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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male who is transferred from
OSH for fall and rib fractures. History as per patient as
well as transfer paperwork. He slipped last night
approximately 3 AM, falling on his left side. Denies any
head strike, LOC or neck pain. At outside hospital, CT torso
showed 6 through eighth left rib fractures as well as a
moderate pneumothorax. He has been maintained on 3 L nasal
cannula. He also has a left elbow x-ray without fracture.
His complaints here are the same with left rib pain. CHEST (PORTABLE AP) showed 1. Known small left pneumothorax is not well appreciated on the current supine
exam. No contralateral mediastinal shift to indicate tension.
2. Minimally displaced left seventh and eighth posterolateral rib fractures,
as seen on prior CT chest.
3. Mild bibasilar atelectasis. CHEST (AP AND LAT) showed Interval placement of left-sided pigtail catheter. No definite pneumothorax.
Probable trace left pleural effusion and bibasilar streaky atelectasis.
Redemonstration of left seventh and eighth posterolateral rib fractures. CHEST (PA AND LAT) showed Comparison to ___. The left chest tube is in stable position. No
pneumothorax is identified. Normal size of the heart. Mild elongation of the
descending aorta. No pleural effusions. No pulmonary edema. CHEST (PA AND LAT) showed Compared to chest radiographs ___.
Indwelling, left pigtail pleural drainage catheter, unchanged in position in
the left hemithorax anteriorly at the level of the carina. Tiny left apical
pneumothorax new or newly apparent. Lungs grossly clear. Small left pleural
effusion appreciated only on the lateral view, unchanged. Displaced left
middle rib fractures noted. Normal cardiomediastinal silhouette. Right lung
and pleural space are normal. CHEST (PA AND LAT) showed Left-sided pigtail catheter is unchanged. Small left pleural effusion stable.
There is stable subsegmental atelectasis in the left lung base. Bilateral
humeral prosthesis are again seen. No pneumothorax. Cardiomediastinal
silhouette is stable. CHEST (PA AND LAT) showed Left-sided pigtail catheter has been removed in the interim. There is a small
left apical pneumothorax. The lungs are low volume. There is a small left
pleural effusion. Bilateral humeral implants are in place. Cardiomediastinal
silhouette is stable. The patient was diagnosed with Multiple fractures of ribs, left side, init for clos fx, Fall on same level, unspecified, initial encounter. The patient was treated with Pigtail placement for pneumothorax. At the time of discharge, the patient had Left ___ rib fractures and pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the Trauma Surgical Service on
___ for evaluation and treatment of left ___ rib fractures
and pneumothorax. The pneumothorax was managed with a pigtail
placement. Pigtail was initially put to suction and subsequent
chest X-rays were obtained showing a tiny apical pneumothorax
which was stable once on water seal. 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 during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The 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: Mr. ___ underwent robot assisted pancreaticoduodenectomy 12
days ago. At the time of discharge, he had no enzymatic or
clinical evidence for pancreatic leak and his drains were
removed. His liver function was abnormal consisting of elevated
liver injury tests without elevation in bilirubin. He underwent
scheduled lab studies as an outpatient yesterday and was found
to have an
unexpected significant leukocytosis but almost complete
resolution of his liver function abnormalities.
Mr. ___ has been eating, and his appetite has been improving.
He is moving his bowels without nausea, vomiting, or distension.
His abdominal pain has been decreasing except for persistence of
right upper quadrant mild discomfort. After his labs were drawn
he had a fever to 101.3 and was sent to the ER. Chest: Frontal and lateral views showed Platelike right base atelectasis and additional scattered areas of minor
linear atelectasis/ scarring. No definite focal consolidation. Radiology showed 1. Status post recent Whipple with inflammation and wall thickening of the
hepaticojejunostomy, infectious process could be present. No definite fluid
collection.
2. Moderate amount of free fluid in the pelvis.
3. Bibasilar atelectasis.
NOTIFICATION: Change in preliminary read was discussed with Dr. ___
telephone at 22:05 on ___. US ABD LIMIT, SINGLE ORGAN showed 1. The bowel at the hepaticojejunostomy demonstrates distention and mural
thickening in keeping with recent CT findings, with surrounding inflammatory
fat changes.
2. Small amounts of free fluid are seen adjacent to this area, but no
organized collection which would be amenable to drainage at this time.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 10:56 AM. The patient was diagnosed with POSTPROCEDURAL FEVER, LEUKOCYTOSIS, UNSPECIFIED . At the time of discharge, the patient had 1. Leukocytosis
2. Fever of unknown origin. The patient was given written instructions concerning 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 s/p robotic assisted Whipple on ___ was
readmitted to the HPB Surgical Service for evaluation of fever
and leukocytosis. On admission patient was afebrile with WBC
28.6. Patient's blood and urine cultures were sent for
microbiology evaluation. Patient was started on IV Cipro/Flagyl,
made NPO with IV fluids. Abdominal CT scan revealed a dilated,
edematous pancreaticobiliary limb without bile or pancreatic
duct dilation, no definite fluid collection. On HD 2, patient's
WBC was 30.2, he remained afebrile. Abdominal US was obtained
for possible drainage or aspiration and was negative for any
organized, drainable fluid collection. Patient's diet was
advanced to regular, he was continued on antibiotics, remained
afebrile with LFTs WNL. On HD 3, patient's WBC started to
downward, antibiotics were switched to oral. Patient's urine
culture was negative and blood cultures were nothing to grow.
Patient's C.diff test was cancelled secondary to normal, formed
stool. Patient was discharged home on PO antibiotics x 14 days
total, he will repeat abdominal US on ___ and will be seen by
Dr. ___. He will also repeat his blood test.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a pleasant, ___ year old gentleman who reports being
struck by a car while en route to a football game earlier this
morning. The patient reports that he was mildly intoxicated, and
was struck by a car at approximately 30mph. He reports brief
loss
of consciousness. He was taken to ___, and
received an extensive trauma workup, including CT scan of the
head, c-spine, and torso. Plain films demonstrated a comminuted
fracture of the ulnar distal diaphysis, a displaced open
midshaft
tibial diaphysis fracture, as well as a proximal fibular
diaphyseal fracture, with evidence of a possible chronic right
medial malleolus fracture. Due to concern over the neurovascular
status, a CTA was obtained which demonstrated evidence of a
short
segment occlusion of the proximal right peroneal artery adjacent
ot the tibial fracture site with out extravasation, with distal
reconstitution of the artery. The patient was diagnosed with FX ULNA SHAFT-CLOSED, FX TIBIA SHAFT-OPEN, MV COLL W PEDEST-PEDEST. The patient was treated with ORIF R ulna, IMN R tibia, fasciotomies R leg
closure of fasciotomies. At the time of discharge, the patient had R ulna fracture, R tibia/fibula fracture, L great toe proximal
phalanx fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the orthopaedic surgery service on
___ with R open tib/fib, R ulna, L P1 fractures. Patient
was taken to the operating room and underwent IMN R tibia,
fasciotomies, ORIF R ulna. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Pt returned to OR 2 days later for
closure of the fasciotomies. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Please see operative report for full
details.
Musculoskeletal: After procedure, patient's weight-bearing
status was transitioned to RUE ___, RLE WBAT, LLE WBAT.
Throughout the hospitalization, patient worked with physical
therapy and occupational therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA 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 hemodynamically stable.
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 HD#, POD #***, 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: ___ y/o M with h/o CVA in ___ with residual left-sided weakness
on Coumadin presents to ED with abnormal CT as a transfer from
___. The patient's son found him sitting against the side
of his bed and the son found him difficult to awaken. The
patient reports that he had felt increased left sided weakness
the night before and slid to the floor. He denies head strike or
LOC. He was brought to ___ where his CT Head showed
"rightward shift of septum pellucidum without mass or bleed." CT HEAD W/O CONTRAST showed No acute intrathoracic abnormality. NECK CT WITH CONTRAST showed 1. The study is limited by artifact from dental amalgam.
2. No evidence of abscess or parotiditis.
3. There is periapical lucency around teeth numbers 2, 3 and 15.
4. The main pulmonary artery is at the upper limits of normal, measuring 3.1
cm, which can be seen in patients with pulmonary arterial hypertension. The patient was diagnosed with Weakness. The patient was treated with n/a. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Urinary tract infection
SECONDARY DIAGNOSIS:
Stroke recrudescence
Weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M with h/o CVA in ___ with residual left-sided
weakness, AF/hx DVT (on Coumadin), presented to ___ after
being found by his son to be confused and have left-sided
weakness, transferred to ___ for concern for acute
intracranial process given midline shift on CT (determined by
___ neurosurgery to be congenital). Found to have Klebsiella
UTI I/s/o likely BPH. Neurologic symptoms thought to be ___
recrudensence from recent strokes and improved with antibiotics.
He is being discharged to rehab to continue ___, and will
complete a 7-day course of bactrim.
#Klebsiella UTI
The patient presented to the ___ ED from ___ with a
positive urinalysis. The patient denied any dysuria, but
endorsed foul-smelling urine and polyuria at initial
presentation. WBC 11.4 on admission, downtrended to 7.4 with
treatment. He was started on Unasyn empirically in the ___ ED
(due to concern for dental abscess) and was eventually narrowed
to bactrim to complete a 7-day course.
#Midline shift
The initial concern at OSH was for intracranial bleed or mass,
however repeat ___ at ___ was read as stable from prior,
"midline shift" actually likely congenital abnormality.
#?BPH:
The patient endorses a history of urination almost every hour at
his baseline with sensation of incomplete emptying. Likely risk
factor for his UTI. Offered Flomax but patient declined.
#Weakness
Seen by neurology in ED who felt his symptoms represented
recrudescence of his stroke symptoms I/s/o UTI. His weakness
improved back to baseline within ___ hours of antibiotic
treatment. Seen by physical therapy that assessed that the
patient "remains limited by fatigue and continues to require
assistance for all mobility thus will require discharge to
___ at this time."
#Non-anion gap metabolic acidosis
On admission to the hospital, he was found to have a normal
anion gap metabolic acidosis. On history, he reported that he
had been experiencing intermittent episodes of diarrhea and
loose stools a few days prior to his admission. This resolved
prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ with NSCLC (poorly differentiated SCC, s/p 4 cycles
___, now C1D6 on ponatinib (study drug, has received 4
doses), presenting now with fevers, malaise, and abdominal pain
most notable in RUQ. Radiology showed 1. No cholelithiasis or intrahepatic biliary ductal dilation.
2. Incomplete visualization of the pancreas.
3. Multiple liver masses as seen on the prior CT torso. Radiology showed 1. Since ___ CXR, a left upper lobe nodule has decreased in size and
intrathoracic lymphadenopathy has also decreased. Please see serial CT and
PET-CT exams for more recent serial comparison of these findings.
2. Small bilateral pleural effusions are new. Radiology showed 1. Acute pancreatitis.
2. Multiple liver metastasis, slightly larger since ___.
3. No evidence of bowel obstruction or ischemia.
4. Right iliac bone metastasis, stable.
Findings discussed with Dr. ___ at 4:40 p.m. on ___. The patient was diagnosed with FEVER, UNSPECIFIED, ABDOMINAL PAIN RUQ, MAL NEO BRONCH/LUNG NOS. At the time of discharge, the patient had Primary:
Acute pancreatitis
Urinary tract infection
Sepsis
Secondary:
Tachycardia (accelerated junctional rhythm)
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>___ with NSCLC (poorly differentiated SCC, s/p 4 cycles
___, now C1D6 on ponatinib (study drug, has received 4
doses), presenting now with fevers, malaise, and abdominal pain
most notable in RUQ, found to have acute pancreatitis.
# Acute pancreatitis - Patient had classic symptoms of
pancreatitis, elevated lipase, and CT evidence of mild
pancreatic inflammation. BISAP score was 3. RUQ negative for
cholelithiasis or cholecystitis. Reported mild ETOH use.
Ponatinib is reported to cause pancreatitis. Symptoms improved
with bowel rest, IV fluid resuscitation, and pain control with
IV toradol, then transitioned to acetaminophen/oxycodone.
Ponatinib was held. He tolerated a low residue, low fat diet,
and his pain was well controlled with oxycodone and
acetaminophen.
# Enterococcus UTI - Symptomatic, complicated (male, +SIRS).
sensitive to ampicillin. Endorsed dysuria, urinary frequency,
suprapubic discomfort. He was started on
Amoxicillin/clavulonate, D1 = ___ to complete 7 day course on
___
# SIRS/Sepsis - Resolved. Likely secondary to pancreatitis and
UTI as above. Currently afebrile, still tachycardic
# Anemia / HCT drop - Asymptomatic, has dropped from H/H ___
on admission to 9.7/27.5 on discharge. ___ have had slow GI
bleed from toradol but stools were guaiac negative prior to
starting toradol and upon discharge. Increased omeprazole from
20 to 40mg daily.
# NSCLC: Poorly differentiated SCC, s/p 4 cycles ___, on
admission, was C1D6 on ponatinib (study drug, has received 4
doses). Ponatinib was held for now as above. Continued
antiemetics. Dr. ___ oncologist, offered guidance
during this hospitalization.
# Accelerated junctional rhythm: ECG was checked ED given
concern for ACS presenting as epigastric pain, and showed
question Afib with RVR to 100s and ST depressions in V3-V5.
Repeat EKG was read as accelerated junctional rhythm. Remained
hemodynamically stable and heart rate improved with metoprolol
(replacing propranolol). Cardiac enzymes were cycled, with trop
<0.01, 0.02.
# Anion gap metabolic acidosis: ___ have been secondary to
starvation ketosis given ketones in urine and decreased PO
intake. No history of diabetes/hyperglycemia to suggest DKA,
and lactate WNL. No history of significant alcohol intake or
other ingestions, and renal function WNL. Resolved with IVF and
advancing diet.
# HTN: Slightly hypertensive during this admission with blood
pressure ranging 130-160 systolic. Held home propranolol and
started metoprolol as above for heart rate control. ___ have
hypertension in the setting of pain and infection, but if he
remains hypertensive, would recommend starting anti-hypertensive
agent as an outpatient
# HLD: Initially held simvastatin while trending LFTs. Upon
discharge, decreased dose from 80 mg daily to 40 mg daily.
# Mild COPD: Albuterol as needed.
# BPH: Continued finasteride 5 mg daily, terazosin 10 mg daily.
# GERD: Increased omeprazole to 40mg daily.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ years old woman from ___ with a history of HIV
on HAART (CD4 count about ___ years ago was about 500 and viral
load has been undetectable for at least ___ years),
hypertension, T cell lymphoma (HTLV-1 positive) s/p 6 cycles
CHOEP last ___, stroke without deficits on lovenox,
presenting fatigue for the past several weeks. Chest: Frontal and lateral views showed New moderate cardiomegaly and mild pulmonary edema. No pleural effusion or
focal consolidation. CHEST (PORTABLE AP) showed Compared to chest radiographs ___.
Moderate enlargement of the cardiac silhouette is new since ___ after
the previous, large right juxta mediastinal mass had resolved, when chest CTA
on ___ showed considerable central lymphadenopathy. There is mild
pulmonary vascular engorgement, but the findings could be due to pericardial
effusion as well as cardiomegaly. There is no pulmonary edema or
consolidation. Pleural effusion is small if any.
Right supraclavicular central venous infusion catheter ends close to the
superior cavoatrial junction.
RECOMMENDATION(S): Since there are questions about pericardial effusion as
well as subtle pneumonia, I would recommend chest CT, or at least conventional
chest radiographs.. CHEST (PA AND LAT) showed Compared to chest radiographs since ___ most recently ___.
Moderate enlargement of cardiac silhouette has improved and there is less
mediastinal venous and pulmonary vascular engorgement. No pulmonary edema,
pleural effusion or pneumothorax.
Right supraclavicular central venous infusion catheter ends close to the
superior cavoatrial junction. ABDOMEN US (COMPLETE STUDY) showed No evidence of cholecystitis. No evidence of biliary obstruction. Normal
abdominal ultrasound. Cardiac MRI showed Please note that this report only pertains to extracardiac findings.
There is a small right pleural effusion. Right hilar lymph node conglomerate
is grossly unchanged but better evaluated on prior CTA. There is increased
signal intensity in the right lung apex, likely similar to prior chest CT.
Likely tiny left renal cyst (series 1101, image 267).
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with Coronary angiogram
Right heart catheterization. At the time of discharge, the patient had Primary Diagnosis
=================
Non-ischemic Cardiomyopathy
Heart Failure with Reduced Ejection Fraction
Secondary Diagnosis:
====================
HIV
T-cell lymphoma
Anemia
Hx of 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>___ years old woman from ___ with a history of HIV
on HAART, T-cell lymphoma (HTLV-1 positive, s/p 6 cycles CHOEP
last ___, hypertension, and history of CVA on Lovenox
without residual deficits who presents with fatigue, persistent
tachycardia and dyspnea found to have newly depressed EF ___.
#HFrEF:
#NON-ISCHEMIC CARDIOMYOPATHY:
Newly depressed EF ___, most likely multi-factorial related
to toxin-induced cardiomyopathy (s/p 6 cycles hydroxydaunorubin)
vs. HIV vs. tachycardia-induced as she has had persistent
resting sinus tachycardia documented since ___. She did
undergo coronary angiogram as there were questionable wall
motion abnormalities on TTE, although no evidence of CAD, making
ischemic cause unlikely. She was started initially on IV Lasix,
although relatively unresponsive to Lasix and diuresis limited
by developing ___. Right heart catheterization was preformed
showing low right sided filling pressures, PCWP 7, with CI 2.1.
Diuresis was discontinued due to low filling pressures, and she
was started on lisinopril 2.5mg and digoxin 0.125mg for
inotropic support. She was counseled on checking her weight
daily at home, and will be discharged on Lasix 20mg PRN to be
taken for weight increase > 3 lbs. Cardiac MRI was preformed
while inpatient, although results still pending at discharge.
Plan to follow up in heart failure clinic on ___. She will need
a digoxin trough level checked at that time, goal trough level
0.5-0.9 ng/mL.
#SINUS TACHYCARDIA:
Patient has had persistent resting sinus tachycardia documented
since ___. TSH and cortisol within normal limits as of
___, and hemoglobin at baseline, although she is anemic
(HgB . Most recent CTA in ___ negative for PE and low
suspicion given that patient is anti-coagulated on lovenox. Most
likely compensatory component in the setting of newly reduced
EF.
#HX EMBOLIC STROKE:
Admitted ___ for subacute embolic stroke, with symptom
resolution (difficulty speaking, slurred speech, L facial droop
and L sided neglect at that time). TTE with bubble study did
show PFO. Started on Lovenox BID. Per last oncology note, plan
to continue anticoagulation for at least a month after
chemotherapy. Lovenox was continued at discharge, along with
home atorvastatin. Plan to follow up with hematology/oncology
(Dr. ___ to determine duration of anticoagulation
treatment.
# HIV:
CD4 count ___ years ago about 500, previously undetectable viral
load for at least ___ years, with newly detectable viral load 3.3
on admission, CD4 count 282. Possibly contributing to cause of
new cardiomyopathy as above. ID consulted while inpatient with
plan to follow up as an outpatient with Dr. ___. Home Atripla
was continued.
#T-CELL LYMPHOMA:
HTLV-1 positive, s/p 6 cycles of CHOEP (last ___ without
any sign of residual disease on her PET scan on ___.
Resolution of hilar masses per most recent outpatient PET
(___). Plan initially to pursue prophylactic intrathecal
chemotherapy within the next month or two. Plan for continued
discussions between cardiology (Dr. ___ and
hematology/oncology with regards to safety and timing of further
chemotherapy as an outpatient.
#HYPERTENSION:
Discontinued home labetolol due to low cardiac index.
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 176.5lbs
DISCHARGE CR: 1.3
[ ] Please encourage patient to check daily weights at home
[ ] Home diuretic: furosemide 20mg PRN for weight gain of > 3lbs
[ ] Medications added: lisinopril 2.5mg, digoxin 0.125mg
[ ] Medications discontinued: labetalol
[ ] Repeat BMP at heart failure clinic follow up, if Cr
up-trending (>1.3) consider discontinuation of Lisinopril, as
well as dose adjustments in HAART therapy (tenofivir and
emtricitabine will need to be dose reduced)
[ ] Also, if Cr up-trending (>1.3) please discuss with
hematology/oncology discontinuation of Lovenox or alternative
anticoagulation plan
[ ] Check digoxin level at heart failure clinic follow up,
patient instructed to hold her digoxin the morning of her
appointment so that a level will be accurate, resume digoxin if
level within normal limits, hold if supratherapeutic
[ ] Please follow up results of cardiac MRI, results pending at
discharge
[ ] Follow up scheduled ___ ___
[ ] Patient has newly detectable HIV viral load, follow up with
infectious disease (Dr. ___ scheduled ___
[ ] Continued home Lovenox on discharge for history of embolic
stroke, follow up with hematology/oncology (Dr. ___ to
determine duration of anticoagulation
# CODE: full, presumed
# CONTACT: HCP: ___, son. ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of asthma who presents with
fevers (Tm ~ 100.6) and fatigue/myalgias for 2 weeks with
anterior non-radiating chest pain and dyspnea on exertion. She
was seen by her PCP ___ ___ with 5 days of intermittent fevers,
with Tm ~100.7. She denied nausea, vomiting, sore throat,
rhinorrhea, diarrhea, urinary symptoms, rash. Labs at that
appointment including CBC, chem7, UA, Strep, EBV, and lyme
serologies were negative. Due to persistent fevers, additional
labs were checked on ___ which included LDH 167, CK 100,
D-dimer 2260, and blood cultures. Due to elevated D-dimer, she
was referred to the ED.
In the ED, initial vitals were: 99.0 90 123/73 22 100%. Labs
were notable for WBC 11.2, INR 1.0, D-dimer 554. EKG showed SR,
normal axis, and isolated TWI in III. Rt ___ was negative for
DVT and CTA chest was negative for pulmonary embolism. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. Radiology showed No evidence of pulmonary embolism or aortic abnormality. Pelvis showed Normal pelvis x-ray The patient was diagnosed with FEVER, UNSPECIFIED, CHEST PAIN NOS. At the time of discharge, the patient had Primary Diagnosis:
Fever of Unknown Etiology
Secondary Diagnoses:
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>Ms. ___ presented with fevers, fatigue, and chest pain for
two weeks. She had an elevated DDimer but her CT angiogram was
negative and her ECG was normal. Her fevers and symptoms were
most suspicious for rheumatologic disease and she had an
elevated ESR/CRP. She had a pelvic xray to assess for ankylosis
spondylitis that was normal. She requires follow up with her
primary care physician within two weeks for further evaluation.
# FEVER: Patient presented with 2 weeks of intermittent fevers
and fatigue x 2 weeks. Outpatient w/u included negative negative
EBV abd lyme serologies. The symptoms were most likely c/w a
rheumatologic or CTD given the fatigue, SI tenderness, and
shoulder pain but could also be due to a viral illness. Given
normal ECG and readily reproducible chest pain, acute cardiac
process was unlikely. Infectious etiologies were also
considered. She had an elevated ESR and CRP. She had a pelvic
xray that was normal. She also had an HIV test sent that was
pending at the time of discharge and later returned negative.
She should see her primary care physician within two weeks to
consider further evaluation. She remained afebrile and
hemodynamically stable throughout her hospitalization.
# MUSCULOSKELETAL PAIN/Costochondritis: Given normal ECG and
negative CTA, PE is unlikely. DDimer is sensitive but not
specific so elevated DDimer in setting of normal CTA is
reassuring. The normal ECG and negative trops argue against
ACS. The reproducible nature of the CP is also reassuring that
this is not ACS and suggests that this is MSK in nature. She
also had sacroilitus on physical examination. She had a pelvic
xray that was normal.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with polymyositis, recent PNA 1 month ago, sent in for
evaluation of tachy-brady syndrome. Patient wearing heart
monitor, was noted to have pauses up to 5 seconds last evening.
Asked to come in to ED. Over past month, has been having
intermittent chest tightness and palpitations. These episodes
last ___ minutes. Also having intermittent dyspnea and
decreased exercise tolerance. Reports episodes in which she
feels lightheaded and a sensation of warmth, but denies any
dizziness or loss of consciousness. This sensation occurred last
night around time of pause. Has had cough over past few weeks
that was non-productive, but over past few days now productive
of thick yellow sputum. ED vitals: 98.9 50 139/78 16 99%. Radiology showed Cardiomegaly without congestive heart failure. Subsegmental
atelectasis in the lung bases. Radiology showed mpression:
1. Moderately enlarged left ventricular cavity size with normal global and
regional systolic function. The LVEF was normal at 65%. No CMR evidence of
prior myocardial scarring/infarction.
2. Moderately enlarged right ventricular cavity size with normal global and
regional systolic function. The RVEF was normal at 54%. No CMR evidence of
right ventricular fatty infiltration/dysplasia.
3. Based on limited views of the tricuspid valve, suggestion of prolapse of a
scallop of the anterior tricuspid leaflet. Additional imaging (? TEE) may be
indicated to further characterize tricuspid valve anatomy.
4. Moderate-to-severe tricuspid regurgitation. Moderate mitral regurgitation.
5. The indexed diameters of the ascending and descending thoracic aorta were
mildly increased and normal, respectively. The indexed diameter of the main
pulmonary artery was moderately increased.
6. Severe right atrial enlargement. Mild left atrial enlargement.
7. A note is made of bibasilar atelactasis.
Compared to the prior CMR report dated ___, there is increased
biventricular dilation as well as a slight increase in tricuspid regurgitation
and right atrial dilation. The main pulmonary artery now appears moderately
dilated and there is moderate mitral regurgitation.
The images were reviewed by Drs. ___,
___, and ___. Radiology showed No evidence of acute disease. The patient was diagnosed with CARDIAC DYSRHYTHMIAS NEC. The patient was treated with Right and left heart catheterization ___. At the time of discharge, the patient had Primary Diagnosis: Sick sinus syndrome, tricuspid regurgitation
Secondary Diagnosis: Polymyositis; upper respiratory infection,
likely viral. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ yo woman with h/o untreated polymyositis and
worsening TR who presents with one month of an intermittent
chest squeezing sensation and palpitations and worsening dyspnea
on exertion. Transtelephonic monitoring revealed episodes of
atrial tachycardia with offset pauses of up to 5.5 seconds. She
was found to have worsening RA/RV enlargement and tricuspid
regurgitation compared to cardiac MRI in ___, so she was
evaluated by cardiac surgery for tricuspid repair and after an
extended family meeting, amenable for tricuspid repair.
# Sick sinus syndrome: Patient with most recent echocardiogram
showing severe tricuspid regurgitation and enlarged RA/RV, so
was given ___ of hearts monitor. Found to have episodes of
atrial tachycardia followed offset pauses, longest of which was
5.5 seconds, so called to come to ED for evaluation. Patient
seems to be symptomatic with these pauses, though she complains
only of "squeezing" sensation in heart and warmth on top of her
head, no dizziness or lightheadedness. Denied any syncopal
episodes. She was evaluated by EP for possible pacemaker
placement, but given her severe tricuspid regurgitation, it was
thought that having her evaluated for tricuspid valve repair
with epicardial ventricular pacemaker lead placement during the
open heart surgery would be a better option. She was started on
low dose metoprolol to control her atrial tachycardia and was
monitored on telemetry.
# Presyncope: report of warmth/lightheadedness correlating with
the pause on her outpatient monitoring. Couple episodes of
similar sensation intermittently correlating with the pauses,
but patient did not have any episodes of syncope.
# Severe TR with concomitant RA/RV enlargement: Patient's
echocardiogram on ___ showed severe TR and right atrial
enlargement. Patient did not have evidence of right heart
failure on exam during this hospitalization, but did complain of
worsening DOE. She had cardiac MRI done for comparison to her
___ imaging, and it showed worsening RA/RV enlargement and
worsening tricuspid regurgitation. Family meeting with cardiac
surgery team was had and patient decided to proceed with
tricuspid valve repair after the ___. She had right
and left heart catheterization done to evaluate pressures and
coronaries of her heart prior to surgery and showed clean
coronaries and mild diastolic dysfunction. Patient and family
will contact cardiac surgery in a few weeks to schedule her
surgery.
# Cough, likely upper respiratory infection: Initially
concerning given her recent history of community acquired
pneumonia and leukocytosis to 13, but her leukocytosis resolved
on HOD#3 and WBC remained normal for the rest of
hospitalization. She continued to have cough and white sputum
production but no fevers/chills. There was no consolidation on
admission CXR, and her physical exam had rhonchi/crackles but no
decreased breath sounds or egophony. Her blood cultures were
negative and urine cultures were contaminated. She was given
cough syrup and tessalon perles for symptomatic management. Her
repeat CXR for pre-op also did not show consolidation.
# Anemia: Initially hct in high ___ but dropped to mid ___
without evidence of bleeding. Labs were checkec for possible
hemolysis but bili was normal and haptoglobin was in upper limit
of normal. Active type and screen were kept for possible need
for transfusion but her hct remained stable after initial drop.
# Thrombocytopenia: Plt stable around 140s, unclear etiology.
# Polymyositis: Rheumatology consulted and disease thought to be
very quiescent at this time with CK at 399, which is much
improved from her prior levels. CRP nl ESR only mildly elevated
at 45. Given protein in her urine, other rheumatology serologies
were sent to evaluate for lupus or other autoimmune entities
involving kidney, but other than positive ___ at 1:160 speckled
pattern (present in previous testing), all the other labs were
negative/normal (C3/C4, Anti dsDNA, Anti-La, Anti-Ro, anti RNP,
scleroderma antibody and centromere)
===================================================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o with hx of glaucoma of left eye, HTN, HLD,
hypothyrodism, with recent unwitnessed fall on an icy driveway
approximately 1 week ago. She does not think she sustained loss
of consciousness but does endorse a positive headstrike. The
patient was seen by a primary care physician 2 days ago for
facial swelling/ecchymosis, and her ophthalmologist yesterday,
who both advised her to present to the ED for further workup and
evaluation. The patient was then evaluated at ___ w/
imaging
workup earlier today and found to have L SDH, L orbital
fracture,
and L radius fracture and was then transferred to ___ given
evidence of intracranial injury. Pt endorses double vision over
the past week but no changes in visual acuity. Denies any
dizziness, nausea, vomiting, chest pain, shortness of breath,
abdominal pain, or changes in her bowel habits. Neurosurgery who
did not think that you head bleed need surgery. Plastics for the
Left orbital wall fracture and did not offer surgery at this
admission but would consider treating as an outpatient. Patient
presented with diplopia but Plastics did not appreciate any
entrapment. She was iagnosed with a urinary infection and a 3
day course of antibiotic was prescribed. Radiology showed No acute fracture or dislocation seen. Degenerative changes. Chest: Frontal and lateral views showed Slight blunted left costophrenic angle, very trace pleural effusion not
excluded; no large pleural effusion seen, including on the lateral view.
No obvious displaced fracture identified, although evaluation of the ribs is
limited on this study, particularly on the left. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. Acute fracture of the inferior orbital wall extending anteriorly and
laterally into the left zygoma. There is 8 mm depression of the fracture
fragment into the left maxillary sinus, which is filled with mixed density
blood products. There is also a small left lateral orbital wall fracture.
2. There is asymmetric thickening of the left inferior rectus muscle, when
compared with the right, with adjacent blood products and fat stranding. This
finding raises the concern for inferior rectus injury.
3. Additional impacted fracture of the anterolateral wall of the left
maxillary sinus, with minimal 1 mm posterior displacement.
4. The pterygoid plates are intact.
5. Incidental note again made of the known left subdural hematoma, measuring
5 mm in maximal thickness. Although not fully assessed on this face CT. The patient was diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Left subdural hematoma, Left orbital wall fracture, diplopia,
urinary tract infection (UTI). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o with history of glaucoma of left eye, with recent
unwitnessed fall on icy driveway X 1 week ago. She is unsure if
she sustained loss of consciousness. Was seen by PCP today for
facial swelling/ecchymosis who advised her to present to the ED
for further workup and evaluation. The patient was then
evaluated at ___ w/ imaging workup and found to have L SDH,
L orbital fracture, and L radial fx and was then transferred to
___. Pt c/o double vision, binocular, since the incident. She
reported diplopia. Neurosurgery did not think her SDH was
operative, Ophtho evaluated and suggested L eye coverage for
diplopia. Plastics suggested that they would not offer surgical
treatment for her L orbital fracture during this admission but
this will be considered during the follow-up in clinic. Tertiary
exam was uneventful. Once the patient was ambulating well,
tolerating a diet and moving her bowels she was discharged with
instructions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/stage IIB pancreatic cancer s/p whipple ___
currently cycle 2 of gemzar, p/w epigastric pain radiating into
the back similar to prior pancreatitis. Pain present for past 3
days. Started a few hours after eating about 4 bowls of ice
cream. Was trying to ___ load" in preparation for his
chemotherapy on as he usually loses appetite afterwards. Also
with about 5 episodes of NBNB emesis. +normal bowel movements,
passing flatus. No fevers. Radiology showed No cause for pain identified in the abdomen or pelvis. No evidence of
obstruction or abscess. The patient was diagnosed with ABDOMINAL PAIN EPIGASTRIC, MALIG NEO PANCREAS NOS. At the time of discharge, the patient had Pancreatic insufficiency
Pancreatic adenocarcinoma s/p Whipple. The patient was given written instructions concerning 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 w/pancreatic cancer presents with abdominal pain
concerning for pancreatitis. CT Abd pelv negative for concernign
features. Lipase nl. LFTs downtrending over the day. Pain likely
related to high fat intake in context of pancreatic
insufficiency. Creon dosage likely insufficient to handle fat
load from the ice cream. No lipase elevation or WBC elevation to
suggest a high degree of pancreatic inflammation, but it is
unclear to me how much pancreatic tissue is left after the
whipple. Patient wil f/u with oncology for further malignancy
management.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old ___ speaking lady with history of active drug
use
(cocaine), HCV cirrhosis c/b portal hypertension (ascites,
esophageal varices, HE), as well as complex ID history including
recurrent MDR UTI in setting of nephrolithiasis, MSSA
endocarditis c/b spinal osteomyelitis (___), R shoulder
osteomyelitis (___), MRSA septic arthritis c/b septic emboli to
lungs (___), panhypopitutarism, and IDDM who presents with back
and abdominal pain, malaise, and question of hemoptysis. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute findings within the abdomen or pelvis to explain the patient's
reported symptoms.
2. Cirrhosis without focal liver lesion.
3. Portal hypertensive sequelae, including esophageal and splenic varices and
worsening splenomegaly. Mild-to-moderate ascites has improved.
4. Stable left nephroureterolithiasis with chronic mild left hydronephrosis
and atrophy. No right nephrolithiasis.
5. Stable L1 compression fracture. No acute fracture.
6. Mild anasarca.
7. Hemorrhoids or rectal varices. SHOULDER ___ VIEWS NON TRAUMA LEFT showed No acute osseous abnormality. Fluid collections cannot be evaluated for on
radiographs. US EXTREMITY LIMITED SOFT TISSUE LEFT showed Fluid about the lesser tuberosity may represent a ganglion cyst or biceps
tenosynovitis. Its continuity with the AC joint is suggestive of chronic
rotator cuff tear. Possible small glenohumeral joint effusion. The patient was diagnosed with Finding of oth substances, not normally found in blood. At the time of discharge, the patient had PRIMARY DIAGNOSES:
-Recurrent complicated cystitis
-Pancytopenia
-Shoulder pain
SECONDARY DIAGNOSES:
-Chronic HCV cirrhosis
-Insulin dependent type II diabetes mellitus
-Panhypopituitarism
-History of transfusion reaction
-Cocaine use disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with history of active drug use (cocaine,
fentanyl x2), HCV cirrhosis c/b portal hypertension (ascites,
esophageal varices, HE), as well as complex ID history including
recurrent MDR UTI in setting of nephrolithiasis, MSSA
endocarditis c/b spinal osteomyelitis (___), R shoulder
osteomyelitis (___), MRSA septic arthritis c/b septic emboli to
lungs (___), panhypopitutarism, and IDDM who presented with
back and abdominal pain, malaise, and question of hemoptysis,
ultimately diagnosed with UTI in setting of known retained renal
stone.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o right total hip in ___ at ___
complicated by intermittent swelling and DVT's of this extremity
presenting for right leg pain. Sent from ___ for further
evaluation and treatment. She reported a fall in approx.
___ and since that time has had recurrent swelling of the
right lower extremity. Her pain has been acutely worse for the
past month. US INTERVENTIONAL PROCEDURE showed 1. Imaging Findings - as above.
2. Procedure - Uneventful ultrasound-guided aspiration of the right iliopsoas
bursal collection yielding 3 cc serosanguineous fluid which was sent for Gram
stain/culture as well as cell count/differential, and metal ion analysis.
3. Procedure - Uneventful ultrasound-guided aspiration of the right hip
pseudocapsule yielding less than 1 cc serosanguineous fluid which was sent for
Gram stain/culture.
I Dr. ___ personally 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 LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right lower extremity veins. HIP 1 VIEW IN O.R. showed Intraoperative radiographs. For further details please refer to the operative
report in the ___ medical record. The patient was diagnosed with Pain in right hip. The patient was treated with Status post irrigation and debridement/decompression of right
hip vasculature/bursa. At the time of discharge, the patient had Bursitis and fluid collection with compression of femoral
vasculature. The patient was given written instructions concerning 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 compression of the femoral vasculature in the right
lower extremity and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for irrigation, debridement, and decompression of the right hip
bursa/vasculature, 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#3. 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.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI in the RLE extremity, and will be discharged on aspirin and
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: ___ with a PMH significant for poorly
controlled DM complicated by right below knee amputation and
chronic left foot ulceration who was recently admitted at ___
for MSSA vertebral osteomyelitis and abscesses, R psoas abscess,
and phlegmon. She was discharged on ___ with plans to continue
a 6-week abx course with oxycodone for pain control, and had f/u
appointments pending with CHA ID, podiatry, vascular surgery,
and her PCP. Yesterday the patient experienced worsening ___ R
flank/midline pain and intermittent stabbing RLQ pain not
controlled with her pain meds. She presented to ___, had a
CT scan and workup that was unrevealing of acute concern, and
transferred to ___ for pain management. Radiology showed There is a right-sided PICC line whose distal tip is poorly seen but likely in
the distal SVC. Heart size is within normal limits. There is again seen
subsegmental atelectasis at the lung bases bilaterally. There are no signs
for overt pulmonary edema or pneumothoraces. Overall findings are stable. The patient was diagnosed with Low back pain. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Vertebral osteomyelitis
Psoas abscess
Acute pain
SECONDARY DIAGNOSIS:
Diabetes mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ___ with a PMH significant for poorly controlled DM
compicated by right below knee amputation and chronic left foot
ulceration recently discharged from ___ on outpatient abx for
MSSA vertebral oseomyelitis, T9-12 abcesses/phlegmon, and psoas
abscess transferred from OSH with back and abdominal pain
uncontrolled with home oxycodone. She had a CT scan performed
which did not show any progression of infection. She improved
with PO medications and was discharged home with plan for close
follow up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old with a complex medical history,
relevant for history of lung and esophageal cancer, on
palliative care, ___ disease, atrial fibrillation on
warfarin, recurrent UTI's with an indwelling Foley ___ urinary
retention, who presented with weakness, found to have evidence
of a UTI, admitted for inpatient antibiotic treatment and
consideration of hospice options.
Patient has had a complex oncologic history, including
esophageal cancer s/p chemoradiation in ___, with a repeat
hospitalization here at ___ ___
and found to have an enlarging lung mass. This was presumed to
be lung cancer, though esophageal origin could not be excluded
without biopsy. He was treated with palliative XRT during his
stay by Dr. ___.
Given his multiple medical problems including severe aortic
stenosis the patient and his family opted for not pursuing
aggressive or invasive therapeutic options at that time. He did
not have a biopsy because it was thought to be too high risk. In
___ he was set up with hospice and other services at
home, and started working with palliative care. He indicated in
___ at his Onc follow-up that he would like to be DNR/DNI
and would not like any aggressive life sustaining measures
including dialysis, IV fluids, artificial respiration or
anything that would be uncomfortable. If he needed to be
transferred to the hospital for comfort then that would be
acceptable. A MOLST form was filled out at that time. Patient's
family notes that he experienced a change of thought and signed
a FULL CODE version of his MOLST on ___. They brought that
version with them, which is scanned and in the chart on this
admission. He therefore has been full code on hospice since
___.
Per family patient has had a progressive but slow decline in
functional status. Has been at home with his wife, with private
assistants helping in the morning and the evening, and hospice
workers visiting once in the afternoon. Patient's wife says he
has had an indwelling Foley catheter for urinary incontinence
(also ? retention contributing to frequent UTIs), and this has
only been changed twice in the past year.
Per family, patient had urine tested several weeks ago, with UA
demonstrating concern regarding UTI. Patient had been on
fosfomycin ppx regularly, but this finding prompted
administration of ciprofloxacin 250 q12h. Another antibiotic was
also prescribed when interval UA also appeared dirty, though the
family does not recall what this was. Family notes his urine was
dark, but only started to become purulent a few days ago. They
note with the onset of purulent drainage from the catheter.
In the ED, initial vitals were:
- Exam notable for: Oriented to person place and time, no
focal neuro deficits
- Labs notable for: WBC 4.8 (78% neutrophils), H/H 10.8/34.9,
Na 141, Cr 1.2, lactate 1.9, UA -> leuk, mod blood, > 182 WBCs,
38 RBCs.
- EKG showed 1st degree AV block PR 221, HR 77
- Imaging was notable for: CXR -> New elevation of the right
hemidiaphragm which obscures the right hilar mass. Patchy
opacities in lung bases may reflect atelectasis but infection or
aspiration cannot be excluded.
- Patient was given: a new Foley Catheter, Ceftriaxone,
Azithromycin (500 mg ordered)
Upon arrival to the floor, patient is responsive to questions,
resting comfortably, requires redirecting to participate in
conversation. Answers with words that are hard to distinguish.
Feels comfortable.
12-point ROS notable for family also being concerned regarding
ongoing possibility of aspiration. They note he has had
increased sputum and mucus production over the past week, with a
more prominent cough (has a chronic cough at baseline). No new
fevers or chills. They do not note a definite aspiration event.
No abdominal pain. No nausea or vomiting. ROS otherwise negative
unless indicated above. CHEST (AP AND LAT) showed New elevation of the right hemidiaphragm which obscures the right hilar mass.
Patchy opacities in lung bases may reflect atelectasis but infection or
aspiration cannot be excluded. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had # Acute bacterial UTI secondary to Ecoli
# Right hilar lung cancer
# Chronic Atrial fibrillation
# Aortic Stenosis
# ___ Disease
# Dementia
# Chronic 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>This is an ___ year old male with chronic atrial fibrillation,
___ Disease, dementia, systolic CHF, prostate cancer
with urinary retention and chronic indwelling Foley catheter
admitted with bacterial urinary tract infection, culture
showing Ecoli sensitive to Bactrim, foley changed and initiated
on antibiotics, showing clinical improvement able to be
discharged home.
# Catheter-associated bacterial UTI: Patient presented with
progressive weakness and confusion, with purulent drainage from
foley on initial exam. His foley catheter was exchanged and
cultures growing >100k cfu E coli, resistant to ceftazidime,
sensitive to meropenem and bactrim. Patient transitioned to
Bactrim and was able to be discharged (last day bactrim planned
for ___
# Atelectasis - Patient admission chest xray raising concern for
RLL process pneumonitis vs. atelectasis vs. pneumonia. On
admission exam, lungs clear, no hypoxia or other respiratory
findings. Pneumonia or atelectasis were felt to be unlikely
given his reassuring clinical picture. He was monitored
without development of respirator findings.
# R hilar lung cancer
# Goals of care:
Patient presented about ___ year after his initial evaluation
regarding a right lung mass, for which he been seen by oncology,
declined biopsy or additional procedures, and had received
empiric radiation therapy. Per prior documentation he
had been DNR/DNI and was currently receiving hospice care. On
this admission, family and patient reported wanting to be full
code, although they were open to further discussions, but only
in the context of requested oncology follow-up. Per discussion
with family, there was no other long-term provider who they
felt comfortable having this discussion with. Patient family's
goal was to help him regain some strength and return home. He
was set up with an oncology follow-up appointment at time of
discharge. He was continued on Acetaminophen 650 mg PO BID and
Naproxen 250 mg PO Q12H for pain.
# Systolic CHF - Continued home Lasix
# Chronic Atrial fibrillation - INR 3.3 on day of discharge;
per discussion with pharmacy, Coumadin dose adjusted to 3mg
daily; continued metoprolll
# ___ - Continued Carbidopa-Levodopa
# Diabetes type 2 - Continued home Humalog 75/25, but at reduced
dose (as below) due to low-normal fingersticks.
# GERD - Continued PPI
# Dementia - Continued QUEtiapine; patient on this
longitudinally, but given history of ___ would consider
weaning in long-term to reduce risk of worsening ___
symptoms
# BPH - continued Tamsulosin
# Dysphagia : continued Prethickened liquids</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 Afib, schizophrenia,
elilepsy, s/p laminectomy w/ new L2 compression fx, and prior
DVT on lovenox, epilepsy who presented to ___ for hematocrit
drop. Radiology showed 1. Large right gluteal hematoma measuring 9.5 x 4.9 x 10.7 cm.
2. No evidence of diverticulitis. Moderate fecal loading throughout the
entire colon.
Change in wet read discussed with Dr ___ by Dr ___ at 18:00 ___. Radiology showed 1. No evidence of pulmonary embolism.
2. Unchanged multinodular thyroid goiter.
3. Compression fractures of T6 and T7 of uncertain chronicity. Unchanged T12
compression fracture. Radiology showed Limited study with nonvisualization of the calf veins bilaterally; however, no
evidence of deep venous thrombosis in the visualized right or left lower
extremity. Radiology showed Abnormal course of the right PICC line, which is seen heading towards the
right internal jugular vein.
Findings were conveyed by Dr. ___ to Ping via telephone at 10:41 on ___, 5 minutes after discovery. The patient was diagnosed with ANEMIA NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Gluteal hematoma
SECONDARY DIAGNOSES:
Bacterial colonization of urinary tract
Schizophrenia
Chronic pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ hx of afib, schizophrenia, DVT on lovenox, s/p
laminectomy w/ new L2 compression fx, epilepsy who presents with
a gluteal hematoma.
# Gluteal Hematoma: Hct 22 from 37 in the setting of systemic
anticoagulation for prior deep venous thrombosis. At ___
scan was conducted and showed a large right gluteal hematoma.
Surgery was consulted and recommended that her hematocrit be
trended and that emergent ___ embolization be considered if she
were to become unstable. Her hematocrits were trended and
remained stable at ___. At the time of discharge Hct was
26.5.
# Bacterial colonization of urinary tract: During this
admission, the patient was initially thought to have a urinary
tract infection. Her urine culture grew Pseudomonas and
Stenotrophomonas. The patient was initially treated with
intravenous antibiotics (gentamycin then cefepime given
extensive antibiotic allergies), but they were discontinued
because the patient never developed a fever or leukocytosis to
suggest infection. Instead, it was thought that she had chronic
bacterial colonization of her urinary tract due to her chronic
indwelling foley. Her foley was removed, and the patient
successfully voided without evidence of urinary retention.
# DVT: Given that the patient was started on systemic
anticoagulation in the setting of deep venous thrombosis in
___, the patient was deemed to have completed close
to a 3 month course. In the setting of her bleeding, she was
not restarted on systemic anticoagulation, but prophylactic
subcutaneous heparin was started on ___ without
complications.
#Schizophrenia: The patient was continued on her home
perphenazine and olanzapine without complications.
#Seizure disorder: The patient was continued on her home
levetiracetam, dilantin, and ativan without complications.
#Chronic Pain: The patient was continued on her home pain
regimen (morphine CR and ___, tizanidine, prn methocarbamol,
acetaminophen, and dilaudid) without complications.
#Afib: The patient's heart rate remained well-controlled during
this admission. Given her CHADS score = 2, no systemic
anticoagulation was administered. The patient is being
discharged on prophylactic subcutaneous heparin (see above).
#Decubitus Ulcers: The patient has a history of decubitus
ulcers. Wound care was consulted during this admission and
aided in management.
#Edema: The patient's home lasix was held in the setting of her
gluteal hematoma. This was restarted at the time of discharge.
# Communication: Patient communication and medical
decision-making was condcuted with the aid of her guardians
___ ___ ___
___ ___ and case managers ___
___ ___ ___, ___ ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ of T1DM, ESRD s/p failed kidney transplant (___) and
pancreas transplant (___) now on PD, HTN, CAD (s/p DES to LCx
on DAPT in ___, PVD s/p b/l BKA presents complaining of nausea
and vomiting. Symptoms have been ongoing for the past 5 days.
Patient unsure what caused this acute illness. Endorses mild
diffuse abdominal pain, SOB that began around the same time that
the n/v began. Denies f/c, diarrhea, CP. No blood in vomit. He
states that he has been unable to keep any of his medicines
down, but that he has been getting his peritoneal dialysis
nightly. He also states that he has been taking all of his
insulin as prescribed, even when he slowed down PO intake with
n/v. No recent sick contacts, recent travels, recent illnesses
or antibiotics. Radiology showed Small right pleural effusion with adjacent atelectasis. The patient was diagnosed with Nausea with vomiting, unspecified, Oth diabetes mellitus with ketoacidosis without coma, Long term (current) use of insulin. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Diabetic ketoacidosis
Hypertensive emergency
SECONDARY DIAGNOSIS
ESRD on peritoneal dialysis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ of T1DM, ESRD s/p failed kidney transplant (___) and
pancreas transplant (___) now on PD, HTN, CAD (s/p DES to LCx
on DAPT in ___, PVD s/p b/l BKA who p/w n/v, elevated glucose,
anion gap metabolic acidosis c/f DKA.
=================
ACTIVE ISSUES
=================
# Gap Metabolic Acidosis concerning for DKA: Patient had had
multiple admissions in the past for DKA and a pattern of
non-compliance. However, patient stated he had been compliant w/
insulin at home. There were no recent illnesses or stresses that
he reported and no recent alcohol use. Upon review of
medications with ___ Diabetes specialists, however, patient
stated that he had only been taking novolog and also
intraperitoneal insulin (i.e. not taking any long-acting
insulin). On admission, patient had an anion gap metabolic
acidosis w/ glucose 341 upon arrival that uptrended to 463 in
the ED before being placed on insulin gtt. Patient was anuric,
so urine ketones were not checked. Patient was restarted on SC
insulin upon arrival to ICU floor w/ end therapy for insulin
being detemir 4U at breakfast and 6U at bedtime, novolog 5U w/
meals, novolog sliding scale w/ meals. He also will receive 18U
of novolin insulin in his PD fluid. ___ clarified his insulin
regimen prior to discharge. Patient notably had some abdominal
pain and nausea the day of discharge, but his laboratory work
was unremarkable except for mild leukocytosis.
# Hypertensive emergency, type II NSTEMI: Trop was elevated to
1.47 upon arrival, downtrended subsequently. Patient had a poor
baseline of known CAD and is s/p DES to ___ in ___. Has ESRD
but baseline trops 0.4-0.5. EKGs unchanged from prior. Most
likely demand ischemia I/s/o hypovolemia ___ DKA and/or
contribution from hypertensive emergency. Cards saw patient in
ED and said no intervention or heparin gtt at this time.
Continued home ASA/Plavix, Lipitor 80 and Coreg. Echo
demonstrated no marked changes from his prior.
# HTN Urgency/Emergency: Presented w/ sBP in 200s, improved to
170s in ED. Had a trop leak as above, thought to be possibly
demand ischemia ___ to hypertension. By the time he arrived to
the ICU, his BP had normalized. Patient stated he was not able
to keep PO meds down at home given n/v, hence the elevated BP
upon arrival. Patient just had one episode of SBP > 180 on the
day prior to his discharge, though this improved once he took
his oral home blood pressure meds.
# Anemia: Patient demonstrated a downtrending Hb from prior
without evidence of hemolysis or bleeding. He did not require
transfusion. He stated he was due for his Aranesp infusion,
which was originally to be ___. His peritoneal dialysis team
including Dr. ___ was contacted for follow-up. On review of
his CBCs, it was noted that he has had a long-standing anemia
with some predominance of myeloid precursors. Hematology
consultation as outpatient is suggested.
# Hyponatremia: likely pseudohyponatremia given elevated
glucose. Resolved w/ tx.
# ESRD on PD: s/p failed kidney and pancreas transplant. Renal
consulted to continue PD in house. Continued home sevalamir,
nephrocaps, and prednisone. He noted that after peritoneal
dialysis he had stomach pain and difficulty taking his home
meds. His outpatient nephrologist was contacted regarding
management strategies for this, such as leaving in 100cc to
prevent pain.
=================
CHRONIC ISSUES
=================
# Anemia: at baseline, monitored
# Depression: Continued home celexa and Wellbutrin
# GERD: continued home PPI
# Gastroparesis: continued home reglan
Transitional issues:
- patient notably refused ___ on discharge.
- patient has blood and peritoneal cultures that require
follow-up.
- Patient is being discharged on an insulin regimen of novolog 5
units at breakfast, lunch, and dinner, with 4 units of levemir
at breakfast and 6 units at dinner. He also injects 18 units of
novolin into 6L 1.5% peritoneal dialysis bag. He was written for
new supplies.
- Patient had ongoing presence of anemia on discharge, with Hb
downtrending from 10 to low 7s this admission. Seemed most
consistent with downtrend in the setting of inflammation, with
patient being due for his outpatient Aranesp. On review of his
CBCs, however, it was noted that he has had a long-standing
anemia with some predominance of myeloid precursors. Hematology
consultation as outpatient is suggested. Dr. ___ was
contacted re: setting up outpatient PD team to provide Aranesp.
- his abdominal pain mostly occurs toward the end of his PD
sessions; Nephrology may consider leaving residual fluid to
reduce the discomfort of the final fluid pull of his PD, as
suggested by inpatient Nephrology consultation
- Patient had slight leukocytosis on discharge labs. He should
ideally receive follow-up sets of labs including CBC within one
week.
# Communication: HCP: ___ (MOTHER)
Phone number: ___
Cell phone: ___
# Code: DNR/DNI (confirmed)
Greater than 30 minutes were spent on this patient's discharge
day management.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M w/ T1DM s/p kidney-pancreas transplant in ___ presenting
with fever, abdominal pain, and nausea since this AM. ABDOMEN US (COMPLETE STUDY) showed Unremarkable right upper quadrant ultrasound. RENAL TRANSPLANT U.S. showed 1. Unchanged elevated main renal artery peak systolic velocity and intrarenal
artery resistive indices since ___.
2. Normal grayscale appearance of the left lower quadrant transplant kidney. Radiology showed Nonobstructive bowel gas pattern. Chest: Frontal and lateral views showed Subtle focal opacity, relatively rectangular in shape, projecting over the
anterolateral left sixth rib, which may be due to prior rib injury or may be
external to the patient. Correlate with history. Shallow oblique radiographs
would help further assess. The patient was diagnosed with Fever, unspecified, Unspecified abdominal pain. At the time of discharge, the patient had Viral illness
status post kidney and pancreas transplant. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ M w/ T1DM s/p kidney-pancreas transplant in ___ presenting
with fever, abdominal pain, and nausea.
#Fever: One isolated temperature at home of 101.5. Afebrile
here. Given immunosuppression, covered broadly with vanc/zosyn
in the ED. Monitored overnight off antibiotics and had no repeat
fever.
#Nausea: ___ be viral gastroenteritis given fever, isolated
nausea and elevated LFTs. Symptoms resolved on admission to the
floor.
#Abdominal Pain: History consistent with dyspepsia or PUD. RUQUS
negative, lipase wnl. Begun on empiric acid suppression with
famotidine.
#Transaminitis: No elevation of bili so unlikely biliary. LFT
elevations can be seen in viral illnesses. No imaging to suggest
acute hepatic process. CMV and EBV pending at discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH extensive diverticular disease of the ascending
colon, transverse colon, descending colon and sigmoid colon w/
hx GI bleed following colonoscopy last ___, Grade 1
hemorrhoids, HTN, HLD, Obesity s/p gastric bypass, GERD, p/w
BRBPR.
Patient reports that around noon on the day of presentation
(___) she began having crampy abdominal pain and bowel movements
with bright red blood that filled the toilet bowl. She had four
bloody BMs at home, then started to feel very weak and
lightheaded. She fell when getting off the toilet, then called
EMS, who brought her to the ED. only on aspirin 81mg, no
anticoagulation. no NSAID use. No emesis, no melena. No recent
constipation, straining, or diet changes. CTA ABD AND PELVIS showed 1. No source for GI bleeding identified. No evidence of active extravasation.
2. Colonic diverticulosis without diverticulitis.
3. Moderate background atherosclerotic disease of the abdominal aorta. No
evidence of occlusion or significant stenosis of the abdominal aorta, celiac
axis, SMA, or ___.
4. Status post Roux-en-Y gastric bypass without evidence of obstruction. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with Colonoscopy. At the time of discharge, the patient had Diverticular bleed. The patient was given written instructions concerning 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 prior GIB, severe pan-colonic
diverticulosis, hemorrhoids, and obesity s/p R-en-Y gastric
bypass who presented with symptomatic, hemodynamically unstable
BRBPR presumably of diverticular origin.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ with PMH including castrate-resistant
prostate cancer metastatic to bone, AF on Coumadin, CAD CABGx4,
chronic back pain s/p laminectomy, and recurrent umbilical
hernia, who presented to ___ with confusion and dyspnea. CHEST (PORTABLE AP) showed Heart size is enlarged. Mediastinal contours are stable. Large pleural
effusions are better characterized on the recent chest CT, left more than
right. There is mild vascular congestion but no overt pulmonary edema. No
appreciable pneumothorax. Radiology showed No evidence of deep venous thrombosis in the right lower extremity veins. CHEST (PORTABLE AP) showed Heart size is enlarged. Left pleural effusion is small. Right pleural
effusion is small to moderate. There is mild vascular congestion but no overt
pulmonary edema. No definitive consolidation to suggest infection present.
Sclerotic foci in the right humerus are most likely consistent with metastatic
prostate cancer. The patient was diagnosed with Disorientation, unspecified. At the time of discharge, the patient had PRIMARY
- systolic heart failure exacerbation
- community acquired pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY
=============
___ w/ metastatic castrate-resistant prostate CA (on leupron),
AF (Coumadin), CAD (s/p 4vCABG), HFrEF, HTN, DM admitted w/ CAP
(completed levofloxacin) and HFrEF exacerbation, improved with
diuresis.
ACTIVE ISSUES
=============
#) ACUTE SYSTOLIC HEART FAILURE EXACERBATION:
Pt presented with shortness of breath in the setting of
decompensated systolic heart failure in the setting of diuretic
non-adherence. Workup notable for elevated proBNP and bilateral
pleural effusion thought to be secondary to heart failure
exacerbation. Received diuresis with Lasix 40mg IV BID with
improvement. Continued home metoprolol. Discharged on Lasix 40mg
PO BID. Discharge weight 89.99kg.
#) COMMUNITY-ACQUIRED PNEUMONIA
Presented with shortness of breath likely secondary to heart
failure exacerbation (as above) but concern for possible
pneumonia so treated empirically for community-acquired
pneumonia, initially with ceftriaxone and azithromycin and then
transitioned to levofloxacin (completed on ___.
#) DELIRIUM
On admission, patient with confusion likely secondary to
delirium in the setting of acute illness and improved with
management of active issues (as above).
CHRONIC ISSUES
==============
#) Metastatic Prostate Cancer: Followed by Dr. ___. Recent
visit showed his metastatic prostate cancer is progressing and
his PSA is rising. Of note, he is refractory to Zytiga and
enzalutamide. Palliative care was consulted for pain control.
#) Atrial fibrillation: continued on warfarin (adjusted
accordingly) and home metoprolol.
#) DM: held home glyburide during admission and managed with
insulin sliding scale.
#) CAD: continued home aspirin and atorvastatin
TRANSITIONAL ISSUES
===============================
#) Pt noted to have pleural effusions thought to be secondary to
heart failure during admission. Pt should follow up with
Interventional Pulmonology to determine if the effusions persist
despite diuresis, and consideration of thoracentesis.
#) Needs repeat INR checked on ___ and adjustment of
Coumadin accordingly.
#) Needs BMP checked on ___ and repletion of electrolytes
accordingly.
#) Need to monitor volume status and adjust diuretic
accordingly. Discharged on Lasix 40mg PO BID. Discharge weight
89.99kg.
#HCP/Contact: ___ (wife) ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with a past medical history notable for
Elher-Danlos syndrome, poorly controlled DM2, platelet
dysfunction disease, chronic pain, steroid dependent asthma and
seizure disorder who was transferred from rehab facility on
___ presenting with worsening left hip pain, bilateral leg
weakness, and progressive urinary incontinence. Patient reported
her worsening symptoms of lower extremity pain/weakness/numbness
and urinary dysfunction began 2 days prior to presentation. She
noticed that she was unable to lift her legs out of bed and
unable pass urine. She couldn't recall a specific traumatic
event, but noted that there had been many opportunities in the
prior 3 weeks for fractures to occur during her bed transfers.
At rehab patient had a hip XR which demonstrated a femur
fracture. She presented to the ___ for further evaluation, and
likely orthopedic fixation. Pt denies dyspnea, CP, abdominal
pain, or fevers or chills. MR ___ SPINE W/O CONTRAST showed 1. Disc degenerative changes identified at L2/L3 and L4/L5 levels as described
in detail above.
2. 10 mm gallstone is re- demonstrated and previously noted by abdominal CT in
___ Portable AP chest x-ray. showed 1. New left PICC line with distal tip projecting over right atrium.
Recommended to retract PICC line by ___ cm for positioning in lower SVC.
2. Mild asymmetric pulmonary edema, unchanged from prior radiograph.
NOTIFICATION: Positioning of left-sided PICC line was discussed over the
phone by Dr. ___ with IV nurse ___ on ___ at 11:20, at the
time of review. MRI CERVICAL AND THORACIC showed 1. There is a new wedge compression deformity of the T7 vertebral body new
since exam of ___, as well as mild interval worsening of retropulsion
of fragments of chronic T8 vertebral body collapse. This results in severe
spinal canal narrowing at T8-9 and moderate to severe narrowing at T7-8, which
compresses the ventral aspect of the cord without evidence of underlying cord
signal change.
2. There is chronic epidural lipomatosis at T7-8 and T8-9 which contributes
to spinal canal narrowing at these levels.
3. Additional degenerative changes of the cervical spine as described above.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 8:00AM, 5 minutes after discovery of
the findings. Radiology showed There has been interval open reduction and internal fixation of a proximal
femoral fracture. Please see the operative report for further details. VENOUS DUP UPPER EXT UNILATERAL showed Nonocclusive thrombus within 1 of 2 left axillary veins adjacent to indwelling
PICC. The left brachial vein containing PICC appears patent. CHEST (PORTABLE AP) showed As compared to the previous image, no relevant change is seen. Minimal
atelectasis at the left and right lung bases. No evidence of pulmonary edema,
pneumonia or pleural effusions. No pneumothorax. Unchanged left PICC line. A
hyperlucent line over the upper abdomen is likely caused by a skin fold. Known
healed rib fractures. VENOUS DUP UPPER EXT UNILATERAL LEFT showed Nonocclusive thrombus in one of the two paired left axillary veins, with a
similar appearance to the prior study. CT CHEST W/O CONTRAST showed 1. No CT evidence of tracheobronchomalacia.
2. Unchanged compression fractures at T7/T8 with severe spinal canal
narrowing, better evaluated on the recent MRI.
3. New consolidation/atelectasis with surrounding ground-glass opacities in
the right upper lobe may represent a focus of aspiration, given the secretions
in the patulous esophagus, or developing infection.
4. New left fifth and sixth rib fractures from ___. 5.
Triangular-shaped calcification in the left arytenoid may relate to prior
injection; please correlate with treatment history. CHEST PORT. LINE PLACEMENT showed The ET tube tip is at the origin of the right mainstem bronchus and should be
retracted for better positioning. The left sided chest tube terminates in the
upper hemi thorax on the left. There is no pneumothorax demonstrated. There
are multiple rib fractures noted on the left with a adjacent subcutaneous air.
Right central venous line tip terminates at the level of superior SVC. CHEST (PORTABLE AP) showed The ET tube tip is 4 cm above the carinal, unremarkable. The NG tube tip is in
the stomach. The right internal jugular line tip is at the level of superior
SVC. Left chest tube is in place. Overall there is no change in the
appearance of the lungs CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the endotracheal and
nasogastric tubes have been removed. With the left chest tube on water seal,
there is possibly a small left apical pneumothorax. Portable chest radiograph showed 1. Worsening left pleural effusion. Oval opacity along the peripheral left
upper hemithorax is also likely due to effusion. No pneumothorax.
2. Fractures of the lateral left ___ - 7th ribs are likely acute. HIP 1 VIEW showed Status post ORIF left proximal femur fracture, in overall anatomic alignment. CHEST (PORTABLE AP) showed Left chest tube has been pulled there is no evident pneumothorax. Minimally
increased in size in left pleural effusion. No other interval changes. NON-INVASIVE PERIPHERAL ARTERIAL STUDY showed No evidence of flow-limiting stenosis in either lower extremity. THORACIC SINGLE VIEW IN OR showed Instrumentation, with posterior laminar hook on longitudinal rod placement.
For details of the procedure please consult the operative report.
Incidental atelectasis and/or fluid most likely along the horizontal fissure
on the left. Recommend followup with chest radiograph. CHEST (PORTABLE AP) showed As compared to the previous image, the venous introduction sheet on the right
has been removed. Staples are new and seen over the spine and the left chest
wall, of the vertebral stabilization. No evidence of larger pleural
effusions. Minimal fluid overload. No pneumothorax. Borderline size of the
cardiac silhouette. The patient was diagnosed with FX NECK OF FEMUR NOS-CL, ACCIDENT NOS. The patient was treated with - Open reduction internal fixation left proximal femur fracture
performed by Dr. ___ (___).
- Anterior vertebrectomy of T7-T8 with fusion of T7-T9, Anterior
spacer x1, and vertebroplasty performed by Dr. ___
___ and Dr. ___ (___).
- Left Chest tube placement (___).
- Total laminectomy of T7 and T8, fusion T3 to T12, multiple
thoracic laminotomies, autograf performed by Dr. ___
(___).. At the time of discharge, the patient had Left proximal femur fracture
Thoracic vertebral body fractures at levels T7 and T8
Acute kidney injury
Hyperkalemia
Hypoimmunoglobulinemia
Left upper extremity thrombus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ is a ___ woman with a complicated hisotry
of Elhers-Danlos syndrome, poorly controlled T2DM, platelet
dysfunction disease, chronic pain, steroid dependent asthma, and
seizure disorder who presents with worsening left hip pain,
bilateral leg weakness, and progressive urinary incontinence
concerning for code cord. Subsequently found to have a left
proximal femur fracture s/p ORIF on ___, T7/8 vertebral
compression fractures s/p surgical stabilization on (anterior
___ posterior ___, and ___ s/p resolution. Her hospital
course was complicated by hypogammaglobulinemia s/p IVIG
infusion, stable left axillary vein thrombus around PICC line
(not put on anticoagulation give her vWF), and non-healing
sacral decubitus ulcers (present prior to admission, managed by
wound care). No significant bleeds during her hospitalization.
Her hospital course is outlined by problem below:
ACTIVE ISSUES:
# T7/T8 Compression Fractures c/b Cord Compression s/p
Anterior/Posterior Fusion: Presented with urinary incontinence,
bilateral leg weakness and poor rectal tone. Retropulsion of the
disk into the cord with no cord signal change demonstrated on
MRI ___. Symptoms concerning for cord compression, likely due
to pathologic fractures, particularly given her history of
prednisone use, DM and ED syndrome. Pt s/p anterior fusion of
T7-T9 w/ spacer and vertebroplasty on ___ and s/p posterior
fusion of T3-T12 on ___. Placed in TLSO brace for out of bed
activity. Had frequent neuro checks. Neuro exam remained stable
with no worsening of bowel incontinence, lower extremity
weakness, and lower extremity sensory loss. Pain was controlled
with a combination of Dilaudid, MScontin and Tylenol. Patient
was followed by Ortho ___, Thoracics, and Heme/Onc.
# L Femur Fracture s/p ORIF: Presented with L hip pain. Hip XR
on ___ showed L femoral neck fracture. Likely caused by trauma
with bed transfers in setting of chronic prednisone use,
baseline low-level activity, poorly controlled DM2 and obesity.
Patient s/p ORIF of left femur fracture performed on ___.
Incision site healing well. Discharged touchdown-weight bearing
LLE. Pain was controlled with a combination of Dilaudid,
MScontin and Tylenol.
# Ulcers: Presented with ulcerations around coccyx, inferior
buttucks folds, and labia. Likely precipitated by bedridden
status, poor immune function (DM, chronic prednisone),
incontinence soilage. Managed with appropriate wound care and
regular repositioning. Seen by wound care and dermatology.
# LUE thrombus: LUE U/S on ___ showed nonocclusive thrombus
within 1 of 2 left axillary veins adjacent to indwelling PICC. L
PICC lined was discontinued and a R peripheral was placed.
Repeat LUE U/S on ___ showed stable appearance of thrombus. No
additional anticoagulation was provided given increased risk of
bleeding secondary to underlying ___ disease. R
PICC line was removed.
# Anemia: Hgb downtrended to 6.5 om ___ in the setting of
having undergone posterior fusion of T3-T12 the day prior (Hgb
of 9.0 on ___ before surgery). Patient received 1u pRBCs and
her Hgb returned to baseline. Drop in Hgb likey ___ to
intraoperative bleeding and hemovac output. Her baseline HGB has
been 8.0-9.0 during this hospitalization.
# L Pleural Effusion: Developed L pleural effusion during
hospitalization. Chronic bilateral crakcles L>R and diminished L
breath sounds. Engaged in chest ___, regular incentive
spirometry, and flutter valve. Provided with intermittent
supplemental )2 up to 4L.
CHRONIC ISSUES:
# Asthma: Stable. Presented on prednisone 40 mg BID which was
weaned during hospitalization (decreased to 35mg BID on ___, to
30mg BID on ___, to 25mg BID on ___, to 20mg BID on ___, to
15mg BID on ___, to 10mg BID on ___, to 7.5mg BID on ___, to
5.0mg BID on ___. Given Ipratropium-Albuterol Nebs. Her home
doses of Flovent, Albuterol Inhaler, Flovent, Singulair, and
Theophylline were continued.
# Poorly controlled type 2 diabetes: Stable. No hypoglycemic
episodes during hospitalization. Pt was taking 30u novolog 70/30
with meals with additional ___ throuhgout the day to manage
her glucose during this hospitalization.
# Elhers-Danlos syndrome: Stable. Will require outpatient follow
up with Rheumatology.
# ___ disease: Stable. Hematologist documents "not
___ disease, but rather a intrisic bleeding
disorder that responds to DDAVP and can be treated as such. In
addition she should have platelet transfusions for larger
surgeries to help with homeostasis." Platelets and Desmopressin
were given prior to each operation.
# Seizure disorder: Stable. History of absence seizures. No
events during hospitalization. Continued home Lamotrigine.
# Depression: Stable. Continued home Cymbalta.
# Thrombocytosis: rising platelet count for past week. Up to
900s on day of discharge. Unclear etiology. likely reactive
from previous procedures and sacral decub. Recommend recheck of
platelets in one week to monitor for resolution.
# Steroid Taper: Of note patient has been on long steroid taper,
if patient is hypotensive, may be sign of adrenal insufficiency
- recommend low threshold to restart steroids.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ previously healthy presenting in the ED with
week long episode of cough and fever which progressed from runny
nose and sneezing. He reports cough productive of green sputum.
Denies any fevers prior to today. Also denies dyspnea. No
history of asthma, but does smoke. Since developing cough he has
cut back on cigarette use since it makes his breathing worse. No
sick contacts. He had pneumonia once as a child but never since
then.
In addition, yesterday he started developing ___
sharp,nonradiating, testicular pain aggravated with movement or
coughing. He also noticed scrotal pain and swelling. His
testicular pain is what brought him to the ED. He reports one
episode of diarrhea yesterday and has not had a bowel movement
today. No N/V, no dysuria.
He also reports one sexual encounter one two weeks ago. Initial
referral noted that encounter was unprotected, but he reports
condom use. He received yearly HIV testing, with most recent
testing in ___ or ___.
In the ED, initial vitals were: 100.4 109 112/66 18 97% RA
- Labs were significant for leukocytosis of 11.8, lactate 1.0,
UA with 98 WBCs and negative nitrites
- Imaging revealed:
CT Abd/Pelvis:
Right inguinal hernia containing vessels and fat with
associated fat
stranding. No evidence of upstream small bowel abnormality.
Scrotal US:
1. Asymmetrically increased fat in the right inguinal canal may
represent a right inguinal hernia.
2. Normal appearance of bilateral testes and epididymides.
CXR:
Right middle lobe and left lower lobe regions of consolidation
which may represent pneumonia given patient's history. Repeat
after treatment suggested to document resolution.
He was seen by surgery, who felt that hernia was not
strangulated or incarcerated, and that he could have outpatient
follow up.
- The patient was given 1g CTX, 500mg azithromycin, 2L NS, 5mg
IV morphine, and 1g tylenol
Vitals prior to transfer were: 98.7 86 101/57 18 94% RA
Upon arrival to the floor, initial vitals were 98.5 101/58 77
20 95% RA. Radiology showed Right middle lobe and left lower lobe regions of consolidation which may
represent pneumonia given patient's history. Repeat after treatment suggested
to document resolution. SCROTAL U.S. showed 1. Asymmetrically increased fat in the right inguinal canal may represent a
right inguinal fat containing hernia.
2. Normal appearance of bilateral testes and epididymides. Radiology showed 1. Asymmetric thickening within the right inguinal canal suggests inflammation
or infection involving the spermatic cord, in the setting of UTI.
2. Scattered areas of consolidation within bilateral lung bases suggests an
atypical pulmonary infection.
NOTIFICATION: The updated impression above was discussed by Dr. ___
___ with Dr. ___ on the telephone on ___ at 22:34, 8
minutes after the discovery of the findings. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, URIN TRACT INFECTION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
==================
1. Atypical pneumonia
2. Vasitis
SECONDARY DIAGNOSIS:
====================
None. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>=== SUMMARY ===
___ with no significant PMH who presented with fever, testicular
pain, and cough.
=== ACUTE ISSUES ===
# Pneumonia: Patient presented with one week of productive cough
and one day of fevers. In ED patient was tachycardic (109) and
febrile (100.4). CXR performed was consistent with atypical
pneumonia and patient was started on azithromycin and
ceftriaxone. Patient was discharged on levofloxacin 10 day
course to treat both pneumonia and vasitis.
# Vasitis: Patient presented with 1 week of discomfort with
urinating that evolved into dysuria and hematuria. Came into ED
yesterday due to acute onset non-radiating groin pain. Reported
sexual encounter prior week (MSM). Scrotal ultrasound performed
in ED ruled out testicular torsion. CTAP did not show evidence
of hernia but did show asymmetric thickening within the right
inguinal canal suggests inflammation or infection involving the
spermatic cord. UA with 98 WBC, 13 RBC, few bacteria, and
negative nitrites. Patient received IV ceftriaxone and
azithromycin per above. Additionally received IM ceftriaxone
dose in hospital and was discharged on 10 day course of
levofloxacin to treat pneumonia, possible chlamydia infection,
and vasitis in an MSM patient.
=== CHRONIC ISSUES ===
None.
=== TRANSITIONAL ISSUES ===
#Pneumonia: Patient diagnosed with atypical pneumonia and
discharged on 10d levofloxacin. Please follow up for resolution
of symptoms.
#Vasitis: Patient presented with acute onset groin pain that was
ruled out for testicular torsion and incarcerated hernia. Was
treated for inflammation of spermatic cord seen on CT-AP with IM
CTX and discharged on 10 day levofloxacin course. Was
additionally prescribed 10 pills oxycodone 5mg for pain. Please
follow up and assess for resolution of symptoms.
#Hernia: Scrotal ultrasound showed increased fat in the right
inguinal canal may represent a right inguinal hernia but no
herniation was noted on CTAP. Patient advised to avoid heavy
lifting for next ___ days at least. Please follow up and assess
for evidence of hernia.
#HIV Testing: Patient reports sexual encounter week prior. HIV
testing was not performed in hospital. Please follow up and
consider HIV testing if clinically appropriate.
Code Status: Full
HCP: None Selected </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ y/o F with a PMHx significant for HTN, HLD,
Afib on coumadin, sCHF, cardiomyopathy with recent EF 35% and
recent admission here s/p fall with ankle fracture now
presenting from rehab with respiratory distress, hypotension and
likely sepsis. Radiology showed Suboptimal evaluation of the left mid to lower lung due to
overlying battery pack. If this is areas of high clinical concern, consider
repeat with re-positioning of the patient. There are extremely low lung
volumes. Right basilar atelectasis is seen. Blunting of the right
costophrenic angle could be due to small pleural effusion.
Gaseous distention of the stomach and possibly of the bowel. Radiology showed Gaseous distention of the stomach with mildly dilated air-filled
loops of small bowel raise concern for a small bowel obstruction. Radiology showed Multiple mildly dilated fluid-filled loops of small bowel without
clear transition point seen, which taper gradually, may be due to ileus,
however, early or partial obstruction is not excluded. No free fluid or free
air.
Marked elevation of the right hemidiaphragm with overlying right basilar
atelectasis. Right lower lobe consolidation may relate to atelectasis;
however, an infectious component is not excluded.
High-density material seen in the dependent portion of the gastric fundus,
correlate with recent ingestion. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the lung volumes continue to be low.
Moderate atelectasis at both the left and the right lung bases. Moderate
cardiomegaly, unchanged as compared to the previous image. Currently no
evidence is seen of pneumonia or pulmonary edema. The patient has received
the nasogastric tube. The course of the tube is unremarkable, the tip of the
tube projects over the proximal parts of the stomach. The pacemaker is in
unchanged position. Gastric overinflation, seen on the previous image, has
substantially decreased. New right IJ line.
AP radiograph of the chest was reviewed in comparison to prior study obtained
the same day earlier.
The right internal jugular line has been inserted with its tip most likely at
the level of cavoatrial junction. The precise assessment is difficult given
the substantial elevation of the right hemidiaphragm. To secure its position
at the cavoatrial junction or above, it should be pulled back 3 cm. There is
otherwise no substantial change in the cardiomediastinal appearance with the
left mediastinal shift and substantial elevation of the right hemidiaphragm
with adjacent bibasal areas of atelectasis. The NG tube tip is in the
stomach. was done. Radiology showed Bimalleolar fractures unchanged in alignment. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the nasogastric tube has been removed.
The lung volumes remain extremely low and areas of friable extensive
atelectasis are seen at both lung bases. There is no pulmonary edema and no
larger pleural effusions are visualized. Mild cardiomegaly. Unchanged position
of the left pectoral pacemaker. CHEST (PORTABLE AP) showed A small region of new opacification has developed at the lateral aspect of the
right middle lobe. This could be early pneumonia. Lung volumes remain severely
low, particularly the right lung above the elevated right hemidiaphragm which
obscures a substantially consolidated right lower lobe, suffering from
collapse or pneumonia P the condition of the left lower lobe is similar and.
All of the basal pulmonary abnormalities have developed since ___.
Moderate cardiomegaly is stable. Pleural effusions are presumed, but not
substantial. Right internal jugular line ends close to the inferior cavoatrial
junction. Transvenous atrial biventricular pacer defibrillator leads are
continuous from the left pectoral generator, and unchanged. There is no
pneumothorax. CT CHEST W/O CONTRAST showed 1. Diffuse lung disease characterized by ground glass, reticulation and
traction bronchiectasis, with localized hyperdense opacity in the right lung
base. The latter is strongly suggestive of amiodarone lung toxicity in the
setting of a hyperdense liver. The more diffuse findings may also be due to
drug toxicity, although coexisting infection or edema is 1possible.
2. Cardiomegaly with enlarged left atrium suggesting mitral regurgitation.
Marked atherosclerotic calcification including the coronary arteries.
3. Calcified splenic artery aneurysm, stable since ___.
4. Elevated right hemidiaphragm.
5. Right PICC malpositioned in right internal jugular vein as documented on
recent CXR of ___.
NOTIFICATION: ___ discussed findings with Dr ___ on ___ 30 minutes after interpretation. Radiology showed No significant excursion of the right hemidiaphragm following sniff test,
suggestive of diaphragmatic paralysis/dysfunction. CHEST (PA AND LAT) showed As compared to the previous radiograph, the previously malpositioned PICC line
in the left jugular vein has been pulled back. However, on today's
examination, the PICC line appears to project over the right axillary region.
The line should be completely withdrawn and repositioned.
The previous right internal jugular vein catheter was removed. There is
unchanged mild cardiomegaly at lower lung volumes. These low lung volumes are
essentially caused by an elevation of the right hemidiaphragm, better
appreciated on the lateral than on the frontal radiograph. No current
evidence of larger pleural effusions, pulmonary edema, or pneumonia. Unchanged
pacemaker leads and left pectoral pacemaker generator. The patient was diagnosed with SEPTICEMIA NOS, ACUTE RESPIRATORY FAILURE, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS, URIN TRACT INFECTION NOS. The patient was treated with CVL placement. At the time of discharge, the patient had PRIMARY: Amiodarone-Induced Pulmonary Fibrosis
Interstitial Lung Disease
SECONDARY: Systolic Congestive Heart Failure, 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>PRIMARY REASON FOR HOSPITALIZATION
=================
___ y/o F with a PMHs significant for HTN, HLD, Afib on coumadin,
sCHF, cardiomyopathy with recent EF 35% and recent admission
here s/p fall with ankle fracture who presented from rehab with
respiratory distress, hypotension and likely urosepsis. She was
treated for urosepsis with ceftriaxone. Her shortness of breath
was likely amiodarone toxicity in combination with other
steroid-responsive interstitial lung process. She will require
further diagnostic workup as an outpatient with pulmonology.
Active Issues
=================
# Respiratory Distress
Patient has had severely decreased lung volumes ever since ___ on imaging. Initially she was admitted in respiratory
distress and required BIPAP in the ED; however, soon after
arrival to the MICU she was weaned to shovel mask and then nasal
cannula. Initial differential for cause was unclear and
included sepsis vs. flash pulmonary edema vs. pneumonia. She
continued to do well until ___ when she acutely
decompensated and required BIPAP once again. Etiology was
initially unclear and neurology was consulted and there was no
evidence of neuromuscular disease. She was then successfully
diuresed and was able to be weaned back to shovel mask. High
resolution CT chest on ___ showed pulmonary fibrosis
consistent with amiodarone toxicity. Thus, amiodarone was
discontinued and patient initiated on steroids. She received
high dose IV solumedrol for 2 days and improved dramatically.
Oxygen was weaned to 2L NC on transfer to the floor. Plan for
prednisone taper per Dr. ___. Vasculitis and rheumatologic
work-up was initiated and negative to date on discharge. She
will followup with pulmonology for further diagnosis and
management. Prednisone will continue at 60mg per day for 2 weeks
then taper by 10mg weekly until 20mg daily. This dose will
continue until pulmonary followup. Atovaquone for PCP
prophylaxis, omeprazole for GI prophylaxis, and Ca/VitD for BMD
loss prophylaxis were initiated prior to discharge.
# Weakness
Appears to have had a decline in overall strength from a
baseline of weakness (was able to walk a block, stand in the
shower several weeks ago) for unclear reasons, possibly due to
deconditioning in the setting of recovering from ankle fracture.
There is concern for an underlying neurological process that may
contribute to respiratory weakness; however neurology has been
consulted and does not feel there is any neuromuscular disease
contributing given that her CK nml and she has no focal
neurological deficits.
# Urosepsis
The patient was admitted from rehab with WBC of 15.6, tachypnea
and hypotension, fevers to 100.2 in the ED, ultimately requiring
pressor support and BIPAP in the ED thus meeting criteria for
septic shock. She initially had a lactate of 3.8 in the ED
which then downtrended to 2.4 after 1500cc of IVF. Source of
infection initially felt to be pna given new onset cough vs.
urinary given dirty UA in the ED. CXR done in the ED of poor
quality but could not exclude pneumonia, although R lower lobe
consolidation could represent atelectasis. She was on
norepinephrine to maintain MAP>65 and was slowly weaned of
pressors (off since ___ with gentle fluid rescuitation
given hhere severe CHF. She was empirically treated with
Vancomycine and cefepime. Urine culture eventually grew pan
sensitive E coli and she was narrowed to Ceftriaxone and
completed a 10-day course.
#Leukocytosis
Ms. ___ initially presented with leukocytosis with bandemia
in the setting of urosepsis. This resolved with abx. Her WBC
count rose while on steroids and was felt to be attributed to
this. No focal s/s of infection, no diarrhea, no fevers, and
stable VS on discharge. A followup CBC is requested after
discharge at the receiving facility, and listed on the page 1.
# Ileus vs Obstruction
Patient admitted with mild diffuse abdominal pain and
tenderness. KUB in the ED was concerning for obstruction
(although she was having bowel movements). Given initial
concern for intra-abdominal process, patient was treated with
Vanc/zosyn while in the ED. Ct abd/pelvis concerning for
obstruction vs. ileus, no free fluid. Surgery was consulted and
felt that her presentation was most consistent with ileus ___
urosepsis as above. Given low suspicion for intra-abdominal
infection and that this is likely an ileus, will not continue
zosyn. It was unclear if this was truly a new process, as she
appeared quite distended on prior recent exams and her stomach
is full on CT abd/pelvis. There was some concern for outlet
obstruction or gastroparesis. An NGT was placed for
decompresison and her symptoms improved with zofran prn nausea
medication. Eventually NGT was removed and she was transitioned
to a full diet.
# ___ on CKD
Patient admitted with Cr of 2.7 up from baseline of around
1.3-1.4. This was most likely ___ pre-renal etiology, as her cr
improved back to baseline with fluid rescusitation.
# Hyponatremia
Patient with new hyponatremia of 129 upon presentation from
prior in the low-mid ___. Given septic picture as above,
hyponatremia was most likely due to hypovolemic hyponatremia
(although differential diagnosis for hyponatremia is quite
broad) as sodium quickly returned to baseline.
# ___
At home patient is on Aspirin, Lisinopril, Spironolactone and
Torsemide. Medications were initially held due to septic
picture, but were restarted and well tolerated.
# Afib on coumadin
Patient known to have afib and is on coumadin at home. Home
medications include coumadin, amiodarone and metoprolol. Home
dose metoprolol was initially held due to sepsis. INR elevated
upon admission, so coumadin was initially held. As above,
amiodarone was stopped on ___ given concerning for toxicity
leading to pulmonary fibrosis and metoprolol restarted on ___,
with dose increased. She remained A-V paced thereafter.
# L ankle fracture
Patient was recently admitted here under orthopedics for a L
ankle fracture s/p fall which was managed non-surgically.
Orthopedics saw her while she was hospitalized. She had repeat
imaging and a cast was placed on ___. She will need follow-up
with Dr. ___.
# Insomnia
Will continue home dose zolpidem with careful holding
parameters.
TRANSITIONS IN CARE
=====================
Communication: Patient, and husband- ___ ___
Code Status: DNI but okay to rescusitate, continue to discuss
Prednisone will continue at 60mg per day for 2 weeks then taper
by 10mg weekly until 20mg daily. This dose will continue until
pulmonary followup.
Followup will be with pulmonology, cardiology, orthopedics, and
primary care
CBC and Chem-10 to be checked the day following discharge from
the hospital</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female with PMHx cerebral palsy (non-verbal at baseline),
seizure d/o (baseline ___ who presents with lethargy and
increased seizure activity. Per the patient's mother, her
primary caretaker, she was doing well until ___. She went to
her Dayhab where she was noted to be more lethargic than usual.
This continued into the evening, and her mother also noted
increased seizure activity. ___ AM, her mother had
difficulty waking her from sleep and they also noted erratic
breathing. A room air O2 sat was 88% so she was brought to the
ED. Her seizure activity manifests as arm jerking and extension
with eye deviation to either side. She averages ___ seizures a
day, although this can increase day to day. Her mother also
states that she has a tendency to spit out some of her pills so
may not always get the prescribed dose of antiseizure meds. Radiology showed Low lung volumes, making evaluation suboptimal. Left greater
than right perihilar alveolar opacities could relate to asymmetric edema
versus infection. Radiology showed Bibasal patchy opacities, may represent aspiration or infection. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had PRIMARY:
Aspiration Pneumonia
Neutropenia (transient)
SECONDARY:
Cerebral Palsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o female with PMHx cerebral palsy (non-verbal at baseline),
seizure d/o (baseline ___ who presents with lethargy and
increased seizure activity, found to have consolidation on CXR
concerning for aspiration PNA.
# Pneumonia - Consolidation on CXR concerning for pneumonia,
likely aspiration given patient's history of CP and seizures.
Sister reports patient has seizures with oral stimulation.
Initially started on Unasyn, then transitioned to Augmentin
after S&S evaluation. Patient initially required 3LNC, but
rapidly improved to O2sat in the mid ___ on RA. Speech and
swallow eval showed concern for aspiration due to seizure
activity during evaluation and weak oral musculature.
Recommended pureed diet with thin liquids. Per S&S team,
patient has similar risk of aspiration with either thin or thick
liquids. Family not considering PEG or G-tube as an option.
Therefore, final recommendations are pureed food with thin
liquids without further S&S eval. Patient to complete 7-day
course antibiotics, last day ___.
# Decreased MS/Increased seizures - Baseline up to 10
seizures/day, manifested as arm jerking and blank stare x ___
seconds. Phenobarb level is 31 in the therapeutic range.
Electrolytes wnl with exception of slightly increased potassium.
Infection most likely etiology of increased seizure activity.
Labs do show evidence of dehydration as well with creatinine and
BUN elevated and ratio > 20. TSH normal. Seizure activities
decreased to baseline after treatment of infection. Seen by
Neurology Consult in the ED and they are in agreement with plan
for treatment of pneumonia.
# Pancytopenia - Has chronic macrocytic anemia, likely ___
phenobarbital. This admission also had thrombocytopenia and
leukopenia. Has intermittently been thrombocytopenic before,
although not to this extent. No signs of bleeding/bruising
currently. Pancytopenia could be a reaction to bone marrow
suppression due to infection. Hematology evaluated smear, saw
atypical lymphocytes c/w infection, no schistocytes, no abnormal
RBC morphology except some hypochromacia. Patient was
transiently neutropenic on ___, but ANC increased to 1200 on the
day of discharge (___). Platelet also to ___ from nadir of ___.
Plan to have ___ re-draw labs on ___ and fax to Dr. ___
___ follow up. Expect counts to improve as infection is being
treated. B12, folate wnl, iron panel all normal, but retic
count low.
# Hyperkalemia - mildly hyperkalemic on admission- repeat on the
next day was 4.3.
# Hypothyroidism - Continued levothyroxine, check TSH as above
# Patient remained DNR/DNI throughout admission, confirmed with
family - mother and sister.
# Transitional issues:
- Aspiration PNA- last day of Augmentin ___.
- Pancytopenia- all lines recovering on the day of discharge.
Plan to have ___ draw CBC with diff on ___, to be faxed to and
followed by Dr. ___.
- Aspiration risk- S&S evaluation showed aspiration risk,
recommended pureed diet with thin liquids. Plan to have ___
repeat swallow eval at home.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo otherwise healthy male presents d/t neck injury s/p fall
onto neck while fipping off of trampoline. Pt reports he was
trying to perform a double front flip off of the trampoline (is
a ___) and accidentally landed on his neck/didn't
complete the rotations. Pt reports midline neck pain, no motor
or sensation in his lower extremities. Some sensation in uppers
and unable to move left arm. Injury occurred at 12am. No
additional complaints. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No fracture, infarction, hemorrhage, edema or mass. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Bilateral facet dislocation at C4-5 and "perched facets" with
retrolisthesis of the C5 vertebral body causing severe narrowing of the spinal
canal.
2. Subtle, nondisplaced fracture of the C5 right superior articular facet.
3. Subtle, nondisplaced fracture of the C4 left inferior facet.
4. A combination of C4 on C5 anterolisthesis and epidural hematoma results in
at least moderate to severe spinal canal narrowing.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the ___ ___ at 2:43 AM, 5 minutes after discovery
of the findings. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed No evidence of fracture or dislocation. CT T-SPINE W/O CONTRAST Q321 CT SPINE showed 1. No evidence of traumatic fracture or dislocation. CT L-SPINE W/O CONTRAST Q331 CT SPINE showed 1. No traumatic fracture or dislocation. C-SPINE, TRAUMA showed Bilateral facet dislocation at C4-5 with anterolisthesis of C4 with respect to
C5. There is associated spinal canal narrowing. CERVICAL SINGLE VIEW IN OR showed Screening for procedure guidance. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed 1. Near anatomic alignment status post fixation of a previously seen C4 on C5
anterolisthesis bilateral jumped facets.
2. Expected postsurgical changes following C4-C5 decompression and cervical
spine fixation with seroma/hematoma at the laminectomy bed. Susceptibility
artifact from the hardware obscures the ligamentum flavum and facets.
3. Edema and cord expansion consistent with contusion centered at the C4-C5
level, as described. No evidence of cord transection. No foci of low T2
signal to suggest cord hemorrhage.
4. Disruption of anterior and posterior longitudinal ligaments at C4-C5. The
ligamentum flavum is obscured by hardware susceptibility artifact.
5. Absent flow void within the left vertebral artery suspicious dissection
given the mechanism of injury. This is confirmed on subsequently performed
CTA of the neck. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Endotracheal tube tip is at the upper clavicular level, approximately 6 cm
above the carina. Nasogastric tube extends well into the stomach.
Of incidental note is a cervical fusion device in place. CTA NECK WANDW/OC AND RECONS Q25 CT NECK showed 1. Absent filling of the V2 and proximal V3 segments of the left vertebral
artery with distal reconstitution of the V4 and cephalad V3 segments via
retrograde flow. Findings likely represent sequela of vertebral artery
dissection given previously seen C4 and C5 jumped facets.
2. Anteriorly angulated and displaced anterior midline mandibular fracture
fragment containing the medial and lateral incisors.
3. Near anatomic alignment status post decompression and posterior fixation of
previously seen C4 and C5 anterolisthesis and bilateral jumped facets. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. Minimally displaced fracture through the labial mandibular alveolar ridge
involving ___. No fracture of the teeth.
2. The mandibular condyles are well seated within the glenoid fossa. No other
mandibular fractures.
3. Postoperative findings from reduction of C4-C5 anterior subluxation and
perched facets are partially imaged.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephoneon ___ at 8:38 AM, 2 minutes after
discovery of the findings. CHEST PORT. LINE PLACEMENT showed ET tube tip is 6.5 cm above the carina. Left subclavian line tip is at the
level of low SVC. Heart size and mediastinum are overall unremarkable. Lungs
are clear. There is no pleural effusion or pneumothorax. CHEST (PORTABLE AP) showed Left subclavian line tip is at the level of mid to lower SVC. ET tube tip is
5.5 cm above the carinal. Heart size and mediastinum are stable. Lungs are
clear. Minimal bibasal atelectasis have developed in the interim. CHEST (PORTABLE AP) showed 1. ET tube terminates approximately 4.9 cm above the carina in grossly
appropriate location. A left subclavian line terminates at the low SVC/
cavoatrial junction.
2. Apparent increased lucency of the left lung as compared to the right may be
due to overlying soft tissue/projectional in nature.
3. No focal lung consolidation. No pulmonary vascular congestion. No
pneumothorax or right pleural effusion. Right costophrenic sulcus not seen. CHEST (PORTABLE AP) showed No focal infiltrate. CHEST (PORTABLE AP) showed In comparison with the study of ___, the cardiac silhouette is within
normal limits and there is no evidence of vascular congestion, pleural
effusion, or acute focal pneumonia. There is some indistinctness of the left
hemidiaphragm medially, suggesting some volume loss in the left lower lobe.
The endotracheal tube and left subclavian catheters are unchanged, and the
spinal fixation device remains unchanged. CHEST (PORTABLE AP) showed Comparison to ___. The left central access line was removed.
Unchanged retrocardiac atelectasis. Borderline size of the cardiac silhouette
without pulmonary edema. No pleural effusions. No pneumonia. The
endotracheal tube remains in constant position. CHEST (PORTABLE AP) showed No change. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. CHEST (PORTABLE AP) showed Compared to ___ radiograph, left retrocardiac opacification has
worsened and is accompanied by volume loss, consistent with collapse of the
left lower lobe. Adjacent small to moderate left pleural effusion has
increased in size. Right lung is slightly hyperexpanded but grossly clear. CT ABD AND PELVIS WITH CONTRAST showed 1. Dense consolidation with air bronchograms involving the left lower lobe is
partially imaged. While this may represent atelectasis, pneumonia cannot be
completely excluded on the basis of this study.
2. Elsewhere within the lung bases are heterogeneous ground-glass and nodular
opacities, which may relate aspiration, however superimposed infection also
cannot be excluded.
3. No acute process within the abdomen or pelvis.
4. Status post gastrostomy tube placement, without evidence of complication. CHEST (PORTABLE AP) showed Comparison to ___. No change in extent and severity of the known
left lower lobe consolidation with air bronchograms. No new consolidations.
No pleural effusions. Borderline size of the cardiac silhouette. Correct
position of the tracheostomy tube. C-SPINE (PORTABLE) showed No evidence of hardware complication. CHEST (PORTABLE AP) showed Previous pulmonary vascular congestion has resolved. Left lower lobe
consolidation began developing on ___ and has been severe, without
improvement since ___. Since the mediastinum remains shifted to the
left I suspect this is largely atelectasis, although concurrent pneumonia is
not excluded. It suggests poor clearance of secretions, perhaps due to
bronchial occlusion or weekend diaphragm or cough reflex. Clinical
correlation advised.
There is no appreciable pleural effusion, heart size is normal.
Tracheostomy tube is midline. The patient was diagnosed with Unsp disp fx of sixth cervical vertebra, init for clos fx, Other fall from one level to another, initial encounter. The patient was treated with ___
1. An open tracheostomy and a percutaneous gastrostomy tube.
___
1. Open treatment, posterior, cervical fracture-
dislocation.
2. Posterior fusion C3-C4, C4-5, C5-6, C6-7.
3. Posterior instrumentation C3 through C7.
4. Laminectomy C3-C4, C4-C5, C5-C6.
5. Allograft, morselized.
6. Autograft, same incision.. At the time of discharge, the patient had 1. Acute respiratory failure and need for enteral nutrition,
status post C4-5 dislocation and C3 through C7 fusion, and C4
through C5 laminectomies.
2. Fracture dislocation C4-C5.
3. Spinal cord injury, C4 quadriplegia.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Brief ___ Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the
___ in stable condition. TEDs/pnemoboots/SC Heparin were used
for postoperative DVT prophylaxis. Intravenous antibiotics were
continued postop per standard protocol. Initial postop pain was
controlled with oral and iv pain medication. Standard Spinal
Cord Injury Bowel Program. Trach and PEG was done on ___.
The patient subsequently developed fevers to 103 on ___. A CXR
noted on ___ a LLL consolidation/infiltrate and started on
Vancomycin/Cefepime on ___. The patient was then switched to
PO Levofloxacin 750mg Daily for a 5 day course on ___. The
patient has been afebrile for 48 hours with a stable WBC's.
Physical Therapy, Occupational Therapy, Spiritual Services, and
Social Work were utilized for help with his care and coping
during hospitalization.
Neurology was consulted initially for ? left vertebral artery
dissection. Per Neurology: It was not entirely clear whether
there was a true dissection or an in situ vessel narrowing;
however, further imaging would not change management. Neurology
recommended to take ASA 81mg for stroke prevention.
OMFS was also initially consulted for loose fractured fragment
of anterior mandible that would need to be fixated. The segment
was reduced into place with the aid of
two 24 gauge bridle wires by interconnecting the fractured
segment to non-fractured segments of the mandible and splint
placement. There is a strict non-chew diet with anterior
mandible segment for four weeks in place.
Dispo Planning:Discharge to Acute Spinal Cord Rehab from TICU
DAILY EVENTS: ___: s/p OR with ortho/spine, admitted to TICU.
CT max/face: No evidence of acute facial bone fracture. Sinus
disease as described above. Front lower teeth noted to be loose.
MR C-spine: no further c-spine compression. L subclavian line
placement. On neo, then norepi for goal MAP >85. CTA neck: There
is non visualization of the left vertebral artery (V2 and V3
segments) with reconstitution of the left vertebral artery at
the V4 level (series 2, image 199) most likely due to a
dissection and thrombosis. The bilateral carotid arteries and
right vertebral artery are patent. The basilar artery is patent.
Exam: shrugs shoulders, able to flex right UE at elbow.
sensation above nipples. ___ motor LUE and b/l ___. Appropriate
and following commands when given breaks from sedation. Pain
well controlled with prn dilaudid, Tylenol.
___: Weaned to extubate and extubated in the morning. Failed
extubation as he couldn't cough up secretions and re-intubated
via awake nasal fiberoptic. CT Sinus revealed labial mandibular
alveolar ridge fracture involving ___ ___. OMFS c/s, stated
no acute intervention, but should be splinted. Will evaluate
splint once clear extubation plan is known. OG Tube unable to be
passed, likely secondary to laryngeal edema. DHT may have to be
placed via ___ guidance. BAIR hugger started as patient was
hypothermic. Neurology c/s to help manage vertebral artery
dissection.
___: levophed d/c'ed, steroids d/c'ed, pt remained intubated,
additional attempts at NGT/OGT/dobhoff failed, called ___ but
can't place dobhoff on ___, could do tomorrow (order is in),
plan for trach/peg ___. D/c'ed steroids per spine. Spine drain
d/c'ed. OMFS placed temporary splint on lower teeth, needs more
permanent splint once ETT out
___: Patient with intermittent desats to high ___ on PS.
Cancelled ___ guided OG/NG tube given trach/PEG tomorrow. Rehab
screen initiation discussed with CM.
___: Trach and PEG placed in OR. OMFS to re-wire mandibular
splint this AM.
___: OMFS re-wired mandibular splint in pm, but it fell off.
They will have their attending come look and determine if they
need to go to OR for this. will need to be on strict non-chew
diet x 4 wks. Accepted to ___ rehab. Discussion/updates
with family at bedside. TF started, tolerating well. foley
d/c'd, st cath instead. a line and cvl d/c'd. started gabapentin
for pain. no trach mask trials yet. c/o tightness everywhere in
am, given Ativan.
___: Re-wired by ___. ___ will set up follow up. No further
intervention planned at this time from their stand point.
Patient did spike a fever overnight with increased sputum
production. Chest x-ray is unremarkable. Bronchoscopy performed
and BAL sample obtained.
___: Patient spiked fever at 2200 at 101.7F. Cultures ordered
yesterday night so no further cultures ordered. Tylenol given.
___: Tol 4 hrs spont vent, then requested to be put back on
rate-control for comfort, but was satting well. Pulls TVs of
350-400 on his own, gets 500 on rate-control. bilateral LENIs
negative. Family asking to speak with spine surgery before
discharge to rehab. My ICU updated, family's questions answered.
Febrile to 102.6 in pm.
___: Patient found to have ulcer at the inferior aspect of
trach site. Wound culture sent and patient started on Keflex.
This is likely source of fever at this time. Evaluated by ACS
who removed sutures from trach collar. Patient spikes a fever
overnight but has not had any significant change clinically.
Planned for discharge to ___ on ___.
___ - continues to spike fever ___. CBC uptrending.
Decision made not to send to rehab. CT Abd/Pelvis showed
collapse left lower lobe vs. infiltrate. no intraabdominal
pathology. Bronch performed, revealed thick mucous plugs in left
upper and lower lobes. Suctioned and BAL sent. Started on
Vanc/Cef for broad spectrum coverage.
___ - febrile again overnight. blood cultures, urine
culture sent. not tolerating pressure support well. kept on rate
throughout most of the day and evening.
___: Patient afebrile throughout day. Vancomycin increased to
1500mg Q12h given low vancomycin level.
___: Fever/WBC increase likely secondary to tracheobronchitis.
Switch Vanc/Cef to Levoflox to complete 8 day course total. D/c
to rehab. Insurance screening. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/PMH sCHF, HTN, CKD, hepatitis C and HCC s/p liver
transplant in ___ presents with several weeks of dyspnea and
RLE swelling.
In the ED initial vitals were: 98.4 80 138/70 18 99% RA
EKG: Sinus with LAD and RBBB
Labs/studies notable for: Hb 6.7, ___: 22147, Cr 5.6
Guaiac negative stool
Patient was given:
___ 11:19 IV Furosemide 40 mg
Vitals on transfer: 98.2 71 146/71 16 97% RA Radiology showed Mild pulmonary venous congestion and edema with small pleural effusions.
Bibasilar opacities most likely represent atelectasis but underlying
infectious etiology cannot be ruled out. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. Radiology showed 1. Trace perihepatic simple ascites.
2. Small right and trace left pleural effusion. Small pericardial effusion.
3. Fiducial markers within an enlarged prostate gland.
4. No acute abnormality within the imaged abdomen and pelvis. The patient was diagnosed with Heart failure, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES:
==================
1. Acute on Chronic Systolic CHF
SECONDARY DIAGNOSES:
====================
1. Normocytic Anemia
2. Chronic Kidney Disease
3. Hepatitis C
4. HCC s/p liver transplant. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with a significant past medical
history of HFrEF, HTN, CKD, hepatitis C and ___ s/p liver
transplant in ___, who presented with several weeks of dyspnea
and RLE swelling.
# Acute on chronic HFrEF exacerbation: The etiology of this
patient's heart failure is non-ischemic per his outside medical
records. He presented with a progressive 10 kg weight gain
despite a recent increase in his home Torsemide dose (60mg to
140mg). The etiology of his likely exacerbation is unclear. In
addition, his renal function appeared stable from his baseline
and reports good urine output. He denies any symptoms to suggest
an ischemic or arrhythmogenic etiology. His exam was also
notable for an absence of a murmur, to suggest worsening
valvular disease. He was diuresed with IV Lasix 160 BID. His
ECHO showed preserved EF without much acute change from last
Atrius ECHO. His weight went down 8 lbs. He symptomatically
improved. He is being discharged Torsemide 100 mg BID.
Nephrology team followed inpatient, with suggestion to consider
metolazone as outpatient. He had good diuresis with torsemide
dosing as above. Continued home carvedilol for B-blockade.
# Normocytic anemia: The patient had a reduced Hb to 6.7 on
admission, which is down from his baseline of ___. The likely
etiology of his anemia is uncertain, however this could be
related to his CKD. He was Guaiac negative in the ED and denies
any melena or hematochezia. He only reports mild epistaxis. He
could also have a component of iron deficiency anemia. He
received a blood transfusion with an appropriate increase in his
Hb. His CT abdomen/pelvis did not show a retroperitoneal
hematoma or bleed. He is relatively iron deficient given CKD,
with plan for outpatient iron to be arranged by renal team.
Consider outpatient colonoscopy given overall downtrending iron
deficiency anemia.
# CKD: The patient's Cr appears to be at baseline on admission.
He currently has a fistula in place, however he is not currently
receiving HD. Renal was consulted this admission and closely
monitored his volume status. He will follow up with them as an
outpatient, and if there are any acute changes in weight, HD
will be considered. He was continued on home Calcitriol and his
Sodium bicarbonate was held in the setting of his volume status.
His sodium bicarbonate was resumed on discharge.
# Hepatitis C and HCC s/p liver transplant ___: The patient is
currently doing well without any signs of infection or
rejection. His LFTs were within normal limits throughout his
hospitalization. There is no evidence to suggest this is a
source of his volume overload. He was continued on Cyclosporine,
with dose adjustments, and continued on his home
Sulfameth/Trimethoprim SS 1 TAB PO DAILY and Mycophenolate
Mofetil 500 mg PO BID. Please note his cyclosporine dosing was
changed to ****</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with a PMHx of asthma (baseline PF
~250), allergic rhinitis, OSA (on CPAP), chronic sinusitis, DM,
depression, who presented with fever, chills, wheezing, dyspnea,
headache.
The patient has had the above sx for the past 4 days. In
addition, she reported loss of appetite, anorexia, cough
productive for yellow sputum. She did not endorse recent travel
or sick contacts, med non-adherence. Typical triggers for asthma
include cold/winter months. The patient presented to her PCP,
received nebs x2, but minimal improvement and SaO2 88% so
transferred to ___ for further management. Chest: Frontal and lateral views showed Chronic right basilar opacity is grossly similar in appearance as compared to
the prior study. No definite new focal consolidation. The patient was diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a PMHx of asthma (baseline PF ~250), allergic
rhinitis, OSA (on CPAP), chronic sinusitis, DM, depression, who
presented with fever, chills, wheezing, dyspnea, headache. She
was found to have an asthma exacerbation.
# Asthma exacerbation. Trigger may be weather change vs. related
to infection. No definite source of infection seen on ___.
However given symptomatic fevers and chills and cough prior to
presentation pneumonia couldn't be ruled out given chest xray
was equivocal. She was started on levofloxacin 750mg, 5 day
course (day ___. Patient was treated with 40mg oral
steroids and albuterol nebs/ipratropium nebs advair and
azithromycin while in the ED.
# DM. Poorly controlled, likely due to getting half NPH in ED
w/breakfast in AM and steroids. Takes metformin at home and
states she takes no other ISS. ___ on ___ ___ were
downtrending after 10 U and then again 8 U. Much improved prior
to discharge at 149
## TRANSITIONAL ISSUES:
- Patient on too many sedating medications in the outpatient
setting. Consider reducing/ weaning them. Patient informed of
risks of sedating medications with OSA and encouraged to
maintain absolute adherence to CPAP use when sleeping and to
discuss absolute need of these medications with her prescribing
physicians
- On levofloxacin ___ - ___
- Lisinopril started due to elevated pressures
- f/u with PCP</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with depression and cognitive disorder NOS
admitted from home after home ___ services expressed concern
regarding the patient's safety.
.
The patient denies complaints today, and states she feels
"good." She denies f/c/s, cough, sob, cp, abdominal pain,
dysuria/hematuria.
.
Per verbal report of the home ___, the patient's husband who
lives with the wife is unwell and on HD. Another daughter
suffers from severe depression is currently having difficulty
taking care of both parents. The visiting nurse cites ___ as
the HCP however she does not have any contact information. Code
status is full code as the family refuses to address this issue
with the visiting nurse when she has brought it up in the past.
There is some concern for negligence and the visiting nurse
raised concerns that the patient, as the daughter currently with
the patient is a potential alcoholic and the ___ expressed
concern about her ability to safely care for the patient at
home. Regarding her psych/neuro issues pt follows with Cognitive
Neurology at ___. She has been
taking a complex regimen of psychotropic medications. Cognitive
Neurology had been managing a portion of her medications, but
have strongly recommended that the patient be seen by
Psychiatry.
.
ED Course: initial VS: 98.2 104 173/89 16 100% RA. Labs notable
for FeNa 0.94% (urine Na 98), wbc 8.8, Cl 90, bicarb 20, creat
0.8. She was given 1mg lorazepam and 1L NS. Chest xray notable
for tortuous aorta exerting mass efect on the trachea, deviating
it to the right, ?aneurysm (unsure if it is new, none to
compare) and fullness in hila suggestive of possible pulm HTN.
Also compression deformity in upper lumbar/lower thoracic area
of unclear temporality - exam negative for tenderness. CT Head
w/o contrast negative. Vitals prior to transfer 154/80, hr 108,
rr16, t 98.6 sat98 ra.
.
Currently, the patient is without complaint resting comfortably
in bed. Radiology showed 1. Prominent pulmonary arteries, suggesting pulmonary arterial hypertension.
2. Right tracheal deviation at the level of the aortic arch; aneurysm cannot
be excluded.
3. Compression deformity of a lower thoracic or upper lumbar vertebral body,
age indeterminate. Correlation for pain at this level is recommended.
Findings were reported to ___ by ___ by telephone at 2:04
p.m. on ___ at the time of discovery of these findings. Radiology showed 1. No evidence of acute intracranial hemorrhage or mass effect.
2. Left frontal focal calcification, which may be post-infectious or
represent a calcified cavernoma.
3. Expanded sella- attention on f/u. The patient was diagnosed with ALTERED MENTAL STATUS , HYPOSMOLALITY/HYPONATREMIA, HYPERTENSION NOS, SCHIZOPHRENIA NOS-UNSPEC, DIABETES UNCOMPL ADULT. At the time of discharge, the patient had Primary: Hypovolemic hyponatremia
Secondary: Cognitive disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ___ year old woman with depression and cognitive
disorder NOS admitted from home after home ___ services
expressed concern regarding the patient's safety, found to be
hypovolemic with abnormal electrolytes and off baseline mental
status.
.
# Hypovolemic hyponatremia: Improved with IV normal saline.
Most likely secondary to decreased oral intake. Other causes of
change in mental status were ruled out with head CT, serial
cardiac enzymes, and urine analysis.
.
# Safety concern: By report of the ___, there is concern for
the patient's well being at home, in the setting of her usual
caretaker being out of town. Discussed with case management,
social work, and home ___ in addition to contacting the primary
care-giver who is currently on vacation in ___ to
ensure safe discharge plan.
.
# Depressive and cognitive disorder: At baseline is AAO x1
(name) and able to recognize only close friends/family members.
She is able to ambulate and use a commode, she is able to eat
and drink. She is maintained on a cocktail of psychotropic
medications, which were not changed on this admission, with the
exception of holding haldol.
.
# Expanded sella: Seen on CT head read. In an ___ year old
patient, this may be age related. She has no obvious endocrine
abnormalities (hyponatremia more likely explained by
hypovolemia). Given her age and co-morbidities, no further
inpatient work-up will be performed, and consideration of a
follow-up CT scan as an outpatient in several months may be
indicated.
.
# DM: held home anti-hypoglycemics in favor of sliding scale
insulin in-house
# HTN: Continued home lisinopril
# Intermittent tachycardia: Chronic. Tachycardia on admission
resolved with fluids.
.
====</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of PE (lovenox), Anxiety, AML (in complete remission,
undergoing consolidation with high dose ara-C), who was recently
admitted for neutropenic fever found to have hepatic
microabscesses, now admitttd with increased size of hepatic
lesions despite ___s per review of discharge summary from 1 week ago, patient was
admitted for febrile neutropenia, for which ID was consulted and
felt that patient likely had transient bacteremia from
mucositis,
as she was found to have hepatic microabscesses. She was
discharged on 14 day course of ertapenem (planned to end
___ and was supposed to have a CT scan following
completion
of therapy. CT was completed on ___ and was found to have
increased size of hypodense lesions with hyperemia so was
referred to ED for admission. Radiology showed Uncomplicated 18-gauge targeted liver biopsy x 4, with specimen sent for
microbiology and cultures as well as histopathology. The patient was diagnosed with Hepatomegaly, not elsewhere classified. The patient was treated with Liver biopsy ___. At the time of discharge, the patient had # Hepatosplenic candidiasis
# Liver abscess
# AML, in remission. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRINCIPLE REASON FOR ADMISSION:
___ PMH of PE (lovenox), Anxiety, AML (in complete remission,
undergoing consolidation with high dose ara-C), who was recently
admitted for neutropenic fever found to have hepatic
microabscesses, admitttd with increasing size of hepatic lesions
despite ___ntibiosis initially changed
to vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
Etiology of her abscess is unclear, which will make
determination
of abx course difficult. Given imaging findings and positive
glucan (and since it worsened despite ertapenem) favor possible
hepato-splenic candidiasis. afebrile with normal LFTs, and
appears to be healing. Favor continue broad GNR/anaerobic
coverage with pip/tazo and fluconazole for candidiasis. Will
need
likely prolonged treatment of at least two weeks. Will arrange
home services and ID follow up next week. Otherwise she had
developed moderate neutropenia which improved
after initiating treatment as above. Likely related to resolving
abscess.
# Hepatic microabscesses:
Etiology of abscesses remains unclear. Grew in size despite 2
weeks of ertapenem as outpatient. No significant fevers and no
liver test abnormalities. Antibiosis initially changed to
vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
- ___ remaining infectious studies
- ___ flow cytometry on liver sample
- Con't pip-tazo/fluconazole; D1 effectively ___.
- ___ in ___ clinic next week for final abx course
# Neutropenia: Admitted with mild neutropenia. ___ eventually
dropped to 750 on ___ before recovering prior to discharge.
Potentially medication induced vs effect of infectious abscess.
#Hx of PE: Lovenox was held prior to liver biopsy. Of note, she
was not maintained on heparin gtt due to patients firm desire to
avoid PIV, lack of additional IV access, and asympomtatic nature
after >3 months of anticoagulation. She was restarted on
therapeutic following biopsy without incident.
#Hx of AML in remission
Continued acyclovir ppx. Flow cytometry was sent on liver biopsy
specimen. Will need to follow up with Dr. ___ week
(either ___ or ___ for further treatment planning.
# Vaginal spotting:
Noted on admission. Likely due to delayed Lupron dosing.
Resolved.
#Anxiety
Continued escitalopram
# Anemia in malignancy
Stable to improving sp consolidation chemotherapy
# Billing: >30 minutes spent coordinating and executing this
discharge plan</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with long history of chronic neck and low back
pain who presents with acute on chronic low back pain.
Ms. ___ had had ___ problems with neck and back pain
since a car accident at the age of ___. She notes that the pain
became much worse after the delivery of her first child in ___,
and underwent L4-L5 and L5-S1 anterior lumbar interbody fusion.
The pain improved and she was doing yoga several times a week
for control, however she then developed refractory neck pain and
underwent anterior cervical diskectomy in ___. Her pain
has been manageable since this time until ___ last week she
aggrevated the pain after using a leaf blower. She now describes
severe shooting bilateral lower back pain with radiation into
her hips and right anterior leg and great toe. The pain is worse
with sitting up and laying down and her leg occasionally gives
out. She developed two episodes of urinary incontincence
yesterday so she presented to the ED.
In the ED intial vitals were: pain 9, T 97.8, HR 114, BP 91/68,
RR 16, O2 94%RA. Initial CBC and Chem7 were wnl. Ortho/spine was
consulted who recommended MRI to r/o cord compression and pain
management. MRI C/T/L spine showed no cord compression with post
surgical changes C4-C7 along with disc bulge at C3-C4. There
were also post surgical changes at L4-S1. Patient was given IV
dilaudid x3 and ativan x1 before admission to medicine for
further management.
On the floor, patient reports severe pain as above. She denies
recent fevers or chills. No chest pain, shortness of breath, or
cough. She reports chronic constipation but denies nausea,
vomiting, or abdominal pain. She notes her neck pain is at its
baseline. She denies any history of IVDA and notes no bowel
incontinence or urinary retention. ROS is otherwise
unremarkable. Radiology showed Postsurgical changes. No evidence for cord compression or compression of the
cauda equina. Radiology showed PA and lateral film in the absence of prior chest radiographs:
Normal heart, lungs, hila, mediastinum and pleural surfaces. No appreciable
atelectasis. No evidence of pneumonia. The patient was diagnosed with OTHER ACUTE PAIN , OTHER CHRONIC PAIN , LUMBAGO. The patient was treated with L4-S1 laminectomy and fusion. At the time of discharge, the patient had Lumbar spondylosis, pseudarthrosis and foraminal stenosis.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman who presents with acute on chronic severe neck
and low back pain. Previous films have identified a
pseudarthrosis and she elects to undergo revision spine surgery.
She was initially admitted to medicine for the initial workup
but was transfered to the Spine service post-op. Please see
Operative Note for procedure in detail.
Post-operatively she was given antibiotics and pain medication.
A pain service consult was obtained and recommendations
followed. A hemovac drain was placed intra-operatively and this
was removed POD 2. Her bladder catheter was removed POD 3 and
her diet was advanced without difficulty. She was able to work
with physical therapy for strength and balance. She was
discharged in good condition and will follow up in the
Orthopaedic Spine clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of 60 pk yr smoking hisotry, EtOH abuse, and
remote history international travel p/w hemoptysis x 1 day.
Patient reports he started coughing yesterday and developed
sudden onset frank bloody sputum. He was in his usual state of
health. He has a 60 pk year smoking history and drinks ___
drinks per night. He denies vomiting/wretching. He is from ___
___, immigrated ___ years ago, with last international travel ___
years ago to ___. He denies prolonged immobility,
dysphagia, weight loss, fevers, chills, N/V, reflux. Radiology showed Right upper lobe opacity which may represent pneumonia, although,
hemorrhage is not excluded. Please refer to the following CT for additional
findings. Radiology showed 1. Ground-glass opacity in the right upper lobe is most likely hemorrhage. A
component of infection such as atypical or bacterial pneumonia cannot be
excluded.
2. Mild bronchiectasis.
3. Biapical scarring.
4. Moderate emphysema.
5. Tortuous prominent bronchial arteries, which are sometimes associated with
bronchiectasis, are likely the source of the hemoptysis. If continued
bleeding, consider interventional radiology consult.
6. Dilated aneurysmal descending thoracic aorta. Recommend continued
followup to ensure stability.
Changes to the wet read regarding the prominent bronchial arteries were
discussed with Dr. ___ at 3:46 p.m. on ___ via telephone by Dr.
___. Changes regarding the aortic aneurysm were discussed with Dr. ___
at 10:25 p.m. on ___ via telephone by Dr. ___. The patient was diagnosed with OTHER HEMOPTYSIS. The patient was treated with Bronchoscopy. At the time of discharge, the patient had Hemoptysis secondary to vascular malformation/bronchiectasis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># HEMOPTYSIS: Hemodynamically stable on admission. Started
suddenly 1 day prior to admission and he had 2 episodes.
Differential diagnosis included lung cancer/brochoalveolar
malignancy/esophageal cancer (60 pack year smoking history, yet
no weight loss or dysphagia), TB (immigrated from ___ ___ yrs
ago, last travel to ___ ___ years ago. However, no fever, no
leukocytosis, no hilar adenopathy), bronchiectasis, PNA (again
no fever or leukocytosis), PE (negative CTA, WELLS 1), ___
___ varices ___ drinks per night, yet no wretching
or vomiting). CTA w RUL ground glass opacity concerning for
alveolar hemorrhage vs atypical infection vs bacterial
infection, with no evidence of PE, no mass. Per radiology, more
likely hemmorhage rather than infection, enlarged bronchial
arteries possibly amenable to ___ embolization. He remained
stable with no additional episodes and therefore did not go for
embolization. Patient was not started on antibioitcs on
admission as he was afebrile with no leukocytosis. Sputum for
acid fast x 3 were sent and were all negative. Pulmonology was
consulted and recommended a bronchoscopy which showed no active
bleeding but some residual blood. A large clot was blocking
smaller airways and they were unable to remove it. No lesions or
masses were seen. Pulmonology will set up outpatient follow up
with patient. Cytology from lavage is still pending at
discharge. Episode thought to most likely be from vascular
malformation and or bronchiectasis in setting of pending
cytology.
# ALCOHOL ABUSE: Patient endorsed drinking ___ drinks per day.
He scored 0 repeatedly on CIWA and did not require
benzodiazapines. He was given thiamine, folate, MVI daily. He
was prescribed a Rx at discharge for these
==================================================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ female with a no significant past medical
history who presents with 24 hours of cough, shortness of
breath. She noted a gradual onset of subjective fevers, myalgias
and cough over the day prior to admission. Radiology showed Right middle lobe pneumonia. The patient was diagnosed with FLU W RESP MANIFEST NEC. At the time of discharge, the patient had Influenza
Pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ female with an insignificant past medical
history presenting with 24 hours of cough, shortness of breath
wth radiographic evidence of a RML PNA.
#. PNA: She had symptoms of influenza with fevers, myalgias, and
cough for approximately ___ days prior to admission. She was
initially observed in the ED and was given 5 liters of IV fluids
overnight. She was then admitted for further observation. She
tested positive for influenza and her chest x-ray showed a right
middle lobe pneumonia. She was treated with Tamiflu 75mg BID for
5 days and levofloxacin 750mg PO daily for 5 days. Her CURB-65
was 0. After a night of monitoring and treatment her symptoms
were greatly improved.
She was a college student living with other students. She was
told that she should wear a mask for 5 days from the onset of
symptoms of from her last fever. She was also told that her
friends should be screened for symptoms or be evaluated for
treatment. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with h/o vfib arrest s/p AICD
___, prior MI, HLD s/p fall yesterday AM now
transferred from OSH with L renal laceration and RP hematoma.
Briefly, patient reports tripping over snow bank yesterday
morning and landing on L side. He denies any presyncopal
symptoms or head strike/LOC. He
developed hematuria later in the day and presented to
___ where CT imaging demonstrated multiple
L renal lacerations without active extravasation. Given degree
of renal injury, he was transferred to ___ for further
evaluation. CT abdomen and pelvis with contrast. showed 1. Multiple wedge-shaped left renal cortical lacerations extending into the
renal pelvis, associated with spillage of contrast from the renal calyces into
the large perirenal hematoma, consistent with a grade 4 injury. The renal
vessels are intact.
2. Nondisplaced fracture in the lateral aspect of the left 10th rib.
3. Small volume of free fluid in the pelvis.
4. No evidence of bowel injury or pneumoperitoneum.
5. Intraluminal linear defect suggestive of a dissection involving the distal
right iliac and right common femoral artery.
6. Left pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 15:12 pm, 5 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed In comparison with the study of ___, there has been the development of
increased opacification at both bases with silhouetting of the left
hemidiaphragm. This is consistent with bilateral atelectatic changes and left
pleural effusion. In the appropriate clinical setting it would be difficult
to exclude superimposed pneumonia/aspiration, especially in the absence of a
lateral view.
External pacer device remains in place. Radiology showed 1. Re-demonstration of multiple wedge-shaped left renal cortical lacerations
extending into the renal pelvis, associated with persistent spillage of
contrast from the renal calyces into an enlarging perirenal collection.
2. Intraluminal linear defect suggestive of dissection again seen in the
distal right iliac/right common femoral artery.
3. Small volume free fluid the pelvis.
4. Worsening bibasilar atelectasis and interval increase in size of left
pleural effusion, which still remains small in volume. Fluoroscopic images of abdomen for cystoscopy, stent placement showed Intraoperative images were obtained during cystoscopy and left retrograde
pyelogram, with placement of left ureteral stent. Please refer to the
operative note for details of the procedure. The patient was diagnosed with Laceration of left kidney, unspecified degree, init encntr, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with cystoscopy with left ureteral stent placement
insertion of foley catheter. At the time of discharge, the patient had Left renal laceration
Left retroperitoneal hematoma
Left kidney urine extravasation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with h/o vfib arrest s/p AICD placement
(___), prior MI, and HLD who presented to ___ as a transfer
from an OSH with CT findings of left renal laceration and a
retroperitoneal hematoma after a mechanical fall. Fall is likely
mechanical as patient tripped over a snow bank without any
pre-syncopal symptoms, head strike, or loss of consciousness.
Given degree of renal injury, he was transferred to ___ for
further evaluation. On arrival, patient was afebrile and
hemodynamically stable with Hct of 32 (35 at OSH 5 hours prior),
unremarkable FAST examination, and UA demonstrating gross
hematuria. Given findings, the patient was admitted for
observation and serial Hct in the setting of a known RP
hematoma. On admission patient had a repeat CT abdomen pelvis
that was notable for multiple wedge-shaped left renal cortical
lacerations extending into the renal pelvis (grade IV injury),
with associated extravasation from the renal calyces. There was
also note of a nondisplaced fracture in the lateral aspect of
the left 10th rib. Patient was admitted to the acute surgical
service and was kept NPO on IVF, with targeted pain management.
Aspirin was held. Urology was consulted and recommended
conservative management with close monitoring of post residual
volumes. On ___, a repeat CT abdomen pelvis was ordered and
demonstrated expansion of the left perirenal collection with
contrast from the renal calyces. Given these findings both
interventional radiology and urology were consulted to discuss
management options. Ultimately the patient went to the OR on
___ for cystoscopy with left ureteral stent placement.
Patient also had a foley catheter placed at that time. There
were no adverse events in the operating room; please see the
operative note for details. Pt was taken to the PACU until
stable, then transferred to the ward again for observation. On
return to the floor subcutaneous heparin was started for DVT
prophylaxis and the patient was started on a regular diet which
he tolerated well. Creatinine on admission was 1.3/1.4, but
downtrended to 1.0 on the day of discharge.
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.
TRANSITIONAL ISSUES
===================
[]Left Renal laceration/urine extravasation: Patient had foley
placed on ___. This is to stay in place for a minimum of 1
week. Patient should be seen in ___ clinic for evaluation
prior to foley removal. He has been provided the number to
schedule an appointment ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with severe AS, cerebral angiopathy who presents after a
fall. History is taken from the daughter as the patient's memory
is very poor. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence for acute intracranial abnormalities. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No fracture or subluxation.
2. Multilevel cervical degenerative disease. CHEST (PA AND LAT) showed No acute cardiopulmonary process identified. DX PELVIS AND FEMUR showed 1. No acute fracture or dislocation.
2. Mild bilateral hip osteoarthritis.
3. At least moderate left knee osteoarthritis, with suggestion of medial and
lateral compartment joint space narrowing. The patient was diagnosed with Syncope and collapse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F with history of severe AS and cerebral amyloid
angiopathy who presents with syncope.
#Syncope: Given lack of history, difficult to tell if
mechanical, orthostatic, arryhthmogenic or structural cause of
syncope. No sign of infection. UA negative. Patient had recently
been evaluated for TAVR (deemed high risk for SAVR) for known
severe AS. However, both the patient and her daughter remain
hesitant to pursue TAVR at this time. While hospitalized, no
events on telemetry, orthostatics borderline without clear
symptoms (SBP 170->151). Aortic stenosis potential cause but
given the lack of other symptoms (angina, dyspnea, CHF) it was
decided with the patient and her daughter that it was not worth
pursuing TAVR at this time when the true cause of fall is very
unclear. She was discharged to rehab with the plan to bridge to
an ALF with home services (currently lives alone with no
services).
#Cerebral Angiopathy/Dementia: Very severe memory dysfunction.
Cannot remember hour to hour. However, still very functional and
pleasant. Had one episode of agitation while here and required a
PRN dose of olanzapine 2.5mg.
#Depression/Insomnia: Continued home fluoxetine
#Constipation: Continued senna/miralax
#Hypothyroidism: continued levothyroxine 25mcg daily </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman w/ PMH of bipolar disorder, cervical spine
surgery, HTN, HLD, p/w ___ weeks of visual changes and
increasing pain on the side of her head. Two weeks prior to
admission, she noted some "black threads" floating across her
vision, which she has never experienced before. About a week
prior to admission she started noting blurry vision and noted
halos around lights. She also experienced photophobia with
tearing on exposure to light, and tried to wear sunglasses but
found that did not help. This problem initially caused trouble
driving at night, and progressed to make it hard for her to
watch television or use the computer. She denies double vision
or pain with eye movement. She feels that her left eye is
somewhat worse than her right. On ___, when she woke up she
noted that she was "totally blind" for a few minutes, and could
only see white throughout her visual field. This resolved
spontaneously. Radiology showed 1. No acute intracranial process.
2. Intracranial vessels demonstrate no stenosis, aneurysm formation or
dissection.
3. No evidence of dural sinus thrombosis. Radiology showed 1. No signal changes in the brain to suggest PRES.
2. No obvious focal signal, contour or enhancement abnormality of the optic
nerves; however, dedicated orbital post contrast images were not performed.
3. Non-specific scattered foci of increased FLAIR-signal intensity in the
white matter, likely sequelae of chronic small vessel disease. Bifrontal
atrophy. The patient was diagnosed with HEADACHE, VISUAL DISTURBANCES NEC, MANIC-DEPRESSIVE NOS. The patient was treated with lumbar puncture. At the time of discharge, the patient had visual changes. The patient was given written instructions concerning 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 pt is a ___ year-old woman with PMHx of bipolar disorder,
HTN, HL and prior cervical spinal surgery who presented with
bilaterally blurred vision for the past week and head pain
associated with a soft tissue mass on the L side.
# NEURO: The patient presented with a reportedly rapid
deterioration of vision in the week prior to admission, with
vision ___ b/l on admission. However, when we tried the
patient with her glasses (which she initially refused and said
they didnt help), she improved to ___ b/l. Opthalmology exam
on admission showed no evidence of retinal or papillary disease,
no glaucoma, but did note bilateral cataracts. Temporal
arteritis was clinically unlikely given no true history of jaw
claudication, location of head pain associated with soft tissue
mass on the side of head, and unrevealing optho exam (showed
only cataracts), and good temporal artery pulse without
nodularity along the artery. The patient's reported history of
rapidly worsening vision was concerning for possible bilateral
optic neuritis. The patient got a head CT with and without
contrast which showed no acute intracranial process. LP showed
benign CSF and culture were negative at discharge. MRI was
preformed once we confirmed with neurosurgery that her prior
spinal surgery metal was MRI compatible, and did not show
evidence of optic neuritis or MS. ___ evoked potentials
showed no abnormality. Since there was no evidence of
inflammatory or infectious process in the CNS which could be
causing the visual changes, the patient with discharged with
outpatient ophthalmology follow up.
# HEAD MASS: The patient originally complained that her head
mass had been growing in the recent weeks - months and was
causing increased pain. However, CT head showed likely sebaceous
cyst in the area, unchanged from ___. Additionally,
outpatient PCP notes noted the mass several months ago. This, it
was felt that there was no urgent issues with the mass and
further managment was deferred to her PCP.
# PSYCH: H/o bipolar disorder. When the patient was admitted she
said she was somewhat "down" but denied suicidal ideation. She
has regular outpatient psych treatment. Home medications were
continued during admission.
# CARDS: Continue antihypertensives (HCTZ, lisiopril,
amlodipine) and simvastatin
# PPx:SQH</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female presenting as a basic trauma transfer after a
rollover MVC. Unknown loss of consciousness. Unknown if the
patient was restrained as she was found unrestrained in the car.
Unknown loss of consciousness. Patient has dementia at baseline
and is unable to provide any additional history. Patient was
found to have an unstable C2 fracture. A chronic C1 fracture.
She was found to have pelvic rami fractures of unclear
chronicity. She was treated with IV antibiotics and tetanus. Radiology showed 1. No acute cardiopulmonary process.
2. Increased interstitial markings in the lungs most suggestive of a chronic
underlying interstitial abnormality.
3. Deformities of the left superior and inferior pubic rami which are most
likely, though not definitively chronic. If further clarification desired,
consider additional plain films of the pelvis/hip. The patient was diagnosed with Unsp disp fx of second cervical vertebra, init for clos fx, Car passenger injured in collision w car in traf, init. At the time of discharge, the patient had type III odontoid fracture
Urinary Retention
Clostridium Difficile. The patient was given written instructions concerning 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 who sustained a ___ yo F who was admitted
to the Emergency department after a reported rollover motor
vehicle crash. Unknown loss of consciousness. Given mild
dementia at baseline, accurate history was difficult to obtain.
CT head, neck, torso, showed unstable C2 fracture and a chronic
C1 fracture, and pelvic rami fracture. She was given IV
antibiotics and tetanus shot prior to transfer.
Orthopedic spine surgery consulted and type III odontoid
fracture with extension into the left lateral mass diagnosed.
Recommended non-operative management in hard ___ collar.
Orthopedic surgery consulted for pelvic fracture and
non-operative management was recommended and she was cleared for
full weight bearing.
Neuro: The patient was alert and oriented throughout
hospitalization although did have waxing and waning periods of
confusion. Geriatric medicine was consulted to assist in
managing dementia symptoms. Pain was managed with standing
Tylenol and low dose oxycodone. Narcotics were limited as much
as possible.
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 given a regular diet which she
tolerated well without difficulty. Patient's intake and output
were closely monitored. On HD2 foley catheter was placed for
urinary retention and she failed voiding trial x2. Urology was
consulted and recommended holding home oxybutynin dose and
outpatient follow up for voiding trial and further urodynamic
studies as needed.
ID: The patient's fever curves were closely watched for signs of
infection. On HD7 patient had abdominal pain and loose stool.
C.diff sample sent and positive. She was therefore started on
oral flagyl and her abdominal pain resolved.
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.
Rehab stay anticipated <30 days. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed 1. Degenerative changes of the cervical spine with moderate and severe spinal
canal stenosis from C3-C4 through C5-C6 with compression of the spinal cord
and abnormal cord signal at these levels. Increased cord signal appears to be
diffuse and could be due to edema from recent trauma. No evidence of blood
products seen within the spinal cord.
2. Moderate and severe bilateral neural foraminal narrowing at C4-C5 and
C5-C6.
3. Prevertebral soft tissue edema extending from C2-C3 to C6-C7. CHEST (PORTABLE AP) showed No acute intrathoracic process. MRI OF THE THORACIC SPINE WITHOUT CONTRAST showed 1. Severe spinal stenosis at L3-4 and L4-5 levels due to disc bulging and
facet degenerative changes with compression of the thecal sac and crowding of
the cauda equina nerve roots. Foraminal changes as described.
2. Mild degenerative changes in the thoracic region without spinal stenosis or
cord compression. No abnormal signal within the spinal cord. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed 1. Comminuted fracture of the inferior orbital wall with inferior displacement
of bony fragments, herniation of orbital fat, and blood in the right maxillary
sinus.
2. The inferior rectus muscle abuts the posterior bone fragment without
herniation through the bony defect.
3. Bilateral nasal bone fractures. CR - CERVICAL SINGLE VIEW IN OR showed Intraoperative images were obtained during bilateral C3-7 laminectomies.
Please refer to the operative note for details of the procedure. Radiology showed There has been posterior fusion from C3 to T1. No hardware related
complications are seen. There are degenerative changes with loss of disc
height, worse at C4-C5 and C5-C6. There are degenerative changes with loss of
intervertebral disc height at numerous levels. The patient was diagnosed with Unsp superficial injury of unsp part of head, init encntr, Fall on same level, unspecified, initial encounter. The patient was treated with C3-C7 Laminectomy; C3-T1 Fusion ___ with Dr. ___. At the time of discharge, the patient had 1. Cervical spondylotic myelopathy.
2. Cervical degenerative disc disease.
3. Cervical spinal stenosis, C3 to 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>Ms. ___ is a ___ y/o F who initially presented to OSH s/p
mechanical fall where she was found down. At the OSH she was
found to have a comminuted
right inferior orbital wall fracture with blood in the sinus,
slight injury, with displacement of the inferior rectus muscle
as well as nasal fractures. Also labs were notable for mild
rhabdo. She was transferred to ___ for further care. The
patient reported burning pain in her bilateral hands as well as
weakness. Ortho ___ was consulted and recommended MRI T and L
___. The patient remained in a hard cervical collar. Ortho
___ diagnosed the patient with central cord syndrome s/p
hyperextension injury to the cervical ___. Plan was to take
the patient to the OR for C3-C7 laminectomy and C3-T1 posterior
instrumented fusion.
Ophthalmology evaluated the patient's right eye orbital wall
fracture and there was no evidence of intraocular trauma.
Plastic Surgery was consulted for nasal bone fractures and no
immediate surgical intervention was warranted. It was
recommended she follow-up in clinic with Dr. ___ in
approximately ___ weeks to discuss next steps and possible need
for operative repair.
CK was monitored and downtrended.
On HD2, the patient was taken to the OR with Ortho ___ and
underwent C3-C7 Laminectomy; C3-T1 Fusion on ___.
Patient was admitted to the ___ ___ Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.
Post op course is complicated by acute blood loss anemia, pain
and persists with upper extremity weakness and pain. She was
treated with 2 units PRBC's for her blood loss anemia.
Opthamology and Plastics teams were consulted for her Orbital
wall fracture and nasal fractures. She will require sinus
precautions (HOB>30 degrees, no blowing nose, no drinking from a
straw) per plastics team and outpatient follow up. She will also
follow up with her primary ophthalmologist on discharge.
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 ___ yo M with psychiatric history and ETOH abuse
with progressive mental decline over past ___ yr presenting to ED
for psych eval/social services.
Seen by Cog Neurology clinic ___ for cognitive decline. See
their note for more details, but in summary he has had ___ year of
decline, more acute decline in past ___ months. Felt to be very
impaired on exam, with significant frontal deficits, but no
overt parkinsonian traits (does reports some visual
hallucinations). Felt to have early onset dementia of unclear
origin; possible frontotemporal dementia vs alcoholic dementia. CHEST (PORTABLE AP) showed No acute cardiopulmonary process seen. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Dementia
history of alcohol abuse
SECONDARY DIAGNOSES:
diabetes
depression
hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ yo M with psychiatric history and ETOH abuse
with progressive mental decline over past ___ yr presenting to ED
for psych eval/social services. Per cognitive neurology,
decline is most likely ___ alcoholic dementia.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH listed below presents due to brusing, found to be
profoundly thrombocytopenic. ___ days ___ bruising noted and
she went to ___ day where platelet count
was 3. She was sent here for further evaluation. Patient denies
history of thrombocytopenia or any autoimmune illnesses. CT abdomen and pelvis without contrast showed No evidence of retroperitoneal bleed. The patient was diagnosed with Thrombocytopenia, unspecified. At the time of discharge, the patient had Thrombocytopenia
Hemolytic anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospital Course: Ms. ___ is a ___ h/o HTN, tob dependence,
recent sinusitis (rx'd with abx) presenting with acute
thrombocytopenia (nadir 3K). No signs of bleeding,
hemodynamically stable. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year old female with a history of COPD,
paranoid schizophrenia, s/p multiple abdominal surgeries and
recurrent SBO including hospitalizations in ___ and ___.
All of which were managed medically until she presented with
one day of abdominal pain on ___. She describes pain as
located in upper abdomen and feeling of gas and distention. She
stated she had both BM and flatus one day prior. The patient is
on a bowel regimen at home and has been adherent but has chronic
constipation and states that her bowel movements have been at
her baseline. She had no nausea and was tolerating an oral
diet as of this AM. She denied having fever, chills, dizzyness,
pt with SOB at baseline. She was concerned her stomach pain may
be related to someone at group home poisoning her which is a
chronic complaint. Radiology showed Dilated small bowel loops and air-fluid levels consistent with
small bowel obstruction. No free air. The patient was diagnosed with INTESTINAL OBSTRUCT NOS, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS. At the time of discharge, the patient had Small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was admitted to the inpatient ward under the
Acute Care Surgery service on ___ for further management of
her small bowel obstruction. Her KUB on admission showed
several dilated loops with paucity of colonic gas concerning for
a small bowel obstruction. She was kept NPO and given IV fluids
until her bowel function returned. She was given IV narcotic
and non-narcotic pain medications. Daily electrolyte levels
were checked and repleted (if necessary) while she was NPO.
Because her bowel obstruction hadn't cleared and she was still
having nausea, a ___ tube was inserted on hospital day
3.
On hospital day 6, Mrs. ___ began to pass flatus and show
signs of returning bowel function. She was slowly started on a
regular diet, which she tolerated well. At the same time, she
was resumed on her home medications. Her bronchodilator therapy
and COPD regiment was also initiated, while her supplemental
oxygen was discontinued. She was given an aggressive bowel
regimen to assist in facilitation of a bowel movement, which she
later achieved.
At the time of discharge, Mrs. ___ was hemodynamically
stable, afebrile, and in no acute distress. She was tolerating
a regular diet, voiding without issue and ambulating with
minimal assistance. Since she has no pain at this time, no
prescriptions for discharge were necessary and she will resume
all her prior home medications. A follow-up appointment with
her PCP has been provided. Mrs. ___ is being discharged
to her group home via a chair car.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/HCV and EtOH cirrhosis c/b ascites, variceal bleed,
hepatic hydrothorax, PVT (stopped coumadin for procedure), and
HE in the past that presents as transfer from ___ ED
for worsening SOB. He was admitted to ___ from
___, where they performed a therapeutic thoracentesis and
drained 1.5L fluid with analysis suggestive of transudative
effusion. Ultimately thought to be ___ hepatic hydrothorax. CTA
there was negative for PE. He was discharged on a Na restricted
diet in addition to lasix 40mg, spironolactone 100mg daily, and
5 days moxifloxacin for unclear reasons. Patient has been taking
diuretics as prescribed, but has been non-compliant with Na
restricted diet. Following discharge, patient was breathing
without difficulty and had no DOE, or cough. Beginning ___,
he developed worsening DOE and felt as if his stomach was
"hardening up". DOE worsened on ___ to the point that he was
SOB after walking several feet. He called the GI fellow today,
with the recommendation to go to ___ for further evaluation
and potential transfer. At ___, CXR demonstrated R.
sided recurrent effusion. Patient was then trasnferred to ___.
In the ED, initial vitals were: 98 83 124/70 24 94% 3L NC. He
underwent diagnostic thoracentesis downstairs which was bloody,
but showed WBC ___ w/82%PMN. He received 2g IV ceftriaxone, and
was admited to E/T for further evaluation and management of
effusion.
On the floor, patient states no complaints. He reports mild RLQ
pain for several days and "hard" stomach. Denies current SOB,
fever, cough, wheeze, chills, N/V, diarrhea, dizziness,
lightheadedness, confusion, dysuria, chest pain, palpitations,
weakness, numbness, or paresthesias Radiology showed PA and lateral chest, unchanged since ___.
Large right pleural effusion and right lung collapse are unchanged. Relative
midline position of the mediastinum suggests the fluid did not accumulate
acutely. Left lung is clear. Radiology showed AP chest compared to ___, 2:23 p.m.:
Small right pleural effusion has decreased substantially since earlier in the
day. A short segment of small bore catheter projects over the right lateral
pleural sulcus. No pneumothorax. Rightward mediastinal shift suggests
substantial atelectasis in the right lung, or pleural restriction. Left lung
clear. Heart size normal. Evaluation of the patient with hepatic hydrothorax
after catheter drainage.
Portable AP radiograph of the chest was reviewed in comparison to ___.
There is interval decrease in the right pleural effusion with still present
substantial amount of pleural fluid and basal atelectasis. Upper lung is
essentially clear. Minimal atelectasis at the left lung base is noted. No
pneumothorax is seen. was done. Radiology showed Mild interval decrease in size of right pleural effusion. The patient was diagnosed with PLEURAL EFFUSION NOS, SHORTNESS OF BREATH, ABDOMINAL PAIN UNSPEC SITE, CIRRHOSIS OF LIVER NOS. The patient was treated with Thoracentesis ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
- Hepatic hydrothorax
SECONDARY DIAGNOSES:
- Cirrhosis
- Hepatitis C. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with HCV/EtOH cirrhosis c/b hepatic hydrothorax presents
with recurrent R. pleural effusion likely hepatic hydrothorax.
#R pleural effusion, likely hepatic hydrothorax: Pt presented
with shortness of breath and R pleural effusion on imaging, most
likely hepatic hydrothorax, thought due to non-compliance with
low salt diet and progression of PVT. Had a thoracentesis with
pigtail catheter placement on ___, with 5.5L of output.
Catheter was removed ___. Lasix was increased to 80mg po
bid, and spironolactone was increased to 200mg daily. Pt
improved clinically, with decreased shortness of breath. Serial
CXR showed decreased size of the R pleural effusion.
Interventional radiology was consulted, and they felt pt could
potentially undergo TIPS if indicated despite PVT; this was not
pursued given improvement on increased doses of diuretics.
Interventional pulmonology felt there was no role for
pleurodesis, even if other therapies failed. Pleural fluid
culture showed no growth as of ___.
#Ascites: Worsening ascites over several days likely
multifactorial in the setting of SBP, dietary indescretion, and
PVT occlusion. Patient with >250PMN in ascitic fluid in ED;
however, likely due to bloody tap given absence of other
signs/sx and high hct in fluid (21). Pt had no h/o of prior
peritonitis. Ceftriaxone was started in the ED but discontinued
after the patient was admitted. Fluid culture showed no growth
as of ___. Pt on high dose diuretics as per above.
#Chronic PVT: CT showed evidence of completely occluded PVT as
compared to partial occlusion on imaging earlier this year.
Patient stopped taking coumadin prior to hernia repair and never
restarted. PVT likely predisposing to worsening ascites and
hydrothorax. Pt was not restarted on coumadin, as it was not
indicated for his chronic PVT.
#H/o hepatic encephalopathy: Pt showed no evidence of confusion
or encephalopathy during admission. Was continued on rifaximin
and lactulose.
#H/o variceal bleed: Hct remained stable.
#HCV/EtOH cirrhosis: Pt is currently being evaluated for
transplant. Otherwise, as per above.
#CKD: Cr remained stable and at baseline. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man with history ___ A, DeBakey
type I aortic dissection s/p graft to ascending aorta in ___
who presented to the ED with tearing chest pain and BLE
weakness.
He was walking down the stairs the morning of ___ when he had
abrupt onset of tearing chest pain, similar to his previous
dissection, accompanied by SOB and diaphoresis. He sat down on
the stairs and noted BLE weakness. He took ASA and called EMS.
On EMS arrival he was able to wiggle his toes, but had no other
movement of his BLE. His chest pain completely resolved prior to
arrival in the ED. CT chest, abdomen and pelvis with contrast showed 1. Status post type A aortic dissection graft repair with similar extent of
the dissection flap involving the descending aorta and abdominal aorta,
terminating at the level of the origin of the inferior mesenteric artery.
2. When compared to ___, interval increase in the degree of aneurysmal
dilatation of the descending thoracic and abdominal aorta, measuring up to 4.8
cm in the descending thoracic aorta and 3.9 cm in the infrarenal abdominal
aorta.
3. Interval increase in the size of the false lumen, much of which is
thrombosed, and interval decrease in the size of the true lumen.
4. The celiac axis, superior mesenteric artery, inferior mesenteric artery,
the right renal artery, and the inferior left renal artery continue to be
supplied by the true lumen. The superior left renal artery is supplied by
both the true and false lumen.
5. A disc bulge at L3-L4 results in moderate narrowing of the vertebral canal.
6. Mild pulmonary edema.
RECOMMENDATION(S): If there is concern for spinal cord infarct, MR is
recommended for further evaluation. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Except for mild atherosclerotic disease in the cervical and intracranial
vascular structures, no significant abnormalities are seen on CT angiography
of the head neck. No dissection is visualized in the cervical arteries. CHEST (PORTABLE AP) showed Nearly resolved bibasilar opacities since prior.
Stable appearance of descending thoracic aorta. VENOUS DUP UPPER EXT UNILATERAL LEFT showed Completely occlusive thrombus within 1 of the left brachial veins at the
antecubital fossa. Completely occlusive thrombus along the course of the left
cephalic vein.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:11 pm, 2 minutes
after discovery of the findings. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. MRI CERVICAL AND THORACIC. showed Increased T2/STIR signal spanning from C5-C6 to T12, more conspicuous in some
areas than others, and demonstrating enhancement postcontrast, consistent with
spinal cord infarct.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 5:15 pm, 5 minutes after discovery
of the findings. UNILAT UP EXT VEINS US RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. The patient was diagnosed with Acute infarction of spinal cord (embolic) (nonembolic). The patient was treated with s/p lumbar drain d/c on ___. At the time of discharge, the patient had Acute spinal infarct C6-T12
Aortic dissection
Atrial fibrillation
Diabetes
Hyperlipidemia
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 ___ man with history of atrial
fibrillation and ___ aortic dissection s/p graft in
___ who presented with tearing chest pain, SOB, and bilateral
lower extremity weakness, concerning for spinal cord infarction
secondary to dissection. Exam notable for bilateral lower
extremity weakness R>L with diminished sensation to pinprick
consistent with anterior spinal cord syndrome. MRI notable for
spinal cord infarct spanning C5/C6 to T12 which is consistent
with the deficits of the corticospinal and spinothalamic tracts
at and beyond these levels. Additionally, patient demonstrates
weakness of the L hand, etiology is likely secondary to a
separate central cord syndrome related to canal narrowing as
identified on cervical MRI with small posterior disc buldges at
the level of C3-C6. He was initially managed in ICU with lumbar
drain and then eventually transferred to NIMU s/p removal. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ left-handed woman with a past medical
history of one lifetime grand mal seizure, discoid lupus,
depression, anxiety, migraine, psoriasis who presents with
significant retrograde amnesia. History is obtained from patient
and her sister. Patient initially was symptomatic at home in
front of her son but unable to contact son at this time. MR HEAD W AND W/O CONTRAST T___ MR HEAD. showed 1. Acute infarct involving a punctate area of the left hippocampus.
2. Findings consistent with sinus disease.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:16 pm, 10 minutes after
discovery of the findings. The patient was diagnosed with Transient global amnesia. At the time of discharge, the patient had Left hippocampal stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ left-handed woman with a past medical
history of one lifetime grand mal seizure, discoid lupus,
depression, anxiety, migraine, psoriasis who presents with
significant retrograde amnesia. Exam on presentation otherwise
nonfocal with no other abnormalities. She had an MRI of the
brain which revealed a small left hippocampal stroke. We
performed a CTA head and neck which did not show severe
atherosclerosis. TTE did not reveal LV embolus. Telemetry has
been without abnormal rhythms. We have initiated
hypercoagulability work-up. She will need two weeks of cardiac
monitoring as an outpatient, which she will need to discuss with
her PCP to arrange. We have started her on aspirin 81 mg daily
and atorvastatin 40 mg daily for secondary stroke prevention.
She had 48 hours of EEG which were normal. She had bland CSF
studies.
She has evidence of a recent shingles infection. She was
complaining of parasthesias in the affected area. We have
prescribed her a two week course of pregabalin. She can request
additional medication from her primary physician if needed. We
have not made any other changes in her home medications. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o Portugese speaking F presents from OSH s/p
fall today.
Per patient's daughter, patient was placing groceries in the car
when she fell striking her head on the concrete. Her son who was
with her denies any loss of consciousness at time of fall. She
was brought to ___ where a head CT was performed
and showed L sylvian fissure SAH. Due to the location of the
hemorrhage, the patient underwent a CTA of the head which was
negative for aneurysm. She was transferred to ___ for further
neurosurgical evaluation. Radiology showed mpression: Right ICA<40% stenosis.
Left ICA<40% stenosis. Radiology showed 1. Left frontal convexity focal subarachnoid hemorrhage, unchanged over an 18
hour interval, with no new hemorrhage.
2. Two well-defined hypodense lesions within the left basal ganglia may
represent lacunar infarcts in the setting of hypertension or, alternatively,
prominent ___ spaces.
3. Multiple punctate supeficial calcifications scattered throughout cerebral
cortex consistent with old, healed neurocystercerosis; is there a seizure
history? The patient was diagnosed with TRAUM SUBARACHNOID HEM, UNSPECIFIED FALL. At the time of discharge, the patient had Left subarachnoid hemorrhage in sylvian fissure.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o F who was admitted to the neurosurgery
service s/p fall without LOC. Imaging studies revealed a left
subarachnoid hemorrhage in the sylvian fissure. She was admitted
for monitoring as well as a syncopal work-up. Urinalysis and
culture was negative for an infectious process. Cardiac enzymes
were negative. On ___, she underwent a CTA which showed a
2-mm left PCOM aneurysm versus infundibulum. No neurosurgical
procedure was required.
The patient underwent a repeat head CT on ___ which was stable
from her prior exam. During her inpatient stay, she was
hemodynamically and neurologically stable. Her pain was treated
with narcotic and non-narcotic analgesics.
In terms of her syncope work-up, a carotid ultrasound showed
less than 40% ICA stenosis bilaterally. An ECG showed a heart
rate of 70 in sinus rhythm with possible left ventricular
hypertrophy. An echocardiogram was obtained prior to the
patient's discharge, but a formal read was not available. The
imaging was suboptimal due to poor windows and the patient's
body habitus.
Ms. ___ was discharged on ___. She was instructed to
contact the ___ clinic for a follow-up appointment in
four weeks with a non-contrast head CT prior to her appointment.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ developmental delay, COPD on 2L home O2, history of
recurrent non-small-cell lung cancer with recurrent airway
obstruction requiring stenting, who presents with respiratory
distress. Caregiver reported 3 days SOB. EMS reported O2 sats
___ on RA and RR ___. ED vitals were sig for tachycardia to 107,
O2 94% w/ supplemental O2 and RR 33. ED labs significant for WBC
18.7, VBG ___ with lactate of 2.3. CXR with LLL
consolidation. Albuterol nebs x4, Mg 2gm, stress dose steriods
and broad spectrum abx began in ED. Despite interventions, pt
remained tachypneic with VBG w/ pCO2 of 65, so patient was
intubated. He was hypotensive around the time of intubation and
received 2L NS. Of note, patient has undergone multiple bronchs
for tumor debridement and stent placement by IP service, with
most recent bronch on ___ which showed granulation tissue around
stent and small tumor implants treated with argon plasma
coagulation (APC) and cryo. Radiology showed Left lung base opacity has progressed since prior. This opacity is part due
to known underlying mass with likely component of postobstructive atelectasis
and/or infection. Radiology showed Right mainstem intubation. Endotracheal tube side port at the junction. No
other change.
NOTIFICATION: Findings were already known to the clinical team at time of
interpretation and discussed by Dr. ___ with Dr. ___ at approximately
13:30. Comparison to ___. Progression of the pre-existing
left mid lung and lower lung parenchymal opacities. The presence of a
coexisting pleural effusion is likely. No change in appearance of the right
lung. The feeding tube has been pulled back and should be advanced by
approximately 12 cm to be can securely positioned in the stomach. was done. CT CHEST W/O CONTRAST showed Left bronchial stent intact in terms of position in caliber, now occluded by
secretions and at its tip by growing left hilar mass. Upper and lower lobe
bronchi now entirely occluded, with complete collapse of the upper lobe and
new atelectasis or postobstructive pneumonia in the lower. New small left
pleural effusion is secondary to occlusion.
New air in duration, prevascular mediastinum and pericardial effusion could
both be due to malignant involvement.
Severe emphysema right lung. No right-sided pneumonia. CHEST (PORTABLE AP) showed ET tube is in standard position. NG tube tip is high, the side port is at the
mid esophagus and should be advanced for more standard position at least 8.5
cm. Peripheral opacities in the right lung have increased worrisome for
aspiration. There is no evident pneumothorax. Left lung mass and large area
of consolidation throughout the left lung are better evaluated on prior CT.
Cardiac size cannot be evaluated. CHEST (PORTABLE AP) showed Small right effusion has minimally increased. Right lung peripheral opacities
are minimally increased worrisome for aspiration. Almost complete whiteout of
the left lung with some aeration of the left apex has worsened. There is no
evident pneumothorax. ET tube is in standard position. NG tube tip is in the
stomach but the side port is in the lower esophagus, again should be advanced
for more standard position Radiology showed The nasogastric tube has been advanced with the distal tip and side-port now
within the body of the stomach. The rest of the study is unchanged. There is
again seen near complete whiteout of the left lung with only a small amount of
aerated lung at the apex. There is a unchanged small right-sided pleural
effusion. There are no pneumothoraces. Radiology showed Support lines and tubes are unchanged in position. There is increased
opacification of the left lung with only a small portion of the apex aerated.
Overall, the findings are unchanged. There is a small right-sided pleural
effusion and developing consolidation at the right base. There are no
pneumothoraces. Radiology showed There is a new right-sided PICC line with the distal lead tip in the distal
SVC. Nasogastric tube tip and side port are within the stomach. There is
again seen near opacification of the left lung with sparing at the apex.
There is slight improved aeration at the apex. Small right-sided pleural
effusion is seen. There remains opacities at the right base. Radiology showed In comparison to ___ radiograph, the left hemi thorax is nearly
completely opacified, with near complete collapse of the left lung. This may
be due to reaccumulation of secretions within the patient's left bronchial
stent, as previously demonstrated on CT of ___. Coexisting left
pleural effusion is difficult to quantify in the setting of but may have
increased since the prior radiograph. No other relevant change.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:37 AM, 5 minutes after
discovery of the findings. Radiology showed There is an orogastric tube whose tip and side port are within the body of the
stomach. The rest of the lines and tubes are unchanged. Cardiomediastinal
silhouette is within normal limits. There is slight decrease in the
left-sided pleural effusion and improved aeration. There remains a small
right-sided pleural effusion. Parenchymal opacities within the right mid and
lower lung fields are unchanged.
NOTIFICATION: Are CHEST (PORTABLE AP) showed 1. Near complete collapse of the left lung with a significant leftward
mediastinal shift, unchanged compared to prior study.
2. Emphysematous changes are noted.
3. The endotracheal tube is 9 cm above the carina. Recommend pulling forward
4cm.
RECOMMENDATION(S): Recommend pulling endotracheal tube forward 4 cm.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:05 ___, 15 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed Compared to chest radiographs most recently ___.
Endotracheal tube has been advanced to standard placement. The small region
of aeration at the left apex has decreased. Left lung still largely
collapsed, accompanied by small but increasing left pleural effusion. Mild
pulmonary edema in the right lung unchanged. No pneumothorax.
Right PIC line ends in the mid SVC, esophageal drainage tube in the upper
stomach. Radiology showed 1. Consolidation at the left lung base. Recommend chest radiograph if one
has not been recently obtained.
2. Nonspecific bowel-gas pattern although assessment is somewhat limited. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently ___ at 05:22.
ET tube has not been advanced at least 4 cm, as previously suggested.
New interstitial abnormality in the right lower lung is probably edema.
Minimal aeration has returned the apex of the left lung, still otherwise
collapsed. Bronchial stent is still present in the left main and lower lobe
bronchus.
SUBSEQUENT CHEST RADIOGRAPH, 04:39 ON ___, AVAILABLE TIME OF THIS REVIEW
SHOWS APPROPRIATE REPOSITIONING OF THE ENDOTRACHEAL TUBE. CHEST (PORTABLE AP) showed No relevant change as compared to ___, 04:39. Near complete
opacification of the left hemi thorax, with mediastinal shift to the left.
Stable appearance of the right lung with non characteristic interstitial
opacities at the right lung bases. No new focal parenchymal abnormalities.
Stable position of the monitoring and support devices. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
No appreciable change in an nearly complete collapse of the left lung,
accompanied by in in indeterminate volume of pleural effusion. Heterogeneous
opacification in the right lower lobe could be dependent edema, in a patient
with emphysema, but pneumonia is not excluded.
Left bronchial stent is difficult to identify. If still present it is
probably occluded. ET tube in standard placement. Nasogastric drainage tube
ends in the stomach. Right PIC line ends in the low SVC. No right
pneumothorax. Right pleural effusion is small if any. Radiology showed Dilated loops of large and small bowel. These findings are concerning for
ileus, not obstruction.
Findings in the left lung base were better evaluated on the dedicated chest
radiograph from ___.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:58 ___, 10 minutes after
discovery of the findings. PORTABLE ABDOMEN showed Mild improvement since prior exam. Chest single view showed Improved aeration of the left lung. ET tube at the carina facing the right
mainstem bronchus. CT abdomen and pelvis showed 1. Severe diffuse distention of colon up to 8 cm without evidence of
obstruction, consistent with colonic ileus. No evidence of free air.
2. Moderate anasarca.
3. Consolidation at the left lung base is consistent with known pneumonia. CHEST (PORTABLE AP) showed Mild interval volume loss left lung.
Otherwise as above Radiology showed 1. Improved lung volume with resolution of left lower lobe collapse.
2. Persistent left hilar mass without new consolidation. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Previously collapsed left lower lobe and lingula have substantially read
expanded, though some atelectasis persists. Bronchial stent in the left main
bronchus extending at least to the level of the upper lobe takeoff. No
pneumonia pulmonary edema. Right pleural effusion is small, unchanged. No
mediastinal widening.
Tracheostomy midline. Right PIC line ends in the upper SVC. Radiology showed Stable chest radiograph. CT CHEST W/O CONTRAST showed Despite left main bronchus stent in situ, large left hilar mass/adenopathy
encases the left main bronchus and occludes the left upper lobe and superior
segment of left lower lobe bronchi and severely narrows the left lower lobe
basal truncus.
Bronchial impaction and airspace consolidation involving the posterior aspect
of the left upper lobe, lingula and basal segments of the left lower lobe.
Postobstructive pneumonia cannot be excluded. CHEST (PORTABLE AP) showed Comparison to ___. The previously correctly positioned right PICC
is now malpositioned and coiled in the right internal jugular vein. The line
needs to be repositioned. No pneumothorax.
The endotracheal tube is in correct position. The relatively extensive left
predominant parenchymal opacities of multifocal distribution are overall
stable.
NOTIFICATION: The findings were discussed in person with the referring
physician ___ at 09:05, on the eleventh staff ___, on occasion
of the radiology ICU conference, approximately 90 min of the acquisition of
the image, and 1 min after observation. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed Comparison to ___, 05:19. The malpositioned PICC line on the right
is in unchanged position. The line needs to be repositioned. Otherwise
unchanged radiograph. No pneumothorax. CHEST PORT. LINE PLACEMENT showed Comparison to ___, 10:28. The right PICC line is still
malpositioned, the tip is now located in the internal right-sided jugular
vein. The device needs to be repositioned. Stable appearance of the heart
and the lung parenchyma. No evidence of pneumothorax. Radiology showed Successful placement of a 41.5 cm right arm approach single lumen PowerPICC
with tip in the distal SVC. The line is ready to use. Radiology showed No significant interval change since the prior exam. Radiology showed 1. Interval increase of the left mid lung opacification partially due to
underlying lung lesion but postobstructive pneumonia cannot be ruled out.
2. Interval reposition of right PICC line looping in the right internal
jugular vein and terminating in the right brachiocephalic vein Radiology showed Multiple nondilated air-filled loops of large and small bowel, decreased in
extent since the prior radiograph. Radiology showed Interval decrease in gaseous distention of multiple loops of large and small
bowel. CT Abdomen and Pelvis showed 1. No evidence for acute intra-abdominal process.
2. Prominent, lobulated appearance to the ileocecal valve, which may simply
represent a prominent ileocecal valve. Additional diagnostic considerations
include a transient/early ileocecal intussusception without evidence of
obstruction, with a focal mass considered less likely given the lack of prior
findings from the previous CT dated ___. If clinically indicated,
further evaluation could be performed by colonoscopy or potentially MR
enterography.
3. Contrast enhancement involving the right peripheral zone of the prostate,
which may be secondary to prostatitis.
4. Known, large invading mediastinal mass with extension into the left
atrium.
5. Multiple pelvic osseous lucencies which appear unchanged from the prior
examination, but warrant continued attention on follow-up.
This preliminary report was reviewed with Dr. ___
radiologist. Radiology showed Successful replacement of a 40 cm right arm approach double lumen PowerPICC
with tip in the low SVC. The line is ready to use. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with ___: patient was intubated
___: Bronchoscopy and BAL
___: Right PICC placed
___: Tracheostomy and PEG tube placement
___: Interventional radiology procedure to fix coiled PICC
___: Midline placed (this access remains in p[lace at
discharge). At the time of discharge, the patient had Primary: actue hypercarbic respiratory failure
Secondary: pneumonia, advanced non-small cell lung cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with advanced NSCLC s/p multiple IP procedures with
palliative stenting and COPD who presents with acute hypercarbic
respiratory failure.
#Acute hypercarbic respiratory failure requiring tracheostomy:
Patient was intubated in the setting of his respiratory failure.
The respiratory failure is was caused by his non-small cell lung
cancer, which causes narrowed airways and risk of
obstruction/mucous plugging. Throughout his hospitalization, he
had mucous plugs plus copious secretions. He also underwent
multiple bronchoscopies to clear out the mucous/secretions.
After he had been intubated for one week with unsuccessful vent
weaning, he underwent a trach/PEG procedure on ___. He was
gradually weaned from the ventilator and was tolerating PSV as
of ___, tolerating trach mask as of ___ (including overnight),
and using speech valve as of ___. On the floor he was able to
work with physical therapy and continued tolerating his speaking
valve.
#Pneumonia:
The patient was treated with an 8 day course of vancomycin and
ceftriaxone for ventilator associated pneumonia, exacerbated by
a post-obstructive picture from his non-small cell lung cancer.
A sputum culture was also obtained that was positive for
stenotrophomonas, and he was treated for 7 days with Bactrim.
After that course was finished, he had another fever. He was
started on vancomycin and zosyn on ___. This was narrowed again
to Bactrim on ___ when sputum culture again grew
Stenotrophomonas; he completed a ___nemia:
The patient was found to have anemia, likely secondary to anemia
of chronic disease. During this hospitalization, he was
transfused a total of 2 units packed red blood cells. H&H stable
for many days prior to discharge.
# Hyperkalemia: Pt had recurrent episodes of hyperkalemia
requiring treatment. Renal was consulted and they felt this was
a side effect of Bactrim. This has resolved now that he is off
this medication.
# Abdominal Pain and constipation:
Pt has been having intermittent abdominal pain on exam. CT A/P
performed showed ? of intermittent intesussception, although
clinically his pain is greatly relieved when he has a bowel
movement, so it is likely related to constipation. He is
discharged with numerous PRN laxatives and will need these
titrated to ensure he has regular BMs.
# Cancer-related pain
He has been started on standing dilaudid with additional doses
PRN.
# Prostate Abnormality on CT:
Patient likely has metastatic prostate cancer with PSA of 69 and
lytic bone lesions. This is unlikely to be life limiting given
the advanced state of his lung cancer and he is on no treatment
for this.
#Protein-calorie malnutrition
Patient is cachectic in the setting of his cancer. He is on
continuous nepro tube feeds at 50 mL/hr per PEG tube.
# Advanced Non-small cell lung cancer:
#GOALS OF CARE
This patient has terminal cancer with life expectancy is likely
less than ___ months. He is unable to communicate well s/p
trach, he is largely bedbound due to deconditioning and advanced
cancer and has cancer related pain; quality of life appears to
be minimal. He is not a candidate for chemotherapy or radiation.
His primary lesion encases major airways and errodes into the
right atrium, suggesting he is at ongoing risk for sudden death
with PEA arrest from various irreversible and unsurvivable
causes (massive exsanguination, tamponade, etc.).
It is the belief of his guardian and of this author that his
full code status is medically inappropriate and far more likely
to cause him suffering than to prolong life. Unfortunately, his
guardian does not have the legal authority to change his code
status and the patient does not have the capacity to make this
decision himself. A lawyer at the ___
___ is petitioning the court to expand the powers of his
guardian ___ from The Arc of
___, ___. This hearing is on or around
___. The attorney at ___ (___) will
continue to follow the case and offer support if needed, but
they are not the primary party making the petition.
TRANSITIONAL ISSUES
- Continue ___ and speech therapy to maintain his ability to move
and communicate independently.
- Adjust PO dilaudid as needed for pain
- Adjust bowel regimen as needed for one BM daily (constipation
causes him significant abdominal pain)
- Continue to follow the legal petition for the guardian to be
able to change code status. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with PMH significant for ___ and
HTN presenting from ___ with CT Head
concerning for cystic mass with hydrocephalus. History is
limited
due to patients neurologic status, information obtained from
transfer records. Per records, patient presented to PCP office
with complaints of headache and left sided neck pain for the
past
2 months, went to ___ where CT Head was obtained
finding a 1.7cm by 1.9cm cystic mass. Per documentation and ED
staff, patient was awake upon arrival however prior to consult
patient became difficult to arouse and answering questions with
interpreter. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Obstructive hydrocephalus from a 2.2 cm hypodense lesion at the level of
the foramen of ___. The lesion likely is suggestive of craniopharyngioma. MR HEAD W AND W/O CONTRAST showed 1. Suprasellar mass extending to foramen ___ most likely due to
craniopharyngioma.
2. Obstructive hydrocephalus with mild periventricular edema seen in the
lateral ventricles.
3. Optic chiasm is deformed from the posterior aspect. CHEST (PRE-OP AP ONLY) showed There are no prior chest radiographs available for review.
Lungs are fully expanded and clear. Heart is mildly enlarged. Pulmonary
vasculature is top-normal caliber, but there is no pulmonary edema pleural
effusion. CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. Unchanged intermediate density 2.6 x 1.9 cm suprasellar mass extending to
the level of the foramen of ___, likely representing craniopharyngioma, with
persistent posterior deformity of the optic chiasm. Bilateral A1 segments of
the anterior cerebral arteries past inferiorly to and contact this mass,
without luminal narrowing.
2. Unchanged moderate obstructive hydrocephalus with mild transependymal
edema.
3. Patent intracranial vasculature without significant stenosis, occlusion,.
4. Bilateral posterior communicating artery origin protuberance most likely
due to infundibula given conical appearance. PRE-SURGICAL PLANNING WAND STUDY showed Suprasellar mass most likely due craniopharyngioma is unchanged compared to
the prior study. Examination performed for surgical planning. CT HEAD W/O CONTRAST showed 1. Postoperative changes including pneumocephalus, swelling and mass effect.
2. New right parietal subarachnoid hemorrhage and small bilateral
intraventricular hemorrhage.
3. Residual calcifications in the sella. MR HEAD W AND W/O CONTRAST showed Status post resection of the sellar and suprasellar mass with expected
postoperative changes.
Enhancement within the sella turcica, along with residual calcification noted
on the CT scan, suggests a small amount of residual tumor in this location. CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. Postsurgical changes from right frontal craniotomy and sellar mass
resection with residual calcifications in the sella suggestive of residual
tumor.
2. Unchanged areas of right frontal intraparenchymal hemorrhage, right insular
subarachnoid hemorrhage and intraventricular hemorrhage, with mildly increased
surrounding vasogenic edema, though degree of mass effect appears unchanged
compared the prior examination with up to 8 mm leftward midline shift, and
effacement of the right lateral ventricle. Pneumocephalus has mildly improved
compared the prior examination. No new focus of hemorrhage. No CTA spot sign
to suggest active hemorrhage.
3. Increasing right hemispheric superficial soft tissue hemorrhage and fluid
collection, with increasing swelling extending to the right face and
periorbital soft tissues.
4. Otherwise patent intracranial vasculature without significant stenosis,
occlusion, or aneurysm.
5. Persistent irregular beaded appearance of the internal carotid arteries,
which can be seen in the setting of fibromuscular dysplasia.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:07 AM, 5 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed 1. A enteric tube terminates in the stomach.
2. Low lung volumes, with atelectasis at the left lung base CHEST (PORTABLE AP) showed In comparison with the study of ___, there is increasing opacification
at the left base, consistent with pleural fluid and volume loss in the left
lower lobe. Monitoring and support devices are unchanged. No acute pneumonia
or vascular congestion. CT HEAD W/O CONTRAST showed 1. Similar intracranial hemorrhage. No new hemorrhage.
2. Stable leftward shift of midline structures.
3. Decreased size of the third ventricle. Mildly more dilated left lateral
ventricle and mildly more effaced bilateral ventricle.
4. Stable effacement of the suprasellar, perimesencephalic, pre pontine
cisterns. CT HEAD W/O CONTRAST Q111 CT HEAD showed No significant change compared to ___ at 21:16. CT HEAD W/O CONTRAST showed 1. Stable subdural collection overlying the right frontal lobe deep to the
right frontal craniotomy with slightly increased edema and increased midline
shift.
2. Concern for loss of grey white interface right temporal and parietal lobes
worrisome for developing infarct versus possible artifact.
3. Stable intraparenchymal hemorrhages of the right anterior temporal and
right frontal lobe extending into the basal ganglia.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 6:05 ___, 10 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. Elevated left diaphragm. ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Cerebral cysts. The patient was treated with ___ Craniotomy for Tumor Resection. At the time of discharge, the patient had Craniopharyngioma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female presents with headaches found to have a 1.7cm
by 1.9cm cystic mass. She was transferred to ___ from an OSH
for further care and evaluation by the Neurosurgery Team. She
was admitted to the Neuro ICU.
#Right Craniotomy for Tumor Resection: The patient was taken to
the OR and underwent a right craniotomy for tumor resection. She
remained intubated post operatively and was taken immediately to
CT scan for a post-operative NCHCT which demonstrated
improvement of hydrocephalus and SAH and small amount of
hemorrhage in the resection bed. She was loaded with 1 gram of
Keppra in the OR and continued on 500mg BID. She was on
dexamethasone, and urine output was monitored q1h and serum
osmolality, sodiums and specific gravity was monitored q6h. A
post-operative MRI was ordered and that showed some residual
tumor. She remained stable over the remaining few days and was
transferred to the ___ on ___. She continues to have a
waxing and waning exam and got a Head CT due to lethargy on
___ and ___, both of which were stable. On ___ the
patient was brighter on AM exam and her labs were closely
monitored. She was ordered for ___ and OT, who recommend rehab at
discharge. Sutures and staples were removed on POD#13 as
incision was clean, dry and well healed.
ENDOCRINE - patient was closely followed by Endocrinology for
the following:
#DI: The patient has been on DI watch with frequent serum sodium
and UA checks. On ___ she was hypernatremic to the 158 with
increased serum osmolarity and decreased urine spec gravity. She
was given DDAVP with good effect. She was instructed to drink
to thirst with goal of 1 liter a day. On ___ her sodium was
down to 137 from 147 and on repeat check later in the day down
to 133, likely SIADH, and 1.2L fluid restriction was initiated.
On ___ the patients sodium had normalized to 138 and she
continued to drink to thirst. Her serum sodium and urine labs
were monitored closely every six hours. Overnight on ___ she
met criteria for DI, and was given 1mcg of DDAVP with good
effect. The patient urine output, Sodium, and Specific Gravity
continued to wax and wane. She received DDAVP on ___ with good
effect. Endocrine continued to follow and recommended having
her drink to thirst with goal of 600cc every 4 hours. Labs
checks were relaxed to Q 8 on ___ and ___. Starting on
___ patient was given standing DDAVP 10mcg intranasal daily at
9pm.
#Panhypopituitarism: Preop labs showed low LH (low suggesting
hypogonadism), low cortisol (suggesting secondary adrenal
insufficiency), low Prolactin (suggesting pituitary hypofunction
___ mass effect), and low FT4 (suggesting central
hypothyroidism). She was given 100 mg IV hydrocortisone
intraoperativly and started on Decadron 4q6 postop and tapered
to 2mg BID.
#Leukocytosis
Patient was noted to have persistent elevated white blood cell
count. She was afebrile. Urine and Blood cultures were negative.
CXR was negative for acute infection process. ___ Doppler US were
negative for DVT. Leukocytosis is possibility related to
dexamethasone and taper of this medication was started. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ female with a history of
autoimmune hemolytic anemia on prednisone, diastolic heart
failure, ESRD s/p renal transplant and recent left big toe
amputation who presents with positive blood cultures growing
gram-positive cocci in clusters.
She had a blood draw blood draw from her portacath on ___
at ___ clinic when it was noted that the dressing was
labeled from ___ with no on the end of port tubing. Blood
cultures were drawn and she was given a dose of vancomycin.
Blood cultures were positive and she was called today by her
doctor to return to the ER for admission.
She saw her podiatrist this week who prescribed her clindamycin
for some drainage from the foot she has been taking. She has not
had any other fevers/chills, chest pain, shortness of breath,
abdominal pain, dysuria or rash
Of note, patient was recently admitted to ___ service ___
for diatolic heart failure exacerbation. She was diuresed, had a
planned left lower extremity arteriogram to evaluate left hallux
dry gangrene now status-post left peroneal artery angioplasty
and left hallux amputation. Discharge weight 57.9kg
In the ED initial vitals were: 98.2 64 112/50 18 100% RA
- Labs were significant for lactate 2.0
- blood cultures were repeated
Vitals prior to transfer were: 98.1 68 96/50 20 100% RA
On the floor, patient has no complaints and is feeling well.
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. CHEST (PA AND LAT) showed Moderate cardiomegaly with mild pulmonary edema, small bilateral pleural
effusions. Radiology showed Status post amputation of the left great toe with soft tissue swelling noted.
No convincing signs for osteomyelitis. CHEST (PA AND LAT) showed Improved pulmonary edema. Bibasilar opacities adjacent to the small bilateral
effusions are likely atelectasis but superimposed infection cannot be
excluded. The patient was diagnosed with BACTEREMIA 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>BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ female with
a PMH of autoimmune hemolytic anemia on prednisone, diastolic
heart failure (recent exacerbation ___, ESRD s/p renal
transplant on sirolimus, and recent left hallux amputation
(___) who presented with positive blood cultures drawn off
of her accessed port at clinic. Her blood cultures eventually
grew coag negative staph bacteremia. Given her hx. of
immunocompromise, she was initially started on vancomycin with
vanc locks. The infectious disease doctors were ___. Pt.
remained afebrile, without a leukocytosis, without further
evidence of growth on cultures. As such, this blood cx. was
thought to be a contaminant. Pt. was discontinued off
vancomycin. Pt's Hgb was noted to trend down from 8 to 6. She
was transfused two units of specially matched blood from the
___ Cross given her extensive history of blood
antibodies. She was discharged with close outpatient follow-up.
ACTIVE ISSUES
==============
# Coag Negative Staph Bacteremia: Pt's port was mismanaged at
rehab facility. Port was left accessed with old needle in
place. As such, pt. had outpatient blood cultures with returned
initially with gram positive cocci. For concern for bacteremia,
pt. was admitted for further work-up. Given immunosuppression,
pt. was started on daptomycin (given hx. of VRE colonization)
and later transitioned to IV vanc with vanc locks per ID
consultation. Blood cultures later turned coag negative staph.
This was thought to be a contaminant as no other blood cultures
returned positive. She lacked any infectious symptoms on
admission. Podiatry was consulted who felt that her healing
left hallux amputation site was without infection. She was
discharged off antibiotics.
# Autoimmune hemolytic anemia with exacerbation: Pt. is known
to have autoimmune hemolytic anemia, s/p splenectomy, on chronic
prednisone. Her H/H downtrended on admission. She remained
hemodynamically stable. After speaking with blood bank, a
sample of the pt's blood was sent to the ___ Cross. 2
units of matched blood were found. She received 2 units of
pRBCs without issue. Her H/H remained stable. Her hemolysis
labs were noted to be near their usual baseline or improved.
# Hyponatremia: Pt. noted to have hyponatremia. On further
evaluation, it seems pt. had some nausea, vomiting, and poor PO
intake in the several days leading up to hospitalization. This
in addition to her diuretic therapy likely resulted in
hypovolemic hyponatremia. Diuretics temporarily held and PO
intake improved. Hyponatremia slowly resolved with improved PO
intake and diuretics were resumed.
# ___ on CKD: Pt. with increased creatinine to 2.2 from 1.5.
Likely pre-renal azotemia as pt. improved as she reached
euvolemia.
# Peripheral Vascular Disease complicated by Left Hallux
Arterial Ulceration/Gangrene status-post Left Peroneal Artery
Angioplasty and Left Hallux Amputation: Pt. with amputation on
___. Podiatry evaluated the site and felt that there was no
active infection on admission. Also was felt that her wound
would likely not heal without improved arterial supply to the
foot. Pt. was encouraged to present to her already scheduled
outpatient vascular work-up. She was continued on atorvastatin
and clopidogrel.
#HTN: Pt. with some low-normal BPs on admission. As such, her
hydralazine was decreased to 25mg PO TID.
CHRONIC ISSUES
================
#Diastolic Heart Failure: Pt's torsemide were temporarily held
given hypovolemia but were later resumed. Discharge weight
below.
# Type II Diabetes Mellitus: ISS while in house.
# Atrial Fibrillation / Atrial Flutter status-post Atrial
Appendage Ligation: Pt. not candidate for warfarin given
previous life-threatening GI bleeds in the past. She was
continued on metoprolol for rate control.
TRANSITIONAL ISSUES
=======================
# Discharge Weight: 58.2kg
# Repeat Blood Cultures: Per ID, pt. should have repeat blood
cultures off port in ___ days from ___ to ensure no further
growth of coag negative staph.
# Wound Dressing: Continue daily wet to dry dressing changes
# Repeat Labs: Pt. should have repeat CBC and Chem 7 to check
for worsening anemia and hyponatremia ___ days following
discharge.
# Recent Amputation: Pt. should be non weight bearing on left
forefoot. She can be full weight bearing on left heel. When
walking, she should use forefoot offloading shoe.
# Nonhealing foot: Podiatry evaluated her foot on
hospitalization. no concern for infection at this time. There is
continued concern that the blood supply to her left foot is
limited. She should follow-up with vascular as scheduled.
# Port Care: Port should be deaccessed at this time. She will
require a port flush ___ weeks from ___.
# BP Regimen: Hydralazine reduced from 50 TID to 25 TID at
discharge as pt's BP was within normal limits in the setting of
averaging ___ doses of 50mg hydralazine a day during her
hospital stay.
# Code: Full, confirmed
# Emergency Contact: Emergency contact is ___
(daughter, HCP) @ ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ male with bladder cancer s/p robotic radical
cystectomy and ileal loop on ___ with Dr ___. Post
operative course was unremarkable and he was discharged home on
___. He initially did well at home until yesterday when he
presented to ___ in ___ overnight with vague
abdominal pain and malaise. He ad a CT which showed bilateral
mild hydronephrosis, which is to be expected, and was otherwise
unremarkable. His labs were notable for a wbc of 34, elevated
LFTs and UA concerning for infection. CHEST (PA AND LAT) showed 1. Bibasilar opacities may represent atelectasis or aspiration.
2. Subcutaneous emphysema along the right lateral chest/upper abdominal wall,
which should be correlated with site of recent surgery/instrumentation. Radiology showed 1. Dilated loops of large bowel which is new since CT abdomen and pelvis
___. This is most consistent with a focal colonic ileus. Toxic
megacolon cannot be excluded. Radiology showed 1. Interval resolution of large bowel dilatation since abdominal radiograph ___.
2. Dilated small bowel loops, unchanged since CT abdomen ___,
compatible with postoperative ileus. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Acute 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 ___ was admitted to Dr. ___ service on ___
with the above history. At ___ he had a CT which
showed bilateral mild hydronephrosis,
which is to be expected, and was otherwise unremarkable. His
labs were notable for a wbc of 34, elevated LFTs and UA
concerning for infection. In the ___ ED he was seen with wbc now
elevated to 64. He was afebrile but his leukocytosis and loose
stools were felt to be concerning for c. dificile colitis and he
was started on broad spectrum antibiotics including coverage for
c dificile with PO flagyl as well as cefepime and vancomycin.
On HD2 formal ID consult was obtained. He had initial
difficulties having a bowel movement and thus c. dificile
amplification assay was unable to be performed however urine and
blood cultures remained negative so empiric treatment for c.
dificile was continued. ACS were consulted and recommended
serial KUB to assess for risk of toxic megacolon, this was done
and was normal.
On HD3 ID recommended taking off cefepime and vancomycin which
was done. His WBC continued to trend down. He complained of
slight dizziness and nausea which was self limited.
On HD4, complained of some right lower extremity pain. Given
recent surgery lower extremity venous ultrasounds were obtained
to rule out DVT and were negative. Repeat KUB showed some
colonic dilation which was within normal limits per radiology.
WBC continued to downtrend .
On HD5 c. dificile assay was resulted and was negative. Urine
and blood cultures remained negative. Discussed with ID consult
team and given lack of other source and clinical scenario there
was high suspiscion for c. dificile colitis. He was clinically
improved with WBC down to 16 and trending down, he was afebrile
with normal exam. As a result it was recommended to continue
empiric course of treatment for c. dificile colitis to consist
of 14 days of PO vancomycin.
At the time of discharge on HD5 the wound was healing well with
no evidence of erythema, swelling, or purulent drainage. His
drain was removed and his scrotal edema, which was monitored
daily, was markedly improved. The ostomy was perfused and
patent. Follow up appointments were discussed and the patient
was discharged home with previously arranged visiting nurse
services to be continued. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ gentleman with past medical history
significant for hypertension and BPH, who presents with a 3-day
history of worsened right lower extremity claudication. He had
some intermittent paleness and coolness of the foot as well. He
was seen in an outside hospital where an ultrasound showed an
occluded popliteal artery. He was started on heparin and
transferred to our institution. Radiology showed Occlusion of the right popliteal and peroneal arteries. Findings
were communicated to Dr. ___ over the phone by Dr. ___. Radiology showed 1. Exam is unchanged compared to recent chest radiograph from ___.
2. No active abnormality. Radiology showed 1. Mild perinephric fat stranding, particularly surrounding the lower poles
of both kidneys. No concerning renal lesions. No hydronephrosis. No
radiopaque urinary tract calculi.
2. Unusual soft tissue density adjacent to the right ureterovesical junction
within the bladder which likely reprsents clot, although a tumor cannot be
outruled.
3. Non-opacified vessels in the right lower lobe. Although suspicion for PE
is low, it cannot be outruled. CTA chest is recommended for further
evaluation. This finding was discussed with Dr ___ (___) via
telephone at the time of discovery (9:20, ___.
4. Soft tissue stranding and a small amount of hematoma within the left groin
related to the recent surgery.
5. Trace bilateral pleural effusions. Chronic interstitial changes in both
lung bases.
6. Enlarged prostate gland with a volume of approximately 67 cc.
7. Subcentimeter enhancing lesion within segment V of the liver that likely
represents a small hemangioma.
8. Severe mitral valve calcification. The patient was diagnosed with LOWER EXTREMITY EMBOLISM, HYPERTENSION NOS. The patient was treated with ___
1. Ultrasound-guided access to left common femoral artery with
placement of ___ sheath.
2. Selective catheterization of the posterior tibial artery on
the right ___ order vessel.
3. Abdominal aortogram.
4. Right lower extremity arteriogram.
5. Placement of 20 cm infusioning ___ catheter and
initiation of lysis.
___
1. Selection of right posterior tibial artery ___ vessel.
2. Right lower extremity imaging.
3. AngioJet thrombectomy of distal posterior tibial artery.
4. Closure of access with ___ Perclose device.. At the time of discharge, the patient had Right lower extremity claudication. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ presented with a 3-day history of right lower
extremity claudication. Imaging studies performed at outside
hospital were consistent with right popliteal artery occlusion,
for which purpose he max started on a heparin drip and
transferred to our institution for further evaluation and
management. Decision was made to take the patient to the
operating room for angiography/angioplasty. Findings were
consistent with right popliteal artery occlusion with distal
reconstitution of anterior and posterior tibial arteries. A
___ catheter was placed and initiation of lysis was
performed (see Operative Note for further details). Patient was
taken back to the ward after a brief uneventful stay in the
PACU. After overnight lysis, he was taken back to the operating
room for lysis check. A patent popliteal artery with 2-vessel
runoff through AT and ___ confirmed success of the lysis
treatment. All hardware was removed. A ___ Perclose was
placed for hemostasis, and the patient returned to the floor
after a brief PACU stay. Heparin drip was continued and warfarin
therapy started.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed appropriately with oral
medications. A noticeable improvement in pain was reported after
the procedure. 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. Findings on CT consistent
with non-opacified vessels in right lower lobe were concerning
-even with low suspicion- for pulmonary embolism. Given
patient's reassuring clinical status, further studies were not
pursued. 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. Urine output on POD#1 from
initial surgery was noted to be grossly bloody, which was
attributed to the recent administration of thrombolytics. Given
persistence of hematuria, a Urology consult was requested on
POD#2 and heparin drip was discontinued. Recommendation was made
to start continuous bladder irrigation overnight, urine analysis
and cytology, as well as a CT urography (refer to Reports for
details). Findings were reassuring, although an unusual density
within the bladder (likely a clot) prompted recommendation for
outpatient follow-up. Hematuria cleared and CBI was stopped
after overnight treatment. Three-way Foley catheter was removed
and patient voided with no issues. 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 was started on warfarin on POD#1 of the
second procedure and bridging with enoxaparin was initiated.
Arrangements were made prior to discharge for anticoagulation
management.
At the time of discharge, Mr ___ was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with hepatitis C (genotype 3 cirrhosis, on
treatment week 8 of sofosbuvir and ribavirin) and
sarcoid-induced cirrhosis with a history of heavy alcohol abuse
in the past who presented to ___ ED with with nausea,
vomiting, headache, fatigue for 3 days. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent portal veins with reversal of flow in the main, right and left
portal, unchanged from the prior examination.
2. Cirrhosis with no evidence of ascites.
3. No focal liver lesions.
4. Stable splenomegaly and perisplenic varices. Radiology showed No evidence of pneumonia. Hilar and mediastinal lymphadenopathy represents
known history of sarcoidosis. Radiology showed Findings consistent with colonic ileus. CT ABD AND PELVIS WITH CONTRAST showed 1. Cirrhotic liver with multiple varices and splenomegaly related to portal
hypertension.
2. Retroperitoneal and to a lesser extent mesenteric lymphadenopathy that
appears stable compared to ___ is likely therefore related to
patient's underlying sarcoidosis rather than a lymphoproliferative disorder. CT CHEST W/CONTRAST showed Mild congestive heart failure explains new small right pleural effusion, small
vessel plethora of the lungs and mild edema in the left lower lung.
Mild pulmonary sarcoidosis and extensive mediastinal/bilateral hilar
lymphadenopathy are stable since ___.
Cirrhosis with large splenic and small paraesophageal varices. CHEST (PA AND LAT) showed Heart size is top-normal. Mediastinal and hilar lymphadenopathy is unchanged.
Lungs demonstrate no evidence of interval development of new consolidation.
No pleural effusion or pneumothorax is seen.
Clinically warranted, in a patient with neutropenia, assessment with chest CT
might be justified CHEST (PA AND LAT)CHEST (PA AND LAT)i showed There is new platelike atelectasis of the base of the left lung. Mild
interstitial abnormality which it developed between ___ and ___ has improved. No evidence of new infection. Heart size normal. No
pleural effusion. CHEST PORT. LINE PLACEMENT showed Left PICC line is seen terminating in the right atrium, no pneumothorax. The
PICC nurse was instructed to pull back 1 cm. The patient was diagnosed with NAUSEA WITH VOMITING. At the time of discharge, the patient had 1. Acute CMV infection with high load viremia. The patient was given written instructions concerning 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 sarcoidosis (on cellcept, pred on admission) and Hep C
cirrhosis (genotype 3), Childs C MELD 14, presented with fevers
and pancytopenia, found to have primary CMV infection.
# febrile neutropenia: ___ CMV (107,000 on admission dropping to
70,900 by discharge) plus MMF in combination with ribavirin
causing anemia. We ruled out Lyme, EBV, Parvo B19, underlying
hematolgical disorders, C.diff, and full respiratory panel was
negative. UA negative. Fevers likely ___ CMV itself. Cefepime
stopped as blood cultures were consistently negative.
-increased Pred from 5 to 10 for evidence of adrenal fatigue.
-conted ganciclovir IV (will need a total of 2 weeks treatment)
-PICC line and discharge with OPAT follow up on ___. ID will
assess length of treatment based on CMV viral load.
-restarted ribavirin at low dose 200mg daily after stopping soon
after admission for anemia and evidence of hemolysis, a known
side effect of Ribavirin.
# Pancytopenia: Likely ___ CMV plus MMF in combination with
ribavirin causing anemia Fevers likely ___ CMV itself. Improved
on ganciclovir.
-contd to hold MMF
-monitored clinically
#Back Pain - Patient has complained of non-localizing back back
for several days. He can recount a specific day last week where
he pulled a muscle in his back after twisting while lifting a
heavy bag. He does experience some occasional pins and needles.
Abscess unlikely; presentation consistent with acute pinched
nerve.
- monitored for changes in physical exam--none.
# HCV/Sarcoid/EtOH Cirrhosis: Well-compensated of recent, though
has a history of decompensation with ascites, hepatic
encephalopathy. His last liver ultrasound from ___
did not show any focal liver lesion. Last endoscopy was done in
___ and showed grade 1 varices for which he is on
propranolol. Currently, MELD 8, ___ class B without
evidence of decompensation by hepatic encephalopathy, GI
bleeding, or SBP.
- Continued home lactulose and rifaximin
- Held beta-blocker in the setting of potential infection
- Held diuretics in the setting of potential
infection/hypovolemia
# HCV: Genotype 3. Currently on treatment with sofosbuvir and
ribavirin, the latter of which was decreased in dose given
anemia requiring transfusion. Will continue current treatment,
but discuss decreasing/changing given pancytopenia per above
- Continue HCV treatment with sofosbuvir 400mg daily; will
supply while he is inpatient.
- RESTARTING ribavirin at 200mg daily; started holding original
dose of 600 DAILY on ___. Went 3 days without Ribavirin.
# Sarcoid: Complicated by hypercalcemia, hepatic cholestasis,
lung involvement. Currently on immunosuppressive regimen of
prednisone, cellcept.
- Will continue to hold MMF (his pulmonologist agrees) in light
of suppressed bone marrow. Counts increasing.
- per pulm and rheum, can hold mmf indefinitely at this point,
as his Sarcoid is mild.
- Continue home prednisone 5mg daily, though he will temporarily
need a 10mg dose while he fights his CMV infection
- Continued home Bactrim infection ppx</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with past medical history significant for DM2 and a right
partial calcenectomy on ___ p/w fevers, increased pain,
redness, swelling of right ankle/heel wound. She states that the
pain has increased over the last ___ days and is traveling
halfway up her leg. Over this time period, she reported fevers
and an overall feeling of malaise and fatigue. Also increased
malodor and drainage. Radiology showed 1. No evidence of pneumonia.
2. Mild pulmonary vascular congestion. Radiology showed 1. Large soft tissue defect in the heel, apparently exposing the calcaneus.
Correlate with physical examination. If the calcaneus is indeed exposed, this
is by definition osteomyelitis.
2. Periosteal reaction in the lateral ?calcaneus/cuboid is also suggestive of
chronic osteomyelitis. Radiology showed 1. Left PICC tip is in right atrium. If withdrawn by 2 cm, tip will be in low
SVC.
2. Interval increase in left base atelectasis with possibly a new small left
pleural effusion.
Results were conveyed via telephone to Sal, IV nurse, ___ on
___ at 12 p.m, 5 minutes after observation of findings. The patient was diagnosed with ULCER OF ANKLE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN. The patient was treated with ___ Right ankle I&D
___ Right Below the Knee Amputation. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Right heel ulcer complicated by deep posterior compartment
infection now s/p R below the knee amputation
SECONDARY DIAGNOSES:
Diabetes Mellitus, uncontrolled
Peripheral neuropathy
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>___ PMHx ___ s/p L TMA (___), s/p R hallux partial amputation
(___), s/p R heel debridement (___), s/p R partial
calcenectomy (___) now presents with R calcaneus draining
purulent material with radiographic findings c/w chronic
osteomyeltitis now s/p R calcaneal debridement and R BKA.</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 no PMHx who
poresented to ___ ED on the day of admission from a concert.
Per report the patient was at a concert, where he became
intoxicated on ___ and Marijuana , but his ETOH was negative
on screening. He seized during the concert at some point which
led him falling down a flight of stairs, hitting his head. There
was brief loss of consciousness and on regaining consciousness
patient was A&Ox1, agitated, and combative. Per report he was
moving all extremities with full strength. He then had 2
episodes of projectile vomiting. He was intubated for airway
protection (GCS 7). On imaging CT shows SDH at falx and
tentorium, small bifrontal SAH, and left temporal SAH. Also
seen is a nondisplaced basilar skull fracture. 1gm of dilantin
was given and 100mg tid started. ___ the ICU he continued to be
febrile and he remained intubated per toxocology recs secondary
to concerns for a febrile reaction from the ___. Radiology showed 1. Small subarachnoid hemorrhage involving the inferior frontal lobes
bilaterally.
2. Small subdural hematoma layering along the tentorium and falx.
3. Non-displaced fracture extending through the left occipital bone to the
foramen magnum. Radiology showed 1. Again seen is a nondisplaced fracture of the base of the skull extending
from the left occipital bone to the foramen magnum.
2. No fracture or malalignment involving the cervical spine. Radiology showed No acute cardiopulmonary process. Endotracheal tube in
appropriate position. Radiology showed No change in small subarachnoid hemorrhage involving the inferior
frontal lobes bilaterally, small subdural hematoma layering along the
tentorium and falx, and nondisplaced fracture extending from the left
occipital bone to the foramen magnum. Radiology showed No acute cardiopulmonary process. Radiology showed No change in small subarachnoid hemorrhage of the inferior
frontal lobes bilaterally, small subdural hematoma layering along the
tentorium and falx and non-displaced fracture extending to the left occipital
bone to the foramen magnum. Radiology showed New right base consolidation suspicious for pneumonia but without
pleural effusion. Mild vascular congestion. Radiology showed Worsening right middle and lower lobe pneumonia. Findings are
concerning for aspiration. Radiology showed No change in small subarachnoid hemorrhage in the inferior frontal lobes
bilaterally, small subdural hematoma layering along the tentorium and falx and
nondisplaced fracture extending to the left occipital bone to the foramen
magnum. Evolving bifrontal contusions. Radiology showed Worsened infiltrates in the right lower lobe and right middle
lobe with new right effusion. Chest, AP portable single view. showed Persistent right-sided pneumonic infiltrates, extension of
infiltrates into left lower lobe area of moderate size. The patient was diagnosed with CL SKL BASE FX/MENIN HEM, ALTERED MENTAL STATUS , DRUG ABUSE NEC-UNSPEC, UNSPECIFIED FALL. At the time of discharge, the patient had PRIMARY DIAGNOSES:
1. Subdural hematoma
2. Amphetamine overodose
3. Acute rhabdomyolysis
4. Intracranial hemorrhage
5. Seizure
6. MSSA pneumonia
7. Hypoxemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted on ___ from the emergency department
to the SICU following a seizure after ingesting an unknown
substance. A CT showed subdural, subarachnoid, punctate
hemorrhage and a basal skull fracture. He was loaded with
dilantin and sedated with fentanyl and versed. Initial
toxicology labs obtained were negative for any identifiable
substances. A repeat non-contrast head CT showed a stable bleed.
Toxicology was consulted and recommended aggressive hydration,
sedation and normothermia. Profolol was started as a sedative
agent. His labs were reflective fo a rising creatinine kinase as
well as elevated LFT's. The patient consistently became febrile
to 102 when sedation was weaned for neuro exams.
___: The patient remained sedated and maintained a goal urine
output of 100-140cc of urine an hour. He was afebrile. When
sedation was weaned, he followed commands intermittently. He
also experienced vigorous shaking off sedation. He was
thrombocytopenis down to 82 after a platelet cound of 171 on
admission. Heparin was held and labwork for DIC were sent.
Fibrinogen returned at 444.
___, the patient was started on EEG for question of seizures.
His NG output was bilious coffee grounds for which he was
started on protonix. Sputum cultures grew out gram negative rods
and cipro was started. A chest x-ray showed a new right base
consolidation and patient with MSSA pneumonia but without
pleural effusion and mild vascular congestion. Patient continued
to be sedated with wean on ___ and ___.
Patient was extubated on ___ and was originally placed on 15L
NRB. Was changed to face tent mask later that day. Bedside
ultrasound showed impressive consolidation of right lung base
but minimal pleural effusion. Patient was weaned to ___ NC and
had gradual improvement of his respiratory status. Antibiotics
were changed to nafcillin, ciprofloxacin, and flagyl but then
narrowed to PO clindamycin. Patient had poor IV access and a
right EJ was placed. Patient continued to have good urine output
and the foley catheter and IV fluids were stopped. Patient was
afebrile for 2 days before transfer to the floor. The issue of
withdrawing from school was mentioned the patient and patient's
family and will be something they will discuss to determine
patient's future course. Clinically and radiographically,
pneumonia improved before transferring to the floor on ___.
On the floor, Patient was continued on a 10 day course of PO
clindamycin for MSSA pneumonia. Patient remained neurologically
stable. As the seizures ___ the ED were felt to be provoked by
ingestion of a toxic substance, and patient had remained seizure
free following his admission, Neurology felt that phenytoin
could be discontinued, although the Patient was instructed not
to drive for 6 mos. Pt's skull fracture and
SDH/SAH/post-concussive syndrome remained stable, and Patient
was instructed to follow-up with Neurosurgery ___ 4 weeks
following his discharge. Patient initially had significant
muscle pain secondary to rhabdomyolysis, which improved over his
hospitalization. His CK continued to trend downwards. Patient's
thrombocytopenia continued to improve and his platelet count was
within normal limits on the day of discharge. The results of
several toxicology studies remained pending at the time of
discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ prior history of CAD w/MI in ___ and ___ x ___ s/p excision
on ___ p/w hypotension and fevers.
Patient states that he been in his usual state of good health
and underwent local resection of BCC lesions to his left
shoulder and left lower back approximately 4 days prior
presentation. States that he felt well over the weekend, and gf
who had been caring for surgical sites did not note any
discharge, although had been tender. Yesterday began to develop
fever to 102 (forehead temp strip) and subjective chills. He
denies any nausea, vomiting, diarrhea, abdominal pain, cough,
chest pain, shortness of breath, headache. States that he took
acetaminophen which reduced his fever, however today while at
work he noted that his fingers became very white and he had
shaking rigors.
As such he presented to his ___ urgent care
providers, they're noted to be febrile to 103, in addition
hypotensive at 80/40. Received approximate 750 cc normal saline
as well as vancomycin prior to arrival. Had been planned for
direct admission, however given his hypotension he was referred
to the ED for stabilization. Blood cultures were obtained prior
to presentation, in addition has a reportedly negative chest
film.
Per OP note: T of 102.7 at ___. Is three days s/p basal cell
carcinoma excision on left shoulder and mid lower back and was
on keflex for that and this site apparently does not appear
infected. Urine dipstick negative, urine cx, blood cx pending,
CBC with normal WBC count, but Creatinine is 1.7 today, which is
up from normal baseline. Per Dr ___ not on
___. She has given him IVF in Urgent Care, and BP is
stable; HR has come down from 106 to 95 with fluids. CXR
negative. He has also received one gram of IV Vancomycin given
past history of presumed MRSA sepsis in ___ in setting of lower
exremity cellulitis (no positive cultures). He also had elevated
transaminases that admission attributed to a statin.
.
In the ED, initial VS were 99.4 83 96/51 16 95% RA. Received 1L
NS and pip-taz. Labs notable for Cr 1.3, lactate 2.1, AST/ALT
:71/102 Tbili: 1.7. RUQ US negative.
.
On arrival to the floor, patient denies pain or shortness of
breath.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail. Radiology showed 1. No evidence of cholelithiasis or cholecystitis.
2. Gallbladder polyp measuring 0.9 cm. Recommend follow-up in 6 months to
document stability.
3. Echogenic liver consistent with fatty infiltration. More advanced forms of
liver disease such as cirrhosis or hepatic fibrosis cannot be excluded on this
study.
These findings were discussed with Dr. ___ by Dr. ___ by telephone at
2:30 a.m. on ___. The patient was diagnosed with FEVER, UNSPECIFIED. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Cellulitis
SECONDARY DIAGNOSIS:
Transaminitis
Thrombocytopenia
Normocytic anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ Y/o man with hx Hypertension, hyperlipidemia presenting with
fevers, with elevated lactate to 2.1, hypotension on
presentation meeting criteria for severe sepsis.
#Fever: Cellulitis at recent skin surgery site of excision of
basal cell carcinoma:
I also think he may have had viral prodrome with high fever and
lab changes detailed below. Patient initially presented with ___
SIRS criteria (fever, tachycardia) with elevated lactic acid and
Cr. Sources of infection include cellulitis from recent ___
excision site on Lt shoulder vs transient bacteremia ___
procedure. Other etiologies to considered included PNA, UTI,
cholangitis given hyperbilirubinemia, gastroenteritis given
diarrhea, and viral infection. CXR and UA were negative for
infection. Cholangitis was thought to be less likely as patient
was not having any abdominal pain. Furthermore, RUQ U/S was
reassuring. Empirically started on vancomycin and zosyn. Zosyn
was later discontinued as it was thought cellulitis was the most
likely source. Patient's blood pressure responded to IVF
resuscitation. Patient discharged on Bactrim, he will be treated
for a full 10 day course (___).
# Transaminitis: Present since ___. RUQ US showing fatty liver,
although cannot rule out hepatic firbosis and cirrhosis. DDx
includes NAFL, cirrhosis, vs statin use. Hepatology serologies
were negative. Patient does not have signs of cirrhosis on
physical exam. ___ consider hepatology follow as an outpatient
for further workup.
# Hyperbilirubinemia: New onset, indirect > direct, indicating
hemolysis vs ___'s syndrome. Reticulocyte count,
haptoglobin, and peripheral smear inconsistent with hemolysis.
Peripheral smear showed no schistocytes, no spherocytes, some
Burr cells (? liver disease), and neutrophils. Patient's Tbili
trended down during hospitalization.
# Thrombocytopenia: Seems to be chronic, however trending down
now. New downtrend may be ___ infection, liver disease, vs
antibiotics. Platelets remained stable.
# Anemia: Iron studies consistent with anemia of chronic
disease. H/H were stable.
# ARF: Cr elevated to 1.7 at ___. Baseline is 1.0
in ___. Etiology likely pre-renal. Patient s/p 3L NS. Cr back
at baseline.
# HTN: Atenolol was help in setting of severe sepsis. Patient to
continue atenolol on discharge.
# Hypercholesterolemia: Atorvastatin held in setting of LFT
elevation. Re-started upon discharge.
# CAD s/p MI
- Continue aspirin.
# BCC x ___ s/p excision
- Daily dressing change
- Suture removal 2 weeks from procedure (___)
- Continue to f/u with Dr ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with PMH NASH cirrhosis (Childs B, on transplant list),
Meniere's disease, recently discharged home ___ after
admission for hyponatremia presenting with diarrhea, weakness,
and tremors. On ___ patient felt well. On ___ patient woke
up and felt a little confused so she took 45 mL of lactulose.
She immediately threw this up. She took another 45 mL of
lactulose which stayed down. She then proceeded to have 12
watery, non-bloody, non-black bowel movements between the hours
of 0800 and 1700. She did not have nausea and no further
vomiting. Her daughter called Dr. ___ told her to come to
the ED. CHEST (PA AND LAT) showed No infiltrates LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Coarsened nodular liver, in keeping with cirrhosis. There is splenomegaly
without ascites.
2. Patent portal vein without evidence of thrombus. The patient was diagnosed with Diarrhea, unspecified, Nonalcoholic steatohepatitis (NASH). At the time of discharge, the patient had Acute hepatic encephalopathy. The patient was given written instructions concerning 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 NASH cirrhosis (Childs B) c/b ascites and hepatic
encephalopathy who presents with acute hepatic encephalopathy in
setting of recent profuse diarrhea.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man w PMHx significant for DMII, HTN,
HLD, GERD, and recent hospitalization for C. diff pancolitis
with >6 weeks of watery diarrhea who presents with abdominal
pain and diarrhea. 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. 3 mm gallbladder polyp. A ___ year follow-up ultrasound may be performed to
assess stability.
RECOMMENDATION(S): Consider ___ year follow-up right upper quadrant ultrasound
to evaluate stability of the gallbladder polyp. The patient was diagnosed with Dehydration. The patient was treated with Colonoscopy and EGD ___. At the time of discharge, the patient had # Inflammatory Bowel Disease with acute flare complicated by
diarrhea
# Diabetes type 2 with hyperglycemia
# Transaminitis
# Hypertension
# GERD
# Hyperlipidemia
# 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 past medical history of DM2, GERD, recent
hospital stay for Cdiff colitis discharged ___ readmitted
___ with worsening diarrhea, status post colonoscopy with
significant colitis, biopsy concerning for inflammatory bowel
disease, now status post initiation of steroids with
improvement, course complicated by transaminitis, resolving,
able to be discharged home on steroids and new insulin regimen
# Inflammatory Bowel Disease with acute flare complicated by
diarrhea - patient admitted with diarrhea and abdominal pain in
setting of recent hospital stay for similar that had been
attributed to ___; repeat cdiff testing was negative, as was
infectious diarrhea workup, which prompted additional workup in
including colonoscopy and EGD that showed colitis, biopsies
demonstrating signs of chronic colitis thought to be consistent
with new diagnosis of inflammatory bowel disease. Patient was
started on steroid pulse with improvement in stool frequency
(>12/day to 6/day) and inflammatory markers (CRP 40 to 10).
Quant gold negative, hepatitis serologies revealed he will need
outpatient vaccinations. VIP peptide pending at discharge.
Discharged on prednisone taper, with plan to decrease 5mg every
week, and hold at 30mg daily until his GI follow-up on ___.
# Diabetes type 2 with hyperglycemia - patient with poorly
controlled fingersticks as outpatient on metformin and
sulfonylurea (A1c 10). In setting of above steroid pulse,
patient developed worsening hyperglycemia requiring initiation
of insulin. Patient seen by ___ consult, and after trials of
several different regimens, was maintained on a 70/30 regimen
with good control. Patient instructed on adminsitration, seen
by ___ educator. Patient given clear instructions for how to
adjust insulin regimen with prednisone taper. Verbal signout
given to PCP who agreed with plan. Ensured insurance coverage
and discharged with 70/30 kwikpen. Given above diarrhea, opted
not to restart home metformin until stools completely
normalized.
# Transaminitis - course complicated transaminitis, peaking at
ALT 98 AST 69 before trending down. Patient workup included an
ultrasound that showed steatosis--patient may benefit from
hepatology referral. ___, AMA, ___ all negative. Suspect
underlying cause was steroids in combination with acute illness,
on top of underlying steatosis. At discharge ALT 76 AST 38.
Would consider rechecking at follow-up to ensure resolution.
# Gallbladder polyp - seen on ultrasound; recommmended for ___
year follow-up
# Hypertension - continued lisinopril
# GERD - continued PPI
# Hyperlipidemia - continued statin
# Asthma - continued advair
Transitional Issues
- Newly started on prednisone for new diagnosis of inflammatory
bowel disease; discharged on 40mg prednisone daily, to decrease
5mg every week, hold at 30mg daily until GI follow-up
- Novolog 70/30: 120 units at breakfast, 60 units at dinner; per
___ insulin should be tapered with prednisone as follows:
When at prednisone 35mg, change to 70/30 100 units with
breakfast, 50 units with dinner; when at prednisone 30mg,
change to 70/30 90 units with breakfast, 40 units with dinner.
- Incidentally found to have 3mm gallbladder polyp. Per
radiology, a ___ follow-up ultrasound may be performed to
assess stability.
- RUQ ultrasound showed steatosis--patient may benefit from
hepatology referral</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with significant psychiatric history with multiple
self-inflicted stabbings necessitating exploratory laparotomies
in the past ___ years now s/p recent laparotomy/repair of colotomy
with repeat self-inflicted injury to his midline wound. Patient
again obtained a ink-pen and inserted the pen via his midline
wound at 7PM. Patient reports mild abdominal tenderness and
thinks that he was 'close to the aorta.'
He denies fevers or chills, denies nausea or vomiting. He
continues to endorse his desire to self-mutilate in order to end
his life and/or leave his facility. CT ABD AND PELVIS WITH CONTRAST showed 1. A portion of the anterior transverse colon communicates with, and is in
close proximity/adherent to, the open midline abdominal wound. Of note, the
left JP drain appears to terminate within the lumen of the transverse colon.
2. Interval development of a 5.3 x 5.2 x 11.8 cm right anterior abdominal wall
fluid collection which extends through the abdominal wall muscles and deep to
the fascia. It contains locules of air, with significant surrounding
inflammatory changes, concerning for an abscess.
3. Tubular air-containing foreign body within the sigmoid colon in the shape
of a drinking straw. Additional curvilinear radiodensity in the right
anterior abdominal wall subcutaneous fat may represent another foreign object.
4. High density particulate material within the stomach may represent ingested
foreign bodies. Similar smaller densities also noted in the right lung base,
new from ___.
5. Mild intrahepatic and extrahepatic biliary dilatation is unchanged. CHEST PORT. LINE PLACEMENT showed Left PICC is in good position, terminating in the low SVC. Ultrasound superficial showed The majority of patients abscess has already drained through tract in the
skin. No drainable fluid collection. CHEST (PORTABLE AP) showed Left PICC tip is in thecavoatrial junction. Cardiac size is normal. The lungs
are clear. There is no pneumothorax or pleural effusion. Radiology showed 1. Interval debridement of the previously described right anterior abdominal
wall fluid collection, with an open surgical defect in this region. No
significant residual fluid collection or new abscess identified.
2. Re-demonstrated is direct communication between the transverse colon and
the midline anterior abdominal wall defect.
3. Unchanged appearance of foreign body within the pelvis. The patient was diagnosed with Laceration of transverse colon, initial encounter, Intentional self-harm by other sharp object, init encntr, Foreign body in penis, initial encounter, Intentional self-harm by other specified means, init encntr. The patient was treated with ___ Exploratory laparotomy and suturing of enterotomy and
placement of drain.. At the time of discharge, the patient had Perforated intestine
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 admitted to the trauma team after a suicide
attempt. He was taken to the operating room to repair the
enterotomy. The patient tolerated the procedure well and was
transferred to the floor for close monitoring. Urology was
consulted for insertion of styrofoam into penis and they
recommend a cystoscopy as an outpatient, although the patient
had no further urological complaints during the hospitalization.
Incidentally the patient was noted to be hepatitis C positive
with high viral count. Hepatology was consulted who recommended
outpatient follow-up. IV ciprofloxacin and flagyl were started
postoperatively as there was open bowel in the abdomen for 24
hours. Post operative day four the patient was advancing his
diet and was able to tolerate PO medication. A PICC line was
placed post operative day 7 for antibiotics. Post operative day
8 the wound was opened and packed. Post op day 9 the patient was
febrile to 102 a fever work up was done and a CT scan showed a
___ fistula through transverse colon to midline. He
was started on vanc and zosyn and then per Infectious Disease
recs, changed to ceftriaxone and PO flagyl. The following day
the patient became febrile again and started growing GPC's from
the PICC. The PICC was removed, and the patient remained
afebrile throughout the hospitalization after the PICC was
removed. The patient also received a TEE to rule out
endocarditis. The echo was normal. Pyschiatry was also involved
in the patients care at this point to evaluate the patient.
Blood cultures grew out S. viridans, and infectious disease was
able to make final recommendations on antibiotics which included
1 gm IV Ceftriaxone Q24H ___ - ___ 750 mg PO
levofloxacin QD ___ - ___ 500 mg PO flagyl Q8H
___ - ___. The patient self discontinued his IV access
2 days before switching from ceftriaxone to levofloxacin. The
levofloxacin was started early. The patient was afebrile,
tolerating a diet, voiding and pain was under control prior to
discharge. The midline fistula was managed with an ostomy pouch
and output had been slowing down.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ status post fall with bilateral distal radius fractures.
Patient was walking and tripped over a dog's leash. Patient
landed unto her outstretched arms. EMS took patient to ___. Patient was evaluated with wrist films and transferred
for orthopedic evaluation at ___. Patient denies any numbness.
Denies any other injuries. The patient was diagnosed with FX DISTAL RADIUS NEC-CL, UNSPECIFIED FALL. The patient was treated with bilateral ORIF distal radius. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the Orthopaedic Trauma Service for
repair of bilateral distal radius fractures. The patient was
taken to the OR and underwent an uncomplicated open reduction
internal fixation bilateral wrists. The patient tolerated the
procedure without complications and was transferred to the PACU
in stable condition. Please see operative report for details.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
The patient was transfused 0 units of blood for acute blood loss
anemia.
Weight bearing status: nonweightbearing bilateral upper
extremities.
The incision was clean, dry, and intact without evidence of
erythema or drainage; and the extremity was NVI distally
throughout. The patient was discharged in stable condition with
written instructions concerning precautionary instructions and
the appropriate follow-up care. All questions were answered
prior to discharge and the patient expressed readiness for
discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old M with a PMH of Crohn's disease (___),
polio (shorter R leg), CAD s/p 1 stent who presents with ___
days
of abdominal cramping and loose, nonbloody stools. Radiology showed 1. Nonspecific, nonobstructive bowel gas pattern.
2. No pneumoperitoneum. The patient was diagnosed with Crohn's disease, unspecified, without complications. At the time of discharge, the patient had C.diff
intestinal infection
Inflammatory bowel disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY/ASSESSMENT: ___ year old M with a PMH of Crohn's disease
(___), polio (shorter R leg), CAD s/p 1 stent who presents
with ___ days of abdominal cramping and loose, nonbloody stools,
now improved. C.diff positive overnight. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of stage IIIC metastatic
melanoma (with renal and right-sided ilioinguinal metastases)
status post chemotherapy, immunotherapy, and cyberknife,
currently on study drug LOXO-101 (TRK inhibitor), NASH cirrhosis
complicated by hepatic encephalopathy, esophageal varices, and
ascites, with multiple recent admissions notably for
Enterobacter
bacteremia/spinal osteomyelitis requiring IV cefepime
complicated
by C. difficile colitis s/p completed treatment course who
presents w/AMS that was noted by his ___ today. MR CODE CORD COMPRESSION PT27 MR SPINE showed 1. Findings consistent with L1-L 2, L3-L4 discitis osteomyelitis, worse at
L3-L4, and worsened since ___, with worsened bone loss. Epidural
phlegmon at these levels, with moderate to severe central canal narrowing at
L3-L4.
2. Extensive paravertebral edema, no abscess.
3. Artifact versus enhancement of the roots cauda equina L3-L4.
4. Enhancement inferior T9 endplate, likely represent Schmorl's node. Lumbar spine radiograph, single lateral view. showed Intraoperative film during on going lumbar fusion and laminectomy. RENAL U.S. showed 1. Slightly limited evaluation of the right kidney as above, with
nonvisualization of the lower pole due to shadowing by overlying bowel gas.
No hydronephrosis seen on either side.
2. Incidentally noted splenomegaly, spleen measures 19.1 cm. Chest radiograph, portable AP upright. showed PICC line terminating at cavoatrial junction. L-SPINE (AP AND LAT) showed Status post L2-3 and L3-4 laminectomy. Osseous destruction of the endplates
of L3-4 and L1-2 is re-demonstrated, with interval decrease in anterior
intervertebral disc space and mild widening of the posterior elements at L3-4
suggesting the possibility of a degree of ligamentous instability. The patient was diagnosed with Other dorsalgia, Altered mental status, unspecified. The patient was treated with s/p Posterior laminectomies L2-L4 on ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Chronic osteomyelitis and cord compression
SECONDARY DIAGNOSOIS:
___ cirrhosis
Coagulopathy
Urethral trauma
Constipation
History of C. diff colitis
Stage IIIC metastatic melanoma
Chronic pancytopenia
Macrocytic anemia
Toxic-metabolic encephalopathy
Pre-renal ___. The patient was given written instructions concerning 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 Statement for Admission:
================================
Mr. ___ is a ___ with history of stage IIIC metastatic
melanoma (with renal and right-sided ilioinguinal metastases)
status post chemotherapy, immunotherapy, and cyberknife,
currently on study drug LOXO-101 (TRK inhibitor); NASH cirrhosis
complicated by hepatic encephalopathy, esophageal varices, and
ascites; with multiple recent admissions notably for
Enterobacter bacteremia/spinal osteomyelitis requiring IV
Cefepime, complicated by C. difficile colitis. ___ presented with
altered mental status and found to have worsening
osteomyelitis/diskitis with compression fractures, for which ___
underwent surgical washout and was admitted to medicine for
further management.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with PMH notable
for diabetes and ESRD on HD who presents to the ED with chest
pain. CHEST (PORTABLE AP) showed Intra-aortic balloon pump tip is projecting approximately 3.8 cm below the
roof of the aortic arch. Moderate to severe interstitial pulmonary edema is
demonstrated within element oval pillar edema in the right infrahilar area. Carotid Doppler Ultrasound showed Moderate stenosis of the bilateral internal carotid arteries. VENOUS MAPPING FOR DIALYSIS ACCESS showed Patent bilateral great saphenous veins with diameters above.
Bilateral small saphenous veins are not visualized. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Mild pulmonary edema, with basilar predominance, has improved substantially
since ___. Intra-aortic balloon pump has been removed. Small pleural
effusions are presumed. No pneumothorax. Left basal opacification is new.
This could be atelectasis or alternatively early aspiration pneumonia.
Careful followup advised.
RECOMMENDATION(S): Repeat chest radiographs in 8 hr. ABDOMEN US (COMPLETE STUDY) showed Normal abdominal ultrasound. Normal gallbladder. Radiology showed Nonspecific and nonobstructive bowel gas pattern. CT HEAD W/O CONTRAST Q111 CT HEAD. showed 1. No evidence of acute intracranial abnormalities. However, if there is
strong clinical suspicion for acute infarct and no contraindications, MRI is
more sensitive for acute ischemic changes.
2. Generalized brain atrophy greater than expected for age.
RECOMMENDATION(S): MRI is recommended if there is high clinical suspicion for
acute ischemia/infarct.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 12:12 into the Department of Radiology
critical communications system for direct communication to the referring
provider. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. Acute to subacute foci of infarcts are seen within the right frontal lobe,
right sub insular cortex, and left frontal lobe, with associated FLAIR signal
abnormality. No evidence of acute intracranial hemorrhage.
2. In the region the right retina, incidental note is made of a T2 hypointense
signal which demonstrates low signal on the susceptibility weighted sequence,
which may be concerning for a retinal hemorrhage. A dedicated ophthalmology
consult is recommended for further evaluation.
3. Chronic microangiopathy.
RECOMMENDATION(S): Ophthalmology consult is recommended for further
evaluation.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 11:26 AM, 10 minutes after
discovery of the findings. Radiology showed There is left ventricular prominence. There remains patchy opacity at the
left base which is unchanged. This again could represent atelectasis or early
aspiration. There are no pneumothoraces. Portable upright chest x-ray showed Stable mild pulmonary edema and no evidence of pneumonia. The patient was diagnosed with Chest pain, unspecified. The patient was treated with Cardiac catheterization w/o intervention ___
Intra-aortic balloon bump placement and removal ___
Cardiac Cath with ___ ___. The patient was given written instructions concerning 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 ___ PMH notable for diabetes and ESRD on
HD who presented with chest pain and found to be having a STEMI
so he was admitted to the CCU. Cardiac cath showed 3 vessel
disease so there was no intervention done, he was returned to
the CCU with an IABP, and he was planned for CABG. The morning
he was supposed to go for CABG he developed global amnesia, MRI
was performed and showed bilateral cortical infarcts (possibly
old), so CABG was cancelled and he underwent high risk PCI with
placement of 3 DES. He was discharged on aspirin, Plavix and
atorvastatin.
#AMS/GLOBAL AMNESIA: patient with AMS and global amnesia w/
psychomotor slowing since ___ AM, patient unable to explain why
he is in hospital/his name/where he is from. Etiology unclear.
Patient w/ b/l small cortical infarct on MRI, however per neuro,
likely does not explain patient's clinical presentation. EEG w/
no e/o seizure activity, CT head negative for acute intracranial
abnormalities. Psych consulted who felt that patient's
presentation most c/w hypoactive delirium in setting of acute
illness/hospitalization. Per family has history of depression
and possible hallucinations. Blood and Urine Cx negative.
Patient was started on amantadine with slight improvement of
psychomotor slowing. Per psych this could also be an acute
stress reaction, and if that is the case it will likely improve
slowly over time. Patient w/ hx positive toxocara Ab, however
per ID, unlikely that toxocara would cause amnesia.
Cysticercosis Ab came back negative, Toxocara Ab positive, so
started on 5d course of albendazole 400mg BID. His global
amnesia resolved completely prior to discharge.
#STEMI: Patient presented w/ ___KG showing STEMI
with anterior ST elevation in V1 and V2 with STD and TWI in
V4-V6, I and aVL, trops w/ peak to 0.28. Patient underwent
cardiac cath which showed 3VD, and was planned to have CABG.
IABP placed to maximize coronary flow, removed shortly due to
development of abdominal pain (described below). However, on day
prior to scheduled CABG, patient developed acute onset amnesia
(described above) and CABG was deferred. TTE w/ LVEF ~45%,
mildly reduced global left ventricular systolic function with
regional hypokinesis of the distal septum and apex. Patient was
treated w/ heparin gtt until he returned to cardiac cath w/
placement of 3 DES. Patient discharged on ASA, Plavix, and
atorvastatin. He was not discharge on a beta blocker because of
his orthostatic hypotension. Due to the holiday We were not able
to discharge him on ticagrelor which would require
prior-authorization and contacting his insurance (both closed on
___). Please transition him to ticagrelor as an
outpatient. Ticagrelor has less interaction with INH and is
preferred given his history of stroke during admission.
#FEVERS: Unclear etiology. The patient developed fevers >100.4
after he was transferred to the floor. CXR, UA were not
consistent with signs of infection. UCx and BCx were negative.
His Toxocara Ab was positive and cystercicosis Ab was negative,
so with ID following he was treated empirically for Toxocara
with a 5d course of albendazole. He was afebrile for several
days prior to discharge.
#ABDOMINAL PAIN AND DIARRHEA: During hospital course, patient
developed severe abdominal pain w/ elevated lactate, likely ___
bowel ischemia iso balloon pump. Balloon pumped removed w/
resolution abdominal pain. Guiac negative. C. diff negative.
#ORTHOSTATIC HYPOTENSION: Patient developed orthostatic
hypotension that was noticed after he was transferred to the
floor and started working with ___. The differential included
medication effect (metoprolol), fluid shifts with HD,
hypovolemia vs ANS dysfunction iso poorly controlled DM. He was
given intermittent IVF boluses and was run even at HD but
remained orthostatic so his metoprolol was stopped and he was
started on midodrine 5mg TID. Prior to discharge his orthostatic
hypotension improved, but he was still mildly orthostatic.
# BILATERAL CORTICAL INFARCTS: TTE negative for any vegetations.
Possibly cholesterol emboli following cath. ___ have been
contributing to AMS/amnesia as above. It is also possible that
these are old and were not new this admission.
# TRANSAMINITIS: Unclear etiology. ID was consulted to see
whether this could be caused by his INH therapy and they felt it
was unlikely to be the cause. His transaminitis gradually
resolved throughout this admission.
# RETINAL HEMORRHAGES: These were seen on MRI so optho was
consulted. Per records at ___ had recent optho surgery and
has known retinal hemorrhages and retinal proliferation from DM.
He is legally blind.
# ESRD: Receives dialysis M, W, F. No electrolyte abnormalities
or significant acidosis during hospitalization. Continued ___
calcitriol, calcium acetate, sodium bicarbonate.
#ANEMIA: Stable. Likely iso ESRD.
#DIABETES: Not currently on any glycemic agents or insulin. He
was put on a HISS while in the hospital.
#LATENT TB: Asymptomatic, not active. Continued ___ isoniazid
___ mg daily with vitamin B6</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with recently
diagnosed metastatic RCC complicated by left malignant pleural
effusion who presents with shortness of breath and weakness. Chest: Frontal and lateral views showed Substantial increase in now large left pleural effusion, with subsequent
rightward shift of the cardiac silhouette. Small right pleural effusion.
Evidence of pulmonary nodularity seen in the region of the right mid to lower
lung. CHEST (PORTABLE AP) showed 1. Interval placement of a left-sided chest tube with substantial interval
decrease in size of a left pleural effusion, now trace in appearance.
2. Minimal streaky opacities at the left lung base may represent atelectasis,
however the possibility of slight re-expansion edema should also be
considered.
3. Mild cardiomegaly and mild pulmonary vascular congestion. The patient was diagnosed with Pleural effusion, not elsewhere classified. The patient was treated with Pleural catheter placement ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with history of hypertension,
anemia and metastatic renal cell carcinoma diagnosed in ___ by mediastinal lymph node biopsy with known metastases to
lung, bone, mediastinal/hilar and periaortic lymph nodes s/p
initiation of treatment with Nivolumab/Zometa (C1D1 ___ who
presents with dyspnea due to recurrent malignant pleural
effusion. She underwent placement of a PleurX catheter with IP
and was discharged to rehab. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with a history of ESRD on dialysis, diabetes,
hypertension, hyperlipidemia, restrictive lung disease who
presented to the ED with acute onset dyspnea, found to have SBP
elevated to the 200's with evidence of volume overload on CXR
without clear inciting factor. CHEST (PORTABLE AP) showed Worsening pulmonary edema.
Stable bilateral effusions.
Stable moderate cardiomegaly Chest CT. showed 1. No significant change in moderately extensive areas of round atelectasis
in each lung. widespread pleural plaques suggesting sequela of prior
asbestos exposure. No evidence for coinciding or superimposed asbestos
related interstitial lung disease.
2. New mosaic pattern of attenuation which can be seen with parenchymal
abnormalities including scroll vascular congestion, inflammatory types of
pneumonitis, atypical infectious processes, or air trapping associated with
small airways disease.
3. Newly apparent right lobe thyroid nodule, measuring up to 25 mm.
RECOMMENDATION(S): When clinically appropriate follow-up thyroid ultrasound
evaluation is recommended. The patient was diagnosed with Chronic pulmonary edema. At the time of discharge, the patient had PRIMARY DIAGNOSIS
=================
Pulmonary Edema ___ End Stage Renal Disease on Hemodialysis
Hypertensive Urgency. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE
=====================
___ male with a history of ESRD on dialysis, diabetes,
hypertension, hyperlipidemia, restrictive lung disease who
presented to the ED with acute onset dyspnea, found to have SBP
elevated to the 200's with evidence of volume overload on CXR
without clear inciting factor.
ACUTE ISSUES
===========
#Volume overload
#Dyspnea:
Patient presented with significant volume overload with SBPs
elevated to the 200's and CXR demonstrating worsening pulmonary
edema. Unclear what precipitated hypervolemia. Patient aware of
volume restriction and undergoing dialysis 3x week without
changes to regimen or medications. Patient noting stable BPs as
outpatient
making flash pulmonary edema less likely; however, patient with
unstable BPs since admission. No recent echo in OMR so CHF
possible. Also possible that patient was slowly gaining weight
that was missed because of gastroparesis (volume overloaded with
dry weight decreasing). Patient was placed on BiPAP in the ED
and initiated on a nitro drip. Renal was consulted for emergent
ultrafiltration in the setting of hypervolemia with compromised
respiratory status. Patient responded well with successful
titration of O2 down to home 3L O2 NC with good saturations and
d/c of nitro drip with some improvement in BPs. Repeat blood gas
was without evidence of hypercarbia. TTE demonstrated mild LVH
with normal LV systolic function. No obvious
valvular pathology or pathologic flow identified. CT Chest was
obtained in setting of restrictive lung disease with possible
contribution to dyspnea and no CT for ___ years. CT chest
demonstrated no significant change in moderately extensive areas
of round atelectasis in each lung. widespread pleural plaques
suggesting sequela of prior asbestos exposure. No evidence for
coinciding or superimposed asbestos
related interstitial lung disease. Also, a new mosaic pattern of
attenuation which can be seen with parenchymal abnormalities
including scroll vascular congestion, inflammatory types of
pneumonitis, atypical infectious processes, or air trapping
associated with small airways disease. And finally, newly
apparent right lobe thyroid nodule, measuring up to 25 mm.
#Hypertension: Patient with SBPs to the 200's on arrival to the
ED, likely in the setting of volume overload. Patient on home
regimen of clonidine BID, amlodipine daily with BP's
well-controlled, without recent changes to medication regimen.
Per Patient, BP's measured during dialysis run around 120's
systolic, but can drop to SBP 90's. Patient stating that he
adheres to BP regimen and that he took both clonidine and
amlodipine the AM of presentation. Patient placed on nitro drip
in ED with improvement in SBP to 140-150's. Patient without
headache, lightheadedness, visual changes, chest pain throughout
ICU course. Previously with SOB but resolved after initiation of
nitro drip and after ultrafiltration. BPs continued to be
intermittently elevated in ICU with systolic BPs to the 170's
and patient asymptomatic.
#Leukocytosis: Patient with elevated white count to ~16. Likely
stress response in the setting of dyspnea with resolution to
11.2 in the ICU. CXR without evidence of infection. However,
with significant underlying lung disease, difficult to discern
new opacities. Chest CT obtained which demonstrated no
significant change from prior. Patient remained without evidence
of infection throughout ICU stay.
#Elevated troponin: Troponin in ED slightly elevated to 0.04
(around baseline in past) in the s/o renal disease. EKG without
changes concerning for ischemia. Repeat troponin slightly
elevated to 0.06, but not outside patient's baseline elevation
per review of OMR. Patient asymptomatic. TTE obtained which
demonstrasted normal LV function.
CORE MEASURES
=============
# Code Status: Full code
# Emergency Contact: Sister
# ___
# Disposition: HOME</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ w ___ notable for AF on Xarelto, morbid
obesity, previous admission for vertebral discitis/osteomyelitis
___ obstructive nephrolithiasis and klebsiella bacteremia (s/p
ureteral stent), OSA (not adherent to CPAP), OA s/p b/l knee
replacement, hypothyroidism, and multiple abdominal surgeries
who
presents with ___ erythema and swelling. TIB/FIB (AP AND LAT) RIGHT; DX ANKLE AND FOOT showed 1. Unchanged soft tissue swelling along the dorsum of the foot.
2. Unchanged focal osteopenia in the lateral tuft of the first distal
phalanx, which may represent osteomyelitis.
3. No acute abnormality in the ankle tibia or fibula. US EXTREMITY LIMITED SOFT TISSUE RIGHT showed Extensive subcutaneous edema in the superficial tissues of the right anterior
shin, without evidence of focal drainable fluid collection. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins.
However, the calf veins are not well-visualized on the current study. The patient was diagnosed with Cellulitis of right lower limb, Unspecified atrial fibrillation, Long term (current) use of anticoagulants. At the time of discharge, the patient had Cellulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ w PMH notable for AF on Xarelto, morbid
obesity, previous admission for vertebral discitis/osteomyelitis
___ obstructive nephrolithiasis and klebsiella bacteremia (s/p
ureteral stent), OSA (not adherent to CPAP), OA s/p b/l knee
replacement, hypothyroidism, and multiple abdominal surgeries
who presented with ___ erythema concerning for cellulitis, now
resolving on Bactrim.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a pleasant ___ w/ CAD, HTN, DL, HBV, cavernous
sinus thrombosis and DLBCL on C6 of da-R-EPOCH (D1 ___ p/w
AMS. Pt is unable to provide any history due to his AMS. I
called his partner/hcp ___ at ___ whose line went
directly to ___ and I left him a message to return my call. I
also called ___ ___, the
SNF from which he was transferred. I spoke with his nurse who
noted he's been feeling weak the past week but AOx3. He was
recently diagnosed with KLEBSIELLA PNEUMONIAE UTI ___ and
started on Cipro. Radiology showed No acute cardiopulmonary process. CT ___ W/O CONTRAST showed Slightly hyperdense lesions with mass effect along the right lateral ventricle
and an asymmetry along the subependymal region of the fourth ventricle
concerning for underlying mass lesions and given patient's history, lymphoma
would be of greatest concern. Recommend further evaluation with MR ___ with
contrast.
RECOMMENDATION(S): MR ___ with contrast. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Numerous FLAIR hyperintense lesions demonstrating patchy enhancement seen
throughout the supratentorial and infratentorial structures, with
intraventricular and leptomeningeal involvement. These findings are new from
the prior MRI examination in ___ and to suggest lymphoma.
2. Background findings of global parenchymal volume loss and chronic small
vessel ischemic disease.
3. Moderate to severely motion degraded examination.
4. No evidence of infarction or hemorrhage. DX CHEST PORTABLE PICC LINE PLACEMENT showed Right PICC line tip is at the cavoatrial junction. Heart size and mediastinum
are stable. Lungs overall clear. There is no appreciable effusion. There is
no pneumothorax. Radiology showed The final image demonstrates the tip of the nasogastric tube to project over
the stomach, pointing back on itself toward the GE junction. Radiology showed The tip of the nasogastric tube extends to the upper stomach however the side
port projects over the distal esophagus and continued advancement is
recommended. DX ABD PORT LINE/TUBE PLCMT 3 EXAMS showed 3 sequential images demonstrate advancement of a Dobhoff, the tip ultimately
terminating over the stomach on the final image. CT HEAD W/O CONTRAST showed 1. No acute hemorrhage.
2. Multiple intracranial masses and associated areas of edema appears similar
to the ___ head CT, better assessed on the ___ brain
MRI.
3. Paranasal sinus disease. Radiology showed Intermittent penetration and trace aspiration with nectar thick and thin
liquids during the swallow.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services). Radiology showed The right-sided PICC line is absent. No retained catheter fragments are seen.
Heart size is within normal limits. Lungs are clear. There are no
pneumothoraces. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with PICC placement ___, discontinued prior to discharge. At the time of discharge, the patient had #Primary:
Secondary CNS lymphoma
#Secondary:
Stage IV diffuse large B-cell lymphoma
History of cavernous sinus thrombosis
Chronic hepatitis B infection
Dysphagia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PATIENT SUMMARY:
================
Mr. ___ is a ___ y/o male with a hx of DLBCL s/p 6 cycles of
da-R-EPOCH (c6d1 ___ as well as CAD, HTN, HLD, HBV and
cavernous sinus thrombosis who presented with AMS, imaging with
new intracranial lesions c/w CNS Lymphoma.</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 who is referred in for left
forearm redness and swelling x 4 days. She is ___ weeks s/p
revision with thrombectomy of left forearm AV graft.
Pt had her L forearm AVG thrombectomized and revised on ___.
HD started to cannulate the AVG again on ___. On ___, the
HD unit noted erythema, edema, and warmth on the AVG. The R HD
cath was used and is currently being used for HD. On ___,
blood cxs were done and Vancomycin 1g and Gentamicin 120 mg were
given on ___. Vanco 1g and GM 80 mg were administered
on ___ and ___ (day of admission). She has been afebrile and in
her usual state of health. Per the HD RN staff, the graft
erythema and edema were not
improving prompting the patient to present to the ER for
evaluation. Radiology showed 1. Normal wall to wall color flow was seen in the left upper extremity AV
graft.
2. There is a collection measuring up to 2.5 cm surrounding the graft, which
may be secondary to a hematoma or thrombosed pseudoaneurysm; a superinfection
cannot be excluded. Radiology showed Cardiomegaly. Findings consistent with CHF/fluid overload. The patient was diagnosed with DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT, ACCIDENT NOS, END STAGE RENAL DISEASE. At the time of discharge, the patient had left forearm cellulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to ___ from dialysis on ___ after she
was noted to have worsening erythema and swelling of her left
forearm fistula site. Vancomycin and gentamicin had been started
___ when the erythema was first noted, and continued with HD
through her R HD catheter.
In the ED, ultrasound was ordered and transplant surgery team
was consulted. Ultrasound of the left forearm showed normal
flow in the graft, as well as a collection measuring up to 2.5
cm surrounding the graft consistent with hematoma or thrombosed
pseudoaneurysm however a superinfection could not be excluded.
She was subsequently admitted to the ___ Surgical Service
where she was monitored and continued on vancomycin and
gentamicin with HD which was performed on ___ via the HD
catheter. The patient remained afebrile and hemodynamically
stable on the floor, without any worsening or spread of the area
of erythema.
Blood cultures from the dialysis center and those drawn on this
admission have been negative to date, and she is now being
discharged back to her living facility with plans to continue
antibiotics with hemodialysis.
TRANSITIONAL ISSUES
===================
-Discharge back to ___ in ___ where she resides
-Continue vancomycin and gentamicin during HD
-HD through R HD catheter only, do not use AV fistula in L
forearm
-Please continue to monitor erythema of L forearm as well as
around HD catheter
-Patient needs an appointment for follow-up with Dr. ___
___ week </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ with no significant past medical
history who presents with multiple weeks of right sided weakness
both in the upper extremity and more recently in the lower
extremity. More recently over the past few days he has noticed
difficulty with his gait and now tends to shuffle more slowly to
maintain his balance. This morning he began to notice a headache
and presented to ___ where a CT of the
head showed a left sided frontal mass (as described below). He
was given one dose of 10mg IV decadron and transferred to ___
for further work-up of primary vs. metastatic disease. Radiology showed 1. Predominantly rim enhancing lesion in the left frontal lobe as described
with stable right sided midline shift. Differential considerations would
include high-grade glioma, metastasis, resolving hematoma, and less likely
infection. Additional small enhancing lesion in the right temporal lobe
suggests metastasis as leading differential.
2. No acute infarct. Radiology showed No acute intrathoracic process. Linear density in the left upper
lung likely represents scarring. Radiology showed 1. Stable peripheral enhancing lesion in the left frontal lobe as described
with stable right-sided midline shift. Additional stable small enhancing
lesion in the right temporal lobe. Differential considerations remain
metastasis, high-grade glioma, and less likely infection.
2. Irregularly shaped enhancing mass in the right retromolar trigone extending
into the mandible/bone marrow suspicious for an additional metastatic lesion. Radiology showed Left frontal rim-enhancing mass with increased vascularity
causing vasogenic edema and mass effect as described above. Given the second
smaller focus of abnormal enhancement in the right temporal lobe, the
possibilities for diagnosis should include metastatic lesion as well as
primary brain tumors. Radiology showed 1. Suprahilar mass in the left upper lobe with pathologic enlargement of
hilar and mediastinal lymph nodes concerning for primary lung malignancy with
nodal metastases.
2. No evidence of distant metastatic disease in the abdomen or pelvis.
3. Endotracheal tube with the tip 14 mm above the carina and may be retracted
slightly. Radiology showed Status post left frontal craniotomy and mass resection with
postsurgical changes as expected along with a 9 mm focus of left frontal white
matter hemorrhage, presumed to be related to the recent procedure. Radiology showed 1. Status post left frontal craniotomy with resection of dominant left
frontal mass. There is, however, thick nodular enhancement in the surgical
bed, which raises suspicion for residual tumor. Additionally, right inferior
temporal enhancing lesion and the right retromandibular trigone lesion are
also again noted and raises suspicious for metastatic disease.
2. Again noted is vasogenic edema within the surgical bed with a stable 9mm
rightward shift of midline structures. Continued followup is recommended.
3. Post-surgical changes include a small left subdural hematoma, hemorrhage
within the surgical bed, and small amount of hemorrhage layering posteriorly
within the occipital horns of lateral ventricles as well as within the fourth
ventricle. Radiology showed 1. NG tube with tip in the proximal stomach, but side holes near the GE
junction. Advancement is recommended.
2. Overinflation of the ET tube cuff. Additionally, ET tube should be
withdrawn by several centimeters for more standard positioning.
3. Left hilar fullness concerning for lung malignancy. Chest CT is
recommended for further evaluation.
4. New mild interstitial pulmonary edema. Radiology showed 1. ET tube approximately 3 cm from the carina. Enteric tube in the proximal
stomach, but tube should be advanced to ensure location of proximal side holes
in the stomach.
2. Improvement in interstitial edema. The patient was diagnosed with BRAIN CONDITION NOS. The patient was treated with ___: L frontal craniotomy for tumor resection. At the time of discharge, the patient had L frontal brain mass
Cerebral edema
Lung 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>The patient was admitted from the emergency department to the
neurosurgery floor on ___. Mr. ___ was taken to
the operating room on the ___ and underwent a left
craniotomy and removal of tumor. He tolerated the procedure well
and was extubated in the operating room. He was transferred to
the Neuro ICU
post-operatively. She underwent a post-operative non-contrast
head CT which showed expected post-operative changes. He was
kept intubated and sedated overnight.
On ___, The patient was weaned off sedation in the morning. The
patient was written for a decadron wean. Neurology and radiology
and medical oncology were consulted. He had a CT of his torso
which showed suprahilar mass in the left upper lobe with
pathologic enlargement of hilar and mediastinal lymph nodes
concerning for primary lung malignancy with nodal metastases.
No evidence of distant metastatic disease in the abdomen or
pelvis. Endotracheal tube with the tip 14 mm above the carina
and should be retracted for appropriate positioning.
As well as a post operative MRI which showed status post left
frontal craniotomy with resection of dominant left frontal mass.
There is, however, thick nodular enhancement in the surgical
bed, which raises suspicion for residual tumor. Additionally,
right inferior temporal enhancing lesion and the right
retromandibular trigone lesion are also again noted and raises
suspicious for metastatic disease. Again noted is vasogenic
edema within the surgical bed with a stable 9mm rightward shift
of midline structures. Post-surgical changes include a small
left subdural hematoma, hemorrhage within the surgical bed, and
small amount of hemorrhage layering posteriorly within the
occipital horns of lateral ventricles as well as within the
fourth ventricle.
On ___, The patient was extubated in morning and tolerated
extubation well. The patient was mobilized out of bed to chair
and exhibited an improved exam. On exam, the patient moved all
extremities slowly antigravity to command. He moved his right
upper extremity less than his left upperextremity. Eyes were
open spontaneously. Pupils were equal and reactive. On ___ he
was transferred to the SDU where he was monitored over the
weekend. On ___ he remained stable and was discharged to rehab. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is ___ year old woman with hx notable for recent
anterior
STEMI in ___ (LAD occluded mid at origin of large
diag-->crossed s/p PCI to mLAD, LCx with 80% mid, Ramus with 80%
proximal disease, RCA occluded with collateral), HFrEF (LVEF
30%,
akinetic and aneurysmal, ?mural apical thrombus, on warfarin)who
presented to ED w/progressive dyspnea on exertion and chest
discomfort. CHEST (PA AND LAT) showed Patchy bibasilar airspace opacities, potentially atelectasis, though
aspiration or infection is not excluded. Small right pleural effusion. The patient was diagnosed with Other chest pain. At the time of discharge, the patient had Primary:
===============
Dyspnea
New atrial fibrillation
Chest pressure
Acute on chronic systolic heart failure with EF 30%
Secondary:
===============
Coronary artery disease
Possible mural thrombus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with PMHx notable for recent anterior STEMI in
___ (LAD occluded mid at origin of large diag --> crossed
s/p PCI to mLAD, LCx with 80% mid, ramus with 80% proximal
disease, RCA occluded with collateral), HFrEF (LVEF 30%,
akinetic and aneurysmal, possible mural apical thrombus, on
warfarin) admitted for worsening exertional dyspnea and chest
pressure most likely due to acute CHF exacerbation and newly
discovered a-fib vs. a-flutter. She improved rapidly with one
dose of IV Lasix and had stable HRs on increased dose of
metoprolol succinate.
# ATRIAL FIBRILLATION vs FLUTTER
# POSSIBLE MURAL THROMBUS
A-fib/flutter newly discovered on telemetry during this
admission in setting of recent STEMI and HFrEF, with well
controlled rates overall. Likely related to recently discovered
(possible) apical mural thrombus during last admission. INR
sub-therapeutic on admission and so patient was initially
bridged on heparin gtt until therapeutic. Home metoprolol dose
was increased from 12.5mg daily to 50mg daily (succinate)
# DYSPNEA / MILD HYPOXEMIA
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
Presented with worsening exertional dyspnea with new oxygen
requirement, most likely from acute heart failure exacerbation
in setting of reduced EF and recent STEMI. BNP 8800 upon
arrival, reportedly with JVD elevation upon cardiology
evaluation in ED but appeared euvolemic at time of discharge
without further diuresis aside from initial day. Also with newly
discovered paroxysmal atrial fibrillation likely contributing.
Less concerned for ACS
given mild troponin elevation is down-trending with flat MB and
more likely residual from recent STEMI. Would expect much more
profound symptoms and EKG changes if in-stent thrombosis, and
patient has been adherent to anti-platelet medications. Symptoms
resolved and on room air following modest diuresis.
# CHEST PRESSURE
# CAD s/p RECENT ANTERIOR STEMI
Recently with DES to LAD for STEMI with re-presentation
including sub-sternal chest pressure. EKG with interval
improvement and down-trending troponin, negative MB. Overall low
concern for acute thrombosis. Symptoms completely resolved with
treatment of presumed CHF exacerbation. Metoprolol succinate was
increased per above. Continued statin, aspirin, Plavix.
# OSTEOPOROSIS
- held alendronate while inpatient</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old right handed woman who
presents with acute onset of left sided weakness. ED STROKE CTA HEAD AND NECK WITH PERFUSION Q14 CT HEADNECK showed 1. Occlusion of the proximal M1 segment of the right middle cerebral artery.
2. Increased mean transit time throughout the entire right MCA territory with
a a matched deficit of blood volume and blood flow.
3. Atherosclerotic plaque at the origin of the left vertebral artery causes
moderate stenosis.
4. Nonenhancing opacity in the right upper lobe is suspicious for pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 1:38 pm, 5 minutes after discovery of
the findings. Right internal carotid arteriogram.
Right middle cerebral arteriogram.
Right MCA mechanical thrombectomy.
Follow-up right internal carotid arteriogram.
Right common femoral arteriogram. showed Right M1 occlusion with successful revascularization after third pass
thrombectomy consistent with TICI Grade 3.
RECOMMENDATION(S): Follow-up magnetic resonance imaging CHEST (PORTABLE AP) showed Right suprahilar opacity, likely represents pneumonia. Follow-up recommended
to document resolution in 6 weeks.
RECOMMENDATION(S): Chest x-ray in 6 weeks MR HEAD W/O CONTRAST showed 1. Scattered small foci of slow diffusion with somewhat more confluent area
involving the right putamen compatible with late acute to early subacute
infarction in the distribution of the right middle cerebral artery.
2. No evidence of intracranial hemorrhage.
3. Diffuse parenchymal volume loss with probable chronic small vessel ischemic
disease. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No intracranial hemorrhage.
2. Evolving known right MCA infarct. The patient was diagnosed with Cerebral infarction, unspecified. The patient was treated with Iv tPA
Thrombectomy. At the time of discharge, the patient had Acute ischemic stroke in R MCA territory. The patient was given written instructions concerning 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 Neuro ICU after undergoing
successful mechanical thrombectomy where TICI III reperfusion
was obtained at 1431, 2h11m after LKW time. Her deficits rapidly
improved. She was antigravity but still neglecting minutes after
thrombectomy. On arrival to the ICU she had L field cut,
prominent L facial droop, subtle neglect, and 4 to 4+ strength
throughout her L hemibody. by the morning of ___ her facial
droop had significantly improved, her field cut had resolved,
and her strength was somewhat improved. MRI showed only small
area of infarction at the R putamen and border of the internal
capsule, as well as 3 other punctate areas of cortical infarct,
2 in the L parietal lobe and 1 in the L frontal lobe.
Etiology was felt likely cardioembolic given distribution of
infarcts (bilateral anterior circulation infarcts, M1 thrombus.
She was treated with permissive hypertension to 180/105 per
routine post-tPA guidelines. She was mobilized and had interval
CT at 24 hours post-tPA. She was started on aspirin, and
continued on home atorvastatin 20 mg qpm (LDL 70). A1c was 5.9.
TSH was normal. She was subsequently transferred to the
Neurology Floor.
While on the floor, she was monitored on telemetry with evidence
of atrial fibrillation with rapid ventricular response. She was
restarted on her home metoprolol and after discussion with
family it was decided to start on anticoagulation therapy with
Eliquis 5mg twice daily. She underwent an Echocardiogram which
showed some mild CAD but no intracardiac thrombus or septal
defect. She was evaluated by ___ and recommended for acute
rehab.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year old woman with history of diabetes,
hypertension, and left chronic subdural collection/hematoma, who
presents with left eye ophthalmoplegia. Chest: Frontal and lateral views showed No acute cardiopulmonary process. MRI AND MRA BRAIN PT12 MR HEAD showed 1. Interval worsening of extra-axial dural thickening, enhancement with
involvement of the left tentorium, posterior falx, extending into the left
anteromedial middle cranial fossa. Involvement of the left cavernous sinus.
Encroachment on the lateral wall cavernous sinus, proximal third cranial nerve
within cavernous sinus, and cisternal segment fifth cranial nerve.
2. Differential considerations include subacute infection, inflammatory
process, granulomatous process including sarcoidosis, Wegner's, idiopathic
hypertrophic pachymeningitis. Malignancy is less likely, cannot be excluded.
3. Extensive intracranial areas of vascular narrowing, likely atherosclerotic.
NOTIFICATION: ___ The patient was diagnosed with Other paralytic strabismus, left eye. The patient was treated with Lumbar Puncture. At the time of discharge, the patient had Complete left ophthalmoplegia
Multiple cranial neuropathies. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with history of diabetes, hypertension, and
left subdural collection, presenting with subacute progressive
painless complete left ophthalmoplegia consistent with multiple
cranial neuropathies.
Neurologic exam notable for complete LT ptosis, unreactive pupil
at 3mm, inability to move the LT eye in any direction of gaze,
consistent with complete III, IV, and VI nerve palsies.
Laboratory studies from prior admission reviewed notable for
positive quantiferon gold and AChR antibodies which are of
unclear significance. MRI ___, with contrast showed interval
worsening of her extra-axial dural thickening, contrast
enhancement with involvement of the left tentorium, posterior
falx, extending into the left anteromedial middle cranial fossa.
There is also involvement of the left cavernous sinus and
encroachment on the lateral wall cavernous sinus, proximal third
cranial nerve within cavernous sinus, and cisternal segment of
the fifth cranial nerve. Labs notable for elevated CRP of 13.2,
ESR of 48, negative Sjogrens antibodies, Hepatitis panel, ___,
Lyme PCR, and RPR. SPEP and UPEP pending. Lumbar puncture was
performed and notable for glucose 94, protein of 50, WBC 3 (95%
lymphocytic), RBC 2, CSF was sent for Cytology, flow cytometry
and a large hold was saved. Neurosurgery team was consulted to
assess for the possibility of biopsy and will follow her as an
outpatient. Rheumatology recommended sending IgG subclasses
1,2,3,4, cyclic citrullinated peptide antibody which are
pending. The question of empiric treatment with steroids was
raised, however this was held given the possibility of biopsy.
Etiology unclear, but given the painless, subacute, and
progressive nature of her symptoms concerns are for
inflammatory, granulomatous, autoimmune, or neoplastic process.
After neuroradiology discussion differential includes
sarcoidosis, histiocytosis, mycobacteria infection, IGD4-related
disease, and idiopathic focal pachymeningitis. She will
follow-up with neurosurgery for consideration of biopsy
depending on LP results.
Transitional Issues:
====================
#NO MEDICATION CHANGES
[] Follow-up with neurosurgery
[] Follow-up LP/serum labs pending</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with spina bifida, chronic hydronephrosis with neurogenic
bladder s/p ileal conduit urinary diversion, HTN, discharged
___ for mgmt of MDR e coli UTI on ertapenem, returns with
persistent right flank pain and left arm pain.
Pt reports he was discharged from the hospital yesterday with
___ R flank pain. He has chronic R flank pain and reports ___
is bearable for him. He reports he went ___ and took oxycodone.
Slept a little but it was difficult because of the pain. This
morning he awoke with severe pain, took oxycodone again. He
reports he felt "crappy" because of the severe pain, up to
___. He reports chills but no fevers initially. He has chronic
chills though. He reports nausea but no vomiting. He later
noticed L arm swelling and pain near midline site. Because of
this, he took his temp and it was 100.4. He then came to ED. He
reports no cough, diarrhea. R flank pain is unchanged in quality
and location, just more severe. He got dose of ertapenem
yesterday before discharge and was due at noon time but did not
take the dose because he was returnign to ED.
Pt was admitted ___ with severe RUQ abdominal/flank pain and
urine culture positive for Klebsiella oxytoca and ESBL E. coli.
Discharged ___ on course of ertapenem via L arm midline.
In the ED, initial vitals were: 98.4 104 150/96 16 99% ra
- Labs were significant for: WBC 8.2, Hb 14.5, plt 335, K 5.5,
BUN/Cr ___
- UA with neg leuks, 27 WBC, few bacteria, 0 epi
- Imaging revealed: UE U/S with clot around midline as well as
clot on right upper extremity as well
- The patient was given: IV dilaudid 1mg, IV ___, SQ enoxaparin
100mg, 5mg PO oxycodone BILAT UP EXT VEINS US showed 1. In the left upper extremity, there is an occlusive DVT involving the left
basilic vein surrounding the PIC line.
2. In the right upper extremity, there is an occlusive DVT involving the
subclavian vein, and possible involvement of the right internal jugular vein.
NOTIFICATION:
___ were d/w Dr. ___ by Dr. ___ at 6:30pm on the day of the exam
by phone. The patient was diagnosed with URIN TRACT INFECTION NOS, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS. The patient was given written instructions concerning 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 h/o spina bifida, chronic hydronephrsis w/
neurogenic bladder s/p ileal conduit urinary diversion, HTN and
recent discharge ___ for management of MDR E. Coli UTI on
ertapenem, returning with right flank pain and left arm pain
#Right flank pain: this is a chronic issue since last admission,
when he was discharged with ___ pain. Since this is the primary
cause of his readmissions, an extensive discussion regarding his
care was begun. The patient reported that he left his prior care
at ___ due to a frustration with not
receiving pain medications and for his dissatisfaction with
readmission for pain. He reported that he took nothing at home
when he is not in pain but has a lot of difficulty controlling
his flares. At baseline, he says that he can be comfortable
without oxycodone. At the time of previous discharge (___), he
had received oxycodone 10 mg q4h PRN. However, he reports that
he did not fill this prescription yet, and so was not taking
oxycodone at home. His pain regimen during this hospitalization
included: Initial dilaudid 1 mg IV in the ED x1 on ___ and
x1 on ___, dilaudid 0.5 mg IV q4h on ___, Throughout admission
he received: tylenol 1 g q8h standing, gabapentin 300 mg BID and
600 mg qHS, oxycodone 10 mg q4h, increasing to 15 mg q4h on
___, lidocaine patch, tizanidine 4 mg qHS starting ___.
A pain management team was consulted, and the plan to use
dilaudid IV during the initial admission with transition to po
was determined. In addition, records were obtained from
___ to see his history of hospital visits,
which included an average of about ___ monthly visits for right
flank pain. The treatment plan varied with each visit and per
patient and records, there was nothing consistent that worked
for pain management. Per records from ___ narcotic
registry, the patient has not filled a significant number of
prescriptions for oxycodone. He does take them intermittently,
consistent with his history of right flank pain flares.
Ultimately, we coordinated care for him to see a chronic pain
specialist at ___, where he is planned for follow up. Upon
discharge, he had not required dilaudid IV for >24 hours and had
not required any PRN medication overnight. The patient was
satisfied with his oral regimen and wanted to "get back to a
normal life".
#Left arm pain: The patient had a bilteral upper extremity
ultrasound in the ED which showed bilateral DVTs. The left
upper extremity clot was associated with his midline, although
the midline remained patent. Anticoagulation with lovenox
1mg/kg BID and coumadin 5 mg was started on ___. His INR
increased to 1.2 by the time of discharge on ___, but given
the short course of therapy, dose was not adjusted. He was
planned for follow up the morning after discharge with the
___ pharmacy clinic @ ___ for
warfarin management and he was written a prescription for INR
draw for that day (___). Given subtherapeutic INR at time of
discharge, he received a prescription to continue lovenox until
his PCP ___. He is projected to stay on coumadin for at
least 3 months. His left midline was kept in place throughout
admission.
#MDR E. Coli and Klebsella UTI: he was kept on carbapenem
coverage with meropenem 500 mg q6h (ertapenem not available on
formulary). He was discharged on the same ertapenem as per
initial plan for a total of 14 day course (___). </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with no significant past
medical history who initially presented to an outside hospital
with abdominal pain and jaundice, found to have cholelithiasis
and hyperbilirubinemia, transferred to ___ for consideration
of
ERCP. MRCP showed The gallbladder is packed with numerous small gallstones, but no features of
cholecystitis.
Three 2 mm gallstone seen in the distal CBD, but no intra or extrahepatic bile
duct dilatation. The patient was diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction. The patient was treated with ERCP ___. At the time of discharge, the patient had Cholethiasis
Choledocholithiasis
Jaundice. The patient was given written instructions concerning 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 no significant past medical
history who initially presented to an outside hospital with
abdominal pain and jaundice, found to have cholelithiasis and
hyperbilirubinemia, transferred to ___ for ERCP.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is an ___ ___ speaking male with a PMHx of CAD s/p
CABG, AS s/p AVR presenting with chest pain and shortness of
breath starting at rest morning ___ being admitted for
nuclear stress test after attempt in the ED was not successful.
Most of history is provided through aid who speaks ___ and
able to translate for the patient.
The patient developed left-sided chest pressure that did not
radiate the morning of ___. He denied symptoms in his neck
or jaw. At the time, he had no accompanying vomiting, but he
reports nausea. There was no abdominal pain. He left his room
and went to report his symptoms and felt weak, so 911 was
called. He had accompanying shortness of breath. The patient
denies having episodes of this type of pressure before. His
symptoms of chest pressure occurred at rest. The patient
reiceved a full-strength ASA and nitroglycerin by EMS. His pain
resolved after strenght ASA and nitroglycerin as well as while
being in air conditioned area.
He has not noticed lwoer extremity edema and notes that he
sleeps with 3 pillows at baseline. He recently has not required
more pillows.
In the ED, initial vitals were 67 122/71 18 98%. In the ED, CXR
was negative for PNA, troponins were negative times 2, and the
EKG in the ED was at the patient's baseline (stable LBBB).
Patient was admitted to the ED observation unit for 2 sets and a
stress. He was unable to cooperatie with the stress test. Plan
is to admit to cardiology for stress test on ___ as the
stress lab will be closed tomorrow and the patient has multiple
risk factors. In ED observation, the patient was noted to be
sundowning and received Zydis. Vitals prior to transfer: 98.0 86
153/86 16 98%.
On arrival to the floor, the patient has no complaints of chest
pain.
On review of systems, he denies cough, melena, hematocehzia, or
BRBPR. He denies recent fevers, chills. He denies weight loss or
weight gain. He denies n/v, abdominal pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations. Radiology showed 1. Pleural thickening along the lateral aspect of the right lung and posterior
left lung with underlying streaky opacities at the right base could reflect
scarring, atelectasis or infection in the appropriate clinical setting.
2. If there is no prior film for comparison to document stability of these
findings, CT is recommended for further evaluation non-urgently. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Primary Diagnosis:
Costochondritis
Secondary Diagnosis:
Coronary Artery Disease
Dementia
Sick sinus syndrome s/p dual chamber pacemaker. The patient was given written instructions concerning 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 an ___ ___ speaking male with a history of CAD
s/p CABG, aortic stenosis s/p AVR who presented with chest pain
and shortness of breath starting at rest morning ___ being
admitted for nuclear stress test after attempt in the ED was not
successful.
# Coronary artery disease: s/p 1-vessel CABG.: In the ED,
troponins were negative x2 and EKG was at baseline (atrial paced
at 60 with LBBB). Patient did not tolerate initial stress test
due to agitation but read states that the patient probably had
uniform tracer uptake in the stress and rest images throughout
the left ventricular myocardium in the setting of soft tissue
attenuation. He was admitted for a repeat study. At time of
admission he denies any chest pain, shortness of breath,
lightheadedness, or dizziness and did not have any over course
of admission. Following weekend, a repeat nuclear stress was
attempted but patient said he did not want to have one and
refused to cooperate with study. He was discharged given
resolution of symptoms and reassuring work up with negative
cardiobiomarkers and unchanged EKG. He was continued on home
aspirin, statin, and atenalol.
# Aortic stenosis: s/p AVR with a ___ tissue valve
on ___. Clinically the patient appeared evolemic. this
admission No need for diuresis. He will need a follow up TTE as
an outpatient to for valve surveillance. TTT showed EF of ___
initially following valve replacement. He was continued on home
lasix 20mg daily. Lisinopril 5mg daily was added to his regimen
this admission.
# Pleural thickening noted on CXR: Radioogy recommends chest CT
if there are no prior filmd for comparison to document stability
of these findings. Per radiology, this does not need to be done
on an urgent basis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o HTN and hypothyroid presents with progressive left leg
pain referred to ___ out of concern for osteosarcoma. She was
in her normal state of health until last year when she had a
mechanical fall. She had no pain after this fall,
but about one month later she developed pain in her left hip
(which she describes as deep in her groin, but also over the
area of the greater trochanter). This pain radiated down to her
foot. It is intermittent, coming in paroxysms, which last
minutes to an hour. Over the next several months, the pain
increased in severity, and became incredibly disabling. She is
no longer able to drive, and no longer able to work (she had
worked as a home health aid for elderly adults). It also would
wake her up from sleep. During this period, she lost about 15
pounds, though tells me she was eating normally. She denied
night sweats and fevers, though had rigors when her pain would
flare. She has had a fair amount of medical work up for this
pain. I have requested records, but per patient: trial of muscle
relaxants and tramadol, hip joint injection (3 days of relief),
MRI of her spine, and then a "back surgery" for a diagnosis of
sciatica (did not make any difference), and rehab stay. Despite
all of this, her pain continued to worsen. Last week, she went
back to her PCP who performed an x-ray of her hip. Two days ago,
her doctor called her and informed her that the x-ray showed
osteosarcoma and told her to present to ___. CT-guided bone biopsy showed Technically successful CT-guided biopsy of a left proximal femoral lesion. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. Study is mildly degraded by motion. Additionally, study was terminated
before completion due to patient inability to tolerate exam.
2. Within limits of study, no evidence of hemorrhage, mass effect or acute
infarction.
3. Evaluation for metastatic disease is limited secondary to lack of
postcontrast images. If continued concern for intracranial metastatic
disease, consider repeat exam when patient can tolerate study.
4. Global volume loss and probable microangiopathic changes. CT abdomen pelvis showed 1. No evidence of metastatic disease in the abdomen or pelvis.
2. Cortical irregularity of the left femoral neck and greater trochanter is
only partially evaluated on current exam and is better characterized on prior
MR hip performed ___.
3. Please refer to separate report of CT chest for description of the
intrathoracic findings. CT CHEST W/CONTRAST showed 1. Innumerable small lung nodules measuring up to 8 mm in the left lower lobe
concerning for metastases. No primary lesion identified. No lymphadenopathy.
Findings could represent metastases from the newly identified femoral lesion
or from previously resected primary lung cancer given postsurgical changes in
the right lower lobe.
2. Please refer to separate report from concurrent CT abdomen pelvis for
description of findings below the diaphragm. FEMUR (AP AND LAT) LEFT showed Large lucent lesion of the intratrochanteric region of the left proximal femur
extending into the femoral neck and subtrochanteric region. There is likely
areas of endosteal scalloping, though the degree to which is difficult to
ascertain on x-ray. Contrast enhanced mass infection protocol MRI is
recommended for further evaluation Radiology showed Large aggressive appearing mass involving the left femoral neck,
intratrochanteric and subtrochanteric regions of the left proximal femur.
Possible etiologies include metastatic disease, myeloma, lymphoma, or a
primary bone tumor. There is endosteal scalloping along the mass with
apparent cortical breakthrough and extraosseous extension along the posterior
aspect of the distal femoral neck, posterior greater
trochanter/intertrochanteric region, and posterior subtrochanteric region
concerning for increased risk of pathologic fracture. Orthopedic oncologic
evaluation should be considered.
Two uterine masses are identified, one of which indents upon the endometrial
canal. These may represent fibroids, however other etiologies cannot be
excluded. Additionally there is blood products within the endometrial canal
which measures up to 5 mm in thickness. Pelvic ultrasound is recommended for
further evaluation.
1.6 cm hyperintense lesion of the inferior pole of the right kidney is
partially imaged on localizer sequence only. This is likely to represent a
renal cyst. Correlation with prior abdominal or renal imaging is recommended.
If no prior imaging is available, nonemergent renal ultrasound is recommended
for further evaluation.
RECOMMENDATION(S): As above.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:24 am, 90 minutes after
discovery of the findings. The patient was diagnosed with Malig neoplm of conn and soft tiss of left low limb, inc hip. The patient was treated with Left bone biopsy ___. At the time of discharge, the patient had Leg pain
Bone mass concerning for cancer
Lung lesions concerning for cancer
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>___ h/o progressive & disabling left hip and weight loss with
imaging concerning for osteosarcoma admitted for expedited work
up.
1. Severe left leg pain with large lucent lesion of the left
proximal femur
-In combination with systemic symptoms and radiographic
findings, bone lesion is concerning for primary malignancy of
bone. However, given h/o lung cancer it is possible this is
metastatic. s/p ___ biopsy ___. Orthopedic oncology
sawa patient recommending weight bearing as tolerated (WBAT)
with walker to alleviate some pain. She will follow up with
orthopedics next week to discuss biopsy results; if this is
primary bone cancer ___ cannot manage
this and she will need to get her care at ___. Recommend
radiation oncology referral pending biopsy results. Pain
medication was titrated and well-controlled on oxycontin 10mg
BID with oxycodone ___ Q6 hours PRN with acetaminophen and
lidocaine patch. Discharge with bowel regimen and home ___.
2. Lung lesions h/o adenocarcinoma of the lung
-s/p right lower lobectomy ___ found to have Stage Ib T2NxM0
invasive moderately differentiated adenocarcinoma of the lung.
Question whether lung lesions are metastatic lung vs bone and
will await bone biopsy prior to lung biopsy. If she has a
primary bone malignancy will need to obtain lung biopsy. If lung
and bone lesions are metastatic lung cancer she can return to
her previous oncologist Dr. ___ at ___
___.
3. Orthostatic hypotension and dizziness
-Patient may have multiple causes of dizziness including
orthostatic hypotension, secondary to pain, or in setting of
intracranial process (brain mets). Dizziness does not seem to
correlate with oxycodone. Patient was only able to tolerate
limited MRI (without contrast) that did not show acute
intracranial process. Orthostatic hypotension resolved with
holding antihypertensives and giving IV fluids. At time of
discharge dizziness resolved. Recommended taking her time when
changing positions.
4. Anemia
-Suspect due to malignancy. Continue to monitor.
5. Constipation
-Likely in setting of narcotics started on bowel regimen.
Stressed the importance of continuing a bowel regimen to prevent
opioid-induced constipation.
6. Uterine Fibroid
-Initially seen on MRI hip concerning for fibroids, and
radiology recommending pelvic ultrasound. CT pelvis confirms
uterine fibroid and no further workup indicated at this time.
7. Right Renal cyst
-Initially seen on MRI hip concerning for renal cyst, and
radiology recommending renal ultrasound. CT pelvis confirms
renal cyst and no further workup indicated at this time.
8. Insomnia and anxiety
-Insomnia and anxiety are resulting in increased pain, which we
discussed. She required ___ prior to MRIs and procedures. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o HTN, RA with multiple recent admissions presenting
with fever. Patient had two recent admissions to ___. The
first was in early ___ for prolonged fevers, LLE cellulitis, R
septic knee s/p washout on ___ with cultures growing coag
negative staph, and bacteremia with cultures growing strep G.
She was discharged on ___ on Penicillin G and warfarin for
DVT ppx given her recent knee surgery. She returned one day
later with significant hematemesis. Her bleeding was stabilized
s/p EGD with epi injection x3 and L gastric artery embolization
x2. She was discharged to rehab on Vacomycin for continued
treatment of her R septic knee and bactermemia. Radiology showed Mild interstitial edema, unchanged from ___. Radiology showed No deep vein thrombosis left or right lower extremity Radiology showed Fluoroscopically guided single-lumen PICC line replacement via a
right sided venous approach. Final internal length is 48 cm, with the tip
positioned in the distal SVC. The line is ready for use. Radiology showed No evidence of a DVT in the left upper extremity. The patient was diagnosed with FEVER, UNSPECIFIED, CELLULITIS OF LEG, HYPERTENSION NOS. The patient was treated with ___: Right knee washout with removal of hardware and
antibiotic spacer placement performed by Dr. ___.
___: ___ line placement. At the time of discharge, the patient had sRight septic knee. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o HTN, RA with recent admissions for severe sepsis
with R septic knee and UGIB ___ GE junction ulcer presenting
with fever, due to R septic knee s/p washout, removal of
hardware, and abx spacer</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old gentleman with a history of EtOH
abuse for ___ years with a positive history of DTs and
withdrawal seizures who was discharged from detox 5 days prior
to presentation. He was binging since discharge and presented to
the ED with slurred speech and nausea/vomiting. He was noted to
be dry heaving at triage and seeking detox. He drank ___ of
vodka on the night of admission, last drink about 8:30PM. His
last reported seizure was on ___.
He has also been experiencing epigastric pain, black and bloody
stool. Per patient he had a recent endoscopy ~1 month ago which
revealed esophageal ulceration and gastritis. He was scheduled
for 6 week followup. He initially had vomitus with frank blood
that became coffee ground over course of 2 days.
His mother endorses he has had a 40 lb weight gain over last six
months, largely carried in abdomen and face. His baseline is 175
lbs. He endorses a history of Hepatitis C that was treated with
6 months of ribavirin and IFN. Radiology showed No acute cardiopulmonary process. Radiology showed No acute intracranial abnormality. Global atrophy. The patient was diagnosed with ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-UNSPEC. At the time of discharge, the patient had Alcohol intoxification
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>Mr. ___ is a ___ year old male with a history of EtOH abuse
for ___ years complicated by DT and withdrawal seizures,
discharged from detox 5 days prior to admission, who presented
to the ED with EtOH intoxification.
# EtOH Abuse: Patient was stable on arrival to MICU. Serum tox
screen was positive for benzos; serum EtOH was 253. He placed on
CIWA protocol with Diazepam. He was given thiamine, folic acid
and multivitamins, and IV fluid resuscitation. He remained
stable and was transferred to the medicine floor on HD1. While
on the medicine floor he remained clinically stable, requiring
___ doses of diazepam throughout his 3 days on the medical ward.
He expressed a desire to go to detox. He was evaluated by
psychiatry for qualification for dual diagnosis program. He
stopped scoring and no longer required his CIWA scale. His
diazepam and CIWA scale were discontinued because he was no
longer in active withdrawal.
# ?GI bleed. Patient reported black bowel movements at home; in
the ED patient's stools were guiaic negative. Differential
included ___ tear vs gastritis vs esophageal ulcer,
PUD. He had evidence of gastritis on EGD 1 month prior. Boerhave
syndrome felt unlikely given no mediastinal widening on CXR, and
lack of deep cervical or subcutaneous emphysema. He was typed
and screened, 2 large-bore IVs were placed, and he received 40
mg pantoprazole BID. He was transferred to the MICU
hemodynamically stable and had no further episodes of bleeding.
He remained hemodynamically stable on the medicine floor with no
episodes of bleeding. His H/H remained stable and was 14.6/41.7
on discharge.
# Abdominal pain: Patient complained of vague abdominal pain,
thought likely secondary to ongoing hepatitis C/inflammation.
Per his history he has had RUQ abdominal pain for several months
and it has been unchanged in severity and quality. He had a
cholecystecomy in ___ for chronic cholecystitis. Pancreatitis
unlikely given lipase of 45. He has a history of hepatitis C
treated at ___ with 6 months of Ribavirin/IFN. His liver
enzymes were persistently elevated during his hospitalization
with ALT>AST suggesting ongoing viral hepatitis. Hepatitis
serology was negative for Hepatitis B Antigen, Hepatitis B core,
and positive for Hepatitis B antibody. Hepatitis C viral load is
pending.
# Shaking: Mr. ___ endorsed shaking of his arms, thought to
be pseudoseizure vs malingering: Felt highly unlikely to be
genuine seizure activity given inconsistent presentation, lack
of post-ictal state, resolution with distractability, purposeful
movements during episode. No evidence of hypoglycemia or active
infection. He was monitored throughout the hospital stay with
no events concerning for acute neurological pathology.
# HCV: Likely this was contracted from IVDA. This was treated at
___ with 6 mo Ribavirin/IFN. LFTs suggestive of ongoing liver
inflammation, showing a pattern inconsistent with EtOH
hepatitis. HCV viral load is pending. HBV serologies sent, which
were positive for HbsAb, and negative for Hepatitis Antigen and
Core as above, so patient was vaccinated. LFTs downtrended
slightly during ICU stay.
# Narcotic abuse: Mr. ___ endorses IVDU most recently ___ years
ago. However he had dilated pupils on presentation to ICU. He
had a negative Utox but the assay does not detect oxycodone. It
was thought possible that he was withdrawing from an opiate as
well. He was monitored throughout his hospital stay; aside from
abdominal pain, he showed no signs or symptoms opiate
withdrawal. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of diastolic CHF, recent mechanical aortic
valve
re-do and CABG in ___, AFib, and Mobitz I heart block now
with
PPM who presents from home with pleuritic chest pain. Radiology showed Cardiomegaly without acute cardiopulmonary process. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Chest pain, unspecified, Acute kidney failure, unspecified, Heart failure, unspecified. At the time of discharge, the patient had PRIMARY:
Non-cardiac chest pain
Acute Kidney Injury
SECONDARY:
Acute on chronic diastolic heart failure
Aortic stenosis s/p ___
Atrial Fibrillation
Diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of diastolic CHF, recent mechanical aortic
valve re-do and CABG in ___, AFib, and Mobitz I heart block
now with PPM who presents from home with pleuritic chest pain
#Chest Pain
Pleuritic chest pain 3 weeks after CABG concerning for potential
PE. Was found to have subtherapeutic INR as outpatient. He had a
VQ scan which showed low probability for PE. Trops downtrending
on admission, EKG reassuring. His chest pain is likely secondary
to a musculoskeletal etiology as the pain is very much
reproducible on palpation and is localized to a specific spot on
the left upper chest. His chest pain improved greatly and was
manageable with oxycodone.
___:
Admission Cr 1.7 from discharge value of 1.1. Appears volume
overloaded. Endorses good appetite. Volume overload was an issue
since discharge, and it seems patient may have been taking
inappropriately low dose of Lasix (40mg BID). He was given 60mg
IV Lasix with effect and his Cr downtrended to 1.6 the following
day. He was discharged on 80mg PO Lasix with follow up Cr as
outpatient.
#Acute on chronic diastolic CHF:
EF estimated 45-50% on echo post-CABG and ___ ___. Appears
volume overload with pedal edema although denies
dyspnea/orthopnea. Likely etiology of olverload is insufficient
Lasix dosing. As above, given 60mg IV Lasix and discharged on
80mg PO Lasix. He was instructed to weigh himself daily and
contact cardiologist if weight is increasing.
#Aortic stenosis, s/p mechanical ___ (On-X)
Briefly on heparin gtt. INR level was 2.4 on discharge.
#AFib:
Continued patient on metoprolol for rate control. He was given
9mg warfarin daily while inpatient. INR level was 2.4 on
discharge.
#DM: Continued on home insulin: glargine 28u qam, then Humalog
___ with meals.
#HLD: Continued on atorvastatin
#GERD: Continued home omeprezole
#BPH: Continued finasteride, tamsulosin
TRANSITIONAL ISSUES
[] Please repeat Bun/Cr and K as outpatient.
[] Suspect chest pain is musculoskeletal in etiology. Patient
discharged with extra 10 pills of oxycodone 5mg. Please assist
with pain management
[] Please adjust Lasix dose PRN. Discharged on Lasix 80mg PO.
[] Discharge weight: 104.3 kg
[] Decreased potassium 20meq PO BID to daily. Consider
increasing back to BID if potassium level is low
[] Consider PPM interrogation as outpatient and increasing rate.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ y/o male w/PMHx notable for HTN and
gout
who presents with 3 weeks of worsening right ankle pain. Says
that about 4 weeks ago, colchicine was stopped by PCP, he thinks
due to possibly causing/contributing to his leg neuropathy.
Approximately 1 week later, he notes he started having right
ankle pain. Felt like he "turned" his ankle, but with no
reported trauma. Right ankle began to swell, and ROM became
more
painful. Then developed right knee pain, swelling, and
erythema,
as well as right ___ MTP pain, swelling and erythema. This was
constant, progressive, became severe, was aggravated by walking,
and was mildly alleviated with Advil. Was treated by PCP/urgent
care for possible right lower leg cellitis with dicloxacillin
___ on ___, with no improvement. Around that time, he also
developed left ___ MTP pain, erythema, swelling, and reduced
ROM.
Has had increasing difficulty walking, yesterday was nearly
bed-bound due to the pain. Radiology showed Chondrocalcinosis in the right knee joint. No acute fracture or dislocation.
No cortical destruction to suggest acute osteomyelitis radiographically. Soft
tissue swelling. Radiology showed Soft tissue swelling and claw toe deformity of the first MTP joint. The patient was diagnosed with Localized swelling, mass and lump, lower limb, bilateral. At the time of discharge, the patient had Polyarticular gout flare
Claw toe of the right great toe with associated 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>___ y/o M w/ HTN and gout who has developed subacute, progressive
joint pain and swelling in a polyarticular distribution in
setting of stopping colchicine shortly prior to initial onset of
symptoms. Right knee joint fluid crystal analysis consistent
with gout flare. Imaging also concerning for possible
underlying CPPD disease.
.
# Polyarticular gout flare - improving with steroid regimen
- Likely trigger was stopping colchicine.
- s/p solumedrol 40 mg IV x1 on ___, prednisone 40 mg PO on ___
and ___, solumedrol 40 mg IV on ___, solumedrol 30 mg IV on ___,
prednisone 30 mg PO on ___.
- Prednisone taper plan: 30 ___ stop
- Colchicine 0.6 mg PO daily (renal function stable)
- Pain control w/ Tylenol standing and oxycodone PRN
- There were no signs of active infection, no abx given, blood
cultures were no growth (final), and joint fluid culture (right
knee) remain no growth to date as of the day of discharge..
- XR of right ___ MTP to eval for erosive joint disease done per
Rheumatology recs: no evidence of erosive joint disease.
- TSH, iron studies, and alk phos were unremarkable, not
suggestive of other causes of CPPD disease.
- ___ had no record of patient's report allopurinol allergy;
further testing can be considered as an outpatient at discretion
of Dr. ___
- ___ clinic follow-up has been arranged for ___ at
2:00 ___ w/ Dr. ___
.
# ___ - mild, resolved
- Slight elevation in Cr after admission, possibly due to an
element of dehydration and NSAID administration in ED
- Expect he will tolerate colchicine without adverse renal
consequences, as he has taken it for many years prior to it
being recently discontinued
.
# Ulnar neuropathy - chronic, progressive, right affected more
than left
- Continued home B12/folate, though he has not responded to this
treatment.
- Rheumatology felt this was possibly due to claw toe deformity
- Rheumatology recommended that the patient follow-up with
outpatient Podiatry for eval of possible intervention on claw
toe deformity. I have discussed this issue with the patient and
his family at length, and the patient is reticent to pursue
potential surgical interventions, but I encouraged him to
discuss risks/benefits with his primary care physician and
consider podiatry evaluation as an outpatient.
.
# HTN - continued home Losartan
.
# DVT ppx - heparin subQ
.
# Time spent - 45 minutes spent on discharge-related activities
on the day of discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with the past medical
history of DM type I c/b ESRD on HD MWF, retinopathy, and
hypertension who presents after recent admission and AMA
discharge for altered mental status and failure to go to
scheduled HD session today. He reports that he was at home today
and his dialysis center sent someone home to see him because he
didn't come to dialysis on time as his ride was late. He then
reports that a fireman "tackled" him and caused injury to his
left thigh, before bringing in to hospital. He did not get any
HD
today. Also did not take his BP medications. FEMUR (AP AND LAT) LEFT showed No fracture seen. The patient was diagnosed with Type 1 diabetes mellitus with hyperglycemia, Adult failure to thrive, Long term (current) use of insulin. At the time of discharge, the patient had Hypertensive crisis
Hypoglycemia
End-stage renal disease on HD. The patient was given written instructions concerning 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 the complete past medical history
including type 1 diabetes, end-stage renal disease on
hemodialysis, seizure, hypertension who was admitted admitted
with acute encephalopathy in the setting of hyperglycemia and
accelerated hypertension likely secondary to medication
mismanagement.
Type 1 diabetes
Hyperglycemia
-Per most recent discharge summary, patient was discharged on 15
units of Lantus daily. He reports taking 25 units of Lantus
daily despite recent adjustment to his home insulin regimen. He
will continue on his Humalog 6units baseline with sliding scale
3 times daily with meals. Hypertension
Hypertension
-Continue home Coreg, losartan, clonidine patch
ESRD on HD
-Underwent HD on ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with h/o multiple myeloma with complications
including orbital plasmacytoma and T9-12 spinal cord compression
(now bedbound) who is transferred from outside ER after
suffering a R humeral fracture. She was last admitted here in
___ for the spinal cord compression and received XRT and
high dose steroids. She was discharged to rehab where she was
improving slowly, able to take a few steps with assistance. She
was seen in ___ clinic with decision that given her
reassuring disease markers no treatment was currently indicated
and she should focus on regaining her strength as much as
possible.
The night prior to admission, she reports she was animatedly
demonstrating something with her arms and felt a pop and then
pain in her R arm. She was unable to move that arm and was taken
to local ER where plain film showed distal humerus fracture. She
was transferred to ___ for further care.
In the ER here, she was given morphine and dilaudid for pain
control. She was seen by orthopedic oncology with recommendation
to keep in splint, no surgery.
Upon arrival to the floor, she reports her pain is controlled,
___. She denies any pain elsewhere. Radiology showed 1. Stable lesions within the calvarium.
2. Stable mild loss of vertebral body height in the thoracic spine over
multiple levels.
3. Spiral fracture of the distal humeral diaphysis with mild rarefaction of
the trabeculae. A pathologic fracture is not excluded.
4. Nodular density in the right upper lobe. Consider chest CT for further
evaluation.
These findings were discussed with Dr. ___ on ___. Radiology showed 1. Pathologic fracture through the distal third of the right humerus with
marrow signal abnormality consistent with myeloma or other infilrative
process.
2. Small right elbow joint effusion.
3. Abnormal marrow focu in the left side of the sacrum and right iliac bone,
nonspecific, but compatible with myelomatous deposits
4. Degenerative changes in the lumbar spine.
5. 1.2 cm right upper lobe pulmonary nodule -- recommend a dedicated CT chest
for further assessment.
s The patient was diagnosed with FX HUMERUS SHAFT-CLOSED, STRUCK BY OBJECT OR PERSON WITH OR WITHOUT FALL, ACUTE KIDNEY FAILURE, UNSPECIFIED, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HYPOTHYROIDISM NOS. At the time of discharge, the patient had R humerus pathologic fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted for her R humerus fracture. She had
pain control with morphine IV ___ and only required doses a
few times per day. She was sometimes slightly confused after
receiving pain medications but otherwise coherent. She was seen
by orthopedic surgery and radiation oncology. Given her advanced
age and comorbidities, there was concern that surgical fixation
may lead to a long and uncertain recovery. It was decided she
would be treated with radiation to the fracture site and given a
chance to heal on her own. She received 8 Gy in one fraction on
___. On admission she had acute on chronic renal failure
which resolved to her baseline (Cr ___ with IV fluid
hydration. For her multiple myeloma, she had not been on
systemic treatment recently other than dexamethasone which was
started when she was admitted for spinal cord compression in
___. her paraproteins were rechecked and her kappa/lambda
ratio has increased only slightly from ___, while
immunoglobulins show stable IgA level with worsening reciprocal
suppression of IgG and IgM. Despite only small changes in her
paraproteins, she may need systemic treatment given her new
fracture. She will follow up with her primary hematologist to
discuss further care. Imaging studies here also redemonstrated a
chest nodule which needs to be followed up with dedicated chest
CT if clinically warranted.
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
____________________________________
___, MD, pager ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo F with osteoporosis who fell while walking her
dogs and fractured her left iliac crest. On presentation, she
had no pain at rest, however, passive extension of hip elicited
extreme pain. She had minimal bruising over lateral hip. In the
ED, she was evaluated by ortho and deemed not needing surgical
intervention. However, her ambulation was limited by pain, so
she was admitted for pain control and ___ re-evalaution. Radiology showed Lateral left iliac wing fracture. Radiology showed Incomplete non-displaced fracture through the proximal left
humerus, involving the greater tuberosity and surgical neck. No dislocation.
Findings were discussed with Dr. ___ by Dr. ___ at 2:30 p.m. via
telephone on the day of the study, 25 minutes after discovery. The patient was diagnosed with JOINT PAIN-PELVIS. At the time of discharge, the patient had Mechanical Fall
Iliac wing fracture
Proximal Humerus Fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ yo F with h/o osteoporosis who presents after a
fall and is found to have an iliac wing and proximal humerus
fracture admitted for pain control.
1. Iliac wing fracture/Humerus fracture: Sustained after a
mechanical fall. She was evaluated by ortho who recommended
weight bearing and ROM as tolerated, pain control, and
outpatient follow-up. Her pain was controlled with PO dilaudid,
ibuprofen, and tylenol. She was also told to take a stool
regimen to prevent constipation. She worked with ___ who cleared
her for discharge with use of a walker. She was told to take
Vitamin D and calcium to help with bone strength, but she also
needs to establish with a PCP/endocrinologist for DEXA and
bisphosphonate initiation.
2. Anemia: Normocytic. No recent baseline. No evidence of
bleeding, except for hematomas after fall. The patient will need
repeat Hct check as an outpatient as well as screening
colonoscopy.
3. Anxiety: Continued sertraline
4. HTN: The patient had low-normal BP here and, therefore,
lisinopril will not be restarted on discharge.
5. HLD: Statin
# CODE STATUS: Full
# CONTACT: ___ (friend) ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with RA, s/p R THA c/b distal femur fracture s/p ORIF ___
at ___, c/b persistent wound infection. She underwent I&D of
the wound, followed by repeat I&D and revision of her plate for
possible malunion, then a third I&D of her wound in ___.
Denies fevers chills, nausea, emesis, light headedness. She
notived bloody drainage from her surgical incision last night.
She has had mid thigh pain for the last 1 month and is unable to
weight bear in the RLE. Seen at OSH where she was found to have
purulent drainage from the surgical wound. She was given 1g of
vancomycin IV prior to transfer. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. The
calf veins are not well visualized.
2.4 cm minimally complex fluid collection involving the lower lateral thigh
represent a small seroma but an infected fluid collection is not excluded. Radiology showed 1. Probable background COPD.
2. Mild cardiomegaly and upper zone redistribution, but no overt CHF.
3. No focal consolidation or fusion.
4. Probable small hiatal hernia.
5. Calcified granulomas again noted, unchanged, consistent with prior
granulomatous disease.
6. Probable osteopenia. Radiology showed 1. Assessment of fine detail limited by metal artifact not withstanding the
use of metal suppression sequences.
2. Fluid collection along the posterolateral right thigh deep to the prior
surgical incision and appearing superficial to the deeper muscular
compartments, spanning up to 7 cm in craniocaudal extent with the largest
axial components measuring up to 3.6 x 2.0 cm just above the knee, as detailed
above. Note, CT is unable to distinguish between sterile an infected fluid
collections. No evidence of subcutaneous gas.
3. No obvious evidence of osteomyelitis such as osteolysis or periosteal new
bone formation. Note, further evaluation for osteomyelitis is limited due to
extensive hardware-related artifact.
4. Suspect areas of ununited fracture fragments at the distal aspect of the
comminuted femur fracture. DX HIP AND FEMUR showed Femoral fracture with fixation hardware in-situ appears partly healed
proximally, but the distal end of the fracture is still visible. I note the
cement at the tip of the femoral stem has broken since the previous relative
the remote radiograph. I small amount of lucency adjacent to the tip of
interlocking screws just distal to the distal fracture component (most cranial
screws).
RECOMMENDATION(S): I note that there are no available postoperative images
for comparison, recommend correlation with any interval postoperative imaging. FEMUR (AP AND LAT) RIGHT showed As above. DX CHEST PORTABLE PICC LINE PLACEMENT showed New right PIC line ends in the low SVC.
Heart size top-normal. Mild interstitial abnormality and accompanying
vascular congestion is probably early edema, unchanged since ___.
There is no appreciable pleural abnormality or any focal consolidation. The patient was diagnosed with Infection following a procedure, initial encounter, Oth postprocedural complications of skin, subcu, Oth surgical procedures cause abn react/compl, w/o misadvnt. The patient was treated with 1. Revision open reduction internal fixation right femoral
nonunion.
2. Irrigation and debridement of fracture skin to bone
right femur.
3. Placement of antibiotic spacer right femur.. The patient was given written instructions concerning 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 femoral ___ and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for revision ORIF of right femur,
removal of hardware and placement of an antibiotic spacer, 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. She was seen by infectious disease, who evaluated
her and recommended nafcillin IV antibiotic therapy for
management of her leg infection.
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
flat foot TDWB and neuro intact 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 ___ female with history of afib on Eliquis
who
presents to ___ on ___ s/p fall, +LOC, with a
mild TBI. Patient reports tripping over a door mat which caused
her to fall
striking the left side of her face/head. She is amnestic to the
events after the fall and reports she woke up in the ambulance
on the way to the hospital. An OSH CT head showed acute
intraparenchymal hemorrhage 2 x 15 x 15 mm in size within a
gyrus superiorly in the right anterior parietal region. She was
transferred to ___ ED for neurosurgical evaluation. Radiology showed No definite acute fracture. Multilevel osteoarthritic changes. Radiology showed Suboptimal study due to underpenetration from overlying soft tissue. No
obvious acute fracture. Moderate to severe tricompartment osteoarthritic
changes. CHEST (PA AND LAT) showed Small left pleural effusion. Mild left basilar atelectasis.
Mild pulmonary vascular congestion. The patient was diagnosed with Contus/lac/hem crblm w LOC of 30 minutes or less, init, Contusion of other part of head, initial encounter, Unspecified atrial fibrillation, Long term (current) use of anticoagulants, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had PRIMARY DIAGNOSIS
Intraparenchymal hemorrhage
SECONDARY DIAGNOSIS
Chronic lymphedema
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>This is a ___ year old female with ___ notable for AFib on
apixaban presenting as transfer from ___
following a fall with headstrike, noted to have intraparenchymal
hemorrhage, transferred for neurosurgical evaluation and then
transferred to the medicine service and managed conservatively
per neurosurgery
recs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with ESRD (on HD MWF),
chronic anemia, BPD, who is being admitted for further
evaluation
and management of suspected symptomatic anemia. Chest: Frontal and lateral views showed Mild interstitial pulmonary edema with central pulmonary vascular congestion,
increased compared the prior study.
Trace bilateral pleural effusions. The patient was diagnosed with Anemia, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Anemia of chronic inflammation
Dizziness
SECONDARY DIAGNOSES:. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman with ESRD (on HD MWF),
chronic anemia, BPD, who was admitted from his outpatient
dialysis center due to dizziness and weakness during dialysis,
concerning for recurrent anemia. His hemoglobin stable was on
arrival. He received 1u PRBC transfusion which improved his
symptoms, and he did not have any further dizziness.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old female with COPD, ESRD on HD (MWF),
chronic low back pain on opioids, and recent pneumonia diagnosis
who was sent to the ED from her nursing home (___) with
lethargy and hypoxia. Of note, she was being treated for
pneumonia with Azithromycin and Levofloxacin, with her last day
of antibiotics on ___. She continued to have a production
cough, and was hypoxic to 85% on RA which improved to 92% on 2L
NC. When EMS arrived, she had SpO2 95% on RA.
.
In the ED, initial VS were: T 97.7, HR 81, BP 92/27, RR 14, and
SpO2 96%. She was lethargic but arousable to voice. She was
coughing. EKG showed LVH with no priors for comparison. CXR
showed large PNA on left. Labs were significant for WBC 19 with
83% PMN, 4% bands, and lactate 0.9. She was given Vancomycin,
Aztreonam, and Azithromycin for HCAP (unknown Zosyn allergy).
Her SBPs dropped into the ___ and was minimally fluid
responsive. She received 2 L IVF. Her SBP did improve somewhat
with stimulation. She was admitted to the MICU. VS prior to
transfer were T 99.8, HR 82, BP 97/36, RR 20, and SpO2 100%.
.
On arrival to the MICU, she was hypoxic to mid-80s on 4L NC. She
was suctioned and placed on 6L, with her O2 sats improving to
the mid to low ___. She was complaining of having to urinate.
.
Review of systems:
(+) Per HPI, otherwise unable to obtain. Radiology showed Confluent consolidation in the left upper lobe and likely
additional focus of consolidation in the right lower lobe, suggestive of
multifocal pneumonia. Recommend treatment and followup to resolution to
exclude underlying lesion. Radiology showed AP chest compared to ___:
Large mass-like area of consolidation, with small cavitations has not improved
appreciably since earliest recent chest radiograph ___. Whether this
is pneumonia, lung abscess or mass is radiographically indeterminate. Mild
pulmonary edema persists. A region of mild peribronchial opacification in the
right lower lobe could represent the result of aspirated purulent material.
ET tube is in standard placement, but sharp definition of the cuff suggests
pooled secretions above it. Nasogastric tube ends in the upper stomach but
would need to be advanced 5 cm to move all the side ports beyond the
gastroesophageal junction. Right supraclavicular dual catheter dialysis set
ends in the right atrium. Remnants of the left-sided dialysis set are in the
SVC and right atrium aside from a fragment which has been embolized to the
left lower lobe, unchanged since ___.
Heart size normal. Pleural effusions are small, unchanged. No pneumothorax.
Dr. ___ I discussed these findings at the time of this dictation. Radiology showed Interval worsening of left lung opacification which may be due to progressive
pneumonia or worsening edema. An underlying lung mass cannot be excluded.
Relative lucency of the left costophrenic angle is suggestive of a loculated
pneumothorax.
Results were discussed over the telephone with Dr. ___ by Dr. ___ at
11:58 on ___ at time of initial review. Radiology showed 1. Dense consolidation of the left upper and lower lobes with mediastinal
lymphadenopathy and bronchial tree occlusion. Findings may be seen in either
extensive pneumonia, although an underlying malignancy cannot be excluded. A
contrast-enhanced CT would better differentiate between these two entities and
can be correlated with the patient's dialysis schedule.
2. Retroareolar soft tissue within the left breast for which correlation with
mammography would be recommended.
3. Sequelae of liver cirrhosis and portal hypertension including splenomegaly
and ascites.
4. Cholelithiasis and distended gallbladder without definitive secondary
signs of cholecystitis.
5. Atrophic kidneys compatible with end-stage renal disease. Radiology showed 1. No evidence of acute intracranial abnormality.
2. Chronic mucosal thickening of the bilateral maxillary and sphenoid
sinuses, with interval development of air-fluid levels in the mastoid air
cells and dependent fluid in the nasopharynx, likely secondary to protracted
supine positioning and intubation. Radiology showed AP chest at 5:21 compared to ___ for at 6:40:
Masslike consolidation in the axillary region of the left lung is a little
smaller. I am still concerned that it may mask a lung carcinoma. Pulmonary
vasculature remains mildly engorged but there is no edema. Cardiomegaly is
mild and unchanged. There is no appreciable pleural effusion or pneumothorax.
ET tube is in standard placement. Remnant catheter fragments end in the right
atrium and left lower lobe, as before. Right supraclavicular dual channel
hemodialysis set ends in the right atrium. An upper enteric drainage tube
passes into the nondistended stomach and out of view. Radiology showed 1. Left upper lobe pneumonia superimposed on mild pulmonary edema. Recommend
follow up radiograph ___ weeks after treatment to evaluate for underlying
parenchymal lesion.
2. Embolized catheter fragment within a pulmonary vessel, likely from the
abandoned dual lumen catheter, is unchanged in position since ___. Per
the report from that study, a CT was recommended at that time and may have
been performed at an outside institution. Radiology showed 1. Normal brain CT.
2. Mucosal thickening in the paranasal sinuses as described above. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, HYPOSMOLALITY/HYPONATREMIA, OTHER CHRONIC PAIN , UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA. The patient was treated with Intubation (___)
Electrical Cardioversion (___)
Bronchoscopy (___). At the time of discharge, the patient had Primary Diagnoses:
MRSA Pneumonia
Severe Sepsis
Clostridium Difficile Infection
Cirrhosis (HCV Infection)
Atrial Fibrillation eith Rapid Ventricular Response
Secondary Diagnoses:
End Stage Renal Disease on Hemodialysis
Chronic Back and Knee Pain
Chronic Obstructive Pulmonary Disease
Opioid Dependence. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ year old female with ESRD on HD (MWF),
cirrhosis on imaging, HCV infection, and chronic low back pain
on opioids who presented with lethargy found to have pneumonia.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Reason for consult: malaise and shaking episodes x 2 days
HPI: Ms. ___ is a ___ RHF with h/o uncontrolled DM, HTN and
HLD who presents with 4 discrete episodes of head shaking in the
setting of subjective fever, chills malaise and L temporal
headache over the past 2 days. History obtained from patient,
daughters and her sister (who witnessed one of the events). CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. MR HEAD W AND W/O CONTRAST showed 1. No acute intracranial findings.
2. T2/FLAIR signal hyperintensity in the periventricular, deep, and
subcortical white matter which is nonspecific but likely on the basis of
chronic small vessel ischemic disease. The patient was diagnosed with PSYCHOSIS NOS. At the time of discharge, the patient had Epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Seizures: Patient was admitted to the general neurology
service. Infectious evaluation was benign. Metabolic
evaluation was notable for hyperglycemia (mostly in the 200s.
While in some situations this can precipitate seizures, this was
not felt high enough to cause her seizure activity and likely
represents her glucose baseline. She was started on Extended
EEG to evaluate for inctal/interictal activity. She was started
on Keppra for seizure control, which was 750mg PO BID on
discharge. Social work was consulted for diagnosis coping and
to aid in access to medical care. Prelim read of her EEG (as
previously noted)- no seizure or epileptiform activity, but L
intermittent temporal slowing seen. MRI was done, and revealed
non-specific white matter changes, but without a clear epileptic
focus. The most likely etiology of her seizures is due to
longstand neurologic changes from microvascualr disease in
setting of her hypertension and diabetes. She was felt to be
safe for discharge with outpatient follow-up. She was
counselled on Mass law regarding inability to drive for a
minimum of 6 months following a seizure.
# DM T2: A1C in ___ was 11.4, with surgars ranging initially
during this hospitalization from 150s-low 300s. Endocrinology
was consulted and recommended initiation of Lantus 10u QAM.
Diabetes educator was consulted and saw the patient prior to
discharge.
----------
Transitional Issues
- Neuro: TO follow up on outpatient basis for likely new
diagnosis of epilepsy
- Endocrine- to f/u at ___.
- Insurance- SW saw patient and is working towards helping her
acquire better coverage through ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old man with right lower lung
adenocarcinoma s/p RFA ___, not currently on chemotherapy,
and a remote PMH of prostate cancer with positive margins
treated with prostatectomy and adjuvant radiation. Lung cancer
diagnosed in ___, he has previously undergone SBRT of RUL lung
lesion. Today his family called outside hospital concerned that
pt was sleepy, weak, coughing, and had an episode of hemoptysis.
Upon arrival to ___ pt clinically stable, afebrile,
no pain or acute complaints. Normal WBC, chem 7, hct, plt. UA
negative. CXR showed small right apical pneumothorax, small R
effusion on lateral film. ___ spoke with ___ (Dr. ___
who requested transfer for diagnostic pleural tap. Per ___, abx
will start based on findings (abx held to this point). OSH labs
CHem 7 wnl, hct 36.7, wbc 9.4, plt 330. UA neg. CHEST (PA AND LAT) showed In comparison with the study of ___, on the upright view there appear
to be 2 or possibly summary air-fluid levels but could represent areas of
loculated or hydrothorax. No definite pneumothorax is appreciated. The
remainder the study is essentially unchanged. An unusual appearance to the tip
of the Port-A-Cath raises the possibility of it extending into the azygos
system. The patient was diagnosed with OTHER PNEUMOTHORAX, PLEURAL EFFUSION NOS, OTHER HEMOPTYSIS, OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had Primary diagnoses:
#Pleural effusion secondary to RFA
Secondary diagnoses:
#Fatigue
#Depression
#HTN. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old man with right lower lung
adenocarcinoma s/p RFA ___, not currently on chemotherapy,
and a remote PMH of prostate cancer with positive margins
treated with prostatectomy and adjuvant radiation who p/w
fatigue x1 day, findings of apical pneumothorax, pleural
effusion, question of PNA on CXR at ___, transferred to
___ for evaluation of diagnostic/therapeutic tap at request of
family members and ___.
# Pleural effusion: initially diagnosed at ___ with
apical PTX, pleural effusion based on radiologic findings,
cough, and fatigue/malaise. VS stable, WBC normal. Consulted ___
who report these changes are known complications of RFA and that
as pt afebrile, no concern for pna. Also effusion small so
difficult to tap. His outpt oncologist (Dr. ___ agreed,
thus thoracentesis was deferred. UA normal. By last day in
hospital oxygenation 97%, better than baseline on RA. Pt also
able to walk without experiencing significant decrease in
oxygenation. Family updated frequently. Note that no PTX noted
on repeat CXR's at ___.
# Fatigue: pt presented with fatigue, ___ noted that this was in
great part the family's impetus to bring pt to ___
___. By day of discharge pt had greatly improved, was
smiling and more happily interactive with staff. Consider
fatigue most likely secondary to depression, also
post-procedural fatigue. No other localizing signs/symptoms of
infection on h&p. Pt receiving adqueate treatment of lung
cancer.
# Depression: pt reported he is tired by frequent hospital
visits and inability to function as he has in the past. On
admission he endorsed passive suicidal ideation, did not repeat
this line of conversation during subsequent days of admission.
Currently treated with paroxetine. Defered management of
depression to outpt.
# CODE STATUS: presumed full, pt could make up mind during this
admission. </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 a past medical history
of
sCHF, left parietal ischemic infarct ___ L carotid stenosis s/p
CEA (followed by Dr. ___ ___, HTN, HLD and DM who
presents today with slurred speech and left facial droop.
History
is obtained from the patient's wife. Chest: Frontal and lateral views showed Minor basilar atelectasis without definite focal consolidation. Difficult to
exclude trace left pleural effusion. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Hemorrhagic transformation of a left parietal lobe infarction.
2. No vascular occlusion or aneurysm.
3. Approximately 33 % stenosis of the right internal carotid artery, stable
from ___.
4. Severe stenosis of the right V1 segment, unchanged from ___.
NOTIFICATION: The wet read was discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 2:28 ___, 5 minutes after discovery
of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Large left parietal intraparenchymal hemorrhage which appears increased in
overall size relative to prior examination. Surrounding vasogenic edema is
not significantly changed in extent. No evidence of midline shift. Subtle
effacement of adjacent sulci is mild.
2. No foci of new hemorrhage. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed No acute fracture or subluxation involving the cervical spine. Moderate to
severe multilevel degenerative changes with moderate central canal narrowing
at the C5-C6 and C6-C7 levels. MR HEAD W AND W/O CONTRAST showed 1. Enhancing left parieto-occipital lesion with surrounding edema and acute
blood products is suspicious for a primary brain neoplasm. Presence of edema
beyond enhancement is against an enhancing subacute infarct. This finding is
new since the previous MRI.
2. Small areas of acute infarct in the right frontal cortical subcortical
region. PORTABLE HEAD CT W/O CONTRAST showed 1. Re-demonstrated hemorrhagic transformation of the left parietal lobe
infarction. No new hemorrhage.
2. Re-demonstration of right frontal acute/subacute infarct. No new infarct. The patient was diagnosed with Cerebral infarction, unspecified, Slurred speech. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ICU COURSE:
Mr. ___ was admitted to the neurology ICU on ___ after
presenting with dysarthria and left facial droop and was found
to have a new left parietal hypodensity with intralesionsal
hemorrhage.
On admission to ICU, he was continued on home medications, blood
pressure was kept under 140 with prn hydralazine. MRI brain
showed an acute right frontal cortical-subcortical stroke and a
left parieto-occipital hemorrhage. It was unclear if pt had
hemorrhagic transformation of an initially ischemic stroke or
whether there was an underlying lesion in the left
parieto-occipital area. His exam remained unchanged and he was
transferred to the floor on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o male with a history of CKD, CAD s/p
NSTEMI (___), known infrarenal aortic dissection, NSCLC s/p
XRT, chronic pancreatitis, DM2 c/b neuropathy, retinopathy,
nephropathy, and gastropathy, chronic pain and medication
non-compliance sent by PCP for admission ___ worsening kidney
function. RENAL U.S. showed 1. No hydronephrosis. Increased cortical echogenicity compatible with
underlying medical renal disease.
2. Incidental trace ascites and right pleural effusion. CHEST (PA AND LAT) showed Right upper lobe pneumonia. The patient was diagnosed with Acute kidney failure, unspecified, Dehydration, Other specified abnormal findings of blood chemistry, Hypokalemia. At the time of discharge, the patient had Acute Kindey Injury
SECONDARY:
Gastroparesis
Diabetes Mellitus Type 2
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>Mr. ___ is a ___ y/o male with a history of CKD, CAD s/p
NSTEMI (___), known infrarenal aortic dissection, NSCLC s/p
XRT, chronic pancreatitis, DM2 c/b neuropathy, retinopathy,
nephropathy, and gastropathy, chronic pain and medication
non-compliance sent by PCP for admission ___ worsening kidney
function (CR 2.9) suspected from contrast induced nephropathy
and ongoing symptoms of gastroparesis which improved with home
regimen as well as initiation of erythromycin. While here
hydralazine and nitrates were started for blood pressure
control. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is ___ with h/o paranoid schizophrenia, CAD, DM,
chronic headaches, and autonomic dysfunction who was found down
tonight and brought to the ED. As per ED documentation, the
patient was found down by a bystander lying in a grassy area by
___. FSG was 126 at that time.
The patient has a well documented history of falls due to his
autonomic neuropathy, schizophrenia, and medications. He was
admitted ___ for fall; during this hospitalization, the
patient was ruled out with cardiac enzymes. Also had a normal
head CT and MRI. He was noted to be orthostatic, with 50 point
drop in SBP from lying down to standingl he was given
fludrocortisone and salt tabs upon discharge. Of note, the
patient has a history of labile BPs due to his autonomic
dysfunction. Radiology showed No evidence of acute disease. Radiology showed No evidence of acute intracranial process. Radiology showed No evidence of cervical spine fracture, acute alignment abnormality, or
prevertebral soft tissue abnormality. The patient was diagnosed with ALTERED MENTAL STATUS , HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL. At the time of discharge, the patient had PRIMARY DIAGNOSES:
1. Acute encephalopathy
2. Symptomatic hypoglycemia
3. Polypharmacy
SECONDARY DIAGNOSES:
1. Paranoid schizophrenia
2. Diabetes mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is ___ with h/o paranoid schizophrenia, CAD, DM,
chronic headaches, and autonomic dysfunction who was found down.
# Fall: The patient was found down. Ddx of fall inclues known
autonomic dysfunction and orthostasis, hypoglycemia (given
recent low BS readings), mechanical given parkinsonism, vs
cardiac. The patient does have significant cardiac history but
denying any chest pain, trops negative x 2 and EKG without
ischemic changes. Tele was without events. Orthostatics were
positive (known autonomic dysfunction). Fludrocortisone was
confirmed with PCP and was ___. ___ saw the patient in
house. Vitamin D was found to be low so repletion dose was
started.
# Wandering from home / dementia: the patient was getting 24
hour care from his grandson, however, wandered away from home
when left for a few hours. Talked with the patient and grandson
about the ___ to going to rehab vs long term care unit,
however, both strongly preferred that the patient stay at home.
The grandson said he could assure 24 hour care. Case management
helped set up increased home services.
# HTN: BP's stable in house. The patient was continued on
fludrocortisone.
# DM: recent low ___ at home. Lantus dose was decreased by more
than 50%, and oral hypoglycemic agents were DCed. ___ were stable
in house in the ___.
# h/o headaches: cont topamax
# CAD s/p DES and CABG ___: con't ASA, Plavix, and simvastatin
- unclear indication to continue plavix at this time, will defer
to PCP +/- cardiology decision if the patient should continue
plavix in the future
# CKD: baseline creat mid 1s, creat on admission 1.5, which
trended down during admission.
# schizophrenia: Per psychiatrist, the patient was psychotic in
___ when she switched him to Zyprexa and off other
antipsychotic meds. Since that time Zyprexa has fallen off his
med list for unknown reasons. She recommended restarting Zyprexa
at a low dose of 2.5 mg at night, and follow up outpatient with
psychiatrist. Continued home citalopram. Diazepam was down
titrated in the hospital and then DCed due to patient somnolence
during the daytime. Per the psychiatrist, he had previously been
on a higher dose, and was down titrated a few months ago prior
to this as well.
# Parkinsonism: thought to be ___ antipsychotic meds. Cont
amantidine.
# GERD: cont simethicone, ranitidine
# HEALTH CARE PROXY: ___ (daughter in law)
___, grandson ___, home phone
___
# CODE STATUS: full code
TRANSITIONAL ISSUES
- follow up with PCP
- follow up with psychiatry for further titration of psych meds
- unclear indication to continue plavix at this time, will defer
to PCP +/- cardiology decision if the patient should continue
plavix in the future
- continue to monitor ___ and titrate insulin as needed</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman who was transferred to ___
from ___ after he presented to ___ with a single stab
wound to his right upper abdominal quadrant/right flank region.
He received 2u of blood at ___ and was urgently transferred
to ___ for further management. Upon arrival, GCS was 15,
E-FAST was positive in the RUQ, so he was taken to the operating
room emergently for an exploratory laparotomy. Intraoperative
course was notable for evacuation of 600 cc of clotted blood,
and a single traumatic injury to segment 6 of his liver that was
hemostatic. Abdominal washout and exploration was negative for
any other acute injuries. He did not receive any additional
blood. He was extubated at the conclusion of the case, off of
all pressors, and was transferred to the ___ for postoperative
care. TRAUMA #3 (PORT CHEST ONLY) showed Heart size is top-normal. Azygos vein is distended potentially due to volume
overload. Bibasal opacity, right more than left are noted. There is no
pneumothorax. There is potentially small amount of right pleural effusion not
clearly seen on current examination. CHEST (PORTABLE AP) showed Heart size and mediastinum are unchanged. Minimal bibasal atelectasis is re-
demonstrated. There is no pneumothorax. There is no interval increase in
pleural effusion. CHEST (PA AND LAT) showed In comparison with the study of ___, there again are low lung volumes that
accentuate the transverse diameter of the heart. No evidence of pneumothorax.
Mild atelectatic changes are seen at the bases, especially on the right. The patient was diagnosed with Laceration of liver, unspecified degree, initial encounter, Lac w/o fb of abd wall, r upper q w penet perit cav, init, Oth foreign body or object entering through skin, init. The patient was treated with ___ - Exploratory laparotomy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman who was transferred to ___
from ___ after he presented to ___ with a single stab
wound to his right upper abdominal quadrant/right flank region.
He received 2u of blood at ___ and was urgently transferred
to ___ for further management. Upon arrival, GCS was 15,
E-FAST was positive in the RUQ, so he was taken to the operating
room emergently for an exploratory laparotomy. Intraoperative
course was notable for evacuation of 600 cc of clotted blood,
and a single traumatic injury to segment 6 of his liver that was
hemostatic. Abdominal washout and exploration was negative for
any other acute injuries. He did not receive any additional
blood. He was extubated at the conclusion of the case, off of
all pressors, and was transferred to the TSICU for postoperative
care.
NEURO: While intubated, he was kept sedated. His pain was
controlled first with dilaudid PCA which was transitioned to
pills when he was tolerating a diet. His pain was otherwise
well-controlled. On the floor, his pain was managed with po
oxycodone, with which he was discharged.
CARDIOVASCULAR: He was closely monitored postoperatively in the
intensive care unit. He remained hemodynamically stable
throughout his hospitalization.
PULMONARY: He was successfully extubated postoperatively and
transitioned to nasal cannula. This was weaned and he was given
and taught how to use incentive spirometer and mobilized early
to prevent atelectasis.
ABDOMINAL/GI: He underwent exploratory laparotomy and the right
upper quadrant stab wound was kept open and packed with
moist-to-dry dressings. He was started on a diet early which was
advanced as tolerated once he had bowel function.
RENAL: A foley catheter was placed intraoperatively for urine
output monitoring. This was removed at earliest possibility.
HEME: Postoperatively, his hematocrit levels were closely
monitored and remained stable. He was subsequently started on
subcutaneous heparin for DVT prophylaxis.
Upon discharge, Mr. ___ was doing well, afebrile, and
hemodynamically stable and within normal limits. He received
discharge instructions and teaching, along with follow up
instructions. He verbalizes agreement and understanding of
discharge plans.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is an ___ old man with a history urinary
retention, bioprosthetic valve replacement, HTN, smoking, and
lung nodules, presenting with light-headedness and near syncope. CHEST (PA AND LAT) showed Mild bibasilar atelectasis. The patient was diagnosed with Paroxysmal atrial fibrillation. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
#New-onset atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSIS:
#Hypertensive Urgency
#Thrombocytopenia
#Macrocytic Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ old man with a history of urinary
retention, urethra stricture s/p dilation (___), recurrent
UTIs, bioprosthetic aortic valve replacement (___), HTN,
smoking, lung nodules, and underlying mood disorder who
presented to ___ from an outpatient visit with near-syncope
and new-onset atrial fibrillation with rapid ventricular
response.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: PCP: ___ ___
___ with adenocarcinoma of the HOP diagnosed in ___ at a
hospital in ___ treated with a CBD stent in ___. He
presented with severe epigastric pain. He was offerred a Whipple
at that time and declined because he could not find anyone to
care for his daughter. He had an ERCP with stent placement in
___ which alleviated his pain. He then developed
severe epgiastric, b/l rib and mid abdominal pain 3 weeks ago.
In that time interval he applied to the insurance company twice
to have his surgery done in ___ where his sister lives
because he had no one to care for his dtr. He was denied twice.
He had a repeat ERCP on ___. The pain was not alleviated by
ERCP. For the past 10 days he has developed severe R back pain
worse when laying on his back. No clear association with food as
he has not been able to eat. He has been nauseous without
emesis. He has recently moved his care to the ___ area to be
closer to this family. In the last ___ days he has developed
worsening jaundice, abdominal pain, subjective fevers and chills
and presents to the ER for evaluation. He reports acholic stools
and dark colored urine. His appetite has been poor and has been
having weight loss. + constipation. He feels faint from the
pain.
.
In ER: (Triage Vitals:7 98.2 83 126/82 16 100 )
Meds Given: zosyn, morphine, zofran
Fluids given: 1LNS
Radiology Studies:abdominal CT
consults called: surgery
.
PAIN SCALE: ___ in stomach and back; back > stomach
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ +] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ +]Anorexia [ ]Night sweats
[ +] ___25__ lbs. weight loss/gain over __3___ months Radiology showed Pancreatic head mass, as described above. Pancreatic parenchyma appears
atrophic. The pancreatic duct is dilated. There is apparent narrowing of the
splenomesenteric confluence. SMV and SMA are patent. Extensive intrahepatic
and extrahepatic biliary ductal dilatation. Biliary stent is in place. No
pneumobilia is detected. Above findings concerning for nonfunctioning biliary
stent. Radiology showed Placement of a 10 ___ internal-external drain through the left biliary
system and an 8 ___ internal-external drain through the right posterior
biliary system. Both drains are connected to bags. If the drainage remains
clear, both tubes can be capped tomorrow in the evening. Radiology showed 1. Successful and uncomplicated plasty and stenting of common bile duct using
a 6 cm, 10 mm metallic stent.
2. Given the intraprocedure finding of additional mild narrowing involving the
level of the proximal common bile duct (near the confluence) and central left
hepatic duct, bilateral multipurpose catheters were left in place to ensure
the possibility of future access. Radiology showed Successful removal of the bilateral anchor drains with Gelfoam
embolization of the exit tracts. The common bile duct stent appears to be
patent with free flow of contrast to the duodenum. The patient was diagnosed with JAUNDICE NOS, ABDOMINAL PAIN OTHER SPECIED, MAL NEO PANCREAS HEAD. The patient was treated with -Endoscopic ultrasound with biopsy
-Left subclavian port placement
-Diagnostic Laparoscopy with peritoneal washings
-___ guided angioplasty and stenting of bile ducts. At the time of discharge, the patient had Pancreatic Cancer
Cholangitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ yo M with a PMHx of locally advanced pancreatic
adenocarcinoma s/p ERCP X2 with deferment of ___, who now
p/w RUQ pain worrisome for cholangitis and is now s/p placement
of PTC
.
## Cholangitis and biliary stricture
Cholangitis is likely secondary to biliary stricture ___ to
pancreatic adenocarcinoma. Pt has been noted in the past to
have CBD dilatation on abd CT s/p ERCP x 2. As a result pt
underwent ERCP but unable to cannulate CBD, so then underwent ___
guided placement of percutaneous drains with good improvement in
his bilirubin. He was placed initially on Zosyn, then
transitioned to Augmentin after his drains were capped with good
effect. He was given a about 2 weeks of antibiotics. ___
internalized his drains with a metal stent 1 cm past he
bifurcation successfully, with improvement in his bilirubin.
However, he continued to have pain at his residual R PTC drain.
Thus, the decision was made to take the patient back down to ___
on ___ for removal of both his R PTC, and L PTC drain. He
tolerated the procedure well and his LFT's were downtrending
after the procedure. ___ followed the patient and were ok with
discharge.
.
## MALIGNANT NEOPLASM, PANCREAS
Initially diagnosed earlier this year and treated with ERCP and
stenting only due to insurance reasons. He has moved to ___ for
further care. Repeat CT here confirmed pancreatic mass with
vascular involvement. EUS with biopsy confirmed the dx of
adenoCA of pancreas. CA ___ was elevated in the ___. Per
Surgery, given vascular involvement of tumor, he is not a
resection / Whipple candidate at this time, and recommend neo
adjuvant chemo/XRT. At the time of his EUS, he also underwent
fiducial placement for anticipated chemo. He then underwent
diagnostic laparoscopy with peritoneal washings and port
placement for anticipated chemo. Peritoneal washing results
were negative. He was seen by Medical Oncology and has outpt
f/u scheduled with Dr. ___, as well as Dr. ___.
The seriousness of his condition was emphasized to the patient.
He was encouraged to make a decision regarding the location of
his treatment as soon as possible. I informed the patient that
this medical condition would likely shorten his life. He said
he understood and would try and expedite his decision. Please
note, the patient continually refused his SC heparin despite
information about the risks and benefits of this therapy.
.
##PAIN, ABDOMINAL-EPIGASTRIC
Lipase elevated to 382 concerning for pancreatitis. He was
initially treated with supportive care, then transitioned to
opiate therapy. He was started on Oxycontin and Oxycodone for
breakthrough. The sedative effects were explained, to avoid
with alcohol driving/machinery. The patient was asked to call
his pharmacy to check to see if these medications were covered.
On ___ the nursing staff called the pharmacy and they
indicated that oxycontin would not be covered. As a result, his
regimen was changed to MSIR and MSContin. The patient did not
tolerate the MSIR and thus he was sent out on MSContin and
oxycodone. He was encouraged to establish care with a provider
where he would receive his cancer treatment so they could
continue to titrate his pain regimen. The patient was also
placed on Tylenol TID and a bowel regimen.
.
# CONSTIPATION
The patient was informed of the side effects of narcotics
including constipation. He understood but intermittently
refused his bowel regimen.
.
# Transitional Issues:
-Follow up with Dr. ___ Hem/Onc the day of discharge and
Dr. ___ the surgery team in ___ weeks
-Follow up LFT's and CBC in 1 week</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with a history of
recurrent AML following his matched unrelated allogeneic
transplant with Cytoxan and TBI conditioning on ___, who
remains in remission following his DLI but with complications of CHEST (PA AND LAT) showed Unchanged small right pleural effusion. Low lung volumes without focal
consolidation to suggest pneumonia. ABDOMEN US (COMPLETE STUDY) showed Gallbladder sludge without evidence of cholecystitis. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had PRIMARY:
Skin and soft tissue infection
SECONDARY:
Chronic graft vs host disease
Compression fracture
Acute myeloid leukemia
Chronic systolic heart failure
Hypothyroidism
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>Mr. ___ is a ___ man with a history of
recurrent AML following matched unrelated allogeneic transplant
with Cytoxan and TBI conditioning ___, currently in
remission but with severe scleroderma second to
steroid-refractory GvHD who presents from home with complaints
of fever and weakness. Although a chest x-ray, blood cultures
and urine cultures did not indicate infection, patient has had
multiple courses of antibiotics in the past for pseudomonas
susceptible to ceftazidime. Accordingly, ceftazidime was
continued for ___s an outpatient Mr. ___ and his
primary oncologist will discuss next steps in treating GvHD.
# Fever. Remained afebrile during admission. Unclear etiology as
he had no localizing symptoms other than nausea. Dull RUQ pain
resolved shortly after admission. CXR unremarkable. Most likely
source of infection would be chronic lower extremity wounds,
which have previously grown GPCs and Pseudomonas. Abdominal u/s
obtained due to complaints of RUQ pain, showed only biliary
sludge, no cholecystitis. Flu PCR negative. Blood, urine
cultures were negative. Initially started on Vancomycin and
Ceftazidime. Vancomycin stopped ___ given no blood culture
growth for 48 hrs. Ceftazidime was continued, based on prior
cultures, for ___nding ___.
# Compression fractures.
# Pain.
Patient with compression fractures noted on CT lumbar spine from
___, with marked osteopenia noted on imaging. Patient is high
risk for pathological fracture given steroid use and relative
inactivity. Continued oxycontin and oxycodone for pain control,
with IV Dilaudid for dressing changes. On ___, pt requested
evaluation by chronic pain service to try to decrease opioid
usage. Per their recommendations, Oxycontin was decreased from
30mg BID to 20mg BID, Oxycodone decreased to ___ Q4H, and
Gabapentin increased from 600mg TID to ___ TID.
# AML: No evidence for recurrent leukemia. Continued Atovaquone
for PCP prophylaxis along with Acyclovir, Azithromycin, and
Posaconazole (dose decreased with interactions with Sirolimus).
# Chronic Extensive GVHD: Has manifested as skin, liver, mouth,
eyes and lungs, with possible BOOP in past. Continued issues
with sclerodermic skin changes. Currently on sirolimus and
prednisone 20mg daily. Ruxolitinib discontinued during last
hospitalization as it was felt to be of little benefit. Has
trialed numerous medications in past, including enbrel, gleevec,
sprycel, low dose IL-2 injections, cellcept, Treg DLI infusion,
and Abatacept. He was maintained on Prednisone and Sirolimus
during admission.
# Extensive lower extremity wounds. Patient with significant
ulcerated lower extremity skin wounds with previous
superinfection with Streptococcus and Pseudomonas. Follows with
Dr. ___ here at ___ as well as Dr. ___ at ___. Home
Cipro/Amoxacillin held due to Vancomycin and Ceftazidime, but
resumed prior to discharge. He was followed by the wound care
team during admission, and received daily dressing changes.
# Systolic CHF: TTE during hospitalization on ___ showing newly
depressed EF of 35% with possible hypokinesis of the
inferoseptal and inferior walls from the base to mid-ventricle,
also with elevated NT-pBNP at that time. Was started on
metoprolol at that time, with plans to start ACE inhibitor and
uptitrate metoprolol if persistent LV function on cMRI. Recent
cMRI showed mild systolic dysfunction, small pericardial
effusion but no evidence of pericardial constriction. Metoprolol
was continued during this admission.
# Hypothyroidism. TSH recently check and found to be low at
0.06, but free T4 normal. TFTs were re-checked and showed free
T4 to be low, so Levothyroxine dose was increased from 88mcg
daily to 100mcg daily.
# Depression. Seen by psychiatry consult service on ___, who
recommended increase Venlafaxine dose, as well as continuation
of outpatient psych follow up. Venlafaxine increased to 75mg qAM
and 37.5mg qPM.
TRANSITIONAL ISSUES
=======================
[ ] ___ will see patient at home
[ ] Increased Levothyroxine to 100mcg daily.
[ ] Decreased Oxycontin to 20mg BID, and Oxycodone to ___
Q4H PRN pain.
[ ] Increased Gabapentin 900mg TID.
[ ] Patient is to START Ruxolitinib Study Med 5 mg PO BID on
___ upon arrival to home.
# CODE: Full Code
# EMERGENCY CONTACT HCP: ___ (fiancee/HCP)
___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o ___ disease, HTN, depression, anxiety, chronic low
back pain who presents with bilateral arm numbness and weakness.
In late ___, while walking his ___, he fell
onto his hands sustaining a flexion-extension whiplash type
injury. No headstrike or LOC. He had some neck pain but did not
get evaluated at that time. One week later in the beginning of
___ he developed bilateral hand numbness and clumsiness,
so he scheduled an appointment with his local orthopedic surgeon
___ in ___. Dr. ___ decreased
sensation below both elbows with some weakness and prescribed a
Medrol Dosepack. Once week later the patient was re-evaluated by
Dr. ___ noted significant interval decrease in strength
in bilateral upper extremities, MRI reportedly showed large C4-5
disc herniation compressing the cord and right ventral nerve
root, and subsequently sent the patient to ___. Spine surgery
was consulted for further evaluation and treatment. The patient
reports numbness below both elbows as well as significant
weakness in both arms. Denies urinary or fecal incontinence.
Denies urinary retention. Denies fever/chills. CHEST RADIOGRAPHS showed No evidence of acute cardiopulmonary disease. CERVICAL SINGLE VIEW IN OR showed Status post anterior cervical discectomy and fusion at C4-C5. Please see the
operative report for further details.
Mild to moderate degenerative disc disease at C2-C3. CHEST (PA AND LAT) showed New small platelike atelectasis in the left upper lobe The patient was diagnosed with DISC DIS NEC/NOS-CERV. The patient was treated with 1. Anterior cervical decompression and arthrodesis C4-5.
2. Application of interbody cage, machined allograft.
3. Application of anterior cervical instrumentation C4-5.
4. Spinal cord monitoring.. At the time of discharge, the patient had 1. Cervical spinal cord injury C4-5.
2. Severe cervical stenosis, secondary to herniated disk C4-
5.
3. Recent history trauma.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#0. Physical therapy
was consulted for mobilization OOB to ambulate. 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: For compete H&P see medicine nightfloat note dated ___, but
in brief, ___ w/ ___ H of of anxiety who presented to ___
Urgent Care with hematuria and LLE swelling. ___ reports
that he has had LLE paresthesias and pain for the past few weeks
but thought it would go away. Over the past few days he noticed
LLE swelling. He had a ___ physical examination today
and was found to have hematuria on routine labs and was referred
to ___ Urgent Care. ___ states that he did not notice
hematuria at home but states that he has dark urine at baseline.
No bruising or bleeding elsewhere. No dysuria, urgency,
incontinence, incomplete voiding, noctiuria, abdominal pain or
back pain. At the urgent care he was noted to have gross
hematuria. LLE ultrasound revealed extensive DVT and was
referred to ___ for further management. VENOUS DUP EXT UNI (MAP/DVT) RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins.
Known DVT in the left common femoral vein. The patient was diagnosed with Acute embolism and thrombosis of left femoral vein, Acute embolism and thrombosis of left iliac vein. At the time of discharge, the patient had Primary: Left lower extremity deep venous thrombosis, pulmonary
embolism with pulmonary infarction, hematuria
Secondary: Anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ y/o male with a past medical history of
anxiety who presented to ___ Urgent Care with hematuria and
LLE swelling and was found to have an extensive LLE DVT. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ h/o IMI s/p 2v-CABG ___, HTN, DM, GERD, p/w left-sided
CP radiating to left upper scapula and left arm since yesterday,
constant, waxing and waning, not pleuritic, positional, or
exertional, with no clear exacerbating or alleviating factors,
without dyspnea, diaphoresis, nausea, or vomiting, fevers,
chills, cough, abd pain, vomiting, or diarrhea. +ST and
rhinorrhea for the past 2 days as well. Radiology showed Interval resolution of prior pleural effusions. Right basilar opacity could
be due to prominent mediastinal fat given configuration on the lateral View
though infection is difficult to entirely exclude. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Scattered mucous plugging.
3. Middle lobe atelectasis. The patient was diagnosed with Chest pain, unspecified. The patient was treated with ___ Coronary angiogram with placement of drug eluting stent. At the time of discharge, the patient had Primary
Non-ST Elevation Myocardial Infarction
Secondary
Coronary artery disease s/p Coronary Artery Bypass Graft. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo woman with h/o MI s/p 2v CABG ___ who
presented with left shoulder and neck pain and found to have
NSTEMI. Troponin peaked at 0.48. She underwent cath which showed
failure of vein graft to RCA. Drug eluting stent was placed in
her native RCA with good restoration of flow. She was started on
clopidogrel. She will follow up with her usual doctors.
# NSTEMI:
The patient presented with left-sided chest pain radiating to
the left upper scapula and left arm. EKG not localizing. She was
found to have elevated troponin which peaked at 0.48. She
underwent cath which showed failure of vein graft to RCA. Drug
eluting stent was placed in her native RCA with good restoration
of flow. She was started on clopidogrel. She will follow up with
her usual doctors.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male transferred from ___ to ___ for management of
new ___. Patient was last seen at his baseline on ___ at
approximately 10:00pm. This morning on the telephone with his
son his mental status was acutely altered, therefore the son
called ___. He was BIBA to ___, and
underwent a ___ that was reported as "an acute left
temporoparietal intraparenchymal bleed measuring 5.5 x 4.2 x 6
cm with mass effect and left to right midline shift by 2-3mm."
Patient received 5mg IV Vitamin K and 2 units FFP at ___
___ in addition to 1g Keppra. He was then transferred to
___ for further management. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No arterial venous malformation, aneurysm or dissection.
2. Slight increase in size of left temporal lobe hemorrhage with spot sign.
RECOMMENDATION(S): Note is made of mild asymmetry on the left vocal cord
(image 111, series 5), probably consistent with secretions, if there is any
clinical concern related with this finding, direct visualization is
recommended Radiology showed Endotracheal tube terminates 5.6 cm above the carina. Clear lungs. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. New small subdural hematoma along the posterior falx.
2. New extra-axial collection most suggestive of a subdural hematoma along the
left temporal convexity measuring up to 8 mm in maximal width.
3. Status post left craniotomy with near complete evacuation of large left
intraparenchymal hematoma with 1.7 x 1.5 cm and 1.1 x 1.3 cm areas of residual
blood products within the resection cavity and improved rightwards shift of
normally midline structures.
4. Mild increase in mass effect along the left lateral ventricle with near
complete effacement of the temporal, occipital and frontal horn.
NOTIFICATION: The findings were discussed by Dr. ___ with NP. ___ on
the telephone on ___ at 9:18 ___, 5 minutes after discovery of the
findings. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed The tip of the feeding tube is in the stomach. The tip of the endotracheal
tube projects 5 cm above the carinal. No other change. CT HEAD W/O CONTRAST Q111 CT HEAD showed Status post left parietal craniotomy and placement of subdural drainage. In
comparison with the most recent study the subdural hematoma has decreased at
the convexity, however there is residual subdural hematoma at the left
temporal parietal region, measuring approximately 7 mm in thickening, with no
significant mass effect, there is persistent effacement of the sulci
throughout the left cerebral hemisphere and right intraventricular hemorrhage,
close followup is recommended.
RECOMMENDATION(S): Residual left temporal parietal subdural hematoma is re-
demonstrated, close followup with head CT is advised. CHEST (PORTABLE AP) showed Asymmetric pulmonary edema much more severe in the right lung has worsened
since ___. Right basal consolidation is new, likely atelectasis, but
should be followed to exclude pneumonia. Pulmonary vasculature is engorged,
but heart size is normal. Pleural effusion small on the right if any. No
pneumothorax.
ET tube in standard placement. Nasogastric tube passes below the diaphragm
and out of view. CHEST (PORTABLE AP) showed No change. CT HEAD W/O CONTRAST showed 1. Interval removal of a left subdural drainage catheter with decrease in size
of a left subdural hematoma compared to prior.
2. Mild interval increase in size of edema surrounding a left temporal
intraparenchymal hemorrhage although the size of hemorrhage is unchanged.
3. Unchanged small intraventricular hemorrhage and subdural hematoma layering
along the right tentorial leaflets. CHEST (PORTABLE AP) showed No change. DX CHEST PORTABLE PICC LINE PLACEMENT showed There is a new left-sided PICC line with tip at the cavoatrial junction.
There is continued opacity at the right base consistent with infiltrate. This
is more prominent over time when comparing to multiple films over the past few
days. There is pulmonary vascular redistribution most marked on the right and
a patchy area of alveolar infiltrate in the left lower lung. It is unclear
how many of the pulmonary findings are due to asymmetric pulmonary edema or if
an infectious infiltrate is present in the right lower lobe CHEST (PORTABLE AP) showed No change. CHEST (PORTABLE AP) showed ET tube tip is 6 cm above the carinal. Left PICC line tip is at the level of
lower SVC. NG tube tip passes below the diaphragm most likely terminating in
the stomach.
Heart size and mediastinum are unchanged as well as there is no change in
large right pleural effusion and associated atelectasis as well as hilar
prominence. CHEST (PORTABLE AP) showed Left PICC line tip is at the cavoatrial junction. Heart size and mediastinum
are stable. Large right pleural effusion and right basal consolidation are
re- demonstrated, with overall no substantial change since the prior study.
ET tube tip is 6 cm above the carinal. NG tube tip passes below the diaphragm
with its tip not included in the field of view. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the extent of the right pleural
effusion has minimally decreased. Unchanged mild pulmonary edema. Borderline
size of the cardiac silhouette. Elongation of the descending aorta. The
monitoring and support devices are constant. Radiology showed Tracheostomy tube in good position. CHEST (PORTABLE AP) showed Left PICC line tip is at the level of cavoatrial junction. Heart size and
mediastinum are stable. There is interval progression of pulmonary edema with
extensive opacification of the right lung that might represent either
progression of pulmonary edema or worsening of infectious process.
Tracheostomy is in place.
Bilateral pleural effusions are moderate to large, unchanged VENOUS DUP UPPER EXT UNILATERAL showed Noncompressibility, central intraluminal filling defect and absent color flow
of the right cephalic vein near the antecubital fossa, consistent with a
superficial vein thrombosis. No evidence of propagation or deep vein
thrombosis. CHEST (PORTABLE AP) showed Substantial improvement in what was very asymmetric pulmonary opacification
over just 48 hrs suggests this was largely pulmonary edema. Moderate right
pleural effusion is smaller and the pulmonary vascular and mediastinal
engorgement have also improved. Left PIC line ends in the upper right atrium,
all approximately 3 cm below the estimated location of the superior cavoatrial
junction. CHEST (PORTABLE AP) showed Large right pleural effusion increased, probably responsible for leftward
mediastinal shift. Right upper lobe and left lung grossly clear. Heart size
normal. Left PIC line ends close to or just beyond the superior cavoatrial
junction. No pneumothorax. Tracheostomy tube midline. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Limited visibility of the veins below the popliteal vein. Within these
confines, no evidence of deep venous thrombosis in the right or left lower
extremity veins. CHEST (PORTABLE AP) showed As compared to previous study of 1 day earlier, moderate right pleural
effusion is similar, but small left pleural effusion and adjacent left basilar
opacification have slightly worsened. No other relevant changes. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Evolving left 5mm subdural hematoma and craniotomy without shift of midline
structures. No new hemorrhage. CHEST (PORTABLE AP) showed As compared to ___, no relevant change is seen. Borderline size
of the cardiac silhouette. Mild fluid overload but no overt pulmonary edema.
The tracheostomy tube and the left PICC line are in constant position. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Minimally increased size of a left subdural with minimal adjacent mass
effect. No new hemorrhage. CHEST (PORTABLE AP) showed As compared to ___, no relevant change is seen. Left PICC line
and tracheostomy tube are in correct position. The pre-existing signs
suggesting pulmonary edema and a small to moderate right pleural effusion are
constant in extent and severity. No new parenchymal opacities. Normal size
of the cardiac silhouette. CHEST (PORTABLE AP) showed Slight interval improvement in the aeration of the right lung base. CHEST (PORTABLE AP) showed No significant interval change when compared to the prior study. Radiology showed Mild pulmonary edema is new as compfrom ___. Unchanged right
basilar atelectasis. CHEST (PORTABLE AP) showed As compared to ___, the lung volumes have decreased. Mild
pulmonary edema persists. Normal lung volumes. Normal size of the cardiac
silhouette. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Relatively stable left temporoparietal subdural hematoma, causing mild
effacement of the sulci and measuring approximately 7 mm in thickness since on
the prior examination, no new areas of hemorrhage are visualized.
2. Unchanged area of low attenuation in the left temporal and left
periventricular trigone, with no significant mass effect or new areas of
hemorrhage.
3. Small amount of longer remains visible on the right occipital ventricular
horn.
4. Slightly smaller left scalp hematoma, suggesting interval improvement Radiology showed There is a left-sided PICC line with the distal lead tip at the proximal right
atrium, unchanged. Cardiac silhouette is within normal limits. There is
unchanged mild pulmonary edema. No focal consolidation or pneumothoraces are
seen. There is bibasilar subsegmental atelectasis, stable. CHEST (PORTABLE AP) showed Compared to previous radiograph of 2 days earlier, cardiomediastinal contours
are stable. Pulmonary vascular congestion is accompanied by minimal
interstitial edema. More confluent right infrahilar opacity probably
represents asymmetrical edema given similar distribution on prior radiographs,
it is less likely due to localized aspiration or developing infectious
pneumonia. CHEST (PORTABLE AP) showed No relevant change as compared to ___. Tracheostomy tube in
constant position. Normal size of the cardiac silhouette. Mild elongation of
the descending aorta. No pleural effusions. No pneumonia, no pulmonary edema
are Portable chest radiograph showed Malpositioned PICC, which is directed superiorly either the SVC or azygos
system. New, small, right pleural effusion.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 12:26 ___, approximately 30
minutes after discovery of the findings. CHEST (PORTABLE AP) showed Left PICC tip is in thelower SVC. No other interval changes. . The patient was diagnosed with INTRACEREBRAL HEMORRHAGE, ACUTE RESPIRATORY FAILURE. The patient was treated with Hemi-craniectomy and ___ evacuation on ___
Trach/PEG on ___. At the time of discharge, the patient had Left temporoparietal IPH
Subdural Hemorrhage
C difficile Colitis
Ventilator Associated Pneumonia
Delirium
Atrial Fibrillation with Rapid Ventricular Response. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospital summary:
___ year old male with past medical history of ___, atrial
fibrillation on sotalol/Coumadin prior to admission, PVD, HTN,
hypothyroidism presenting s/p fall with left intraparenchymal
hemorrhage requiring urgent surgery for left craniotomy with
evacuation on ___. Since surgery, has undergone placement
of tracheostomy and PEG tube on ___ for persistent
ventilator dependence. No further surgical issues and hemorrhage
deemed stable via serial imaging. However, when he was started
on an heparin gtt for AFib on ___, he was noted to have a small
increase in a left subdural hematoma on repeat head CT ___ so
heparin was stopped. Course further complicated by A fib with
RVR. He completed a course of vanc/cefepime for enterococcus in
urine and GNR in sputum, however, on ___ patient again had
respiratory decompensation and was treated with ceftriaxone for
a pan-sensitive Klebsiella pneumonia which grew from sputum on
___ to ___. Also found to have C diff infection on ___ and
started on PO vancomycin and IV metronidazole. Metronidazole was
stopped on ___. Plan to continue PO vancomycin for 2 weeks
after stopping ceftriaxone (final day of PO vancomycin planned
for ___. Final week of hospital course characterized by
intermittent agitation due to multifactorial delirium (recent
intracranial hemorrhages, multiple hospital acquired infections,
prolonged ICU stay), requiring Seroquel and soft mittens to
prevent pulling at lines and tracheostomy tube. He had multiple
episodes of rapid atrial fibrillation, treated with metoprolol
tartrate, amiodarone, and digoxin.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who presented to the ER from OSH with a 1 day h/o RUQ abd
pain with ?acute cholecystitis. Pt. noted severe RUQ abdominal
pain that radiated to her back around 11 am one day ago. Over
the
course of the day, her pain worsened which prompted a visit to a
OSH ED. She had a CT AP, which report is unavailable, however a
subsequent RUQ US showed mild extrahepatic duct dilatation with
poor distal CBD visualization. She was then transferred to
___
for an MRCP, which was not able to be completed. While at ___, her labs were noted as: AST,ALT 97, 65, lipase 52, WBC
13.5, TB 0.7. She was started on Unasyn and xferred to ___ for
MRCP. The MRCP was significant for acute cholecystitis, without
choledocholithiasis. Given her consistent pain, ACS was
consulted
for evaluation and management. She is currently c/o RUQ
abdominal
pain, with nausea and non bloodly/ non bilious emesis. She
denies
fevers, and chills. +BM, and flatus. MRCP showed 1. Mildly distended gallbladder with pericholecystic fluid and cholelithiasis
along with a focus of hyperintensity on T1 weighted images within the cystic
duct with adjacent mural hyperenhancement and thickening. This constellation
of findings is likely reflective of a cystic duct stone resulting in acute
cholecystitis. No evidence of perforation.
2. Mild central intrahepatic and common bile duct dilatation with the
intersphincteric segment of the distal common bile duct demonstrating mural
thickening and progressive hyperenhancement. These findings may be related to
a recently passed stone. There is no choledocholithiasis otherwise seen in
the common bile duct.
3. No evidence of acute pancreatitis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 9:48 AM, 10 minutes after discovery of
the findings. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Right upper quadrant pain, Calculus of bile duct w/o cholangitis or cholecyst w/o obst. The patient was treated with Laparoscopic cholecystectomy
endoscopic retrograde cholangiopancreatography. At the time of discharge, the patient had Acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented with ___ and elevated LFTs.
She underwent an MRCP which did not show any evidence of
choledocholithiasis. She was started on IV unasyn and underwent
a laparoscopic cholecystectomy on ___. She tolerated the
procedure well. However, she was noted postop to have
persistently elevated Tbili. She was scheduled to undego an ERCP
on ___ and the procedure was started but aborted due to food
noted in her stomach and concern for aspiration. She then
underwent a repeat ERCP on ___ with CBD stone removal and
sphincterotomy performed. After this procedure, her Tbili began
to downtrend. She was tolerating a regular diet, ambulating,
voiding and pain controlled with oral pain medications. She was
discharged home with appropriate followup instructions. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed 1. Findings concerning for osteomyelitis along the medial plantar aspect of
the distal phalanx of the great toe with subjacent ulceration.
2. Interval development of new minimally displaced intra-articular fracture
along the lateral base of the distal phalanx of the great toe. Radiology showed Status post resection of the head of the proximal phalanx and base of the
distal phalanx of the great toe with surrounding soft tissue swelling.
Remainder of the examination is unchanged from the same day foot radiograph. The patient was diagnosed with Cellulitis of left toe. The patient was treated with Toe debridement
attach
Pertinent Results:
___ 04:30PM BLOOD WBC-8.4 RBC-2.91* Hgb-8.3* Hct-27.0*
MCV-93 MCH-28.5 MCHC-30.7* RDW-15.7* RDWSD-52.9* Plt ___
___ 07:45AM BLOOD WBC-8.4 RBC-2.66* Hgb-7.4* Hct-24.5*
MCV-92 MCH-27.8 MCHC-30.2* RDW-15.7* RDWSD-52.8* Plt ___
___ 04:30PM BLOOD ___ PTT-52.7* ___
___ 03:00PM BLOOD ___
___ 04:30PM BLOOD Glucose-198* UreaN-101* Creat-4.1*#
Na-135 K-4.0 Cl-94* HCO3-24 AnGap-17
___ 07:45AM BLOOD Glucose-140* UreaN-80* Creat-4.0* Na-134*
K-3.1* Cl-92* HCO3-23 AnGap-19*
___ 04:30PM BLOOD Calcium-10.3 Phos-5.1* Mg-2.4
___ 07:45AM BLOOD Mg-2.0
___ 12:00AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
___ 04:41PM BLOOD Lactate-1.8. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># L TOE OSTEOMYELITIS
# DIABETIC FOOT ULCER: presented with a L toe diabetic ulcer and
osteomyelitis, ___ s/p debridement of L hallux and IPJ resection.
Per podiatry team, OR
findings point towards source control. In light of this, will
complete 5-day course of linezolid and ciprofloxacin based on
isolation of strep (likely the main pathogen) on operative
cultures and pseudomonas on previous swab. Will follow up with
podiatry on ___. Will have home ___ and nursing. He may leave
dressing intact until follow-up.
[]F/u OR micro/path
[]Heel touch only left foot in surgical shoe
[]Keep dressing clean, dry, and intact,
CHRONIC DIASTOLIC HEART FAILUE
HYPOKALEMIA: remained euvolemic. Will resume home maintenance
torsemide and potassium replacement on discharge.
ATRIAL FIBRILLATION WITH SLOW VENTRICULAR RESPONSE ON COUMADIN
CHA2DS2 SCORE= 4 NOT ON NODAL AGENTS: Originally held warfarin
due to supratherapeutic INR. INR 2.5 on ___. Restarting at 2.5
mg daily rather than alternating 2.5/5. Patient to have INR
followed for further adjustments.
CHRONIC KIDNEY DISEASE STAGE V
ANEMIA of CHRONIC DISEASE: Continued home medications. Patient
takes Procrit on ___. He is opposed to blood transfusions.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M w/hx of HIV (on HAART, CD4>700 on ___ and
undetectable viral load), ESRD (on HD ___ since ___, s/p
failed renal transplant, on Prednisone), T2DM, HTN and colostomy
(placed after anal resection), now presenting with abdominal
pain. RENAL TRANSPLANT U.S. showed Elevated resistive indices with apparent lack of diastolic flow, progressed
since ___. Some of this may be technical as diastolic flow is
demonstrated at the upper pole. Short interval follow-up can be performed. CT abdomen and pelvis without contrast showed 1. Nonspecific stranding surrounding the transplanted kidney in the right
lower quadrant is slightly increased from prior and could reflect infection.
Recommend correlation with urinalysis.
2. No nephrolithiasis or hydronephrosis.
3. Cholelithiasis, with no evidence of cholecystitis.
4. Moderate cardiomegaly with mild pulmonary edema. The patient was diagnosed with Right lower quadrant pain. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Acute allograft rejection
End stage renal disease on hemodialysis. The patient was given written instructions concerning 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 HIV (on HAART, CD4>700 on ___ and
undetectable viral load), ESRD (on HD ___ since ___, s/p
failed renal transplant, on prednisone), T2DM, HTN and colostomy
(placed after anal resection), now presenting with abdominal
pain concerning for graft rejection.
# Acute allograft rejection:
He had RLQ abdominal pain with imaging findings concerning for
acute allograft rejection. CT shows stranding, transplant
ultrasound shows elevated resistive indices. UA without evidence
of UTI. Rejection was likely precipitated by missing prednisone
doses. He was started on prednisone 60mg with improvement of
symptoms. He will be discharged on prednisone taper as described
below. He was given Tylenol, ibuprofen and hydromorphone PO for
pain control; he did not require PRN pain medications in the day
prior to discharge. Transplant surgery evaluated him for
possible explant, and determined that there was no acute
indication to explant the kidney at this time.
# ESRD on HD (Stage V CKD, s/p DDRT in ___ w/chronic allograft
glomerulopathy - ___. Sevelamer was increased to 2400
TID w/ meals for hyperphosphatemia. He received HD on ___.
Continued calcitriol and nephrocaps.
# HTN: Hypertensive upon admission as did not take HTN meds
during the past week. Continued Amlodipine, Labetalol and
losartan with adequate blood pressure control.
# Type 2 Diabetes:
Patient with history of diabetes and on home glargine. A1C 6.8%
likely doesn't reflect true glycemic control given not adherent
to steroids, and also likely reduced RBC life span. Continued
glargine and insulin sliding scale.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ y.o female with h.o obesity s/p gastric bypass, CCY
and reversal of gastric bypass, HTN, DM, asthma, opiate
dependence/addiction, depression/anxiety, DVT/PE, who presents
with epigastric abdominal pain.
Pt reports several months of progressively worsening odynophagia
and epigastric abdominal pain after eating. Pt feels it is
difficult to eat and has been losing weight. 12lbs over last few
months. Pt reports nausea and occasional vomiting. Last vomiting
___, no hematemesis, no diarrhea, constipation, melena or
brbpr. Yesterday, pt ate 1 hard boiled egg, ___ cup popcorn, and
6oz chicken noodle soup. She reports she has been trying to stay
hydrated. Pt reports feeling increased weakness and difficulty
with mobility due to her nutritional status. Pt reports last BM,
small this am and yesterday normal BM, +flatus. Pt with prior
h.o candidial esophagitis. Current presentation may be similar
per pt. Current pain is ___ and "throbbing". She otherwise
denies travel, sick contacts, new foods. Pt reporting T max
100.9 at home.
Other 10PT ROS reviewed and otherwise negative negative
including headache, dizziness, CP, sob, palpitations, cough,
URI, dysuria, hematuria, joint pain, rash, paresthesias. Radiology showed 1. No evidence of mesenteric ischemia. Widely patent arterial vasculature.
2. Status post multiple bowel surgeries without any evidence of bowel
obstruction at this time.
3. Stable dilatation of the left biliary system as well as the central
pancreatic duct. Prior MRCP from ___ should be referred to for better
evaluation the biliary tree and pancreatic duct.
4. Sigmoid diverticulosis without any evidence of active diverticulitis. Radiology showed Patient is status post gastric bypass. No evidence of leak identified.
Dilated proximal small bowel loops are seen. A short follow up KUB is
recommended to evaluate further.
NOTIFICATION: These findings were communicated to the ordering physician ___.
___ by Dr. ___ telephone at 16:44 on ___ at the
time of review with recommendations for follow up KUB. Radiology showed Single dilated small bowel loop is the jejunojejunostomy anastomosis site,
also seen on recent CT study. THis may be physiological.N o definitive
evidence of obstruction. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with EGD with biopsy. At the time of discharge, the patient had Primary: Esophagitis, esophageal candidiasis, Gastritis
Secondary: abd pain, history of narcotics abuse on ___, hx
DVT/PE. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/PMH of gastric bypass, multiple prior abdominal surgeries,
s/p complete reversal of her gastric bypass, CCY, esophageal
candidiasis, opiate abuse, HTN, and DVT/PE p/w epigastric
abdominal pain and nausea.
# Epigastric abdominal pain/nausea: Pt with recent h/o
esophageal candidiasis s/p treatment. Now with post prandial
epigastric pain and odynophagia. EGD notable for esophagitis and
gastritis; biopsies taken and showed persistent ___. She was
continued on her home PPI and sucralfate with the addition of
cholestyramine and started on PO fluconazole. She did not
tolerate cholestyramine. Given ongoing pain, while in house she
was evaluated by the bariatric surgery team who did not think
that surgical intervention would improve bile reflux. She was
also seen by the pain management team who recommended outpatient
nerve block given concern for nerve entrapment at surgical site
and continued use of tramadol PRN. She will need outpatient
follow-up with ___ further evaluation and treatment.
Fluconazole will finish on ___.
# Leukopenia- Noted on previous admissions as well. Resolved
without intervention.
# Malnutrition: due to odynophagia. PO intake improved
significantly following treatment for esophagitis.
CHRONIC ISSUES
# DVT/PE- Difficulty obtaining a therapeutic INR as an
outpatient over the past year. Patient was continued on
therapeutic lovenox alone during her hospitalization and
coumadin was held at discharge given concerns for patient's
medication compliance and insight into how to adjust warfarin
dosages. She has follow-up with ___ further
consideration of the risks and benefits of continued
anticoagulation.
# anxiety/depression: continued home meds (reconciled with
outpatient psych provider) and weaned clonazepam 0.5/wk per
their recs. Quetiapine was halved while inpt due to interaction
with fluconazole but should be restarted at home dose when
fluconazole course is completed.
# Medication Reconciliation: Patient has recently filled
prescriptions at three different pharmacies and reported
different doses and frequencies for several medications than
those noted in OMR. Medications discussed with patient's PCP,
___, and outpatient nurse. Gabapentin was stopped,
Seroquel was continued at 100mg qAM and 300mg qPM (but decreased
when fluconazole was started due to interaction), and Klonipin
was continued at 0.5mg qAM and 2mg qPM (tapered to 1.5 mg after
1 week per outpt psychiatrist). She was instructed to choose one
pharmacy to fill all of her prescriptions at to limit confusion
in the future. She will need close outpatient follow-up with her
PCP and psychiatrist for further titration of her psychiatric
medications.
# hx narcotics abuse: pt was continued on home ___. Pain
management was discussed with ___ provider who
preferred not to dc the patient on ultram, however given ongoing
pain and pain consult recommendations, this was continued. </s> |