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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o CAD s/p CABG s/p posterior MI with ischemic CM EF ___ with resultant VT with multiple syncopal episodes resulting in ICD implantion in ___, asthma, OSA, hyperlipidemia presenting for persistent cough for nearly 2 weeks and increasing dyspnea over the last 2 days. He also experienced 3 episodes of distinct lightheadedness over the previous 24hrs which he says felt similar to prev episodes of VT. He denies any CP or feeling palpitations at the time. Denies PND/ orthopnea, worsening DOE. Denies NV, diaphoresis w/ these episodes. Pt was recently admitted ___ after being admitted for an asthma exacerbation complicated by several runs of VT. Prior to admission, he had been using his albuterol inhaler up to ___ puffs 5 to 6 times within a few hours. During this time, he experienced several episodes of lightheadedness (his sensation of VT, doesn't get palpitations) and received a ICD shock. PPM interrogation then confirmed episode of VT that broke with single shock at that time. He had 2 other prior episodes of ___ seconds that broke spontaneously and pace terminated. He received PO steroids, as well as antibiotics for mild diverticulitis flair and was subsequently discharged ___. Pt reports he has since completed antibiotic course for diverticulitis, though d/s summary states that abx should be through ___. He returned to the ED again yesterday for lightheadedness and concern for VT. In the ED, initial vs were: 97.7 72 128/76 32 95%. Interrogation in ED that time noted single episode of 15 beat VT, no ICD firing. He received solumedrol and Vanc/levaquin for possible RLL infiltrate on CXR. He was admitted to medicine initially for management of pneumonia, being transfered to Cardiology for management of VT. Radiology showed Subtle opacity in the medial right lung base may be due to early pneumonia and/or congestion. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Primary: pneumonia systolic heart failure exacerbation asthma exacerbation Secondary: ventricular tachycardia diverticulitis. The patient was given written instructions concerning 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 CAD s/p CABG s/p posterior MI with ischemic CM EF ___ with resultant VT with multiple syncopal episodes resulting in ICD implantion in ___, asthma, OSA, hyperlipidemia presenting for persistent cough for nearly 2 weeks and increasing dyspnea over the last 2 days despite treatment with steroids of asthma flare, treated for pneumonia, volume overload, asthma exacerbation . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with recent spinal surgery presenting with upper back pain, fever, and abnormal laboratory tests x 24 hours. The patient has been inpatient at ___ after a Revision spinal surgery. She noted a fever last night which was measured as high as 101.6, which did return despite Tylenol. Per the staff at her rehabilitation hospital, there has been significantly more swelling and erythema around the incision site. Her labs were also notable for an elevated wbc and decreased hct. Radiology showed No acute cardiopulmonary process. DX THORACIC AND LUMBAR SPINES showed The most superior aspect of the thoracic spinal fusion hardware appears to be positioned more posteriorly than on in the intraoperative radiographs, potentially due to hardware migration. Please see the thoracic CT report for more details. CT T-SPINE W/O CONTRAST showed 1. Limited evaluation due to patient positioning, absence of IV contrast and beam hardening artifact. 2. Subcutaneous emphysema at T1-2 is nonspecific, and may be postsurgical in nature. However emphysematous changes secondary to infection cannot be excluded on the basis of this examination. Recommend clinical correlation. 3. Within limits of examination, no definite CT evidence of osteomyelitis or discitis identified in thoracic spine. If additional evaluation is warranted a contrast enhanced study may be helpful, however this will be limited in evaluation due to beam hardening artifact. 4. At T1 through T4 posterior spinal rods and hooks are suggested to being within bone graft material approximately 1.5 -2 cm posterior to the lamina. Recommend clinical correlation and correlation with surgical history for evaluation of hardware orientation. 5. Probable mild left hydronephrosis, partially imaged. 6. Stable small right pleural effusion. 7. Approximately 12 mm mesenteric lymph node as described. Recommend clinical correlation. 8. Limited evaluation of the liver suggests at least one 8 mm hypoattenuating area that is nonspecific. Recommend clinical correlation. If clinically indicated, further evaluation may be obtained via dedicated hepatic imaging. NOTIFICATION: Findings and recommendation discussed by Dr. ___ with Dr. ___ at 17:45 on ___. Radiology showed Status post thoracic spine hardware removal. Please see the operative report for further details. SCOLIOSIS SERIES showed Degenerative changes, scoliosis, alignment abnormalities as detailed above. Interval removal of thoracic hardware. No evidence of complication of remaining hardware. CHEST PORT. LINE PLACEMENT showed In comparison with study of ___, there is an placement of a left subclavian PICC line that extends to the mid to lower portion of the SVC. The upper spinal fusion device has been removed. No evidence of acute focal pneumonia or vascular congestion. NOTIFICATION: ___, a venous access nurse. Radiology showed There is a new left-sided central venous catheter with the distal lead tip in the distal SVC. Visualized lung fields are grossly clear. There is moderate thoracolumbar scoliosis with convexity to the left side centered at T7 and to the right side centered at T12. There is minimal anterior wedging of several mid to lower thoracic vertebral bodies causing thoracic kyphosis, unchanged. There is again seen posterior fixation hardware from T11 down to S1 with metallic disc prostheses at L4-L5 and L5-S1. Overall, these findings appear unchanged from the previous. The patient was diagnosed with FEVER, UNSPECIFIED. The patient was treated with 1. Incision and drainage. 2. Removal of instrumentation. 3. Fusion exploration. 4. V.A.C. 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>___ presented to the ___ emergency department on ___ from her rehabilitation facility with fever, back pain and leukocytosis and decreased hct. CT scan of her thoracic spine revealed loss of fixation of the thoracic instrumentation from prior revision fusion on ___. She was taken to the operating room on ___ for emergency incision and drainage, removal of instrumentation, and washout of posterior wound. A wound vac was placed at the time of surgery. Refer to the dictated operative note for further details. The surgery was performed without complication, the patient tolerated the procedure well, and was transferred to the PACU in a stable condition. TEDs/pneumoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were started in the emergency department and continued postoperatively. Urine culture was positive for pseudomonas. Intra-operative cultures were negative. She was closely monitored for signs of infection postoperatively. Initially, postoperative pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. ___ remained in halo and traction to 20lbs. She was also fitted for CTLSO brace for when out of bed. The wound vac and hemovac were removed on post-operative day three. Infectious disease was consulted and recommends continuing parenteral antibiotics, specifically vancomycin and cefepime for about 6 weeks. PICC line placement was consented for and placed on ___. Traction was discontinued on ___ and she was placed back in halo vest. She will remain in halo vest for about 3 months. On the day of discharge she was tolerating oral pain medication, urinating without difficulty, and tolerating regular diet. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male admitted for polytrauma after motor cycle collisionwith large soft tissue defect over left tib/fib fracture. Patient reports he was driving at approximately 25mph when he was cut off and had to lay down his motorcycle. Patient was itially transported to ___ and subsequently transferred to ___. Upon arrival was seen by ACS for polytrauma and ortho for management of open left tibial fracture. Taken to OR urgently for washout, external fixation and wound vac placement of open left tib/fib fracture. Radiology showed No acute findings on this trauma chest radiograph. Please refer to outside hospital CT chest for further details. Radiology showed Intraoperative placement of external fixating device across distal tibia/fibula fracture as described. Please see surgical note for operative details. Radiology showed 1. Full shaft width superior displacement of the distal clavicle relative to the intact acromion indicative for at least Grade III acroclavicular injury with prominent associated soft tissue swelling. 2. No acute fracture. Radiology showed 1. Minimal calcific atherosclerosis without evidence of significant stenosis. Patent bilateral inflow and outflow vessels with normal bilateral lower extremity runoffs. 2. Again seen is complicated and comminuted displaced open fracture of the left distal fibula and tibia. The distal fibular fracture appears to extend into the ankle mortise. Partially visualized bones of the foot appear intact. The patient was diagnosed with FX SHAFT TIBIA W FIB-OPN, FRACTURE ONE RIB-CLOSED, LUNG CONTUSION-CLOSED, MV TRAFF ACC NEC-MOCYCL. The patient was treated with ___ ORTHO 1. Washout and debridement open fracture down to and inclusive of bone, left tibia. 2. Closed treatment left tibia-fibula fracture with manipulation. 3. Application multiplanar external fixator, left leg. 4. Application VAC sponge less than 50 sq cm left leg. . ___ ORTHO 1. Washout and debridement open fracture down to and inclusive of bone left tibia. 2. Removal external fixator under anesthesia. 3. Open reduction and internal fixation left bimalleolar ankle fracture with internal fixation. 4. Intramedullary (IM) nail left tibia. 5. Insertion of antibiotic cement delivery device. . ___ PLASTICS 1. Debridement of open fracture. 2. Radial forearm free flap reconstruction. 3. Split thickness skin graft of left forearm donor site (10 x 6 cm).. The patient was given written instructions concerning 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 ___ service after a motorcycle crash where he sustained an open tib-fib fracture, bilateral first rib fractures and pneumomediastinum. His left lower extremity fracture was determined to be a grade 3 open left tibia-fibula fracture and patient was taken to the OR on ___ by Orthopedic service for washout and debridement of open fracture with application of multiplanar external fixator and wound VAC to anterior left lower extremity wound defect. Plastic surgery was consulted on ___ for flap coverage planning to left lower extremity (LLE) wound defect. On ___, the patient returned to the OR with both Orthopedics and Plastics services. Orthopedics began with washout and debridement of LLE wound, removal of external fixator with open reduction and internal fixation left bimalleolar ankle fracture with internal fixation and Intramedullary (IM) nail left tibia with insertion of antibiotic cement delivery device. Plastics then did a radial forearm free flap reconstruction to LLE wound defect and placed a split thickness skin graft to left forearm donor site. Patient tolerated all of these procedures very well. Patient was admitted to Plastic surgery service and placed on bedrest for 5 days after the final surgery with close monitoring of free flap to LLE. He received Toradol x 3 days post-operatively and then transitioned to 121.5mg of ASA QD as part of a free flap anticoagulation protocol. On POD#5, all surgical dressings were removed and flap remained warm, pink and viable. All LLE incisions remained patent and without signs of infection. Patient's LLE was maintained in a pre-fabricated posterior support splint for the remainder of his stay and he was discharged home with same. Left forearm incision and skin graft sites were patent and without signs of infection or breakdown. Left thigh donor site remained open to air to dry. Patient began a LLE dangle protocol three times a day on POD#5 with incremental increases in dangle times each day as part of flap dependency training. The LLE free flap tolerated dangle challenges well. . Neuro: Post-operatively, the patient's pain was managed with a dilaudid PCA and/or IV pain medications with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: The patient was given IV fluids during pre-op periods of NPO and directly post-operatively until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was started on a bowel regimen to maintain bowel movements. Patient was commenced on Flomax PO for urinary retention post-operatively. Patient able to void freely and without difficulty during the remainder of admission. Intake and output were closely monitored. . ID: Post-operatively, the patient was given 3 doses of IV cefazolin and then IV gentamicin was added on ___. Gentamicin was discontinued on ___ and patient was maintained on cefazolin (and then keflex) alone until ___. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during a portion of this stay and was transitioned to Lovenox prior to discharge for purposes of teaching self lovenox injections. Patient was discharged home with 2 weeks of lovenox therapy. . At the time of discharge on HD#12, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating with crutches and non wt bearing on LLE, voiding without assistance, and pain was well controlled. All incisions were clean and intact without signs of infection or breakdown. LLE flap site remained pink, warm and viable. LLE was maintained in pre-fab posterior splint with ace wrap to just below knee. Left forearm skin graft site was healthy and pink with 100% take.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ yr old G2p1 presenting with RLQ pain, near syncope and pain.She reported the acute sonnet of symptoms and presented to the ER. PELVIS, NON-OBSTETRIC showed Findings highly worrisome for ectopic pregnancy: Large amount of hematoma/hemoperitoneum in the pelvis, which, along with an absence of intrauterine gestational sac and elevated beta HCG, highly worrisome for ruptured ectopic pregnancy. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:06 pm, 2 minutes after discovery of the findings. The patient was diagnosed with Unspecified ectopic pregnancy without intrauterine pregnancy. The patient was treated with operative laproscopy, right salpingectomy, removal of ectopic pregnancy. At the time of discharge, the patient had ruptured ectopic. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>On ___, Ms. ___ presented to the emergency room with RLQ pain, hypotension and vaginal posting. She had a positive pregnancy test and ultrasound imaging concerning for hemoperitoneum and ruptured ectopic pregnancy. An HG of 8900 was noted and no intrauterine pregnancy. She received IV resuscitation and 3 units of red cells and in the ER and was taken urgently to the operating room. She underwent an operative laproscopy, evacuation of hemoperitoneum, and right salpingectomy for ruptured ectopic. Please see the operative report for full details. Her pre-operative HCT was 36.8. Patient received 2 additional units of packed red blood cells intra-operatively, for a total of 5 units. EBL was 4000cc. PACU HCT was stable at 36.5. Her coagulation factors were trended and were stable. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV toradol. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, ibuprofen, and Tylenol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. She expressed significant tearfulness regarding these events and pregnancy loss. Patient was seen by Social Work during her admission. She will have outpatient followup with this service. She was discharged to home with outpatient followup in one week. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old right handed young lady, with past history of Ebstein anomaly, ___ s/p unsuccesful ablation in ___, intratrial communication, who presented to the ED with sudden onset difficulty comprehending and producing speech and right sided facial droop and arm weakness. Patient was last well seen at 19:00, code stroke called at 19:30. She was brought by EMS and per their report, she was talking normally until suddenly she was unable to find words and had some difficulty comprehending speech, with a right facial droop, and she became unable to hold her right arm up. She was immediatly brought to our ED. It was also noted that she had one episode of incontinence. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, lightheadedness, vertigo, tinnitus or hearing difficulty. She reports feeling tired and sleepy. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath, but required oxygen on the field due to saturation in the high 80's. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denies arthralgias or myalgias. Denies rash. Radiology showed 1. No acute intracranial abnormality, with no evidence of infarct or hemorrhage. No CT perfusion abnormality to suggest ischemia or infarct. 2. Unremarkable CTA of the head and neck. 3. Bilateral enlarged cervical lymph nodes, which may be reactive. Radiology showed Mildly prominent heart size for age although potentially exaggerated by technique; follow-up standard PA and lateral radiographs may be useful to reassess when feasible. No evidence of acute disease. Radiology showed 1. Acute to subacute infarction involving the left putamen and caudate head. 2. Likely old small area of infarction in the right periventricular region adjacent to the lateral ventricle. These findings were discussed with Dr. ___ by Dr. ___ at 2:15 p.m. on ___ by telephone. Radiology showed Changes of Ebstein anomaly as described above. Otherwise unremarkable examination. In particular, there is no evidence of pulmonary embolism. Radiology showed No evidence of DVT in either the right or left lower extremity. Radiology showed Hypodense area in the left lenticular nucleus and head of the caudate nucleus is compatible with evolving left MCA stroke. ___ areas of hemorrhage or hemorrhagic conversion are identified. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. At the time of discharge, the patient had -L caudate/putamen 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>___ y/o R-handed F with hx of Ebstein anomaly with ASD, WPW syndrome s/p unsuccessful ablation in ___ presenting with acute onset dysarthria, word-finding difficulty and R-sided weakness with MRI notable for L caudate/putamen stroke. Cardiac workup revealed arrhythmia with ASD/PFO due to known abnormalities, likely cardioembolic source of clot. Started on anticoagulation with heparin, now transitioned to coumadin with lovenox bridge. #Neuro: Admission neurologic exam was notable for dysarthric speech, word-finding difficulty, R-facial asymmetry and R-sided weakness. MRI was notable for L caudate/putamen stroke, likely of embolic etiology in the setting of recently started OCP. TTE and ___ studies were done without clear source of embolism, and coagulation panel was unremarkable. Patient was started on heparin drip and transitioned to coumadin with lovenox bridge upon discharge. Patient was also evaluated by cardiology as below. ___ and speech and language consults were obtained, which recommended outpatient follow-up. Symptoms were monitored daily with improvement in ___ language fluency, dysarthria and weakness throughout the course of admission. Upon discharge, patient could speak in ___ word ___ sentences, had mild persistent asymmetry of the lower R facial musculature and mild dysarthria. #CV: Patient underwent TTE for evaluation of possible cardioembolic source and delineation of congenital anomaly. Ebstein's anomaly with ASD was confirmed. EKG was consistent with ___ syndrome. Patient was found to be hypoxic to 89% on 6L O2, raising the concern for pulmonary embolism. CTPA was negative for PE. Patient was evaluated by both the cardiology service and the ___ Adult Congenital Heart Disease service to evaluate chronic versus acute onset hypoxemia. Both services felt that her hypoxemia was physiologic given the extent of her shunting and that there was likely no worsening of her defect, but that cardiac surgery should be pursued in the near future. O2 supplementation was stopped given physiologic shunting. Patient's O2 saturation ranged between 82-93%/RA without any evidence of cyanosis, tachypnea or dyspnea. Patient was started on heparin and transitioned to coumadin with lovenox bridge. #Resp: Patient was kept on continuous O2 monitoring. Had a desat to the los ___ while in the shower with associated cyanosis, which was thought to be vasovagal. No PE on CTPA. Her O2 sats remained in the mid-high ___ on room air. #FEN: Patient was maintained on cardiac healthy diet. #HEME: Started on anticoagulation with heparin, now transitioned to coumadin with lovenox bridge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o woman with history of rheumatic fever, paroxysmal atrial fibrillation, type 2 diabetes mellitus, hypertension, and hyperlipidemia who presented with shortness of breath and palpitations. She was found to be in an SVT by paramedics and converted to sinus with adenosine. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Unremarkable abdominal ultrasound. Normal gallbladder without gallstones or acute cholecystitis. CHEST (AP AND LAT) showed No definite radiographic evidence for pneumonia. Mild bibasilar atelectasis. The patient was diagnosed with Supraventricular tachycardia, Bradycardia, unspecified. At the time of discharge, the patient had -Supraventricular tachycardia -Paroxysmal atrial fibrillation -Hypertension -Hyperlipidemia -Type 2 diabetes mellitus -Subdural hematoma -Hyperthyroidism -Osteoarthritis -Rheumatoid arthritis -Gait instability. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of rheumatic fever, paroxysmal atrial fibrillation, type 2 diabetes mellitus, hypertension, hyperlipidemia who presented with shortness of breath and palpitations. She was found to be in an SVT by paramedics and converted to sinus with adenosine. She was started on verapamil as an inpatient and tolerated it well. She was discharged home with continued services. # Supraventricular tachycardia: Arrived to the hospital in NSR following the adenosine. Unclear precipitant. EKG without ischemic changes and serially negative troponin. No signs or symptoms of infection. She appeared euvolemic on exam. She was started on verapamil 120 mg daily with good effect, HRs in the ___ and no additional episodes of SVT. TSH was slightly low but free T4 was normal. She was discharged with no antiocoagulation for embolic prevention in the setting of underlying paroxysmal atrial fibrillation given recent chronic subdural hematoma and multiple recent falls; this risk-benefit trade-off was discussed with daughter and patient. # Hypertension: Antihypertensives discontinued during last admission in setting of orthostasis and recent fall in favor of verapamil. # Recent subdural hematoma: Patient was recently admitted for fall with headstrike, imaging showed chronic subdural hematoma. Will follow-up with ___ clinic. # Hyperthyroidism: Continued methimazole. TSH was low (0.22) but free T4 was ultimately normal. Recommend rechecking with PCP at followup. # Gait instability: 8 falls in the last year. None since last discharge. Has a walker, but per her daughter does not always use. Very important to patient to remain independent. She was discharged home with continued services.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: From Admission HPI: Mr. ___ is a ___ yo M well known to the neurosurgery team who is s/p urgent L1-L3 laminectomies, and L2-3 diskectomy on ___ for cauda equina syndrome. He was discharged to ___ but presented on ___ with ongoing wound dehiscence and poor healing. He was admitted for placement of a wound vac system and initiation of IV antbiotics. He reports no fevers, chills or sweats. He notes some improvements in ___ strength with ongoing ___. CT L-SPINE W/O CONTRAST Q331 CT SPINE showed 1. Compared to ___, there has been interval evacuation of the previously seen large posterior subcutaneous hematoma. There is subcutaneous gas in the region of the hematoma. Recommend correlation with recent evacuation. 2. There is indistinctness of the posterior spinal musculature, which could represent a persistent, though decreased, hematoma. 3. Linear lucency through the right L2 inferior facet may represent a minimally displaced pars defect or artifact Radiology showed Left-sided PICC line in situ with the tip more medial than would be expected, but in discussion with the referring NP I was assured that the PICC line is not intra-arterial or extra-luminal. The tip projects 2 cm inferior to the carina, then placing it in the low SVC. The patient was diagnosed with Infection following a procedure, initial encounter, Oth surgical procedures cause abn react/compl, w/o misadvnt. The patient was treated with Placement of irrigating wound vac (___) on ___ Wound irrigation and debridement on ___ with placement of incisional vac. At the time of discharge, the patient had Wound dehiscence. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ was admitted to the ___ on ___ from ___ for concern of wound dehiscence and infection from his prior urgent L1-L3 laminectomies, L2-3 diskectomy on ___ for cauda equina syndrome. On ___, he was started on IV cefazolin and received placement of a ___ irrigating wound vacuum which he tolerated well. He did not complain of any subjective fevers, chills, or sweats and his WBC was within normal limits. He remained stable overnight. On ___, he reported tolerating the wound vac well. He was eager to return to rehab but per Dr. ___ was asked to remain in house on antibiotics and with a vac change scheduled for ___ where he could also be examined by Dr. ___. On ___, he continued to tolerate the wound vac and was neurologically stable. He remained afebrile without any WBC. On ___, the wound vac was changed and the patient continued to do well. On ___, in the early morning the team was notified that WoundVac dressing was leaking. Upon inspection, the foam was found to be intact, and the dressing wasreinforced. On ___, the patient's neurological and motor exam remained stable. The team changed the wound-vac dressing with Dr. ___ changed ___ irrigation fluid from saline to Dakins ___. On ___, the patient continued to do well and was without fever or complaint. The WoundVac dressing maintained a good seal. On ___ the patient remained neurologically stable. His wound vac remained in place and he was preparing for surgery on ___. On ___ the patient was taken to the operating room and underwent a Lumbar Wound Revision. His case was uncomplicated and he was extubated in the OR and recovered in the PACU. He was transferred to the floor when stable. He was placed on vancomycin, cefepime, and flagyl for antibiotic coverage pending an ID consult. On ___, the patient continued to be stable on the floor with a stable neurological exam. He was seen by ID who recommended vancomycin, ceftazidime, and flagyl while awaiting culture speciation. The patient continued to remain stable in house from on ___ and ___ where he continued on vancomycin, ceftazidime, and flagyl. He did have a run of ventricular tachycardia on ___, lytes and a formal EKG were obtained that were unremarkable. The patient was discharged in stable condition on ___. He was discharged on Vancomycin 1500 mg q8h and ertapenem 1g q24h both until ___. The patient's incisional vac was changed on the day of discharge. This vac will be changed by the Prevena ___ Wound Nurse ___ cell: ___ on ___. Per the infectious disease team, there was no need for ID follow up at this time. However, the infectious disease team at ___ will continue to monitor the final speciation of his wound cultures and will notify the team at ___ should any antibiotic changes be necessary. This plan was discussed with the patient prior to discharge and the patient expressed understanding. He will call to schedule a two week follow up with Dr. ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old male who is status post Stent assisted coiling of a basilar aneurysm on ___ and reports ongoing left visual field "gap" and poor visual acuity with fine print for the past 4 days. . The patient reports that he was in his yard lifting heavy bags of mulch for about 2.5 hours when his legs buckled, he lost balance and tried to ambulate without success. He reports feeling as if he was in a "drunken stupor". MRI AND MRA BRAIN showed Bilateral occipital infarcts right greater than left side likely subacute in nature. No evidence of hemorrhage. No mass effect or hydrocephalus. MRA shows flow signal in the base of the aneurysm . The patient was diagnosed with VISUAL DISTURBANCES NEC, HYPERTENSION NOS. At the time of discharge, the patient had Subacute 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>___, Patient was admitted to the floor after being evaluated in the emergency department. He was started on Plavix and aspirin. Stroke neurology was consulted and recommended an ophthalmology consult as well as an MRI/MRA to evaluate for stroke. On ___ Mr. ___ had visual field testing which demonstrated the presence of a left homonymous hemianopsia. On ___ he underwent MRI/MRA which showed subacute right temporal, bilateral occipital infarcts right greater than left. It was felt that the strokes were possibly a result of dehydration in the setting of exertion. On ___ he remained neurologically stable and at the time of discharge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. He will follow up as an outpatient to complete his work up with a TTE and follow up with Dr. ___ in ___ weeks in clinic.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with PMH polycystic kidney disease w/ polycystic liver, chronic abdominal pain who presented with 1 day of abdominal pain and fever. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute abdominopelvic process correlating with the patient's symptoms. 2. Numerous cysts throughout the liver and bilateral kidneys, in keeping with history of polycystic kidney disease. 3. Persistent mild enlargement of the common bile duct measuring up to 9 mm, unchanged compared to multiple prior studies and stable since at least ___. The patient was diagnosed with Epigastric abdominal tenderness. At the time of discharge, the patient had Polycystic kidney disease complicated by cyst rupture Polycystic liver Chronic neck pain Chronic abdominal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with PMH polycystic kidney disease w/ polycystic liver, chronic abdominal pain who presented with 1 day of abdominal pain and fever. #Abdominal pain/fever: Likely due to cyst rupture, as symptoms are similar to prior flares of her polycystic kidney/liver disease and she has no other signs or symptoms of infection. Held off on antibiotics. Spoke to urology consult on the phone who said that the patient has an appointment in 2 weeks and can follow up as an outpatient for decortication; nothing to do in the meantime to prepare for this clinic visit, and would not do decortication while the patient is having a cyst rupture. Fever downtrended by second day of admission. Continued home oxycontin. Given IV dilaudid while vomiting, changed to PO by second day of admission. Also gave Tylenol, though patient reported that this had no effect. Patient reported being back to her baseline chronic level of abdominal pain. Her home oxycontin is for her neck pain. She requested dilaudid on discharge. I discussed with her that she needs an overall pain management plan with her outpatient providers and dilaudid is not a good long term option, especially now that she is back to her baseline level of pain. We agreed to a very short course to help bridge her to her next PCP appointment, which has been scheduled for early next week. Also continued home promethazine and prochlorperazine</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Primary Care Physician: ___ . CHIEF COMPLAINT: failure to thrive, confusion . HISTORY OF PRESENT ILLNESS: Pt with pmhx of HTN, HLD, DM, etoh abuse who presents with increased memory loss and failure to thrive. . Pt was unable to make his cognitive neurology evaluation today and refused to get his B12 injection. ___ NP advised his daughter-in-law to bring pt to ED for further workup. Pt denies any pain pain. New onset urinary incontinence and possible fecal incontinence x2 days per daughter-in-law. No known falls and no fevers. History otherwise limited as pt is only oriented to person. In the ED initial vitals were: 98.4, 66, 176/54, 16, 98% - Labs were significant for hgb 13.9 (MCV 101) and relatively unremarkable chem-7. Urine and serum tox screens negative. - Patient was given nothing. On the floor, an interview is conducted with the aid of a ___ interpreter. Pt is able to state his name. He is unsure where he is or what the date is. He denies any pain, including back and abdominal pain. He states he has not had any trouble with his bladder however he is noted to be incontinent. He does not know what medications he takes. Review of Systems: unable to obtain Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST showed No acute intracranial process. MR HEAD W AND W/O CONTRAST showed No acute hemorrhage or acute infarction. Generalized volume loss. T2/FLAIR signal hyperintensity in the periventricular and subcortical white matter bilaterally predominantly in the frontal lobes most likely secondary to chronic small vessel ischemic change. Right frontal lobe encephalomalacia The patient was diagnosed with SEMICOMA/STUPOR. At the time of discharge, the patient had PRIMARY: Delirium Vascular Dementia SECONDARY: Hypertension Type II Diabetes Mellitus Excessive Ethanol Use. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M PMHx atherosclerosis, DM, B12 deficiency, and EtOH abuse presented with acute on chronic delirium. He had a full delirium workup negative for reversible etiologies along with MRI Brain showing chronic small vessel ischemia and he was discharged to rehab # Delirium / Dementia: Patient presents with relatively new onset memory loss per family. Per report it seems it may be waxing/waning so unclear if current status represents dementia versus delirium, possibly combination of both. He was scheduled to have a cognitive neurology appointment but was unable to make as outpatient. Per family (___), patient had had a question of mild memory impairment over the summer (and was thus referred for neuropsychological evaluation, previously relatively independent in ADLs, went to bank, took daily walks, did own cooking, however ___ drinks/day). Only over the last 7 days has he had significant decompensation (urinary and bowel incontinence, wandering hallways of his apartment complex because he didn’t remember where he lived, forgetful and “not himself”, hygiene and upkeep poor, apartment unclean). History and physical exam otherwise unremarkable except for somonolence and disorientation. Differential included electrolyte abnormalities or uremia (none noted), infection (normal vitals and WBC), hepatic encephalopathy (LFTs normal, no cirrhosis stigmata), UTI (clean UA), intracranial process (CT/MRI show no acute process), ethanol withdrawal or Wernicke's encephalopathy ___ drinks per day, scoring minimally on CIWA, no improvement with thiamine/folate/MVI), normal pressure hydrocephalus (no characteristic gait, no evidence on imaging, variably continent therefore likely functional), thyroid disease (normal TSH), neurosyphilis (RPR negative, no other signs of tertiary syphilis), and B12 deficiency (had been refusing shots as outpatient but B12 within normal limits, no evidence of neuropathy, on high dose oral cobalamin). MRI/CT Brain showed chronic small vessel disease without acute disease process making vascular dementia more likely. Epilepsy/post-ictal state and meningeal process were considered but felt to be unlikely given lack of clinical signs/symptoms and stable clinical and mental status. Throughout his time, patient remained oriented to person and hospital only and never knew date. He was given thiamine/folate/B12 supplementation. Physical Therapy recommended ___ rehab and he will see outpatient cognitive neurology to continue workup of his delirium. #Urinary Incontinence: Patient with reported new urinary incontinence, likely relate to dementia/delirium process as above. No signs of hydrocephalus concerning for normal pressure hydrocephalus. No back pain or other focal neurological deficits concerning for spinal cord pathology. No signs of UTI based on UA. Patient was intermittently using toilet, so this was felt to reflect functional pathology in the setting of dementia/AMS. # Hypertension: Hypertensive on arrival to floor in setting of missing home anti-hypertensives; continued on home lisinopril and added HCTZ. # Acute Kidney Injur: On ___, noted to have Cr 1.3 from baseline 1. Patient has elevated BUN/Cr likely prerenal with dehydration in setting of low PO intake. Patient was repleted with IV fluids and his discharge Cr was 1.3. # EtOH Use: Per HCP, patient drank at least ___ drinks per day. As an inpatient, he was started on folate, thiamine, MVI for nutrition support and concern for ___'s encephalopathy and was monitored on CIWA scale for >48 hours; patient only scored for confusion and the scale was discontinued. # DMII: Poorly controlled and kept on insulin sliding scale as inpatient as well as diabetic heart-healthy diet. # B12 deficiency: Continue home dose ___ units B12 daily with B12 level being WNL # HLD: Chronic stable issue continued on home simvastatin. # Code: Full Code confirmed with HCP # Emergency Contact: HCP/daughter-in-law ___ ___ or grandson ___ ___ # ___: ___ # Transitional Issues - Continue dementia workup (consider LP/EEG); ___ cognitive neurology - Continue high-dose oral B12 therapy to minimize further worsening of cognition - Minimize access to ethanol - Control vascular dementia risk factors (HTN, DM) - Given CKD and baseline Cr 1.0-1.3, regularly evaluate continuation of metformin for diabetes control given risk of lactic acidosis</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a PMH of RA, Nephrotic syndrome c/b renal vein thrombosis on warfarin and hypertension who presented yesterday to the ED with low back pain after being unable to get up. She had several years of low back pain escalating over the past few weeks (midline over left gluteal, worst with ambulation, multiple recent falls, worsening difficulty standing) but has no leg weakness or numbness (but legs “give out” several times over past few weeks), has chronic urinary incontinence (unable to reach bathroom in time for 1 month, nocturia multiple times per night), but has no urinary retention or fecal incontinence/retention, and she was febrile at triage. Radiology showed MRI of the cervical spine, thoracic and lumbar spine without and with IV contrast: Study somewhat limited due to motion pulsation artifacts and lack of axial postcontrast sequences through the cervical and the upper thoracic spine. 1. C-spine: Multilevel, multifactorial degenerative changes, moderate to severe canal narrowing at C3-4, C4-5 and C5-6 levels with deformity and some degree of compression on the cord. T2 hyperintense foci in the posterior aspect of the cord at C4 and C5 levels, question related to myelomalacic changes or other etiology. Multilevel moderate to severe foraminal narrowing from C3-C7 levels with deformity on the nerves. 2. Multilevel degenerative changes in the thoracic spine, with mild canal and foraminal narrowing at T8-T9 and T9-T10 levels. No compression on the thoracic spinal cord. 3. Multilevel, multifactorial degenerative changes in the lumbar spine, most prominent at L3-4 level. L1-2: Mild canal narrowing L2- 3: Mild canal and foraminal narrowing L3-4: Moderate to severe canal narrowing with compression on the thecal sac and crowding of the nerves in the thecal sac Bilateral moderate to severe foraminal and mild subarticular zone narrowing with deformity on the L3 and L4 nerves. Bilateral facet degenerative changes, with small to moderate amount of fluid in the facet joints. A small slightly T2 hyperintense focus in or adjacent to the right ligamentum flavum indenting the thecal sac outline, may represent a cyst or a focus of ossification. L4-5: Mild canal, mild to moderate foraminal narrowing L5-S1: Mild foraminal narrowing. Prominent epidural fat encasing the thecal sac at L4-5 and L5-S1 levels. No fluid collection or abnormal enhancement is noted to suggest epidural abscess. 4. Enlarged slightly heterogeneous thyroid ; a 1.1cm focus in spleen-? Hemangioma/solid or cystic lesion; right kidney larger than left; mildly prominent aorta; bilateral adnexal cysts, larger one on the left measures 2.8cm. Correlate with ultrasound RECOMMENDATION(S): Consider spine/ neurosurgery consult to decide on further management. Correlate with ultrasound- thyroid, spleen, kidneys, aorta and adnexa. CT head without contrast. showed No acute intracranial process. The patient was diagnosed with FEVER, UNSPECIFIED, LUMBAGO, ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION. At the time of discharge, the patient had Primary: Lower back pain, weakness Asymptomatic Pericarditis Secondary: Nephrotic syndrome ___ to membranous nephropathy Renal Vein thrombosis on warfarin Hypertension Diastolic Heart Failure EF > 55%. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a PMH of RA, Nephrotic syndrome, hypertension and renal vein thrombosis on coumdin who presented yesterday to the ED with low back pain found to have fevers, EKG consistent with pericarditis, and developed transient somnolence in ED and so was transferred to MICU for concern of bacterial meningitis. # Pericarditis: Patient presented with chest pain at home that has now resolved. On arrival to ED patient was without chest pain but did have diffuse ST segment elevation with mild PR depressions. Etiology ___ be secondary to rheumatoid arthritis vs. idiopathic vs. viral. Per rheumatology it is unlikely that pericarditis is secondary to RA definitively. Also a possibility that patient had a viral pericarditis though denies prodromal viral symptoms prior to admission including fever, chills, rhinorrhea, and cough. Echocardiogram was also reassuring without evidence of pericardial effusion. She was not treated with on NSAIDs/colchicine due to ___ and known membranous nephropathy. # Fever/Altered mental status: Patient with RA/Nephrotic Syndrome on chronic corticosteroids and azathioprine presented with back pain and difficulty with ambulation and was found to have fevers. Differential includes CNS/Spine source (ruled-out by MRI and exam, no meningeal signs, no delirium or focal neurological deficits), cardiac inflammatory source (can develop fever in setting of pericarditis), pulmonary (no dyspnea/cough, normal CXR), urinary source (incontinence but no dysuria and UA unremarkable), skin source (no signs/symptoms). Infectious work-up was negative for an acute process. There was concern that patient had meningitis given encephalopathy and fevers, however given her rapid improvement and resolution of fevers/AMS her antibiotics were discontinued. Ultimately her fever ___ have been attributable to her pericarditis though resolved this hospital course. # Lower Back Pain with associated lower extremity subjective weakness: The ___ lower back pain and weakness that brought her to the hospital was ultimately felt to be secondary to possible dehydration and spinal stenosis symptoms. MRI imaging of her C, T, and L-spine was completed. Patient was noted to have multiple levels of foraminal narrowing and degenerative changes. Ortho spine assessed patient and noted that the findings did not warrant any surgical intervention. The ___ neurologic exam also remained intact while in the hospital. Ultimately it was determined that after ___ assessment patient could be discharged home with continued physical therapy sessions and outpatient spine clinic follow up. # ___: Patient came to hospital with normal renal function but developed ___ during course of ED stay. Her losartan and furosemide were held initially and she was given gentle IVF and her Cr normalized. Chem-7 should be checked on ___ to assess renal function. # Membranous Nephropathy with renal vein thrombosis: Chronic stable issue stable proteinuria and on prophylactic warfarin post-renal vein thrombosis. She was maintained on prednisone 5mg and azathioprine 50mg TID as well as warfarin for post-renal vein thrombosis prophylaxis and omeprazole for GIB ppx. INR should be checked on ___ and warfarin dose adjusted appropriately. INR was supratherapeutic on admission and warfarin dose decreased to 4 mg from 6 mg. Goal INR of ___. # HFpEF: Held furosemide in setting of ___. Patient remained euvolemic on exam. It was felt that daily weights should be monitored on discharge and if weight increased > 3 lbs then furosemide should be restarted at 80 mg BID. # HTN: Chronic stable issue continued on amlodipine. Losartan was initially held secondary to ___ but restarted prior to discharge. # Asthma: Patient remained without wheezing or cough this hospital course. Home inhaler regimen continued. #Incidental Imaging Findings: Right kidney larger than the left, better assessed on the prior CT abdomen study. Adnexal cyst noted on both sides on the localizing images series 3, image 6, the larger 1 on the left measuring 2.2 x 2.9 cm.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ female with h/o HTN, HLD, GERD and osteoarthritis who is not on anticoagulation presented to the ED s/p fall. She was reportedly walking down stairs when she tripped and fell down ___ steps. She landed on her right side with +HS, -LOC. She was having epistaxis at the scene that resolved prior to arrival. Upon arrival she was complaining of right elbow pain and facial pain. She denies any numbness or tingling in the arms or legs. Radiology showed Dislocation of the right elbow with associated fracture at the distal humerus. Discussed with Dr. ___. Radiology showed No acute fracture or dislocation. CT HEAD W/O CONTRAST showed 1. No acute intracranial process. 2. Acute nasal septum and right nasal bone fracture. CT C-SPINE W/O CONTRAST showed 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes of the cervical spine. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed Acute right nasal bone fracture and nasal septal fracture with overlying soft tissue swelling. Radiology showed Persistent subluxation of the right elbow joint. ELBOW, AP AND LAT VIEWS IN O.R. RIGHT IMPRESSION: Images from the operating suite show steps in placement of a fixation device about right elbow fracture. Further information can be gathered from the operative report. showed Images from the operating suite show steps in placement of a fixation device about right elbow fracture. Further information can be gathered from the operative report. CT UP EXT W/O C RIGHT Q51R showed 1. Fractures of the lateral epicondyle and coronoid process as described above. 2. There is dislocation of the proximal ulna posteriorly and laterally in relation to the trochlea. 3. Abnormal subluxation at the radiocapitellar articulation. The patient was diagnosed with Unsp fracture of lower end of right humerus, init, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with closed reduction, hinged external fixator ___, Krod). At the time of discharge, the patient had Elbow fracture-dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a elbow fracture-dislocation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for closed reduction and hinged external fixation, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with OT who determined that discharge to home with family support was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB in the operative extremity, and does not require DVT prophylaxis on discharge. 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: Mrs. ___ is a ___ year-old female with a two year history of peripheral neuralgia of her hands and feet. She has sought care via her primary care physician and ___ neurologist for this condition, among others as listed in her history (noted below). The patient states that over the last month, she has begun to experience worsening back pain ("my spine feels like it's on fire"), as well as pain and numbness of her legs. She also states that over the last two weeks, she suffered frequent episodes of urinary and rectal incontinence. Radiology showed Fluoroscopic images from the operating room demonstrate placement of a corpectomy device within C6. There is anterior fusion from C5-C7. No hardware related complications are seen. Please refer to the operative note for additional details. The total intra service fluoroscopic time was 9.2 seconds. The patient was diagnosed with DISC DIS NEC/NOS-CERV. The patient was treated with ___ C6 corpectomy, C4-C7 fusion. At the time of discharge, the patient had Cervical 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>Ms. ___ was admitted to the Neurosurgery service on ___ due to concerns, as exhibited on MRI, of a spinal cord lesion at the C5-C6 level. She was admitted to the inpatient ward and kept NPO, given IV fluids overnight in preparation for an operative intervention on her cervical spine. Surgical intervention was discussed on ___. Dr ___ surgery's risks and benefits and the patient consented to surgery. Surgery was moved to ___ because of OR scheduling/ timing. The patient was kept inpatient in preparation for surgery. On ___ Ms. ___ remains neurologically intact with the exception of motor strength 4- bilat tricep and 4+ right quad/hamstring. Ms. ___ was consented for the OR and will be NPO for planned C6 corpectomy and C5-C7 fusion on ___. On ___, the patient was taken to the OR for her scheduled procedure, which she tolerated well. Please see the operative report for further details. Post-operatively, the patient was recovered in the PACU and transferred to the inpatient ward for further management and observation. Her pain was controlled with narcotic and non-narcotic analgesics. On ___ her JP drain was discontinued and her pain was controlled. She was ambulating independently. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with a PMHx og pemphigus on steroids, HTN, recent PNA treated as an outpatient p/w functional decline over the last 4 months. Radiology showed 1. Large hiatal hernia. 2. No acute cardiopulmonary abnormality. The patient was diagnosed with OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had ___ syndrome Mineralocorticoid deficiency. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with a past medical history of pemphigus, on long term corticosteroids, with recent functional decline of uncertain etiology. # Functional decline: The patient and her family report a rapid functional decline starting 4 months prior to the patient's hospitalization. The patient was referred to the ___ emergency department by a member of the housestaff who was caring for her husband on the ___. The patient has a history of chronic steroid use for pemphigus (prednisone 12.5 mg QOD x years, with higher doses in the past), although the disease has been inactive for many years. The patient's overall past medical history is concerning for iatrogenic ___ syndrome evidenced by cataracts, glaucoma, psychiatric disturbances, proximal weakness/wasting (CK 15), glucose intolerance (A1C 6.4), recent infections (dental abscess, pneumonia), osteoporosis c/b vertebral fractures and skin thinning. Her more recent problems stem from treatment of a dental abscess. While undergoing treatment for the abscess her corticosteroids were stopped. She was re-evaluated by her PCP who diagnosed her with adrenal insufficiency. She was started on cortisone acetate 5 mg BID and fludrocortisone. She subsequently developed severe hypokalemia and a more rapid physical decline including substantial weight loss. Her major complaints include weakness, decreased appetite and fatigue. She had no focal neurologic findings. She was able to stand from a seated position. Her B12 was found to be low and she was started on supplementation. TSH was normal (1.2) as was AM cortisol (15). The patient's albumin was 3.7. MMSE score ___. She was found to be orthostatic. The patient also admitted to depression given her current physical state and her husband's illness. Overall her presentation was consistent with iatrogenic ___ and mineralocorticoid deficiency. She was discharged on prednisone 2.5 mg daily and fludrocortisone 0.1 mg daily. Potassium supplementation was provided as well. The patient should undergo diagnostic and age appropriate cancer screening due to her significant weight loss. Treatment for depression should be considered as well. # GERD/ulcer prophylaxis: Stable. The patient was continued on omeprazole while hospitalized. The need for a PPI should be reassessed if the patient is fully tapered off of corticosteroids. # Glaucoma: Stable. The patient was continued on brimonidine eye drops. # Diabetes mellitus: The patient's diabetes was most likely induced by her long term corticosteroid use. Her A1C was 6.4%. She was given sliding scale insulin while hospitalized. Rapaglinide was continued at discharge. TRANSITIONAL ISSUES ******************* 1. PCP follow up 2. Taper prednisone and fludrocortisone as appropriate 3. Please check CBC, Chem 10 on ___ 4. Diagnostic and age appropriate cancer screening recommended 5. Consider treatment for depression</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female with history of back surgery x2, posterior instrumented fusion of L3-5, now with back pain for the last few weeks. Presented to ___, an MRI was obtained and showed multifactorial lumbar stenosis with complete effacement of CSF at L1-2, and retrolisthesis of L1 on L2. The patient endorses intermittent fecal incontinence the last few days with worsening back pain. She endorses back pain that radiates to bilater groins, and numbness to bilateral knees that extends down to bilateral inner calves. CT L-SPINE W/O CONTRAST Q331 CT SPINE showed 1. Status post laminectomy and posterior fusion of L3 through L5 without definite evidence of hardware related complications. Note is made of that the left L5 pedicle screw which appears to extrude beyond the vertebral body by 11mm. 2. Severe degenerative disc disease at L1/L2 causing severe spinal canal stenosis. 3. Bilateral punctate renal stones with mild fullness of the right renal collecting system. Radiology showed There has been posterior fusion extending from L3 to L5. No definite hardware complications are seen on these radiographs; however, the recent CT scan demonstrated extrusion of the left L5 pedicle screw beyond the anterior margin of the vertebral body. There are degenerative changes with loss of intervertebral disc height at multiple levels. There is retrolisthesis of L1 over L2 which measures 5 mm on flexion and 10 mm on extension. This constitutes abnormal motion. No definite compression deformities are seen. CHEST (PA AND LAT) showed No previous images. Cardiac silhouette is within normal limits and there is no vascular congestion, pleural effusion, or acute focal pneumonia. Of incidental note is evidence of a is lumbar fusion device. The patient was diagnosed with Other intervertebral disc degeneration, lumbar region. At the time of discharge, the patient had Severe spinal stenosis L1-L2. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>On ___ the patient presented to an OSH for back pain and fecal incontinence and was transferred to ___ for further evaluation after an MRI was obtained and was consistent with lumbar stenosis with complete effacement of CSF at L1-2, and retrolisthesis of L1 on L2. The patient was admitted to the Neurosurgery service and was admitted to the floor for further care and evaluation. On ___ the patient had flexion and extension films done which demonstrated that the patient has extrusion of the left L5 pedicle screw beyond the anterior margin of the vertebral body. There are degenerative changes with loss of intervertebral disc height at multiple levels. There is retrolisthesis of L1 over L2 which measures 5 mm on flexion and 10 mm on extension. This constitutes abnormal motion. She remained neurologically intact with paresthesias to her right knee although stated this has been stable since she had a knee replacement ___ years ago, and also endorsed paresthesias from the lateral aspect of her left knee to left distal great toe. Her dexamethasone regimen was discontinued. On ___ surgery was offered to patient who declined until after ___. TLSO brace ordered. ___ consult placed. On ___ the patient's exam remained neurologically stable. Her pain was well controlled. Surgery was again offered but was declined by the patient as she requested to wait until after the holiday. She was seen by ___ while wearing the TLSO brace and was recommended for home ___. She was discharged in stable condition. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is ___ ___ yo s/p ___ x1 on ___ whose post op course was complicated by acute kidney injury requiring dialysis, post operative seizure with negative head CT on dilantin followed by neurology, atrial fibrillation on coumadin. He has been stable for the last week, his weight has not changed, and over the last 3 days he has noticed increased shortness of breath. He denies fever or chills, no productive sputum, denies chest pain or palpitations, no increase in lower extremity edema. His shortness of breath has worsened today with dyspnea on minimal exertion, but denies problems lying flat. He went to ___ where he had an echocardiogram which showed a moderate to large pericardial effusion. He was transfered for further evaluation CHEST (PORTABLE AP) showed Pericardial drain is in situ. No evidence of pneumothorax or pneumomediastinum. Otherwise unchanged radiograph. CHEST PORT. LINE PLACEMENT showed As compared to the previous radiograph, the size of the cardiac silhouette has not substantially changed. No pulmonary edema. No pleural effusions. No pneumonia. Moderate retrocardiac atelectasis. CHEST (PORTABLE AP) showed RETROCARDIAC OPACITY IS LARGELY LEFT LOWER LOBE ATELECTASIS AND SMALL EFFUSION, NOT APPRECIABLY CHANGED RECENTLY. LUNGS OTHERWISE CLEAR. HEART SIZE BORDERLINE ENLARGED. LEFTWARD TRACHEAL DEVIATION REFLECTS LARGE CHRONIC THYROID MASS. The patient was diagnosed with ACUTE PERICARDITIS NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT. The patient was treated with pericardial drain placement. At the time of discharge, the patient had pericardial effusion with tamponade. The patient was given written instructions concerning 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 cardiac surgery service and was taken urgently to the cath lab for drainage of pericardial effusion that was causing tamponade physiology. He tolearted the proceedure well. A pericardial drain was placed for drianage of approximately 620cc of bloody drainage. He was transferred to the CVICU for monitoring. During his stay in the ICU he was hypertensive and medications were adjusted. He had episodes of rapid afib and was bolused with amiodarone and continued on amiodarone taper. He was resumed on coumadin therapy. His pericardial drain was removed on POD#1. He remained HD stable. TTE was obtained at discharge which was unchnaged from previous per report. He was cleared for discharge to home on POD# 2 All f/u appointments arranged. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ ___ y/o M with a PMH of paroxysmal a. flutter on eliquis, constrictive pericarditis, ischemic cardiomyopathy (LVEF 40%), type 2 DM and HTN who presents with SOB and fatigue and is diagnosed with atrial flutter with RVR and acute on chronic sCHF. Radiology showed Small left pleural effusion with left lower lobe opacity, which may reflect atelectasis, however pneumonia cannot be excluded. Mild interstitial pulmonary edema. NOTIFICATION: Updated read was discussed with Dr. ___ by Dr. ___ telephone at 16:52 on ___, approximate 30 min after discovery. The patient was diagnosed with ATRIAL FIBRILLATION, HEART FAILURE NOS, ATRIAL FIBRILLATION, HYPERTENSION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS Atrial flutter with rapid ventricular response Acute on chronic systolic cardiac heart failure Lactic acidosis due to metfromin overdose Acute kidney injury Acute liver failure Urinary tract infection SECONDARY DIAGNOSIS Coronary artery disease Type II diabetes mellitus Dyslipidemia. The patient was given written instructions concerning 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 a PMH of paroxysmal a. flutter on eliquis, constrictive pericarditis, ischemic cardiomyopathy (LVEF 40%), type 2 DM and HTN who presents with SOB and fatigue and is diagnosed with atrial flutter with RVR, acute on chronic sCHF, ___, ALF and urinary tract infection. ACTIVE ISSUES # Atrial flutter: Patient with PMH of paroxysmal afib, is admitted with atrial flutter with a RVR of 114. Patient was given a loading dose of digoxin 0.125 mg PO/NG Q6H (2 Doses), and was then mantained on digoxin 0.0625mg PO QD and metoprolol tartrate 25mg PO Q6H. Patient's HR around ___ with medication, asymptomatic. Will be kept on that dose of digoxin, and will receive metoprolol succinate 100mg QD. Has indication for anticoagulation, is receiving apixaban 2.5 mg PO/NG BID. # Acute on chronic sCHF: Patient with PMH of ischemic cardiomyopathy with an LVEF 40%. At admission the PE was suggestive of mild fluid overload (JVP elevated to jaw, billateral crackles and +1 edema in BLE). However, due to constrictive pericarditis, diuresis was managed with caution. He received lasix IV bolus of 20 mg and was then transitioned back to home dose of furosemide 20mg PO QD. His discharge weight is 68kg (down from 70.5 at admission). # Metabolic acidosis high anion gap/ Lactic acidosis: At admission lactate was 4.3 and patient had a high anion gap that peaked at 28. The lactic acidosis was attributed to hypoperfusion and/or metformin overdose. The patient has shown slow downtrend throughout hospitalization. Last lactate= 3.2. # ___: Patient admitted with Cr: 1.6. (Baseline ___. Probably secondary to hypoperfusion. Peaked at 1.8. At discharge 1.4. # Acute liver failure: There was evidence of transaminitis since admission, with ALT 374 AST 377. There was also an increase in INR up to 2.9 and the patient was not oriented (possible grade I hepatic encephalitis). The lab values downtrended slowly with medications and patient's mental status improved. # UTI: Urine culture was positive for PROTEUS MIRABILIS >100,000 ORGANISMS/ML. The patient did not report any symptoms. He received ceftriaxone 1g Q24H for 5 days and will be sent home with cefpodoxime 100 mg Q12h for 2 days. # Disposition: On ___, the patient reported to the team that he adamantly wished to be discharged home. His providers had been working on getting rehab placement, and occupational therapy had recommended either home with 24-hour supervision or rehab placement. Given the patient's insistence, the risks and benefits of going home without adequately supervision were explained to his daughter, ___. Risks included potentially life threatening falls and his impaired ability to call for help appropriately. Attempts were made to discuss the patient's care with the patient, but his grandson, who was by the bedside, was incredibly rude to the care team and particularly to the ___ interpreter; he refused to step out of the patient's room when asked. CHRONIC ISSUES # CAD: Evidence of CAD on past stress test. No current CP. Patient was kept on Atorvastatin 20 mg PO/NG QPM # Type II DM: had been receiving metformin at home. HPI suggested metformin toxicity, so patient was kept on an insulin sliding scale. Fingersticks in 150s-200s. Patient will be discharged without metformin, shoulf F/U diabetes treatment with PCP. A1C 8.0% # Dyslipidemia: Will be kept on Atorvastatin 20 mg PO/NG QPM # Depression: Will be kept on Paroxetine 10 mg PO/NG DAILY # FEN: Heart-Healthy diet </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH notable for chronic migraine and right total knee replacement ___ and recent knee infection s/p washout and IV antibiotics ___, presenting with one week of diarrhea and severe ___ migraine headache. Patient was discharged from ___ following her knee washout about one month ago on IV ertapenem, then was switched to IV clindamycin about one week ago. States that she developed watery, non-bloody diarrhea around that time and was tested for C diff which was negative. Clindamycin was stopped three days ago and PICC line was discontinued. Endorses fever to ___ two days ago and has since been taking Tylenol around the clock. The patient reports a ___, throbbing headache primarily over the R forehead but also w/ L-sided pain for the past 2-days, w/ 10 episodes of associated emesis, nonbloody and non-bilious. No photophobia or phonophobia. Per OMR and the patient, these features are characteristic of her migraine headaches, for which she is on prophylaxis with lamotrigine, and which she tries to treat with zofran and ibuprofen. She has failed treatment with calcium She believes that these severe headaches have been becoming more frequent (used to occur every ___ months, now every ___ months). She is managed for her migraines as an outpatient w/ plan for botox injection. With regards to her knee, she has noted some swelling of the knee and states that the pain is about the same. She has been able to ambulate on her knee with a crutch. In the ED, initial vitals are as follows: 98.4 16 99/59 16 100%RA. Exam was notable for abdomen soft, tender to palpation in LLQ and hypogastrium with guarding. Right knee with +edema, no erythema, able to range fully. Labs notable for non-gap metabolic acidosis. The pt had non-con CT abdomen/pelvis which was limited without IV contrast, No gross bowel pathology, No large fluid collections or free air. In the ED, she received 3L of NS. She also received 1mg Dilaudid IV x for abdominal discomfort and migraine, 4mg IV Zofran x2. Vitals prior to transfer 98.8F, 72, 16, 98/68, 98%RA. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematochezia, dysuria, hematuria. Radiology showed Normal chest. Radiology showed Limited exam, without evidence of acute bowel pathology or large fluid collections. The patient was diagnosed with DIARRHEA, NAUSEA. At the time of discharge, the patient had Acute on Chronic migraine Diarrhea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with hx of right total knee replacement, recently hospitalized at ___ for knee infection s/p washout, s/p one month course of IV antibiotics, admitted for one week of non-bloody diarrhea and migraine. #Migraine: The patient's migraine improved with IV fluids, IV zofran, and IV dilaudid 3 mg q2H prn pain. She briefly reported nausa and emesis during this time, which resolved on its own. The day prior to discharge, patient started to feel better. #Diarrhea: This spontaneously improved upon admission such that she had no bowel movements on HD1, one bowel movement on HD2, and no bowel movements on HD 3. C diff repeated at ___ was negative. All stool studies were negative: fecal culture, campylobacter culture, ova and parasites, and fecal culture r/o E coli. CT abd and pelvis was also reassuring. #R knee: Noted to have mild effusion on exam, but patient had full ROM and was able to ambulate. This was evaluated by ortho, who in consultation with her home orthopedist decided not to tap her knee. The patient was told by her orthopedist to take warfarin for 6 weeks after the washout (to end ___, but it was noted that her INR was subtherapeutic (1.1). Because it would take her longer than this time to become therapeutic on coumadin, in consultation with pharmacy, she was given enoxparin 30 mg BID SC for DVT ppx. She was discharged with 3 more doses of enoxaparin. #Asthma: stable and asymptomatic during hospitalization. We continue home flovent and wrote for albuterol nebulizers PRN, which she did not require.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo man ___ C5-C6 quadriplegia, recent dx metastatic bladder cancer now presents with lightheadedness, syncope yesterday. CT HEAD W/O CONTRAST showed No acute intracranial process. Please note that MRI is more sensitive for the detection of acute infarction and mass. Radiology showed No acute cardiopulmonary process. Known metastatic lesions not clearly delineated. CT abdomen and pelvis with contrast showed 1. No acute intra-abdominal process, no findings to explain patient's symptoms. Known biopsy-proven urothelial cell carcinoma extending along the right lateral lateral wall, possibly slightly decreased compared to the prior study. 2. Paracaval and right external iliac chain lymphadenopathy appears grossly unchanged compared with prior study. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Primary: Hypovolemia, lightheadedness, hypotension Secondary: Bacteruria, paraplegia, metastatic bladder 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>___ yo man PMH C5-C6 paraplegia, recent dx metastatic bladdercancer now presents with lightheadedness, syncope and bacteruria. #Lightheadedness/hypotension: Likely ___ hypovolemia as lactate and Na improved with IVF, with low volume potentially related to recent chemo administration. On first day of admission, had episode of lightheadedness with SBP 97, vitals and sx improved in ___ with IVF. Unlikely vertigo or medication effect given no symptoms nor signs of vestibular disturbance and per heme-onc his chemo regimen unlikely to cause vestibular effect, especially as sx occurred several days after treatment. CT head to r/o metastatic disease was negative. Autonomic dysfunction is also on the differential given paraplegia, however less likely given hypovolemia as noted above. No evidence of active infection at this time. Patient continued to have some lightheadedness initially after sitting up, but this improved over the course of his admission and he was able to sit in wheelchair without difficulty at time of discharge. #Bacteruria: Initial concern for UTI given sx and UA with >182 WBC and bacteria; however, 6 epis in UA and Ucx, while growing >100K pseudomonas, also grew skin/genital flora making contamination/colonization likely.Given paraplegia and urinary stasis, uses condom catheter and is on tamsulosin with Bactrim ppx as outpatient. Has had prior tx for urinary retention and remote hx of UTI in past. No culture data in our system but known colonization. Difficult to fully assess sx given paraplegia, but no WBC elevation, no fevers. Initially covered with CTX and then switched briefly to cipro when pseudomonas speciation was released, but sensitivities showed only intermediate sensitivity to Cipro and patient improved even without adequate antibiotic coverage, making colonization and not active infection even more likely. Antibiotics stopped and patient restarted on home bactrim ppx on discharge. ___ benefit from intermittent self-caths if retention predisposing to UTI's (f/u with urology). #Metastatic bladder CA: Received cisplatin/gemicitabine ___. Followed closely by heme-onc. #Paraplegia: No sensation or motor function below nipple line. Cared for closely by wife who is ___. >30 min spent on discharge coordination on day of discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female status post outpatient right long finger A1 pulley release on ___. Returned to ___ on ___ with complaint of increased throbbing pain and swelling with possible Radiology showed Retained foreign body in proximal volar long finger soft tissues, with severe soft tissue swelling. Findings were noted by Dr. ___ on ___. Radiology showed Status post I&D right long finger. Please see operative report for further details. The patient was diagnosed with OTHER POST-OP INFECTION, ACCIDENT NOS. The patient was treated with 1. Irrigation of right long finger flexor tendon sheath. 2. Removal of multiple foreign bodies from surgical wound.. At the time of discharge, the patient had Right hand / long finger surgical wound infection with foreign bodies. The patient was given written instructions concerning 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 I&D of wound infection on right hand. The patient was taken to the OR and underwent an uncomplicated I&D and removal of foreign bodies. 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 PO pain meds. The patient tolerated diet advancement without difficulty and made steady progress with ___. Infectious diesease and psychiatry were consulted Weight bearing status: nwb rue, finger ROM as tolerated. The patient received ___ antibiotics as well as pneumoboots for DVT prophylaxis. The incision was clean. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will not require DVT prophylaxis. 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: HPI: The pt is a ___ y/o LHF with a history of occasional migraine headaches who was transferred to ___ from ___ for concern of encephalitis. She had presented there after 4d of worsening right sided headaches with photophobia, nausea and vomiting, and fever of unclear duration. She had initially presented to her PCP, who prescribed doxycycline on ___ and di lyme serology (reportedly negative), and then went to ___ today for wrosening of her symptoms. Her head CT showed right temporal lobe edema, which was confirmed on an MRI. Her CSF showed 745 WBC, 76% lymphocytes and 23% monocytes, 20 RBC, glucose 43, protein 179, gram stain negative. Her labs were notable for a normal WBC and a negative CrP, suggestive of a viral infection. She was transferred here for further management. Clinically, there were no concerns for seizures. No difficulties with producing or understanding speech. MR HEAD W AND W/O CONTRAST showed Again noted are changes related to patient's known encephalitis. The FLAIR signal abnormality/edema within the anterior right temporal lobe has increased from prior study, but the patchy enhancement in this region has decreased. There is unchanged mass effect on the right lateral ventricle. There is no hemorrhage or infarct. CHEST PORT. LINE PLACEMENT showed Right -sided PICC terminates just below the cavoatrial junction and could be pulled back approximately 1 cm to reposition in the low SVC. The patient was diagnosed with VIRAL ENCEPHALITIS NEC, VIRAL MENINGITIS NEC. The patient was treated with lumbar puncture. At the time of discharge, the patient had HSV ENCEPHALITIS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Neurology: Mrs. ___ was admitted, started on acyclovir, vancomycin, ceftriaxone, and ampicillin. She was connected to vEEG. She stated that she had been having episodes of metallic smells concerning for temporal lobe seizures. She was started on keppra 750mg BID. Her EEG showed slowing in the right temporal lobe but no epileptiform activity. It was discontinued after 24hrs. She was given toradol and tylenol #3 for pain control. She had a normal neurological exam and was asymptomatic after ___ days of admission. She had a repeat MRI on ___ that showed a stable right temporal lobe hyperintensity but did not have as much contrast enhancement. She had a repeat LP done on ___ that had an improved WBC count of 130. She was deemed stable for discharge and to complete a 3wk course of acyclovir. # ID: Her bacterial cultures from the initial lumbar puncture at ___ were negative. She came back HSV1 PCR positive. She was taken off antibiotics after negative cultures and kept on acyclovir. The rest of her viral testing was negative. The repeat HSV is pending. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx ESRD secondary to chronic HTN and cardiorenal syndrome on MWF HD, HFpEF, Afib on Coumadin, COPD on intermittent home O2, presenting with SOB, weakness, poor appetite, tachycardia, hypotension, and productive cough. Over past week he has felt congested and has had a productive cough with chills. On ___ at ___ he was sent home due to tachycardia to 140s and told to take his metoprolol. No fluid was removed. He returned to ___ on day of admission but HR was in 120s so was sent to ED for further evaluation, and did not take metoprolol. At HD on ___, little fluid was removed as well. Radiology showed There is unchanged cardiomegaly. The right-sided pleural effusion has decreased since previous and is now small in size. There remains fluid within the right minor fissure. There is no overt pulmonary edema or focal consolidation. There are no pneumothoraces. Suture anchors are seen within the right humeral head. CHEST (PORTABLE AP) showed Comparison to ___. Minimal increase in extent of a pre-existing right pleural effusion. Minimal increase in severity of the right basilar atelectasis. Moderate cardiomegaly persists. No new parenchymal changes. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Normal hepatic parenchyma. Trace perihepatic ascites. Gallbladder polyps. Possible cholelithiasis with no evidence of cholecystitis or bile duct dilation. Small left kidney with cortical thinning. The patient was diagnosed with Hypokalemia. The patient was treated with ___ HD ___ HD. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Acute Systolic Heart Failure Atrial Fibrillation with Rapid Ventricular Rate ESRD SECONDARY DIAGNOSIS: COPD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old M with PMHx ESRD secondary to chronic HTN on ___ HD, HFpEF (___), Afib on Coumadin, COPD on home O2, who presented with dyspnea, generalized weakness, poor apetite, tachycardia, hypotension and productive cough initially admitted too the MICU for presumed volume overload after missing ESRD who was subsequently transferred to the CCU for further management after he was found to have severe global biventricular systolic dysfunction on TTE: # Acute Systolic Heart Failure Exacerbation # NSTEMI Patient presented with dyspnea, tachycardia, and hypotension consistent with volume overload after missing his HD session on ___ prior to admission due to tachycardia. On day of admission, patient sent from HD to emergency room for tachycardia. Etiology of tachycardia and hypotension thought to be secondary to atrial fibrillation with rapid ventricular response and dyspnea and cough thought to be secondary to volume overload after missing dialysis. TTE on admission revealed severe global hypokinesis with newly depressed EF 25%. After controlling his rate with metoprolol and volume removal, patient had a subsequent TTE with severe LV diastolic dysfunction suggestive of restrictive cardiomyopathy and EF 30%, likely secondary to his ESRD and HTN with low suspicion of ischemic etiology. Patient was discharged home on Metoprolol 100mg XL daily, ASA 81mg daily, and atorvastatin 80mg daily with appropriate primary care and cardiology outpatient follow up. # Hyperkalemia # ESRD on HD (___ schedule) Patient presented with acute hyperkalemia likely secondary to intravascular hypovolemia as suggested by elevated cell counts) and missed HD sessions prior to admission. Urgent ultra filtration was performed in the ED on admission and patient received HD two sessions on ___ and ___. # Paroxysmal atrial fibrillation Patient has history of cardioversions and takes warfarin and metoprolol. Given atrial fibrillation and rapid ventricular rates with resultant hypotension, decision was made for amiodarone load. Patient in sinus rhthym on discharge. Patient discharged on amiodarone 400mg BID through ___ and then daily, Metoprolol 100mg XL daily for rate control, and warfarin with goal INR ___. # Transaminitis Patient had ALT/AST elevation to 300s, which were downtrending/stable prior to discharge. Etiology unclear, either secondary to hepatic congestion in setting of volume overload versus medication side effect from empiric antibiotics given on admission given his initial undifferentiated hypotension, tachycardia, and cough. Amiodarone also possible. RUQ u/s obtained and unremoarkable. TSH normal. Abdominal exam benign. His outpatient primary care provider was contacted who will follow up for resolution outpatient. # COPD # OSA Patient continued on home O2 at night in hospital. Started Advair as patient was not on home inhaler. # Anemia # Thrombocytopenia Stable in patient, presumed secondary to ESRD. Patient is s/p on Ferumoxytol ___. # Hyperlipidemia: Atorvastatin replaced home pravastatin. # Peripheral neuropathy: Continued gabapentin. # Gout: Continued home allopurinol. # History of Recurrent Cdiff: Patient takes oral vancomycin at home for prophylaxis. Patient did not receive vancomycin in house as did not have prior documentation for this for pharmacy release of medication and in-house C.difficile negative. # BPH: Home Doxazosin recently discontinued outpatient prior to admission in setting of hypotension. TRANSITIONAL ISSUES =========================== - Patient discharged with transaminitis w/ possibility of amiodarone effect, please assess for resolution on follow up. - Patient's newly discovered restrictive cardiomyopathy was felt to be related to his ESRD and history of HTN. Please evaluate for alternative causes as clinically indicated, i.e amyloidosis. - Amiodarone load for atrial fibrillation initiated on ___ and patient discharged on amiodarone 400mg BID on ___. He will start amiodarone daily on ___. - The patient was found to be C.diff negative and therefore his PO vancomycin was stopped. - Patient was discharged with an INR of 1.8. His warfarin dose was decreased to 1.5mg daily given his amiodarone. His INR should be closely followed, and adjustments made as needed for goal INR ___. - The patient was not started on an ___ given low blood pressures. Please consider outpatient initiation as tolerated in the outpatient setting. # Code: Full, confirmed # Communication/HCP: ___ Wife/HCP ___ (H), ___ (c); Daughter ___ is ___ contact/co-HCP ___ # DRY WEIGHT: 65kg</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is an ___ female with a past medical history significant for advanced Alzheimer's dementia with behavior issues, depression, DVT on warfarin, rectovaginal fistula with sigmoid colostomy, who is presenting from ___ ___ with several days of low-grade fever and lethargy. CHEST (PORTABLE AP) showed Patient is rotated and kyphotic in position. The patient's chin overlies the left lung apex, obscuring the view. Given the above, there relatively low lung volumes. Right midlung atelectasis seen. Re-demonstrated mild streaky basilar opacities may be due to atelectasis/mild aspiration. Gaseous distension of the stomach/bowel in the left upper quadrant. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormality. The patient was diagnosed with Weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with a past medical history significant for advanced Alzheimer's dementia with behavior disturbances, depression, DVT on warfarin, rectovaginal fistula with sigmoid colostomy, who is presenting from ___ with lethargy, found to have hypernatremia, leukocytosis, with possible aspiration pneumonitis on CXR. Patient's hypernatremia and Cr improved with hydration. Per ___ discussion with daughter, family preferred to continue oral feeding with soft/pureed foods despite aspiration risk at this time. TRANSITIONAL ISSUES ==================== [] Patient is on a variety of medications. Given her age and multiple comorbidities, she would benefit from deprescribing. [] ___ should check INR on ___ and resume Coumadin if in range [] Encourage oral hydration as much as possible given patient's risk of dehydration [] Please follow up blood culture pending at discharge. ACUTE ISSUES ADDRESSED ======================= #Hypertnatremia Patient presenting with a sodium of 153. Likely hypovolemic hypernatremia in the setting of poor PO intake reported by daughter. Patient was slowly repleted with NS followed by D5W (received total of 2.5L). Na improved from 153 -> 143 on day of discharge. #Leukocytosis Patient presented with white blood cell count of 12 with a neutrophil predominance. No clear evidence of infection was found. Chest x-ray was without consolidation but with possible mild aspiration/atelectasis, UA without evidence of infection, LFTs within normal limits. Flu PCR negative. UCx and BCx without growth at time of discharge. Most likely cause of leukocytosis is aspiration pneumonitis given aspiration risk described below. Given lack of clear etiology, improvement in patient mental status, and lack of fevers, no antibiotics were given. Leukocytosis downtrended on day of discharge. #Aspiration Risk Speech & Swallow saw the patient and were concerned about aspiration. Patient was initially maintained NPO. Per conversation with daughter, patient had been doing well with 1:1 feeding and cueing at living facility. Given this, she expressed a preference to continue feeding patient despite aspiration risk. Patient was transitioned to pureed diet with thin liquids. #GOC Per last ___, pt is full code. The daughter confirmed that her mother would want everything done to prolong her life. ___ on CKD Per ___ records, the patient's baseline creatinine is ___. Cr on admission was 1.5, likely in the setting of decreased PO intake. Improved with IV fluids to 1.0. #DVT on warfarin Patient with DVT diagnosed in ___ on indefinite anticoagulation. On admission, INR elevated at 3.5. Warfarin was held with plan to recheck at ___ and restart if within range. INR on day of discharge 3.1. #Alzheimer's dementia Continued home donepezil, memantine, risperidone. Held lorazepam given concern for deliriogenic effects. #Hypertension (Goal <150/80 given age/frailty) Continued home atenolol #Depression Continued home trazodone QHS, citalopram CORE MEASURES #CODE: Full (confirmed w daughter, ___ in ___ #CONTACT: ___ (Daughter) Phone: ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH significant for paraplegia s/p fall from roof (___), multiple surgeries, chronic non-healing sacral decubitus ulcer, recent bilateral psoas abscesses (___) s/p ___ drainage, recurrent PE/DVT on Coumadin, no known cardiac history who presented to the ED ___ with a chief complaint of "spike like" substernal chest pain radiating to his back. He reports having a similar episode 1 week ago that lasted for about one hour. This time the CP started ___ at 5PM and lasted until ___ at 5AM. He was driving when the chest pain started and did not notice any exacerbating or alleviating factors. The pain was so severe that he was unable to sleep. It radiated down his L arm and was associated with nausea. CHEST (PA AND LAT) showed No acute intrathoracic process. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Right lower lobe bronchial wall thickening may be secondary to inflammatory or infectious airways disease. 3. Incidentally noted 4 mm left upper lobe nodule. Recommend follow-up per ___ criteria below. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommend in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:49 pm. The patient was diagnosed with Precordial pain. The patient was treated with Cardiac catheterization with no PCI.. At the time of discharge, the patient had Primary Diagnosis: NSTEMI Secondary Diagnosis: History of DVT/PE Paraplegia with chronic pain Sacral and heel pressure ulcers. The patient was given written instructions concerning 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 ___ ear old man with paraplegia secondary to a fall in ___, chronic pain, recent bilateral psoas abscesses who presents with acute onset chest pain and troponin elevation. He was found to have troponin elevation but no STE on EKG. He was taken the cath lab for coronoary angiography on ___, ___, which showed no significant blockage, moderate ___ LAD disease, and nothing to stent. The plan is to optimize medical management for his CAD by starting atorvastatin 80mg, metop succinate 25 mg, and ASA ___oes not want to take Plavix, so he will just be on dual therapy with warfarin + aspirin. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old woman with a history of factor V leiden with prior DVT and PE as well as ?TIA and ?neurogenic bladder (details of this are not clear at this point, since we do not have any documentation how this diagnosis was made) who presents with an episode of memory loss then right facial droop and right arm and leg weakness this afternoon. MR HEAD W/O CONTRAST showed No significant abnormalities are seen on MRI of the brain without gadolinium. The patient was diagnosed with OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had Right-sided 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>Ms ___ was admitted to the Stroke Service at ___ ___ after presenting with right-sided weakness. MRI of her brain was negative for evidence of stroke. Her weakness was felt to be functional in origin considering the drift without pronation and the clear signs of give-way weakness, but full strength with encouragement. Her UA was notable for 86 WBC, + nitrites, and large leukocyte esterase with only 3 epithelial cells, concerning for UTI. She had recently completed a 7 day course of Macrobid. She was restarted on another 7 day course of Macrobid and instructed to discuss this with the physician who manages her urinary difficulties. A urine culture at ___ was done and was found to be positive for E.coli, however, further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) was thought to be uncertain. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ yo M w/ hx of COPD, PNA this year, moderately severe dementia, afib, CKD, HTN who presents with respiratory distress. Son reports pt was watching TV when he started choking and gagging with gurgling sounds. The pt was respondent during this time, engaging with his son. No LOC. Family denies fall. In the ED, initial vitals: T98.3 HR 105 BP 150/56 RR 25 100% on BIPAP. He had a chest x-ray which showed "Patchy opacities in the lung bases may reflect aspiration or infection. Mild pulmonary vascular congestion", concerning for PNA. Given 4.5 g zosyn, 1gm vanc, 125 methylpred, 1L NS. He was intubated using 20 mg etomidate and 100 mg succinylcholine. He was placed on fentanyl and midalozam drips for sedation. After intubation, he was given an additional 1L NS for hypotension ___, after which his pressure improved to 103/62. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Predominantly chronic 9 mm thick right frontoparietal subdural hematoma with scattered hyperdensity suggestive of acute on chronic hemorrhage. No significant mass effect or midline shift. 2. 9 mm thick left chronic subdural hematoma or subdural hygroma versus prominent subarachnoid space secondary to involutional changes. NOTIFICATION: Findings were discussed with Dr. ___ by ___ phone at 3:40am on ___, immediately following discovery. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed No acute fracture or traumatic malalignment of the cervical spine. CHEST (PORTABLE AP) showed No relevant change as compared to ___. In the interval, the patient has been extubated and the nasogastric tube was removed. The size of the cardiac silhouette is slightly enlarged. There are signs of bilateral mild basal apical blood flow redistribution, suggesting mild pulmonary edema. In addition, subpleural, peripheral and predominantly basal interstitial opacities are noted. This could be caused by interstitial pulmonary edema or an underlying interstitial lung disease. These 2 entities could be differentiated using CT. CHEST (PORTABLE AP) showed -Heart size and mediastinum are unchanged. There is interval substantial progression of bibasal consolidations concerning for aspiration or progression of multifocal infection. -Stable appearance of subpleural, peripheral predominantly basal interstitial opacities. -Likely mild pulmonary vascular congestion. -Possible new right small pleural effusion. Video oropharyngeal swallow showed Trace aspiration penetration with thin liquids and nectar. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. The patient was diagnosed with Pneumonitis due to inhalation of food and vomit. At the time of discharge, the patient had PRIMARY: -hypoxia secondary to aspiration pneumonia -possible COPD exacerbation -global systolic dysfunction, unclear etiology -acute on chronic subdural hemorrhage SECONDARY: -bulbar dysfunction -dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M w/ afib, COPD, moderate-severe dementia presenting with acute respiratory failure and chest x-ray concerning for bilateral infiltrates. # altered mental status, progressive dementia: He was initially intubated in ED for airway protection in the setting of altered mental status with mixed picture of hypercarbic and hypoxic respiratory failure. Patient's mental status continued to improve after being called out of ICU, although he remained altered. Per family, patient was at baseline. Dysarthric, somewhat appropriate in responses, but not always intelligible. Notably, pt with progressive dementia over past year. Moderate-to-severe per FAST testing w/ PCP. Pt has HTN, smoking hx, but normal lipid panel; possible component of vascular dementia. Pt additionally found to have acute on chronic SDH which could be responsible for, at least in part, his altered state; no focal findings on neuro exam. Neurosurgery consulted; did not feel SDHs were responsible for current presentation. Patient was continued on home donepezil. Home melatonin was held. # aspiration PNA: concern given CXR opacities and acute respiratory distress. Likely in setting of dementia. No foreign body on CXR. Likely etiology of mixed hypercarbic and hypoxic respiratory failure esp in setting of COPD. Could also be CAP/aspiration given polymicrobial sputum specimen; S/S of sputum unable to be performed given polymicrobial nature of infxn. Legionella, MRSA, rapid viral panel negative. S/S consulted in ICU who made patient strict NPO. Eventually was reevaluated with video and patient was advanced to pureed/honey diet. In reagrds to antibiotics, patient received Vanc/cefepime (___), flagyl ___, then switched to monotherapy with unasyn ___. # hypoxia: The most likely cause for his respiratory failure was an aspiration event given history of gargling and chocking in the context of bilateral infiltrates and a history of moderate-severe dementia. He was treated with Vancomycin/Cefepime/Azithromycin. Emphysematous changes were noted on CT C-spine and he was also treated with solumedrol for a 5 day COPD exacerbation course. TTE was done which demonstrated severe global left ventricular systolic dysfunction (EF 20%) and regional RV systolic dysfunction. His respiratory status improved and he was extubated on ___ prior to callout to medicine floor. # COPD: Wheezy on exam, hypercarbic, extensive smoking hx, CT findings of possible interstitial lung dz suggestive of COPD. No prior PFTs, no use of inhalers or O2 at home. Received Albuterol/ipratropium nebs. Received a short course of azithro (z-pak) and solumedrol (___) followed by a 4 day pred burst. Consider PFTs/pulm f/u as outpatient. # h/o subdural hemorrhage: For his moderate-severe dementia with a suspected component of vascular dementia he underwent NCHCT on admission which was negative for ICH or acute process, although positive for likely chronic frontoparietal SDH. He did not have a reported history of trauma or falls. Neurosurgery was consulted and recommended no acute surgical intervention and followed with repeat NCHCT in 6 weeks as an outpatient for monitoring. His neurology exam was non focal. Home ASA was continued and SQ heparin was started. He underwent speech and swallow evaluation for aspiration. # global systolic dysfunction: New, identified on echo. Consider infiltrative vs toxic vs diffuse CAD. Started on 40 atorvastatin. He had no signs of volume overload. Given his poor functional status and advanced dementia decision was made not to pursue further work-up as an inpatient. # HTN: Hypotensive in ED required 2L fluids with appropriate response. Hypertensive up to SBP 170s in ICU post-extubation, improved s/p IV hydral and labetalol. Patient's SBPs remained 150-160 while on medicine floor. # CKD: Baseline creatinine ~1.2. Stable/better than baseline during hospitalization. # BPH: Foley placed in ED. Removed on xfer to floor ___. Restarted home finasteride on medicine floor. Patient on condom cath given urinary incontinence. # Glaucoma: Blind in L eye. Continued home timolol, latanoprost gtt. #Primary prevention: continued ASA 81mg.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ female with past medical history significant for insulin-dependent diabetes mellitus and NASH ___ B/C) c/b encephalopathy, esophageal varices (s/p bleed several years ago), recurrent hepatic hydrothorax requiring monthly taps, and HCC who was seen in transplant clinic today and referred to the ER for severe right sided chest pain (pleurtic in nature) and shortness of breath. Radiology showed Large right pleural effusion which has increased since last month's exam. Radiology showed Interval placement of a right-sided chest tube. CHEST (PORTABLE AP) showed In comparison with the study of ___, the right chest tube remains in place and there is no evidence of pneumothorax. There may be some increase in the degree of pleural effusion with underlying compressive atelectasis. The low lung volumes are substantially lower. Mild atelectatic changes and possible small effusion on the left. ABDOMEN US (COMPLETE STUDY) showed 1. Cirrhotic liver with lesion in the left lobe better characterized on recent MR abdomen as suspicious for HCC. 2. Portal vein and its major branches are patent. No ascites. 3. Splenomegaly. CHEST (PORTABLE AP) showed Right pigtail appears to be outside of the pleural space and needs to be repositioned or removed. Right pleural effusion appears to be similar to previous examination, moderate or potentially even minimally decreased as compared to ___ and substantially decreased as compared to ___. No pneumothorax is seen. Vascular congestion/minimal interstitial edema are unchanged. CHEST (PORTABLE AP) showed In comparison with study of ___, the right pigtail catheter is been removed and there is no evidence of pneumothorax. Continued right pleural effusion that may be slightly larger than on the previous study with underlying volume loss in the right lower lobe. There are low lung volumes that accentuate the prominence of the transverse diameter of the heart. Mild indistinctness of pulmonary vessels could reflect mild elevation of pulmonary venous pressure. No evidence of acute focal pneumonia. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Moderate right pleural effusion redistributed, probably unchanged in volume. Pulmonary vascular congestion in the left lung has worsened slightly. Mild cardiomegaly unchanged. No pneumothorax. Portable chest x-ray showed Pulmonary venous congestion. Right pleural effusion. Mild elevation of the right hemidiaphragm. CT CHEST W/O CONTRAST showed 1. Large right pleural effusion and right lower lobe collapse, not significantly changed compared to the prior study. 2. Linear consolidation along the right middle lobe may represent atelectasis versus an infectious process. 3. Heterogeneous left thyroid nodule, increased in size since the prior study. Recommend further evaluation with thyroid ultrasound if not previously worked up. RECOMMENDATION(S): Thyroid ultrasound. CHEST (PORTABLE AP) showed 1. Large right pleural effusion has increased substantially over 2 days, responsible for worsened with right middle lobe and right lower lobe atelectasis. 2. Stable mild left pulmonary vascular congestion. Radiology showed Successful right internal jugular access with transjugular intrahepatic portosystemic shunt placement with decrease in porto-systemic pressure gradient. 4 liters of large pleural effusion were drained. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently ___. Previous large right pleural effusion is now small. No pneumothorax. Pulmonary and mediastinal vasculature is now engorged and there is new mild pulmonary edema. Consolidation at the base of the right lung could be atelectasis surviving the previous large pleural effusion. Cardiac silhouette is mildly enlarged. Chest x-ray showed Mild pulmonary edema and small right pleural effusion, stable. Atelectatic changes at the right lung base, developing pneumonia cannot be excluded. US NECK, SOFT TISSUE showed A small, tubular tract of fluid is identified within the superficial soft tissues of the right neck, over the puncture site. This is likely a small amount of fluid following the tract of the catheter used for recent TIPS procedure. No organized hematoma is identified. Radiology showed Right pleural effusion is increased in size from prior exam, now small to moderate. Mild bilateral pulmonary edema appears similar. No pneumothorax. Cardiac silhouette appears unchanged. CHEST (PA AND LAT) showed Comparison to ___. Lung volumes have decreased. Stable mild to moderate right pleural effusion. The pre-existing pulmonary edema is overall moderate in severity. Moderate cardiomegaly persists. No new parenchymal opacities. The patient was diagnosed with Pleural effusion, not elsewhere classified. The patient was treated with - Chest tube placement - Transjugular intrahepatic portosystemic shunt (TIPS) - Right thoracentesis. At the time of discharge, the patient had Primary: -___ Cirrhosis ___ B/C) -Hepatic hydrothorax -Pancytopenia -Coagulopathy -Hepatocellular carcinoma Secondary: -Bipolar vs. schizophrenia disorder -Asthma -Umbilical hernia -Type 2 diabetes mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ female with past medical history significant for insulin-dependent diabetes mellitus and NASH cirrhosis ___ B/C) complicated by a history of encephalopathy, esophageal varices (status post bleed several years ago), recurrent hepatic hydrothorax, and HCC who presents with shortness of breath, chest pain and evidence of a right hepatic hydrothorax. #NASH cirrhosis ___ B/C) #Hepatic hydrothorax The patient has a history of NASH cirrhosis ___ B/C), currently on the transplant list and followed by Dr. ___ as an outpatient. Her cirrhosis has been complicated by encephalopathy, esophageal varices (status post bleed several years ago), recurrent hepatic hydrothorax, hyponatremia on tolvaptan and HCC. For this admission, she presented with shortness of breath, pleuritic chest pain, minimal ascites on exam, found to have a large right pleural effusion on CXR, concerning for hepatic hydrothorax. Her recurrent hydrothorax on presentation occurred the setting of her spironolactone being decreased from 100 mg daily to 25 mg daily secondary to hyponatremia. While in the ED, the patient had a pigtail placement with drainage of 1L of fluid with symptomatic improvement. At this time her chest tube was clamped. On admission, the patient had a MELD score of 14 and was without any localizing signs of infection. The chest tube was removed on ___ and the patient remained stable with good O2 saturation on room air. Her pleural fluid studies were consistent with a pseudoexudate, most likely hepatic hydrothorax. Her home diuretics were initially held due to creatinine increase to 1.3 from baseline of 1.0. She was given albumin 75g x2 and 25g x1. As her creatinine returned to baseline levels, Lasix ___ IV was started as diuretic therapy to treat her continuing hydrothorax. An abdominal ultrasound was also obtained which showed no lower abdominal ascites. The patient was evaluated by interventional radiology for TIPS placement given her continued recurrences of hydrothorax on diuretic therapy. The interventional radiology team performed the TIPS procedure and a right thoracentesis (draining 4 L) on ___. Following TIPS, there was concern for ischemic hepatitis given significant elevation in LFTs and up-trending INR, however these values stabilized and downtrended after several days. She spiked a fever to 100.7 F post TIPS with a mild leukocytosis, was pan-cultured (blood cultures no growth, and no growth in urine or sputum culture), but remained afebrile since with a normal WBC. Following TIPS and thoracentesis, she also reported some hemoptysis, thought to be due to epistaxis, though this resolved. During her hospitalization, frequent CXRs were obtained to monitor recurrence of her right hepatic hydrothorax. Prior to discharge, the most recent CXR showed stable residual hydrothorax. The patient was continued on rifaximin, ursodiol, vitamin B12, and lactulose during hospitalization. On discharge she was breathing well on RA and MELD score was 19. # Pancytopenia On admission, the patient had evidence of pancytopenia (WBC 2.2, Hgb 10.8, plt 22) that was stable from prior admission. Her pancytopenia has been persistent since her first labs recorded in the ___ system on ___. She is followed by a hematologist in ___, Dr. ___ (___). Per her hematologist, the patient's pancytopenia is most likely due to her liver disease though she had at one point considered an autoimmune process. A bone marrow biopsy was preformed by her hematologist on ___, notable for erythroid hyperplasia, normal number of megakaryocytes, suggesting hypersplenism as main etiology of her cytopenia. There was no evidence of lymphoma, MDS, or MPD (BM report from OSH placed in chart). We trended her CBC, which showed improvement #Coagulopathy INR was 1.4 on admission, stable from prior admission. The patient's coagulopathy was thought to be due to underlying liver disease. INR remained stable around 1.4-1.7 until after the TIPS, when it increased to 2.3 likely in the setting of lier ischemia. However, the INR downtrended to 1.9 on discharge. </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 history of fatigue, weakness, and hypophonia since ___ diagnosed with "myasthenia-like syndrome" with multipe negative myasthenia antibody profiles, POTS, gastroparesis, SIBO who presented to the ED with reports of progress weakness, dyphagia, and weight loss. CHEST (PA AND LAT) showed No acute intrathoracic process. The patient was diagnosed with Weakness, Dyspnea, unspecified. The patient was treated with Electromyography (EMG) ___. At the time of discharge, the patient had Primary diagnosis: Generalized weakness NOS Malaise 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: ___ year-old woman with history of fatigue, weakness, and hypophonia since ___ diagnosed with "myasthenia-like syndrome" with negative myasthenia antibody profile, POTS, gastroparesis, SIBO who presented to the ED with reports of progress weakness, dyphagia, and weight loss.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with hx of GERD, diverticulosis, and multiple diverticular bleeds who is presenting with hematochezia one day after discharge from hospital with similar presentation. Admitted ___ with hematochezia which resolved. HCT 25.9 at discharge after 3 units PRBC yesterday when he was having no BMS. EGD ___ -. Today 3:30 awoke with bloody bowel movement filled the toilet bowl therefore to ED. No BM since that time. In the ED, initial VS: T 96.6 BP 142/76 HR 83 RR 18. Transfused one unit at time I am seeing the patient in the ED. Reports very mild left lower quadrant discomfort, no nausea, vomiting, diarrhea, fever, chills. Last colonoscopy Ocotber with diverticulosis of the sigmoid colon, descending colon, and transverse colon but no active bleed. After this last admission he was to follow up with Dr. ___ Radiology showed 1. No evidence of active gastrointestinal bleeding on this exam. 2. Diverticulosis without evidence of diverticulitis. 3. Stranding around sigmoid colon appendage, this may represent the sequelae of prior epiploic appendagitis. Radiology showed Uncomplicated superior mesenteric arteriogram with no evidence for extravasation, pseudoaneurysm or early draining vein. The patient was diagnosed with GASTROINTEST HEMORR NOS, HYPERTENSION NOS, RECTAL & ANAL HEMORRHAGE. The patient was treated with ___ Right hemicolectomy with primary anastomosis. At the time of discharge, the patient had Right colon lower gastrointestinal 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>Mr. ___ is a ___ with HTN, GERD, diverticulosis, and multiple diverticular bleeds who is presenting with BRBPR, with presumed diverticular source. . # BRBPR: The patient has had multiple episodes of bright red blood per rectum, likely ___ diverticular bleeds. He was most recently admitted on ___, during which he was transfused 3U PRBCs, with a crit 25.9 at the time of discharge. Colonoscopy from ___ with evidence of diverticulosis of the sigmoid, descending, and transverse colon. An EGD done on previous admission (___), was normal with no ulcers or other potential sources for bleeding. The patient was discharged then represented with another episode bright red blood per rectum. The patient was initially doing well on the floor, but had episode of BRBPR with feeling of dizziness and shortness of breath; was given another unit of PRBC. CTA was not able to localize the source; showed e/o diverticulosis. . While in the unit, the patient was transfused for goal crit of 30, receiving 4 units PRBC. He had a tagged RBC scan which did not show bleeding source and the patient was not taken to ___ for embolization. Surgery was also on board, and because no specific bleeding vessel was found, the patient was taken to the OR on ___ for R hemicolectomy. . # HTN: The patient's home atenolol was held in the setting of his GI bleed. It was restarted postoperatively when hemodynamically stable and the patient was tolerating PO's. . # Back pain: The patient's home percocet was continued preoperatively. APS was consulted for postoperative pain management and an epidural was placed. He was also started on a PCA. On POD#3, the epidural was removed and he was transitioned to oral pain medications. At discharge, he reported adequate pain control with an oral regimen. . # GERD: On PPI at home, was held perioperatively and restarted on POD#2 when tolerating PO's. Postoperatively, the patient remained stable on the surgical floor. His intake and output was monitored. On POD#3 after removal of the epidural, his foley catheter was removed at which time he voided without difficulty. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. His hematocrit remained stable. His WBC remained normal. His electrolytes were monitored and repleted as needed. He was encouraged to mobilize out of bed early as tolerated, which he was able to do independently. He was also started on SC heparin postoperatively for DVT prophylaxis. Initially postoperatively, he was kept NPO and given IV fluids for hydration. A NG tube was placed intraoperatively and removed on POD#1. On POD#2 he reported passing flatus and he was started on clear liquids, which were slowly advanced to a regular diet. On POD#3, he was tolerating regular food without nausea/vomiting. He was hemodynically stable and afebrile. His pain was adequately controlled with oral pain medication and he was out of bed ambulating independently. He was discharged to home with follow up scheduled in ___ clinic ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo woman w/ a hx of HTN, HLD, ESRD on dialysis, multivessel CAD, asthma and pHTN who presents with c/o shortness of breath. Patient says she has been short of breath for 'months' and that she has been in and out of the hospital and ___ has helped her. She says ambulating even ___ feet requires significant effort and the assistance of multiple helpers. She has a history of pulmonary hypertension and multiple recent admission for dyspnea. She endorses 6 pillow orthopnea that has been stable for the past ___ months. For the last ___ weeks she feels he shortness of breath is worse. She has also had mild nausea without vomiting or diarrhea. Denies chest pain, chest pressure. No fevers or chills. Denies dizziness or lightheadedness. Patient tried albuterol at home with some improvement but her symptoms persisted so she went to the ED. Patient is due for dialysis today which she did not receive. Patient denies any recent weight gain, in fact she says she has been losing weight at dilaysis over the last several weeks. No new dietary indescretions. Radiology showed Mild pulmonary vascular congestion. Radiology showed 1. No evidence of pulmonary embolism. Mild interlobular septal thickening consistent with vascular engorgement /early pulmonary edema. 2. Small to moderate right-sided pleural effusion with adjacent compressive atelectasis and fluid within the minor fissure. 3. Abdominal ascites 4. Renal osteodystrophy with new compression fractures since ___. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC. The patient was treated with ___: right heart catheterization. At the time of discharge, the patient had Primary: pulmonary hypertension Secondary: ESRD on HD, systolic congestive heart failure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo woman w/a hx of HTN, HLD, ESRD s/p failed transplant on dialysis, severe multivessel CAD and pHTN who presents acute on chronic dyspnea on exertion. # Shortness of breath/pulmonary HTN: patient presented with acute on chronic dyspnea on exertion in the setting of known moderate to severe pulmonary hypertension. EKG was unchanged and troponins were at baseline. Repeat ECHO here showed some progression of pulmonary artery hypertension with elevated in PA pressures and global RV dysfunction. Patient's symptoms were likely due to worsening of her pulmonary hypertension in the setting of slight volume overload. Patient underwent right heart cath on ___ to assess pulmonary hypertension and responsiveness to vasodilators, which she failed. Pulmonary service was consulted who recommended keeping patient close to dry weight as possible, starting advair BID, and having close follow-up in ___ clinic for possible IV prostacyclin therapy. CTA thorax was also done which showed no PE or evidence of ILD. Patient symptomatically improved after dialysis treatments and initiation of albuterol nebulizers. Patient was also started on isosorbide mononitrate for potential responsiveness to nitrates. She was discharged with a prescription for albuterol nebulizer and advair and will follow-up in ___ clinic for her pulmonary HTN. # CAD: multivessel disease not amenable to intervention on previous cath in ___. Patient did not c/o chest pain, troponins remained at baseline, EKG was unconcerning. She was continued on metoprolol, aspirin, atorvastatin 80. # Asthma: patient reported symptomatic improvement with nebulizer treatments. She was given a prescription for albuterol nebs as well as adavair. # ESRD on HD: nephrology was consulted, patient received dialysis as per home schedule. Patient received dialysis as needed, next due date is 2.19. CHRONIC ISSUES # HTN: stable, continued metoprolol, losartan # HLD: continued atorvastatin 80mg # GERD: continued omeprazole # Chronic pain: pain controlled with tylenol # Seizure Disorder: patient reports nonconvulsive seizures. Continued keppra 500 mg QHS and QHD ___. # Hypothyroidism: continued levothyroxine 75 mcg # Anxiety: continued home lorazepam 0.5 mg tablet TRANSITIONAL ISSUES 1. Patient has close followup to discuss further workup and therapy for her severe pulmonary hypertension, which is likely the cause of the progressive decline in her exertional capacity. 2. Patient remained full code.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of RLQ abdominal wall abscess/infection of unknown etiology s/p debridement by Dr. ___ in ___ presented to the ED today with increased erythema and drainage from her prior debridement site. Patient has been visiting ___ clinic approxiamtely once per month for wound checks since her debridement in ___ and has also been receiving daily wound care by a visiting ___ nurse. Per prior notes, patient's RLQ abdominal wound had been slowly improving over time and had most recently been evaluated approximately 3 wks ago. Since that time patient reports increased drainage from two "holes" in her wound, as well as mildly increased erythema. She denies any fevers or increased pain. Due to the change in appearance of the wound and the failure to improve since her last clinic visit, her ___ nurse urged her to come to the ED today. She has not had any changes in her bowel movements and says she is eating a "regular" amount. She has never had a colonoscopy. CT ABDOMEN AND PELVIS WITH CONTRAST. showed 1. Interval enlargement of a now 9.7 x 8.3 x 11.1 cm heterogeneously enhancing mass, likely arising from the cecum, with at least two sinus tracts extending to the skin surface. 2. Interval increase in size and number of multiple hepatic lesions favor metastases over abscesses given interval growth of smaller lesions from ___, and lack of current infectious symptoms. US pending for further evaluation and for feasibility for biopsy. 3. The constellation of findings above are suspicious for colorectal carcinoma with hepatic metastases, less likely infection. 4. The sigmoid colon abuts this mass and local invasion cannot be excluded. No bowel obstruction. 5. Interval complete drainage of a previously seen large right subcutaneous collection. No residual superficial fluid collection. 6. Complex small- and large-bowel containing ventral hernia, not significantly changed from ___. RECOMMENDATION(S): A liver ultrasound is recommended to further evaluate and characterize liver lesions and assess for feasibility for US-guided biopsy. NOTIFICATION: Findings were discussed in person with Dr. ___ Dr. ___ on ___ at 14:00, 5 minutes after they were made. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Multiple solid-appearing hypoechoic liver lesions corresponding to abnormality seen on same-day abdominal CT. Findings are highly concerning for metastases. These lesions are amenable to ultrasound-guided biopsy. Ultrasound-guided biopsy. showed Uncomplicated 18-gauge targeted right liver biopsy x 1. The patient was diagnosed with OTHER POST-OP INFECTION, CELLULITIS/ABSCESS OF TRUNK, ACCIDENT NOS. The patient was treated with ___: Liver biopsy. At the time of discharge, the patient had Colonic mass with liver metastasis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old female with a history of RLQ abdominal wall abscess/infection s/p debridement in ___, who now presented to ___ on ___ with complaints of increased erythema and drainage from her prior debridement site. On HD1, she had a CT Abd/Pelvis and liver ultrasound which showed concern for suspicious for colorectal carcinoma with hepatic metastases. She was admitted to the Acute Care Surgery team. On HD3, the patient underwent an ultrasound-guided targeted liver biopsy. The finalized pathology report on ___ indicated metastatic adenocarcinoma, moderately-differentiated, consistent with a colorectal primary. The patient was notified of this finding, the Hematology/Oncology team was consulted and outpatient follow-up appointments were made for the patient to follow-up for outpatient care. The patient was alert and oriented throughout hospitalization. Pain was controlled with oral pain medication. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. The patient remained stable from a pulmonary standpoint. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient tolerated a regular diet. The patient's intake and output were closely monitored. The patient's fever curves were closely watched for signs of infection. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male history of rheumatoid arthritis and prostate cancer concern for left knee periprosthetic joint infection. Had a total knee arthroplasty done around ___ with Dr. ___ in ___, decubitus and to become part of the ___. States 1 day ago he noted acute onset of mild left knee pain. Knee was previously asymptomatic no issues. By the morning the pain had worsened and he presented for evaluation. Denies any fevers or chills. Denies any trauma. Denies any twisting movements. Denies any headache nausea vomiting changes in appetite sick contacts. Denies any numbness or paresthesias. KNEE (2 VIEWS) LEFT showed There has been interval removal of the left knee prosthesis and placement of an antibiotic spacer. There is no evidence of an acute fracture. CHEST PORT. LINE PLACEMENT showed Left PICC line is seen with its tip in the distal SVC. CHEST (PORTABLE AP) showed No previous images. There is enlargement of the cardiac silhouette without vascular congestion, pleural effusion, or acute focal pneumonia. CHEST (PORTABLE AP) showed There is a right internal jugular central venous catheter, which terminates in the lower superior vena cava. There are low lung volumes. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is stable in appearance. No acute osseous abnormalities are identified. CHEST (PORTABLE AP) showed 1. Improved pulmonary edema. 2. Bilateral pleural effusions, left greater than right, with bibasilar atelectasis. The patient was diagnosed with Infect/inflm reaction due to internal left knee prosth, init. The patient was treated with L TKA I+D and liner exchange with Dr. ___ ___. At the time of discharge, the patient had L prosthetic joint infection, MSSA Sepsis from ___ blood stream infection Atrial fib with RVR. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a L periprosthetic joint infection and was admitted to the medicine service. The patient was taken to the operating room on ___ for L TKA I+D with liner exchange by Dr. ___, ___ the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the TSICU with a hemovac drain in place to the L knee. In the TSICU patient was extubated, arterial line was discontinued, pressor support weaned as appropriate. Patient developed Afib with RVR refractory to diltiazem drip, transitioned to metoprolol and heparin gtt with appropriate improvement in symptoms. Patient was started on IV antibiotics of vancomycin and ceftriaxone empirically, transitioned to ancef per culture sensitivities of MSSA bacteremia/PJI. Pt was transferred to the medicine floor: </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a PMH significant for chronic alcohol use disorder who was recently seen in the emergency department for withdrawal and subsequently placed in detox. He is now presenting with hallucinations and tremors. The patient reported that after his discharge from detox, he began heavy daily consumption of EtOH. His last drink was on the day of admission. He reports feeling unwell since that drink. He reports having hallucinations of people and colors for the past ___ days. CR chest PA lateral showed 1. Mild pulmonary vascular congestion. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence for an acute intracranial abnormality. MRI AND MRA BRAIN PT12 MR HEAD showed 1. Incomplete brain MRI with diffusion weighted and T1 weighted images only. No acute infarction. 2. Motion limited brain MRA. No occlusion or high-grade stenosis is seen 3. Flow in the cavernous and supraclinoid right internal carotid artery appears minimally diminished compared to the left, which may be due to asymmetric atherosclerosis. 4. M1 segment of the right MCA appears smaller in caliber than the left, unclear whether secondary to diminished flow or technical factors. 5. Flow is poorly seen in the intracranial left vertebral artery, likely due to its small size, as it was shown to be diminutive on the prior MRI. Flow suboptimally visualized in the proximal right intracranial vertebral artery, likely due to technical factors, with good flow seen in its mid and distal portion. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. Diffuse mild pachymeningeal FLAIR hyperintensity and enhancement. Additionally, there is engorgement of the cerebral cortical veins and the dural venous sinuses and a more superiorly convex pituitary gland which has increased in height since prior MRI of ___ constellation of findings most consistent with some component of new intracranial hypotension, possibly secondary to recent lumbar puncture. 2. 2.5 cm extra-axial midline enhancing signal abnormality along the posterior clivus is favored to represent engorged venous plexus. Although retroclival hematoma is considered less likely given the degree of enhancement observed, since this is new from prior study of ___, short-term (3 days) follow-up is recommended. 3. No additional acute intracranial abnormality identified. No evidence of alcoholic/Wernicke encephalopathy. 4. Chronic global parenchymal volume loss, stable. RECOMMENDATION(S): Short-term (3 days) follow-up head imaging with CT or MRI, as above. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality on noncontrast head CT. Specifically no evidence of acute large territory infarct or intracranial hemorrhage. 2. Previously seen enhancing retroclival lesion is not visualized. No evidence of retroclival hematoma. The patient was diagnosed with Alcohol dependence with withdrawal, unspecified, Tremor, unspecified, Chest pain, unspecified, Visual hallucinations. The patient was treated with Lumbar puncture with sedation (___) MRI with general anesthesia. At the time of discharge, the patient had PRIMARY DIAGNOSES: Hallucinations Likely underlying dementia SECONDARY DIAGNOSES: History of alcohol 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 male with a PMH significant for chronic alcohol use disorder presented with hallucinations c/f withdrawal vs. delirium.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male who complains of MANDIBLE FX. Patient transferred from OSH with open mandible fx. Mixed martial fighter got hit in the face. Got morphine at OSH. Complains of jaw pain, headache. Denies neck pain. Denies chest pain or shortness of breath. Denies abdominal pain. Given ampicillin at OSH. Timing: Sudden Onset Radiology showed 1. No acute intracranial injury. 2. No acute fracture or traumatic malalignment of the cervical spine. 3. Non-displaced fracture at the left ramus of the mandible is fully assessed on the CT facial bones performed earlier the same day. Radiology showed 1. Mildly displaced obliquely oriented fracture through the right mental tubercle of the mandible extending between the right central and lateral incisors with 5-mm anterior displacement and 3-mm overriding of the right fracture fragment. 2. Non-displaced fracture through the left ramus of the mandible extending to the coronoid process. 3. No additional facial bone fractures. The patient was diagnosed with MANDIBLE FX NOS-CLOSED, STRUCK BY OBJECT OR PERSON WITH OR WITHOUT FALL. The patient was treated with ORIF right PS fracture, CRMMF Left subcondylar fracture. At the time of discharge, the patient had Bilateral Mandible Fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman admitted to the hospital after being punched in the face. He was reported to have sustained an isolated mandible fracture. He was transferred here for further management. Upon admission, he was made NPO, given intravenous fluids, and underwent additional imaging. On cat scan imaging of the head he was reported to have no acute intra-cranial injury. C-spine imaging showed no mal-alignment of the spine. Because of his injury, he was evaluated by the Oral Maxillary service who recommended surgery. The patient was taken to the operating room on HD #2 where he underwent an open reduction internal fixation of right parasymphysis fracture and a closed reduction maximum mandibular fixation of the left subcondylar fracture. The operative course was stable with a 50cc blood loss ( please see operative note). The patient was extubated after the procedure and monitored in the recovery. His post-operative course has been stable. He has been afebrile and his pain has been controlled with oral analgesia. He has resumed a full liquid diet withiout any difficulty in swallowing. He has been instructed to continue antiobiotic coverage for 1 week and peridex rinses for 2 weeks. He will follow- up with ___ surgeons in ___. A copy of the discharge summary and operative note were given to the patient at discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: ___ Location: ___ Address: ___ Phone: ___ Fax: ___ HPI: ___ with Hx seizure disorder, multiple traumatic injuries, EtOH abuse, recent admission at ___ for EtOH withdrawl (d/c ___, presents for detox. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-CONTIN. At the time of discharge, the patient had primary: EtOH dependence secondary: h/o seizure disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with Hx seizure disorder, multiple traumatic injuries, EtOH abuse, recent admission at ___ for EtOH withdrawl (d/c ___, presents for detox. # EtOH withdrawal: Patient requested medical detox, will plan to seek longer-term assistance via the ___ system. He has a social worker, psychiatrist, and psychologist that he works with in the ___ system. Refused our social work/case management support. He has no history of withdrawal-related seizures. Only scored on CIWA once, the night of ___. Continued thiamine, folic acid, and MVI. # h/o seizure disorder: No history of EtOH withdrawl seizure. Continued Keppra # Back pain: Likely ___ injury from a fall. No evidence of neurological deficit. Only mild midline tenderness. Provided ibuprofen PRN. # ADHD: held methylphenidate, continue propranolol # Tobacco abuse: nicotine lozenges # Med rec: ideally we could get his medication list from the ___, however given the holiday this was not possible # Code: FULL</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx of DCIS (Dx ___ who only took tamoxifen for a couple of years then stopped taking it because of side effects. Two weeks ago, she was at dinner with a friend and had a couple sips of wine (adamantly denies being drunk). She had a minute of word finding issues as well as word slurring. ___ friend ___ notice but it was a loud bar. She dismissed it as nothing and didn't seek any medical attention. On ___ she developed a bi-temporal ___ constant pressure headache with the sensation of pressure behind ___ right eye. She has been under a lot of stress with the recent hospitalization of ___ mother for a vertebral dissection. She is unsure if stress contributed to ___ headache and feels that she is hypersensitive to ___ own symptoms because of ___ mother's symptoms. She does not typically have headaches. She developed some occipital pain and neck stiffness so she went to a masseuse on ___ and ___ and had several deep neck manipulations during the massages. After these massages, she had intermittent feelings of lightheadedness (not room spinning vertigo), left sided numbness (especially ___ face). She was worried that these episodes may represent strokes so she took aspirin ___ yesterday and today. This morning, she made an appointment with the PCP to evaluate ___ headache. After making the appointment, while at the bank, she had an episode where it was very difficult for ___ to sign ___ name on ___ check. She became very concerned. This resolved in a minute. When she told this to ___ PCP, he sent ___ to the ED for evaluation. While in the ED she complains of intermittent episodes of mental slowing. Neurology was consulted for recommendations on workup and management of these episodes. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Findings suggestive of nonocclusive right carotid bulb focal dissection. Recommend clinical correlation. If clinically indicated, consider carotid ultrasound further evaluation. 2. No evidence of acute intracranial hemorrhage. 3. Ectasia of the ascending aorta measuring up to 4.4 cm. Recommend clinical correlation. 4. Mild heterogeneity of bilateral thyroid glands with 2 mm right thyroid gland nodule. Recommend clinical correlation. If clinically indicated, consider dedicated thyroid ultrasound. 5. Please note MRI of the brain is more sensitive for the detection of acute infarct. 6. Partially visualized lungs demonstrates 4 mm right upper lobe pulmonary nodule. Recommend clinical correlation and correlation with dedicated chest imaging. RECOMMENDATION(S): 1. Findings suggestive of nonocclusive right carotid bulb focal dissection. Recommend clinical correlation. If clinically indicated, consider carotid ultrasound further evaluation. 2. Ectasia of the ascending aorta measuring up to 4.4 cm. Recommend clinical correlation. 3. Mild heterogeneity of bilateral thyroid glands with 2 mm right thyroid gland nodule. Recommend clinical correlation. If clinically indicated, consider dedicated thyroid ultrasound. 4. Partially visualized lungs demonstrates 4 mm right upper lobe pulmonary nodule. Recommend clinical correlation and correlation with dedicated chest imaging. NOTIFICATION: Final reading was communicated to ED QA nurses for clinician and patient followup. Radiology showed 1. No acute infarction and no evidence for other acute intracranial abnormalities. 2. Fat-suppressed axial images are limited by motion artifact. There may be high signal in the posterior right carotid bulb corresponding to the small focal dissection seen on the preceding CTA. CTA images are concerning for the presence of the small focal dissection in the right carotid bulb. 3. Unremarkable appearance of the major intracranial arteries. Chest radiograph. showed No acute cardiopulmonary process. Specifically no large intrathoracic mass. The patient was diagnosed with Anesthesia of skin, Other visual disturbances. At the time of discharge, the patient had Sensory Changes of Unknown Etiology, likely cervical muscle tension vs. cervical radiculopathy.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>She was admitted for concern of carotid artery dissection. However history is not consistent (consists of 1 min of difficultly gathering thoughts; lightheadedness; and intermittent decreased LT on left side) with dissection and ___ clinical Exam was nonfocal except for physiological anisocoria (R 2->1.5, L 2.5 to 2) and 90% decreased Lt on RUE and R face. MRI showed no acute stroke, MRA images were reviewed on rounds and appeared to be inconclusive. Imaging seems more consistent with artifact than with dissections, but patient was started on aspirin 81 mg daily and Patient should have repeat CTA in ___s follow up with neurology. In terms of stroke workup A1c 5.8, LDL pending at time of discharge. Transitional Issues: - Repeat CTA in ___ weeks - outpatient PCP and neurology followup </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a PMHx of HTN and HLD who presents from his PCP office with nausea, L arm pain, and EKG changes. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. The patient was diagnosed with Abnormal electrocardiogram [ECG] [EKG], Dizziness and giddiness. The patient was treated with ___ Cardiac Catheterization. At the time of discharge, the patient had Primary Diagnosis: -Acute Myocardial Infarction (NSTEMI) s/p 2 DES to RCA/PDA -Hypertension Secondary Diagnosis: -Hyperlipidemia -Asymptomatic Leukocytosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT AND PLAN: Patient is a ___ with PMHx of HTN and HLD who presents with nausea, L arm pain, and EKG changes found to have an NSTEMI, concern for inferior wall ischemia with EKG changes c/b bradycardia and 3rd degree block. # CORONARIES: RCa disease now s/p x2 DES ___ RCa and PDA) # PUMP: EF of 55% # RHYTHM: Sinus but CHB with junctional escape, post perfusion sinus rhythm with 1st degree AV block #THIRD DEGREE HB/BRADYCARDIA: In the ED, his initial EKG showed complete heart block with triggered fascicular idioventricular rhythm versus a relatively rapid His-fascicular escape in the ___. At the time he was placed on beta-blocker per ACS protocol and junctional rhythm slowed to the ___. He went to the cath lab, and underwent junctional rate improved to the ___ after thrombectomy and stenting of RCA. His heart block was thus most likely ___ AV nodal infarct in setting of RCA occlusion. EP was consulted and no temporary pacing wire was placed with the expectation that block would likely resolve w/reperfusion of the AV node. Beta blockers were held, would likely benefit beta blocker initiation as an outpatient. Patient was also asked to follow up with outpatient Holter monitoring with Cardiology followup. Patient was asymptomatic on discharge, ambulating comfortably in sinus rhythm with first degree AV block and HRs of 65-80. # NSTEMI: On presentation had ST depressions in V2-V6 with Trop-T 2.84. Atypical symptoms of nausea, L arm pain had resolved prior to arrival in our ED. He was taken to the cath lab where he was found to have RCA completely occluded. He underwent thrombectomy and DES to ___ RCa and PDA. He underwent Plavix and integrillin loading in ___ cath lab and was continued on Plavix. He was started on statin, ASA, ACE. As above metoprolol was held. Troponins were trended to peak. # HTN: Patient switched from amlodipine to lisinopril 2.5 mg daily. # HLD: Rosuvastatin 20 mg daily continued #Leukocytosis: WBC overall down from admission (15.2->10) with no signs of infection. This was likely due to stress reaction from NSTEMI, and resolved during the course of hospitalization. </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 past medical history most notable for hyponatremia and resistant hypertension who presents with headache and hypertension noted in clinic. His other medical issues are notable for GERD, obstructive sleep apnea on CPAP, and type II diabetes. Esophagram showed 1. Mild smooth narrowing in the distal esophagus near the gastroesophageal junction. There was hold up of the 13 mm barium tablet there for greater than 10 minutes. 2. Mild esophageal dysmotility. The patient was diagnosed with 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>Mr. ___ is a ___ year old male with a history of resistant hypertension, type II diabetes mellitus, obstructive sleep apnea on continuous positive airway pressure, and chronic hyponatremia who presented with two days of headache and elevated blood pressure and found to have worsening hyponatremia, admitted for further workup. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with recent history of ERCP for gallstone pancreatitis who now presents with recurrent RUQ pain/vomiting. She underwent ERCP/Sphincterotomy on ___. She was followed by the ACS service but did not wish surgery at that time; a follow up appointment was scheduled for ___, and she was discharged to rehabilitation at ___. Her hospital course was also notable for some fluid retention that resulted in persistent hypoxia that was treated with diuresis with furosemide and her inhaled COPD medications. Today she presents from rehab after developing RUQ pain and emesis, reportedly bilious, since last evening. She has reportedly vomited ___ times. No recorded fevers. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cholelithiasis without evidence of cholecystitis. 2. No intrahepatic biliary duct dilatation. The common duct is dilated measuring 1 cm. This is a stable finding relative to prior ultrasound dated ___. Correlation with lab values, however, is advised for possible cholangitis. CHEST RADIOGRAPHS showed Findings suggesting mild pulmonary edema, which has increased. Increased opacity at left base, probably atelectasis although not specific. Radiology showed 1. Distended gallbladder with a large gallstone and pericholecystic fluid concerning for acute cholecystitis. 2. Resolving pancreatitis with improvement in pancreatic edema, peripancreatic stranding and resolution of intra-abdominal fluid. 3. Diverticulosis without diverticulitis. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on ___ at 9:22 ___, 10 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Cardiomediastinal silhouette is stable. Interval increase in vascular congestion is demonstrated. Left hilar enlargement is noted and should be further assessed to exclude the possibility of a left hilar lesion. Bibasal opacities have progressed and might be potentially concerning for aspiration. Percutaneous cholecystostomy tube placement under ultrasound guidance. showed Successful ultrasound-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. CHEST (PORTABLE AP) showed Bibasal opacities are present, concerning for infectious process. Slight interval decrease in the hilar size bilaterally might be consistent with improvement of vascular enlargement. No overt pulmonary edema is seen. No pneumothorax is demonstrated. Small pleural effusion is most likely present. The patient was diagnosed with CHOLELITHIASIS NOS. The patient was treated with ___: ___ percutaneous cholecystostomy drainage. 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>The patient presented to ___ Emergency Department on ___. Pt was evaluated by the acute care surgery team.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ cough x1 month, dyspnea at rest, worse on exertion for several days. Cough productive of yellow sputum. No fevers or chills. No chest pain, tightness, or discomfort. Dyspnea seems positional, worse when lying down. . He was seen by his primrary care doctor on ___, and was thought at the time to have bronchitis, and given duration, was treated with a Z-Pak. . In the ED, an EKG showed sinus tach at 116, normal intervals, normal axis, possible old anterior infarct, inferior nonspecific ST changes, no priors. A bedside ECHO showed no effusion, but LVEF was commented that it might be slightly slow. CTA showed no dissection, no PE to the subsegmental levels, moderate sized bilateral pleural effusions with central pulmonary vascular congestion and mild interstitial edema, as well as mild cardiomegaly with top normal size of the left ventricle. CXR was read as moderate cardiomegaly, mild-to-moderate pulmonary edema, focal infrahilar opacity. . In the ED, initial VS: 96.1 ___ 22 97% . Labs were notable for a D-Dimer 680*, CO2 21, BUN 25, BNP 1701*. . He was given 40 mg IV Lasix in the ED, to which he put out 1680 cc. He was, however, given 1 L NS for taachycardia. . Prior labs are ntoable for an A1c of 10.6 ___, trending down to 6.1 ___. Most recent lipid panel is Chol 276, HDL 43, LDL 201 ___. . Currently, he says that he has had high intake of salty foods over ___, and had ___ food yesterday evening for dinner, and this AM as well. He has had night swats fo rthe past few days which cause him to soak his shirt. His shortness of breath has come on gradually over the past ___ days. It is made worse with exertion, and he can only climb 1.5 gliths of stairs. Laying down makes it worse, and he has awoken from his sleep and needed tos it up to catch his breath. He denies using any extra pillows. He has also been having congestion. he ___ any new weight loss or gain. His cough has been prsent for about a month, and occasionally is productive with yellow/green sputum. he has some lower abodminal pain which he attributes to constipation. He had an episode of vomiting 3 days ago, but has sbuseqnetly resovled. he is constipation. . REVIEW OF SYSTEMS: Denies fever, chills, headache, vision changes, rhinorrhea, sore throat, chest pain, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed 1. Moderate cardiomegaly including substantial increase. Clinical correlation is suggested. True cardiac enlargement is a consideration, but the possibility of a pericardial effusion could also be considered clinically. 2. Mild-to-moderate pulmonary edema. 3. Focal infrahilar opacity, of uncertain significance. It may reflect focal edema, but a separate process such as developing focal opacity such as pneumonia or atelectasis is an additional consideration. Short-term follow-up radiographs are suggested to evaluate further. Radiology showed 1. Moderate-sized right greater than left pleural effusions, with central pulmonary vascular congestion and mild interstitial edema, and mild cardiomegaly with left ventricular prominence, concerning for cardiac decompensation. 2. No aortic dissection. No pulmonary embolus detected to the subsegmental levels. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. The patient was treated with Pharmacologic stress test Cardiac Catheterization. At the time of discharge, the patient had Primary: New severe systolic congestive heart failure Secondary: Hypertension Diabetes Mellitus Type 2 Hyperlipidemia Obesity. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Primary Reason for Hospitalization: =================================== Mr. ___ is a ___ with no known cardiac history but many CAD risk factors including T2DM, HTN, HLD, Obesity, smoking, who presented with 1 month of progressive dyspnea, orthopnea due to new onset CHF. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y.o. female referred to ___ ED after a brain MRI today showed a new left frontal brain mass. The patient had reported a seizure 2 nights ago which was witnessed by her young daughter. It was described with + LOC and all extremities were shaking. Unclear length of time. Patient had no memory of event (Postictal) and afterwards she was found with a chipped tooth, laceration of her tongue and urinary incontinence. She denies any other episodes since then. She saw her PCP and an MRI was obtained today was showing a brain lesion and was subsequently referred to us for further management. CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS showed No findings to suggest malignancy in the abdomen or pelvis. CTA HEAD WANDW/O C AND RECONS showed 1. This report is generated without 3D reformats. If additional information is obtained, an addendum to this report will be issued. 2. Hemorrhage and developmental venous anomaly in the left frontal region without an identifiable nidus, most consistent with underlying cavernous malformation or less likely AVM. If clinically indicated, this could be confirmed with conventional angiogram. 3. Otherwise, no acute findings. Evaluation of the patient with frontal mass. Assessment for the presence of primary lesion. TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen after administration of IV contrast. Axial images were reviewed in conjunction with coronal and sagittal reformats. FINDINGS: Assessment of the mediastinum demonstrates normal aorta and pulmonary arteries. Anterior triangular thymic tissue is present. Left axillary lymph nodes are larger than right axillary lymph nodes and although non-pathologically enlarged on both sides, are still prominent. Extensive glandular tissue is noted in the breasts bilaterally with relative paucity of the fat tissue. Imaged portion of the upper abdomen will be reviewed separately as part of the CT abdomen and the corresponding report will be issued. Aorta and pulmonary arteries are unremarkable. Heart size is normal. There is no pericardial or pleural effusion. Airways are patent till the subsegmental level bilaterally. There are no lytic or sclerotic lesions worrisome for infection or neoplasm. Lungs are clear. There is no evidence of interstitial lung abnormality. IMPRESSION: No evidence of intrathoracic malignancy demonstrated Of note are multiple bilateral axillary lymph nodes, left more than right, nonspecific and potentially may be reactive. Also extensive presence of glandular tissue within the breast might be consistent with recent history of nursing or pregnancy, please correlate clinically. showed No evidence of intrathoracic malignancy demonstrated Of note are multiple bilateral axillary lymph nodes, left more than right, nonspecific and potentially may be reactive. Also extensive presence of glandular tissue within the breast might be consistent with recent history of nursing or pregnancy, please correlate clinically. The patient was diagnosed with OTHER CONVULSIONS, SWELLING IN HEAD & NECK. At the time of discharge, the patient had Left frontal brain lesion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was admitted to the Neurosurgery service for further work-up of her left frontal lesion. The patient was started on Keppra for seizure prophylaxis (and likely seizure at home prior to her presentation). Frequent neurologic checks were ordered. Further imaging was required to assess the intracranial lesion further. A CTA of the head and CT of the torso were ordered. CTA revealed Hemorrhage and developmental venous anomaly in the left frontal region without an identifiable nidus, most consistent with underlying cavernous malformation or less likely AVM. CT chest/abdomen/pelvis was negative for malignancy On ___ Patient did not have any seizures overnight. She remained neurologically stable. Patient will be scheduled for the OR with Dr. ___ week. She will be contacted with the information once the OR has been booked. She was discharged home in stable condition. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo M well known to the Neurosurgical service s/p ___ Left CEA, s/p ___ wound exploration hematoma evacuation. He presented today to ___ after episode of dysarthria. Patient's daughter reports today at 12pm she was driving the patient and noted slurred speech and L facial droop. She reports "it lasted for longer than his other episodes" but is unable to say how long it last. She also reports a similar, but shorter episode also happened on ___ but they did not seek medical attention at that time. At ___ a CT head and CTA head and neck were done which were concerning for possible L carotid dissection. He was given aspirin 325mg and started on a hep gtt @ 1400u/hr and transferred to ___ for Neurosurgical evaluation. Right common carotid artery angiogram of the right anterior intracranial circulation. Left common carotid artery angiogram of the left carotid bifurcation and left anterior intracranial circulation. Right common femoral artery angiogram. ANESTHESIA: ANESTHESIA: Moderate sedation was provided by administrating divided doses of 1 mcg of fentanyl and 30 mg of midazolam throughout the total intra-service time of 30 during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. TECHNIQUE: OPERATORS: Dr. ___, Neurosurgery Vascular Fellow and Dr. ___, attending physician performed the procedure. Dr. ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. The patient was brought to the angio suite and positioned on the angio table. Conscious sedation was administered. The patient was prepped and draped in usual sterile fashion and a time-out was performed. The right common femoral artery was localized using anatomic landmarks and a 6 ___ long sheath was placed using Seldinger technique over ___ wire and micro puncture kit. A ___ 2 diagnostic catheter was used to select the right common carotid artery. Aforementioned views were obtained. Next, the left common carotid artery was selected. Aforementioned views were obtained. At the end of procedure diagnostic catheter was removed and the arteriotomy site was closed with Angio-Seal. PROCEDURE: Two-vessel cerebral angiogram. FINDINGS: Right common carotid artery: The right carotid bifurcation shows some signs of arteriosclerotic disease without significant stenosis. The right anterior intracranial circulation is unremarkable. There is significant cross-filling of the left hemisphere via pial collaterals from the left anterior cerebral artery. There is no filling of the left middle cerebral artery. Left common carotid artery: The carotid bifurcation on the left is free of arteriosclerotic disease or stenosis. The left internal carotid artery shows occlusion at the level of the supraclinoid internal carotid artery just past the ophthalmic artery origin. IMPRESSION: Left supraclinoid internal carotid artery occlusion. Filling of the left hemisphere via pial collaterals from the left anterior cerebral artery. RECOMMENDATION(S): Medical management. showed Left supraclinoid internal carotid artery occlusion. Filling of the left hemisphere via pial collaterals from the left anterior cerebral artery. RECOMMENDATION(S): Medical management. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. There are few left periatrial and temporal lobe deep white matter subacute infarcts. 2. There are stable chronic infarcts, and stable significantly diminished left ICA, MCA flow voids, better evaluated on CTA head and neck ___. . The patient was diagnosed with Aphasia. The patient was treated with Cerebral angiogram (___). At the time of discharge, the patient had Primary diagnosis: TIA Secondary diagnosis: Left supraclinoid internal carotid artery occlusion. Filling of the left hemisphere via pial collaterals from the left anterior cerebral artery.. The patient was given written instructions concerning 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 transient right facial drop (upper motor neuron pattern) and aphasia; symptoms resolved and MRI was negative for new infarct. CTA and cerebral angiogram showed left supraclinoid internal carotid artery occlusion (with filling of the left hemisphere via pial collaterals from the left anterior cerebral artery). Continued on aspirin, Plavix and Atorvastatin for secondary stroke prevention. Counseled family on permissive hypertension (goal SBP 110-140, may run up to 180) to prevent stroke as pt is collateral dependent. Pt advised to maintain adequate hydration and eat a normal amount of salt with his diet. Of note, on the day prior to discharge, pt was found to be mildly orthostatic. He was asymptomatic with SBP 150s sitting to 130s standing. He was given IVF and then developed left armpit pain and SBP 200s. This resolved. EKG and troponins x3 were unremarkable. He was discharged home in stable condition (SBPs 130s-170s on day of discharge); physical therapy cleared pt for home prior to discharge. ============================ TRANSITIONS OF CARE ============================ -Pt should have long term permissive hypertension (goal SBP 110-140, may run up to 180) to prevent stroke as pt is collateral dependent. Pt advised to maintain adequate hydration and eat a normal amount of salt with his diet. -Iron studies pending at discharge for normocytic anemia. PCP to ___. = = = = = = = = ================================================================ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack = = = = = = = = ================================================================ 1. Dysphagia screening before any PO intake? (X) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented? () Yes (LDL = ) - (X) No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (X) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No 9. Discharged on statin therapy? (X) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (X) Yes [Type: (X) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (X) N/A </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p appendectomy ___ years ago in ___ presents with L-sided ABD pain, nausea, and vomiting. Radiology showed 1. No acute intra-abdominal pathology. 2. Incidental 19 x 14 mm left adrenal nodule, which can be evaluated via MRI, as an outpatient. RECOMMENDATION(S): Outpatient MRI to evaluate the left adrenal lesion. The patient was diagnosed with Left upper quadrant pain. At the time of discharge, the patient had Primary: Abdominal pain Nausea and Vomiting. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ s/p appendectomy ___ years ago in ___ presents with L-sided ABD pain, nausea, and vomiting. The abdominal pain was intermittent, with periods of severe pain followed by sudden abatement, possibly consistent with renal colic. UHCG negative. The patient had CT ABD/PELVIS with contrast that revealed no acute pathology, however was not optimized to evaluate for stones. She was observed overnight with some tachycardia up to 130 at highest. She was given 1L IVF and managed symptomatically with Zofran, Tylenol, and ranitidine. Her pain and accompanying tachycardia resolved by the following morning at which time we did not feel repeating a CT for stone protocol would be worthwhile as it seems she passed the stone, if there ever was one there. She tolerated PO diet. She was discharged in stable condition. Unclear etiology of this episode, but would recommend urology follow-up for evaluation of possible kidney stones.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: 3 days ago started having severe pain in rectum "deep". felt like "she was having a baby". ___. pain worse with trying to defecate, but did not resolve when she was off commode. there all the time. after 3 days felt she had to come in. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently one ___ Mild cardiomegaly has probably increased although some of the differences due to difference in radiographic projection and semi-erect positioning. Mild interstitial abnormality, particularly bronchial cuffing and possible bronchospasm suggest mild congestive heart failure and possibly cardiac asthma. There is no focal consolidation or appreciable pleural effusion. The patient was diagnosed with Unspecified abdominal pain, Other specified diseases of anus and rectum. At the time of discharge, the patient had Constipation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ admitted with rectal pain. #Based on CT/exam (large amount of stool in vault and pain reproduced on exam) Likely due to impacted stool. After disimpaction felt better. Pain recurred and with enema several large bowel movements. Since that point no recurrence of rectal pain. Start miralax. After touching base with PCP stopped ___ of her meds that she was neither taking or intermittently. Anti-cholinergic effect of meds for urinary incontinence might have been culprit. Did have intermittent epigastric/chest pain/bloating. Unclear whether related to constipation. Did check EKG/CXR/troponin. Improved with simethicone. Would recommend also checking TSH in case contributing to constipation. # HTN - did have elevated BP in morning before taking meds. Recommend takes ACE at night and beta blocker in morning. SBP in 160's but did not increase meds given age and wide pulse pressure and concern about weakness and falls. #DM - continue home metformin. glucoses reasonable #Hyponatremia - mild. with hydration resolved from 132 -> 139 #Weakness - attributed to poor POs for some time and not getting out of bed. ___ eval felt unsafe to go home and therefore transfer to rehab. # Anxiety - during hospital stay, patient became very worried about many issues - BP, headache, abd pain and idea of going to rehab. Per family this is baseline. #TRANSITION - check TSH </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt with Stage IV Follicular Lymphoma and prostate CA treated with one cycle of Bendamustine and Rituxan (R on ___ who presents to the ER with fever to 103 and rigors. Radiology showed No acute cardiopulmonary process. Radiology showed 1. No obvious evidence of active infectious or inflammatory process in the neck or chest. No evidence of pneumonia. 2. Significant decrease in size of bilateral axillary lymph nodes which no longer meet CT size criteria for pathological enlargement. Interval increase in the degree of minimal fat stranding surrounding lymph nodes likely represents post-treatment change. 3. A single focus of minimally enlarged lymph nodes in the IIb cervical station on the right with minimal fat stranding, also likely represents post-treatment change given the morphologic similarity to the changes in the axillary lymph nodes. Radiology showed Small bilateral pleural effusions with bibasilar consolidations concerning for pulmonary edema or pneumonia. Dr. ___ these results with Dr. ___ on ___ at 9:28 AM via telephone. Radiology showed No evidence of deep vein thrombosis in the right lower extremity. assess for evidence of infection or lymphoma in chest, pelvis, abd CONTRAINDICATIONS for IV CONTRAST: Cr increasing COMPARISON: CT torso ___ TECHNIQUE: Standard departmental protocol CT of the chest abdomen pelvis was performed without intravenous contrast administration. Coronal and sagittal reformats were obtained. Total exam DLP 936 mGy-cm. FINDINGS: Abdomen: Interval development of new small bilateral pleural effusions, with associated bibasilar subsegmental atelectasis. For further details of the chest, please refer to dedicated report of CT chest done same day. Mild diffuse heterogeneity of the liver parenchyma is noted on this limited non contrast exam. Mild splenomegaly measuring 14.9 cm in length appears unchanged. Normal-appearing gallbladder, pancreas, bilateral adrenal glands. Mild bilateral perinephric fat stranding, nonspecific. Mild calcific atherosclerosis of a normal caliber abdominal aorta. Borderline prominent mesenteric, retroperitoneal and periportal lymph nodes appear slightly improved since prior, measuring up to 10 mm in short axis. Normal-appearing small bowel. No evidence of intraperitoneal ascites. Mild misty mesentery unchanged. Pelvis: Normal-appearing partially full urinary bladder. Normal-appearing prostate and seminal vesicles. Pelvic phleboliths. No evidence of pelvic free fluid. Mildly prominent bilateral inguinal chain lymph nodes appear slightly improved, measuring up to 15 mm in short axis. Normal-appearing colon and appendix. Moderate bilateral hip joint osteoarthritis. IMPRESSION: 1. No acute intra-abdominal pathology identified. 2. Interval development of new small bilateral pleural effusions with associated subsegmental atelectasis. For further details of the chest, please refer to dedicated report of CT chest done same day. 3. Slight interval improvement in retroperitoneal, periportal and inguinal lymphadenopathy. 4. Other chronic findings such as mild splenomegaly as above. showed 1. No acute intra-abdominal pathology identified. 2. Interval development of new small bilateral pleural effusions with associated subsegmental atelectasis. For further details of the chest, please refer to dedicated report of CT chest done same day. 3. Slight interval improvement in retroperitoneal, periportal and inguinal lymphadenopathy. 4. Other chronic findings such as mild splenomegaly as above. Radiology showed 1. A single right middle ethmoid air cell contains mild aerosolized secretions, which is in the absence of associated fluid is a nonspecific finding with regard to the possibility of acute sinusitis. No fluid in the paranasal sinuses to clearly suggest acute sinusitis. 2. Mild mucosal thickening in the paranasal sinuses indicates mild chronic inflammation. Radiology showed 1. No evidence of acute intracranial abnormalities. 2. Moderate diffuse ventricular enlargement, out of proportion of sulcal enlargement. This could reflect cerebral atrophy with central predominance. Alternatively, this could reflect communicating hydrocephalus. If subependymal lymphomatous involvement or other intracranial lymphomatous involvement is highly suspected, then further evaluation would be best performed by MRI. MRI would also be more sensitive for intracranial infection. 3. 6 x 4 mm sclerotic lesion in the outer table of the left parietal bone at the vertex most likely represents an osteoma. Given the history of lymphoma, follow-up could be obtained to assess stability. Radiology showed 1. Small bilateral pleural effusions and residual dependent pulmonary edema, new since ___. 2. No evidence of intrathoracic infection. 3. No central adenopathy. Left axillary adenopathy improved since ___. 4. Probable anemia. Radiology showed No evidence of mass, mass effect or abnormally enhancing lesions. Radiology showed Successful fluoroscopically guided lumbar puncture, draining 16 cc of cerebrospinal fluid. Laboratory analysis is pending. Dr. ___ was present and supervsing for the entire procedure. ___, NURSE PRACTITIONER The patient was diagnosed with FEVER, UNSPECIFIED, LYMPHOMA NEC UNSPEC SITE, CA PROSTATE. The patient was treated with Fluoro-guided lumbar puncture. At the time of discharge, the patient had 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>___ with PMH HTN, h/o SVT, stage IV follicular lymphoma and prostate CA presents wtih fevers to 102 for 2 days and neck pain with cough. . #Fever and rigors - Pt presented with fevers to 102-103, and with headache, neck pain, drenching nightsweats and poor PO intake. Extensive infectious work-up was undertaken for bacterial, viral, and fungal causes without any positive tests. Headache/neck pain was not thought to be meningitis, as pt was tender on lateral posterior neck and tender on scalp in occipital area, without any visual disturbances. Pt was empirically treated with vanc/unasyn, evetually on vanc/zosyn/levofloxacin/tamiflu. Pt underwent extensive imaging including CT head, neck, chest, abd, pelvis which were only notable for ventriculomegaly in head. Subsequent MRI was negative for acute hydrocephalus or other evidenec of acute disease. As culture data returned, vanc/zosyn/tamiflu were stopped. Pt underwent LP, for ? lymphoma in brain without any abnormalities concerning for infection or lymphoma. Pt seemed to defervesce spontaneously. At discharge, it is thought that pt likely had a viral infection, which caused his illness. . In the setting of getting IVF for fevers and poor PO intake, pt developed some pulm edema requiring O2, but was given 40iv lasix with complete resolution of O2 requirement. . # Pancytopenia: Pt's pancytopenia is attributed to his acute viral illness. Outpatient team may recheck CBC and consider BM biopsy is this does not resolve within ___ weeks of discharge. . #Stage IV Follicular Lymphoma s/p ___ C1 D1 Bendamustine and Rituxan ___. Pt did not receive any chemotherapy while hospitalized. . #Prostate CA - ___ 6, no active treatment at this time. Pt was continued on flomax. . #CKD III with mild Cr elevation (Cr 1.2 -> 1.4): Losartan was stopped on admission due to worsening Cr and was not resumed as pt's SBPs were in 100-120s and metoprolol was increased for SVT. . #Hx of SVT - Pt had episode of SVT in 130-150s which terminated spontaneously. Pt only minimally symptomatic and HD stable. Metoprolol was incrased from 25mg po xl to 75 po xl. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year old female with a history of breast cancer ER/PR positive, HER2 negative diagnosed in ___ s/p resection/XRT/hormonal treatment, prior history of ovarian cancer (treated with chemo in ___, seizure disorder and Factor V Leiden complicated by DVTx2 on warfarin, who presented to OSH neurology for frequent falls with back pain. Radiology showed 1. 3.9 cm asymmetric right breast soft tissue mass seen at the visualized lower thorax. Correlation with mammography and clinical exam is recommended. 2. 5.5 cm irregular soft tissue attenuation mass abutting the posterior pleural surface in the left lower lobe. Few epicardial lymph nodes identified on the visualized lung bases. Please refer to the CT chest from the same day for further details. 3. Innumerable ill-defined hypodense masses throughout the liver parenchyma, in keeping with diffuse metastases. 4. Pancreatic head is heterogenous in attenuation. No pancreatic ductal dilatation. Metastases or primary pancreatic neoplasm is not excluded. 5. 7 mm hyperdense lesion at the pancreatic body may relate to interdigitation of fat versus a small cystic lesion such as IPMN. 6. 1.1 cm rounded lesion at the lateral limb of the left adrenal gland is suspicious for metastatic deposit. 7. No lymphadenopathy. No evidence of osseous metastases in the abdomen and pelvis. Radiology showed 1. Large 3.4 x 5.3 cm left lower lobe lesion, along with left upper lobe and right lower lobe nodules are highly suspicious for metastatic disease. 2. Multiple enlarged left hilar, lower paratracheal and upper paratracheal nodes are lymph node metastatic involvement. 3. There are no bone metastases. 4. Moderate-to-severe coronary artery calcification. 5. Mild centrilobular, paraseptal emphysema and mild diffuse bronchial thickening are likely smoking related. 6. Please refer to concurrent CT abdomen and pelvis for detailed description of abdominal findings. Radiology showed Left PICC ends in the left brachiocephalic vein. Again seen is opacity overlying the left lower hemithorax medially consistent with known mass. Mild interstitial opacities are decreased from prior study and may represent resolving edema. Radiology showed Left PICC now ends at the confluence of the brachiocephalic veins. Radiology showed Left PICC terminates in the lower SVC. Radiology showed Stable appearance of the chest including lymphadenopathy and a left lower lobe opacity worrisome for malignancy. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Diffusely infiltrative hepatic metastases were better delineated on recent CT 2. No visualized flow in the left portal vein. This vessel, which was atretic on the recent CT, is likely being compressed by adjacent metastases. . The patient was diagnosed with OTHER MALAISE AND FATIGUE, HISTORY OF FALL, LONG TERM USE ANTIGOAGULANT. The patient was treated with ___ PICC line placement ___ PICC line removal. At the time of discharge, the patient had PRIMARY: -Breast cancer most likely metastatic to liver and lung -Urinary tract infection -Hyponatremia SECONDARY: -Factor V ___ -History of DVTs -Seizure disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of breast cancer (___), ovarian cancer (___), Factor V Leiden on warfarin for history of two DVTs, and seizure disorder with two recent falls who presented for concern of metastatic malignancy. She was discharged home with hospice. # Mental status changes. During admission, patient became more restless and unable to concentrate or focus. She was intermittently alert and oriented x3, and mental status waxed and waned throughout the day. This was likely multifactorial and may be related to hospital delirium, liver dysfunction due to tumor burden, decreased clearance of sedating medications (diazepam, narcotic pain meds), seizure disorder or possible leptomeningeal disease (MRI negative). During admission she developed new asterixis and abnormal lfts, most c/w greater burden of disseminated intrahepatic disease than seen on imaging. She was treated with lactulose with mild improvement. No obvious infection was found. Neuro Oncology was consulted and Dr. ___ the patient. MRI brain at OSH negative. # Metastases to the lung and liver, new. Primary is unknown. Based on history of breast and ovarian cancers, these are most likely. However, given pace of disease, a more aggressive tumor is favored. T She was at high risk for clotting given her history of clots and metastatic malignancy. Her warfarin was held, and she was started on a heparin drip to prepare for liver biopsy to guide further management. However, on day of biopsy, patient stated she did not want any further diagnostic or therapeutic tests. After discussion with her family, the patient changed her mind and the biopsy was scheduled for the following day. On the day of the rescheduled biopsy, the patient again stated she did not was the procedure and wanted to go home. After a family discussion, the biopsy was postponed until she felt better. During the the rest of her admission, the goals of care changed the biopsy was no longer pursued. # Factor V Leiden on warfarin. She had supratherapeutic INR on admission. INR 3.8 at OSH. INR 2.9 on admission here. Warfarin was held. Heparin gtt was started. Liver biopsy was not ultimately pursued. Given change in goals of care, anticoagulation was discontinued. # UTI. Complained of urinary frequency. She did have chief complaint on admission of falls and balance issues. UA with moderate bacteria, small leuks. UCx >100k pansensitive Ecoli. She was treated with ceftriaxone 1g Q24H from ___ to ___. Recheck of UA (given ongoing mental status changes) showed no UTI. # Hyponatremia. Resolved after 1L IVF. Serum and urine osm low. Urine Na 24. Consistent with hypovolemic picture. Less consistent with SIADH. # Falls. This appeared to be mechanical in nature. Exam shows full strength and mildly uncoordinated heel to shin on left. She has intact sensation and no signs of cord compression or cauda equina on exam. She would require MRI imaging or a bone scan to evaluate for bony disease. Physical Therapy recommended patient be discharged to rehab. Her goals of care changed, and she was discharged to home with hospice. # Seizure disorder: No seizures since ___. Continue home phenobarbital and phenytoin. Drug levels were within normal range. ACCESS: ___ placed ___ and removed on ___ on discharge EMERGENCY CONTACT: Next of Kin: ___ Relationship: DAUGHTER Phone: ___ Other Phone: ___ ### TRANSITIONAL ISSUES ### -Home with hospice. -Symptomatic medications - olanzapine, morphine, scopolamine, lidocaine patch. -Avoid hepatically-cleared medications given ongoing encephalopathy. -Anticoaguation discontinued given hospice goals. -Inpatient neurologist Dr. ___ these changes to reduce sedation, but we will defer to outpatient neurologist: - stop Phenytoin Sodium Extended 400 mg PO HS - start Phenytoin 150mg in the morning and 200mg at bedtime</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ ___ speaking lady with idiopathic tracheal stenosis s/p multiple silicone stent placement, removal, and revisions (last on ___ with multiple admissions for dyspnea presenting with dyspnea. CT CHEST W/O CONTRAST showed 1. Status post tracheal stent removal with recurrent tracheal stenosis, beginning approximately 2.5 cm below the level of the vocal cords and spanning a craniocaudal dimension of 3 cm. There is associated marked circumferential but smooth tracheal wall thickening at the level of the stenosis, and differentiating tracheal wall thickening from granulation tissue is difficult to determine on this examination. Minimal linear tracheal secretion is noted and the distal airways remain patent. 2. Enlarged, nodular thyroid, as seen previously. As seen previously, the inferior aspect of the thyroid encircles the anterior aspect of the trachea at the superior aspect of the tracheal stenosis. The patient was diagnosed with OTHER DISEASES OF TRACHEA AND BRONCHUS, ASTHMA, UNSPECIFIED, HYPERTENSION NOS. The patient was treated with Bronchoscopy with tracheal dilitation with IP ___. At the time of discharge, the patient had Primary Diagnosis: - Idiopathic Tracheal Stenosis Secondary Diagnosis: - Asthma - 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>BRIEF HOSPITAL COURSE ___ old never smoker with known idiopathic tracheal stenosis s/p cervical tracheal resection and resconstruction in ___, silicone stent placement and removal at least three times, last removal ___ complicated by granulation tissue requiring multipledebridements, who presents with progressive dyspnea similar to prior episodes of tracheal stenosis. A CT was performed which confirmed a diagnosis of re-stenosis. The patient underwent flexible bronchoscopy on ___, with serial tracheal dilations. No stent was placed. The patient with plan to followup in the operating room in ___ days for possible cryotherapy. Her home medications for asthma and depression were continued.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ visiting from ___ who experienced several days of sub-xyphoid discomfort as well as two weeks of L sided chest discomfort. Her pain was not pleuritic or worsened by activity or position. SHe has a chronic cough that is unchanged. She has not had SOB, DOE, dizziness, palpitations, fever or weight loss. She has not had hemoptysis. She flew in from ___ in ___ and has not had any prolonged immobility since that flight and she walked on the flight in the aisle. She noticed some bilateral mild ankle edema after the flight that has since improved. She presented to the ED with the above symptoms and torso CTA disclosed a L main to segmental non-occlussive PE and Left lower lobe bronchiectasis. She received IV heparin. CTA chest and CT abdomen and pelvis with contrast showed 1. Nonobstructing pulmonary embolus extending from the distal left main pulmonary artery to the distal left lower lobar pulmonary artery. No associated pulmonary infarct. No CT evidence of right heart strain. 2. No acute aortic abnormality. 3. Left lower lobe bronchiectasis with focal areas of mucous impaction and peribronchial consolidations along with ___ nodularity at the base of the right upper lobe in the setting of a small hiatal hernia with mildly ectatic esophagus, this most likely represents multifocal aspiration pneumonia. Ectatic esophagus and hiatal hernia can be further evaluated with nonemergent barium esophagram, if clinically indicated. 4. Two 3 mm subpleural nodules in the right upper lobe lack suspicious features. These do not require followup in the absence of high risk factors. If high risk factors, such as smoking are present, followup CT in ___ year is advised per ___ society recommendations. 5. No acute findings in the abdomen or pelvis. 6. Trace, diffuse mesenteric fat and superficial soft tissue stranding, consistent with trace anasarca. 7. Prominent bladder distension. Correlate clinically to exclude neurogenic bladder. 8. Trace S shaped thoracolumbar curvature. The patient was diagnosed with CHEST PAIN NOS, ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had acute pulmonary embolism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with acute pulmonary embolism. This is likely cause of her symptoms of chest pain. She also has a pattern of bronchiectasis on CT chest, but describes a chronic unchanged cough and is without fever or worsened breathing. #PE The most notable risk factor for PE is airplane travel but that was over 2 months ago. She flew from ___ to ___ 2 months ago and then spent 8 hours in a car driving to ___ 8 days before admission. Immediate work up for inheritable hypercoagulable states would not change immediate management. Since she has not had colonoscopy before, she should undergo colon cancer screening in future. No clinical evidence of right heart strain so no echo performed.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a history of advanced dementia who was found down at home with a fever and abdominal tenderness and brought to ___. His trauma work up included a CT abdomen/pelvis which showed inflammation and stranding around the left iliac artery at site of prior external iliac to femoral bypass graft. He was transferred to ___ in ___ and admitted to the vascular surgery service. CTA ABD AND PELVIS showed 1. Unchanged appearance of small circumferential fluid around common iliac artery grafts site with adjacent fatty stranding concerning for graft site infection. 2. Patient is status post aorta bi-iliac stent graft placement with no evidence of leak or rupture. 3. Diverticulosis without diverticulitis. Radiology showed Right PICC terminates at the cavoatrial junction. The patient was diagnosed with Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init, Oth surgical procedures cause abn react/compl, w/o misadvnt. The patient was treated with ___ Right upper extremity PICC line placement. At the time of discharge, the patient had Suspected infection of left external iliac to femoral bifurcation 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>Mr. ___ is a ___ year old male with a history of advanced dementia who was found down at home with a fever and abdominal tenderness and brought to ___. His trauma work up included a CT abdomen/pelvis which showed inflammation and stranding around the left iliac artery at site of prior external iliac to femoral bypass graft. He was transferred to ___ in ___ and admitted to the vascular surgery service. His home xarelto was initially held due to concern for possible bleed. He was started on broad spectrum intravenous antibiotics and was eventually narrowed to nafcillin when his cultures resulted positive for MSSA. Repeat CTA of his abdomen/pelvis was stable. He had a transesophageal echocardiogram which was negative for signs of infection of his artificial mitral valve or pacemaker leads. A right upper extremity PICC line was placed for long-term intravenous antibiotics. His Xarelto was restarted on ___. He was able to tolerate a regular diet, get out of bed and ambulate without assistance, void without issues, and pain was controlled on oral medications alone. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with metastatic renal cell carcinoma currently on nivolumab (S/p 3 cycles) with progressive disease. In early ___, he was found to have B/l pulmonary embolism when he presented with shortness of breath at ___. He was initiated on therapeutic enoxaparin 150 mg BID (1 mg/kg BID). About two weeks ago, with progressive shortness of breath, he was admitted to ___ and found to have severe volume overload. He was diuresed over 15 pounds and discharged on oral lasix. In the last two weeks he has developed new neurologic symptoms. He describes headaches off-and-on, but mainly morning, sometimes associated with fogginess or confusion. He has also had occasional blurry of vision, although he can not describe if it is restricted to one eye or a particular visual field. He also describes a sensation of his tongue being thick and weak. He finds it relatively difficult to speak. He has also had some dysphagia, although no episodes of coughing, choking on food or water/liquids. In the past week, he has also had bladder symptoms, particularly decreased control and urge incontinence. He denies any bowel incontinence. He denies any facial droop/weakness, muscle or limb weakness, gait problems, cognitive issues, falls. He has had some numbess over the left thigh, infrequently, but no other peripheral neuropathy. CT HEAD W/O CONTRAST showed 1. Three dural-based hyperdense metastatic lesions identified within the head. Correlation with prior imaging (not available at the time of this interpretation) is required to evaluate for chronicity or interval growth. 2. No evidence of infarction, hemorrhage, or edema. CTA CHEST WANDW/O CANDRECONS, NON-CORONARY showed 1. Interval increase in the number and size of innumerable metastatic lesions to the bones, soft tissues, and pulmonary parenchyma. 2. Coalescent hilar adenopathy extends into the lower lobe vasculature as tumor thrombus bilaterally with new pleural effusions and associated compressive atelectasis bilaterally, left greater than right. 3. Limited evaluation for pulmonary emboli due to poor bolus timing. MR HEAD W/O CONTRAST showed Unchanged oval-shaped extra-axial parafalcine lesion in the left convexity, associated with other lesions as described above involving the frontal calvarium, right side of the clivus and left temporomandibular condyle, consistent with metastatic disease, the examination is limited without contrast. MRI THORACIC AND LUMBAR showed 1. Overall, extensive metastatic disease is re- demonstrated throughout the thoracic a lumbar spine. New metastatic involvement is seen involving T7, T8, and T9 vertebral bodies compared to the prior CT from ___. 2. Involvement of metastatic disease with T12 also appears to be new compared to the prior exam. Although no definite cord signal abnormalities are identified, extensive soft tissue is seen extending into the spinal canal, and left neural foramen causing mass effect on the spinal cord. However, please note that this study is limited due to lack of IV contrast. 3. Extensive metastatic disease is re- demonstrated involving the vertebral bodies the lumbar spine, including pathologic fragmentation of the L3 vertebral body. No definite cord abnormalities identified within lumbar spine. 4. Although evaluation of the posterior chest wall masses is limited on this exam, there appears to be progression of disease. A dedicated chest CT could be helpful for further evaluation. NOTIFICATION: ___ were d/w Dr. ___ by Dr. ___ by phone at 5:35p on the day of the exam. The patient was diagnosed with HEADACHE, SHORTNESS OF BREATH, SEC MAL NEO BRAIN/SPINE. At the time of discharge, the patient had Metastatic Renal Cell Carcinoma Brain Metastases Hemoptysis. The patient was given written instructions concerning 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: ==================================== Mr ___ is a ___ yo M with metastatic renal cell carcinoma with progressive disease on nivolumab, who was admitted with headache, dyaarthria and hemoptysis. </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 severe CAD (CTO mid-LCx since ___, repeated PCI to RCA for ___ stenosis, last POBA ___, CVA (left periventricular subcortical infarct post cath ___, HTN, HLD, AF not on anticoagulation, ESRD on HD MWF, who presents with a four day history of emesis. CT ABD AND PELVIS W/O CONTRAST showed 1. No evidence of acute process involving the abdomen or pelvis. 2. Colonic diverticulosis without evidence of acute diverticulitis. 3. Stratification of the wall of the urinary bladder is unchanged since ___, and may be related to chronic inflammation. 4. Changes related to avascular necrosis of both femoral heads again noted. The patient was diagnosed with Nausea with vomiting, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES #Nausea, vomiting #Coronary artery disease #Elevated troponin SECONDARY DIAGNOSES #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>=================== PATIENT SUMMARY =================== ___ with severe CAD (CTO mid-LCx since ___, repeated PCI to RCA for ___ stenosis, last POBA ___, CVA (left periventricular subcortical infarct post cath ___, HTN, HLD, AF not on anticoagulation, ESRD on HD MWF, who presents with a several-day history of nausea and vomiting associated with food intake. Of note, he had been just admitted to Cardiology for the same presentation. At that time, the etiology of his nausea/vomiting was unclear. During this admission, GI was consulted. CT A/P was obtained, which did not show evidence of gastric outlet obstruction or other significant abnormality. The patient was able to tolerate PO intake with PRN antiemetic zofran. He was discharged home with plan for outpatient GI follow up and EGD. =================== TRANSITIONAL ISSUES =================== [] The patient will need outpatient GI follow up with EGD for workup of his anorexia and nausea/vomiting. This is being arranged through GI office. [] Cardiology recommended a stress test, ideally with exercise MIBI, although most likely will be a pharmacological stress (patient reports he is unable to exercise). =================== ACUTE ISSUES =================== #Anorexia #Nausea, vomiting Patient presented with a 2-month history of anorexia and a several-day history of nausea/vomiting that occurs immediately after eating. Denies any abdominal pain, diarrhea, hematemesis, dysphagia, or early satiety. He stated that certain foods, e.g. oatmeal and cornmeal, trigger this, while he is able to tolerate other foods, including eggs and bagels. He endorsed a 20-lbs weight loss during the past two months, though ___ records do not show a significant weight change. The etiology remains unclear. GI was consulted. CT A/P did not show evidence of gastric outlet obstruction though on review with Radiology, did show significant calcifications of his celiac artery and SMA. However, chronic mesenteric ischemia was felt to be unlikely given the lack of pain. Other differential for his presentation includes persistent digoxin effect; worsening metaplastic changes of esophagus (though no dysphagia), worsening PUD (though no abdominal pain); worsening ___ ulcers vs. progressive intrusion of hiatal hernia. By ___, the patient was able to tolerate multiple meals without emesis, and as such it was felt to be reasonable to discharge the patient home with outpatient gastroenterology follow-up and EGD. He was also provided with PO Zofran 4 mg q8H PRN nausea. QTc 360. # Coronary artery disease # Elevated troponin to 0.15, which downtrended to 0.14. EKG without acute ischemic changes; changes were thought to be c/w dignoxin. He did not have any chest pain this admission. Cardiology recommended stress testing with exercise v. pharm mibi. =================== CHRONIC ISSUES =================== #End-stage renal disease on hemodialysis Received hemodialysis per his usual ___ schedule. #CODE: Full, presumed #CONTACT: ___, ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ORTHOPAEDICS HPI: ___ w/severe dementia and hx multiple medical comorbidities including CKD and CAD, and prior right cephalomedullary nail for R hip fx approx ___ years ago at ___, now s/p unwitnessed fall at ___ approx midnight last night. He was taken to ___, where workup was reportedly negative, and XR initially read as negative. The patient was discharged per wife was able to walk but with pain in R hip and was favoring right side. XR was later noted to reveal a right acetabular fx, and patient was contacted and asked to come to ___ for evaluation. Per his wife he is ambulatory with a walker at baseline, occasionally with wheelchair for long distances. CT head and Cspine were negative at OSH. Radiology showed Right acetabular fracture. CHEST (PORTABLE AP) showed No significant interval change from earlier this same date. Radiology showed 1. Comminuted fracture of the the right acetabulum, with involvement of almost the entire acetabulum. Interior displacement the anterior portion of the major quadrilateral fragment. 2 tiny calcific densities seen within the femoroacetabular joint, detailed above. 2. Fractures of the right parasymphyseal superior pubic ramus and probably also a nondisplaced fracture of the right inferior pubic ramus. 3. Status post ORIF old healed right proximal femur fracture. No hardware loosening or displacement identified. 4. Bilateral bowel containing hernias, left larger than right. No dilated loops to suggest obstruction. 5. Non-specific soft tissue stranding in the perirectal region and in the right lower quadrant of the abdomen. 6. Marked enlargement of the prostate, with bladder wall thickening. Clinical correlation is requested. RENAL U.S. showed 1. Mild bilateral cortical renal atrophy, right greater than left. 2. No hydronephrosis. 3. 1.7 cm simple left renal cyst. 4. Enlarged prostate, measuring at least 9 cm in width. CHEST (PORTABLE AP) showed Since ___ severely enlarged cardiac silhouette has gotten bigger, moderate right pleural effusion has developed, pulmonary edema is new, predominantly in the lower lungs where there is also new heterogeneous consolidation. Overall findings suggest concurrent pneumonia and cardiac decompensation. Radiology showed Redemonstration of a complex, comminuted fracture involving the anterior and posterior columns of the right acetabulum. Please see the report from the recent prior CT of the pelvis from ___ for further characterization. The patient was diagnosed with FRACTURE ACETABULUM-CLOS, UNSPECIFIED FALL, AORTIC VALVE DISORDER, HYPERTENSION NOS. At the time of discharge, the patient had PRIMARY: Right acetabular fracture SECONDARY: Chronic Kidney Disease, 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: ============================ ___ with HTN, CKD, BPH, dementia with multiple recent falls who presnted with right acetabular fracture in the setting of a fall, mangaging non-operatively, hospitalization complicated by acute on chronic kidney injury. # Right Acetabular Fracture: Traumatic in setting of recurrent falls and known osteoporosis. Seen by orthopaedics who feel that fracture can be managed non-operatively. Specifically they feel that joint is currently set in a way as to facilitate healing with touch down weight bearing status on the Right Lower extremity and that surgical intervention would not result is a shorter duration of recovery or greater short term mobility. # Recurrent Falls/Dementia: Long standing history of falls. Thought to be related to underlying dementia and deconditioning. Evaluated by Neurology in the past with concern for NPH though no formal diangosis. Infectious workup negative during admission # Acute on Chronic Kidney Injury: Creatinine on admission 2.3 and has been stable since. Baseline creatinine 1.8. CK not signficantly elevated. No hydronephrosis seen on renal US. FeNa 2.5% suggestive of renal sodium wasting and likely ATN. Creatinine downtrending on discharge. # Hypertension: On lisinopril, labetolol, and amlodipine at home, but lisinopril was held on admission in setting of ___. In absence of lisinopril, he was noted to be more hypertensive especially in the mornings that was thought be exacerbated by pain and anxiety. During admission, labetalol was from 200mg BID to ___ TID and amlodipine increased from 2.5mg to 5mg daily with goal BP <150/90. Restart lisinopril as an outpatient pending stability in renal function. # Troponinemia: Patient has reported history of CAD, though history unclear. CK initially elevated in setting of fall with unclear duration of immobility, CK-MB index was normal. The patient was asymptomatic without chest pain or dyspnea, EKG with LBBB block but no Sgarbossa criteria thus thought not to reflect active ischemia. Troponin continued to elevate in the absence of ischemia thought to reflect decreased renal clearance with low grade troponin leak from hypertension. He was continued on aspirin. CHRONIC ISSUES: # BPH: Followed by Dr. ___ Urology. Continue tamsulosin and recently started finasteride. # Hypothyroidism: TSH was elevated in acute illness but free T4 normal. Was continued on levothyroxine. # Iron deficiency anemia: Hct stable during admission. Started ferrous sulfate daily. # Muscle spasms: continued pramipexole. # Osteoporosis: continued calcium and vitamin D TRANSITIONAL: - Touch down weight bearing on the right lower extremity for two months. - Followup with Dr. ___ in 2 weeks for repeat imaging - Enoxaparin for ___ weeks at least. Course to be determined as outpatient with Dr. ___ Orthopaedics. - Please discuss with Dr. ___ lisinopril pending stablity in renal function. - Pain control with acteaminophen 650mg PO QID, tramadol 25mg PO q12h:PRN pain, and oxycodone 2.5mg PO daily:prn 30min prior to ___. Ensure ongoing bowel regimen to prevent constipation. - Continue calcium and vitamin D - consider starting memantine as an outpatient CORE MEASURES: # Diet: pureed/thin liquid diet # PPX: Enoxaparin # CODE: DNR/DNI # CONTACT/HCP: ___ (Wife): ___ or ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx HTN, HLD, ESRD on HD ___, last dialysis ___ in ___, since ___ via left AV fistula) presents to ED with dyspnea and need for dialysis because his usual dialysis center "did not have paperwork about his ___ dialysis." Chest radiographs showed Pulmonary vascular congestion in the upper lungs without overt edema. Small bilateral pleural effusions. NOTIFICATION: Updated findings from original wet read were communicated to Dr. ___ at 12:21 p.m. on ___ by phone. Radiology showed No definite acute fracture or dislocation. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Endstage renal disease requiring 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>Brief Hospital Course: ___ year old male with PMH of HTN, HLD and ESRD on ___, Th, ___ HD who presented to the ED with volume overload and hyperkalemia (7.2) in the setting of missed HD. The patient had been traveling abroad and did not arrange for HD upon return. He presented to his prior HD center who did not have room for him and instructed him to go to the ED. Prior to his presentation, his last HD session was in the ___ on ___. Upon arrival to the ED, the dialysis/renal team was consulted and the patient was admitted for bedside HD. EKG on admission unchanged from prior. Patient complained of mild SOB but denied any nausea, vomiting, or abdominal pain His K improved from 7.2 on arrival to 4.0 three hours after HD was completed. It was arranged for him to have his next session at ___ in ___ on ___ at 5:00pm and the patient was discharged home following his session. Of note, the patient was hypertensive to SBPs 200 upon admission in the setting of volume overload. His pressures improved to SBPs 140s with dialysis. In addition, the patient's HgB 8.1 which is lower than expected than someone with CKD on EPO (baseline appears to be ~9). No signs of active bleed and patient HD stable. Would consider further work-up as an out-patient. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male past medical history ___ disease, prostate cancer (with reportedly negative recent PET scan), hypertension, and hyperlipidemia who presents with a chief complaint of lightheadedness and a recent fall today. CT HEAD W/O CONTRAST showed 1. No acute large territorial infarction or hemorrhage. 2. Mild paranasal sinus disease, as described above. CT C-SPINE W/O CONTRAST showed No fracture or malalignment. Multilevel degenerative disc disease. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified, Anemia, unspecified, Weakness. The patient was treated with ___ Upper endoscopy. At the time of discharge, the patient had Primary Diagnosis - acute blood loss anemia, ___ upper GI bleed Secondary Diagnoses - acute kidney injury, likely prerenal - lower extremity edema - Parkinsons disease - hypertension - hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman with a past medical history of ___ disease, prostate cancer, and high blood pressure presents with 2 weeks of subacute and worsening fatigue and dyspnea on exertion, likely ___ anemia from GI bleed. =========================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo w/Klatskin tumor diagnosed ___ presents with worsening abdominal pain and leukocytosis. Pt presented in ___ with jaundice, weight loss and abdominal pain. ERCP w/ stent placement relieved symptoms. Biopsy showed malignancy with spread to lymph nodes, lungs and liver. Pt had planned to start palliative chemo however her bilirubin was elevated and then she had a fall at home and was admitted to rehab. She has not yet received any treatment. While at rehab pt began to have worsening pain, fever w/Tmax 102.4 and leukocytosis. She was started on Augmentin on ___ and it appears that fevers resolved, however WBC count continued to rise as well as LFTs. On ___ pt also began to complain of worsening RUQ pain. On arrival to ED pt afebrile, LFTs slightly increased from prior rehab values, elevated WBC count. Pt given unasyn for possible cholangitis and ERCP team was contacted. Pt also fell from bed in ED and CT of head and neck were unremarkable. Vitals prior to transfer 98.3 147/76 99 16 On arrival to floor pt reports RUQ pain. Denies nausea/emesis. +Constipation, last BM 2 days ago. Radiology showed 1. No acute intracranial abnormality. 2. Global atrophy, likely age-related, and moderate sequelae of chronic small vessel ischemic disease. Radiology showed 1. No acute fracture of the cervical spine. 2. Multilevel malalignment with 2 mm anterolisthesis of C3 on C4 and retrolisthesis of C5 on its neighbors, likely chronic and degenerative given the multilevel, multifactorial degenerative disease throughout the cervical spine. NOTE ADDED IN ATTENDING REVIEW: There is significant narrowing of the ventral canal with effacement of the thecal sac and indentation of the right ventral aspect of the cord, due to a lobulated disc herniation at the level of the C4-5 retrolisthesis (2:33, 602b:9). This places the patient at at further risk of spinal cord injury, with appropriate traumatic mechanism, and should be closely correlated with any clinical evidence of new myelopathy. The patient was diagnosed with CHOLANGITIS. The patient was treated with ERCP. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSEMENT & PLAN: ___ yo w/Klatskin tumor diagnosed ___ presents with worsening abdominal pain and fever secondary to cholangitis. #Cholangitis The patient was admitted to the medicine service and was given IV fluids, nothing by mouth, with antiemetics and narcotics as needed. She was given Zosyn empirically and was afebrile. She was taken to the ERCP suite on the morning of ___ which had the following impression: A metal stent placed in the biliary duct was found in the major papilla just inside the bile duct. Cannulation of the biliary duct was successful and deep with a balloon catheter. There were small filling defects inside the metal stent at the biliary tree. The common hepatic duct above the metal stent and the left and right hepatic ducts were normal. No discrete stricture was noted. Normal intrahepatics. Several balloon sweeps were performed. Small amount of debris/sludge was extracted successfully using a balloon. Final cholangiogram showed no filling defects. Given the patient symptoms and the early obstruction of the recent placed metal stent, a decision was made to place a 5cm by ___ double pig tail biliary stent inside the metal stent. Excellent flow of bile was noted. . The patient returned to the floor and advanced to a full diet with no problems by the following day. She will be discharged home on PO cipro/flagyl to complete a 7 day course. #Gallbladder carcinoma - patient has an appointment to see Dr. ___ on ___ to discuss treatment options #falls at home: pt admitted from rehab. seen by ___, okay to go home with home ___ and 24h family support # 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: ___ y.o. ___ gentleman with HTN, CAD s/p 3v CABG in ___, MVR w/ mechanical valve, Afib on coumadin s/p PVI and ICD, systolic cardiomyopathy LVEF 40% ___, and ___ Disease as well as recent admission to the ___ service ___ - ___ for acute sCHF exacerbation and negative work-up for cardiac sarcoidosis with RH catheterization, c/b development of compartment syndrome ___ at cath site requiring fasciotomy and skin graft ___, now presenting with significant bleeding from graft site and increased swelling starting this evening. This was accompanied by some numbness in his fingers which has currently resolved. He had supratheraputic INRs since his discharge from the hospital. Patient is on coumadin for h/o afib and mechanical valve. Given that patient is supratherapeutic on his INR, plastic surgery wanted to know if there is anything that can be done to bring down his INR (vitamin K, FFP, etc), but given mechanical valve, reversal was deferred in the ED. ED also discussed ___ Cards on phone. Not comfortable with reversal, recommend slowly allowing INR to trend down unless concern for vascular compromise. Evaluated by plastics who noted large muscular hematoma on ulnar aspect of proximal forearm and threatened skin graft. They opened prior incision along ulnar aspect of graft and entered large hematoma cavity with diffuse muscular bleeding, no focal vessel. Irrigated and packed with Surgicel/QuickClot. Vitals in the ED: ___ 72 102/65 18 100% Labs notable for: BUN 45, cre 1.5. HCT 28, INR 4.0 Patient given: percocet 1 tab, cefazolin 1g Vitals prior to transfer: On the floor, the patient denies any pain and is filling out a lottery ticket. He states the previous numbness in his fingers has resolved. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is again is substantial enlargement of the cardiac silhouette in a patient with valve replacement and dual-channel pacer with leads extending to the right atrium and apex of the right ventricle. Blunting of the left costophrenic angle is again seen. No definite vascular congestion or acute focal pneumonia. The patient was diagnosed with HEMATOMA COMPLIC PROCEDURE, ABN REACT-PROCEDURE NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT. The patient was treated with ___: Bedside drainage of Right arm hematoma ___: Right arm exploration and evacuation. At the time of discharge, the patient had Primary: - Right arm hematoma - Supratherapeutic INR Secondary: - Chronic systolic CHF - Atrial fibrillation, s/p PVI and Maze with ___ ligation ___ - Mitral regurgitation, s/p mechanical MVR (27 mm St. ___ - Parkinsons disease - Hypertension - Hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y.o. ___ gentleman with HTN, CAD s/p 3v CABG in ___, MVR w/ mechanical valve, Afib on coumadin s/p ICD, systolic cardiomyopathy LVEF 40% ___, and ___ Disease as well as recent admission to the ___ service ___ - ___ for acute sCHF exacerbation and negative work-up for cardiac sarcoidosis with RH catheterization, c/b development of compartment syndrome ___ at cath site requiring fasciotomy and skin graft ___, who presented with significant bleeding from graft site and increased swelling. #Right arm bleeding: On presentation, pt with significant bleeding and swelling from graft site in the setting of supratherpeutic INR. In the emergency department, pt was evaluated by plastic surgery who performed bedside drainage of Right arm hematoma. Post-procedurally, pt was admitted to ___, where his warfarin was held and his INR was reversed with vitamin K. Pt was bridged with heparin when he became subtherapeutic. TTE did not show any thrombi on the mitral valve. Pt underwent Right arm exploration and evacuation by hand surgery on ___, which showed good hemostasis. Notably, pt was found to have difficulty closing his Right hand post-procedurally, although perfusion of the hand otherwise appeared normal. He was restarted on warfarin with heparin bridge. INR became therapeutic on ___, and pt was discharged with a plan to follow up with ___ of plastic surgery. Of note, pt was also discharged with a plan to obtain occupational therapy as an outpatient. #sCHF: Pt appeared to be euvolemic on exam. Pt's torsemide was decreased to 10mg Qday this hospitalization, and he remained roughly euvolemic on this dose.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In brief, the patient states that he was lifting heavy boxes on ___ when he noticed a sudden soreness of his neck and posterior head. On ___, he developed a significant headache. On ___, he had several bouts of emesis which led him to present for evaluation. While at the OSH, he was noted to be hypertensive with a SBP>200 and with an INR of 3.4. He received 2400 units of K-centra for reversal and was transferred to ___ for further evaluation. He last took aspirin yesterday. CT HEAD W/O CONTRAST showed Small volume intraventricular hemorrhage, right-sided. No change in ventricular size. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Similar extent of intraventricular hemorrhage layering dependently in the lateral ventricles, slightly more conspicuous in the left occipital horn since the prior study and small amount of evolving subarachnoid hemorrhage in right temporal sulci with mild regional edema. No significant mass effect, midline shift or large territory infarction. 2. Stable ventricular size since the prior study from ___. 3. Atherosclerotic plaque of the bilateral intracranial ICA resulting in mild left and mild-to-moderate right ICA stenosis. 4. Mild stenosis at the left MCA origin, likely related to atherosclerotic disease. 5. Otherwise patent circle of ___ without evidence of high-grade stenosis,occlusion,or aneurysm. 6. Atherosclerotic narrowing results in 40% stenosis of the left ICA by NASCET criteria. Intimal hyperplasia results in resulting in 55% stenosis of the right cervical internal carotid artery. The patient is status post right carotid endarterectomy. 7. Mild-to-moderate atherosclerotic narrowing of the bilateral vertebral artery origins and mild narrowing of the left subclavian artery origin. 8. Otherwise patent cervical and vertebral arteries without evidence of occlusion, dissection or aneurysm. 9. Additional findings described above. The patient was diagnosed with Headache. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ was admitted to the hospital from the emergency room after signs and symptoms and imaging were consistent with an intraventricular hemorrhage. He was observed in the hospital with frequent neuro checks as well as repeat imaging to assess for worsening symptoms of which there were none. His headache was improving, he was ambulating on his own, and remained stable clinically throughout his hospitalization. ___ was consulted while he was inpatient and titrated and adjusted his diabetes medications accordingly and made recommendations for his home regimen. ___ was consulted and saw him on ___. They recommended home upon discharge after ___ more visits. He was discharged on ___. At the time of discharge he was ambulating with assistance, voiding independently, tolerating PO diet and pain meds, and his vital signs were stable. He will restart his Aspirin on ___ and will restart his coumadin on ___. He should follow up with his PCP regarding diabetes and otitis media. Patient will follow up with Dr. ___ on ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a lovely ___ year old female with a history of HTN, RA, hypothyroidism, right leg neuropathy, and right foot drop who presents to ___ status-post fall with head strike. The patient reports that she was getting out of bed around 3AM this morning to go to the bathroom ("I have a bladder problem"), was using her walker, and prior to getting to the bathroom fell backwards hitting her head on the floor, which had a rug on it. Mrs. ___ had no loss of consciousness before, during, or after the incident, had no change in her vision, no chest pain, no shortness of breath prior to the fall. She is unsure why she fell, but does believe it is related to her baseline poor balance. She subsequently called her emergency response line, and was then taken to the ED by EMS. On presentation, the patient was also complaining of "crushing" chest pain, and was worked up by the ED for this. Mrs. ___ is currently not complaining of any head pain, no dizziness, no nausea or vomiting, no change in her vision/hearing. She does have mild neck stiffness, however. Mrs. ___ has a history of recent falls. She reports falling at least 4 times since ___ when she moved to her assisted living facility. She participates in balance classes twice weekly and does home exercises to improve her balance. At home during the day she uses a cane to ambulate, and at night she uses a walker or a walker with wheels. She is able to walk a city block with a cane without having to stop and without losing her balance. Radiology showed No evidence of fracture. Deformity in the ___ and ___ metatarsals is due to old healed fractures. Moderate degenerative changes, most pronounced at the first TMT and first MTP joint with resulting hallux valgus. Radiology showed Stable left parafalcine subdural hematoma. The patient was diagnosed with TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL, CHEST PAIN NOS. At the time of discharge, the patient had left parafalcine subdural hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was transferred to ___ from an OSH with a non-contrast CT head demonstrating a small left parafalcine subdural hematoma without shift. The patient was admitted to neurosurgery on ___ for close monitoring. A repeat non-contrast CT head was performed on ___, which demonstrated a stable SDH. The patient remained neurologically stable and her home medications were restarted on the morning of ___. Physical therapy was consulted and worked with the patient. They recomended discharging the patient back to her assisted living facility with continued ___. It was recommended the patient change her home environment to have a commode at bedside, but the patient refused this change. On ___, the patient was discharged to her assisted living facility with continued physical therapy. On discharge, she was tolerating a regular diet, her pain was well controlled, she was voiding, and was neurologically stable. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old homeless woman who presents with cough, night sweats and chills. She has had cough intermittently since ___. She was recently seen at the ___ and diagnosed with atypical pneumonia and was treated with 5 days of azithromycin, which improved her symptoms. Over the past few days, she has non-productive cough, shortness of breath and hot flashes alternating with chills. Has had night sweats. She has nasal congestion/rhinorrhea and general malaise. Poor appetite. No chest pain. No lower extremity swelling or erythema, no recent travel. She is living in the shelter with her son. Radiology showed Patchy right upper lobe opacity in a patient of this age is more worrisome for pneumonia as opposed to underlying lesion. No prior is available for comparison to assess for interval change. In the appropriate clinical setting, tuberculosis is not excluded. The patient was diagnosed with RESPIRATORY ABNORM NEC. At the time of discharge, the patient had Primary Diagnosis: shortness of breath Secondary Diagnosis: 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>___ year old homeless woman who was admitted with cough, night sweats and chills accompanied by RUL infiltrate on CXR. # Dyspnea: Patient's dyspnea was felt to be secondary to an upper respiratory URI with associated bronchospasm, which was relieved with Albuterol. Although an infiltrate was noted on CXR, this was likely an old pneumonia for which patient was already treated. In addition, she was afebrile without leukocytosis or hypoxia during entire hospitalization, making an acute process less likely, especially she had already been treated with a full antibiotic course. There was initial suspicion for active tuberculosis with fever and night sweats, but this was felt to be clinically unlikely based on history, physical and radiographic appearance of the infiltrate. Due to risk factors for acquiring latent TB, a ppd was planted and returned negative, which also reinforced low clinical concern for tuberculosis. Patient was discharged with prescription for albuterol. She should have further evaluation for suspected reactive airway disease vs. asthma with outpt PFTs. She should also have repeat CXR in ___ weeks to assess for interval resolution of RUL infiltrate. If infiltrate persists or symptoms worsen, would recommend further evaluation with CT chest and consideration of outpt Pulmonary evaluation. # Tobacco dependence: While in hospital, patient maintained on nicotine patch prn. Upon discharge, patient continued on patches with follow up arranged with PCP for continued management. # Psychosocial concerns: Patient reports difficulty finding housing and stress caring for her young son with significant social support structures. She was seen by social work while in the hospital who recommended case management services through ___ Health or a community mental health agency. The patient was given information on how to obtain these services and will follow up as outpatient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male brought by ambulance from scene after MVC at moderate speed against tree, unknown restrain but +airbag deployment, unknown LOC, no recollection of event Radiology showed 1. Evaluation of the chest markedly limited by low lung volumes, but no gross abnormality is detected. 2. No fracture or dislocation is seen in the pelvis. These results were communicated in person to Dr. ___ by ___ at 3:40 p.m., ___. Radiology showed Right subgaleal scalp hematoma and laceration. No evidence of acute intracranial process, hemorrhage, or edema. These results were given in person to Dr. ___ by Dr. ___ at 3:40 p.m., ___. Radiology showed 1. No evidence of acute fracture or dislocation. 2. Multilevel degenerative changes as detailed above. The patient was diagnosed with OPEN WOUND OF SCALP, MV COLLISION NOS-DRIVER, SYNCOPE AND COLLAPSE. The patient was treated with ___: Repair of scalp laceration. At the time of discharge, the patient had Motor vehicle crash resulting in right parietal scalp laceration and underlying subgaleal hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ arrived at our institution brought in by ambulance after a motor vehicle collision as an unrestrained driver against a tree at low-moderate speed, reportedly losing consciousness. Basic trauma protocol was activated upon his arrival to the emergency department. Physical exam and imaging studies performed, namely CT of the head and neck, were within normal limits but to a right frontoparietal scalp laceration with an underlying subgaleal hematoma. This was repaired successfully with nylon sutures shortly after arrival. Patient was admitted for observation overnight. Given no recollection of the accident or what led to it, an internal medicine consult was requested for proper workup of a possible syncopal episode. After thorough evaluation, they deemed unlikely that patient had syncopated prior to the event. All tests performed, including ECG, telemetry, and blood work were reassuring. It was later reported by one of the family members that the police report had stated that another car had been involved in the accident, leading to Mr ___ collision with a tree. No further medical workup was required and he was cleared from that standpoint. A tertiary survey done 24 hours after admission failed to reveal other injuries. On discharge, patient was doing remarkably well. He was afebrile with stable vital signs. His pain was minimal and well-controlled, and he was tolerating a regular diet, ambulating and voiding without assistance. 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: ___ s/p living related kidney transplant ___ with hyperparathyroidism now s/p neck exploration and removal of b/l upper parathyroid glands on ___. She was discharged on ___ doing well. She notes that since surgery she has had a headache unlike her migraines. The day of presentation, ___, she also notes some abdominal pain and nausea, no emesis. No bowel movement since prior to surgery. She states that her urine seems "slower" but making a normal amount, no dysuria/hematuria. No pain over transplant. Some chills and low grade temperature at home to 100.5. No trouble breathing, erythema at neck site, dyspnea, cough, chest pain, diarrhea. Does note a sore throat. CHEST (PA AND LAT) showed Small bilateral pleural effusions. The patient was diagnosed with FEVER, UNSPECIFIED, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Viral syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ is a ___ year old woman with LRRT who presents with postoperative fever. She was admitted for observation. Nl WBC. Negative UA (UCx contaminated). Negative BCx while in house. Noted some abdominal discomfort that resolved with maalox/lidocaine. Wound did not seem to be source of bacteremia. Renal transplant was consulted and agreed with observation, thinking that she has no localizing signs, and her story, particularly with sick contacts, best fits a viral etiology for her fever. She did have thrush, but it did not contribute to her fevers. Mild elevation in T resolved by HD2. The patient was discharged home 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: ___ yo male with a pmh of renal transplant, iddm who presents with a tongue infection. He reports being on nystatin for thrush for years. Over the past 7 days, he has had worsening pain in his mouth, tongue, and difficulty swallowing, leading to very minimal PO intake. He has made an effort to swallow saliva but that is mostly it. He denies f/c/neck pain/diarrhea/dysuria/rash. He has not had a BM in 7 days due to not eating. He reports working regular ___ prior to these symptoms (7 days on, 12 hour days). He saw an ID doctor ___, Dr. ___ in ___, who recommended admission for IV treatment of his mouth. He came here because he was told he would likely be transferred here from another facility once admitted there. In the ED, initial vitals were: 97.7 92 135/79 18 97% RA - Exam notable for severe ulcerations on tongue concerning for RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. The patient was diagnosed with Acute kidney failure, unspecified, Candidal stomatitis, Dehydration. The patient was treated with EGD ___ Tongue biopsy ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Candidiasis Throat pain Acute kidney injury SECONDARY DIAGNOSIS: Renal transplant End-stage renal disease s/p transplant 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>___ h/o ESRD ___ diabetic nephropathy s/p LURT ___ on MMF/sirolimus, IDDM, ___ of left ear s/p Mohs in ___, NSTEMI who presents with sore throat, found to have ulcerations and white plaque on exam. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ male w/ history of ulcerative colitis and history of Peyronie's disease of the penis who is transferred from OSH ED for penile bleeding/ edema. He recently underwent the second injection of Xiaflex (collagenase clostridium histolyticum)for treatment of the Peyronie's and had a dressing in place for four hours after the procedure. Subsequently, the patient DC'd the dressing and noted significant bleeding and swelling of the penis, mainly from the left side. The patient notes voiding normally w/ no evidence of hematuria. Denies n/v, f/c but endorses significant penile pain. Radiology showed No urethral stricture or disruption. The patient was diagnosed with HEMORR COMPLIC PROCEDURE, ABN REACT-SURG PROC NEC. At the time of discharge, the patient had Penile hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted from the emergency department after an evening of observation to Dr. ___ service for hematoma management and monitoring. The ED checked the patient's hematocrit which was completely stable upon admission and through his time of stay. The ED managed the patient overnight with IV dilaudid and a compresion dressing. The patient was extremely sedated and required catheterization with Foley urethral catheter likely from significant narcotic doses and significant compressive dressing. On the AM of HD1, this dressing was removed and a liquified hematoma was evacuated from the left side of the patient's penis. The dressing was replaced with a sterile gauze dressing and some minor spotting persisted. He was converted to oral pain medications and given tylenol as needed. Penile edema and echymoses were stable and edema was decreasing by time of discharge. At discharge, patient's pain was controlled with oral pain medications, he was tolerating regular diet, he was ambulating without assistance, and voiding without difficulty - a retrograde uretherogram showed no defect in the urethra (patient had reported some question of pneumaturia). Skin at hematoma site was stable and did not appear infected. Specific instructions about wound care were given in addition to home ___ were prescribed. This was also included in this discharge summary. Pt should call to arrange/confirm your follow-up appointment AND if you have any urological questions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ M with DM2, obesity, HCV/EtOH cirrhosis with a recent diagnosis of pancreatic adenocarcinoma who presents with fever, chills, confusion and malaise. Radiology showed Bibasilar opacities, likely representing atelectasis on the right, however the opacities in the left lower lung are slightly more confluent and may represent atelectasis or pneumonia. Mild to moderate cardiomegaly. Radiology showed 1. Limited exam due to suboptimal opacification of the pulmonary arteries however acute pulmonary emboli are noted bilaterally including lobar and segmental branches on the right and segmental branches on the left. No evidence of right heart strain. 2. Small left pleural effusion with bibasilar consolidations may reflect atelectasis or aspiration. 3. Pneumobilia status post stent placement which is in appropriate position. 4. Heterogeneous attenuation of the liver with new vague hypodensity within segment 6 of the liver is noted and given the short-term development is unlikely to represent metastases and may be perfusion abnormality. Portal veins are not assessed on this exam but the prior study mentioned a possible right portal venous thrombus. 5. Unchanged pancreatic head and neck mass with lymphadenopathy in the periportal, retroperitoneal and mesenteric stations. 6. Increasing moderate ascites. NOTIFICATION: These findings were communicated via telephone by Dr. ___ ___ to Dr. ___ at 05:50 on ___, approximately 10 minutes after review. CHEST (PORTABLE AP) showed In comparison with the study of ___, the atelectatic changes at the right base have improved. Left basilar opacification is again consistent with volume loss in the left lower lobe and pleural effusion. In the appropriate clinical setting, it would be difficult to exclude pneumonia in this region, especially in the absence of a lateral view. Continued enlargement of the cardiac silhouette without definite vascular congestion. CHEST (PORTABLE AP) showed Left basal consolidation appears to be slightly more pronounced than on the prior study in might reflect progression of infectious process. Small amount of left pleural effusion is noted. There is no pneumothorax. Cardiomediastinal silhouette is stable The patient was diagnosed with ALTERED MENTAL STATUS , JAUNDICE NOS, MALIG NEO PANCREAS 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>___ M with DM2, obesity, OSA, HCV/EtOH cirrhosis, recent diagnosis of pancreatic adenocarcenoma (___) and cholangitis s/p ERCP (___) with stent placement found to have presumed cholangitis and multisystem organ failure in the setting of overwhelming sepsis. Given his poor prognosis, the patient was transitioned to comfort measure and discharged on hospice. #) PANCREATIC ADENOCARCINOMA: Stage III/IV based on T4 tumor size (tumor encases celiac vessels and is >4cm) and +LNs seen on imaging, but full formal staging has not yet taken place. When it became clear that PTBD would not be placed due to patient's persistent decompensation, patient and family decided to transition to hospice. #) SEPSIS: Patient was admitted with chills, confusion and malaise along with worsening abdominal pain ___ in severity), nausea, poor PO intake and jaundice concerning for cholangitis. He was started on IV vancomycin and pip/tazo upon admission. ERCP was significant for malignant-appearing strictures as well- unfortunately ERCP revealed blockage of biliary drainage with no possible endoscopic intervention. PTBD scheduled ___ was deferred in the setting of continued decompensation. Pip/tazo was d/c on ___. Of note, blood cultures from admission were consistent with strep viridans and subsequent blood cultures from ___ were consistent with gram negative rods, presumably from GI source. Patient was started on meropenem on ___ for concern of sepsis in the setting of fever, tachycardia, and respiratory distress while awaiting PTBD. Interventional radiology subsequently concluded that patient is longer candidate for PTBD due to respiratory issues and concern for instability under anesthesia. Antibiotics were discontinued upon transitioned to comfort measures. #) RESPIRATORY DISTRESS: While in the PACU awaiting PTBD on ___, patient developed tachycardia and increasing respiratory distress with increasing O2 requirements to 10L facemask. The operation was held and he transferred to the MICU. Symptoms were presumably from sepsis and PE. Patient was initially restarted on heparin gtt at lower goal but this was discontinued within ___ given worsening coagulopathy. #) PULMONARY EMBOLUS: On ___ CTA C/A/P showed acute PE bilaterally in lobar and segmental branches for which patient was started on heparin gtt. Heparin gtt was discontinued midnight prior to anticipated PTBD on ___. Heparin gtt was briefly restarted on heparin gtt at lower goal the evening that procedure was deferred but this was again within 12h given worsening coagulopathy. #) HEPATITIS C/ETOH CIRRHOSIS: Peritoneal fluid studies are not consistent with SBP. Scheduled for liver bx with ___ but deferring in setting of acute illness. SAAG>1.1 suggesting likely secondary to portal hypertension. # Communication: HCP:Brother/HCP ___ (___) # Code: DNR/DNI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with ESRD (on HD MWF), NASH cirrhosis (EGD ___ (-)varices, (+)GAVE & portal HTN gastropathy), history of GIB (EGD ___ (+)antral erosions & AVMs), CAD s/p CABG (LIMA to LAD and SVG to PDA ___, pAF (not on anticoagulation), HFpEF, T2DM, who presented with pleuritic chest pain and is admitted for workup and management of chest pain. Chest radiograph showed Low lung volumes with suspected superimposed vascular congestion. Bibasilar atelectasis without definite focal consolidation. The patient was diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs, End stage renal disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with ESRD (on HD MWF), NASH cirrhosis (EGD ___ (-)varices, (+)GAVE & portal HTN gastropathy), history of GIB (EGD ___ (+)antral erosions & AVMs), CAD s/p CABG (LIMA to LAD and SVG to PDA ___, pAF (not on anticoagulation), HFpEF, T2DM, who presented with non-pleuritic chest pain and is admitted for workup and management of chest pain. Most likely etiology is musculoskeletal given reproducibility on exam. # Chest pain. Given that the pain is reproducible on exam, most likely musculoskeletal in nature. Trop 0.04x2, CKMB2. Does not seem to be cardiac chest pain given that it is non-exertional, no radiation, and no associated nausea or diaphoresis. Does not need nuclear stress test at this time. The patient can follow-up with outpatient cardiologist if pain has new exertional component. Can treat pain with diclofenac sodium topical gel post-discharge. # ESRD on HD. ESRD ___ to T2DM. On HD since ___ - MWF. Had HD w/ 1L UF on ___. - Continued Calcium Acetate 1334 mg PO tid with meals - Continued Hectorol 11 mcg IV q HD - Continued vitamin D 1000 units daily # CAD s/p CABG. Continued ASA, metop, imdur, statin. # History Afib (not on anticoagulation ___ GIB). CHADS2VASC 5. Continued metop. Currently in sinus. # DMII. ISS while in hospital. # Anemia: Multifactorial - anemia of renal disease, known GI bleeding. Hgb 8.3 on admission. Hgb 8.6 on discharge, no signs of bleeding. - Continued Venofer 50 mg IV q ___ - Continued Epogen 8000 units q HD # HTN: Normotensive - Continued Amlodipine 10 mg, Isosorbide mononitrate ER 30 mg, Metoprolol succinate XL 150 mg # Nutrition: Low Na, Low K, Low P diet, water restriction to 1.5L per day. Nephrocaps 1 CAP daily. # NASH Cirrhosis (MELD-Na 23) - Patient does not have a history of varices. No clinical e/o decompensation. Patient follows with Dr. ___. # Asthma - Continued home albuterol, fluticasone inhalers. # Depression - Continued home paroxetine. # GERD. - Continued pantoprazole.</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 history of Stage II SCC of the lung on C2D3 of ___, CAD s/p stent, interstitial fibrosis, HIV on HAART, COPD on home O2 2L NC presenting today with increasing SOB and L foot swelling. Radiology showed Stable chest radiograph. No new focal lung consolidation. Radiology showed 1. Evaluation of the distal subsegmental pulmonary arterial branches supplying the bilateral lower lobes due to respiratory motion artifact. Otherwise, no evidence of pulmonary embolism. No acute aortic syndrome. 2. Emphysema dependent reticular opacities at the right lung base, potentially atelectasis. Given chronicity, these could represent sequelae of aspiration or infection in the appropriate clinical setting. 3. Moderate to severe luminal narrowing of the proximal left subclavian artery secondary to noncalcified atherosclerotic plaque. 4. 9 mm AP window lymph node is decreased in size from prior exam from ___, previously 11 mm. 5. Persistent narrowing of the left upper lobe bronchus and partial left upper lobe, lingular atelectasis. 6. Mild intra and extrahepatic biliary ductal dilation is partially imaged however unchanged from prior exams, better evaluated on prior dedicated abdominal imaging. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Sepsis, unspecified organism. At the time of discharge, the patient had Primary: health care associated Pneumonia severe C. diff colitis Secondary: Stage II squamous cell carcinoma of the lung. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with Stage II SCC of the lung who presented with HCAP and recurrent C. diff infection. He continued to receive radiation while inpatient. For his HCAP he was treated with a 7d course of antibiotics (cefepime, transitioned to augmentin). His C. diff was treated with PO vancomycin and PO flagyl. He was also having right sided chest wall pain, associated with swallowing. Rad-onc felt this was most likely a side effect of his radiation. This was managed with Oxycodone and a lidocaine patch. ___ also worked with him while he was here and felt he was strong enough to go home and did not require ___ rehab. He developed neutropenia during his hospitalization, likely due to recent chemotherapy. He was treated with neupogen with normalization of his white blood cell count. He developed volume overload while in the hospital, as his home torsemide was held due to his C. Diff infection. He was treated with IV Lasix and then transitioned back to his home torsemide. He developed a mild ___ so his torsemide dose was decreased to 20mg. With this dose, his Cr returned to baseline. Please continue to assess his volume status and adjust the dose of torsemide as an outpatient. Pt's HIV markers were checked as inpatient. His Viral load was 63 copies/mL. His CD4 count was low (64) but his percentage was normal (32%) so the low CD4 count likely was due to his leukopenia rather than his HIV burden, so he does not need PCP ___. His CD4 count should be rechecked at a follow-up appointment once his white count has normalized. #Acute on chronic respiratory failure secondary to HCAP. The patient has SCC of the lung and is on 2L NC at home, however he developed an increasing oxygen requirement and cough. CTA chest on ___ showed opacities in R lung base that "could represent pneumonia in the right clinical setting". Because the patient had an increased O2 requirement, a worsening cough, and was just discharged from the hospital on ___, he was treated for HCAP. He was initially started on cefepime, and completed his 7d course with augmentin. His O2 requirement improved, and he was actually able to be on room air at times with O2 sat > 93%. He went home on oxygen as he was still intermittently requiring up to 2L. #Recurrent C. diff. The patient had recurrent C. diff which was treated initially with PO vanc. It was not improving, likely because he was being treated for HCAP at the same time, so he was started on IV flagyl. Prior to discharge his diarrhea had decreased in frequency but was still more than his baseline. Because he has had recurrent episodes of C. diff, he was set up with an outpatient appointment with ID to discuss the possibility of fecal transplant. He was discharged on PO vanc and PO flagyl to complete a full 14d course from the day he finished the augmentin for his HCAP. #Odynophagia. The patient was complaining of R sided chest wall pain associated with swallowing. He had a recent endoscopy which showed esophagitis, which is consistent with his long standing GERD treated with ranitidine; however, this is not consistent with R sided chest pain. He had no evidence of oral thrush on exam; however, he could have had esophageal thrush so he was treated empirically with nystatin with no improvement in his symptoms. Rad/onc felt that even though his radiation was directed at his L chest, this pain could be a side effect of the radiation. He was treated with oxycodone 15mg PRN and a lidocaine patch with some improvement of his symptoms. He was discharged home on this regimen. #Neutropenia. Attributed to the ___ he got on ___ and his radiation therapy. He was given neupogen, which was stopped when his ___ recovered. #Pitting sacral and lower extremity edema. The patient's home torsemide was held because he was having >10 loose bowel movements/day from his C.diff infection. He developed pitting sacral and lower extremity edema. He was diuresed with IV Lasix and wore TEDS. Prior to discharge he was restarted on his home torsemide 40mg, but was feeling lightheaded and had SBP <100. For that reason he was discharged on half his home dose (Torsemide 20mg). #HIV. Pt's HIV markers were checked as inpatient. His Viral load was 63 copies/mL. His CD4 count was low (64) but his percentage was normal (32%) so the low CD4 count likely was due to his leukopenia rather than his HIV burden, so he does not need PCP ___. He was continued on his home HIV regimen of Darunivr, Truvada, Ritonavir. #Stage II lung squamous cell carcinoma. Started cycle 2 ___ taxol ___. Continued to receive daily radiation as an inpatient. #L foot and ankle swelling. Minimal swelling on exam without history of trauma, no evidence of infection. CTA negative for PE and negative ___ for acute DVT. #CAD. Continued home ASA, statin #COPD. Continued home tiotropium and albuterol neb prn #Depression. Continued quetiapine and venlafaxine. #GERD. Continued home ranitidine #Subclavian Stenosis. Noted during previous admission. BPs softer in L arm, so BP only checked in R arm.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with a history of multiple myeloma/plasmacytoma who is admitted with increasing back pain. The patient states she has been having more pain for the past month which is why she reestablished care with her oncologist. However she states in the last couple of days the pain has gotten much worse and is interfering with her ambulation. She denies any bowel or bladder incontinence. She endorsees a possible episode of brief numbness in her leg while in the ED prior to admission but denies any other numbness and is very vague about this. She states the pain is worse with any movement such as going from lying to sitting, etc. She denies any recent fevers, significant weight loss, shortness of breath, diarrhea, rashes, or dysuria. She states she had not followed up with oncologist because she was scared but she is not very specific about this. MR ___ AND W/O CONTRAST ___ MR SPINE showed 1. Study had to be aborted in between because of patient discomfort without the acquisition of axial T1 postcontrast images. 2. Stable left sacral mass in keeping with patient's known plasmacytoma causing mild left S1-S2 neural foramen narrowing. This is better evaluated on concurrent MRI of the pelvis. 3. No new lesions are seen. 4. Stable mild degenerative disease at L5-S1 causing moderate left and mild right neural foramen narrowing as described above. Radiology showed Previously biopsied left sacral plasmacytoma is unchanged in size or appearance compared to MRI of the lumbar spine on ___. The lesion is predominantly nonenhancing and presumed necrotic, with mostly thin peripheral enhancement, however there are some mildly thickened areas of peripheral enhancement which could represent residual plasmacytoma, similar to L-spine MRI from ___. The lesion extends across the posterior left SI joint and also causes narrowing of the left L5-S1 and S1-S2 neural foramen, abutting the exiting nerve roots at these levels, unchanged. A chronic fracture of the left anterior sacrum is unchanged. No new fracture or new suspicious osseous lesion. Probable mild degenerative changes about both SI joints. In addition, patchy high STIR signal in both iliac bones --question related to sites of prior bone marrow biopsy. Attention to this area on followup exams is requested. CT HEAD W/O CONTRAST showed 1. Normal study. NOTIFICATION: Findings were discussed by telephone by Dr. ___ with Dr. ___ at 15:17 ___ immediately upon reviewing the examination. The patient was diagnosed with Low back pain. At the time of discharge, the patient had Primary: Multiple Myeloma Secondary: Back Pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT AND PLAN: ___ yo female with a history of multiple myeloma/plasmacytoma who is admitted with increasing back pain. #Transaminitis: Noted on ___, slight elevation of ALT/AST. T bili normal. Unclear etiology, possibly medication-induced but not taking much medication now. No abdominal discomfort or fever on exam. Will monitor closely outpatient. #Constipation: Had 2 bowel movements this morning. Likely as a result of opioids given in the setting of back pain. Added miralax and dulcolax to stool regimen in the past 2 days, continues with Colace and Senna BID. Now controlled on oxycodone prn, off oxycontin. Monitoring closely #Multiple Myeloma/Plasmacytoma/Back Pain: - Plasmacytoma seen on MRI - Consulted neurosurgery to see possible interventions that will help alleviate pain - for now no surgical intervention indicated per their recs -PET Scan on ___ showed that the rim of the left sacral lesion demonstrates borderline increased FDG uptake, possibly due to bony remodeling/inflammation, without clear focal area of differentially increased FDG uptake for biopsy target but otherwise no focus of FDG avid disease. Therefore, no need for sacral biopsy in addition to Rad ONC evaluation. We offered patient biopsy of the lesion at the rim as above but patient refused. - PRN oxycodone - uptitrated oxycontin to 10mg q8 over the weekend, used 80mg total oxycodone in prns/restarted Neurontin 300mg TID on ___ however, discontinued ___ due to AMS/Syncope - Consider palliative care consult if pain uncontrolled - has been stable. - Holding off BM bx as most recent disease markers on ___ are stable, patient has refused in the past but will defer to outpatient provider, Dr. ___ she needs procedure done - ___ consult, rec encourage frequent mobility and maximize independence in ADLs. Assist of 1 for ambulation and transfers out of bed to chair 3x/day with a SC. #Lightheadedness/AMS: Resolved. Likely related to NPO status in addition to pain medications. Obtained blood cultures ___ to rule out infectious process, NTD. Head CT ___ - ruled out acute bleed or infarct. Now on regular diet, received 1L NS while NPO, will continue to monitor closely #Coping: Patient has minimal social support. Son was in ___ custody for 47 days per her report. Daughter is very supportive but patient reports that she is not able to live with her at the current apartment. Has financial constraints. On section 8 but not able to find any suitable housing for now. Consulted ___ for support. Shelter arrangements in process. Consider family meeting with daughter prior to discharge today. Has missed appointments with Dr. ___ as she was afraid of potential interventions she will receive at the clinic. She is very anxious about bone marrow biopsy and/or needle sticks. #Anxiety: Regarding healthcare and procedures. continue on Ativan prn #FEN: - Electrolytes per oncology scales - Regular diet #BOWEL REGIMEN: - Colace/Senna BID + Miralax #DVT PROPHYLAXIS: - Heparin 5000 units SC BID, hold if plts < 50K #ACCESS: - Peripheral IV #Disposition: BMT for now, expected discharge post symptomatic improvement #Code status: full</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with no significant PMH who presented to the ED as a transfer from ___ after a transient episode of word finding difficulties. Neurology was consulted as a code stroke. LKW 4:30pm on ___. MR HEAD W/O CONTRAST PORT ___ MR HEAD showed 1. Study is mildly degraded by motion. 2. Acute to subacute punctate left superior frontal gyrus and corona radiata probable infarcts without definite hemorrhagic transformation as described. 3. Global volume loss and probable microangiopathic changes as described. The patient was diagnosed with Transient cerebral ischemic attack, unspecified. At the time of discharge, the patient had acute ischemic stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with no significant PMH who presented to the ED as a transfer from ___ after a transient episode of word finding difficulties, initially concerned for TIA. Had been considered a candidate for tPA via telestroke, but tPA not administered due to significant improvement in symptoms. Patient was loaded with aspirin and Plavix. Upon transfer, the patient reported that her speech was back to baseline without any residual deficits. MRI head showed acute to subacute punctate left superior frontal gyrus and corona radiata probable infarcts without evidence of hemorrhagic transformation. TTE showed no evidence of source of cardiac embolus. A1c was found to be 5.5 and LDL 102. Patient remained in her baseline functional status and was discharged home safely with ongoing aspirin and atorvastatin and a 30-day course of Plavix.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed Cardiomediastinal silhouette is within normal limits. Increased bilateral interstitial opacities with peribronchial thickening and subtle retrocardiac opacities which may represent pneumonia in appropriate clinical setting. There are no pneumothoraces. Sclerosis within the bilateral humeral heads, may be seen with sickle cell arthropathy. The patient was diagnosed with Hb-SS disease with crisis, unspecified, Other pneumonia, unspecified organism, Chest pain, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with a past medical history notable for severe AS and sickle cell disease who presented with an acute pain crisis in setting of possible community acquired pneumonia.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with a POMHx of micronodular cirrhosis (decompensated by ascites), pancreatic neuroendocrine tumor with met to cirrhotic liver, HTN, HLD, IDDM and CAD, who presents with chief complaint of weakness. Per pt, he has been feeling fatigued for the past several days. He has also been experiencing dyspnea and cough in addition to a chronic headache and neck pain. On day of visit, he also developed diarrhea. Family corroborated that pt has been lethargic at home, but were not available by phone overnight. Per pt, he had undergone a therapeutic paracentesis 1d prior to admission (9L removed). Pt arrived to the PACU for a TIPS procedure and slipped from his wheelchair (evidently due to reduced ___ strength). There was no LOC or head strike. TIPS was deferred due to potential HE. In the ED, initial vitals were T 100.6 P 66 BP 110/51 R 16 O2 Sat 100%. He was found to have asterixis and brown guaiac negative stool per GI in the ED. Labs were significant for K 5.2, Na 132, HCO3 20, Cr 2.1, lactate 1.7, WBC 2.6, AST 73, ascites with 40BWC and 1 poly/62 macrophages, BCx and peritoneal cultures were sent. CXR shows ?small effusions. EKG showed NSR at 68bom and low voltage. He received CTX 2g IV x 1 and was admitted for further management. ROS: per HPI, denies fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, chest pain, abdominal pain, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Color Doppler and spectral waveform analysis was performed. The main, right and left portal veins are patent with hepatopetal flow. Appropriate arterial waveforms are seen in the main hepatic artery. The hepatic veins and IVC are patent. IMPRESSION: 1. Patent hepatic vasculature. No portal vein thrombus identified. 2. Minimal fluid in the pericardial space which does not appear to represent a significant effusion. 3. Large amount of ascites in the abdomen. 4. Heterogeneous hepatic architecture and small left lobe lesion, however visualization of the liver is limited due to the patient's body habitus. 5. Cholelithiasis. showed 1. Patent hepatic vasculature. No portal vein thrombus identified. 2. Minimal fluid in the pericardial space which does not appear to represent a significant effusion. 3. Large amount of ascites in the abdomen. 4. Heterogeneous hepatic architecture and small left lobe lesion, however visualization of the liver is limited due to the patient's body habitus. 5. Cholelithiasis. Radiology showed No evidence of deep vein thrombosis in either leg. Radiology showed AP chest compared to ___ through ___: Interval increase in mediastinal caliber at the level of the vascular pedicle, the pulmonary outflow tract, and upper lobe pulmonary vessels suggest volume overload. Heart size increased slightly. No pulmonary edema as yet. No pleural effusion. Radiology showed 1. No evidence of hydronephrosis or stones. 2. Left renal cyst with a thin septation. 3. Large volume ascites. Radiology showed Bilateral lower lobe opacities/infiltrates that have worsened in the interval. Radiology showed AP chest compared to ___ through ___: Previously questioned bibasilar consolidation is no longer present. Also improved is pulmonary vascular congestion. Mediastinal fullness particularly in the right paratracheal region is a longstanding finding, due to mediastinal fat deposition primarily. Heart size is normal. There is no pleural abnormality. Radiology showed Frontal view suggests a new very small region of consolidation at the base of the left lung projecting over the posterior left tenth rib. The region is so small, I would not expect to see it confirmed on the lateral view, which is essentially clear. In order to verify this finding, we would require oblique views. Lungs are otherwise clear. Small pleural effusions seen only on the lateral view with certainty could have been present previously. Heart size is normal and pulmonary vasculature is unremarkable. Mild mediastinal widening, particularly to the right of midline is nevertheless due to mediastinal fat deposition demonstrated by chest CT on ___. Radiology showed Persistent small pleural effusions. Radiology showed Successful advancement of a nasointestinal tube to the post-pyloric position with the tube terminating at the level of the ligament of Treitz. The tube is ready to use. Radiology showed AP chest compared to ___: Examination centered in the low mediastinum excludes the lung apices. Shows an upper enteric drainage tube ending in the stomach, clear lower lungs, normal heart size, and no appreciable pleural effusion. Radiology showed Successful advancement of the nasointestinal tube to the post-pyloric location with the tube terminating at the level of the ligament of Treitz. The tube is ready to use. Radiology showed NGT terminating within the distal stomach/proximal duodenum. The patient was diagnosed with OTHER ASCITES. The patient was treated with ___ EGD ___ Large volume paracentesis ___ Diagnostic paracentesis ___ Diagnostic and Therapeutic paracentesis ___ ___ tube placement. At the time of discharge, the patient had PRIMARY #Influenza A #Prevotella Sp. spontaneous bacterial peritonitis #Prevotella Sp. bloodstream infections #Acute tubular necrosis #Acute interstitial nephritis #Hepatic encephalopathy SECONDARY #NASH cirrhosis #Refractory ascites #Protein-calorie malnutrition #Pancreatic neuro-endocrine tumour. The patient was given written instructions concerning 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/cirrhosis (presumed NASH), pancreatic neuroendocrine tumor metastatic to liver, coronary artery disease, presents with weakness and fatigue, found to be influenza positive. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with progressive MS who was recently hospitalized for septic shock secondary to ruptured appendicitis s/p exploratory laparotomy with right hemicolectomy, left in discontinuity with an open abdomen ___ ___, interval ileo-colonic anastomosis ___ ___ and delayed abdominal wall closure with placement of wound VAC ___ ___. Her hospital course was complicated by a left common femoral vein DVT. Heparin gtt and warfarin therapy were attempted but she developed bright red blood per rectum. An IVC filter was therefore placed on ___ and anticoagulation was discontinued. She was discharged to ___ and ___ of ___ on ___. Per her husband, she has progressed slowly at rehab but had been tolerating a regular diet. Of note Coumadin was restarted at rehab. Over the past week, she has not been feeling well with malaise, poor PO intake, and occasional nausea and vomiting. This morning, the nursing staff noticed purulent, malodorous fluid discharge from her a right posterior flank 2cm skin opening. She was therefore transferred to ___. CT scan was obtained which showed a 14 x 4 x 4.6 cm lateral right abdominopelvic abscess with a cutaneous fistula. She was subsequently transferred to ___ for further care. On arrival patient was hypotensive requiring Levophed for pressure support. She was give IV fluid resuscitation and 1U pRBC for hct 20.8. Surgery was consulted for further evaluation. CHEST (PORTABLE AP) showed Right IJ central venous catheter tip in the mid SVC region. CHEST (PORTABLE AP) showed In comparison to ___ chest radiograph, the patient has been intubated with endotracheal tube in standard position. Additionally, a a new area of consolidation has developed a left retrocardiac region, and it raises the possibility of aspiration and less likely developing infectious pneumonia. No other relevant change. CT abdomen and pelvis with IV and oral contrast. showed 1. Status post right hemicolectomy with a right lower quadrant drain in appropriate positioning with resolution of the previously visualized fluid collection. 2. No residual fluid collection. A small amount of free fluid in the pelvis. 3. Mild edema of the small bowel loops and gallbladder wall are likely due to third spacing. 4. Stable hemangioma within the liver. 5. Infrarenal IVC filter in appropriate position. CHEST (PORTABLE AP) showed In comparison to prior radiograph from earlier today, a nasogastric tube has been placed, coiling within the esophagus, with distal tip directed cephalad. At the time of this dictation, a separately dictated radiograph has been subsequently performed which confirms successful repositioning. Exam is otherwise remarkable for worsening left retrocardiac opacification. CHEST (PORTABLE AP) showed In compared to sent to the previous radiograph from earlier today, a nasogastric tube has been repositioned, now terminating in the stomach. No other relevant change since the prior study of approximately 1 hr earlier. The patient was diagnosed with Fistula of intestine. The patient was treated with I and D of intraabdominal abscess by a flank incision.. At the time of discharge, the patient had Abdominal abscess Acute sepsis Acute on chronic malnutrition. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Briefly, Ms. ___ was admitted to ___ on ___ for evaluation of a developing abdominal infection. She underwent a right flank exploration with surgical drainage of an abdominopelvic abscess on ___, please see operative note for details. She was admitted to the ICU postoperatively for a persistent pressor requirement and for close monitoring, please see daily ICU notes for details. She was transferred to the floor and her NGT placed post-operatively was removed. Her home warfarin was restarted and she was noted to be malnourished on clinical and laboratory exam; she was offered a PEG tube after failing to take in adequate PO, but refused. Her home medications were restarted when she was stable, and she had a Foley catheter during her hospitalization secondary to persistent post-operative labial swelling and perineal skin irritiaton. On ___, she was found to be medically stable for return to rehab. She was discharged in stable condition with instructions to follow up with her PCP and in ___ clinic. Hospital Issues # Abdominal abscess - s/p open I&D, ___ placed ___ be removed at time of clinic visit, abx course completed (vanc/ceftazidime). # Malnutrition - pt appears chronically malnourished, will require supplemental nutrition via Dobhoff vs PEG vs improved PO intake # Heel ulcer - Pt has chronic heel ulcers that will require outpatient podiatry follow up for potential debridement. # DVT - restart warfarin, INR monitoring continued</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F w/ h/o metastatic breast cancer (liver, skull, and spine mets), s/p C1D8 eribulin, s/p recent admission for confusion returns w/ c/o persistent confusion. Radiology showed 1. Osseous metastatic lesions throughout the thoracic and lumbar spine, more conspicuous and more avid in the thoracic spine as described above, from T5 through T11 levels with no evidence of focal or diffuse lesions throughout the thoracic spinal cord to indicate spinal cord edema or cord expansion. 2. Relatively stable metastatic lesions in the lumbar spine with post-surgical changes, consistent with laminectomies and posterior fixation as described above. 3. Unchanged collection in the surgical bed extending from L3 through L5/S1 levels with no evidence of enhancement to suggest an abscess formation, this collection may represent a seroma, the possibility of a CSF fistula is also a consideration. 4. Compression fracture at the level of L4 with vertebra plana, and unchanged retropulsion, causing anterior thecal sac deformity. A preliminary report was provided by Dr. ___ communicated to Dr. ___ at 16:40 hours on ___, via phone call at the time of the discovery of this finding. The patient was diagnosed with FAILURE TO THRIVE,ADULT, SECONDARY MALIG NEO BONE. At the time of discharge, the patient had Breast 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>Ms. ___ is a very pleasant ___ yo F with metastatic breast cancer (spine, liver, cranium) s/p numerous chemo regimens (letrozole, taxol, capecitabine, doxol, eribulin) and XRT with progressive disease who has had worsening episodes of confusion over the last few weeks. During this admission, she was in her nadir from recent Eribulin and was treated with empiric antibiotics for neutropenic fever. She also required a temporary Foley for urinary retentionm. Both of these had resolved by day of discharge. The patient may have leptomeningeal involvement of her cancer. LP was deferred, and patient made the decision to transition to ___ Focused Care with Home Hospice, living with her children. The goals of care and medications were transitioned accordingly and patient was set up for home hospice prior to discharge in good condition, mentating and ambulating well.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F w/ PMH of lithium-induced ESRD on PD, hemorrhoids, tracheal stenosis, and hypertension recently discharged on ___ after transplant surg admit for diverticulitis (treated conservatively w/ levo flagyl), and then subsequently admitted for UTI and treated with meropenam who presents with blood in BM. She went to ___, where she underwent a CT that showed a 10x7 cm pelvic abscess (unchanged from ___, and then receieved a dose of ertapenam, and was transferred here. She was initally seen a ___, where a CT scan was performed that showed a Large deep pelvic abscess colelction without signficant chance int he size since a study there in ___. Air is present in the bladder, which was thought to be secondary to either a recent bladder cathererization or a colovesicular fistula. There was also free air described in the peritoneal cavity. At ___ she recieved 1 gram of ertapenam. In our ED, she was found to be without fever, chills, nausea, or vomiting. She endorsed minimal lower abdominal pain made worse when she bore down to urinate. . In the ED, initial VS were 98 76 115/65 18 95% On transfer, 97.9 75 107/63 16 95% Labs were notable for a dirty U/A, Na 129, Cr 8.1, Ca 8, Phos 5, AP 471, HCT 26.1. On arrival to the floor, she is AAOx3 and about to bite into a sandwich. . 10 point ros is negative except per above Radiology showed 1. Placement of a 19 cm (tip to cuff) tunneled HD access catheter through a right internal jugular vein approach. The tip is located in the right atrium, and the catheter is ready for use. 2. Uncomplicated ultrasound and fluoroscopically guided single lumen PICC placement via a right brachial venous approach. Final internal length is 43 cm, with the tip positioned in SVC. The line is ready for use. Radiology showed Patent left cephalic and basilic veins with diameters as noted. Radiology showed No deep vein thrombosis in right upper extremity. Radiology showed Patent right cephalic and basilic veins with diameters as noted above. Radiology showed Colon perforation, into a collection which is drained/communicating with the pigtail catheter. The patient was diagnosed with PERITONEAL ABSCESS, URIN TRACT INFECTION NOS. The patient was treated with HD line placement PICC line placement PD catheter removal in the OR Pigtail drain placement into pelvic abscess. At the time of discharge, the patient had Primary Diagnosis: Pelvic abscess Enterovesicular fistula . Secondary Diagnosis: End Stage Renal Disease on 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>ASSESSMENT & PLAN: ___ y/o F w/ PMH of lithium-induced ESRD on PD, hemorrhoids, tracheal stenosis, and hypertension recently discharged on ___ after transplant surg admit for diverticulitis (treated conservatively w/ levo flagyl), and then subsequently admitted for UTI and treated with meropenum who presents with blood in BM, and a concerning CT scan for fistula now s/p drain placement. # Pelvic Abscess with enterovesicular fistula: s/p drain placement Currently draining purulent material. Cultures with polymicrobial infection as well as ___ albicans growing from abscess. Per surgery, no colectomy during this hospitalization, will need to follow up as outpatient. Her Foley continued to drain pus and given the fistula between the abscess and the dome of the bladder urology was consulted and they felt that the Foley needed to stay in long term and that with the foley in place and the pigtail drain, the fistulous tract should resolve on its own. Given her pelvic abscess, PD was contraindicated. An HD line was tunelled in the patient's right chest wall and PICC line was placed on the right as well. The patient went for surgical removal of her PD catheter and the surgical sites were healing well at the time of discharge. For antiobiotics of her infection, she was placed on meropenem and fluconazole. She was also kept on PO flagyl for her c. diff and she will need to continue the flagyl for 14 days after the last dose of her other abx. She will have follow up with ID, Urology, Colorectal surgery for further management of her abscess. The patient was discharged home with her sister caring for her. # ESRD on Dialysis: Ms. ___ was on PD on arrival, but given her abscess PD was held. She was going to need long term management of this abscess and so an HD line was placed and she was started on Hemodialysis. PPD was negative and hep serologies were sent. She tolerated HD well. PD catheter was removed and she tolerated the procedure well without complications. In addition, the renal team was following her and we started sevelamer 800mg PO TID w/ meals. She otherwise did very well from a renal standpoint. As changes in the management of her Dialysis evolved, I constantly updated her outpatient nephrologist so that he was up to date on the plan upon discharge. In addition, we started vein preservation on the LUE and mapping for possible AV fistula vs. graft was done prior to discharge. # RUE swelling: RUE swelling was noticed while she was in the OR having her PD catheter removed. It was initially thought to be ___ blood pressure cuff on that arm, but it did not resolve on arrival to the floor. She had no erythema or pain in the arm, but given she had a PICC line and HD line on the right she was sent for RUE dopplers that was negative for DVT. Unclear why she was having edema and it will need to be followed in the outpatient setting. # UTI: Patient has a history of a fairly sensitive E. Coli in the past, but required treatment with meropenam because of allergies. Mixed flora in urine likely realted to fistula. See abx and management of abscess and fistula as above. # Guiaic Positive Stool: Patient is reported as having guiaic positive brown stool. Etiologies include hemmorhoids, which the patient has a known history of, as well as diverticulitis. HCT is currently at baseline with the patient remaining hemodynamically stable. Hct was stable throughout most of her hospital stay. # Hyponatremia: Patient appears to be euvolemic, could be secondary to SIADH. Resovled without significant intervention. # Macrocytic Anemia: At baseline. Iron studies in ___ suggest ACI. # C. Diff: Patient was 1 day short of completing an antibiotic course for c. dif. will continue flagyl for now given on other abx as well. See above for plan for c. diff management. Essentially flagyl will be continued for 14 days after discontinuation of other abx. # Rash: Appeared to be a fixed drug reaction. The area was marked and despite not changing any of her medications, the rash improved. At the time of discharge it was not present. # PSYCH: Continued home meds: - Fluoxetine 20 mg PO DAILY - Lithium Carbonate 150 mg PO BID - OLANZapine 10 mg PO BID - Lorazepam 1 mg PO QHS:PRN insomina - OLANZapine 5 mg PO ASDIR .</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 metastatic renal cell carcinoma, currently on Axitinib with response to therapy seen on recent CT scan, who present to ___ with generalized weakness and weight loss. He reports feeling more short of breath recently with any sort of activity, worse in the past 3 days. He denies chest pain, palpitations or lightheaded symptoms. He denies nausea, vomiting, diarrhea or constipation. Radiology showed Known right pulmonary and pleural based metastatic lesions are better depicted on the recent CT exam. No acute cardiopulmonary abnormality otherwise identified. Unchanged osseous metastasis involving the right ___ lateral rib. Radiology showed 1. No intracranial hemorrhage or acute territorial infarction. 2. Stable 6 mm left lateral ventricular lesion, better characterized on previous MRIs. Radiology showed 1. No evidence of intracranial metastatic disease. No acute infarct or hemorrhage. 2. Two tiny non-enhancing left lateral intraventricular lesions, stable since ___ given the long-term stability, they likely represent benign etiology such as subependymoma or hamartoma. 3. Moderate global volume loss with mild sequelae of chronic microvascular ischemic disease. The patient was diagnosed with DEHYDRATION, OTHER MALAISE AND FATIGUE, RENAL & URETERAL DIS NOS, MALIG NEOPL KIDNEY. At the time of discharge, the patient had Primary: metastatic renal cell carcinoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with metastatic renal cell carcinoma who presented with shortness of breath and overall weakness, unclear etiology. #. Fatigue/failure to thrive: Patient presented with worsening failure to thrive and fatigue over past months. Etiology unclear, however likely multifactorial secondary to chemotherapy, deconditioning and hypothyroidism. It is not clear this is related to progression of disease as his last CT scan showed improvement in metastatic RCC. TSH elevated with normal T4 and low T3 so patient started on levothyroxine 12.5 mg daily. B12 was low on admission so patient was given IM repletion while here and started on PO supplement on discharge. Cortisol was normal. Patient was seen by palliative care and nutrition. Nutrition recommended supplements. Dexamethasone 2 mg daily was started per palliative care recommendations. An MRI brain was done to rule out metastatic disease and this was negative. Patient was gently hydrated with NS at 100 cc/hr. Axitinib was held as this may be causing some of symptoms, could consider restarting as outpatient. Citalopram was continued for depression. #. Shortness of Breath: Patietn complained of dsypnea on exertion. Given oncology history there is concern for pulmonary embolism; however his sats are 100% on room air and he is not tachycardic. Hypothyroidism may be contributing. Likely he is deconditioned from weight loss and overall decline. Exam and chest x-ray were not not concerning for CHF or PNA. Patient was saturating well and comfortable on room air at rest, however desaturated with ambulation. It was difficult to assess whether this was a true desaturation or a poor measurement. Patient was discharged with home oxygen. #. Metastatic RCC: Patient responding to Axitinib based on last CT scan on ___, however functional status as declined. Pain was adequately controlled with ___ regimen. Axitinib was held as it may have been contributing to symptoms or overall decline. Patient was seen by palliative care and started on dexamethasone. #. BPH: Continued flomax, finasteride.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with history of HTN, pAF, CVA, MR, CKD presenting from his PCP's office with pre-syncope. CT HEAD W/O CONTRAST showed 1. No intracranial hemorrhage. No definite acute large territorial infarction, although MRI is more sensitive the detection of acute infarct. 2. Extensive encephalomalacia centered in the left parietal lobe, likely reflecting prior chronic infarct. CHEST (PORTABLE AP) showed No acute intrathoracic process. The patient was diagnosed with Syncope and collapse, Altered mental status, unspecified. At the time of discharge, the patient had Pre-syncope Presumed UTI Paroxysmal atrial fibrillation HTN BPH Severe mitral regurgitation CKD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted for presyncope. #Presyncope: Telemetry showed only rate-controlled atrial fibrillation. Cardiology was consulted and given recent extensive cardiac workup, they felt this episode was unlikely to be cardiac in origin. TTE was repeated was stable. The most likely cause of presyncope was either UTI or urinary retention. Urinalysis and culture were unable to be performed the first day due to foley trauma with significant hematuria. #Hematuria, urinary retention, BPH, acute blood loss anemia: He developed hematuria after traumatic attempts at placing Foley in the ED. Warfarin was held and initial INR was 2.5.. Urology was consulted and offered foley, but the patient and his family refused citing infection risk. Upon discussion with family, it was agreed to hold warfarin until hematuria resolves and restart warfarin as an outpatient. The patient endorsed significant prostate symptoms and started on Flomax but developed orthostatic hypotension so it was stopped. PVRs improved to 150s. He was not having difficulty urinating at the time of discharge and urine was non-bloody. Last INR was 1.4 on ___ and hemoglobin was 8.6 on discharge, down from admission. #Hypertension: Amlodipine was stopped due to the patient feeling lower extremity weakness while on it. Flomax was started for BPH but he developed relative hypotension, so it was stopped. His BP was noted to be labile. Due to concern that this was contributing to presyncope, decision was made to discontinue all blood pressure meds except for Coreg. His goal systolic blood pressure was 140s-170s. #Possible urinary tract infection: Ceftriaxone were started empirically to treat for possible urinary infection, given his urinary difficulty earlier in his hospital course. Urine cultures were negative. He was afebrile without leukocytosis. He was discharged on Cefpodoxime (renally dosed) to be completed on ___, for total of 7 days. #Transition of care issues: I spoke with Dr. ___ by phone prior to discharge on ___ regarding plan. The patient has follow up scheduled with his PCP and cardiologist later this month. He was discharged with ___ services (___). - Once hematuria has resolved, discuss restarting warfarin. - Patient was given order for a CBC to be drawn around ___ to assess for worsening anemia. - Recommend urology referral if persistent hematuria or difficulty urinating. - Consider restarting Amlodipine if HTN not adequately controlled. Check if applies: [ X ] Mr. ___ is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with a past medical history of stage IV NSCLC metastatic to the adrenals, who presented to clinic with three weeks of dyspnea, cough, weakness, and chills. Radiology showed Area of previously seen FDG avid rounded mass centered in the right middle lobe now demonstrates air-fluid level compatible with cavitation. Superimposed infection would certainly be possible. In addition, peripheral area of consolidation could represent adjacent pneumonia. Chest radiograph showed 1. Interval placement of a right IJ central venous catheter with its tip projecting over the expected location of the superior cavoatrial junction. The proximal to midportion of the central venous catheter is somewhat tortuous, possibly within a distended superior vena cava, less likely arterial or extravascular. Recommend assessing for blood return and correlating with a blood gas. 2. Cavitating right middle lobe mass with new cavitation differential considerations including necrosis or super infection with abscess formation. 3. Indistinct lateral mid to right lower lung opacities could reflect developing pneumonia. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at approximately 1:32 am, 0 minutes after discovery of the findings. CT CHEST WITH CONTRAST showed 1. The known right middle lobe lung mass demonstrates new superimposed infection evidence by a new abscess within it. New right middle and upper lobe pneumonia. 2. Mild interval increase in size of adrenal metastases. 3. Right IJ central venous catheter terminates in the SVC. The patient was diagnosed with Sepsis, unspecified organism, Pneumonia, unspecified organism. The patient was treated with Bronchoscopy with stenting. At the time of discharge, the patient had Non-small cell lung cancer Adrenal Insufficiency Post-obstructive 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 ___ woman with a history of newly diagnosed stage IV non small cell lung cancer with metastases to the adrenals, severe aortic stenosis (area 0.8cm2), HLD, and HTN who presented from clinic with 3 weeks of shortness of breath, cough, weakness and was initially admitted to the ICU with hypoxemia and hypotension, now stable after IP stenting for post-obstructive pna and subsequently tx'ed to the floor. # SEPTIC SHOCK # POST-OBSTRUCTIVE PNA # LEFT BRONCHUS LESION The patient presented with cough, shortness of breath, and evidence of pneumonia on CXR. She was also hypotensive d/t septic shock and required pressors briefly in the FICU. She was started on Vancomycin and Zosyn for post-obstructive pneumonia. CT scan revealed an enlarged left mainstem bronchus tumor. This was removed by interventional pulmonology via rigid bronchoscopy in the OR on ___. A pulmonary stent was placed to maintain the patency of the airway. The patient was given BID mucomist and saline treatments per pulmonology recommendations. Her breathing and pna improved significantly post-procedure. Her abx were narrowed to PO levaquin for completion of 5 day course on discharge. # HYPONATREMIA The patient was noted to hyponatremic on arrival based on the review of baseline Atrius records that revealed a sodium level that varied between 129-131. Her current presentation was thought to be likely SIADH in the setting of her lung cancer, with possible component of hypovolemia. Na stable/improved at 135 on dischare. # METASTATIC LUNG CANCER # GOC A CT chest on admission showed likely tumor necrosis and slight increase in size of suprarenal metastases, unchanged mediastinal lymphadenopathy, and an unchanged 4mm pulmonary nodule. It also revealed an occlusive left main stem bronchus tumor that was removed with subsequent placement of a pulmonary stent on ___ by interventional pulmonology. On ___, the patient expressed a desire to go home with hospice care. After goals of care conversation with family, HCP, and Atrius oncologist it was decided not to pursue any further tests/treatments per patient's wishes. Pt was discharged with home hospice services. # ADRENAL ISUFFICEINCY Pt was started on empiric stress dose steroids in the ICU due to hypotension and known adrenal metastases as well as recent dexamethasone use. She was discharged to complete 2-week hydrocortisone taper # AORTIC STENOSIS: Severe on ___ TTE. She appeared euvolemic on discharge. Billing: greater than 30 minutes spent on discharge counseling and coordination of care.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o missed MI (no intervention, ___, demand NSTEMI (___), COPD, rectal cancer s/p chemoradiation and LAR, synchronous breast cancer s/p lumpectomy, p/w dyspnea CHEST (PORTABLE AP) showed 1. Standard positioning of the endotracheal and enteric tubes. 2. Mild pulmonary vascular congestion and small right pleural effusion. 3. Patchy opacification in the right mid lung field may reflect pneumonia. Chest radiograph showed No interval change compared to prior study, showing mild vascular congestion and pulmonary edema. Radiology showed Lungs are low volume with stable interstitial prominence. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. The ET and NG tube are unchanged. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___. Pulmonary edema present on ___ has resolved. Heart size is now normal. Only a small region of consolidation may be present in the lingula, or this could be the left nipple. There are no other findings to suggest pneumonia. No pleural abnormality. The patient was diagnosed with Heart failure, unspecified. The patient was treated with Intubated on ___, Extubated to Bipap on ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================= HYPERCARBIC HYPOXIC RESPIRATORY FAILURE COMMUNITY ACQUIRED PNEUMONIA COPD EXACERBATION CHF EXACERBATION WIDE COMPLEX TACHYCARDIA ACUTE KIDNEY INJURY TYPE 2 NSTEMI SECONDARY DIAGNOSIS =================== CORONARY ARTERY DISEASE. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with a history of CAD with prior missed MI ___, no intervention), COPD, rectal cancer s/p chemoradiation and low anterior resection, and breast cancer s/p lumpectomy who was initially admitted to the CCU for multifactorial respiratory failure requiring intubation in setting of acute pulmonary edema, pneumonia, and COPD. Course further notable for new wide-complex tachycardia, most likely to be atrial fibrillation with aberrancy. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y.o. M with alcoholic cirrhosis (c/b varices, ascites, SBP - currently listed for transplant as of ___ gout, HTN, GAD, avascular necrosis of hips bilaterally s/p right hip arthroplasty, bilateral inguinal hernia repair, SDH ___ admitted for hyponatremia (Na 127), Tbili 7.3 and MELD 30. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with a 1.8 cm hypoechoic lesion in the right hepatic lobe, new since the prior CT from ___, noting that the CT did not included true arterial phase. Findings raise possibility ___. Further evaluation with dedicated CT or MRI liver recommended. 2. Mild perihepatic ascites. 3. Splenomegaly. Radiology showed Pulmonary vascular congestion without overt edema or focal consolidation. The patient was diagnosed with Abn lev hormones in specimens from female genital organs. At the time of discharge, the patient had PRIMARY: -Hypervolemic hyponatremia SECONDARY: -Alcoholic liver cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with history of alcoholic cirrhosis MELD 30 listed for transplant with several recent admissions for volume overload, gout, hypertension, GAD, bilateral avascular hip necrosis, subdural hematoma who presented to the ED for abnormal outpatient labs (hyponatremic to 127). This was likely due to confusion over his diuretic regimen after recent discharge from ___ on ___. ___ was given albumin and IV lasix and serum sodium improved. ___ was discharged on a regimen of torsemide 80g BID.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with metastatic gallbladder carcinoma status-post gemcitabine/cisplatin and ___ (last dose ___ and recent perforated duodenal ulcer/aspiration with aspiration PNA and bowel obstruction who is admitted from home off of hospice with pneumonia. Radiology showed New bibasilar opacities likely reflect the provided clinical history of left lower lobe pneumonia. Radiology showed Dilated loop of small bowel in the left abdomen measuring up to 3.7 cm along with several air-fluid levels, likely reflecting a degree of partial small bowel obstruction in the setting of extensive multiloculated ascites and peritoneal metastatic disease. Radiology showed 1. Enteric tube terminates just beyond the gastroesophageal junction, likely in the proximal fundus. 2. Partially imaged small bowel dilation, likely reflecting a component of partial small bowel obstruction in the setting of extensive multiloculated ascites. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Previous bilateral lower lobe pneumonia continues to resolved. Upper lungs clear. No pleural abnormality. Heart size normal. Nasogastric feeding tube ends in the stomach. Right jugular central venous infusion port ends just above the superior caval atrial junction. Radiology showed Successful placement of a ___ F MIC gastrostomy tube. The catheter should not be used for 24 hours for feeding but can be used for drainage.. The patient was diagnosed with Sepsis, unspecified organism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o metastatic GB adenoCA with peritoneal spread c/b recent duodenal perforation s/p surgical repair, chronic bowel obstruction with NGT, COPD, and CAD who presents from hospice with SOB and persistent bowel obstruction, and inability to manage symptoms at home. Discharged home with home hospice. # GOC: Patient has metastatic Gallbladder adenocarcinoma and given limited functional status, is not a candidate for systemic therapies. She is well known to palliative care service from her recent admission and notably on last admission patient expressed desire to be comfortable at home. Pt was recently discharged tp home hospice as DNR/DNI/DNH. However, patient became short of breath prior to admission, and EMS was called. Her code status was reversed in ED and confirmed Full Code in the ICU with HCP present. After speaking with daughter and HCP on initial transfer to the floor, they stated they felt like they were "forced" into DNR/DNI status. Palliative care was reconsulted during admission. Had family meeting with Dr ___, patient and HCP on ___. Agreed on DNR/DNI. A palliative venting G tube was placed by ___ ___. Patient and family agreed on discharge to home with home hospice. # Sepsis ___ likely HCAP/Aspiration PNA: Patient admitted with worsened SOB, tachycardia, leukocytosis and procalcitonin > 2. Patinet with recent prolonged hospitalization with prior HCAP/aspiration. Unfortunately, no micro data was obtained at OSH prior to antibiosis. CXR here on admission consistent with LLL PNA. She also has severe ileus / obstruction and bowel translocation is possible. She was initially given vancomycin, ceftazidime, flagyl (___). Vancomycin was discontinued on ___. Antibiotics were continued through ___. Blood cultures were negative. # Bowel obstruction: Patient admitted with abdominal distension in the setting of known malignancy, recurrent/chronic bowel obstruction, and anasarca. On MICU transfer to floors, patient reporting flatus and small BMs. Her NGT was to suction during admission. Of note, patient came in with NGT from home hospice for nausea and pain control. Her exlap stables were removed on ___. NGT was placed to low suction and patient remained NPO. A venting G tube was placed by ___ ___. She was started on octreotide. # Tachycardia: Patient initially in ICU with HR110-120s which persisted on initial floor transfer. The etiology of this tachycardia was attributed to malnutrition / emaciation vs metastatic cancer vs sepsis. HR on last DC summary was documented as 106. Because patient is immobilized with cancer, pulmonary embolism is on the differential, however ___ & ___ CTA was negative for PE. Patient was placed on telemetry monitoring. # Anemia of Chronic Disease: Hb on admission 6.2 and patient received 1U PRBCs with greater than appropriate response. # Non Gap Metabolic Acidosis: Patient admitted with metabolic acidosis likely secondary to PPI usage, with also starvation ketosis. Lactate normal, only trace ketonuria. Minimal uremia. Significant respiratory compensation with pCO2 ~20. She was continued on mIVF D51/2NS @75. CHRONIC ISSUES # Gallbladder Cancer: Widely metastatic. Last chemo (palliative) ___. She received oxycodone for pain control # COPD: On nebs # Hypertension: Held anti-hypertensives due to sepsis TRANSITIONAL ISSUES: ==================== - Dr ___ be palliative care oncologist - Home with ___' ___ - CODE: full at time of transfer home, but hospice intends to discuss w patient - CONTACT: Name of health care proxy: ___ ___: granddaughter Cell phone: ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with a history of DVT and MRI showing the left thigh tumor presents with worsening lower extremity pain and inability to stand. Patient is a poor historian, unable to corroborate history with wife. He reports, over the past 2 weeks has had worsening lower extremity edema and pain with inability to stand on his feet this morning. He denies any chest pain or shortness of breath. US INTERVENTIONAL PROCEDURE showed Technically successful ultrasound-guided left thigh biopsy. Radiology showed 1. Partially visualized lobulated, elongated mass along the course of the left external iliac and femoral vascular distributions measuring 13.5 x 5.0 x 4.1 cm where seen. This likely correlates with the left thigh mass reportedly evaluated per outside MRI on ___, and may represent sarcoma, malignant nerve sheath tumor, or metastasis, including metastatic left external iliac and inguinal lymphadenopathy. 2. Multiple bilateral pulmonary nodules measuring up to 1.7 cm are concerning for metastatic disease. 3. Ill-defined soft tissue lesions about the bilateral glenohumeral joints are incompletely characterized but suggest complex chronic joint effusions. If these are a clinical concern MR imaging may be helpful. 4. Findings consistent with moderately severe interstitial lung disease, probably best conforming to nonspecific interstitial pneumonitis pattern. Early usual interstitial pneumonitis is not excluded by this study, however. 5. Severe diverticulosis without evidence of diverticulitis. Radiology showed 1. Partially visualized lobulated, elongated mass along the course of the left external iliac and femoral vascular distributions measuring 13.5 x 5.0 x 4.1 cm where seen. This likely correlates with the left thigh mass reportedly evaluated per outside MRI on ___, and may represent sarcoma, malignant nerve sheath tumor, or metastasis, including metastatic left external iliac and inguinal lymphadenopathy. 2. Multiple bilateral pulmonary nodules measuring up to 1.7 cm are concerning for metastatic disease. 3. Ill-defined soft tissue lesions about the bilateral glenohumeral joints are incompletely characterized but suggest complex chronic joint effusions. If these are a clinical concern MR imaging may be helpful. 4. Findings consistent with moderately severe interstitial lung disease, probably best conforming to nonspecific interstitial pneumonitis pattern. Early usual interstitial pneumonitis is not excluded by this study, however. 5. Severe diverticulosis without evidence of diverticulitis. Ultrasound-guided biopsy showed Technically successful ultrasound-guided left inguinal mass biopsy. KNEE (2 VIEWS) LEFT; TIB/FIB (AP AND LAT) LEFT showed Findings concerning for nondisplaced insufficiency or pathologic fracture of the proximal tibial diaphysis. Underlying osseous lesion is not excluded, given permeative appearance and MRI is recommended. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 4:14 pm, 10 minutes after discovery of the findings. TIB/FIB (AP AND LAT) LEFT showed Intraoperative radiograph demonstrating bone-cement and internal-fixation of the left proximal tibial pathologic fracture. Radiology showed There has been curettage and packing of a lesion within the left proximal tibia. There has been placement of a medial fracture plate and associated screws. The total intra service fluoroscopic time was 14.7 seconds. Please refer to the operative note for additional details. The patient was diagnosed with Acute embolism and thrombosis of left femoral vein. The patient was treated with ___ thigh mass biopsy ___ ORIF and mass biopsy. At the time of discharge, the patient had # Sarcoma, metastatic # Malignancy-related DVT # Pathologic left tibial plateau fracture # Hyperkalemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of remote prostate Ca, HTN, and CKD who presents with worsening LLE swelling in the context of SFA DVT secondary to compressive left thigh mass that failed to improve with outpatient apixaban. # Left lower leg edema and pain, secondary to: # Left SFA DVT --Recently diagnosed with SFA DVT approximately two weeks ago and started on apixaban. DVT likely secondary to local vein compression by thigh mass (as detailed below). Repeat U/S without essentially unchanged size of clot. Per heme, likely does not represent clot failure, though preference for lovenox at this time rather than resumption of apixaban. Patient started on lovenox 60mg BID (slightly dose reduced for CKD). He then he developed hyperkalemia, so decision was made by Heme to switch back to apixaban, which he tolerated well. He was transitioned to a heparin gtt in anticipation of surgery as below and then restarted on apixaban 2.5 mg BID post-procedurally. # Left tibial plateau fracture --Continued to have severe left lower leg pain, worse with bearing weight, despite therapeutic anticoagulation and increasing multi-modal pain medication regimen, prompting further imaging of the leg. X-rays of the leg showed a non-displaced left tibial plateau fracture which most likely pathologic and not traumatic. Knee immobilizer placed for comfort. Given inability to bear weight due to pain and risk of worsening fracture limiting quality of life, ortho-onc recommended limited surgery to stabilize knee which was done on ___, which patient tolerated well. Intraoperative biopsies taken were pending at time of discharge, but preliminary pathology report suggestive of high grade sarcoma, as previously suspected. # Thigh mass: # Metastatic sarcoma: # Goals of care: Recent MRI demonstrated large soft tissue mass in the left thigh encircling the superficial femoral vessels with associated femoral vein thrombosis (as above) with radiographic features highly concerning for sarcoma. S/p biopsy on ___ and staging CT on ___ that demonstrated lung nodules. First biopsy results were non-diagnostic due to majority of cells being necrotic. Another biopsy was performed, this time of the enlarged left inguinal lymph node (rather than the thigh mass itself), and the results showed likely sarcoma (final stains pending). PET-CT was performed and revealed known disease in thigh/along vessels up to iliac and pulmonary nodules as well as possible small focus in spine. He was seen by oncology who recommended against chemotherapy. He was evaluated by radiation oncology who said they would continue to follow his course and consider palliative radiation therapy depending upon the final pathology results, with radiation commencing no sooner than 2 weeks following his orthopedic surgery (i.e. no sooner than ___. After discussion with palliative care, he was transitioned to DNR/DNI. # Hyperkalemia: developed while on heparin/LMWH despite holding his home lisinopril -HCTZ. Improved initially w/ stopping heparin/LMWH, then worsened again, suspect from lack of bowel movements. Improved after bowel regimen produced multiple BMs. # Constipation: likely multifactorial from opioids, pain, and lack of mobility from severe LLE pain. Improved with aggressive bowel regimen. I spent > 30 minutes of time on discharge planning and in face to face encounter with patient and family TRANSITIONAL ISSUES: ==================== [ ] Intraoperative biopsies from ___ suggestive of high grade sarcoma. Finalized path expected ___. Pt will need hemonc follow up and radiation oncology follow up for palliative radiation therapy planning. Appointments pending at time of discharge [ ] Pt underwent ORIF on ___ with ortho oncology which he tolerated well. He is scheduled for follow up in their clinic for post operative check and staple removal [ ] Post operative pain controlled with oxycodone 10 mg q6h at first. Down titrated to 5 mg q6h on ___ as pain better controlled. Continue to adjust pain meds as needed [ ] Please continue apixaban 2.5 mg BID for recently diagnosed LLE DVT [ ] Patient found to be anemic to 7.1 on ___. Likely multifactorial from iron deficiency anemia, anemia of chronic disease, mild bleeding post operatively and dilutional from fluid administration. Received IV iron on ___ and 1 unit pRBC on day of discharge. Please continue PO iron supplementation </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ pmhx schizoaffective disorder, BPH, presented with L flank pain found on CT scan to have obstructinve L ureteropelvic junction stone & severe hydronephrosis, c/f urosepsis, underwent ___ guided nephrostomy tube now admitted to ICU as pt remains intubated post-procedurally owing to depressed mental status. Radiology showed Successful placement of left 8 ___ nephrostomy tube. RECOMMENDATION(S): Keep drain for bag drainage. Monitor outputs. CHEST (PORTABLE AP) showed Heart size and mediastinum are overall stable appearance but there are new bibasal areas of atelectasis, extensive associated with small bilateral pleural effusion. There is no pneumothorax. Radiology showed Cardiomediastinal silhouette is within normal limits. Bibasilar atelectatic changes with small pleural effusions, predominantly unchanged from prior. There are no pneumothoraces. Radiology showed The left percutaneous nephrostomy tube appears to be laterally displaced as well as having lost its pigtail configuration, concerning for being laterally dislodged from the left renal collecting system. To assess function please correlate clinically. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:04 pm, minutes after discovery of the findings. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again are low lung volumes. Cardiomediastinal silhouette is stable. Bilateral small pleural effusions with compressive atelectasis at the bases. No evidence of acute focal pneumonia. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality or evidence of mass. 2. Severe paranasal sinus disease. CT ABD AND PELVIS W/O CONTRAST showed 1. A left percutaneous nephrostomy tube tip is located in a left lower pole renal calyx rather than the renal pelvis. However, hydronephrosis has resolved. 2. A pre-existing nonobstructive left lower pole calculus has migrated, probably now located adjacent to the pre-existing left ureteropelvic junction stone. 3. New right distal periureteric fat stranding. Consider infection. Correlate with urinalysis. 4. Severe prostatomegaly with evidence of chronic bladder outlet obstruction. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 7:38 pm, approximately 15 minutes after discovery of the findings. Radiology showed Technically successful left 8 ___ nephrostomy exchange. Radiology showed No radiographic evidence of bowel obstruction. The patient was diagnosed with Hydronephrosis with renal and ureteral calculous obstruction. The patient was treated with PCN placement PCN repositioning ___. At the time of discharge, the patient had # Urosepsis # Obstructive uropathy secondary to nephrolithiasis # hypoactive delirium. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male PMHx schizoaffective disorder and BPH who was admitted with urosepsis in setting of obstructing ureteral stone, s/p R. PCN by ___. # Complicated UTI: # Obstructing Nephrolithiasis: # Acute kidney injury (resolved): Presented with fever, leukocytosis, and flank pain all c/w urosepsis. CT abdomen and pelvis noted 11 mm obstructing stone near the left ureteropelvic junction. He underwent PCN placement by ___ with resultant improvement in renal function to baseline. Urine culture growing both MDR E.coli and Proteus, both sensitive to meropenem. He completed total 10 day course of antibiotics following his PCN repositioning on ___. With regards to his PCN, this will remain in place until he has definitive management of his obstructing kidney stone with interventional radiology, in the ___ Building at ___ ___ at 12:30p # Toxic-metabolic encephalopathy: # Schizoaffective disorder: Hospital course complicated by both agitation and hypoactive delirium secondary to acute infection and known schizoaffective disorder. While markedly somnolent, all psychiatric medications were initially held and the psychiatry team was consulted to guide safe resumption of his regimen. Plan at discharge is to hold scheduled benzodiazepines, continue Effexor/ valproate, and continue uptitrating Clozaril by 50 mg daily. Dose on day of discharge (___) should be 275 mg of Clozaril. TRANSITIONAL ISSUES: ================== [] Ensure that patient follows up with interventional radiology after completion of antibiotics for replacement of perc nephrostomy tube (___). Patient should follow up with Urology upon discharge here at ___ for incomplete emptying likely due to BPH- Dr. ___: office (___) ___ at 3:15 pm. ___ ___ floor. [] Psychiatric regimen on discharge has changed; see med rec. Plan at discharge is to hold scheduled benzodiazepines, continue Effexor/ valproate, and continue uptitrating Clozaril by 50 mg daily. Dose on day of discharge (___) should be 275 mg of Clozaril. >30 min spent on discharge planning </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with rheumatoid arthritis s/p bilateral knee replacements and HTN who presents with hematemesis and hypotension. She was recently d/c'ed from ___ (___) after a prolonged admission for fever, severe sepsis, cellulitis and R knee septic arthritis. At that time R knee arthrocentesis showed WBC 25K and 93% PMNs and she was taken to the OR with Ortho for parapatellar arthrotomy and synovectomy on ___. Synovial fluid from the OR was cloudy, though gram stain and cultures were negative. Ortho recommended Coumadin for DVT ppx, goal INR was 1.5-2.0. She was prescribed a course of Penicillin G for her septic joint and her pan sensitive CONS bacteremia. She went to rehab on the ___ and on the ___ she was found down and she began vomiting blood. She was then sent to ___ for further evaluation. Radiology showed Obscuration of the left hemidiaphragm may in part relate to overlying soft tissue; however, underlying consolidation and/or atelectasis may be present. Dedicated PA and lateral views would be helpful for further evaluation. Enlargement of the cardiac silhouette, likely stable, but with a somewhat globular configuration now, underlying pericardial effusion or cardiomyopathy may be present. Radiology showed Chronic changes described above. No evidence of hemorrhage, contusion, infarction or fracture. Radiology showed No fracture of the cervical spine. ATTENDING NOTE: The enlargement of right C5 foramen transversorium is likely due to a vertebral artery loop due to tortuosity. Radiology showed Successful treatment with Gelfoam embolization of a large area of active extravasation of the left gastric artery (gastric fundus). Radiology showed 1. Malpositioned endotracheal tube pointing towards the right main stem bronchus, proximal repositioning by ___ to 2 cm is recommended. 2. Increasing pulmonary vascular congestion and mild edema. Dr ___ communicated the above results (#1) to Dr. ___ at 1:30 p.m. on ___ by telephone. Radiology showed Standard position of support devices. New patchy basilar opacities which may be due to atelectasis, pneumonia or hemorrhage. Radiology showed The previously treated inferior branches of the left gastric, which previously had active extravasation remained occluded in the current study. No evidence of further bleeding or active extravasation was seen. The superior branches of the left gastric artery which were priorly occluded were partially recanalized in today's study, and further treatment was performed with coils and Gelfoam. The gastroepiploic artery was also studied, with no evidence of active extravasation of bleed. In summary, even though no active extravasation or bleeding was identified, prophylactic completion embolization of the superior branches of the left gastric artery was performed with a combination of coils and gelfoam with complete cessation of flow to the treated arterial territory. Radiology showed No evidence of deep vein thrombosis in the left leg. Evaluation of the patient with large gastrointestinal bleeding and new fever. Portable AP radiograph of the chest was reviewed in comparison to ___. The patient was extubated in the meantime interval. The patient is currently in substantial vascular engorgement/interstitial edema. Bibasilar consolidations are unchanged with no interval increase in pleural effusion or pneumothorax. The bibasilar consolidations most likely represent part of pulmonary edema/vascular engorgement, but infectious process in particular in the left lower lung cannot be excluded, further surveillance is recommended. was done. Radiology showed Left-sided PICC line terminates in mid SVC. These findings were discussed with ___, IV team nurse, ___ via telephone on ___ at 3:45 p.m., at time of discovery. The patient was diagnosed with SEPTICEMIA NOS, GASTROINTEST HEMORR NOS, SEPSIS , ACCIDENT NOS. The patient was treated with ___ upper endoscopy ___ embolization of left gastric artery ___ upper endoscopy with epi injection ___ embolization of left gastric artery ___ PICC line placed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Primary Reason for Admission: ___ y/o woman with recent R knee septic arthritis, cellulitis and severe sepsis on Coumadin presenting with hematemesis and hypotension. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx ESRD on ___ HD, PE in ___, mechanical MVR on Coumadin, CAD, HTN who presented from HD w/chest discomfort after R sided fistula clotted, found to be hyperkalemic w/K>8. Patient reports he was at HD and about one hour into treatment he began to feel unwell. Describes feeling lightheaded, nauseous and fatigued. He also developed chest pain/pressure with some associated mild dyspnea which resolved on its own. Patient states symptoms not similar to previous MI. He reports that he was feeling frustrated because he was told the HD nurse put him on the wrong K bath, so he asked to be de-accessed so he could go to the ED to have his fistula evaluated. Chest: Frontal and lateral views showed No acute cardiopulmonary process. The patient was diagnosed with Chest pain, unspecified, Hypokalemia, End stage renal disease. The patient was treated with HD x2 hours, incompleted. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx ESRD on ___ HD, PE in ___, mechanical MVR on Coumadin, CAD, HTN who presented from HD w/chest discomfort after R sided fistula clotted, found to be hyperkalemic w/K>8. #Hyperkalemia: Presented from HD w/chest discomfort after R sided fistula clotted, found to be hyperkalemic w/K >8. Mr. ___ was admitted to the ICU given hyperkalemia. It was felt that his K+ 8.7 on admission was too high risk for immediate AVF clot thrombectomy. He received 10units regular insulin, 1g Calcium Gluconate, 25mg Dextrose x 2. He adamantly refused HD line placement for urgent HD. Given this, HD was attempted via AVF and he did undergo HD for 2 hours. This was unable to be completed due to poor flow. K+ did improve to 5.7 but increased to 7.1 on ___. This is concerning for recirculation with ineffective removal of potassium. This potential issue was brought up last week when patient admitted for subtherapeutic INR, needing IV heparin (persistent high potassium values during the admission). Patient otherwise denies this as being a problem and insists this relates to our particular dialysis machines and/or the way we access his fistula, denying problems with his potassium outside of admissions to ___. Plan was to perform urgent dialysis to lower K and then pursue thrombectomy with ___. However, patient chose to leave AMA on morning of ___. Patient repeatedly and very clearly told that there is high concern for sudden death at home with current level of potassium, particularly with inability to dialyze until ___. He can clearly verbalize this concern, but wishes to go home regardless. He is aware that lethal arrhythmia can develop at home with absolutely no warning and no ability to have time to call ___. We did discuss that compliance with medical recommendations are important part of transplant evaluation and selection. # ESRD on HD MWF: BUN 87, Creatinine 15.2 on admission. No evidence of volume overload or uremia. As above, only tolerated HD for two hours and adamantly refused temporarily HD line. Continued home selevamer and calcium acetate. #HFrEF: TTE on ___ showed moderately-to-severely depressed systolic function secondary to global contractile dysfunction and dyssynchrony w/LVEF 30%. Continued metoprolol, atorvastatin, aspirin. # History of PE: Diagnosed in ___. Therapeutic on Coumadin. continued warfarin. # Hypertension: continued home metoprolol. TRANSITIONAL ISSUES: - patient requires K+ check as soon as possible. Last K+ 7.1 on discharge - patient requires AVF thrombectomy. - full code - HCP: ___ Relationship: Friend; Phone number: ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old female with a history of recent diagnosis of AML NPM1+, FLT3, who presents with worsening right lower extremity calf pain and ankle swelling. She is now d+15 after 7+3. She is being admitted for workup of her worsening right calf pain. Radiology showed 1. No right lower extremity DVT. 2. Right lower extremity nodule with internal vascularity which has increased in size from approximately 2 days prior. Again, this may represent a hematoma, although, a another solid lesion is also a possibility. If this doesn't resolve clinically, either followup ultrasound in 4 weeks or MRI is recommended. Radiology showed 3.2 x 1.8 x 1.3 x cm lesion centered between the flexor hallucis longus and soleus muscles is faintly T1-hyperintense, heterogeneously T2-hyperintense, and has a thick rim of peripheral enhancement with central nonenhancement. This is of uncertain etiology and could represent a developing hematoma, abscess, or a leukemic focus with central necrosis. This lesion should be followed to resolution. Dr. ___ was unable to be contacted via the paging system and findings were entered into the critical results dashboard for direct notification of the ordering provider. The patient was diagnosed with LOCAL SUPRFICIAL SWELLNG, OTHER ACUTE PAIN , PAIN IN LIMB, ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION. At the time of discharge, the patient had right lower extremity nodule. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>A/P: ___ year old female who is s/p 7+3 for NPM1+ FLT3+ AML presenting with persistent right lower extremity pain and swelling. # Right lower extremity pain: Pt presents with right lower extremity pain, which is not a DVT. Based on US findings, may be consistent with hematoma, given flow characteristics. ___ denies any fevers, chills. While pt has pulm nodules, given lack of other infectious sx, would not think that nodules in leg represents fungal process. Also would consider whether this represents leukemic involvement. Given recent neutropenia and abnormal findings, will obtain MRI RLE to furhter characterize the lesion. As pt is reliable and egaer to return home and does not clinically appear to have evidence of significant leg pain/tenderness or other evidnece pathology, that would be worrisome for other emergent processes (e/g/ fasciitis), will DC pt with MRI final read pending with plan to call pt and ask her to return should MRI of RLE reveal issues that require urgent intervention such as biopsy. . # AML with normal cytogenetics NPM1+, FLT3+: Day 14 BM negative. BM from day ___ is pending. . # Pulm nodules: Was noted on prior CT which was suspected to be possible infection (questionably fungal) - bronchoscopy was considered on prior admission however was not performed because patient decided against procedure. Pt will continue voriconazole for treatment of presumed fungal infection with plan to check B-glucan and galactomannan. . # Migraines: Pt may take tylenol prn, though advised not to take standing adn to check temperature prior to taking tylenol. . # Anxiety: Patient is understandably very emotional and gets easily worked up. Pt was continued on lorazepam 0.5mg PO q4h prn . #Asthma - albuterol nebs prn TRANSITION ISSUES # check beta d glucan and galactomannan from ___ and beta D glucan on ___ # follow-up on pulm nodules with repeat CT in 2 weeks # follow-up on RLE MRI results # f/u BM biopsy to assess for CR1</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx for type I diabetes, depression, atrial fibrillation not on anti-coagulation who presents to the ED with abdominal pain, nausea with concerns for clinical cholecystitis. Of significance, patient has a complicated PMH including type I diabetes and depression. Patient states that for the past week or so, she has had worsening abdominal pain, nausea, with some inability to tolerate PO intake, albeit still passing gas and having BMs. US ABD LIMIT, SINGLE ORGAN showed Limited exam secondary to patient discomfort. Within these limitations, there is cholelithiasis without ultrasound evidence of acute cholecystitis. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute intra-abdominal or intrapelvic process. Specifically, no evidence of cholecystitis or colitis. 2. Diverticulosis without evidence of diverticulitis. 3. Cholelithiasis without evidence of acute cholecystitis. CHEST (PA AND LAT) showed No focal consolidations, pneumothorax, or pleural effusion. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with ___: Laparascopic cholecystectomy. 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>Patient is a ___ year old female with past medical history of type I diabetes, depression, and atrial fibrillation not on anti-coagulation who presents to the ED with complaints of abdominal pain, nausea with concerns for clinical cholecystitis. Imaging was completed following arrival which demonstrated cholelithiasis without ultrasound evidence of acute cholecystitis. Therefore acute care surgery was consulted for evaluation and management. She was then taken to the operating room and underwent laparoscopic cholecystectomy on ___. (Please see operative report for details of this procedure). She tolerated the procedure well, was extubated upon completion, and was subsequently taken to the PACU for recovery. Once pain was well controlled, and the patient experienced a return of bowel function, her diet was advanced as tolerated. During this hospitalization, the patient voided without difficulty and ambulated early and frequently. The patient became hypoglycemic and the ___ Diabetes inpatient service adjusted her insulin regimen which she tolerated well. An appointment was made for her on ___ at 1:00PM at the ___ Diabetes ___ to re-evaluate the new insulin regimen. The patient was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well. She was afebrile and her vital signs were stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and her pain was well controlled. The patient was discharged home without services. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with ___ stage IV (brain met s/p resection and cyberknife) C1D8 carboplatin gemcitabine (first round last ___ who presented to ___ clinic today with persistent, severe fatigue and found to have HCT 17%. Pt reported dark BMs for a week. He was sent to the ED for eval. Heme/onc recommended CT torso to assess for hemorrrhagic pleural effusion from his cancer, and also for intraabdominal mass. In ED, patient had one episode of guaiac positive stool, NG lavage attempted but pt did not tolerate placement. Patient complaining of ongoing shortness of breath and had one episode of lightheadedness with standing up in ED, but denies chest pain, n/v, abdominal pain, BRBPR, hemotypsis or hematemesis. . In the ED inital vitals were, T 99.2 126 119/74 16 98% RA. Got 2 L NS in ED and ordered for 2 units blood. Started on protonix gtt. Given cefepime for T 99.2. GI consulted, they will not scope emergently unless he decompensates. Non-con CT of abdomen/pelvis done to evaluate for RP bleed. CXR unchanged from prior. Access is 20-gauge x 2. . On arrival to the ICU, patient reports stable shortness of breath, denies lightheadedness, chest pain, abdominal pain, n/v or other problems. He also reports feeling warm this morning, but no chills. . Review of systems: (+) Per HPI (-) Denies chills. Denies headache, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, abdominal pain. Denies dysuria, frequency, or urgency. Denies rashes or skin changes. Radiology showed No acute cardiopulmonary process. Large right basilar mass and mediastinal adenopathy. Radiology showed 1. No evidence of a retroperitoneal hematoma. 2. Markedly increased retrocrural, retroperitoneal, and mesenteric lymphadenopathy, as described above. 3. Incompletely evaluated large right lower lobe pulmonary mass, not significantly changed in size compared to CT from ___. 4. Richter-type ventral abdominal wall hernia, involving the transverse colon. No evidence of obstruction or strangulation. 5. Nonspecific lucency within the left iliac bone, not significantly changed in appearance. Radiology showed No bilateral lower extremity DVT. The patient was diagnosed with ANEMIA NOS, TACHYCARDIA NOS, GASTROINTEST HEMORR NOS. At the time of discharge, the patient had primary diagnoses: anemia, 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 ___ stage IV (brain met s/p resection and cyberknife) s/p C1 of carboplatin gemcitabine on ___ who presented to clinic with fatigue found to have a HCT of 17 now s/p ICU stay with 5 units PRBCs. . # GASTROINTESTINAL BLEEDING - Patient had guaiac positive stool in the ED (confirmed by ___ physician) with an unsuccessful nasogastric lavage. There was initial concern for upper gastrointestinal bleeding given his hematocrit of 17% (10% drop since ___ - though that was after transfusion for a hematocrit of 23% on ___. Patient has been taking Ibuprofen for headache while on steroids, which could predispose the patient to gastritis among other issues. Patient does report history of polyps on colonoscopy ___ prior and has known diverticular disease, which could be a source for lower GI bleeding. We initiated a Protonix infusion following a bolus and consulted the GI specialists. He was maintained NPO with plans for endoscopy, however HCT stabilized and he remained hemodynamically stable without evidence of frank melana or hematochezia. He received 5 units of packed red cells on admission for his hematocrit of 17%. His HCT stabilized between 24 and 25. Given risks associated with intervention and the lack of evidence for acute bleeding the decision was made to empirically treat with PPI without endoscopy. The protonix gtt was changed to IV BID and then omeprazole 40 mg po BID. His INR was elevated likely in the setting malnutrition and he was given 1 unit of PRBC and vitamin K. Patient was monitored overnight and continued to remain stable. He was discharged with plans to avoid NSAIDS and with a prescription for a PPI. . # SEVERE MICROCYTIC ANEMIA - Patient has unclear hematocrit baseline and has known anemia with recent hematocrit of 23% following recent transfusion in ___ clinic. Chronic GI bleeding, marrow suppression given his underlying malignancy vs. marrow suppressive therapy could be contributing. We monitored his hematocrit serially and transfused as needed. . # METASTATIC NON-SMALL CELL LUNG CANCER - The patient is status-post resection and cyberknife of brain metastatsis and first cycle of chemotherapy. He was continued on his Keppra dosing for seizure prophylaxis and oxycontin and oxycodone for pain. The patient was evaluated by the palliative care team. Patient decided at this time he is interested in full aggressive care including CPR and intubation but not prolonged intubation. Once he feels that he is declining and nearing death, he says that he will likely choose to die without resuscitation but is not at that point now. Patient was discharged with plans for home visiting care (minimal services at this time) and potential bridge to hospice should that be decided as the next step. Patient has plans to follow up with his outpatient oncologist next week and issues of goals of care will be discussed during that visit. . # SINUS TACHYCARDIA - On reviewing his record, patient's baseline heart rate has been in the 110-120s (lowest HR recorded in clinic was 112), except for a single EKG from ___ documenting a rate of 80 bpm. Unclear etiology likely ___ anemia. Patient continued to have sinus tachycardia despite blood tranfusions and IVF making hypovolemia less likely. Had CTA chest on ___ which was negative for PE and patient remained in no respiratory distress, without pleuritic chest pain, and maintained oxygen saturations in the ___ on room air. LENIs were negative for DVT. Also, likely component of overlying anxiety. . # ASTHMA, COPD - Patient denies history of COPD, however given his smoking history, this was likely. Patient did not appear to be in exacerbation during admission. He was treated with albuterol nebulizer treatments as needed. . # FEVERS - Patient had reported temperature of 99.2F in the ED, and was given Cefepime for unclear source. The patient does have stable and chronic non-productive cough, but his CXR did not appear to demonstrate pneumonia. An infectious work-up was performed with reassuring blood and urine cultures. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type s/p ex-lap, radical hysterectomy, BSO, small bowel resection, rectosigmoid resection, omentectomy, pelvic LND, end colostomy, cysto on ___ currently in cycle 4 of chemotherapy (FOLFOX) s/p recent high grade SBO managed conservatively with NGT ___. Radiology showed Enteric tube tip in the stomach. The patient was diagnosed with Unspecified intestinal obstruction. The patient was treated with NGT placement and removal. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the gyn/onc service with an SBO. Given her symptoms were similar to prior recent presentations and she had no peritoneal signs on examination, imaging was referred. An NGT was placed for bowel rest/decompression in the ED. Her white blood cell count was noted to be elevated, but there was no clinical evidence of infection (normal exam, normal lactate). A repeat CBC on hospital day 1 showed a normal WBC She was managed conservatively during her admission with an NG tube. On hospital day 3, she began noticing more stool and gas in her ostomy. She had minimal residual on an NGT clamp trial. Her NGT was removed and her diet was advanced without issue. On hospital day #3 she was tolerating a regular diet. She was discharged home in stable condition with outpatient follow-up planned. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is an ___ year old right handed woman with past medical history of atrial fibrillation not on anticoagulation whom presents as transfer from ___ with suspected left MCA syndrome and consideration of possible thrombectomy. MR HEAD W/O CONTRAST T___ MR HEAD. showed 1. Multiple foci of acute to subacute left MCA territory infarct, likely thromboembolic given distribution pattern. 2. Sequelae of probable chronic small vessel ischemic disease. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:37 am. Fluoroscopic video oropharyngeal swallow showed 1. Trace penetration of nectar thick liquids. 2. Trace silent aspiration with thin liquids. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Radiology showed There is no opacity projecting along the periphery of the right mid lung which may reflect atelectasis and/or consolidation. Patchy retrocardiac opacities likely also reflect atelectasis. There is no pneumothorax or large pleural effusion. The size of the cardiac silhouette is mildly enlarged and there is a tortuous thoracic aorta. No radiodense foreign object is seen within the visualized thorax. Radiology showed No radiopaque foreign object is identified within the abdomen or pelvis. CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK showed 1. Study is degraded by motion and dental amalgam streak artifact, especially limiting evaluation of the posterior fossa. 2. Within limits of study, no definite acute intracranial hemorrhage. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. CT perfusion demonstrates increased mean transit time with areas of mildly decreased cerebral blood flow within the left parietal temporal lobe. If clinically indicated, consider brain MRI for further evaluation. 4. Decreased distal arborization of the left M3/M4 branches, which may correlate with the area of decreased cerebral perfusion. 5. Punctate left expected P1 origin probable infundibulum versus approximately 1 mm aneurysm. 6. Otherwise grossly patent intracranial and cervical carotid and vertebral arteries. 7. 1.5 cm partially calcified inferior left thyroid nodule. Please see recommendation below. 8. Nonspecific cervical lymphadenopathy as described, image may be reactive, however neoplastic or inflammatory etiologies are not excluded on the basis of this examination. Recommend correlation with oncologic history. 9. Limited imaging lungs demonstrate moderate to severe centrilobular emphysematous changes with air trapping. If clinically indicated, consider dedicated chest imaging for further evaluation. RECOMMENDATION(S): 1. Nonspecific cervical lymphadenopathy as described, image may be reactive, however neoplastic or inflammatory etiologies are not excluded on the basis of this examination. Recommend correlation with oncologic history. 2. Thyroid nodule. Ultrasound follow up recommended if not already performed. ___ College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5 cm in patients age ___ or older, or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 21:58 into the Department of Radiology critical communications system for direct communication to the referring provider. The patient was diagnosed with Weakness. At the time of discharge, the patient had 1. Left middle cerebral artery ischemic infarct 2. Atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ woman with history notable for atrial fibrillation (not on anticoagulation), HFpEF, and ___ transferred from ___ after presenting with aphasia and right face, arm, and leg weakness, found to have multifocal L MCA ischemic infarcts. Thrombolytics not administered due to presentation outside the tPA window, and CT imaging of the head and neck otherwise negative for large vessel occlusion amenable to thrombectomy. Mechanism of infarction accordingly most likely atrial fibrillation not on anticoagulation, which, per discussion with Ms. ___ PCP, was due to patient preference. Accordingly, anticoagulation initiated with apixaban to reduce risk of future strokes, along with low-intensity atorvastatin therapy given likely cardioembolic mechanism and low atherosclerotic burden on imaging. Hospital course complicated by non-fluent aphasia and dysarthria, for which SLP evaluation recommended modified diet. TRANSITIONAL ISSUES 1. Continued SLP evaluation and advancement of diet as indicated. 2. Thyroid ultrasound to evaluate incidentally-noted left thyroid nodule. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 85) - () No 5. Intensive statin therapy administered? () Yes - (x) No [Low atherosclerotic burden and cardioembolic mechanism of stroke] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? () Yes - (x) No [Low atherosclerotic burden and cardioembolic mechanism of stroke] 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A 35 minutes were spent on discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/lymphoma, C. diff presents with abdominal pain. Pain started yesterday morning. It is constant and located in the right upper quadrant. Associated with nausea and emesis. The pain is very similar to her prior diverticulitis. She is not on chemotherapy. No fever no chills. She is currently being treated for Cdiff and continues to have diarrhea. Chest radiograph showed 1. No focal pneumonia. 2. Right perifissural opacity appears to correspond to known FDG avid lesion on PET-CT from ___. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cholelithiasis. 2. Gallbladder adenomyomatosis. 3. Ectatic CBD, measuring 9 mm, measuring 8 mm on a recent CT. No ductal stones detected. No intrahepatic bile duct dilation. The patient was diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst. The patient was treated with ERCP with sphincterotomy on ___. At the time of discharge, the patient had Primary: # Biliary Obstruction: ___ choledocholithiasis s/p ERCP on ___ # Post-ERCP pancreatitis Secondary: # C. diff # Lymphoma # Type II DM - diet controlled. The patient was given written instructions concerning 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 w/lymphoma, C. diff presents with abdominal pain due to biliary obstruction now s/p ERCP with sphincterotomy on ___, but with recurrent abdominal pain with improving LFTs but newly elevated lipase most likely due to post-ERCP pancreatitis, which subsequently resolved with conservative measures (NPO, IVF, pain control). On the day of discharge, her lipase had normalized and she was tolerating a normal diet with no abdominal pain. Regarding her biliary obstrcution ___ choledocholithiasis, the patient will follow-up with surgery as an outpatient to discuss possible cholecystectomy, as she did not want to pursue any surgical intervention during this hospitalization. She will complete 5 days of oral ciprofloxacin for ppx per ERCP team recs. She was advised to avoid aspirin, plavix, NSAIDs, coumadin and other anticoagulant medications for 5 days following her procedure. She was otherwise continued on her home medications during hospitalization. Time in care: 45 minutes in patient care, patient counseling, care coordination and other 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: Ms. ___ is an ___ woman with history of hypertension, hyperlipidemia, and hypothyroidism who presents as a transfer from ___ with a complaint of altered mental status in the context of one day of epigastric pain followed by 3 episodes of vomiting. Per outside reports, the patient was complaining of abdominal pain at home with her son. She got up to go to the bathroom, vomited with retching, and walked over to the couch to sit, and her son noted that she "looked off". She was taken to an outside hospital where she was noted to have depressed mental status, aphasic, and progressively became more unresponsive and seemed to have a left gaze preference, right sided facial droop, and was without movement of the right upper or lower extremities. A non-contrast Head CT was obtained, and notable for left frontal IPH. The patient was given Zofran, Ativan in order to obtain the CT scan prior to transfer here. She was given 1 g of Keppra prior to arrival. MRI of the head and MRA of the head. showed 1. In comparison with initial head CT from an outside institution dated ___ at 22:50 7 hours, there is a larger left frontotemporal intraparenchymal hemorrhage with underlying subarachnoid hemorrhage extending towards the left frontoparietal regions as described detail above as well as the left sylvian fissure. There is no evidence of abnormal enhancement surrounding the hematoma or increased vascularity, however underlying conditions cannot be completely excluded, long-term followup until complete resolution of the hematoma is advised. 2. Approximately 4 mm of midline shifting towards the right is identified with adjacent vasogenic edema surrounding the left frontoparietal hematoma. 3. Grossly unchanged oval-shaped T1 hypointense, T2 and FLAIR hyperintense lesion in the right temporal lobe, with partial enhancement and incomplete halo susceptibility suggestive of a second hemorrhagic lesion, measuring approximately 2 x 1.5 cm in transverse dimension, with no significant mass effect. CT chest with contrast showed 1. No intrathoracic findings identified to suggest malignancy. 2. Small bilateral pleural effusions. CT abdomen and pelvis. showed 1. No evidence of malignancy within the abdomen or pelvis. 2. Asymmetric enlargement of the right common femoral vein, compared to the left. Recommend further evaluation with ultrasound to assess for possible AV shunt or thrombus. 3. Slight interval improvement in mild peripancreatic fat stranding, compatible with the patient's known acute pancreatitis. No adjacent fluid collections or vascular complications. 4. No significant change in gallbladder wall edema, possibly due to hepatic dysfunction or third spacing. 5. Please refer to the separate report of the chest CT performed on the same day for thoracic characterization. RECOMMENDATION(S): Recommend further evaluation with ultrasound of asymmetric enlargement of the right common femoral vein, for possible AV shunt or thrombus. PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD showed 1. Mildly increased size of a left frontoparietal and frontotemporal intraparenchymal hemorrhage with a subarachnoid component. Stable to mild increase in midline shift measuring up to 5 mm. No change in effacement the left lateral ventricle or blood tracking near the tentorium. Hyperdense material near the parietal bone suggests continued bleeding. 2. Hypodense foci with some hyperdense streaking over the right temporal lobe is consistent with area of likely second hemorrhagic lesion seen on prior MRI from ___, and appears overall unchanged. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins, specifically the right common femoral vein is patent. Radiology showed The ET tube and NG tube have been removed. Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is stable. Small bilateral effusions have slightly increased in volume. Pulmonary edema is slightly worsened. No pneumothorax is seen Radiology showed Small left pleural effusion with adjacent atelectasis. No definite evidence of pneumothorax. Mild pulmonary vascular congestion. BILAT LOWER EXT VEINS showed 1. Nonocclusive deep vein thrombosis of the right popliteal vein, and occlusive deep vein thrombosis of the right peroneal veins. 2. No evidence of deep venous thrombosis in the leftlower extremity veins. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, RDMS on the telephone on ___ at 10:36 am, 2 minutes after discovery of the findings. Radiology showed Successful deployment of Denali retrievable IVC filter. VIDEO SWALLOW showed Trace penetration with thin liquids. No gross aspiration. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). MRCP showed Incomplete imaging showing no evidence of significant abnormality. Completion of MRCP imaging could be considered or alternatively, if it may be difficult to complete the imaging using MR, multiphasic CT could be considered as an alternative. Portable AP chest showed 1. Status post placement of endotracheal tube, with tip projecting 3.0 cm above the carina. 2. Status post placement of enteric tube, which courses below the diaphragm, with tip projecting outside the field of view. 3. No evidence of complications. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed No cholelithiasis or cholecystitis. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval increase in size of the left frontotemporal intraparenchymal hemorrhage, with underlying subarachnoid hemorrhage and left parietal involving. Mild interval increase in mass effect with midline shift up to 5 mm. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:55 am, 5 minutes after discovery of the findings. CT abdomen. showed 1. Mild peripancreatic fat stranding of bilateral anterior pararenal spaces, right lateral conal fascia, and omentum of the transverse colon, most compatible with acute pancreatitis. No evidence of adjacent fluid collections or vascular complications. 2. Interval new gallbladder wall edema, without cholelithiasis or ductal dilatation, which may be due to interval progression of hepatic dysfunction or fluid resuscitation. The patient was diagnosed with Nontraumatic intracerebral hemorrhage, unspecified. The patient was treated with PEG ___ IVC filter ___. At the time of discharge, the patient had Non traumatic intraparenchymal hemorrhage Pulmonary edema Pancreatitis Dysphagia s/p PEG 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>Ms. ___ is an ___ year old woman with history of hypertension who presented with abdominal pain, vomiting, confusion, aphasia and right sided weakness found to have left fronto-temporal ICH complicated by hematoma expansion and respiratory failure. #Left IPH #Right anterior temporal ischemia with hemorrhagic conversion vs. mass She developed acute onset confusion, aphasia and right sided weakness. Her exam was notable for left gaze deviation, right facial droop, RUE w/d in plane of bed and RLE with dense plegia. She had a NCHCT with left fronto-temporal IPH and right anterior temporal hypodensity. She was intubated in the emergency department given increasing somnolence. She had LFTs which were elevated (~400) with elevated lipase (~1800) and was admitted to the medicine ICU. She had increasing somnolence and serial NCHCT with expansion of her hematoma without increased midline shift. She was transferred to neuro ICU. SBP goal <150 and did not require standing antihypertensives. Her 48 hour NCHCT showed overall stable hemorrhage and subq heparin was resumed. In terms of etiology, given her preceding months of abdominal symptoms, weight loss and an area of hemorrhage and area of hypodensity, suspicion for malignancy was high. She underwent MRI/MRA which showed left fronto-temporal IPH without evidence of contrast enhancement or abnormal vascularity as well as an area in right temporal anterior lobe with contrast enhancement suspicious of underlying malignancy. She had a CT Torso with and without contrast which showed no evidence of malignancy but did show pancreatitis. GI was consulted who recommended MRCP in ___ weeks to assess for underlying malignancy after inflammation has resolved. Alternative etiologies for her IPH were ischemic hemorrhagic conversion, but TTE negative for thrombus and LENIs negative as well. CAA vs. hypertensive etiologies were also considered, but she had no persistent hypertension and no other findings suggestive of CAA on MRI. In the neuro ICU, her mental status improved and she was alert, but not following commands with global aphasia. She was subsequently extubated on ___. She was transferred to the neurology ward service where she continued to improve. She had PEG placed ___. She remained stable from neuro perspective. On discharge, she was alert with improving aphasia, able to speak short phrases softly in ___ and able to follow simple commands in ___. She will have follow-up with neurology and repeat MRI with and without contrast of brain to assess left IPH and possible right anterior temporal mass, amyloid. #Acute on Chronic Abdominal Pain #Pancreatitis Family reported weeks to months of abdominal complaints. She was scheduled for endoscopy as outpatient. Prior to presentation she had acute worsening of her abdominal pain and vomiting. LFTs were elevated (400-600s), lipase was elevated to 1800sand tbili to 1.6. She had CT Torso which showed pancreatitis. She was treated with aggressive fluids for 48 hrs and her liver enzymes normalized. She had no evidence of gallstones, no history of etoh, normal ANCA, triglycerides and calcium. She does however take statin, celocoxib and supplements, all of which have been linked to pancreatitis. These medications were stopped. There was also suspicion for pancreatic malignancy given her history of chronic abdominal issues and 20 lb weight loss. Given inflammation in the setting of pancreatitis, GI recommended MRCP which was performed but not completed due to chest pain (EKG unremarkable) and anxiety. No pancreatic abnormality detected on this limited study. Given the study limitations, she was scheduled for an outpatient EUS and GI follow-up prior to discharge. #Hypoxic respiratory failure She arrived to ED on NRB and was intubated in the setting of somnolence and inability to protect her airway. She was extubated on ___ and required face tent. She had rhonchorous breath sounds and evidence of pulmonary edema on CXR. She was treated with duonebs, albuterol, chest ___ and suctioning. She was given Lasix 10 mg x1 on ___ with improvement in her respiratory status. She was redosed with Lasix 20 mg x1 on ___ and subsequently was sating well on RA. She did not require further dieresis throughout her course. #UTI Had fever to 103 on ___, UCx revealed pan sensitive E. coli. She was treated with CTX for ___. She then had foul smelling urine on ___ and UA was obtained which had many WBC and leuk esterase. UCx showed E. coli sensitive to CTX. She was started on CTX with 7 day course (___). #Dysphagia She had PEG placement ___ without complication. TFs resumed 1200 on ___. Nepro used given hyperkalemia and ___. #Urinary retention She had urinary retention requires Q6H straight caths throughout her hospital course. Given some vaginal irritation and skin breakdown, foley was replaced. Please do void trial at rehab. #Hyponatremia She developed Na from 128-130. Urine lytes suggestive of SIADH. FWF were decreased and she was started on salt tabs 1 g TID. Her Na normalized. Then on ___ she again developed hyponatremia. Repeat urine lytes on ___ still suggestive of SIADH. TSH was rechecked day prior and was 18. Endocrine recommended increasing levothyroxine. FWF was decreased and Na trended upward. Na 134 at time of discharge. #Hypothyroidism She missed 3 days of levothyroxine on admission given patient aphasia and family obtaining med list. TSH 12 on ___, 8 on ___, 18 on ___. Levothyroxine 100 mcg daily increased to 125 mcg on ___ and 150 mcg on ___. She should have repeat TFTs ___ weeks after discharge. #DVT She was grabbing at left leg at times and therefore a lower extremity ultrasound was done on ___ which showed non occlusive right popliteal thrombus and occlusive peroneal vein thrombus. She was hemodynamically stable and sating well on RA. She was felt to be too high risk given her IPH for high dose IV heparin or systemic anticoagulation. ___ was consulted who recommend IVC filter placement which was done on ___ without complications.</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 complains of ABDOMINAL PAIN. gradual onset RLQ pain with radiation to back since ___. + nausea. Small amount of diarrhea. Denies hematuria HPI: rapid onset RLQ pain, h/o stones, some n/v Timing: Sudden Onset Quality: Sharp Severity: Moderate Duration: Hours Location: RLQ Context/Circumstances: feels similar to renal colic Mod.Factors: ___. Associated Signs/Symptoms: none Radiology showed 1. Acute appendicitis. 2. 2cm right adrenal nodule, new from ___ is incompletely characterized, but likely represents an adenoma. Further evaluation with adrenal protocol CT, or MRI could be considered Findings were discussed with Dr. ___ at 3:45 a.m. The patient was diagnosed with ACUTE APPENDICITIS NOS. The patient was treated with laparoscopic appendectomy. At the time of discharge, the patient had appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the acute care service with abdominal pain. Upon admission, she was made NPO, given intravenous fluids, and underwent imaging. On cat scan of the abdomen she was reported to have a dilated, fluid filled appendix suggestive of appendicitis. Because of these findings, she was taken to the operating room for a laparoscopic appendectomy. The operative course was stable with minimal blood loss. She was extubated after the procedure and monitored in the recovery room. During the post-operative course, she reported a headache which resolved with fioricet and toradol. She was started on clear liquids and advanced to a regular diet. She was discharged on POD #1 with stable vital signs. Appointments were made for follow-up with the acute care service and with her primary care provider; ****** Of note: finding on cat scan of abdomen: 2cm right adrenal nodule, new from ___ is incompletely characterized, but likely represents an adenoma. Further evaluation with adrenal protocol CT, or MRI could be considered; Patient was informed of these findings and recommendation made for follow-up with primary care provider. Copy of report given to patient. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with history of hepatitis C status post Harvoni treatment and prior left TKA ___, ___, Dr. ___, who now presents with left knee pain concerning for a prosthetic joint infection. CHEST (PA AND LAT) showed No acute cardiopulmonary process. KNEE (AP, LAT AND OBLIQUE) LEFT showed Small to moderate joint effusion without evidence of acute fracture or dislocation. CHEST (PORTABLE AP) showed Right IJ central venous catheter tip projecting over the upper SVC. No pneumothorax or pleural effusion. Improved pulmonary vascular congestion, now minimal. Retrocardiac opacity, likely atelectasis. CHEST (PORTABLE AP) showed Comparison to ___. The lung volumes are stable. Moderate cardiomegaly persists. Mild retrocardiac atelectasis. No pulmonary edema. No pleural effusions. No pneumonia. Stable correct position of the right internal jugular vein catheter. Knee radiograph showed Postsurgical changes of an T and liner exchange. Moderate effusion with drain in place. Moderate soft tissue edema about the knee and distal thigh. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. Cirrhotic liver morphology with splenomegaly and moderate volume ascites. No evidence of concerning focal hepatic lesions. 2. Patent hepatic vasculature. 3. No hydronephrosis. Radiology showed 1. Technically successful ultrasound guided diagnostic paracentesis. Insufficient fluid for a therapeutic paracentesis. No immediate complications noted. 2. 0.8 L of fluid were removed and sent for requested analysis. CHEST (PORTABLE AP) showed In comparison with study of ___, the cardiomediastinal silhouette is stable. No definite vascular congestion or pleural effusion. Probable atelectatic changes at the right base. However, there is mild asymmetry in opacification on the right, which in the appropriate clinical setting could be consistent with superimposed aspiration/pneumonia. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. Radiology showed 1. Technically successful ultrasound guided diagnostic paracentesis. 2. 0.97 L of fluid were removed and sent for requested analysis. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the study of ___, there is an placement of right subclavian PICC line that extends to the mid to lower SVC. Otherwise, little overall change. CHEST (PORTABLE AP) showed Right PICC line tip is at the level of cavoatrial junction. Heart size and mediastinum are stable. Lungs overall clear except for minimal bibasal atelectasis. No appreciable pleural effusion or pneumothorax. CHEST (PA AND LAT) showed No focal consolidations concerning for pneumonia identified. CHEST (PORTABLE AP) showed New right infrahilar opacities could reflect hilar vasculature or developing pneumonia. BILAT LOWER EXT VEINS showed The left peroneal veins are not visualized. No evidence of deep venous thrombosis in the right or left lower extremity veins. BILAT UP EXT VEINS US showed 1. Small amount of nonocclusive thrombus in the right basilic vein adjacent to the intraluminal catheter. 2. Otherwise, no evidence of deep vein thrombosis in the bilateral upper extremity veins. CTA CHEST showed No evidence of pulmonary embolism or aortic abnormality. 6 mm nodule in the middle lobe, follow-up recommendations as below. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Ultrasound-guided paracentesis. showed Paracentesis was not performed due to patient preference and unlikely significant therapeutic benefit given small amount of ascites present. US ABD LIMIT, SINGLE ORGAN showed Small amount of ascites, the largest pocket in the right upper quadrant. CHEST (PORTABLE AP) showed Left basilar atelectasis. CT ABD AND PELVIS WITH CONTRAST showed 1. 5 mm obstructing stone in the right mid ureter with moderate upstream hydroureteronephrosis. Multiple additional punctate nonobstructing stones in the right kidney. 2. Cirrhotic liver with no focal hepatic lesions identified. 3. Sequela of portal hypertension including small volume intra-abdominal ascites, extensive upper abdominal collateral vessels, paraesophageal varices, and splenomegaly. 4. Cholelithiasis without evidence of cholecystitis. 5. Please refer to separate report of CT chest performed the same day for description of the thoracic findings. CT CHEST W/CONTRAST showed 1. No focal consolidation. Interval worsening of bibasilar atelectasis. 2. 6 mm nodule in the right middle lobe. Please see recommendations below. 3. Please see separately dictated report for findings within the abdomen and pelvis. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ The patient was diagnosed with Sepsis, unspecified organism, Pyogenic arthritis, unspecified, Thrombocytopenia, unspecified. The patient was treated with Left knee I&D, liner exchange ___, ___. At the time of discharge, the patient had Primary: Left knee prosthetic joint infection Hepatitis C cirrhosis Group B strep bacteremia Secondary: PICC associated non-occlusive thrombus Nephrolithiasis Acute kidney injury Pancytopenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY ======== Mr. ___ is a ___ male with history of hep C (Harvoni with SVR ___ cirrhosis complicated by varices, ascities and hepatic encephalopathy, who presented to an outside hospital on ___ with worsening left knee pain, was found to have septic knee arthritis complicated by septic shock s/p I&D and drain on ___ with repeat washout on ___, with course complicated by volume overload and ___, now improving. ACTIVE ISSUES ============== # Septic arthritis # Group B Strep Bacteremia (blood stream infection) Patient presented with knee pain found to have septic knee arthritis complicated by septic shock and group B strep bacteremia status post I&D and liner exchange on ___ with improvement in his blood pressures and lactate. Drain removed on ___. Blood cultures grew group B strep and bacillus species, per ID bacillus species is thought to be a contaminant. Initially placed on vancomycin/cefepime/Flagyl for concern of polymicrobial infection then narrowed to ceftriaxone 2g daily for 6 weeks. He underwent repeat L knee washout on ___ in the setting of recurrent fevers. TTE was without evidence of endocarditis. The infection is thought to be due to potentially gut translocation in the setting of cirrhosis. ___ assessed the patient and recommended home with ___. # Intermittent fevers # Tachycardia Onset ___ while on Ceftriaxone, added vancomycin, broadened to cefepime on ___. Pt continued to spike through broad spectrum ABX despite negative work up and the absence of localizing infectious symptoms. PICC line inserted on ___. UA is negative and blood cultures remained negative. CXR was negative for pneumonia. Repeat arthrocentesis demonstrated neutrophilic predominance concerning for ongoing infection of joint. Patient underwent repeat washout with ortho on ___. Patient defervesced and has been afebrile for >48 hours at time of discharge. He will continue ceftriaxone 2gm daily for 6 weeks (last day ___. # Volume overload # Shortness of breath Dyspneic at baseline following ?VATS procedure ___ years ago. Baseline weight per patient 233 pounds, presented at standing weight of 268. Ongoing volume issues due to need for transfusion of blood products for anemia. Diuresed with Lasix drip, to weight 235 pounds. He will be discharged on torsemide 40mg. # Hep C cirrhosis (Childs C, MELD 24 on admission) Complicated by ascites, varices, hepatic encephalopathy and GI bleed in the past due to gastric ulcers. Not currently listed for transplant. - HE: history of frequent hospitalizations due to hepatic encephalopathy. Patient has been AOx3 without asterixis. Continued home rifaxamin & lactulose TID - Ascites: discharged on torsemide 40mg PO daily - SBP: Will require cipro ppx for life after rx with ceftriaxone - Esophageal varices - last EGD reportedly in ___ though report unavailable. Discharged on home propranolol - Thrombocytopenia: In the setting of infection and liver disease/splenomegaly. Patient received multiple transfusions of platelets in perioperative period. - HCV - treated in ___ with SVR # PICC Associated Nonocclusive thrombus Duplex ultrasound obtained to evaluate for blood clot as cause of ongoing fevers. Non occlusive thrombus identified in right basilic vein adjacent to the intraluminal catheter. PICC continued to be functional. Thrombus not felt to be source of fevers. Elected against anticoagulation of thrombus given size, provocation of PICC and underlying coagulopathy and cirrhosis. #Nephrolithiasis During fever workup, a CT abdomen with contrast was performed on ___ which demonstrated a 5 mm obstructing stone in the right mid ureter with moderate upstream hydroureteronephrosis. Patient denying urinary symptoms or pain. Felt to be an incidental finding and not the source of fevers. # Anemia: Hgb 9.5 on presentation, downtrended to 6.6 while in hospital in setting of multiple procedures. No other source of bleeding. Felt in part to be related to polyphlebotomy. Patient received 3 units of pRBC over hospital course. Hgb on discharge 7.9. #Leukopenia As low as 2.9 during hospitalization. Patient on multiple antibiotics that were felt to be potential culprits (Cipro, vancomycin). Improving with transition back to ceftriaxone, was 3.7 on discharge. # ___ Baseline creatinine 0.9-1.1, initially presenting to ___ ___ with a creatinine of 2.5. Creatinine then trended down to 1.1. Had second insult in setting of supratherapuetic vancomycin. Improved to 1.2 at time of discharge. CHRONIC ISSUES # Hypertension: Held home propranolol while in house due to sepsis. # Hypothyroidism: Continued home levothyroxine.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a history of HCV, EtOH cirrhosis complicated by ___ on chemotherapy who presented to the ED for abdominal discomfort after discussing symptoms with his PCP. Radiology showed 1. Moderately distended gallbladder with mobile shadowing gallstones. Pericholecystic fluid and minimal gallbladder wall thickening is non-specific and can be seen in chronic liver disease. 2. Nodular and heterogeneous liver compatible with cirrhosis with multiple lesions consistent with HCC, better seen on MR from ___. Multiple enlarged portahepatic lymph nodes and moderate ascites. Radiology showed Dilated loops of small bowel may reflect an early or partial small bowel obstruction. Central location of bowel loops indicative of underlying ascites. No free intraperitoneal air. Radiology showed 1. Interval enlargement of the hypodensity in the left lobe of the liver at the site of the prior ablation site. Locules of air are of uncertain significance and superimposed infection is not excluded. 2. Interval enlargement of the known hepatocellular carcinomas and the hepatic hilar and left mesenteric metastases. No new discrete metastases are identified. 3. New moderate ascites. 4. No evidence of a small bowel obstruction. 5. New scattered small lucencies in the pelvis, of uncertain etiology. These would be atypical for hepatocellular carcinoma metastases. If further workup is required, could correlate with an SPEP/UPEP. 6. Cholelithiasis without cholecystitis. Results were discussed with Dr. ___ at 3:15 p.m. on ___ via telephone by Dr. ___ minutes after the findings were discovered. Radiology showed 1. Successful ultrasound-guided paracentesis yielding 1.2 liters of clear yellow fluid. Samples sent for microbiology and chemistry as requested. 2. Radiofrequency ablation bed in the left lobe of the liver is predominately solid with a single locule of gas. The lesion is better seen on the recent CT scan of ___. Radiology showed Ascites with a small amount in the right upper and lower quadrants and no significant amount of fluid in the left upper and lower quadrants. The patient was diagnosed with INTESTINAL OBSTRUCT NOS, MAL NEO LIVER, PRIMARY. The patient was treated with paracentesis ___. At the time of discharge, the patient had symptomatic abdominal ascites liver cancer hepatitis C cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with a history of HCV, EtOH cirrhosis complicated by ___ on chemotherapy who presented to the ED for abdominal discomfort with possible SBO, worsening metastatic disease, worsening ascites, severe constipation. Abdominal Bloating associated with mild pain with low grade fever. no SBO on CT scan. improved with paracentesis ___ but symptoms returned the following day. discussed indwelling catheter to allow frequent drainage of ascites. this would normally be done in a hospice setting, but Mr. ___ now indicates that he is not ready for hospice and wants to get a second opinion. as such, plan for catheter cancelled. he has some small fluid pockets on US but no urgent indication for paracentesis at this time. # HCV and EtOH cirrhosis complicated by HCC. MELD 22. Missed recent chemo x2 out of difficulty getting to clinic. No clear evidence of hepatic encephalopathy. Not on diuretics or lactulose. did not tolerate taking lactulose in the past due to diarrhea even at small doses. He was seen by the liver service with recommendation to start rifaximin. He was also started on aldactone to help with ascites management. His primary oncologist Dr. ___ spoke with the patient ___ regarding his poor prognosis (months) and that further chemotherapy will not help him. He is upset but understands. He plans to seek another opinion from Cancer Treatment Centers of ___. # coagulopathy - likely from liver disease. He received vitamin K 5mg PO x 3 days with little benefit, suggesting coagulopathy due to liver synthetic function # 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: The patient is a ___ year old woman with PMH of seizure disorder, hypothyroidism who presents after being found down in pool and unresponsive. Per report, the patient was in a hot tub and told the people around she felt unwell, and then was witnessed falling into a pool. She was in the pool for several minutes while bystanders attempted to rescue her. The police arrived on the scene first and initiated CPR after not finding a pulse, and water came out her mouth. When EMS arrived she had a pulse and was breathing spontaneously but unresponsive. At ___ ___ she was intubated and sedated with propofol. Reportedly a chest x-ray and head CT without contrast were unremarkable. She was transported to ___ via med flight. In ED initial VS were T 98.5 HR 96 BP 128/92 RR 18 O2 100% on CMV FiO2 50% TV 400 RR 20 PEEP 5. Exam was notable for an intubated a sedated patient with warm extremities and focal myoclonic movements and hyperreflexia. ABG showed 7.25/57/30, lactate 3.8; serum tox screen negative. Neurology was consulted who noted the hyperreflexia and myoclonus and recommended tox consult for possible serotonin syndrome as patient is on citalopram. At this time the fentanyl and propofol were stopped and midazolam drip was started. She was also given lorazepam IV x1. A repeat CT head at ___ ED showed cerebral edema, stable from the study at ___. On arrival to the MICU, she is following all commands. Radiology showed ET tube tip 1.8 cm from the carina. Enteric tube appropriately positioned. Chest radiograph showed The tip of an ETT seen approximately 1.5 cm above the carina and should be retracted for optimal positioning. CT HEAD W/O CONTRAST Q111 CT HEAD showed Persistent, essentially unchanged cerebral edema. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Please note that prior head CT mentioned in history is not submitted for direct comparison. 2. Study is mildly degraded by motion. 3. No evidence of acute infarct. 4. No evidence of dural venous sinus thrombosis. 5. Small enhancing dural-based lesion overlying the right temporal lobe measures up to 6 mm. Allowing for difference technique, finding is grossly similar to ___ prior exam, suggestive of meningioma. 6. Paranasal sinus disease, as described. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:33 am, 2 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. The patient was diagnosed with Cardiac arrest, cause unspecified. At the time of discharge, the patient had Cardiac arrest Seizure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old woman with PMH of seizure disorder with witnessed fall into pool, face down in water for several minutes, found to be without pulse with CPR initiated followed by coughing up water, with ROSC, intubated at ___ transferred to ___ for further care. # S/p cardiac arrest: # Respiratory failure: On arrival to the MICU was following all commands, though when weaned to pressure support took increasingly smaller tidal volumes and eventually apneic so kept intubated overnight on CMV. Extubated in the AM ___. without complications. Since mental status intact on arrival, was not cooled but kept normothermic at 36 C. Etiology of arrest thought to be hypoxemia from being down in pool. Initiating event causing fall into pool thought to be seizure. TTE WNL. Repeat chest imaging on ___ demonstrated a possible RLL infiltrate. This in the setting of increased green sputum production and rising leukocytosis prompted the initiation of Zosyn on ___ for PNA. Anti-pseudomonal coverage was chosen given history of water ingestion. Her leukocytosis resolved, and she had no fevers, and CXR showed no pneumonia, and clinically she did not have symptoms. Prior to discharge, ___ was switched to Augmentin 875mg BID for 4 more days to complete a ___erebral edema seen on non-contrast head CT: Seen on 2 serial CTs, though not seen significantly on subsequent MRI. Per neurology consult, level of edema did not correlate with intact mental status exam. MRI performed to evaluate venous sinus thrombosis as etiology, which was not seen. Small meningioma was noted incidentally. # Seizures ___ did not have any missed doses of medications, so she was continued on her home Dilantin. The night before her seizure and cardiac arrest she had not taken her ativan and hadn't slept well, so it was thought that sleep deprivation may have been a provoking factor. Zonisamide 100mg daily was added, with plan to increase to 200mg daily after 2 weeks. She was continued on cvEEG, and had no seizures captured. She was continued on Ativan QHS for sleep, which she should continue until follow up. She has follow up with Dr. ___ outpatient epileptologist. #Hypothyroidism She was continued on her home levothyroxine 88mcg daily #Depression, anxiety She was continued on her home citalopram 40mg daily, baclofen 10mg TID, and lorazepam 1mg PO QHS PRN insomnia.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx morbid obesity s/p gastric bypass with significant weight loss s/p abdominoplasty with panniculectomy at ___ ___ (___) p/w abdominal abscess. She relates increased abomdinal pain and girth since the abomdinal drain was accidentally dislodged and discontinued several weeks ago. Over the last several weeks and most strikingly over the last ___ days, she had increased pain and fever and presented to ___ ___ where a CT abdomen/pelvis showed a possible abscess at her surgical site. She also notes that a new opening ___ her skin appeared at ___. Given concern for sepsis, she was transferred to ___ from ___. She received zosyn prior to transfer to ___. En route to ___, she was hypotensive and received 1 L IVF. ___ the ED, initial vitals: 98 115 95/54 20 100% Nasal Cannula Ultrasound-guided drainage. showed Successful US-guided placement of an ___ pigtail catheter into the collection. Samples was sent for microbiology evaluation. Removal of 100 cc purulent fluid. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the study of ___, there has been placement of right subclavian PICC line that extends to the lower SVC just above the cavoatrial junction. No evidence of acute cardiopulmonary disease. The patient was diagnosed with Sepsis, unspecified organism. The patient was treated with ___ guided drainage of infected abdominal wall seroma, ___. At the time of discharge, the patient had infected seroma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMHx morbid obesity s/p gastric bypass with significant weight loss s/p abdominoplasty with panniculectomy at ___ ___ (___) p/w abdominal abscess. # Sepsis: On admission, pt meets ___ SIRS criteria (leukocytosis and tachycardia). She also has a presumed source (abdominal wound). She also had hypotension that was fluid responsive. # Infected Seroma: Pt s/p recent abdominal surgery. She has had increased abdominal pain and girth over the last several days. She now has a leukocytosis, tachycardia, and mild hypotension. Imaging from ___ is suggestive of an infectious intraabdominal collection. Plastic surgery saw the pt ___ the ED and recommended medical management with IV antibiotics and ___ drainage of collection. ___ drained 100 cc's of pus from her left-sided collection, wound swab growing MRSA, pigtail left ___ place. Her antibiotics were narrowed to vancomycin alone, PICC was placed given difficult access. She received Oxycodone 2.5 mg PO Q4H PRN pain. She was called out to the plastic surgery service. Given that she continued to have pain ___ her RLQ, a bedside I&D was performed. She tolerated this procedure well and her exam continued to improve. ID recommended 1 week of IV vancomycin followed by 1 week of Bactrim PO which was ordered. # S/p Gastric Bypass: Continued tums, B12, MVI, calcitriol At the time of discharge, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. She was discharged home with ___ services. </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 ahistory of ascending aortic aneurysm, hyperlipidemia, hypertension, lymphoma, and osteoarthritis. She presented with chest pain that began at 4 am. She was in the bathroom when she began to experience ___ centralized chest pain. She denied radiation, nausea, vomiting, diaphoresis, dizziness, or syncope. However on exam, she has a right black eye she cannot explain. Upon arrival to the emergency department she was hemodynamically stable, and given Tylenol for pain. Chest CT revealed ascending aortic aneurysm rupture with active extravasation. Her last echocardiogram in ___ revealed a tricuspid aortic valve. Cardiac surgery was consulted and she was taken to the emergently to the operating room. Chest: Frontal and lateral views showed Right inferior perihilar opacity, concerning for pneumonia. Progressed moderate cardiomegaly and new central vascular engorgement. CTA TORSO showed Ascending aortic aneurysm rupture with active extravasation of contrast near the level of the sino-tubular junction, above the coronary sinuses, resulting in hemomediastinum and hemopericardium with a small amount of mass effect on the right atrium. Blood products also extend along the proximal aortic arch, some of which may be intramural, and along the course of the pulmonary arteries to the subsegmental level on the right and the lobar level on the left, resulting in a decrease in caliber of the affected vasculature. No hemothorax. NOTIFICATION: The findings and recommendation for cardiac surgery consultation were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at approximately 09:05 am, less than 5 minutes after discovery of the findings. Radiology showed The patient is post median sternotomy with repair of a ruptured ascending aortic aneurysm. The tip of the endotracheal tube projects over the mid thoracic trachea. On the initial radiograph, the tip of a right internal jugular Swan-Ganz catheter is looped in the pulmonary artery and the tip projects over the left hilum likely within a branch of the left lower lobe pulmonary artery. This positioning is subsequently corrected on the subsequent radiographs. On the final radiograph the tip projects over the main pulmonary artery, in satisfactory position. Multiple mediastinal drains and chest tubes are present. Patchy opacities at both lung bases likely reflect atelectasis. The size of the cardiomediastinal silhouette is enlarged, likely reflecting a hematoma and postoperative change. No pneumothorax is identified. Chest radiograph showed 1. Interval improvement of pulmonary vascular congestion and edema compared to ___. 2. All support and monitoring devices are in standard position. Chest radiograph showed All support and monitoring devices are in standard positions. No pneumothorax or mediastinal widening. Radiology showed The ET tube, NG tube and the Swan-Ganz catheter are unchanged. Pulmonary edema is slightly worsened. Bilateral effusions are stable. Cardiomediastinal silhouette is unchanged. No pneumothorax is seen. Radiology showed The Dobbhoff tube terminates in the stomach. Otherwise stable exam. CHEST (PORTABLE AP) showed Swan-Ganz catheter tip is at the level of the right ventricular outflow tract. Type of tube passes below the diaphragm terminating in the stomach. ET tube tip is 5 cm above the carinal. There is minimal improvement in the right basal consolidation. The patient is still in mild pulmonary edema. No pneumothorax. Chest radiograph showed 1. Interval insertion of a Dobhoff feeding tube projecting over the right mainstem bronchus. The primary team is aware and the tube has since been removed. 2. Pulmonary edema and bilateral effusions appear slightly worse compared to prior. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:35 pm, 5 minutes after discovery of the findings. Radiology showed No findings of bowel obstruction Radiology showed No definite findings of bowel obstruction. Left lower airspace disease and pleural effusion. Radiology showed The enteric tube now appears to be post pyloric. Radiology showed Compared to the earlier same day examination, the Dobhoff tube has been repositioned with the tip projecting over the expected location of the pylorus, satisfactory. There is a nonspecific bowel gas pattern with relative paucity of visualized bowel gas. The lung apices are excluded from view. Right IJ central venous catheter appears grossly unchanged. This study is not tailored for examination of the lung parenchyma, with left-sided effusion and bibasilar opacities appearing grossly similar. CHEST PORT. LINE PLACEMENT showed Comparison to ___. The patient has received a new left-sided PICC line. The course of the line is unremarkable, the tip of the line projects over the mid SVC. No complications, notably no pneumothorax. Otherwise unchanged radiograph, including the right jugular introduction sheet and the feeding tube. CHEST (PORTABLE AP) showed Comparison to ___. Bilaterally, the extent of the pre-existing pleural effusions has minimally decreased. Areas of substantial atelectasis are still visualized at the left and right lung bases. Moderate cardiomegaly persists. No new focal parenchymal changes. CHEST (PORTABLE AP) showed In comparison with study of ___, there again is substantial enlargement of the cardiac silhouette with moderate pulmonary edema. Retrocardiac opacification is consistent with substantial volume loss in the left lower lobe and probable small effusion. Less prominent changes are seen at the right base. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___. Edema has resolved. Left lower lobe remains densely consolidated accompanied by an indeterminate volume pleural effusion. Moderate enlargement of cardiac silhouette is unchanged. No pneumothorax. Feeding tube passes into the stomach and out of view. Left PIC line ends in the mid SVC. Radiology showed The tip of the Dobhoff projects over the stomach. CHEST (PA AND LAT) showed In comparison with the study of ___, the Dobhoff tube has been removed. Left subclavian catheter is unchanged. Continued enlargement the cardiac silhouette with mild vascular congestion. Opacification at the left base is consistent with substantial volume loss in left lower lobe and pleural fluid. The patient was diagnosed with Chest pain, unspecified. The patient was treated with ___ - Emergent resection of ascending aortic aneurysm rupture and ascending aortic replacement with a 28 mm Gelweave tube graft and coronary artery bypass grafting x 1 with reverse saphenous vein graft to the right coronary artery.. At the time of discharge, the patient had Type A Aortic Dissection Aortic Insufficiency Ascending Aortic Aneurysm Chronic Fatigue Syndrome Follicular Lymphoma of the neck s/p RT Hemorrhoids Hyperlipidemia Hypertension Intertrigo Obesity status post left thigh panniculectomy in ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>She was admitted on ___ and was taken emergently to the operating room. She underwent emergent Ascending Aorta replacement with CABG x 1 with Dr. ___. Please see operative note for full details. She tolerated the procedure well and was transferred to the ___ in stable condition for recovery and invasive monitoring. She weaned from sedation on POD#1 but she was slow to wake. She was arrousable but she required aggressive diuresis with a Lasix drip and was extubated on POD#4. She had tube feeds through a dobhoff tube which was very difficult to place and required ___. Her chest tubes and wires were discontinued in the first few days postop. She was weaned from inotropic and vasopressor support. Beta blocker was initiated and she was diuresed toward his preoperative weight. She had an elevated WBC and grew Citerobacter on a BAL. She was treated with Ceftazadime and Levofloxacin. Levofloxacin is to continue until ___ to complete course of antibiotics for PNA. She remained hemodynamically stable and was transferred to the telemetry floor for further recovery. As PO intake increased, TFs and DHT discontinued. Encourage oral intake/free water with rising Na. She received SC Heparin for DVT prophylaxis. Wound care consult evaluated sternal and right groin wounds. Initially draining serous - which resolved. Softsorb applied to sternal wound to minimize irritation with good effect. She was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 17 she required maximum assistance for mobility, the wound was healing, and pain was controlled with Tylenol only. She was discharged to ___ ___ in good condition with appropriate follow up instructions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF THE PRESENTING ILLNESS: Mr. ___ is a ___ with history of R ankle fracture s/p hardware placement and no history of diabetes presenting with persistent RLE cellulitis. UNILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Cellulitis of right lower limb, Urinary tract infection, site not specified. At the time of discharge, the patient had PIMARY ====== Cellulitis Mixed arterial and venous vascular insufficiency SECONDARY ========= Right Ankle fracture s/p open reduction internal fixation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with history of sick sinus syndrome s/p pacemaker, R ankle fracture s/p ORIF with hardware placement, presenting with persistent RLE cellulitis x2 months. ACTIVE ISSUES ============= #Non-purulent RLE Cellulitis Patient presented to ___ in early ___ for a pneumonia, and was found to have RLE cellulitis, which was treated initially with IV vancomycin, CTX, and azithromycin, and he was discharged on PO doxycycline. Course was extended due to insufficient response, and cephalexin was added on ___. Presenting here due to persistent cellulitis, due to concern from orthopedics given ongoing infection and plan for possible further surgical intervention to right ankle. Patient was afebrile, and hemodynamically stable, and there is no evidence of involvement of the underlying joint or hardware. However, given the persistence of the infection and the possibility for seeding the ankle hardware or cardiac pacemaker, pt was treated initially with IV antibiotics. Patient was seen by infectious disease, felt that some of his skin changes were more consistent with peripheral vascular disease (likely mixed arterial and venous), and therefore recommended discontinuing IV antibiotics and completing a course of cephalexin (end ___. Blood cultures were pending. CRP elevated at 10.9/ESR 46. Recommended outpatient vascular surgery evaluation, which was discussed with pt and his wife prior to discharge home. #Normocytic anemia Most recent hemoglobin in ___ was 10.6. Hemoglobin on admission 7.9. Iron studies consistent with anemia of chronic inflammation. #Complicated UTI Urinalysis in the ED was significant for pyuria and bacteria. Patient also reports increased frequency of urination. Urine cultures grew KLEBSIELLA PNEUMONIAE >100,000 CFU/mL; sensitivities reported after discharge revealed highly resistant (carbapenem resistant, sensitive only to amikacin). Discussed with ID, RNs, and environmental services for appropriate room cleaning. Pt and his wife notified by phone; given lack of dysuria, reasonable to defer further treatment of UTI vs asymptomatic bacteruria. Received one dose of CTX in the ED, and initially treated with PO Ciprofloxacin 500 mg BID, neither of which were active against highly resistant Klebsiella. Chronic Issues ============== # Chronic low back pain Tylenol ___ mg every 8 hours as needed # SSS s/p cardiac pacemaker (per patient, about ___ years ago) # CODE: full (presumed) # CONTACT: ___ H: ___ c: ___ TRANSITIONAL ISSUES =================== - On course of cephalexin 500 mg four times a day through ___ for cellulitis. It is unclear how much of his current findings are due to infection vs peripheral vascular disease. - Will need follow up with vascular surgery for question of peripheral vascular disease - Urine sensitivities for Klebsiella resulted after patient was already discharged. Resistant to nearly all antibiotics (intermediate sensitivity to meropenem, and sensitive to amkikacin). Patient was only having very minor urinary symptoms (just frequency) so the risks of treating outweigh the benefits. However, should he develop more significant urinary symptoms or become septic, this will be a very difficult organism to treat. [x ] The patient is safe to discharge today, and I spent [ ] <30min; [x ] >30min in discharge day management services.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with history of Hodgkin's disease in the ___ treated with chemo RT and autologous bone marrow transplant, also complicated by radiation pneumonitis and hypothyroidism on levothyroxine who now presentes with productive cough, chills, and shortness of breath for 1 week. She reports low grade fevers over the past week, and the sensation of a upper respiratory bronchitis which has moved into her chest. She normally has at least one episode of bronchitis each year in the setting of her known pneumonitis but this episode has persisted longer. The cough is productive of green sputum. She has been using her flovent and albuterol without much effect. No chills or night sweats. She has had some post tussive emesis but otherwise no nausea/vomitting. She works as a ___ grade ___ and notes multiple kids have been sick in school Radiology showed No evidence for acute cardiopulmonary process. Stable paramediastinal radiation fibrosis. The patient was diagnosed with TACHYCARDIA NOS. At the time of discharge, the patient had Primary: community acquired pneumonia Secondary: history of lymphoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with history of Hodgkin's Lymphoma, status post chemo and SCT in ___, residual radiation pneumonitis who presents with cough and shortness of breath x1 week, noted to be tachycardic with lactic acidosis in the ED. She was admitted to the MICU and her lactate resolved and symptoms improved with IV fluids and treatment for community acquired pneumonia. # Community acquired pneumonia: She did have WBC to 15 with mild fevers and productive cough/sputum production. We decided to treat with levofloxcain 750 mg daily x 7 days because of her history of radiation damage and bronchiectasis. Other likely etiologies are a viral URI/bronchitis in the setting of her sick contacts at school with associated reactive airway disease, especially given her normal CXR. She was continued on her home fluticasone inhaler and albuterol inhaler. She did recieve 40 mg of prednisone in the ED but this was not continued. # Tachycardia: Could be in setting of infection, though pt reports very good PO fluid intake. She says she has been running a "high" heart rate in the ___ over recent months at baseline and this is confirmed in prior clinic notes. Pulmonary embolus was considered but her Ddimer in the 200s makes this less likely. No evidence of effusion/tamponade on ED bedside echo. No recent levothryoxine dose changes. We sent an email to her outpatient PCP making them aware that this was an ongoing issue and they may want to pursue cardiac work-up including echo and stress since she has potential for radiation-induced CAD or heart failure. # Lactic acidosis: Unclear why her lactate persisted greater than 4 despite 3L NS in the absence of a significant infectious process. BP is normal on the floor. No abdominal pain or other localizing symptoms. It did resolve the following morning. # Hypothyroidism: Continued home levothyroxine 75 mcg daily.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ man with a h/o alcohol abuse complicated by withdrawal seizing episodes in the past, cirrhosis ___ EtOH and HCV with varices (last admitted in ___ for GI bleed secondary to varices at which time he required intubation, and again in ___ for EtoH intoxication and hematemesis), who was initially admitted for complicated alcohol withdrawal. Surgery area showed Streaky opacities overlying the bilateral lower lobes could represent atelectasis given low lung volumes, however infection cannot be excluded. Slight vascular prominence may be exaggerated by low lung volumes. RECOMMENDATION(S): Consider dedicated PA and lateral view radiographs when tolerated by patient. CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormality on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. Suggestion of bilateral orbital frontal encephalomalacia. 2. Mild left frontal scalp soft tissue swelling without evidence of acute displaced calvarial fracture. 3. Additional findings as described above. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No fracture or malalignment. 2. The palatine tonsils are prominent, slightly greater in the expected for the patient's age, but overall unchanged from prior exam. This could be reactive in nature. Clinical correlation is recommended. Radiology showed 1. Evaluation of the subsegmental pulmonary arterial levels within the lung bases is limited by respiratory motion. Allowing for this, no pulmonary embolism to the segmental level is demonstrated. No acute thoracic aortic pathology is seen. 2. Re-demonstration of nodular contour of the liver compatible with underlying cirrhosis with esophageal varices and bilateral gynecomastia. Radiology showed Lung volumes have improved. There are no new consolidations. Heart size is normal. There is no pleural effusion. No pneumothorax is seen The patient was diagnosed with Alcohol dependence with intoxication, unspecified. At the time of discharge, the patient had #Alcohol intoxication #Acute hypoxic respiratory failure #Fever. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with a h/o alcohol abuse complicated by withdrawal seizing episodes in the past, cirrhosis ___ EtOH and HCV with varices, who was brought in by EMS after being found down. On arrival, patient was minimally responsive and noted to have an EtOH level of 433. He initially received 2 mg IV Ativan, but due to persistent tachycardia with minimal responsiveness, he was admitted to the MICU. On arrival to the MICU, he was arousable, but generally refused to engage in conversation. He received a phenobarbital loading dose, but was not continued on maintenance dosing due to his cirrhosis and stabilization of his symptoms. He had a transient fever, which was felt to be due to aspiration pneumonitis vs ETOH withdrawal, which resolved without antibiotics. He was transferred to the floor on ___, where he remained without signs of alcohol withdrawal. He was seen by SW; at discharge plan for made for the patient to follow-up at the ___ where he could be set up with a case manager. He also expressed interest in following up with his PCP in order to be connected to Behavioral Health Services. #ETOH withdrawal. #Tachycardia. Prior discharge summary notes history of withdrawal seizures which patient denies. On arrival in MICU, patient was tachycardic, tremulous, and nauseous concerning for onset of withdrawal. Serum ETOH 433 on arrival to ED, with elevated lactate to 2.4 (suspect type B lactic acidosis). Received 2 mg Ativan in ED and was reportedly somnolent. Mental status improved on assessment in MICU and patient received reduced phenobarbital load to 5 mg/kg which he tolerated to good effect. He received high dose Thiamine, folate, and multivitamin. The patient was transferred to the floor on ___ and remained clinically stable. He did not exhibit any signs or symptoms of acute alcohol withdrawal and did not require any additional lorazepam (written for 1 mg q4 PRN per ___ protocol). He was continued on Thiamine, multivitamin, folate. He was seen by ___ and expressed interest in programs for Behavioral Health and substance use recovery and was provided with relevant resources. At discharge, a plan was made for the patient to follow-up at ___ where he can be set up with a case manager, as well as with his primary care provider, who was informed about his admission. #Acute Hypoxemic Respiratory Failure Patient noted to desaturate and had oxygen requirement in the MICU. This was likely due to sedation. It resolved prior to discharge. #Fever. Temperature to 101.6F in ED. Mild leukocytosis on admission, which normalized later. CXR with b/l lower lobe opacities favoring atelectasis rather than infection. UA negative for infection. Antibiotics were deferred given hemodynamic stability and low suspicion for infection. On the floor, the patient spiked a fever again to 101.7 the night of ___. UCx was clear and repeat CXR did not demonstrate pulmonary process suggestive of pneumonia. The etiology was thought to be most likely temperature fluctuations in setting of withdrawal. The patient remained afebrile throughout the morning on the day of discharge. He was given return precautions to re-present to care if he developed more concerning respiratory symptoms #Hyponatremia: Na 131 on ___, drop from 139, together with lower blood pressures (systolics <100) was noted. This was thought to be most likely hypovolemic hyponatremia. The patient was treated with IVF and increased PO intake and his blood pressures increased to systolics >110 prior to d/c. #Cirrhosis #Esophageal varices. #Hx ___ tear. Received Nadolol and Lactulose on prior admissions, though does not take these medications as an outpatient. In ___ EGD showed 2 cords of grade II varices seen in the lower esophagus. He was restarted on Pantoprazole, Lactulose, and Nadolol while inpatient. #Coagulopathy: Presented with an admission INR of 1.8. This did not respond to Vitamin K challenge, so likely primarily due to liver disease. #Anemia of chronic disease: His hemoglobin was low on admission but similar to prior values in our system. Likely due to marrow dysfunction from alcohol and cirrhosis, and there was no evidence of active blood loss. ======================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old with history of UC s/p total proctocolectomy and ileoanal pouch, ankylosing spondylitis, type 2 DM, DVT, and recent admission ___ to ___ where he was found to have BPPV and a LLL PE started on Coumadin now presenting with dizziness and chest pressure for one day. Pt was admitted ___ to ___ with complaint of gross hematuria, chest tightness and suicidal ideation in the setting of a steroid taper. He was found to have a LLL PE on CTA chest and was started on Coumadin. Workup, including CTU, was unremarkable, and pt was was planned for urology follow up after discharge. Pt's course was complicated by episodes of dizziness and gait instability. A CT head was negative for an acute process. Pt was ultimately diagnosed with BPPV and planned for outpatient vestibular ___. Pt states that since discharge he continued to have dizziness. He describes the dizziness as constant and states that he feels like the works is "moving back and forth," but denies spinning. He states that it does not stop and start suddenly, rather is persistent. Furthermore, he reports a sensation of falling to both his right and left rather than just his right side during his last admission. He also states that today he developed chest pressure with associated shortness of breath. He states that it feels as though he cannot take in a full breath. The chest pressure was also associated with tingling in his hands and feet which caused a great deal of anxiety. He denies fevers, dysuria, frank hematuria, new joint pain, worsened diarrhea (baseline), abdominal pain, nausea or vomiting. Pt states that he has had some chills recently. Pt states that he back pain and AS symptoms are currently at baseline, but he does not some hand and feet swelling that resolved a few days ago. In the ED, initial vital signs were: 98.4 115 123/75 18 100% RA - Exam was notable for: unsteady gait - Labs were notable for: WBC 9.9, H/H 11.1/38.3, plts 394, Na 136, K 3.5, BUN/Cr ___, INR 3.2, troponin <0.01 x 2, proBNP 16, lactate 3.6 x 2 - UA with >182 RBCs, large blood, 2 WBC - Imaging: CT head did not demonstrate an acute process and CTA chest did not demonstrate an interval PE and known is less distinct - The patient was given: 2L NS, Dilaudid 1mg IV x 2, Oxycodone 5mg PO x 1 - Consults: None Vitals prior to transfer were: 98.2 99 118/54 18 100% RA Upon arrival to the floor,pt states that he continues to have subtle chest pressure, but states that he is overall comfortable. He also has some mild dizziness. CT HEAD W/O CONTRAST showed No acute intracranial process. CTA CHEST WITH CONTRAST showed 1. No interval pulmonary embolism. Previously seen pulmonary emboli are less distinct on the present study. 2. No other acute process is detected. MRI AND MRA BRAIN PT12 MR HEAD showed 1. No acute intracranial abnormality without infarct, hemorrhage, or mass. 2. Small right mastoid air cell effusion. 3. Patent intracranial vasculature without occlusion, dissection, significant stenosis, or aneurysm. No evidence of vascular malformation. The patient was diagnosed with Dizziness and giddiness, Dehydration, Abnormal electrocardiogram [ECG] [EKG]. At the time of discharge, the patient had PRIMARY ======= Anxiety Panic disorder Rule out ACS SECONDARY Pulmonary embolism Hematuria Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old with history of UC s/p total proctocolectomy and ileoanal pouch, ankylosing spondylitis, type 2 DM, DVT, and recent admission ___ to ___ where he was found to have BPPV and a LLL PE started on Coumadin now presenting with dizziness since discharge and chest pressure for one day, found to be tachycardic with an elevated lactate. # Dizziness: Patient reporting new onset dizziness, described as feeling his pulse in his head and his vision beating side to side. Pt was given a diagnosis of BPPV at last admission, however his symptoms are not consistent with this finding. On exam, e/o decreased proprioception on exam w/ nystagmus laterally on prolonged upward gaze. Workup for seropositive autoimmune disorder negative so far: RF<3, ___ neg. CRP 2.5, sed rate 6. B12 503. Cu nl. Vit E low. RPR nl. CT head did not demonstrate an acute process. MRI head with no gross abnormalities. Thought most likely to be a multifactorial peripheral cause (planter neuropathy), with additional strong component of anxiety. Improved with Ativan. Started on Vit E 400u/day and citalopram 0.25mg BID. Should follow up with remaining labs sent by neuro at f/u appointment with Dr. ___ should also be referred to psychiatry from PCP ___ (per psychiatry recommendations, as they think this is the fastest mechanism for him) for ongoing treatment of anxiety. Also has f/u appointment w/ ENT ___ at ___. # Chest pressure, shortness of breath: Pt presents with chest pain/discomfort on deep inspiration. EKG demonstrated non-specific T-wave inversions, but troponin was negative x 2 so ACS ruled out. TTE ___ demonstrated normal LV function, slightly dilated RV, PASP unable to be estimated. BNP low (unreliable given his adiposity); overall, CHF exacerbation unlikely. New tachycardia and pleuritic nature of pain c/f repeat PE, but CTA negative and patient on coumadin. Trial of naproxen ineffective at controlling pain, suggesting pericarditis less likely. Nitro effective at pain control, suggesting angina; However, exercise stress test without inducible ischemia, angina, or echo abnormalities and nuclear stress test without any abnormalities. Seen by psychiatry, who think symptoms may be ___ anxiety attacks. Patient was on longstanding metoprolol, which was held this admission for dizziness and may be exacerbating anxiety and tachycardia. Restarted metoprolol, and started Clonazepam 0.25mg BID, with some improvement in symptoms. Instructed in relaxation techniques as well. # Pulmonary embolism: Pt presents with INR 3.3 and known PE diminished in size without evidence of new PE. Subsequently became subtherapeutic after holding for supratherapeutic INR. Transitioned from coumadin to apixiban 10mg BID, but had hematuria so converted back to Coumadin. Started on heparin GTT. Patient triggered ___ for tachycardia, c/f possible repeat PE in the setting of subtherapeutic Coumadin and heparin, but no HD instability so decision was made not to pursue CT angio and to continue treatment with lovenox as a bridge to heparin moving forward. # Hematuria: Pt presents with UA demonstrating large amounts of blood. He was noted to have gross hematuria during his recent admission with negative initial workup. He had a repeat episode of hematuria after starting apixiban. Urology was consulted during last admission and plan was for urology follow up as outpatient cystoscopy. Outpatient follow up planned on ___. # Ankylosing spondylitis: Pt denies worsening symptoms, however states that he did notice some hand and feet swelling a few days ago that resolved. Continued home gabapentin, methylprednisolone, oxycodone PRN. ESR and CRP WNL. # Hypertension: Restarted metoprolol as above # Depression, recent SI: Pt denies SI/HI. Continued home venlafaxine. # UC: Pt reports some blood in stool following apixiban, but no other abdominal pain or active symptoms. Deferred humira to outpatient. # Diabetes, likely steroid induced: HISS in house, not on any medications at home. # Low testosterone: Held home testosterone in house TRANSITIONAL ISSUES =================== -Should get close psychiatry follow-up for ongoing management of anxiety (both pharmacologic and non-pharmacologic). -f/u pending labs, including anti-GAD and anti-gliaden -recheck INR ___, adjust warfarin dosing accordingly; should instruct patient to stop lovenox. PCP to coordinate with ___. - Patient with hematuria currently in the process of workup; needs outpatient cystoscopy # CONTACT: ___ (sister) ___ # CODE STATUS: Full code </s>