continued on his home gabapentin. # Paroxysmal atrial fibrillatin He was continued on his home metoprolol 12.5mg bid. His home rivaroxaban and all other forms of anti-coagulation were held ___ the setting of thrombocytopenia. # Hyperlipidemia: He initially presented with a transaminitis and his home statin was held during this admission. It was restarted on discharge. ===================== TRANSITIONAL ISSUES =====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ yo F with history of infiltrating ductal breast cancer (triple +, s/p mastectomy and reconstructive surgery, s/p Cytoxan and Adriamycin followed by Taxol and Herceptin as well as tamoxifen) who presented to the ED on ___ with four weeks of cough. CHEST (PA AND LAT) showed Bronchitis at the lung bases. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral ___ opacities and more nodular opacities at the left lung base in combination with bronchial wall thickening and mucous plugging is suggestive of a multifocal infectious process. 3. Calcified left hilar lymph nodes and calcified granulomas in the left lung are suggestive of prior granulomatous infection. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had PRIMARY DIAGNOSIS ----------------- Acute bacterial bronchitis SECONDARY DIAGNOSES ------------------- #HISTORY OF BREAST CANCER #DEPRESSION. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with history of infiltrating ductal breast cancer ___, triple-posotive, s/p mastectomy and reconstructive surgery, s/p Cytoxan and Adriamycin followed by Taxol and Herceptin as well as tamoxifen) who presented to the ED on ___ with four weeks of cough found to have multifocal infectious process. ============== ACUTE ISSUES: ============== #ACUTE BACTERIAL BRONCHITIS The patient presented with cough, dyspnea on exertion, leukocytosis, tachycardia, fever, consistent with a pulmonary infection given her CT findings, most likely acute bacterial bronchitis vs community acquired pneumonia, likely as complication of a prior viral respiratory infection. There was no evidence of PE on CTA. No concern for aspiration. The patient was initially started on ceftriaxone and azithromycin (day 1 = ___ with good response and ambulatory oxygen saturations between 94 to 97 % on room air. The patient was safe for discharge with plan to complete her antibiotic treatment course at home. Prior to discharge, her antibiotics were transitioned to a po regimen with cefpodoxime and azithromycin. Plan for a 5-day course (Last dose: ___ ================ CHRONIC ISSUES: ================ #HISTORY OF BREAST CANCER Dx ___ with a left breast cancer. Grade 2 infiltrating ductal cancer, ER/PR positive,HER-2 positive. S/p mastectomy, Cytoxan and Adriamycin followed by Taxol and Herceptin. S/p ___ years of letrozole. Stable. #DEPRESSION Stable. Continued home venlafaxine. #CODE: Full (presumed) #CONTACT: Name of health care proxy: ___ Relationship: Husband Phone number: ___ ====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male chef here for work from ___ reports having starting on ___ he began to have terrible epigastric pain. The pain was located in the epigastric region but then radiated diffusely throughout the upper abdomen. He also had nausea, but no vomiting initially. The pain continued in waves intermittently for a few days and was initially present after eating but then became present all the time and would get worse with eating or drinking. He on ___ began to have more nausea and tried taking ___ but the taste was so horrible that he vomited. Since then he has had nausea and vomiting with trying to eat and feels that there is "like a ball" in the epigastric region. He has not been moving his bowels for the past few days but previously no issues, no weight loss, no diarrhea. He denies fevers, had a low grade temp in the ED. He is very thirsty at this time and report poor urine outpt in teh past 2 days. He reports an episode of horrible epigastric pain that occured 2 days after he had what he though was bad fish in ___ of this year and a similar episode of again a few days of abd pain about ___ years ago. With the 2 previous episodes the pain was no terrible he thought that he was going to die. He came to medical attention this time before it became so bad. He does not have a hx of abd pain after eating. He does not usually see MDs, is otherwise healthy. Is helping a friend with a restaurant, here in town for about 2 weeks and was feeling well until this happened. 10 systems reviewed and are negative except where noted in the HPI above Radiology showed Normal abdominal ultrasound. The patient was diagnosed with ACUTE PANCREATITIS, VOMITING. At the time of discharge, the patient had Pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male with epigastric pain, nausea, vomiting found to have pancreatitis of unclear etiology. Pancreatitis: Lipase of 400 on admission with nausea at presentation. He has had 2 other episodes requiring hospiatlization in the past in ___, which were attributed to "not moving his bowels right." He had pain with the two prior episodes, but only nausea with this presentation. His appetite was down and he hadn't been taking food in ___ days due to the nausea. He denies heavy alcohol use. He denied drug use aside from marijuana. He had no stones on RUQ. His triglycerides were 48. He is not on any medications at home. Given this is possibly his third occurrence of pancreatitis over the last year, an MRCP would be a reasonable next step in evaluation to further evaluate his anatomy. His lipase normalized and his symptoms resolved with hydration. He tolerated advancement in his diet and was discharged in good condition. Hyperbilirubinemia: His bili was elevated to 2.4 with most of it being indirect. Question of possible ___ disease, though hemolysis (mild anemia) is also possible. It was stable on discharge and may require work-up as an outpatient. Atypical cells in differential on admission: Resolved on repeat in the morning. Transitional issues: - Establishment of primary care for further work-up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ year old male with a history of multiple falls out of bed. At 3am this morning he fell out of bed and struck the left side of his head/ear on a metal bedrail. He felt immediate pain in his neck and went back to sleep for ___ hours and woke with worsened neck pain. He called ___ and was transported to ___ where he was found to have a C2 fracture on C-spine CT that passes bilaterally through the transverse foramen and was transferred to ___ for further evaluation. Neurosurgery service is being consulted for evaluation of cervical fracture. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Atherosclerosis involving bilateral carotid bifurcations. Otherwise, essentially unremarkable CTA of the head and neck. 2. No acute intracranial abnormality. 3. Fractures involving bilateral C2 transverse foramen is again seen. 4. Severe centrilobular emphysema with mediastinal lymphadenopathy in the visualized upper lung zones. The patient was diagnosed with Unsp disp fx of second cervical vertebra, init for clos fx, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had C2 lateral mass 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>On ___, the patient was evaluated at an OSH after suffering a fall and striking his head in his apartment. His head CT showed no acute findings, however, his cervical spine CT revealed a right lateral mass fracture of C2 and so he was transported to ___ for neurosurgical evaluation. He was placed in a Aspen collar and CTA to his neck revealed no arterial injury. It was deemed that this would be best managed with conservative measures including Aspen collar, pain control, and follow up Cervical Spine CT in 6 weeks. He was evaluated by the Chronic Pain Service who made recommendations for pain control given methadone use. On ___ Patient continued to complain of pain. Regimen was adjusted. ___ consult was ordered. ___ was unable to evaluate the patient secondary to pain. On ___ Patient was stable. Awaiting ___ evaluation. He continued on recommended pain regimen. On ___, the patient remained stable and his pain was better controlled. On ___, the patient remained stable and worked with physical therapy. His IV dilaudid was discontinued, as he was out of acute phase of pain. On ___, the patient remained neurologically and hemodynamically stable. He appears comfortable in bed, and is able to participate in the morning neuro-motor exam without being limited by pain. On ___, the patient remained both neurologically and hemodynamically stable. He was able to participate in the morning neuro-motor exam without being limited by pain, and able to make great strides with Physical Therapy - and is now able to be safely discharged home. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Obtained per chart, patient not reliable historian, son not available. Per son in ___ and chart: ___, h/o dementia, TIA, HTN alterntating with hypotension, afib on coumadin, ___, mild MS, mild pulm htn, lower extremity edema discharged from OSH about 2 weeks ago after being treated for PNA saw PCP today and referred to the ___ for confusion, weakness, ? hypotension. Per son she has had decreased PO intake and weakness x3 days, required more supervision taking medications. Also, she had a fall about 4 days ago and hit her head. Has had a cough, no fevers. Also with abdominal pain, no n/v, no diarrhea/constipation or bloody stool. CHEST (AP AND LAT) showed Hiatal hernia, small right pleural effusion. No overt edema or pneumonia. CT HEAD W/O CONTRAST showed 1. No acute infarct, hemorrhage, or fracture. 2. Age-related involutional changes and sequela of chronic small vessel ischemic disease. CT C-SPINE W/O CONTRAST showed No acute fracture, malalignment, or prevertebral soft tissue abnormality. CT ABD AND PELVIS W/O CONTRAST showed 1. Large fecal loading of the colon, most severe in the rectum, with probable mild proctitis. 2. Large hiatal hernia. Radiology showed The heart is mildly enlarged, slightly increased in size since ___. There is increased central pulmonary vascular congestion, without overt edema. There is no pneumothorax, focal consolidation, or pleural effusion. Moderate degenerative changes throughout the thoracic spine appear stable. CT HEAD W/O CONTRAST showed No acute intracranial hemorrhage or mass effect. Other details as above. Correlate clinically the to decide on the need for further workup or followup. The patient was diagnosed with URIN TRACT INFECTION NOS. At the time of discharge, the patient had Altered mental status of unclear etiology Constipation Acute kidney injury Secondary diagnoses: Atrial fibrillation Diastolic congestive heart failure 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>This is a ___ year old female with past medical history of dementia, atrial fibrillation on coumadin, chronic diastolic heart failure, recent OSH stay for pneumonia, with post-discharge period complicated by acute metabolic encephalopathy, admitted ___ and found to have constipation and ___, volume resuscitated and bowel regimen enhanced, symptoms resolved, discharged to rehab. #) Acute Metabolic Encephalopathy - patient with dementia, with baseline several months prior independent of most ADLs, but over recent ___ months has had significant decline, presenting with acute worsening, including agitation and confusion; workup notable for ___ and constipation (see below); with treatment of these issues her mental status improved to recent baseline per family (see below) #) ___: Cr peaked at 1.9 on admission, secondary to dehydration; improved with IV hydration, Cr at 1.1 at time of discharge. ACEi, which was held, was restarted at discharge. # Constipation - admitted without moving bowels x 1 week; was passing flatus and no concern for obstruction; CT showed extensive fecal loading; she received augmented bowel regimen as well as bisacodyl per rectum followed by manual disimpaction. Bowel regimen was continued, with regular stooling. #) ATRIAL FIBRILLATION: CHADS2 = 5. Course was complicated by INR 4.1, prompting holding of Coumadin on day of discharge. #) DIASTOLIC CHF: Lasix held in setting of ___ restarted once patient was taking reliable PO.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of HTN, ___ disease on Sinemet four times a day, chronic low back pain presents for worsening lower extremity weakness. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. No evidence of hemorrhage or infarction. 2. Global parenchymal volume loss and evidence of chronic small vessel ischemic disease. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had PRIMARY DIAGNOSES ----------------- # Falls # Weakness SECONDARY DIAGNOSES ------------------- # Possible UTI # ___ disease # Deconditioning # Hypertension # Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ old woman with a history of ___, reflux esophagitis, breast cancer, ductal carcinoma in situ and radiation to the left breast, and venous stasis ulcers, who is presenting with weakness and falls. ACTIVE ISSUES ------------- # Falls # Weakness: Likely secondary to progressive deconditioning in the setting known ___ disease with possible acute exacerbation by possible UTI as below. Prior falls appear to have been mechanical in nature without characteristics of syncope. While she reportedly has had episodes of hypotension in the past, there was a low suspicion that this was contributing to her presentation as she denied lightheadedness. In addition, blood pressures during her hospital stay have been normal to elevated. Evaluated by neurology. Presentation felt to be inconsistent with cord compression given normal motor exam. Additionally, the patient has repeatedly stated that she would not want surgery. Physical therapy was consulted who recommended discharge to rehab. Her possible urinary tract infection was treated as below. # Possible UTI: Patient presented with pyuria and mild bacteruria. UTI is possible as patient did not have pyuria on prior UAs, though this UA borderline and patient is asymptomatic. Given her worsening weakness and given the lack of other obvious triggers, the decision was made to treat with Macrobid ___ BID for a 5-day course (___). Treatment course was completed prior to discharge # ___ disease # Deconditioning # Home safety: During PCP visit earlier this year, ___ disease thought to be relatively well controlled given ability to ambulate with her walker, and eat and drink without tremor. However, while there may be a contribution of acute medical issues such as a possible UTI to her current presentation as above, underlying ___ disease is likely a contributing factor to falls, weakness, and deconditioning. Given the recurrence of her symptoms, concern for inability of patient to safely take care of herself at home. Already has OT, ___, and ___ set up. Plan for discharge to rehab per ___ as above. Recommend discussing long-term plan pending development of symptoms at rehab. Home Sinemet ___ mg 4 times a day was continued. Outpatient follow up with neurology for later is scheduled. # L knee abrasions: Patient had fallen earlier this year on her knee. Abrasions appear to be healing without signs of infection. Wound care was consulted. --------------- CHRONIC ISSUES --------------- # Hypertension Normotensive on admission. Continued home lisinopril and amlodipine. Of note, atenolol had been discontinued prior to admission though patient and her daughter had been confused about this. They were counseled. Patient should NOT be restarted on atenolol. # Depression Stable. Continued home citalopram 40mg daily (home dose). Of note, the maximum recommended dose for this age group is 20mg dialy given concern for QTc prolongation. EKG was obtained and QTc found to be 429 ms on admission. Thus, home dose was continued. ------------------- TRANSITIONAL ISSUES ------------------- [] completed 5-day course of Macrobid for UTI [] continued on citalopram 40mg daily (home dose). QTc 429 ms on admission and 436ms on discharge. Consider adjusting dose to maximum recommended dose for her age group (20mg daily) [] continued on amlodipine 5mg daily as prescribed by her outpatient providers. However, had not been taking this prior to admission, likely ___ miscommunication. BP controlled on amlodipine & lisinopril, so discharged on 5mg qd. Please f/u BP and adjust amlodipine accordingly [] Per patient and family, patient had not been receiving daily Lasix prior to admission (despite outpatient clinic notes indicating that she was on Lasix 20mg daily). Lasix 20mg PO daily may be used on a prn basis for volume overload / lower extremity edema (euvolemic on discharge). # Emergency contact: ___ (daughter, HCP): ___ # Code: Full (confirmed) </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o perforated diverticulitis s/p robotic sigmoid colectomy (___) now s/p sigmoidoscopy with dilation for anastomotic stricture with finding of colonic perforation on CT scan. He has a known 2 - 2.5cm anastomotic stricture at 20cm treated with CRE balloon dilations under fluoroscopy on ___, ___, and ___, and presented for repeat sigmoidoscopy with dilation earlier today due to recurrent symptoms. Per GI report, sigmoidoscopy was performed under fluoroscopy with gradual progressive dilation of the anastamotic stricture from 12mm to 16.5mm. Post procedure, he developed lower abdominal pain and chest pain around 12:15pm, described as located at the sternum and radiating to both collar bones. The "discomfort" lasted approximately 15 minutes, then subsided. He denies shortness of breath, nausea / vomiting, and/or diaphoresis. EKG demonstrated <___hanges in leads I and II, and he was subsequently referred to the Emergency Room for further evaluation. CXR obtained in the ER found free air under the diaphragam, for which colorectal surgery was consulted. Radiology showed Evidence of pneumoperitoneum raising concern for bowel perforation. Dr. ___, was paged at 3:40 p.m. at the time of discovery. Through ED dashboard, the ED team is aware of free air under the diaphragms. Dr. ___ this at 3:45pm. Radiology showed 1. Distal colonic perforation just proximal to the site of the anastomosis with leakage of air and rectal contrast into the peritoneum. There is no organized fluid collection. 2. Worsening descending colonic thickening and inflammatory changes, when compared to the prior study, compatible with colitis, possibly ischemic, infectious or inflammatory in etiology, 3. 14-mm complex right renal cyst could be further characterized by ultrasound. Evaluation of the patient with perforated colon during sigmoidoscopy with stricture dilatation. AP radiograph of the chest was reviewed, focusing on the lower chest, upper abdomen. The NG tube tip is in the proximal stomach and should be advanced. The stomach remains distended. There is interval decrease in intraperitoneal air. The lung bases are essentially clear. Due to different projection of the radiograph, it's difficult to assess the cardiomediastinal silhouette that appears to be artificially enlarged. was done. Perforated diverticulitis after sigmoidectomy with anastomosis and now with tachycardia, assessment of the central venous line. AP radiograph of the chest was compared to ___. The right subclavian line has a somewhat tortuous course with the tip terminating in the mid SVC at the level of the carina. Correlation with the output of the line is recommended since it is unlikely to follow the usual course and potentially can be in one of the chest wall veins. Also, there is slight interval increase of amount of pleural fluid on the right that should be also further assessed to exclude the possibility of intrapleural position of the central venous line. was done. Evaluation of the patient with bowel perforation, intubated. AP radiograph of the chest was reviewed in comparison to ___. The ET tube tip is 4.7 cm above the carina. NG tube tip is in the stomach. The central venous line tip is at the level of mid SVC. There is interval additional increase in pleural effusion and currently interval development of left lower lobe atelectasis. Patient is in interstitial pulmonary edema. was done. Evaluation of the patient with bowel perforation, intubated, followup. AP radiograph of the chest was compared to prior study obtained the same day earlier. The ET tube tip is 6 cm above the carina. Right subclavian line tip is in the mid SVC. NG tube tip is in the stomach. Bilateral pleural effusions and bibasilar areas of atelectasis are demonstrated, but there is improvement of the left lower lobe atelectasis on the current study. No evidence of pneumothorax. was done. Radiology showed Stable mild bibasilar atelectasis. Mild pulmonary vascular congestion with mild bilateral pulmonary edema. Radiology showed Continued pulmonary edema and bibasilar pleural effusions and compressive atelectasis. Recommend advancement of ET tube. Initial findings were conveyed to ___ of the surgical team on ___ at 10:15 immediately following review by Dr. ___. Radiology showed No radiopaque foreign body besides drains and tubes as above. Findings were discussed with Dr. ___ the phone at time of interpretation at 21:40 on ___. Radiology showed Unchanged bilateral pleural effusions and bibasilar atelectasis. Mild cardiomegaly with mild vascular congestion. Radiology showed AP chest compared to ___ at 5:07 a.m.: Moderate bilateral pleural effusions and mild pulmonary edema have both improved since earlier in the day. Tip of the endotracheal tube at the upper margin of the clavicles, is no less than 5 cm from the carina. Heart size normal. No pneumothorax. Upper enteric drainage tube is curled in the gastric fundus. Right subclavian line ends in the mid-to-low SVC. No pneumothorax. Radiology showed AP chest compared to ___: Previous mild pulmonary edema continues to clear since ___. Substantial right pleural effusion and bibasilar atelectasis remain. The heart size is normal. Azygous distention suggests elevated central venous pressure. The tip of the endotracheal tube just below the upper margin of the clavicles with the chin down, is 4.5 cm above the carina, 2 cm above optimal placement for the chin in neutral position. The right subclavian line ends low in the SVC. No pneumothorax. Radiology showed AP chest compared to ___, 3:54 a.m.: The tip of the new left subclavian line lies alongside the right line in the mid-to-low SVC. There is no pneumothorax or mediastinal widening. Moderate right pleural effusion has been present for several days, as has bibasilar atelectasis. Heart size normal. No pneumothorax. The tip of the endotracheal tube above the upper margin of the clavicles, nearly 6 cm from the carina is 2 cm above standard positioning, as before. Radiology showed Right effusion is somewhat smaller. Radiology showed 1. Mild intra-abdominal and intrapelvic ascites within post-surgical limits. Tiny pockets of fluid along the anterior abdomen and paracolic gutters are accompanied by mild peritoneal and fascial enhancement, reflecting inflammatory changes but indistingushable from infection. This is accessible to US or CT guided aspiration, if warranted. 3. Non-obstructed ileostomy and colostomy. 4. Subcentimeter hypodense renal lesions are statistically likely cysts, but are too small for further characterization on this single phase study. 5. Small pericardial effusion. The patient was diagnosed with CHEST PAIN NOS, DIVERTICULITIS OF COLON. The patient was treated with Sigmoidoscopy with dilation of anastamotic stricture and subsequent perforation - ___ Laparoscopy converted to laparotomy, washout, drainage of pelvis, and diverting loop ileostomy (for perforated colon with peritonitis) - ___ Reopening of recent laparotomy, abdominal washout, mobilization and division of the transverse and descending colon, colon decompression, and open abdomen - ___ Abdominal exploration and washout - ___ Abdominal washout, partial closure colonic mucous fistula, placement of a drain - ___ Fascial closure of abdominal wall - ___. At the time of discharge, the patient had Perforated colon with peritonitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>In the ER, after the patient's CXR showed free air under the diaphragm concerning for perforation, he underwent a CT scan that showed distal colonic perforation proximal to anastomotic site. He was taken urgently to the operating room, where he underwent a laparoscopy converted to laparotomy, washout, drainage of pelvis, diverting loop ileostomy, placement ___ drain on the same day of presentation, ___. He was started on Zosyn and Vancomycin and iniially did well. His blood cultures from that time eventually grew Closridium species not C. perringens or C. septium and Fusobacterium. However, on POD1, ___, he developed hypotension and tachycardia, concerning for septic shock. Resuscitation was began and he was transferred to the MICU, where was managed with levophed. Due to feculent drain outpu, he was taken back to the operating room on the night of ___ for reopening of recent laparotomy, abdominal washout, mobilization and division of the transverse and descending colon, colon decompression, and open abdomen. After the operation, he returned to the ICU and remained intubated/sedated with pressor requirements. He was also febrile ___ morning and had increasing pressor requirements. That same day, he again was taken to the OR for an abdominal exploration and washout. Subsequently, he had interstitial pulmonary edema and was iniiated on the ARDSnet ventilation protocol and his respiratory acidosis impoved. On ___ afternoon, he was transferred to the SICU and management was continued. On ___, he underwent an abdominal washout, partial closure colonic mucous fistula, placement of a drain. On ___ he improved and no longer requied pressors. Diuresis for significant volume overload was begun with lasix drip and albumin, to which he responded. The next day, ___, he went back to the operating room for the final time and underwent fascial closure of abdominal wall. A VAC was placed. Tube feeds through an NGT were begun and advanced, goal of 45 cc/hour. Flagyl was added. Over the next several days, he could not be weaned from the vent. He was slightly confused, but following commands. His line was changed and sent for culture. His culture and blood culures from that time were negative. He had some agitation and required precedex. On ___, zosyn was discontinued and cefepime added. On ___, flagyl was discontinued. On ___, he was extubated successfully, and on ___ he was transferred to the floor. Fluconazole was added. His Foley and NGT were removed and he tolerated a regular diet. On ___, all IV antibiotics were discontinued and PO fluconazole and augmentin were started for a goal total of a 7 day course. The patient was feeling depressed and overwhelmed, as well as anxious, but not suicidal. Social work was consulted. ___ was consulted and evaluated and treated him, eventually recommending home with physical therapy. He was tachycardic consistently between 110-120 and sometimes as high as 130-140 on a few occassions, but denied shortness of breath, chest pain, and had no leg swelling or increased oxygen requirement. He continued to do well. The drain and central line were removed. Immodium was started for high ostomy output. The mucous fistula was capped on ___. Overnight ___, he had a brief episode of tachypnea to 40 with no desaturations on room air, and the symptoms spontaneously resolved. A CXR done then showed only small atelectasis vs effusion. On ___, he continued to ambulate, tolerate a regular diet (goal calories 2800 per nurition), and his ostomy output improved on Immodium. The following day, he was discharged home with his home VAC placed while in the hospital, and asked to follow up with colorectal surgery, as well as his primary care physician to discuss restarting home antihypertensive medications and management of his anxiety. On the day of discharge, he was feeling well, without abdominal pain, tolerating a regular diet, ambulating, with appropriate ostomy output. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with hypothyroidism, obesity, T2DM, recent diagnosis of tracheomalacia, presenting with worsening shortness of breath. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CT TRACHEA W/O CONTRAST showed No or stricture or other fixed structural abnormality of the trachea. There is a decrease in tracheal diameter 41-42% upon expiration. Generalized severe decrease in lobar bronchial diameter upon expiration is more than physiologic expectations and may contribute to mild air trapping. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. The patient was diagnosed with Other specified diseases of upper respiratory tract, Dyspnea, unspecified. At the time of discharge, the patient had Tracheobronchomalacia. The patient was given written instructions concerning 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 w/ hypothyroidism, T2DM, and recent diagnosis of tracheomalacia, who presented with worsening longstanding shortness of breath, likely multifactorial with a large component of tracheomalacia. ACTIVE ISSUES ============= #) Tracheomalacia: Pt has a long standing history of shortness of breath and recent diagnosis of tracheobronchomalacia, who presented with persistent shortness of breath. During admission patient remained with good oxygen saturation on room air and in no respiratory distress. Interventional Pulmonology was consulted and started workup for tracheomalacia and evaluating for possible other etiologies that may be contributing to her shortness of breath. CT trachea and PFTs were performed during admission (results pending on discharge). Treated with nebulizers for symptomatic management of her dyspnea and continued on prednisone and discharged on a prednisone taper. Pt should have outpatient follow up with Interventional Pulmonology for further management. #) Right lower extremity edema: Pt noted to have lower extremity edema during admission, right greater than left. Duplex ultrasound did not show any evidence of DVT. Edema most likely secondary to venous insufficiency. Pt recommended to elevate legs and use compression stockings. CHRONIC ISSUES ============== # hypothyroid s/p thyroid nodule removal: continued home Levothyroxine # Diabetes, DM2: not on insulin. ISS while inpatient # HTN: continued home metoprolol, losartan # CAD: continued atorvastatin, clopidogrel TRANSITIONAL ISSUES =============================== 1. Pt should have follow up with Interventional Pulmonology 2. Need to follow up CT trachea and PFTs (results pending on discharge) 3. Follow up thyroid studies (sent to rule out thyroid disorder contributing to dyspnea) 4. Consider further outpatient evaluation of additional issues that may be contributing to her dyspnea as indicated (including sleep study to evaluate for OSA, TTE, ENT evaluation for VCD, GI evaluation for GERD) 5. Need to obtain outside medical records from ___ and ___ ___ from previous workup done for her tracheomalacia 6. Pt scheduled for follow up with Dr. ___ endocrinology for weight loss management, as her weight may be contributing to her dyspnea. 7. Pt continued on prednisone during admission for treatment of tracheomalacia. Patient discharged on a prednisone taper (decrease by 10mg every three days starting with 50mg). # CODE STATUS: full, presumed # CONTACT: ___ (HCP, partner, ___, ___ (nephew, ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: ___ . CC: fever, dysuria . HPI/EVENTS: ___ yo M h/o HTN, TIA s/p L CEA ___, BPH admitted with 2 days of fever, dysuria, frequency and urgency. At baseline, Mr ___ is very functional, able to ambulate, independent and lives alone. He was in USOH until 1 wk ago when he noted bil flank pain radiating to shoulders. Subsequently noted dysuria, incomplete urination, nausea, and fever. Denies blood in urine. Presented to the ED where he was found to be febrile to 101.2. BP stable. WBC 14. No CVA appreciate. Prostate was enlarged but not tender. He was given 400mg iv of ciprofloxacin, IVF, ibuprofen, zofran, ketorolac. Feeling well upon transfer to the floor. Denies N/V, abd/flank pain, chills. CHEST (PA AND LAT) showed Heart size is top-normal. , unchanged. Tortuous aorta E is unchanged. Lungs are essentially clear. No appreciable pleural effusion or pneumothorax demonstrated. Opacity projecting over the heart on the lateral view is unchanged and most likely reflects extensive fat pad. ABDOMEN US (COMPLETE STUDY) showed Normal abdominal ultrasound. Specifically, no US evidence for pyelonephritis or perinephric fluid collection detected. The patient was diagnosed with URIN TRACT INFECTION NOS, PYELONEPHRITIS NOS. At the time of discharge, the patient had Urinary tract infection Benign prostate hypertrophy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT & PLAN: ___ yo M h/o HTN, TIA s/p L CEA ___, BPH admitted with 2 days of fever, dysuria, frequency and urgency. # UTI: Mr. ___ was admitted with fever 101, dysuria, urinary frequency in setting of BPH. U/A had > 182 WBC/hpf, nit neg. He was found to have WBC 14 but no flank pain to suggest pyelonephritis. Prostate exam in ED also did not reveal signs of prostate tenderness to suggest prostatitis. He was initially treated with IV cipro and then transitioned quickly to cipro. He tolerated this well with immediate defervescence and normalization of WBC to 9. Post-void residuals were checked x3 and revealed no significant retention of urine - all <100 cc. He was continued on motrin PRN for pain/musculoskeletal pain. Doxazosin was also continued - given some history of poor urinary stream, however, finasteride may be considered as an outpt to help further optimize urinary clearance. Mr. ___ Cr rise to 1.6 on HD2 but quickly improved to 1.3 after hydration. # Elevated TBili: Mr. ___ had an admit Tbili of 2.3 - most of which were indirect. Follow up Tbili was 1.6. The etiology is uncertain - ___ possibility and transient sepsis a possibility although there was no signs of hypotension during this stay or in the ED. # CV: h/o HTN, hyperchol, TIA, s/p L CEA, chronic venous insufficiency. Mr. ___ was continued on ASA, statin, metoprolol, HCTZ # OTHER ISSUES AS OUTLINED. . #FEN: [X] IVF [X] Oral [] NPO [] Tube Feeds [] Parenteral #DVT PROPHYLAXIS: [X]heparin sc []SCDs #LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley #PRECAUTIONS: None #COMMUNICATION: pt and step-daughter ___ ___ #CONSULTS: None #CODE STATUS: [X]full code []DNR/DNI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female history of PMR on prednisone who presents with the above fracture s/p mechanical fall. Patient was on the train his morning when she tripped and fell, striking her left hip and the back of her head. No loss of consciousness. Patient was seen and evaluated at ___ ED but requested transfer here since she is a patient of Dr. ___. She endorses left hip pain and possible initial numbness at time of injury but no current numbness or tingling. According to chart review she has been taking ___ mg of prednisone daily for PMR taper. Radiology showed Mildly displaced left intertrochanteric femoral neck fracture with mild varus angulation. Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of acute intracranial abnormality. 2. Layering fluid and locules of air within the left maxillary sinus, findings which may represent acute sinusitis and clinical correlation is suggested. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No evidence of acute fracture or traumatic malalignment. 2. Extensive multilevel degenerative change, most notably at C4-C5 and C5-C6. Multilevel subluxations likely degenerative in etiology. 3. Solitary 3 mm pulmonary nodule at the right upper lobe. As per the ___ society guidelines included below, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ The patient was diagnosed with Displaced intertrochanteric fracture of left femur, init, Occ of rail trn/veh injured by fall in rail trn/veh, init. The patient was treated with Surgical fixation of left hip fracture. At the time of discharge, the patient had Left intertrochanteric hip fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left hip intertrochanteric fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left short TFN, 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 weightbearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of ESRD on HD, DM, Hep C, PVD s/p right fem-BKpop bypass and left fem-AKpop bypass ___ ___ for a right ___ toe nonhealing ulcer and bilateral lower extremity rest pain, now presenting with acute worsening right foot pain. He was in his usual state until ___ days ago when he started noticing right greater than left calf pain. This morning he developed severe right foot pain and parasthesias with discoloration of his right ___ toes. He also noticed decreased foot and leg sensation up to the level of his midshin. He therefore presented to ___ for further evaluation. CTA was obtained at that time which showed occlusion of the right fem-BK pop bypass graft. Given these findings, he was started on heparin and transferred to ___ for furthervascular care. CHEST (PA AND LAT) showed No acute intrathoracic process. The patient was diagnosed with Pain in right ankle and joints of right foot, Other disorder of circulatory system. The patient was treated with 1. Realtime ultrasound-guided access to the left common femoral artery and placement of a ___ sheath. 2. Selective catheterization of the right peroneal artery, a third-order vessel. 3. Percutaneous transluminal angioplasty and stenting of the left common iliac artery using an 8 x 38 iCAST stent. 4. Abdominal aortogram. 5. Right lower extremity angiogram. 6. Percutaneous transluminal angioplasty and stenting of the left common iliac artery using an 8 x 38 iCAST stent. 7. Percutaneous transluminal angioplasty and stenting of the right external iliac artery using a 7 x ___ Innova stent. 8. Percutaneous transluminal angioplasty and stenting of the right peroneal artery and tibioperoneal trunk using a 3 mm x 38 mm Premier Rx coronary stent. 9. Closure of the left common femoral puncture site using an ___ Angio-Seal device.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with ESRD on HD,DM,Hep C,PVD who is status post a right fem-BKpop bypass and left fem-AKpop bypass ___ for a right ___ toe non-healing ulcer and bilateral lower extremity rest pain who presented to ___ ___ on ___ with evidence of a right femoral BK pop bypass occlusion with iliac inflow stenosis on CTA. He was taken to the OR and underwent a thrombectomy RLE peroneal angioplasty. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Post-operatively, he did well without any groin swelling. Nephrology and HD were consulted. He returned to the operating room on POD for an angio. On POD 3 he underwent HD, he was having pain in his calf and he was noted to have a CK level elevated to ___. His CK was checked throughout the stay and remained stable. His calf remained tender, but soft. On POD 4 his pain improved. He worked with physical therapy wand was ddeemed appropriate for home with services. On POD 6 he was able to tolerate a regular diet, get out of bed and ambulate without assistance, void without issues, and pain was controlled on oral medications alone. On ___ his discharge and need for follow-up were explained with the use of an interpreter. He stayed for one additional day for dialysis then was discharged home with ___ and home Physical Therapy, and was given the appropriate discharge and follow-up instructions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of L ACL rupture s/p repair ___ w/ Dr. ___ L ankle pain after motorcycle accident. He was taking a turn when he hit a patch of sand and fell onto his L side with his bike landing on top of him. He has immediate pain in L ankle and was unable to bear weight. Denies weakness or numbness. No LOC or headstrike. Denies pain in other locations. Radiology showed Acute fractures through the proximal left fibula and distal left tibia as above. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with FX ANKLE NOS-CLOSED, FX UPPER END FIBULA-CLOS, MV TRAFF ACC NEC-MOCYCL. The patient was treated with Left tibia IMN. At the time of discharge, the patient had left distal third tibia fracture & ___ fibula fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left tibia IMN, 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. Musculoskeletal: Prior to operation, patient was NWB LLE. After procedure, patient's weight-bearing status was transitioned to WBAT LLE. Throughout the hospitalization, patient worked with physical therapy who determined that discharge to home was most appropriate. Neuro: Post-operatively, patient's pain was controlled by IV pain medication and was subsequently transitioned to oxycodone with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Hematology: The patient was not transfused blood for acute blood loss anemia. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: A po diet was tolerated well. Patient was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. ID: The patient received perioperative antibiotics. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received enoxaparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on ___, POD #2, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The incision was clean, dry, and intact without evidence of erythema or drainage; the extremity was NVI distally throughout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 2 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: ___ h/o HTN, DMII, ESRD on HD MWF via RUE AV fistula, asthma, PVD, with recent dx of RUE axillary DVT who presents for subtherapeutic INR. Of note patient was recently admitted for RUE swelling and was found to have axillary vein DVT. Despite history of GI bleed he was started on warfarin. He also had a Fistulogram on ___ with high grade stenosis of outflow tract which was fixed with balloon angioplasty. The patient presents today for low INR. He had INR of 1.38 and was sent for admission from rehab for heparin bridge. He was referred in when ___ was trialing lovenox for bridge despie ESRD. The patient denies any new chest pain no cough no lightheadedness new hemoptysis or any progression of the symptoms from his baseline. INR recently: ___: 1.38 ___: 1.47 ___: 1.4 ___: 2.3 ___: 2.6 In the ED, initial vitals were: 96.6 88 149/97 24 100% nasal - Labs notable for: Trop 0.07, K 5.4 but hemolysed Troponin 0.07 - Patient was given: IV heparin ggt, duoneb - Vitals prior to transfer: 97.4 87 144/104 22 100% Nasal Cannula Unfortunately patient arrived on floor at 6 am and was unable to obtain ___ interpreter. PAtient however appeared to be in no distress. With phone interpreter he did appear to be AAO to person and place; he reported having baseline body aches he gets before HD. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Chest radiographs from ___ showed Mild interstitial edema, unchanged compared to radiographs of the chest from ___. Small, layering right pleural effusion, decreased from prior. Radiology showed Cardiomegaly with pulmonary edema and small bilateral effusions. Radiology showed Persisting pulmonary edema, and slightly decreased in extent since prior. Increased right basilar opacities may reflect atelectasis and/or consolidation. The patient was diagnosed with Acute embolism and thrombosis of deep veins of r up extrem. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with a history of HTN, DMII, ESRD on HD MWF via RUE AV fistula, and asthma, with recent diagnosis of RUE axillary DVT who presents with subtherapeutic INR, and who was admitted for an inpatient heparin gtt bridge. # axillary vein DVT: # Subtherapeutic INR: Patient has a history of requiring angioplasty of fistula secondary to stenosis, and has history of recent axillary vein DVT (___), and therefore required an admission for IV heparin bridge to warfarin. Prior to admission, patient was taking warfarin dose 3mg daily. He was maintained on IV heparin until ___, when his INR had been in goal therapeutic range ___ for >24hrs. Warfarin dose 3.5mg daily and INR 2.7 at time of discharge on ___. Patient will be on chronic anticoagulation given his concurrent history of atrial fibrillation (see below). Patient was also encouraged to sit up in cardiac chair and elevate his right upper extremity to reduce swelling secondary to DVT. # Hypoxia: # Hypervolemia: # HCAP: Patient on RA at home, but escalated to a 4LNC in the setting of tachypnea and dyspnea. Patient's respiratory status improved with increasing fluid removal at scheduled HD sessions on MWF, however the improvement was suboptimal, with patient endorsing pleuritic chest pain, having productive sputum, and diffuse wheezes and rhonchi. Patient also developed leukocytosis and CXR was also concerning for a R basilar opacity. Urine legionella negative. Sputum cx w/commensal respiratory flora. Strep pneumo pending at time of discharge. Given concern for both exacerbation of patient's known reactive airway disease and pneumonia, patient was treated with 5-day prednisone burst (day 1: ___, 40mgx2days, 20mgx3days, off) and with antibiotics: initially with vancomycin/cefepime on day 1: ___. MRSA swab resulted negative on ___ and vancomycin was discontinued. Patient's leukocytosis improved and he was able to wean off supplemental oxygen. Cefepime was transitioned to PO levofloxacin for a planned total 8-day course of antibiotics, scheduled to end on ___. -continue PO levofloxacin for total 8-day course to end on ___. # Generalized body aches: Patient has diffuse body aches ___ to chronic back pain and leg pain, which are typically worse after post-dialysis. He takes Tylenol ___ TID at home which was continued in house with good pain control. CHRONIC ISSUES: # Atrial fibrillation/Atrial flutter: CHADS2Vasc=3 (CVA, DM). Patient is on warfarin in the outpatient setting and is rate-controlled on metoprolol succinate 50mg daily. As above, patient was admitted with subtherapeutic INR, and was bridged with IV heparin to warfarin with INR goal ___. IV heparin was discontinued when INR was therapeutic for >24hrs. At time of discharge, Warfarin dose was 3.5mg daily and INR was 2.7 on ___. # End stage renal disease on hemodialysis: Patient has ESRD secondary to diabetic nephropathy. He received his scheduled MWF HD sessions while in-house, and as above, increased fluid was removed as part of treatment for hypervolemia. Patient was continued on his home cinacalcet, nephrocaps, and vitamin D. # Asthma: Patient was continued on his home fluticasone INH, albuterol inh, and albuterol nebs q4h:PRN. As above, exacerbation of his reactive airway disease likely contributed to his respiratory distress and patient received 5-day prednisone burst. He was also started on albuterol:ipratropium duonebs q6h:prn, with improvement in his wheezing. -----------------</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of hemoglobin SC, hypertension who presents with 2 days of left upper quadrant abdominal pain. She was seen in ___ on three days prior to presentation for vaso-occlusive crisis of the left arm and was given IV narcotics with improvement in her pain and was discharged with oxycodone. The next day she developed acute onset of left upper quadrant abdominal pain. She has had this pain in the past that was related to her spleen. Her pain is worse now and associated with nausea and an episode of non-bilious non-bloody vomiting. She had a temperature to 100. She reports that breathing or moving worsens the pain. She denies any cough, urinary symptoms, hip pain. She does endorse lower back pain over the last few weeks. CHEST (AP AND LAT) showed Left lower lobe consolidative opacity concerning for pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. CT abdomen/pelvis showed 1. Bilateral lower lobe basal segment mixed ground-glass and consolidative opacities, possibly atelectasis, developing infection, or sequela of acute chest syndrome. 2. Enlarged, heterogeneously enhancing spleen. Difficult to exclude areas of developing infarction. 3. Cholelithiasis. 4. Bilateral femoral head avascular necrosis without evidence of collapse. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with NA. At the time of discharge, the patient had Sickle cell crisis Splenic infarct Pneumonia vs. Acute chest syndrome Bilateral avascular necrosis of the femoral head Transaminitis Acute kidney injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with hemoglobin SC and hypertension who presented on ___ with 2 days of left upper quadrant abdominal pain, found to have splenic infarction, pneumonia vs. acute chest syndrome, and b/l asymptomatic avascular necrosis of femoral head. She was transfused 3 units of blood and improved with pain medications, IVF, and supplemental O2. #Sickle Cell/Hb C Anemia #Splenic Infarction #Pain Crisis Patient has a history of hemoglobin SC, followed by Dr. ___ in hematology, and presented with left-sided abdominal pain and nausea/vomiting, similar to previous splenic pain she had had before. Three days prior to presentation, she had been seen at ___ for a vaso-occlusive crisis of her left arm and was given IV narcotics, discharged with oxycodone. The next day, she developed the LUQ pain and presented to BI on ___. At BI, CT abd/pelvis revealed an enlarged 16cm spleen with with heterogeneous enhancement, concerning for splenic infarction. Surgery was consulted and felt there was no indication for acute surgical intervention. Patient received 2 units of blood in the ED on ___ and was given PO dilaudid, IVF, folic acid, and hydroxyurea. Chronic pain was consulted on ___ and patient was started on dilaudid PCA and 3 days of toradol. On ___, patient was transfused another 1 u pRBC and parvovirus studies were sent for an inappropriate reticulocyte count. When pain was better controlled, patient was transitioned back to PO dilaudid on ___. She was discharged with a prescription for oxycodone as she has taken this at home before. #Acute Chest Syndrome v. Pneumonia Patient endorsed pain upon breathing and intermittent fevers upon admission. CXR and CT showed left lower lobe consolidation concerning for acute chest syndrome v. pneumonia. She was given supplemental O2 and a five-day course of IV ceftriaxone and PO azithromycin. On discharge, her breathing was much improved and was satting high ___ on room air. #Bilateral Avascular Necrosis of the Femoral Head Patient notes that she had hip pain a couple of weeks ago, but on admission did not and was able to bear weight on both legs. On CT A/P, she was found to have bilateral avascular necrosis of the femoral head without evidence of collapse. Orthopedic surgery was contacted, and felt there was no indication for intervention, as patient was asymptomatic. She has clinic follow up scheduled. ___ Patient's baseline Cr 0.9, which was elevated to 1.3 on admission, most likely pre-renal from poor PO intake in setting of abdominal pain. With IVF, patient's creatinine decreased down to 0.6. #Transaminitis Patient had elevated liver enzymes (peak ALT 106, AST 99), which was most likely a manifestation of her vaso-occlusive crisis. She denies a history of substance use and had not started any new medications, though she notes that she started taking hydroxyurea the week prior to admission when she started feeling ill. Patient denied any RUQ pain or tenderness. Labs were monitored and were downtrending before discharge. There was the incidental finding of gallstones on CT AP. #Superficial thrombophlebitis Patient developed tender, palpable superficial veins in left forearm and right antecubital fossa where IVs were placed. This was most likely due to irritation from the IVs, exacerbated by the SC crisis. There was no erythema or fluctuance, and patient had good pulses bilaterally. No signs of infection or DVT. Heat packs were used and the palpable veins subsided, though were not completely gone by the time of admission. CHRONIC ISSUES ============== #Depression/anxiety Continued home fluoxetine 20mg. Home lorazepam decreased from 1 mg to 0.5 mg i/s/o taking dilaudid while inpatient. She did not take this while inpatient and says rarely takes it at home. #Elevated blood pressures She has a documented history of hypertension, although patient does not endorse this and she does not take any anti-hypertensives at home. BPs were often 130s/60s, but did range as high as 160s/80s. It was difficult to tell if the spikes were in the setting of pain. Recommend outpatient follow up. TRANSITIONAL ISSUES =================== [ ] Patient discharged with prescription for 5mg oxycodone q4h and a bowel regimen (Miralax and senna). Please re-assess pain and adjust medication accordingly. [ ] Make sure all vaccines for a functionally asplenic patient are up to date. (Per chart review, patient received PCV13 vaccine on ___, and H. influenza and meningococcal vaccines in ___ [ ] Follow up on LFTs. If liver enzymes do not improve, consider further hepatitis workup. [ ] Follow up on parvovirus PCR and antibodies [ ] Repeat CXR in 4 weeks to ensure that pneumonia/acute chest syndrome is resolving (as per Radiology recs) [ ] Follow-up with hematologist for optimal management of sickle cell anemia [ ] Follow-up with orthopedics team to assess severity of bilateral avascular necrosis of the femoral head [ ] CT scan showed evidence of gallstones. Patient is currently asymptomatic. [ ] Patient's zinc level is 67, the lower limit of normal. Consider zinc supplementation to possibly decrease sickle cell crises and infection [ ] Follow up blood pressure control </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 atrial fibrillation on warfarin, cataracts c/b bilateral vision loss, significant anxiety, polyneuropathy, HTN, HLD, OA, HFpEF, with recent admission for rectal pain and severe constipation (discharged on ___, now representing after numerous telephone calls to outpatient providers with ongoing concerns for severe rectal pain/constipation. CT abdomen and pelvis without contrast. showed 1. No sequela of trauma based on unenhanced scan. 2. Large pancolonic stool burden, including large stool ball in the rectum, without evidence of obstruction. 3. Mild bilateral hydronephrosis with high-density material seen in the dependent portion of the urinary bladder, similar to previous study, could represent small stones. Small air locule within the urinary bladder may be iatrogenic. 4. Small bilateral pleural effusions, unchanged. The patient was diagnosed with Unspecified abdominal pain, Other specified diseases of anus and rectum, Constipation, unspecified, Dehydration, Unspecified atrial fibrillation. At the time of discharge, the patient had 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>Ms. ___ is a ___ woman with a history of atrial fibrillation on warfarin, cataracts c/b bilateral vision loss, significant anxiety, polyneuropathy, HTN, HLD, OA, HFpEF, with recent admission for rectal pain and severe constipation (discharged on ___, now representing after numerous telephone calls to outpatient providers with ongoing concerns for severe rectal pain/constipation, initially refusing bowel medications/rectal exam, but eventually achieved resolution of constipation with oral catharctic agents. Experienced transient BRBPR, with H&H and hemodynamics remaining stable. These were thought to be d/t internal hemmorhoidal bleeding and GI was consulted, at which point it was discussed that ___ would be necessary to make definitive dx. Colonoscopy was not w/in pts GOC, and BRBPR resolved. ACTIVE ISSUES ============= #Rectal Pain and constipation Ms. ___ was recently hospitalized on ___ for rectal pain with constipation which was partially alleviated by inpatient stool regimen. On readmission CT scan showed significant stool burden with no evidence of obstruction. A rectal exam was performed in the ED without fissures noted but patient initially refused all further rectal exams. Per patient and daughter they attempted 5 doses of lactulose at home without resolution of pain/constipation. GI has recommended go lytely, methylnaltrexone, tap water and mineral oil enemas, and manual disimpaction but patient initially refused all treatment. Patient eventually consented to attempt recommended GI regimen, with inability to intake adequate volumes of cathartics. Experienced small volumes of BRBPR, which on exam thought to be due to internal hemorrhoids. At this point, GI was re-consulted and recommended against enemas or manual dis-impaction d/t pancolonic stool burden and risk of rectal intervention I/s/o bleeding. It was recommended pt continue oral cathartic agents, and pt and daughter were told that colonoscopy would be necessary to accurately dx the source of bleeding. Pt and daughter declined colonoscopy at this time as it was not within GOC. Pt experienced BMs with maroon blood on ___, with guiac positive stool sample. H&H and hemodynamics stable throughout this time. Pt and daughter again made aware that proper workup would involve full prep with colonoscopy, and decision was made that this was not within pts GOC. For pain she received tramadol and Tylenol. Morphine was given briefly as a trial to see if pt would be able to tolerate enema or manual disimpaction, but was discontinued after GI recommended oral cathartics I/s/o rectal bleeding, as opioid would worsen constipation. # Bilateral hydronephrosis ___ had a recently diagnosed UTI and urinary retention with bladder distention and suprapubic pain on exam. She was treated with course of ciprofloxacin for her UTI which ended on ___. Her constipation is likely contributing to her urinary retention and suprpubic pain. We have not done any more catheters to be consistent with comfort goals discussed during ___ hospitalization. #A fibrillation on Coumadin Ms. ___ is on ___ at home but has intermittently refused doses. She has been taking it fairly consistently during this hospitalization. She is also currently on 60 mg diltiazem PRN for Afib with RVR. Will go home on previous Warfarin regimen, but will need to followup as an outpatient with PCP regarding the utility of remaining on warfarin given her age and the risk:benefit profile. TRANSITIONAL ISSUES =================== [] Goals of care should be clarified as best as possible. [] Will need ongoing management of chronic constipation. Tolerating miralax and senna combination []Non-emergent evaluation for causes of iron deficiency (endoscopy does not seem to be within ___ for patient) [] f/u to determine whether it is within ___ to continue warfarin as an outpatient, given the fact that pt regularly refused it as inpatient and what the risk: benefit profile is at ___ [] we changed her warfarin dosing to 2mg daily per her daily INR values to treat for a fib but this may need to be discontinued pending goals of care [] will INR checked at clinic on ___ [] Palliative care appointment ___ at 11AM; this will likely be critical in managing stress and discomfort of comorbidities</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 notable for HCV cirrhosis, varices s/p banding, HCC s/p TACE in ___ presents with 3 days of progressive shortness of breath and abdominal distension. The patient additionally reports intermittant fevers for several months which are typically worse at night. He had one episode of vomiting yesterday morning which was nonbloody. He denies any hemoptysis or hematochezia, abdominal pain, chest pain. He states that he has never had abdominal distension like this before. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhosis with sequela of portal hypertension, including splenomegaly and moderate ascites. 2. Patent main portal vein. 3. Mild gallbladder wall thickening, without evidence of stones. This is likely is secondary to third spacing in the setting of ascites. Radiology showed 1. Somewhat limited assessment for lower GI bleeding due to residual oral contrast in the ascending and proximal transverse colon. However no definite evidence for active extravasation. 2. Cirrhosis with portal hypertension including splenomegaly and moderate hemorrhagic ascites 3. Status post chemo embolization of the liver. The known mass in the dome of the liver is difficult to visualize 4. Large hiatal hernia 5. Small left pleural effusion and adjacent atelectasis 6. No evidence for retroperitoneal hematoma 7. Hyperdense cyst with calcification in the right kidney Revised findings regarding impression 1. were discussed with Dr. ___ at 10:24 on ___ by Dr. ___ by telephone CHEST (PORTABLE AP) showed Tip of the endotracheal tube is less than a cm from the carina and oriented toward the rib right main bronchus. This may explain new left lower lobe collapse responsible for leftward mediastinal shift. Large hiatus hernia is visible. Right lung is clear. RECOMMENDATION(S): Withdrawn ET tube 20- 25 mm. NOTIFICATION: Dr. ___ reported the findings to ___, the get remain get Y item is way that degree a may is already at ___ year wall ___ by telephone on ___ at 11:44 AM, 1 minutes after discovery of the findings. MRI abdomen with and without contrast. showed 1. Cirrhosis with portal hypertension, splenomegaly and varices. No evidence of malignancy. Patent portal and hepatic vasculature. Moderate amount of ascites. 2. Large hiatal hernia. 3. Small bilateral pleural effusions. The patient was diagnosed with ANEMIA NOS. The patient was treated with ___: Diagnostic Paracentesis. ___: EGD. At the time of discharge, the patient had Primary Diagnosis ================= Cirrhosis Secondary to Hepatitis B c/b portal hypertension, esophageal varices, ascites. Peptic Ulcer Disease Chronic Iron Deficiency Anemia Secondary Diagnosis =================== -Hypertension -Sleep Apnea on CPAP -Paroxysmal Atrial Fibrillation -Mild Aortic Dilatation -Reflux Esophagitis -Depression/Anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a PMH of HBV cirrhosis, history of alcohol abuse, HCC s/p TACE, and grade 1 varices, presenting with fatigue and shortness of breath, now with guaiac positive stool and a substantial Hct drop found to have ulcers within esophagus, stomach and duodenum. # Peptic Ulcer Disease: Patient presented to ___ after several week history of weakness and shortness of breath. On admission labs were notable for a hemoglobin of 5 and hematocrit of 18.0. He denied any melena, bright red blood per rectum, or hematesis. He was admitted to the MICU for close observation given his history of HBV cirrhosis and grade I varices. Prior to arrival in the MICU, patient received 2 units of packed red blood cells. He underwent a paracentesis which did not reveal evidence of SBP. Abdominal ultrasound was negative for portal venous thrombus. Given significant drop in hemoglobin/hematocrit compared to baseline, he underwent a CTA abdomen and pelvis which showed no definite evidence for active extravasation and no evidence of retroperitoneal hematoma. Given history of esophageal varices, he underwent an EGD which revealed 2 cords of Grade I varices (no evidence of bleeding) as well as multiple ulcers found within the esophagus, stomach, and duodenum t hat could contribute to anemia via slow, chronic GI losses. There was no high risk stigmata that required intervention. H. pylori serology was negative. H. pylori stool antigen was also negative (although patient was on pantoprazole at the time). Patient remained hemodynamically stable with stable H/H. H/H at the time of discharge was 7.1/23.2. He was discharged on pantoprazole 40 mg PO Q12H. He was continued on his home medication of sucralfate 1 gram PO QID. Given his history of cirrhosis and likely GI bleed, he was started on ceftriaxone in the hospital for SBP prophylaxis with transition to ciprofloxacin 500 mg PO daily with end date ___ (total course of 7 days). Of note, the gastric ulcer was not biopsied and will need to be biopsied given risk of transformation to malignancy. As part of further anemia workup, reticulocyte count was 2.2. Haptoglobin was 76. # Cirrhosis HBV and EtOH: complicated by Grade I varices, ascites (new onset). No encephlopathy. CHILDS Class B. He was continued on entacavir. As noted below he was continued on bumetanide 0.5 mg PO daily but his HCTZ was discontinued prior to discharge (to decrease risk of becoming hypovolemic on two diuretics). He was continued on nadolol 40 mg PO daily given evidence of grade I varices on EGD. He underwent MRI of the liver with and without contrast given history of ___ s/p TACE ___. MRI revealed no evidence of malignancy. Given evidence of ascites, a therapeutic paracentesis was planned, however there was no good pocket to tap based on bedside ultrasound evaluation. # Hepatocellular Carcinoma: s/p TACE ___. AFP obtained during hospitalization was 3.3. He underwent an MRI of the liver with and without contrast (as he had an MRI Liver scheduled on ___ given his history of HCC). Results showed cirrhosis with portal hypertension, splenomegaly, and varices with no evidence of malignancy. # Grade I Esophageal Varices: 2 cords of Grade I varices noted on EGD obtained ___. There was no stigmata of recent bleeding. He was continued on nadolol 40 mg PO daily. # Hypertension: In the setting of anemia, anti-hypertensives were discontinued. When H/H improved, he was restarted on enalparil maleate 10 mg PO BID. Given that he was on both hydrochorothiazide and bumetanide, decision was made to discontinue the hydrochlorothiazide to decrease chances of becoming hypovolemic. He was continued on bumetanide 0.5 mg PO daily. Discussion regarding outpatient diuretic regimen should take place at next outpatient appointment. Blood pressure should also be monitored as patient's HCTZ was discontinued. # History of Alcohol Abuse: Continued on multivitamin, thiamine 100 mg PO daily. # Reflux Esophagitis: Discontinued omeprazole 20 mg PO daily and transitioned to pantoprazole 40 mg PO BID as noted above (given evidence of ulcers). He was also continued on sucralfate 1 gram PO QID. # Sleep Apnea: Continued on CPAP. # Paroxysmal Atrial Fibrillation: resolved on own in ___. Not currently on any medications other than nadolol for the esophageal varices. # Depression/Anxiety: Lorazepam 1 mg PO qHS insomnia. # Vitamin B12 Deficiency: cyanocobalamin 1000 mcg PO qday. TRANSITIONAL ISSUES =================== -New Medications: Pantoprazole 40 mg PO Q12H, ciprofloxacin 500 mg PO daily with end date ___. -Please follow up MRI of the liver as this was pending at the time of discharge. -Given evidence of gastric ulcer, will need repeat EGD with biopsy of the gastric ulcer. -Patient noted to have lip smacking during hospitalization. Please consider discontinuing prochlorperazine if concern for tardive dyskinesia. -Consider repeat H. pylori stool antigen test as patient was on high dose PPI at time of sample. -Given evidence of ulcers in esophagus, stomach, and duodenum, please consider workup for ___ Syndrome. -Please follow-up CBC within one week as outpatient. H/H at time of discharge 7.___.2. -Patient was noted to have eosinophilia during hospitalization. Please obtain CBC with differential. If eosinophilia is present please continue workup with Strongyloides testing as patient recently went to ___. -Given microcytic anemia, will need colonoscopy. -Patient was on bumetanide and hydrochlorothiazide prior to admission. His HCTZ was discontinued and he was continued on bumetanide to decrease the diuretic regimen he was on. -Full Code (confirmed) </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p fall down 10 stairs with a R distal tib/fib fx (above existing ankle ORIF hardware). ORIF right ankle showed Intraoperative images were obtained during ORIF right ankle. Please refer to the operative note for details of the procedure. Chest radiograph showed 1. Clear lungs. 2. Mild calcification of the aortic knob. Heart is top normal in size. DX TIB/FIB AND ANKLE showed Distal tibial and fibular fractures status post reduction with overall slightly improved alignment with some residual displacement of each fracture, as described above. CT lower extremity with runoff showed 1. Distal tibial and fibular fractures of the right lower extremity, as described above. Addendum with details of fracture description from an MSK dedicated radiologist to follow. 2. Normal three-vessel runoff of the right lower extremity without evidence of filling defects, thrombus, or contrast extravasation. No pseudoaneurysm formation or entrapment of arteries noted at the fracture site. The patient was diagnosed with Unsp fracture of shaft of right tibia, init for clos fx, Fall (on) (from) unspecified stairs and steps, init encntr. The patient was treated with ORIF Right distal tibia fx ___ ___. At the time of discharge, the patient had Right distal tibia fracture (above existing ankle ORIF hardware). The patient was given written instructions concerning 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 distal tibia fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF Right distal tibia fracture with Dr. ___ 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. Despite repeated attempts to convince patient that rehab was the safest option, patient repeatedly declined rehab placement. Attempts were made with the ___ team to clear him for home, but he remained limited in his mobility. On ___, ___ re-established contact with the patient and he was noted to have improved mobility. However, their final recommendations were for rehab. Patient again declined this. He was seen at bedside again with Orthopaedic house staff ___s with Dr. ___. Patient refused to go to rehab, and preferred to go home. He also requested ___ with an Orthopaedic Surgeon closer to home in ___. After discussing with Dr. ___ was agreed that he should ___ with Dr. ___ on ___ ___. As he repeatedly refused rehab despite our recommendations, we felt the safest option was to provide him with home ___ and OT (versus letting him leave AMA without either). This was set-up for him on ___ and he was provided with a rolling walker. 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 spontaneously. His dressings were changed and a short leg cast was placed. The patient is non-weightbeawring in the Right lower extremity with BUE assist, and will be discharged on Lovenox for DVT prophylaxis. The patient was instructed to follow up with Dr. ___ in 1 week following discharge. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course. He was given a short course of Oxy/Gabapentin for pain control, with instructions to wean/discontinue when no longer needed (in addition to avoiding driving, operating machinery, or taking with sedatives/hypnotics/alcohol). The patient was also given written instructions concerning precautionary instructions and the appropriate ___ care. The patient expressed readiness for discharge. Of note, after clearing and setting up patient for home services, he then stated that he did not want anyone coming to his home. This was revisited, and patient was told that if he declined home services he would be leaving ___ medical advice'. Moreover, we reiterated that he needed home services ___ and OT) for safety reasons. He was eventually discharged with services as previously set-up, and we are hopeful that he is cooperative with the visiting therapists. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F hx HTN and ocular migraines who has had 3 episodes of visual disturbances since ___ and was found to have 2 aneurysms on MRI during outpatient work up. MRI results were communicated to the patient today and in the setting of intermittent right arm numbness she presented to the ED. Pt describes the previous visual disturbances as being "unable to see straight." She felt that her eyes were moving in different directions. All 3 episodes happened when she felt otherwise exhausted. Has hx migraine HAs when she was younger, none recently. Occasional HA, no change in frequency or severity. Deniescurrent HA, nausea, vomiting, current vision changes, numbness, weakness or tingling. Diagnostic cerebral angiogram for evaluation of multiple aneurysms identified on MRA. During the procedure the following vessels were selectively catheterized angiograms were performed: Left internal carotid artery Right internal carotid artery Left vertebral artery Right common femoral artery Three-dimensional rotational angiography of the left internal carotid artery circulation requiring post processing on an independent workstation and concurrent attending physician interpretation and review Three-dimensional rotational angiography of the right internal carotid artery circulation requiring post processing on an independent workstation and concurrent attending physician interpretation and review Ultrasound-guided access to the right common femoral artery showed 1. 15 x 15 mm left ICA bifurcation aneurysm. 2. 15 x 9 mm anterior communicating artery aneurysm that fills from the right. RECOMMENDATION(S): Will discuss at vascular conference plans for treatment The patient was diagnosed with Anesthesia of skin. The patient was treated with ___ diagnostic cerebral angiogram. At the time of discharge, the patient had anterior communicating artery aneurysm left ICA aneurysm. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to neurosurgery service for finding of incidental finding of anterior communicating artery aneurysm and Left ICA aneurysm. #cerebral aneurysms Patient underwent diagnostic cerebral angiogram on ___ which confirmed aneurysms seen on MRI. No intervention was done at this time. Groin was angiosealed and she remained on bed rest for 2 hours. She will follow up outpatient for further treatment. At the time of discharge on ___ she was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ RHM gentleman, past medical history of CAD status post MI, peripheral vascular disease status post stents, hyperlipidemia, OSA not on CPAP, CKD, diabetes, HTN, HLD, and lupus anticoagulant on anticoagulation, presents with a sudden onset of lightheadedness, blurry vision, and triplicate to quadruplicate vision. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Severe atherosclerotic calcification causing severe stenosis at the proximal left subclavian artery, with unremarkable distal run-off. 2. Heavy atherosclerotic calcification of the origin of the left vertebral artery from the left subclavian artery V2 segment of the left vertebral artery demonstrates lack of opacification/heavily diminished opacification with reconstitution at the level of V3, likely due to retrograde collateral flow from the patent right vertebral artery. 3. Given the stenosis at the origin of the left subclavian artery with differential upper extremity blood pressures, it is possible that the lack of opacification of the left vertebral artery is secondary to steal syndrome. Although, occlusion of the left vertebral artery is more likely due to atherosclerotic disease, and the left vertebral artery itself would be expected to be opacified in the setting of subclavian steal. This can be further evaluated with ultrasound of the left vertebral artery. 4. The circle of ___ and its principal intracranial branches are patent. RECOMMENDATION(S): Further evaluation of impression 2 and 3 with ultrasound is recommended. NOTIFICATION: The above findings and recommendation were communicated via telephone by Dr. ___ to Dr. ___ at 13:50 on ___, 5 minutes after discovery. MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ showed 1. No acute intracranial abnormality on noncontrast MRI head. Specifically no acute infarct. 2. There is lack of flow related signal of the left vertebral artery beginning at the distal V1 segment to the V4 segment. Contrast opacification seen in the V3 segment on earlier CTA is likely secondary to retrograde flow. There is no evidence of intramural thrombus or luminal thrombus on T1 fat saturated sequences with apparent preserved flow voids the left vertebral artery. Overall, in conjunction with evidence of high-grade stenosis of the proximal left subclavian artery with preserved flow related signal distally, the constellation of findings would suggest subclavian steal. Retrograde flow in the left vertebral artery can be definitively evaluated with ultrasound. 3. Allowing for mild atherosclerotic disease, unremarkable MRI brain. RECOMMENDATION(S): Further evaluation of impression 2 with ultrasound. Carotid Doppler Ultrasound showed 1. Moderate calcified atherosclerotic plaque yielding a 40-59% degree stenosis 2. Mild calcified atherosclerotic plaques yielding a less than 40 degree percent stenosis. 3. Retrograde flow in the left vertebral artery suggestive of subclavian steal RECOMMENDATION(S): The ultrasound findings confirm the diagnosis from the prior CTA of the head that the patient has subclavian steal syndrome related to an occluded left subclavian artery ostium. The left vertebral artery is patent but has retrograde flow. An interventional radiology consult is recommended for subclavian artery stenting. The patient was diagnosed with Diplopia. At the time of discharge, the patient had TIA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with HTN, HLD, DM, OSA, and +lupus anticoagulant antibodies who was admitted ___ with transient neurologic symptoms including ?diplopia and right upper extremity ataxia in the setting of being bridged with lovenox and off coumadin for a planned dermatological procedure. Imaging shows no infarct, but left vertebral lack of flow and left subclavian stenosis suggestive of a vertebral steal syndrome. His history and resolution of deficits suggests either a TIA (given subtherapeutic lovenox dosing) vs steal phenomenon. His Cr was elevated on admission to 2.7. Because of this, he was bridged with a heparin drip until he reached a therapeutic INR between ___. On discharge, his INR was 2.1. He will need his INR checked again this week. As part of his stroke workup, he had a TTE completed, which showed a ?coarctation of the aorta. Vascular surgery was consulted and recommended outpatient follow up. It also turns out that he is only on warfarin and not on Plavix or ASA, though it is on his medication list. He will need to have this clarified with vascular surgery. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of urosepsis and obstructing kidney stones, aortic stenosis, afib on Xarelto, BPV, CHF with diastolic dysfunction, Barretts esophagus with dysphagia, hypothyroid, chronic lymphedema, HTN and ischemic colitis who is presenting with lower back pain for the past month and chills that started last night. CHEST (SINGLE VIEW) showed No acute intrathoracic process. Specifically, no signs of pneumonia. CT abdomen and pelvis without intravenous contrast showed 1. No acute abnormality in the abdomen or pelvis to explain patient's reported back pain and fever. Specifically, no evidence of hydronephrosis or perinephric abnormality. No fracture. 2. Nonobstructive nephrolithiasis. 3. Sigmoid colonic diverticulosis without evidence of diverticulitis. 4. No evidence of acute appendicitis. 5. A small focus of gas in the bladder is nonspecific but likely related to instrumentation. Please correlate clinically. The patient was diagnosed with Urinary tract infection, site not specified, Cellulitis of left lower limb. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ y/o woman with history of recurrent urinary tract infections complicated by urosepsis, obstructive nephrolithiasis, urinary incontinence, HFpEF, AS, thyroid cancer s/p partial resection, ___ esophagus, chronic back/knee pain, lymphedema who presented with back pain and chills and was found to have urinary tract infection and left lower extremity cellulitis. =============== ACUTE ISSUES: =============== # Urinary tract infection: Patient presented with chills and was found to have pansensitive E. coli urinary tract infection. Imaging was without obstructive nephrolithiasis and showed no radiographic evidence of pyelonephritis. The patient was initially given ceftriaxone, and given allergy to Bactrim and drug-drug interactions with amiodarone, will complete 7-day treatment course with cephalexin (Last day: ___. # Cellulitis: Patient was noted to have left lower extremity erythema and serous drainage consistent with nonpurulent skin and soft tissue infection. She was initially given vancomycin and ceftriaxone and narrowed to cephalexin as above. She was treated with tramadol for discomfort. # Lymphedema: Patient has longstanding history of lymphedema that increased her vulnerability to cellulitis as above. She will follow up in the lymphedema ___ further management. =============== CHRONIC ISSUES: =============== # Chronic back pain # OA knees: Lidocaine 5% Patch daily. Tramadol as above. # Atrial fibrillation: Continued amiodarone and rivaroxaban. # HFpEF: Continued lisinopril, torsemide. # Aortic stenosis: Stable. # HTN: Continued lisinopril. # HLD: Continued rosuvastatin. # Hypothyroidism ___ hashimoto's, thyroid cancer s/p resection: Continued levothyroxine. # Gout: Continued allopurinol. # GERD c/b ___ esophagus: Continued omeprazole. # OSA not on CPAP ====================== TRANSITIONAL ISSUES ====================== - Patient to continue cephalexin 500 mg Q6H to complete 7-day course for E. coli urinary tract infection and cellulitis (Last day: ___ - Patient provided with tramadol for increased discomfort due to cellulitis - Patient will follow up in the ___ clinic - Communication: ___, friend, ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Per Colorectal Surgery Admit Note: MRI abdomen without contrast. showed 1. Small hernia at the umbilicus containing mesenteric fat and postsurgical change. No fluid collection or bowel is seen within this small hernia. 2. Mildly dilated small bowel is slightly improved from the prior CT and may represent a resolving ileus or partial small bowel obstruction. 3. Small to moderate amount of free fluid adjacent to the inferior liver and extending along the right pericolic gutter, slightly decreased compared to prior CT. The patient was diagnosed with OTH CURR COND-ANTEPARTUM, ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had Umbilical Incision 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>___ was admitted to the inpatient Colorectal Surgery Service with Umbilical Incision pain. All laboratory values were stable and she did not have a fever or any other sign of systemic infection. The high risk OB team was consulted given that she is approximately 16 weeks pregnant and had been previously followed by them during her last admission. An MRI of the abdomen was ordered to evaluate for abscess or hernia. The read showed a possible small hernia with fat necrosis. This was reviewed with Dr. ___ this was a nonsurgical issue and there was no fluid collection under the umbilical incision site. There were no other significant finding on MRI related to the surgery, infact, small bowel dilation and post-surgical fluid was improved. She was monitored closely overnight. She tried a Lidocaine patch which did not help significantly. PO Dilaudid did help. All medication choices were discussed with OB. The following morning she was slightly improved. She had her baseline nausea, which improves with food and throughout the day. She is nauseated every morning at home, which seems very consistent with morning sickness. ___ was very concerned about her surgical incisions. I examined the incisions and offered reassurance, she will continue to shower and pat the incision dry. We went over the MRI symptoms again with her husband present. She will be seen ___ at ___ and will follow-up with Dr. ___. It seemed most of the pain was with movement and she felt as though she had to support her abdomen with her hand. We tried an abdominal binder for support prior to discharge. She was discharged home in the care of her husband. The major aspects of her discharge plan was discussed with OB. She was sent home with a small prescription for Dilaudid to use if Tylenol is not covering the pain. We will follow her closely.</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 smoker with a history of metastatic throat cancer s/p laryngeal tracheal resection, s/p removal of L lower jaw, who presented via EMS for evaluation of AMS s/p fall with positive head strike on ___. Per patient's family, he was noted to have continually ingested EtOH through out the day. Per EMS, family notes the patient had a mechanical fall from standing, with positive head strike, and subsequently exhibited altered mental status with slurred speech. Upon these findings, the family notified EMS, who states the patient was alert and oriented x3 upon their arrival. En route, the patient was dehydrated but otherwise hemodynamically stable, and Mr. ___ received 700 mls fluid en route to the ED. Upon arrival to ED Triage, the patient became hypotensive, and displayed episodic AMS with slurred speech. Radiology showed Limited views of the chest and pelvis demonstrating no definite acute abnormalities, left rib fractures better seen by CT. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. Small left occipital scan laceration, closed with staples. No evidence of underlying fracture. CT C-SPINE WITHOUT CONTRAST. showed 1. Bilateral C6 laminar fractures and obliquely oriented fracture of the right C7 articular pillar/superior articular facet, with extension into the transverse process, as described above. If neurologic symptoms are present, MRI is recommended for better characterization. 2. Nondisplaced fractures of the left fifth and sixth, and possibly the third transverse processes without extension to the transverse foramina. 3. Medial left first and second rib fractures. NOTIFICATION: The changes in the above impression from the original wet read were communicated to Dr. ___ by Dr. ___ in person at 20:45, at the time of attending review. CT CHEST, ABDOMEN, AND PELVIS showed 1. Left first and second rib fractures are better seen on concurrent CT cervical spine. No other evidence of acute traumatic injury in the chest, abdomen or pelvis. 2. Severe emphysema. 3. Coronary artery atherosclerotic disease. 4. Gastric distention, with mild dilation of small bowel loops, with no evidence of mechanical obstruction, likely ileus. 5. 1.2 cm left adrenal nodule, statistically benign likely an adenoma but incompletely characterized on this single phase exam. 6. Nodular thyroid. NOTIFICATION: The above findings and changes from the original wet read were communicated by Dr. ___ to Dr. ___ telephone at approximately 20:45, at the time of attending review. MR CERVICAL SPINE W/O CONTRAST showed 1. Anterior wedge fracture of the T1 vertebral body with associated hyperintensity seen on ideal images. Given the clinical history, this likely represents an acute fracture. 2. Fractures of the bilateral C6 lamina, right C7 superior facet, and right C5 inferior facet as seen on prior CT scan. 3. Small midline disc protrusions at C3-C4, C4-C5, and C5-C6 without cord deformity or abnormal cord signal. The patient was diagnosed with FX C6 VERTEBRA-CLOSED, UNSPECIFIED FALL, FX C7 VERTEBRA-CLOSED, OPEN WOUND OF SCALP. At the time of discharge, the patient had head laceration left medial rib fractures of ribs 1 and 2 a fracture of bilateral C6 laminae with extension into C6-7 facet and anterolisthesis of C6 on C7. The patient was given written instructions concerning 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 smoker with a history of metastatic throat cancer s/p laryngeal tracheal resection, s/p removal of L lower jaw, who presented via EMS for evaluation of AMS s/p fall with positive head strike on ___. He was evaluated upon arrival. Imaging revealed T1 vertebral body fracture, and C6 laminar fractures bilaterally for which the patient was placed into a collar. He was also found to have left medial rib fracture of ribs 1 and 2. The patient was seen by ACS and orthopedics as well as physical therapy. During his stay in the hospital the patient required 1L FW restriction for low Na. His chem were monitored. He was also placed on a CIWA scale and was administered a banana bag. The patient did well throughout his stay in the hospital. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with IV pain medication and then transitioned to oral pain medication once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient's diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient will be discharged with the c-collar in place. The patient understands that the collar must stay on for 8 weeks. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o appendectomy for perforated appendicitis complicated by ARDS, ECMO, and subsequent renal failure and right hip disarticulation who returns today for left buttock wound. He has had a pressure sore there for some time and has daily ___ care and was noted to have increasing redness and warmth around the area. He denies any fevers, chills, or foul odor drainage. He does report that he was putting extra pressure on this area over the last few says while working out. He is now home, off all dialysis, and otherwise feels well. US BUTTOCKS, SOFT TISSUE LEFT showed No drainable fluid collection. Soft tissue heterogeneity may reflect the presence of edema versus phlegmon. MRI of the Pelvis showed Findings are compatible with a large area of phlegmon interdigitating within the left gluteal muscular fibers spanning an area of 9.1 x 3.3 cm. No evidence of osteomyelitis. The patient was diagnosed with Cutaneous abscess of buttock. The patient was given written instructions concerning 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 appendectomy for perforated appendicitis complicated by ARDS, ECMO, and subsequent renal failure and right hip disarticulation who returns today with left buttock wound. He has had a pressure sore there for some time and has daily ___ care and was noted to have increasing redness and warmth around the area. He denies any fevers, chills, or foul odor drainage. Soft tissue U/S demonstrated soft tissue heterogeneity reflective of edema versus phlegmon. MRI demonstrated phlegmon interdigitating within the left gluteal muscular fibers spanning an area of 9.1 x 3.3 cm. Interventional Radiology was consulted and reported that there was no drainable fluid collection. After discussion with the patient it was determined that he would go home with PO augmentin x10 days and close follow-up with Acute Care Surgery clinic this week to re-evaluate the wound. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Per Colorectal Surgery Consultation Note: HPI: ___ w one prior episode of uncomplicated sigmoid diverticulitis treated at an OSH approximately 2 months ago, who was admitted to medicine service on ___ w one day of severe lower abdominal pain, found on CT scan to have uncomplicated sigmoid diverticulitis. Patient was placed on IV Unasyn but kept on a regular diet and continues to complain of severe lower abdominal pain with little improvement. Given patient's recent history of diverticulitis and lack of improvement on this hospitalization, colorectal surgery is consulted for further recommendations on management. CHEST PORT. LINE PLACEMENT showed Interval placement of right subclavian PICC line which has its tip in the mid SVC. Cardiac and mediastinal contours are stable. Residual but improved bibasilar streaky opacities suggestive of atelectasis. No pulmonary edema or pneumothorax. RENAL U.S. showed No evidence of hydronephrosis bilaterally.. Radiology showed Findings consistent with acute uncomplicated sigmoid diverticulitis. DOSE: 1057.1 mGy-cm. CT ABD AND PELVIS WITH CONTRAST showed 1. Extravasation of rectal contrast at the anastomotic site consistent with moderate- sized anastomotic leak that tracks superior to the anastomosis. Large amount of free air surrounding the anastomosis and within the peritoneum, retroperitoneum and tracking into the mediastinum. 2. Fluid collection in the anterior pelvis superior to the anastomosis measuring 6.1 x 3.4 cm. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ ___ telephone at 05:00 on ___ immediately after completion of the exam appear CT ABD AND PELVIS WITH CONTRAST showed 1. Loops of dilated small bowel in the left abdomen without a definite transition likely due to ileus. No evidence of obstruction. 2. Status post sigmoid resection with diverting loop ileostomy. No evidence of leak of oral contrast. Large amount of intra and retroperitoneal free air as seen previously. 3. Small fluid collection in the low right anterior abdominal wall likely due to recent surgery. The patient was diagnosed with DIVERTICULITIS OF COLON. The patient was treated with ___ Laparoscopic sigmoid resection. ___ Laparoscopic washout, placement of drain and diverting ileostomy.. At the time of discharge, the patient had Diverticulitis with anastomotic leak after sigmoid colectomy.. The patient was given written instructions concerning 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 inpatient medicine service on ___ for treatment of acute Diverticulitis. Colorectal surgery was consulted as he was given intravenous antibiotics and continued to have pain. On ___ the patients abdomen continued to be tender. On ___ the patient had not had resolution of pain depsite 48 hours of intravenous antibiotics, this included changing therapy, the patient was brought to the OR with Dr. ___. On ___ a Laparoscopic sigmoid resection was preformed. He did well post-operatively and recovered in the PACU, he was then transferred to the inpatient unit. On ___ he was doing well and his laboratory vaules were stable. The foley catheter was removed. On ___ the patient was noted to have a small amount of erythema around the umbilical site. On ___ the patient had a slightly temperature to 100.3 and blood and urine cultures were sent which were negative. On ___ he continued to have a low grade temperature to 100.2 with some Dyspnea. A chest Xray was preformed which showed that the lungs were clear except for some atelectasis. The patient had multiple small bowel movements. On ___ the patient's temperature reached ___ F with abdominal tenderness with a white blood cell count to 14.4. A CT with rectal contrast showed anastomotic leak and the patient was taken to the operating room for Laparoscopic washout, placement of drain and diverting ileostomy. On ___ the patient complained of nausea and heartburn. EKG and troponins were done given the patients cardiac history however, were negative. An NGT was placed with 900cc out. On ___ the ngt continued to put out a liter of outpur. The patient complained on incresed left flank pain however his cital signes were stable. A urinealysis was again sent which was negative. The drain was left in place, it was drainiange brown liquid to serosang. This was likely related to the previous leak. On ___ the foley catheter wsa removed and the patient voided without issue. The ileostomy was putting out liquid stool therefore the nasogastric tube was clamped. On ___ the patient tolerated clear liquids and the intravenous fluids were dicontinued. He was transiitoned to home medications and medications by mouth. On ___ the patient complained of worsened abdominal pain. A CT scan was obtained which showed Small fluid collection, likely ileus, but no obstruction. On ___ he continued clear liquids. He had elevated ileostomy output and this was repleted with intravenous fluid boluses. A PICC line was placed without issue. The ileostomy continued to have increased output. He was given psyllium and loperamide. On ___ the patient's diet was advanced to regular which was tolerated well. The patient's pain was stable. On ___ a vancomycin trough was therapeutic. On ___ Creatinine was noted to be 3.1, a FeNa was 0.3%, UA: 14WBC, neg Eos. Sediment pnd. A Renal US was obtained and normal. He was given intravenous fluids as it was decided he was likely dehydrated and contrast dye. On ___ intravenous antibiotics were transitioned to cipro/flagyl by mouth. On ___ the patient's creatinine was improved to 2.6 and he was discharged home with the drain in place and this was to stay in place until at least his follow-up appointment. THe patient was supported by the nursing staff and seen by social work and the wound ostomy nursing team while in house. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F PMH of ___'s thyroiditis, past abdominal surgeries (hysterectomy/cholecystectomy) and anxiety who presents for worsening of her chronic abdominal pain that she has had since ___ after a bout of C.diff at ___ ___ to abx treatment she received while being treated for pyelonephritis. The C.diff resolved but states that she has had residual abdominal pain described most mid-epigastric, extending around her R side to her back, presently a ___ with improvement of ___. Nothing particularly makes it better besides not eating and pain is worse with eating. Denies any fevers or chills, GERD-like symptoms, CP or SOB. No sick contacts or change in diet/meds, just a remote history of travel in ___ in ___. Radiology showed 1. No acute intra-abdominal process to explain the patient's symptoms. Appendix not definitely seen without inflammatory changes in the right lower quadrant to suggest appendicitis. Moderate fecal load. 2. Mild intrahepatic biliary prominence may be normal in the setting of cholecystectomy. Correlate with labs to determine the role of MRCP. 3. Absent left kidney. The patient was diagnosed with ABDOMINAL PAIN EPIGASTRIC. The patient was treated with EGD - ___ EUS - ___. At the time of discharge, the patient had 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>___ y/o F PMH of ___'s thyroiditis, anxiety, recent recurrent UTI and Cdiff who presented to the ED with several months of abdominal pain, nausea and vomiting likely ___ gastroparesis. . *** Active Diagnoses *** . # Nausea / Vomiting / Abdominal Pain: Likely Gastroparesis: Likely diagnosis for her abdominal pain given feelings of n/v almost immediately after eating with significant improvement on reglan such that pt could tolerate regular PO intake. Could be due to her bout of C. diff that led to gut distention and gastroparesis. Additionally, lab evaluation with Celiac panel, LFTs, CRP, stool studies, H pylori , and lipase were all unremarkable. CT abd/pelvis also unremarkable. Seen by GI who performed EGD and EUS that were unremarkable with no further evidence of gastritis. F/u arranged with GI on outpt basis and continue Reglan until that time. EKG was performed for baseline QTc of 440. . # Weight loss Appears most likely from lack of eating from above reason. Per charts only lost 9 lbs over 6 month period vs pt initial report of 20+. Will likely improve now that is tolerating regular PO intake. . # Anemia: Believed to dilutional after given 3L of IVF, stable while here with iron studies/vitb12/folate all normal. Hct at discharge 35.3. . #Hypothyroidism: TSH found to be elevated at 10 so dosage increased from her 50mcg to 75mcg. Pt setup and instructed to ___ with PCP for further dose adjustment and re-check of her TSH in ___ weeks. . *** Chronic Issues *** . # Anxiety: Stable, on fluoxetine. Pt directed to consider talking with therapists since the loss of her mother. . *** Transitional Issues *** . - ___ with GI to evaluate whether further evaluation needed on outpt basis such as gastric emptying study . - Touch base with PCP regarding repeat TSH check given adjustment of her levothyroxine from 50mcg to 75mcg . - Given pt on reglan, consider repeat EKG to evaluate for prolongation of QTc interval. Normal while checked here. . - Discussed pt seeing psych or therapist given difficulties coping after loss of her mother this past year.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old male who presents with weakness since waking up yesterday morning. He has a history of hypereosinophilia (HES) which he states causes him vague diffuse body pains and weakness (despite now normal eosinophil count), and he has been in rehab since discharge from this hospital on ___. He was initially admitted at this last hospitalization for joint pains and worsening lower extremity ulcers. At that time he was also found to have a DVT and was placed on coumadin after heparin bridge. Pt states that he woke up 1 day PTA and noticed he had wet the bed. He then tried to get up but felt too weak to stand. He required help getting to the commode and was unable to maintain standing posture for more than a few seconds. Radiology showed 1. No acute intracranial abnormality. 2. Subtle hypodensity in the posterior limb of the right internal capsule may be due to artifact. Recommend correlating this with neurologic deficits. Radiology showed No acute cardiopulmonary process. Radiology showed 1. No acute intracranial hemorrhage or evidence of vascular territorial infarction. If concern persists, and the patient is able, would consider MRI for further evaluation. 2. No evidence of aneurysm, pseudoaneurysm, dissection or thromboembolic filling defect. Notably, the level of the thoracic inlet is limited due to streak artifact and thus the origin of the diminutive right vertebral artery and normal caliber left vertebral artery is not well evaluated. 3. Right posterior thyroid nodule. Precise margination is difficult given the streak artifact. If not already performed, would recommend comparison to thyroid function tests and thyroid sonography on a non-urgent basis. 4. Soft tissue in the nasopharynx, likely a polyp. If relevant clinically, this could be correlated to direct examination. Radiology showed No evidence of hemorrhage or infarction. The patient was diagnosed with OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had Weakness - generalized. The patient was given written instructions concerning 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 ___ for concern for evolving stroke on wet read of CT head obtained in ED. The final read of this CT was normal. He could not tolerate an MRI/MRA, so CTA was obtained and was also WNL on wet read. (Final read pending). Just before midnight on ___ he had an episode of mental status change when he was woken up for neuro check which resolved in a few minutes after being awake. Because of this, there was concern for an evolving intracranial process, and a ___ CT scan was performed. The CT scan was negative for any acute intracranial process. In addition, Mr. ___ had a few desaturations overnight - he requires CPAP but refused a face mask. He was given nasal prongs which were thought to be not helpful as he is a mouth breather while sleeping. It is felt that this mental status change could be secondary to CO2 retention while sleeping as this resolved within 5 minutes of awaking. Mr. ___ continued to have upper extremity weakness and pain, L>R, throughout his admission. His L lower extremity weakness improved. His INR was therapeutic at 2.9, so we did not adjust his coumadin dose. We also contacted his Heme/Onc team for recommendations about his pain control medications given his increase in upper extremity pain.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F recently discharged 8 days ago s/p two-staged anterior and posterior L4-S1 fusion by Dr. ___ had been recovering well for the first week after surgery but reports worsening pain over the last week. The pain is particularly in her left thigh. She came into the ED for further evaluation. She has full strength and intact sensation throughout. No bowel or bladder changes. The pain feels similar to when she previously expereinced a PE. Given her recent surgery, ortho spine was consulted. MR ___ AND W/O CONTRAST showed 1. Abnormal T2 signal and enhancement within the L1 and L2 vertebral bodies with post-contrast enhancement also noted within the L1-L2 intervertebral disc space. While these findings could be seen in degenerative disease, infection cannot be excluded. Comparison to prior studies would be useful. 2. Patient is status post L4-S1 posterior spinal fusion. There is no canal compromise in the region of surgery There is mild clumping of the nerve roots in this region suggesting a arachnoiditis. 3. 12.0 cm SI x 5.7 cm TV fluid collection in the posterior subcutaneous tissues likely postoperative UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. LUMBO-SACRAL SPINE (AP AND LAT) showed Status post L4-S1 posterior spinal fusion with no evidence of hardware complication or acute traumatic injury. The patient was diagnosed with LUMBAGO, ARTHRODESIS STATUS. The patient was treated with drainage of superficial seroma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ presented to the ___ emergency department on ___ with worsening back and left leg pain. She has recently undergone an anterior and posterior L4-S1 fusion about 10 days ago. Lumbar radiographs were reviewed which showed appropriate alignment of the lumbar spine in both coronal and sagittal planes. The hardware is in place anteriorly and posteriorly without evidence of loss of fixation or complication. Venous US of the left lower extremity was negative for deep venous thrombosis. Mrs. ___ was admitted to the Ortho Spine service for pain control and physical therapy evaluation. IV steroids were continued for 24 hours during the hospital stay. Acute pain service was consulted and changes were made to patients medications. An MRI of lumbar spine which revealed a post-operative seroma without any central canal compromise. ___ was consulted for ambulation and recommended that Mrs. ___ would benefit from an acute rehabilitation facility. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old ___ speaking male with PMH notable for triple-vessel CAD s/p DES to OM2 on ___, severe AS, Stage V CKD (not yet on HD), T2DM, EtOH cirrhosis, and L ACA CVA (___) who initially presented to the ED with chest pain. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___. Moderate cardiomegaly has increased, mild pulmonary edema is new. No appreciable pleural effusion. No pneumothorax. Rightward deviation and left-sided indentation of the cervical trachea may be slightly more pronounced today than in ___, usually due to an enlarged thyroid. Most recent thyroid ultrasound was performed ___ showing bilateral thyroid nodules. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Normal appearance of hepatic parenchyma. Unchanged bilobed hepatic cyst in the left hepatic lobe. Patent portal vein. No ascites. 2. Relatively normal appearance of the gallbladder. Trace pericholecystic fluid may be related to reported underlying liver disease versus cardiac insufficiency. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ and ___. Since ___ the then new pulmonary vascular congestion in the left lung and moderate enlargement of cardiac silhouette of both cleared. However there is now relatively uniform severe opacification on the right that I hesitate to attribute to either pleural effusions since the examination is reported as having been performed with the patient upright or pneumonia in the absence of air bronchograms or obscuration of any contours in the right hemithorax. RECOMMENDATION(S): Chest CT. Repeat chest radiograph to see if chest CT scanning is indicated. NOTIFICATION: The findings were discussed with ___., M.D. by ___ ___, M.D. on the telephone on ___ at 9:33 am, 1 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. Mild cardiomegaly has increased. Consolidation in the right midlung is more clearly defined, probably pneumonia. Lower lobe findings could be a combination of asymmetric edema and pleural effusion, as well as pneumonia. No left pleural abnormality. No pneumothorax. Rightward shift of the trachea at the thoracic inlet is attributable to enlarged thyroid. Patient had thyroid ultrasound on ___ describing multinodular goiter. AORTA AND BRANCHES showed Extensive atherosclerotic calcification within the abdominal aorta without evidence of abdominal aortic aneurysm. CHEST (PORTABLE AP) showed Comparison to ___. The pre-existing parenchymal opacity at the right lung bases has completely cleared. On the current image, there is no evidence of parenchymal abnormalities. No pulmonary edema. No pneumonia. No pleural effusions. Stable borderline size of the cardiac silhouette. No pneumothorax. Radiology showed Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. The patient was diagnosed with Unstable angina, Athscl heart disease of native coronary artery w/o ang pctrs, Chest pain, unspecified. The patient was treated with ___ TAVR ___ Tunneled HD line. At the time of discharge, the patient had ================== PRIMARY DIAGNOSES: ================== Undifferentiated shock Type II non-ST elevation myocardial infarction Severe aortic stenosis, status post transcatheter aortic valve replacement Chronic kidney disease, initiated on hemodialysis Aspiration pneumonia Paroxysmal atrial fibrillation ====================== CHRONIC/STABLE ISSUES: ====================== Coronary artery disease with known three vessel disease, status post drug eluting stent to OM2 Hypertension Normocytic anemia Ethanol cirrhosis Type II diabetes mellitus Benign prostatic hypertrophy. The patient was given written instructions concerning 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 background history notable for triple-vessel CAD, status post DES to OM2 on ___, severe AS, Stage V CKD (not yet on HD), T2DM, EtOH cirrhosis, and L ACA CVA (___) who initially presented to the ED with chest pain, found to have STE in aVR with diffuse depressions c/f STEMI. Patient was in shock in the ED thought to be cardiogenic. He was treated medically for his MI and received a TAVR during this hospitalization. His baseline CKD worsened requiring hemodialysis which was started inpatient. ==================== ACUTE/ACTIVE ISSUES: ==================== # Shock Hypotensive in ED with lactate elevated to 5.3, status post 1L IVF with improvement in SBP to 100. Most likely cardiogenic shock in the setting of possible ischemia vs. worsening AS, although unclear. Bedside echo without evidence of tamponade. Low suspicion for PE or tension pneumothorax given stable respiratory status. His lactate downtrended in ED and normalized, with stable blood pressures throughout the remainder of admission. # Type II NSTEMI # CAD with known 3VD, s/p DES to OM2 # Severe AS Patient presented with unstable angina, found to have ECG changes concerning for global ischemia. Coronary angiogram prior to this hospitalization on ___ with 3VD and DES to OM2. ECG changes did not appear consistent with in stent restenosis. Troponins/CK-MB rose during initial hospitalization, with high concern for global ischemia in the setting of severe AS, though patient continued to deny chest pain and repeat ECGs did not suggest ischemia. Peaked at 4.85, CK-MB peaked at 116. Cardiac surgery was consulted and echo was performed showing severe aortic stenosis. Cardiac surgery recommended TAVR as patient was high risk for SAVR. TAVR was completed one week into hospitalization after resolution of pneumonia, without complication. Discussion was had regarding antiplatelet/anticoagulant therapy going forward, given requirement for anticoagulation for paroxysmal atrial fibrillation. Decision was made to continue warfarin and clopidogrel alone for duration of DAPT (at least three months), before transitioning to aspirin/warfarin upon completion of planned DAPT therapy. Goal INR is 2.0-3.0. # CKD stage 5 Cr 6.2 on presentation, up from 5.6 on ___ post-cath. 7.0 on ___, status post cath with contrast. Discussion was had regarding further contrast load necessary for TAVR procedure and possibility of HD requirement, which patient understood and accepted. Decision was made to initiate HD post TAVR procedure. Left tunneled line was placed on ___ and HD was initiated on ___. Patient underwent four sessions without issue prior to discharge. Will start outpatient HD at ___ Dialysis Center, with a planned ___ schedule at 4PM. # Aspiration pneumonia Pneumonia, thought to be secondary to aspiration, was present on admission treated with five day course of Unasyn. # Paroxysmal atrial fibrillation New noted ___, persisted for 12 hours, before spontaneous conversion to sinus rhythm. Remained in NSR since. CHADS2VASC 6. Anticoagulation was started with warfarin, with a goal INR of 2.0-3.0, and rate control was maintained with carvedilol 12.5mg BID. ====================== CHRONIC/STABLE ISSUES: ====================== # HTN Hydralazine was discontinued in the setting of starting hemodialysis. Amlodipine 10mg and carvedilol 12.5mg will be continued on discharge. # Normocytic anemia Likely secondary to renal disease with component of iron deficiency anemia. The patient was transfused twice during the course of admission (___). # EtOH cirrhosis Poorly understood history. Has remote history of ascites, no known history of hepatic encephalopathy or SBP. Due for variceal screening. Abdominal US was negative for ascites. # T2DM Hypoglycemic to 50's in ED, improved to 70's on re-check. The patient was on an insulin sliding scale while admitted. # BPH Home tamsulosin was initially held but restarted prior to discharge. ====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo gentleman with newly diagnosed pancreatic cancer, high CEA, liver lesion, starting FOLFIRINOX, presenting with CT finding showing possible reactivated TB during chemotherapy presenting with RUQ pain after liver biopsy 2 days prior. He had been taking PO hydromorphone with minimal effect, and felt pain worsenining; was told to come into the ED. Denies fevers, chills, CP/SOB. He does endorse constipation for five days, and has been taking colace/senna at home. In the ED, CT scan performed which showed new small amounts of nonhemorrhagic perihepatic ascites and new nonhemorrhagic pelvic free fluid, with persistent pancreatic fluid collections. He was noted in clinic to have CT with possible TB, and was placed in a TB rule out room. Radiology showed Nonobstructive bowel gas pattern. Moderate amount of stool in the ascending colon. Abdomen and pelvic CT. showed 1. New small amount of nonhemorrhagic perihepatic ascites. 2. New small amount of predominantly nonhemorrhagic pelvic free fluid, with a small hematocrit level in the deep pelvis. 3. Redemonstration of a known pancreatic head mass, better characterized on prior MRCP. 4. Multiple stable pancreatic walled off fluid collections with surrounding peripancreatic stranding. 5. Stable cavernous transformation of the portal vein. Evaluation of known superior mesenteric vein thrombosis and splenic vein thrombosis is limited however, there is attenuation of the splenic vein, likely secondary to known thrombosis. 6. Persistent enlargement of the left adrenal gland, concerning for metastatic disease as characterized on prior MRCP. NOTIFICATION: The findings were discussed with Dr. ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:30 AM, 20 minutes after discovery of the findings. CHEST (SINGLE VIEW) IN O.R. showed Left Port-A-Cath placement with the final image showing the tip terminating in the region the cavoatrial junction. CHEST PORT. LINE PLACEMENT showed The left subclavian Port-A-Cath extends to the mid to lower portion of the SVC. No evidence of procedure related pneumothorax. No evidence of acute cardiopulmonary disease. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with Port Placement. At the time of discharge, the patient had Pancreatic Cancer Latent TB. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo gentleman with newly diagnosed pancreatic cancer who presented with CT finding showing possible reactivated TB during chemotherapy and with RUQ pain. Abdominal pain - Likely related to recent liver biopsy and/or underlying malignancy. CT done on admission without concerning findings and hemoglobin remained stable throughout the admission. LFTs were monitored and stable. He was started and discharged on oxycodone PRN with good pain control. Latent TB - Prior to admission the patient had a chest CT with a cavitary lesion that was concerning for latent TB and subsequent reactivation during upcoming chemotherapy. ID was consulted. The patient was place din a negative pressure room and sputum studies were done. At the time of discharge returned test were negative. ID felt it prudent to treat the patient for latent TB given the cavitary lesion on chest CT so he was started on isoniazid and pyridoxine. He will follow up with ID as an outpatient. Pancreatic Cancer - A port was placed as previously scheduled during the admission. He will follow up with his primary oncologist as an outpatient later this week with plans to start FOLFIRINOX. Constipation - The patient was admitted with constipation, likely narcotic induced and he was started on a bowel regimen with improvement. He will continue on colace, senna, and miralax.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with CAD s/p DES to LAD and LCx (___ ___, NIDDM, HLD, & HTN p/w syncope for 45 sec today during outpatient nuclear stress test. Patient describes going to the test at 10am this morning, without having anything to eat/drink for 12 hours. He was feeling otherwise well and had the dye infusion for 45 minutes. He then proceeded to have the basal rest images performed and about ___ minutes into it, patient began to see purple, and soon after passed out with no recollection of other symptoms. He denied having any CP, SOB, n/v, palps, diaphoresis, lightheadedness, dizziness, vertigo prior to passing out. When he came to, patient began to experience nausea but NO other symptom. Defibrillator pads were placed on the patient but was not used as patient spontaneously converted into a sinus rhythm after about a 45 sec pause. The test was then canceled and pt brought to ED. Pt presented to cardiologist Dr. ___ on ___ c/o increasing DOE for past several months, no chest pain, but similar to his presentation in ___ to ___ where 4 stents were placed in the LAD and LCx. Last stress test ___ suggested inferolateral ischemia and medical therapy was initiated. . Over the past year, he has reported increasing shortness of breath when he exerts himself, particularly when he is swimming. He does not report chest pain and has not had any associated numbness, lightheadedness, or syncope. The dyspnea resolves when he stops exerting himself. During last clinic visit, Dr. ___ ___ the options of proceeding directly to cardiac catheterization versus obtaining an exercise sestamibi stress test to document the location of any potential coronary ischemia. Patient prefered to proceed with a stress test first. . In the ED, initial vitals were 55 125/66 18 99% 10L Non-Rebreather. Patient denied CP, but stated that he had SOB after passing out. Also had some mild lower abd pain. Labs notable for lactate 3.4, d-dimer ___, Cr 1.2, BUN 21, HCO3 19, INR 1.0, trop <0.01, HCT 40.6. Received zofran 4mg x1. Vitals prior to transfer: 97.8. HR:71 (sinus). BP: 104/58. O2: 98% 3LNC. RR: 18. . On arrival to the floor, patient VSS, completely asx, just hungry. No recent illness, diarrhea, nausea, no recent travel. . ROS as above, otherwise negative. Radiology showed No acute cardiopulmonary process. Radiology showed 1. No pulmonary embolism. Infrarenal abdominal aortic aneurysm with evidence of endoleak, likely type II from a right-sided lumbar artery. No evidence of impending hemorrhage. 2. Linear lucency in the left first rib appears to be well-corticated and may represent remote fracture. 3. A linear lucency in the left S1 with no evidence of cortication may represent a more recent traumatic fracture. Please correlate with clinical history. 4. Thickened bladder wall likely represents combination of collapse and hypertrophy from chronic outlet obstruction due to enlarged prostate, but cannot exclude infectious process. Please correlate with urine analysis. The patient was diagnosed with SYNCOPE AND COLLAPSE, CARDIAC DYSRHYTHMIAS NEC, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with s/p pacemaker implantation. At the time of discharge, the patient had Syncope asystole Secondary: Diabetes Mellitus type 2 Coronary Artery Disease Hypertension ___ Prostatic Hyperplasia Abdominal Aortic Aneurysm Chronic Obstructive Pulmonary Disease Hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y M with past medical history of DM2, CAD s/p PCI + stent placement, hyperlipidemia, COPD who presented with syncopal episode and sinus arrest during an elective nuclear stress test for ongoing DOE (MI equivalent in the past). .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ homeless female with HCV, CAD s/p NSTEMI,polysubstance abuse, s/p R TKR, L knee injury in ___ who presents with chest pain s/p cocaine ingestion brought in by ambulance after being found in the ___ area intoxicated now found to have fractured left tibia. Chest radiograph. showed Mild cardiomegaly and mild interstitial pulmonary edema. DX KNEE AND TIB/FIB showed 1. Subacute transverse fractures of the proximal tibia and fibula with posterior angulation of tibial fracture. Lucencies in the fracture site can represent physiologic changes but pathologic fracture cannot be excluded. 2. Severe tricompartmental degenerative changes of the left knee. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:21 AM, 5 minutes after discovery of the findings. UNILAT LOWER EXT VEINS LEFT showed Limited exam due to patient discomfort. No evidence of deep venous thrombosis in the left lower extremity veins to the level of the popliteal vein. The calf veins were not assessed. CT LOW EXT W/O C LEFT showed 1. Subacute left tibial and fibular shaft fractures with callus formation. 2. Severe tricompartmental osteoarthritis, and there is nonacute fragmentation of the medial tibial plateau with a triangular articular fragment arising from the anteromedial aspect of the medial tibial plateau. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. Radiology showed 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Very limited assessment of the left lower extremity veins due to lack of patient cooperation. No evidence of deep vein thrombosis in the left common femoral and proximal and mid superficial femoral veins. The remaining lower extremity veins were not visualized. KNEE (AP, LAT AND OBLIQUE) LEFT showed 1. No evidence of hardware complication. 2. Callus formation around the proximal tibial and fibular fractures, similar to ___. 3. Severe tricompartmental degenerative joint disease. Radiology showed Left tibial fracture post ORIF, near anatomic alignment. The patient was diagnosed with CHEST PAIN NOS, DRUG ABUSE NEC-UNSPEC. The patient was treated with ORIF left leg (___). At the time of discharge, the patient had Left subacute proximal tibia 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>___ year old homeless woman with HCV, CAD s/p NSTEMI, polysubstance abuse who presents with acute on chronic left knee pain, found to have a subacute proximal left tibia fracture. # Left tibia fracture: Patient reports falling 2 weeks ago and has been having pain in left knee since. She has had multiple falls over the past yaer. She reports going to a clinic where no Xrays were taken. She states she was using a wheelchair and has been walking on the leg, however the pain was very severe. Xray and CT of LLE show subacute fracture of the proximal left tibia and fibula with exuberant surrounding periosteal new bone. Previous Xrays do not show any evidence of deformity in the tibia apart from severe osteoarthritis. No evidence of bony lesions. The patient was taken to the operating room with Orthopaedic surgery on ___ for a left proximal tibia ___ plate, 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 on the Orthopaedic surgery service. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications. The patient was given perioperative antibiotics. She was given pharmacologic anticoagulation for her left popliteal DVT (see below). The patient worked with ___ who determined that discharge to rehab was appropriate. Due to her being homeless, she had a prolonged hospital course as most rehab facilities would not accept her. Staples were removed at 2 weeks as the wound had adequately healed. X-rays of the tibia & knee demonstrated evidence of callus formation at the fracture site with good alignment of hardware and tibia. Knee is in stable varus angulation with severe degenerative changes. 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, wounds were healing well (staples removed at 2 weeks post-op), and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity and will be discharged with ASA 325 mg po daily x 2 weks for DVT prophylaxis as she has completed her course of apixaban for her DVT and had no evidence of DVT on ___ LENIS. 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. The medicine and psychiatry services were consulted during this admission for assistance in the management of her medical and psychiatric comorbidities. Their recommendations are highlighted below. # Left popliteal DVT: ___ ___ showed left popliteal DVT. Started on anticoagulation on ___ with enoxaparin eventually switched to apixaban 5mg BID given CKD. ___ on ___ with no evidence of DVT. Completed course of apixaban on the day of discharge - ___. # Depression/Mood disorder: Patient expressing depression and no desire to live. Feels depressed since her son was shot in ___. Patient was admitted under ___- evaluated by pscyhiatry and found to have suicial ideation. After surgery, psychiatry continued to follow, and the patient was no longer suicidal, stating her SI to be in relation to her knee pain which is now resolving s/p surgical fixation. Psychiatry cleared the patient for medical rehab facility. # HTN: Continued on diltiazem ER 120 mg po daily & amlodipine 10 mg po daily that were started at the last hospitalization. # Chronic renal failure: Baseline Cr approximately 1.3-1.8. Increased to 2.0 post-op but normalized to her baseline of 1.3 1 week prior to hospital discharge. # Normocytic anemia: During hospital stay, the patient's Hct ranged from 29 - 35. This appears close to her baseline of low to mid ___ according to lab results in our system dating back to ___. Etioogy of her anemia may be secondary to CKD. There were no signs of bleeding. It may be worth considering further work up of her cause of anemia as an outpatient. # Polysubstance abuse: The patient reports using drugs the day she arrived to the ED (cocaine and alcohol). Patient has history of withdrawal seizures from alcohol. CIWA scores <10 since admission. No evidence of EtOH withdrawal during this hospitalization. # Asthma: Patient reports having a history of asthma, last hospitalization had recommended outpatient PFTs. Patient had been given ipratropium and albuterol nebs prn.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ year old man with a history of HIV (CD4 306 on ___, VL 200K ___ on ART), adrenal insufficiency on hydrocortisone/midodraine and alcohol withdrawal c/b hallucinosis in the past with recent admission for such who presents with back pain, acute hepatitis. Mr ___ describes 3 days of symptoms of nausea, vomiting, back pain and fever. Describes his fever as shaking chills and sweating, but did not formerly take his temperature. He says he takes the medications he is supposed to and only drank about two beers a day, last drink yesterday. Unable to keep much else down otherwise. Denied drinking any other substances or any other forms of alcohol. Reports a mild frontal headache and chronic lower back pain, which has worsened within the past 3 days. Denies any numbness or weakness or vision change. Denies any loss of bowel or bladder control. Denies passing out or falling, waking up in unusual positions. No other drugs than what he was supposed to have been prescribed. No recent trauma. No recent travel. ED COURSE - Initial VS: 10 99.2 110 118/78 16 96% RA - No exam documented - Labs notable for ALT: 1017 AP: 223 Tbili: 0.4 Alb: 3.9 AST: 2650 Lip: 68 EtOH 296. H/H ___ Eos% 15 (AbsEo 79) 2 bands / 1 atyp on diff. Urine barbituates positive. AG 19 U/A blood SM RBC 1 lactate 2.3 - RUQUS, CT head, and CXR without acute process - Pt was given 1000cc NS, folate, thiamine, and reglan - VS prior to transfer: 0 97.9 84 150/86 15 100% RA Radiology showed No acute intrathoracic process identified. In particular, no infiltrate or consolidation detected. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Chronic appearing right parietal infarct. 2. Chronic left maxillary sinus disease. 3. No clear acute intracranial abnormality on noncontrast head CT. Of note MRI would be more sensitive for the detection of intracranial infection. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. No cholelithiasis or biliary dilatation. MR ___ AND W/O CONTRAST T___ MR SPINE. showed 1. No evidence for abscess formation. 2. Multilevel degenerative changes, most severe at the L5-S1 level with moderate to severe bilateral neural foraminal narrowing at this level. 3. Grade 1 retrolisthesis of L5 on S1, with ___ type 1 changes at this level. LUMBO-SACRAL SPINE (AP AND LAT) showed Superior endplate scalloping involving T12, L1, L2, and L4 and probably also to a lesser degree at L3 and L5, compatible with multiple, subtle, nonacute vertebral body fractures. In retrospect, the appearances are similar to ___, including discogenic and facet degenerative changes and retrolisthesis at L5/S1. If clinically indicated, MRI could help for further assessment. Mild degenerative changes about both SI joints, similar to prior. Faint aortic calcification, an unusual finding in someone of this age. Is the patient a diabetic or do they have vasculopathy? NOTIFICATION: The impression and recommendation above was entered by Dr. ___ ___ on ___ at 15:08 into the Department of Radiology critical communications system for direct communication to the referring provider. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent hepatic vasculature. 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. 3. Mild gallbladder wall edema, likely reactive in the setting of acute hepatitis. CHEST (PORTABLE AP) showed In comparison with the study of earlier in this date, there are slightly lower lung volumes. No evidence of acute focal pneumonia, vascular congestion, or pleural effusion. The patient was diagnosed with Dorsalgia, unspecified, Alcohol abuse with intoxication, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS Acute hepatitis Hyponatremia Nutritional Deficiency Alcohol Abuse Suicidal Ideation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ h/o HIV (CD4 306 on ___, VL 200K ___ on ART), adrenal insufficiency on hydrocortisone/midodraine and alcohol withdrawal c/b hallucinosis in the past with recent admission for EtOH withdrawl requiring phenobarbital taper in the ICU who presents with back pain, nausea and vomiting found to have acute hepatitis of unclear etiology and severe metabolic derangements. #Acute Hepatitis, possible DRESS: Patient initially presented with 3 days of nausea and vomiting. Was found to have a significantly elevated transaminitis with ALT/AST 1017/2650 and normal bilis consistent with a hepatocellular pattern of injury. The etiology in a known alcoholic with HIV on ART with questionable compliance is likely multifactorial. Pt has steatohepatitis which is seen on U/S and has had previously tranaminitis (though not as severe), likely from EtOH and ART, specifically truvada. Given significant elevation there is concern for viral hepatitis as EtOH alone can not explain this degree of transaminitis. Patient is HBcAb positive, so is at risk for reactivation given his steroids for AI and immunocompromised state. EBV, CMV, HCV and HBV viral loads undetectable with IgG positivity for EBV and CMV. HCV Ab negative. Elevated ferritin, though iron is normal ruling out hemochromatosis. Patient is born in ___, and presents with eosinophilia which may be concerning for a parasitic infection though strongyloides Ab negative and stool O&P negative as well. Patient does not have stigmata of chronic liver disease and his synthetic function is intact with relatively normal albumin, INR and plts. He denies any ingestions, other than EtOH, APAP levels are negative x2 and he denies any new medications, though darunavir can cause acute hepatitis. Given his alcohol abuse, there was also concern for ischemic injury if the patient had been down for a period of time, but his CK was not significantly elevated to have concern for rhabdo. U/S with Doppler was negative for thrombotic/obstructive disease. Infiltrative processes and parenchymal texture would be better characterized with cross sectional imaging. Autoimmune testing including AMA and ___ is negative. Ceruloplasmin was wnl. Given patient's recent admission requiring phenobarbital, in addition to his elevated eosinophilia and significantly elevated transaminitis, there is a strong suspicion for DRESS. Patient was given supportive care and his LFTs quickly downtrended. #Severe metabolic and electrolyte derangements: Patient presented with a anion gap of 19 and ethanol level of 296. Measure sOsm 356 with Osm gap of 4 when corrected for EtOH. Lactate was only slightly elevated. Patient denied any other ingestions. Patient had hypokalemia, hypomagnesemia and hypophosphatemia on presentation. Upon receiving mIVF with ___ NS his hypophosphatemia dramatically decreased along with his serum sodium. uOsm 333. The patient likely has poor nutrition with decreased solute intake evidenced by a BUN of 4, therefore there was concern for refeeding syndrome and beer potomania physiology to explain his progressive hyponatremia, though urine electrolytes not entirely c/w this diagnosis, likely multifactorial with ?component of SIADH. Electrolytes corrected with repletion and hyponatremia improved with increased PO intake and fluid restriction. Given concern for severe nutritional deficiency, thiamine has been replenished in addition to Ensure supplementation with meals. #Alcohol abuse/intoxication: patient with multiple admissions for alcohol use, now presenting with acute intoxication. Has history of hallucinosis in the past, unclear if DT or seizures. Scheudled lorazepam was used given his hepatic injury. Patient did not score on CIWA and was able to be quickly downtitrated. #Eosinophilia: Patient has new eosinophilia on presentation. Absolute eosinophilia count 720. Trop negative. Could be ___ AI, though patient is taking steroids and is hemodynamically stable. Parastitic disease was also ruled out. Acute onset is likely not related to malignancy. As above, eosinophilia may be secondary to DRESS. # Back Pain: Patient endorses back pain and has focal tenderness on exam over lower lumbar spine (without paraspinal tenderness). Lumbar XR shows non-acute fractures. No perineal paresthesia and rectal tone normal rules out compression/cauda equina syndrome. Given immunocompromised state, a lumbar spine MRI was obtained which showed chronic degenerative changes and no fracture, abscess or neoplasm. #Adrenal insufficiency: BP suggests that patient is compensated, but eosinophilia might suggest still adrenal insufficiency. Steroids were recently uptitrated at last admission from 5 -> 7.5 total daily. #HIV on ART: last CD4 in the 306 in ___, but with an active viral load 200K. Repeat CD4 in house was 189, viral load pending. Patient admits to inconsistent medication use. Quantiferon gold negative ___. Truvada increases rates of steatohepatitis and darunavir may cause acute hepatitis per pharmacy. Will hold ART for now given unsure compliance and concern for worsening liver dysfunction. Also, patient with need PJP ppx in the future. No signs of thrush. Therefore, his ART and prophylaxis may be held for now and restarted after outpatient follow up. #Anemia, thrombocytopenia: Likely secondary to alcohol abuse. No evidence of bleeding. Stable from prior. MCV 85, likely has multifactorial cause as liver dysnfunction and poor nutrition should cause a macrocytic anemia. #Sinus Tachycardia: Rates 100-110s. No chest pain, trop negative. No dyspnea. Does not appear septic. Patient is not complaining of pain. Likely due to alcohol withdrawal. #Suicidal Ideation: Patient verbalized active SI to ED staff. This is in the setting of acute intoxication. He has repeated suicidal ideation on the floor and was seen by psychiatry who placed him on a ___. Patient was started on citalopram. He was discharged from the medical ward at ___ to the psychiatry ward at ___. TRANSITIONAL ISSUES []discuss reinitiating ART and starting PJP ppx for CD4 count 189 []Make hepatology and primary care physician ___ []Patient discharged on a 1.5 L fluid restriction given hyponatremia. ___ discontinue if sodium normalizes. []On ___, recommend rechecking CBC w/ diff, electrolytes, and LFT's to trend eosinophilia, sodium, and LFT abnormalities. []Consider outpatient orthopedics ___ given spine MRI results.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ metastatic rectal carcinoid tumor s/p open LAR w/ colonic J pouch, segment VII liver resection, and sigmoid colostomy for symptoms of obstruction on ___. Was previously doing fine and now has presented with 1 day history of bloating, nausea, obstipation, and left sided abdominal pain. History obtained through phone interpreter. CT ABDOMEN PELVIS showed 1. Findings concerning for closed loop small bowel obstruction with "whirl" sign in the right mid abdomen. Moderate volume abdominal ascites noted. Difficult to exclude early bowel ischemia. 2. Gastric distention with possible stricture at the level of the pylorus. 3. Multiple liver lesions compatible with known sites of metastasis. 4. Postsurgical changes including end colostomy, ___ pouch. 5. Duplicated right renal collecting system with mild fullness of the lower pole moiety, unchanged. 6. Mild thickening of the distal esophagus could reflect esophagitis. NOTIFICATION: Findings were discussed in person with Dr. ___. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. The patient was treated with Exploratory laparotomy with lysis of adhesions.. At the time of discharge, the patient had Carcinoid tumor and small-bowel obstruction related to internal hernia.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ came to us on ___. She had a CT scan which showed a closed loop small bowel obstruction. She had an NGT placed, made NPO and given IV fluids. Thus, she underwent an exploratory laparotomy with lysis of adhesions on ___. She tolerated the procedure well and was transferred to the PACU in stable condition. On ___, her foley was removed and she was voiding spontaneously. Her NG tube was removed and her diet was advanced to clears but however, she developed an early postop ileus and needed to have her NG tube placed back in and diet made NPO. She was given milk of magnesia and this seemed to help her pass gas so her diet was then advanced and NG discontinued once again. Her pain was initially controlled with a dPCA but once she was tolerating PO, she was switched to oral pain medications. She passed stool in her ostomy, was tolerating a regular diet and ambulating so she was deemed fit for discharge home with ___ for ostomy teaching. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o R thalamic stroke (___) and C4-5/C5-6 DDD presents with ___ weeks of LBP radiating across top of buttock that started a couple days after doing some cleaning and bending over, and 1 day of progressive numbness across her right hip that travels down to her right groin and labia, stating it now feels like "if I touch it I might as well be touching another person because I cannot feel it." She also has numbness over her proximal right anterior thigh, which has developed since coming to the ED. Denies any new weakness or difficulty walking, denies any loss of strength, and no new bowel or frank bladder incontinence. Of note, she also had a colonscopy yesterday. Because of her symptoms she called her neurologist, Dr. ___ advised her to come to the ED for evaluation. MR ___ SPINE W/O CONTRAST showed 1. L4-5 degenerative disc disease and facet arthropathy resulting in grade 1 anterolisthesis, moderate to severe spinal canal stenosis, and mild bilateral neural foraminal stenosis. 2. Multilevel degenerative facet arthropathy. 3. No retroperitoneal hematoma. Radiology showed 1. No evidence for an intra-abdominal mass causing compression of peripheral nerves 2. Incidental findings include an angiomyolipoma of the lower pole of the left kidney and a subcentimeter hypodense lesion in the liver that is too small to characterize but likely represents a cyst or hemangioma. The patient was diagnosed with SKIN SENSATION DISTURB. At the time of discharge, the patient had L4-5 herniated nucleus pulposes Right hip pain, numbness. The patient was given written instructions concerning 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 Neurosurgery service for work-up of her right hip, genital pain and paresthesia. She was initially kept NPO and give IV fluids in case she needed a surgical procedure. A MRI of the L spine revealed a herniated disc at L4-5, but no pathology at L1 to explain her symptoms. Neurology was consulted to assist in working up her paresthesias/pain. Per their recommendation, a CT of the abdomen and pelvis was obtained to rule out pathology that could cause compression of a peripheral nerve. That scan was negative for any process causing nerve compression. Mrs. ___ was discharged home on the afternoon of ___. Per her discharge instructions, she should follow up with Dr. ___ ___ Neurosurgery and Dr. ___ Neurology. An EMG was ordered to further work-up her right-sided paresthesia. Differential diagnoses, per Neurology, are meralgia paresthetica or genitofemoral nerve pathology. The patient was afebrile, hemodynamically and neurologically intact. **Attending of record at time of discharge was Dr. ___ ___, MD.</s>