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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F s/p L TKA ___, s/p revision L TKA ___, now presenting with recurrent L knee dislocations, has failed conservative measures and now elects to undergo definitive surgical management KNEE((SINGLE VIEW) LEFT showed Intraoperative images obtained during closed reduction of the left knee. Please refer to operative report for further details. KNEE (2 VIEWS) LEFT showed There has been interval removal of the left knee total arthroplasty with placement of an antibiotics spacer. A drain is present and postoperative changes including swelling and subcutaneous emphysema are noted. Radiology showed Right-sided PICC is seen with tip terminating at the low SVC. No pneumothorax, pleural effusion, pulmonary edema, or infiltrative opacity. Mild cardiomegaly. Mild degenerative change of the thoracic spine. Radiology showed There is a nonspecific air pattern in the small and large colon. CHEST (PA AND LAT) showed No prior chest radiographs available. Lungs grossly clear. Heart size top-normal. No pulmonary edema pleural effusion. Right PIC line is most readily visible on the lateral view passing to the low right atrium. The patient was diagnosed with Instability of internal left knee prosthesis, init encntr, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause. The patient was treated with ___: L TKA revision ___: L knee exchange of antibiotic spacer ___: L knee gastroc flap. At the time of discharge, the patient had L knee dislocation, s/p L TKA reivsion; s/p left knee antibiotic spacer exchange and gastro flap of left knee. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ year old male with history of end stage renal disease status post failed kidney transplant now on hemodialysis (___), diabetes, and hypertension presenting with pain and swelling at graft site. He was reinitiated on hemodialysis in ___ after receiving a transplant in ___. He still urinates a small amount. Two weeks ago, he went to AV care where they wanted to examine the graft as he had not used it in ___ years. They noticed a narrowing within the graft and performed a balloon dilatation. He had pain afterwards with a hematoma that has now resolved. He underwent successful dialysis session on ___. On ___ morning, he woke with increased pain in graft site. He went to dialysis where they were unable to auscultate or feel bruit/thrill at dialysis or bedside ultrasound. Denies trauma to left arm. He denies fevers, chills, chest pain, shortness of breath, nausea, vomiting, and diarrhea. Radiology showed Uncomplicated left upper extremity AV graft, venous outflow tract and central venography, mechanical thrombectomy, arterial anastomosis embolectomy, angioplasty (7 and 8mm) and venous anastomotic Fluency 8 x 40 mm stent placement. The patient was diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ABN REACT-RENAL DIALYSIS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA. The patient was treated with interventional radiology: fistulogram and thrombectomy with balloon dilation and stent placement. At the time of discharge, the patient had primary diagnosis: graft thrombosis secondary diagnosis: ESRD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT & PLAN: ___ yo male with history of ESRD s/p failed kidney transplant now on HD (MWF), DM, and HTN presenting with pain and swelling at graft site with likely thrombosed AV graft. #Thrombosed AV graft: The patient came to the hospital complaining of pain and tenderness at the site after restarting dialysis for approximately one month. Recent balloon dilatation two weeks ago for narrowing was noted. He has had succesful hemodialysis since but unsuccessful on ___. In the emergency department, initial vital signs were 98.1 71 199/84 16 100% on RA. The transplant consult service suggested admission to medicine, as did the renal consult service (transplant surgery following) and either interventional radiology the following day or AV Care in ___ He was given labetalol for elevated BP's with repeat BP 177/80. The patient was admitted to medicine and the following day received a fistulogram in ___ followed by successful thrombectomy. Afterwards, good flow with appropriate bruit and thrill at graft site confirmed by renal fellow/attending. Hemodialysis was done successfully, confirming graft viability #ESRD status post failed transplant now on HD: The patient was stable in terms of electrolytes without any signs of volume overload or uremia. As described above, he did well on hemodialysis status post thrombectomy. His tacrolimus level was found to be low. He was continued on his sevelamer, multivitamin, tacrolimus, and leuflonamide. He was started on nephrocaps per renal recommendations. #HTN: losartan and labetalol were continued with good effect. #DM: lantus with a humalog insulin sliding scale were continued with good effect. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old right handed woman with a history of sebaceous carcinoma of the nose s/p Mohs and radiation who presents with several episodes concerning for seizure today. Radiology showed 1. Large hiatal hernia. 2. Elevated right hemidiaphragm. No definite focal consolidation. Radiology showed No acute intracranial abnormality. Radiology showed Unremarkable examination, with no anatomic substrate for seizure and only global atrophy. Radiology showed Transverse fracture through the distal ulna without apparent dislocation at the distal radioulnar joint or the radial head. Radiology showed AP and lateral view compared to ___ and ___: Transvenous right atrial and right ventricular pacer leads follow their expected courses from the left pectoral generator. No pneumothorax, pleural effusion or mediastinal widening. Heart size normal. Moderate-sized hiatus hernia has increased. Lungs are clear. No pleural abnormality. The patient was diagnosed with OTHER CONVULSIONS. The patient was treated with Pacemaker placement ___.. At the time of discharge, the patient had Primary: Subnodal block in the setting of Fixed His-Purkinje Disease. s/p Pacemaker placement. Secondary: Traumatic L distal ulnar 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>___ PMHx macular generation (legally blind), HTN, HL, RBBB with LAFB concerning for infranodal conduction disorder who presented with recurrent episodes of altered states of consciousness in the setting of sinus pauses, now s/p PPM placement. # Diminished Responsiveness d/t complete heart block: Multiple events in the past several months with stiffening, LOC, preceeded by an aura and followed by ___ hours of confusion. Accompanied by weeks of SOB, fatigue and anorexia. No focal deficits on neurologic exam except bilateral upgoing toes. Neurologic imaging unrevealing for cause. While here, she was on both cardiac telemetry and EEG. She had a typical event WITHOUT EEG correlate, but WITH 4 second pause on tele. Thus, her episodes most likely represent bradyarrythmia with brain hypoperfusion leading to myoclonus and seizure-like movements, and not primary epilepsy. She was tranferred to the cardiology service for pacemaker placement after an unwitnessed fall ___ with HR ___ and EKG showing 3:1 conduction block. She had placemaker placed ___ without complication. She was treated with vancomycin for 48 hrs after pacemaker placement and keflex x1 day. # Lt ulnar fracture: due to fall. Orthopedics was consulted and recommended orthoplast ulnar gutter splint. Physical therapy and occupational therapy was consulted. # Atrial flutter: Pt was noted to have atrial flutter on telemetry. She was started on rivaroxaban 15mg daily. # Hypertension: Intermittently off beta-blocker while bradycardia was managed as above, restarted after pacemaker placement. Pt was discharged on metoprolol tartrate 12.5mg bid. # Hyperlipidemia: Continued home dose statin. # Wheezing/Shortness of Breath: Continued Fluticasone-Salmeterol Diskus (250/50) with albuterol and ipratropium Q6h as needed. Discharged on Advair and albuterol PRN.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presenting with 3 days of RLQ abdominal pain. Patient was having severe nausea/vomiting x 9 times initially. She was seen at ___ 3 days ago. Patient was tender in the RLQ, WBC was 15.___bd/pelvis was reported as normal appendix, some free fluid in the pelvis and an adnexal cyst. She was discharged home and followed up with her GYN. Patient had persistent abdominal pain localized in the RLQ, no nausea or vomiting, no fevers/chills. Pt went to OBGYN which did a pelvic exam which was normal and negative pregnancy test. Pelvic US was also negative. Radiology showed 1. Thickening of the appendiceal wall with surrounding stranding and a small amount of fluid in the tip consistent with appendicitis. 2. 2.2 x 2.4 cm soft tissue lesion in the medial aspect of the right breast most likely represents a fibroadenoma. Correlation with direct physical exam and mammography if indicated (with a positive family history) is recommended. The patient was diagnosed with ACUTE APPENDICITIS NOS, ABDOMINAL PAIN RLQ. 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>She was admitted to the Acute Care Surgery team and under CT imaging of her abdomen and pelvis showing thickening of the appendiceal wall with surrounding stranding and a small amount of fluid in the tip consistent with appendicitis. She was consented, prepped and taken to the operating room for laporascopic appendectomy. There were no complications. She was continued on IV Cipro and Flagyl postoperatively. Her diet was advanced to regular and she was able to tolerate solids without difficulty. The antibiotics were also changed to oral form and were recommended to be continued for another 7 days after discharge. Her pain was well controlled with po pain medications. Her PCP was contacted for questions pertaining to anticoagulation given her history of PE in ___ and no further anticoagulation was indicated at this time. She was placed on subcutaneous Heparin tid during her stay. She was discharged to home with instructions for follow up with her PCP and in the Acute Care Surgery Clinic.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with h/o congenital intestinal pseudo-obstruction s/p resection and failed intestinal transplant x 2, TPN dependent and with G tube for venting who presents with abdominal pain. Radiology showed Small region of echogenic material within one of the two right brachial veins may represent a non-occlusive thrombus versus visualization of venous valve. This is unchanged from ___. Radiology showed Bowel gas pattern suggestive of obstruction. This study and the report were reviewed by the staff radiologist. Radiology showed Right-sided central venous catheter with no evidence to suggest adjacent infection. Radiology showed Unchanged chest radiograph from previous imaging with no evidence of pneumonia. Radiology showed 1. Left lower lobe consolidation consistent with pneumonia. 2. G-tube is displaced with balloon sitting within the abdominal wall. 3. Presumed bladder outlet obstruction resulting in severe enlargement of the bladder and moderate bilateral renal pelvicaliectasis. 4. Unchanged appearance of the stomach and residual small bowel. 5. Small pleural effusions and free abdominal fluid. Dr ___ the above findings with Dr ___ on ___ at 1410 hours via telephone approximately 1 hours after the findings were made. Radiology showed 1. Bilateral prominent collecting systems suggestive of mild bilateral hydronephrosis. 2. The bladder appears decompressed with a Foley placed inside. Radiology showed No focal fluid collection or abscess identified. Radiology showed Increasing left lower lobe opacity. Radiology showed Deep epigastric arteries, both patent. Veins not demonstrated. Perforators are present. Fatty infiltration of right rectus muscle. Radiology showed NG tube folds back on itself in the body of the stomach. Radiology showed Small region of nonocclusive thrombus again identified in the right brachial vein. No change from the prior studies. The patient was diagnosed with ABDOMINAL PAIN GENERALIZED, OTHER GASTROSTOMY COMPLICATION. The patient was treated with ___ Wound exploration and sharp debridement percutaneous endoscopic gastrostomy.. At the time of discharge, the patient had Primary: G-TUBE MIGRATION Secondary: Congenital intestinal pseudoobstruction s/p intestinal transplant x2, Upper extremity DVT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># G-tube migration - Patient presented with severe pain secondary to G-tube migration. He required IV dilaudid for pain control. Restarted TPN per nutrition recs, used home TPN regimen with some electrolyte additives. ACS & Dr. ___ ___ and performed wound exploration and sharp debridement percutaneous endoscopic gastrostomy on ___. They replaced the G tube and created a stomach osteomy (which will close by secondary intention). The tubes showed good output on suction and was eventually left to gravity with connecting bags. The pain was then controlled with IV Dilaudid and the pt was slowly weaned off of IV Dilaudid over a span of a week. Seen by Pain Medicine for pain control, however, patient was unwilling to try suggested alternatives. Pt cannot take PO medications due to lack of intestines. Patient did not object to being sent home without pain medications other then Fentanyl patches (cannot send patient on IV dilaudid due to risk of overuse). Fentanyl patches and pain control will be followed-up with the patient's PCP. Octeotride was suggested to decrease gastric output, howver, patient verbalized that he could maintain good hydration. Also, electrolytes were stable s/p surgery. # Fever / Sepsis - Patient was febrile between ___. Met sepsis criteria based on fever, tachycardia (as high as 140, sinus tachycardia, consistent with temperature elevation), leukopenia, and suspected infection. Infectious disease specialists were consulted. Ultimately, the source could not be confirmed as there were many possible sources (outlined below). Continued to spike fevers despite vancomycin, cefepime, daptomycin. On ___, pt was febrile most of the day to ___, had sinus tachycardia to the 130-140s. Gave fluid bolus, used cooling blankets, IV tyelenol & toradol. Fevers ultimately resolved with initiation of broad spectrum antibiotics (linezolid, metronidazole, cefepime). Cefepime and metronidazole were discontinued on ___. Linezolid course, ___ - ___, per ID. Lineziolid was discontinued due to agranulocytosis and thus was switched to Doxycycline. Doxycycline would be continued until pt is seen by ID in clinic (treatment for MRSA catheter tip infection). Pt was afebrile on Doxycycline except for one fever s/p surgery. At time of discharge, patient was afebrile and had stable VS. ANTIBIOTICS HISTORY Vancomycin: preadmission - ___ Ciprofloxacin: ___ Fluconazole: ___ Daptomycin: ___ Cefepime: ___ Metronidazole: ___ Linezolid: ___ Doxycycline: ___- ___ Visit # RUE DVT - pt did not adhere to lovenox therapy prescribed in ___. During this admission, RUE US showed stable clot, lovenox was restarted during this admission, but patient refused lovenox shots after 3 days. Heparin drip also tried but discontinued as the patient refused a dedicated line for heparin drip. He communicated full understanding of risks of not treating DVT. After further discussion with patient, heparin drip was started ___. Developed increased RUE swelling ___, and repeat RUE ultrasound showed stable DVT. At time of discharge, pt was explained the risk and benefits of anti-coagulation. The pt fully understood the risk of PE without anticoagulation. He was unwilling to have daily Lovenox shots or Coumadin PR. He persistently declined anticoagulation and is aware of the risk of DVT's, including PE and possible death. . # Pancytopenia - rec'd 2U PRBCs on ___, HCT increased appropriately from ___. He has chronic pancytopenia likely from nutritional deficiency and repeated courses of broad spectrum antibiotics. Got 2U PRBCs on ___ with suboptimal response. Hemolysis labs unremarkable. However, reticulocytes were depressed at 0.9 on ___, likely secondary to linezolid. Linezolid was discontinued ___. The pancytopenia improved after discontinuation of Linezolid, however, patient is still pancytopenic likely from nutritional deficit. It has been stable over the last 2 weeks of his admission. . # Catheter tip infection He has a ___ catheter for TPN. He had a MRSA catheter tip infection on ___ for which he had been started on vancomycin. We continued IV vancomycin, originally planned to complete 4 week course of vancomycin until ___. However, as he developed fevers on ___, vancomycin was continued until ___, at which point vancomycin was changed to daptomycin because of concern that fevers were drug-related. Daptomycin was changed to linezolid on ___ because fevers persisted. CBC monitored daily because marrow suppression is an adverse effect of linezolid. On ___, reticulocytes were low, so linezolid was stopped and changed to doxycycline on ___ for the MRSA catheter tip infection. Because he is TPN-dependent, he is at risk for fungemia, but mycolytic cultures x2 were negative. Soft tissue ultrasound was not suggestive of pocket infection or abscess. Doxycycline was continued until ___ clinic visit for the MRSA catheter tip infection. Discharged with IV Doxycycline. . # Lactobacillus bacteremia - ___ blood culture from ___ catheter grew lactobacillus. Empirically treated with cefepime and metronidazole ___. All other blood cultures negative. . # ___ urinary tract infection - He complained of dysuria on ___, UA was suggestive of UTI, so he received two days of IV ciprofloxacin ___, which was stopped because urine cultures grew yeast. He was treated with fluconazole for 3 days. . # ICD lead infection - Patient had an ICD placed ___ at ___ for Vfib arrest in ___, pocket revision ___, and partial lead and generator removal on ___. CTS has seen and felt that the operative risk of removal of ICD leads is too high. PET-CT did not show increased FDG uptake suggestive of lead infection. . # HCAP - CT showed LLL consolidation, treated with cefepime ___. . # Tooth pain - he complained of tooth pain and a recently chipped tooth, so a panorex was done, he was seen by an oral surgeon, who recommended no intervention for his tooth pain. . # Chronic urinary retention: Has atonic bladder secondary to congenital intestinal obstruction. Renal ultrasound and PET-CT showed hydronephrosis and large, distended bladder. Seen by urology in-house. Required intermittent straight catheterization for bladder decompression during this admission. Will have f/u with Dr. ___. . # Hypernatremia, Hypokalemia, Metabolic Alkalosis - On presentation, was hypernatremic, hypokalemic, and had a metabolic alkalosis. Occurred in the setting of missing 2 days of TPN because of repeated ED visits. Improved with 3.5L hypotonic IV fluids. Venous blood gas consistent with pure metabolic alkalosis. Most likely etiology is gastrointestinal/insensible losses of free water and H+ through the leaky G-tube. Contraction alkalosis likely also contributed in the setting of volume depletion as he was unable to get TPN or hydration. After initial volume resuscitation, electrolytes normalized and were maintained with daily TPN and occassional electrolyte replacement. Normal electrolytes at time of discharge. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ F with a history of bipolar disorder, hypertension, anxiety disorder, with multiple recent syncopal episodes who presents with a syncopal episode. CHEST (PA AND LAT) showed In comparison with the study of ___, the cardiac silhouette remains at the upper limits of normal in size and there is mild tortuosity of the aorta. No acute pneumonia, vascular congestion, or pleural effusion. Specifically, no evidence of old tuberculous disease. Carotid Doppler Ultrasound showed No evidence of atherosclerotic disease in the bilateral carotid vasculature. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had Primary: Syncope Hypertensive Urgency Secondary: Generalized Anxiety Disorder Bipolar 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>Ms. ___ is a ___ F with a history of bipolar disorder, hypertension, anxiety disorder, with multiple recent syncopal episodes who presents following a syncopal episode. #Syncope: Patient has had multiple episodes of syncope over last month, with episodes occurring almost daily the week prior to admission. Prodrome of diaphoresis in addition to a prolonged recovery from the episodes suggest vasovagal etiology, likely in the setting of her recent life stressors with work. Syncope work-up for other etiologies was negative. In particular, ECHO and carotid US showed no signs of stenosis or outflow obstruction. EKGs showed sinus bradycardia, and patient has no history of heart disease, palpitations, arrhythmia thus unlikely a cardiac cause. However, she will go home with ___ of Hearts monitoring. Patient was educated about vasovagal and encouraged to maintain PO intake and use physical counterpressure techniques when she feels symptoms. #Episodic Hypertension: Patient presented with hypertensive urgency at 170/102 on admission, with baseline at 110's/70's, per patient. Patient has had episodic elevations in blood pressure throughout admission, ranging from 110s-170s/70s-100s, though has been asymptomatic. Initial elevation may have been attributed to clonidine rebound (which she takes for night sweats/anxiety). Clonidine was stopped and patient was started on captopril 6.25 TID in the hospital. She was discharged on lisinopril 5 mg daily, and will follow up with PCP for medication titration. Given episodic elevations in blood pressure, sweating, weight loss, there was concern for pheochromocytoma. Urine metanephrines are pending at discharge. #Night Sweats: Patient endorses 7 lb weight loss over past two months with daily night sweats, dissimilar to her hot flash symptoms. CXR normal with no signs of lung mass or TB infection. LDH slightly elevated, though hemolyzed specimen. Patient has had history of longstanding night sweats, often triggered but life stressors. #Diarrhea: Patient endorses watery diarrhea at nights every ___ days, usually attributed to stress episodes. No recent antibiotics, exposure, no association with food, no significant caffeine intake. During hospital stay, patient had no bowel movements. #Wheezing: Patient is asymptomatic, though diffuse bilateral wheezing was heard on exam. Patient notes history of asthma/allergies, particularly worse during this time of year. She uses home mucinex and claritin, which successfully manages her symptoms. ***TRANSITIONAL ISSUES*** [ ] f/u quantiferon gold due to concern for night sweats and weight loss [ ] f/u ___ of Hearts [ ] f/u urine metanephrines due to concern for pheochromocytoma. [ ] Started on lisinopril 5 mg daily, may need uptitration. [ ] Check electrolytes at next visit due to starting lisinopril # CODE: Full, but doesn't want to be kept alive if neurologically not intact. # CONTACT: ___ (private care-friend) ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old gentleman with a PMH of extensive CAD s/p 4-vessel CABG ___ years ago, s/p DES to SVG-RCA and SVG-OM in ___ moderate AS (peak systolic velocity ___, peak/mean gradients ___ mmHg), peripheral vascular disease s/p stenting, s/p L CEA, insulin-dependent diabetes c/b neuropathy and nonhealing ulcer with R ___ toe amp, HTN, HLD, Stage II CKD and hypothyroidism, admitted with acute on chronic dyspnea. Radiology showed Mild congestive heart failure with small right pleural effusion. Bibasilar airspace opacities likely reflect atelectasis, but infection is not excluded. Radiology showed Findings are consistent with osteomyelitis in several toes. Localizing history would be helpful in this regard. Radiology showed Findings consistent with bilateral tibial arterial insufficiency, and additionally, right SFA disease. Radiology showed No acute intracranial abnormality. Radiology showed Femoral approach Swan-Ganz positioned 3.5cm past the border of the mediastinum in a lower segmental pulmonary artery. Recommend withdrawal of Swan-Ganz by 3.5 cm. Intraaortic balloon pump at the level of the superior border of the aortic arch. Recommend withdrawal by 1 cm. Otherwise, little change compared to ___. Results discussed over the telephone with ___ by ___ at 4:20 p.m. on ___ at the time of initial review. Radiology showed Status post right greater saphenous stripping. The left greater saphenous vein is small below the knee, but may have some available length in the thigh. The left small saphenous vein is calcified. Radiology showed Extensive atherosclerotic vascular calcifications including native coronary arteries and aortic and mitral valves. No pericardial effusion. Radiology showed Right-sided PICC line tip at the level of the mid SVC, with interval recurrence of bilateral pleural effusions. These findings were discussed with ___, RN by Dr. ___ via telephone on ___ at 10:00 a.m., at time of discovery. Radiology showed Thrombus in the left cephalic vein. Patent bilateral basilic and right cephalic vein with diameters as noted. Most suitable conduit is right basilic vein. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, AORTIC VALVE DISORDER. The patient was treated with ___ Redo Sternotomy, AVR(23mm tissue), and Coronary Artery Bypass Grafting x 4 (SVG-LAD, SVG-Diag, SVG-RI, SVG-rPDA) ___. At the time of discharge, the patient had Aortic stenosis Coronary Artery Disease, prior CABG ___ Dyslipidemia Hypertension Carotid artery disease, History of Left CEA Pheripheral vascular disease, s/p Bilateral iliac artery stenting Insulin Dependent Diabetes (nephropathy, neuropathy, retinopathy) Chronic Kidney Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>MEDICINE COURSE: Mr. ___ is a ___ year old male with known coronary artery disease who was transferred from OSH for treatment of severe SOB and DOE. CXR on admission was consistent with pulmonary edema. He was initially admitted to the ___ service and started with IV lasix boluses for diuresis. On hospital day 2 he syncopized with precedent lightheadedness. He also triggered for hypoxia with O2 sats to mid ___ on 5L NC. He was switched to a high flow face mask and started on lasix and nitroglycerin drips. A TTE performed that day was notable for severe regional left ventricular systolic dysfunction with focal near-akinesis of the septum, anterior wall, inferior wall and apex and EF of ___ ( down from 60% on Echo rom ___. He was taken to the cath lab on hospital day 3 given progressive hypoxia and syncope. His cath was notable for a newly occluded SVG-RCA and SVG to ramus with significant stenosis. Aortic valve area of ~0.5-0.6cm. . Right heart cath was notable for RA pressure 15, PCWP ~30, cardiac index 1.6 consistent with cardiogenic shock. An intra-aortic ballon pump was placed in the cath lab and he was transferred to the CCU. In the CCU he remained on a lasix drip and nitro drip, titrated to maintain a a CVP of ___. The nitro gtt was weaned on hospital day 5. Isosorbide and hydralalzine were also added for afterload reduction. The patient was weaned from the ballon pump on hospital day 8. The lasix drip was discontinue on hospital 9 and he was started on torsemide for diuresis. The patient likely had progressive demand ischemia of his myocardium secondary to re-stenosis of his grafts and progression of his AS, leading to decreased EF and WMA and cardiogenic shock. The patient also had progression of his AS, now severe with Aortic Valve mean gradient = 24 mmHg. ___ 0.6 sq cm.. His severe AS and decreased EF likely contributed his poor CI and CO. He was evaluated BY CT surgery for aortic valve replacement and revision of CABG, which was initially delayed to allow to time for washout of his prasurgrel. During this time he was also seen by the infectious disease, vascular surgery and podiatry services for non healing ulcer of right foot. He was started on Vancomycin and Zosyn for osteomyelitis of foot.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ CVA Hx, CKD, glaucoma, presents with generalized weakness, confusion. Pt was normal ___ night upon going to bed, woken up by care taker am of morning of presentation, weak and confused. Patient was slumping when placed on toilet. She took his blood pressure which was 117/75 and his heart rate was reportedly 127. They called his neurologist, Dr. ___ recommended he come to the emergency department. They report he has had increased urinary frequency and odor of his urine the past few days. They deny fevers, nausea, vomiting, diarrhea, black or bloody stools or abdominal pain. Patient did have a cough last week which has since resolved. Daughter states that he has had a similar presentation and found to have a UTI in the past. Portable chest radiographs showed Increased hilar haziness may represent pulmonary congestion versus decreased lung volumes. Retrocardiac opacity, likely atelectasis though infection is not excluded. If further clarification, repeat with PA and lateral views with improved inspiration could be performed. Radiology showed Cardiomediastinal silhouette is within normal limits. There are very low lung volumes. There is crowding of the pulmonary vascular markings particularly at the bases. There is also haziness about the perihilar regions which may represent mild pulmonary edema, unchanged. No definite consolidation is seen. There are no pneumothoraces. Retrocardiac opacity seen on the prior chest radiograph, relates to a hiatus hernia. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had Urinary tract infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male with h/o CVA and glaucoma who presents with marked weakness and AMS in the setting of a UTI. # UTI w/ acute encephalopathy - he was treated with IV ceftriaxone 1 gram daily x 3 doses with rapid improvement in mental status to baseline by hospital day 1 - on hospital day 2, he continued to feel well and walked with physical therapy with the aid of a walker and was seen to have strength and functioning close to his baseline - he will be discharged with Macrobid ___ bid to complete a total 7 day course of antibiotics based on resistance profile from urine culture # Sinus tachycardia w/ PAC's - tachycardic on admission, improved with 1.5 L of saline given over 24 hours - heart rate returned to baseline 90's-100 at discharge on qAM metoprolol 12.5 daily # ___ on CKD - Cr 1.9 on admission - renal function improved to Cr 1.3 on discharge CHRONIC/STABLE PROBLEMS # Glaucoma - continued on eye drops and oral antiviral during hospitalization # BPH - continued on home tamsulosin # CVA - continued on home ASA Post discharge care: - he will have home physical therapy initiated after discharge - he will continue his other home supports with nursing/aide - he will follow up with PCP, ___ as scheduled the following week Patient seen and examined on day of discharge and stable for discharge. >30 min spent on DC planning and coordination of care</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ man with history of colon cancer s/p right hemicolectomy and RFA of liver met, now with glioblastoma on treatment with bevacizumab. He was recently admitted early ___ after fall at rehab facility and subsequently received inpatient becacizumab. Per neuro-onc note ___, patient had been very somnolent with decreased verbal output. UA was reportedly positive for a UTI and he was started on levofloxacin. Since his discharge from the hospital ___, he has continued to see urology for urinary retention. At his last appointment ___, it appeared the patient was able to pass a voiding trial. However, patient required foley replacement in the ED later that day for urinary retention. He presents to the ED today for altered mental status, fever, and urinary symptoms. He was noted to have decreased urine output and blood clot in his Foley, which was replaced. He was noted to be markedly agitated and required restraints. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial hemorrhage. 2. Biopsy proven glioblastoma in the right temporal lobe is re- demonstrated. Adjacent edema appears stable to slightly improved as compared to ___. Portable chest radiograph showed No acute cardiopulmonary process. Bilateral pleural plaques are unchanged. The patient was diagnosed with ALTERED MENTAL STATUS , FEVER, UNSPECIFIED. At the time of discharge, the patient had Acute Encephalopathy secondary to UTI Glioblastoma Dementia 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>___ is a ___ man with history of colon cancer s/p R hemicolectomy and RFA of liver met, now with glioblastoma on treatment with bevacizumab presented with fever, ___, and AMS concerning for UTI. 1. Encephalopathy secondary to urosepsis: Alertness has been improving, however still oriented x 0. This is likely closer to the patient's recent baseline secondary to dementia and glioblastoma. Patient initially presented with fever, urinary retention, and altered mental status likely secondary to continued issues with foley catheter/urinary retention. There may be element of post-renal obstruction with blood clots/bleeding leading to ___ and decreased excretion of drug metabolites. Appears to have failed outpatient levofloxacin therapy for previous acinetobacter UTI. -Urine culture revealed levofloxacin resistant staph. -Received 6 days of antibiotics, transitioned to comfort-focused care at discharge. -Blood Cx NGTD -Failed voiding trial so foley was re-inserted. 2. Malnutrition: Given delirium, patient with very minimal PO intake. Occasionally can tolerate ice cream and has been swallowing meds with this. Despite aspiration risk, feeding for comfort is acceptable. 3. ___: Improved. Likely elements of post-renal given urinary retention and blood clot obstructing foley and pre-renal from decreased PO intake in setting of encephalopathy. Improved with foley and IVFs. Baseline 0.9-1.0 4. Agitation: Initially required restraints during acute encephalopathic process from pulling foley. His foley was removed with plans for straight cath to prevent him from needing restraints to keep him from pulling his foley, but he failed voiding trial and foley reinserted. He was continued on Zydis 10 mg QHS for agitation; additional Zydis available PRN. Benzodiazepines were avoided as they were extremely sedating to him. 5. Glioblastoma: S/p chemoradiation and recent bevacizumab treatment. Decision made to no longer pursue treatment and focus on comfort, as his overall prognosis is poor. -If seizures, may use SL Ativan as abortive therapy</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH vascular dementia, h/o ICH, NPH s/p shunt, PE with IVC not on anticoagulation, CAD s/p CABG and LAD stent, AFib (not on coumadin d/t falls), complete heart block s/p pacemaker, BIBA for AMS. Per ED history taken from daughter, at baseline uses a walker and is AOx1. For the past ___ he has had increased agitation and combativeness requiring more seroquel (120mg total past 24hrs). Found to be more somnolent, nonconversant and lethargic today, with new twitching. Over past few weeks patient also noted to be bruising more, ASA81 was discontinued 3 days ago. No sources of bleeding, no diarrhea or fevers noted. Daughter suspects possible UTI, also noted new cough over past few days. UCx recently checked ___ with fecal contaminants. Radiology showed No definite acute cardiopulmonary process. Persistent left basilar opacity likely represents persistent loculated effusion. Radiology showed Motion limited exam; but within that limitation no evidence of acute intracranial process. Radiology showed 1. No radiographic evidence for NG tube placement. 2. Increasing opacification of the right middle and right lower lobes, concerning for aspiration versus pneumonia. 3. Stable, loculated left pleural effusion . Radiology showed 1. No acute abnormality detected in the abdomen and pelvis within the limitations of a non-contrast study. 2. Small volume ascites in the abdomen in the setting of VP shunt. 3. Diverticulosis without diverticulitis. 4. Stable postoperative changes following right colectomy. Please note that the chest will be reported separately by the thoracic imaging section. Radiology showed 1. New right lower lobe and scattered right upper lobe opacities most consistent with aspiration pneumonia. Persistent left lower lobe atelectasis. 2. Large loculated left pleural effusion with new convexity to the anterior margin; consider indolent infection. Small right pleural effusion. 3. Pulmonary hypertension and chronically large thoracic aorta. 4. Dense coronary artery and mild aortic valvular calcifications. Please see report of abdomen CT for further details. Radiology showed AP chest compared to ___, 4:26 a.m.: New large area of consolidation in the right lower lobe is most likely acute pneumonia. Moderate cardiomegaly and left lower lobe atelectasis persist. Transvenous right atrial and ventricular pacer leads are in standard placements. Pulmonary vascular engorgement has decreased, indicating this is not asymmetric pulmonary edema. Radiology showed Right PICC line terminating in the mid-lower SVC. Findings were conveyed by Dr. ___ to ___ via telephone at 15:25 on ___, 5 min after discovery. Radiology showed Normal oropharyngeal swallowing videofluoroscopy. The patient was diagnosed with HYPERKALEMIA, SEMICOMA/STUPOR, HYPOTENSION NOS, HYPOSMOLALITY/HYPONATREMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED, ANEMIA NEC. At the time of discharge, the patient had Primary Diagnosis: Aspiration Pneumonia, Acute on Chronic Kidney Failure Secondary Diagnosis: Anemia, Diastolic Congestive Heart Failure, Vascular Dementia, 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>PRIMARY REASON FOR HOSPITALIZATION: ================================================ Mr. ___ is an ___ with a PMHx of vascular dementia, h/o ICH, NPH s/p shunt, PE with IVC not on anticoagulation, CAD s/p CABG and LAD stent, AFib (not on coumadin d/t falls), complete heart block s/p pacemaker, BIBA for AMS. Found to have ___, hyperkalemia, and developed hypotension in the ED.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with metastatic squamous cell carcinoma to skull base and upper cervical spine. He has extraordinary pain, cervical settling, causing stenosis, and difficulty swallowing secretions because of abnormal alignment and dislocation. Because of the severity of the illness, the natural history of this disease, and with the goal of preserving his spinal cord and restoring the stability of his craniocervical junction, he elected to undergo surgical treatment. Radiology showed 1. Atlntoaxial and craniocervical instability caused by destruction of the right occipital condyle and mass of C1 with widening of the atlantoaxial interval is re-demonstrated. Slightly increased upward migration of the dens is noted. A predominantly lytic process favors metastatic disease, however, osteonecrosis remains a possible underlying etiology. 2. Several potentially enlarged lymph nodes are again seen at level 2, but are not well characterized on this noncontrast study. Correlation with PET-CT is advised if clinically warranted. NOTIFICATION: Findings were entered into Critical Radiology Results dashboard at 5pm on ___ by Dr. ___, as Dr. ___ was not available by page. Radiology showed Unchanged exam from prior study, showing atlantoaxial and craniocervical instability caused by erosive destruction of the right occipital condyle and masses of C1, with widening of the atlantodental interval and mild invagination of the odontoid process into the foramen magnum. Radiology showed No acute intracranial process with unchanged appearance of erosive destruction of the right occipital condyle and lateral mass of C1 with accompanying appearance of atlantoaxial and craniocervical instability. Radiology showed Multiple surgical instruments are noted posterior to the upper cervical spine. Status post occiput to C3 posterior fusion. The hardware appears intact. Endotracheal tube and temperature probe present. Please see operative report for further details. Radiology showed Unremarkable post-operative appearance. The patient was diagnosed with PATHOLOGIC FX VERTEBRAE, SECONDARY MALIG NEO BONE. The patient was treated with 1. Posterior fusion craniocervical. 2. Posterior fusion C1-C2. 3. Posterior fusion C2-C3. 4. Laminectomy, biopsy, intraspinal lesion, extradural, C2. 5. Posterior instrumentation occiput, C1, C2, C3. 6. Open treatment, posterior, cervical fracture. 7. Allograft, for fusion. 8. Wound vacuum-assisted closure application and treatment.. At the time of discharge, the patient had 1. C1 fracture. 2. C2 fracture. 3. Occipital fracture. 4. Infiltrative lesion occiput, C1, C2. 5. Metastatic disease consistent with squamous cell carcinoma, tonsillar. 6. Neck pain. 7. Spinal cord 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>Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was initially transferred to the TSICU and remained intubated for airway protection given difficulty handling secretions. He was weaned off the vent without difficulty and extubated on POD#1 and subsequently transferred to the floor. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Nutrition saw the patient to make recommendations for tube feeds, which were advanced to goal and tolerated well by the patient. The patient was transitioned to pain medication via G-tube. Foley was removed on POD#2. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating tube feeds. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo man with a h/o HTN, depression, ? dementia, admitted to the hospital from the ED with fevers, choledocolithiasis with sludge and intra and extra hepatic biliary ductal dilitation seen on U/S. He has a h/o recent diagnosis of fullness to the pancreatic head, ? malignancy vs inflammation in the setting of ___ lb weight loss over the past year. One year ago he was thought to have developed Celiac disease, but the diagnosis is not secure. Numerous notes in OMR from Drs ___ are reviewed and provide detail. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Choledocholithiasis with new intra- and extra-hepatic biliary ductal dilatation, not present on CT of ___. Both stones and sludge within the CBD. 2. Stable 2.1-cm multiloculated cyst within the right lobe of the liver. Radiology showed 1. Limited examination due to the absence of intravenous contrast, however no suspicious pancreatic mass. A cystic lesion in the pancreatic head in communication with pancreatic duct, likely representing a small side branch IPMN. No further follow-up is needed for this. 2. Slightly prominent proximal intrahepatic biliary ducts. Pneumobilia, related to recent sphincterotomy. Trace perihepatic fluid. The patient was diagnosed with FEVER, UNSPECIFIED, HYPOTHYROIDISM NOS. The patient was treated with ERCP EUS. At the time of discharge, the patient had # Cholangitis with biliary obstruction (choledocolithiasis) # Pancreatic fullness; MRCP report pending # Weight loss/malnutrition, chronic loose stool # Acute GNR acute blood stream infection # New onset Atrial Fibrillation Secondary: # Depression # Hypothyroidism # Glaucoma. The patient was given written instructions concerning 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 with a history of hypertension (not on meds), depression, hypothyroidism now with a fullness in the head of his pancreas, ___ lb weight loss, and biliary obstruction with choledocolithiasis and cholangitis. There was concern for possible malignancy given "fullness" in pancreas. Pt underwent EUS/ERCP, during which stones were extracted from the bile duct. There was "fullness" in the pancreas, which could be concerning for possible malignancy, so pt underwent MRCP evaluation, final read pending. During the hospitalization, pt was treated for cholangitis with an acute GNR blood stream infection. He was treated with Pip/Tazo, and then transitioned to Cipro based upon sensitivities. He was afebrile at the time of discharge, and will complete 10 more days of Cipro. Final culture results remain pending. Surgery followed throughout the hospitalization, and they plan cholecystectomy in outpatient follow up. # Cholangitis with biliary obstruction (choledocolithiasis) # Pancreatic fullness - concerning for possible malignancy; MRCP report pending # Weight loss/malnutrition, chronic loose stool # Acute GNR acute blood stream infection; ___ to cipro Biliary obstruction resolved s/p ERCP with stone extraction. Leukocytosis improving, responding to antibiotics. - Cipro based on sensitivities; will prescribe 10 more days from discharge. - PCP to follow up MRCP - Planning CCY in outpt follow up # Possible new onset Atrial Fibrillation - CHADS2 score = 2 (1 point for hypertension, 1 point for age) At the time of admission, there was concern for new onset afib. Final cardiology read of EKG from ___ shows "appears to be a combination of occasional sinus beats with junctional beats with retrograde P waves along with probably some ectopic atrial beats". His HR remained controlled throughout the hospitalization. Consider follow up EKG as an outpatient to clarify. # Depression - continued sertraline # Cognitive impairment - may be a component of delirium/encephalopathy but concerning re: dementia. - follow up with PCP # ___ - continue levothyroxine # Glaucoma - continue home timolol gtt FULL CODE VTE Prophylaxis: Pneumoboots DISP: home. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ gastroparesis presents with abdominal pain since last night when she went off her liquid/pureed diet and ate pork chops and potatoes. This is her typical response to solid foods according to her. Pain is sharp, was acute onset, located in LUQ, radiating to L back, worse with inspiration. This was accompanied by nausea and vomiting, though no fever. She reports a ___ doctor (___) who wanted to her to see motility specialist Dr. ___ in the near future. She does not recall seeing any other ___ doctor at ___, though OMR indicates she met Dr. ___ in ___. Radiology showed 1. Mild inflammatory change in the lower pelvis adjacent to the sigmoid colon. No abscess. 2. Diffuse fatty deposition within the liver. 3. 1.4-cm hypodensity in the left hemipelvis may represent adnexal cyst in setting of partial hysterectomy. This may be further evaluated with an ultrasound if clinically warranted. Findings discussed with Dr. ___ on the morning of ___. The patient was diagnosed with GASTROPARESIS. At the time of discharge, the patient had 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>___ yo woman with prior history of gastroparesis, now with abdominal pain, nausea, vomiting, after attempt to eat regular solid food. She has an unconfirmed report of C. difficile diarrhea from recent hospitalization. # Abdominal Pain: Likely gastroparesis. GI was consulted and recommended IV Reglan or erythromycin bth of which she has claimed allergies to. Patient requested opiate narcotic pain medication. She has 2 contrainidications to opiates (gastroparesis, and presumed C. diff infection with sigmoid stranding). I declined to give this to her. She had no localizing signs to her abdominal pain on exam, and findings were not consistent with pain throughout the exam. She was afebrile, has no leukocytosis or Left shift), and UA was also clear. She was instructed to keep NPO in hospital. She decided to leave against medical advice, similar to her last hospitalization. # Nausea w/ vomiting in ER: Patient no longer nauseous on medical ward. Received promethazine in the ED. # C. difficile diarrhea: Uncomfirmed. Keep on contact precautions. Will request OSH records. Continued IV Flagyl for now. Patient left against medical advice. # Asthma: Chronic, intermittent. Give Fluticasone 110mcg 2puff BID for now (pulmicort not on formulary). Albuterol prn. Patient left against medical advice. # GERD: patient reports history of GERD for which she takes intermittent PPI (hasn't taken in 2 weeks). As this class of drug is associated with increased C. diff infection, I have advised her to not restart this med without speaking first with her PCP. Patient left against medical advice. # Hypokalemia: 3.3 on admission. Will replete with 40mEq in fist liter of NS # Hypomagnesemia: 1.6 on admission. Will replete with 2mg IV now # Incidental pulmonary nodule: 3mm. Patient with low risk features for malignancy. I informed patient of this finding and low risk of malignancy, and instructed her to follow-up with PCP for further discussion and follow-up imaging as indicated. # Code: Full # DVT prophy: SC Heparin TID</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with ETOH abuse with recurrent alcohol withdrawal, alcoholic cirrhosis, hepatitis C, bipolar disorder, homelessness, history of multiple prior falls and hospitalizations who presented to the ED with alcohol intoxication. DX CHEST PORTABLE PICC LINE PLACEMENT showed Newly placed right-sided PICC with the tip projecting over the inferior right atrium. Retraction of ___ tip in the superior cavoatrial junction. DUPLEX DOPP ABD/PEL showed 1. No evidence of biliary duct dilatation. 2. Patent TIPS. 3. Cholelithiasis. 4. Nonobstructing right renal stones. The patient was diagnosed with Other fatigue. At the time of discharge, the patient had Hypomagnesemia Hypokalemia Hypophosphatemia Alcohol dependence with withdrawal History of seizures Cirrhosis with history of esophageal varices Elevated LFTs Neutropenia Pancytopenia Bipolar 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>Mr. ___ is a ___ male with ETOH abuse with recurrent alcohol withdrawal, alcoholic cirrhosis, hepatitis C, bipolar disorder, homelessness, history of multiple prior falls and hospitalizations who presented to the ED with alcohol intoxication. He was found to have severe hypokalemia and hypomagnesemia. He has been trying to decrease alcohol intake and presented with signs of alcohol withdrawal. He was loaded with Phenobarbital in the ED. He was not having significant signs of withdrawal at discharge. His LFTs are improving and had no evidence of biliary obstruction on ultrasound. He hypokalemia and hypophosphatemia have resolved, and hypomagnesemia is nearly resolved.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with recurrent ovarian cancer currently chemotherapy who presented to the ED this AM with progressively worsening diffuse abdominal pain that began last night. Her pain began last night, but became worse and unbearable this AM around 5am, ___ in intensity at which time she called an ambulance and was brought to the ED. This pain was associated with nausea, but no vomiting. She is passing flatus. Her last BM was ___ AM. Prior to this onset of pain she was feeling well. CT ABD AND PELVIS WITH CONTRAST showed 1. Small bowel obstruction transition in the right lower quadrant may reflect a malignant obstruction. Small volume ascites. 2. Peritoneal/omental/serosal nodularity as detailed above reflects peritoneal carcinomatosis. 3. Additional nonemergent findings detailed above. The patient was diagnosed with Unspecified intestinal obstruction. At the time of discharge, the patient had Small bowel obstruction Ovarian 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 ___ woman with recurrent ovarian cancer on chemotherapy admitted to the gyn-oncology service with SBO with concern for malignant obstruction. Abdominal/pelvic CT on arrival revealed SBO transition in the RLQ concerning for malignant obstruction and peritoneal carcinomatosis. She was made NPO, started on IV fluids and given IV zofran, ativan, and pepcid for nausea. Her pain was controlled with IV morphine. Over the week her diet was slowly advanced and she was transitioned to PO pain meds. On hospital day #4 she was tolerating a regular diet without nausea, emesis, and pain was controlled on oral medications. She was discharged home in stable condition with appropriate outpatient follow-up scheduled. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Ms. ___ is a ___ year old female with past medical history notable for multiple myeloma, recently on pomalyst/dex, and HTN, with recent admission for AMS thought to be due to HSV-2 encephalitis, readmitted due to confusion/AMS and c/f CNS infection. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. No acute intracranial abnormalities. No abnormal enhancement to suggest intracranial infection. 2. Moderate chronic microvascular ischemic changes. 3. Mild pansinus disease. Scattered fluid within the mastoids bilaterally. The patient was diagnosed with Fever, unspecified. The patient was treated with Lumbar puncture ___. At the time of discharge, the patient had #Meningoencephalitis 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>======= SUMMARY ======= Ms. ___ is a ___ year old female with past medical history notable for multiple myeloma, with recent admission due to concerns for HSV-2 aseptic meningitis, readmitted due to fevers and confusion at home. Her repeat infectious workup was largely unremarkable (including negative HSV-2 CSF PCR) except for persistent, although decreased, lymphocytes in her CSF. She was treated empirically with a 10d course of vancomycin, cefepime, ampicillin, and acyclovir for possible HSV-2 meningitis, and other possible bacterial causes. Her hospital course was unremarkable. ============== ACUTE PROBLEMS ============== #Altered mental status #Fevers Recent discharge for presumed aseptic HSV-2 meningits, as patient had presented at that time with similar symptoms of AMS and fevers, with CSF PCR notable for low-level positive HSV-2. She had at that time received both a full IV acyclovir course as well as PO valacyclovir in the outpatient setting. She was subsequently readmitted after several days due to similar symptoms. Of note, her initial fever of T 101.6 in the ED had defervesced prior to initiation of antimicrobial agents. Presumptive diagnosis of HSV-2 aseptic meningitis vs Malloret's meningitis vs undertreated viral/bacterial etiology that was not adequately covered during last admission. Infectious workup largely unremarkable - CSF PCR for this admit was negative for HSV-2, although did demonstrate lymphocytes. She ultimately received a total of 10 days of vancomycin, cefepime, ampicillin, and acyclovir for empiric coverage of possible undertreated viral and bacterial causes. ================ CHRONIC PROBLEMS ================ #Multiple Myeloma She had not been taking her pomalyst on admission per outpatient oncology direction. This was not continued while inpatient as well. She had normal quantitative Ig levels during this admission. # CODE: Full (presumed) # EMERGENCY CONTACT: Name of health care proxy: ___ ___: daughter Phone number: ___ This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old right-handed woman with history of pseudotumor cerebri diagnosed in ___, who is being followed by Neurology for recurrence of headaches and papilledema, recently restarted on Acetazolamide, who presents with fatigue, worsening headache and tingling in hands and feet. Radiology showed 1. Empty sella. Persistent inferior tonsil herniation, similar to MR dated ___ which can be seen in setting of intracranial hypertension as described in: ___ AM, ___ PA. Incidence of cerebellar tonsillar ectopia in idiopathic intracranial hypertension: A mimic of the Chiari I malformation. Am J Neuroradiol ___ 33: ___. Inferior tonsillar herniation is not thought to be due to Chiari I given lack of presence on remote prior exam. 2. No hydrocephalus. Radiology showed 1. Pointed low-lying cerebellar tonsils, approximately 1.5 cm below the margins of foramen magnum and partially empty sella, similar to the recent MRI head study of ___. This can relate to pseudotumor cerebri more than Chiari 1 malformation 2. No evidence of syrinx in the cervical cord or upper thoracic cord included. 3. C5-6: Mild diffuse bulge, with small focal central extrusion, with mild canal and foraminal narrowing. 4. Upper thoracic T3-T4: Mild bowel/right paracentral protrusion ; no significant canal or foraminal narrowing on the sagittal sequences. The patient was diagnosed with HEADACHE. At the time of discharge, the patient had 1. chiari malformation. The patient was given written instructions concerning 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 ___ headaches were different from her previous headaches associated with pseudotumor. This headache was bad throughout the day (regardless of cough/laugh) and was associated with neck pain, upper back numbness, and right more than left hand numbness. her headache was thought to be primarily related to her Chiari malformation. We performed a cervical spine MRI during the stay given her C5/6 distribution numbness and also given her left lower extremity mild proximal weakness and spasticity. This exam was remarkable for low lying cerebellar tonsils consistent with Chiari malformation and also for mild disc bulge at C5/6 that abutted the cord but without cord signal change and with open canal. Ms. ___ will follow up with Neurosurgery for further Chiari evaluation, MRI CSF CINE flow study, and for discussion of neurosurgical evaluation.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ female on Eloquist for Afib who presents to ___ on ___ with a moderate to severe TBI s/p fall. The patient is ___ speaking only, however, her daughter is at bedside, assisting with communication with the patient and proving medical history. The patient has all medical care here at ___. Per the patient and daughter she lives alone. The patient states that yesterday she began to feel nauseas after taking some pills, she put two fingers down her throat to stimulate emesis, when she suddenly passed out. When she awoke she was on the floor, denies headsrike. This morning she complained to her daughter about left ankle pain, her daughter brought her to the urgent care center here at ___. A head CT was obtain along with other imaging, which revealed an acute SDH with minimal MLS. The patient denies n/v, dizziness, blurred vision, but endorses intermittent headaches. CT HEAD W/O CONTRAST Q111 CT HEAD showed Left subdural hematoma measuring up to 1.1 cm with mild mass effect. No shift of normally midline structures. No evidence of intraparenchymal hemorrhage. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 12:37 ___, 2 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed No substantial interval change in appearance of acute subdural hematoma overlying the left cerebral convexity and left aspect of the falx. No new areas of hemorrhage identified. The patient was diagnosed with Nontraumatic subdural hemorrhage, unspecified. At the time of discharge, the patient had subdural hematoma atrial fibrillation h/o kidney transplant 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>#Subdural hematoma: Patient was admitted to the neurosurgical ICU under Dr. ___ on ___ s/p fall with TBI. Repeat head CT showed stable 1.4cm left subdural hematoma without mass effect/midline shift, and no new areas of hemorrhage. Eliquis was held (see below) and she was given 4 units FFP for reversal. She was started on Keppra for seizure prophylaxis, to be continued for 1 week. She remained neurologically intact. She was transferred to the floor on ___ and continued to be stable. #Afib: Eliquis was held on admission given intracranial hemorrhage. HR controlled with home metoprolol. Cardiology was consulted, who agreed with holding anticoagulation until safe from a neurosurgical perspective. Patient was instructed to hold Eliquis for 1 month, until follow up with Dr. ___ a repeat head ___ of Hearts monitor was also recommended for evaluation of arrhythmia that could have lead to fall (although unlikely given that likely vagal from inducing vomiting). She will follow up with her outpatient cardiologist, Dr. ___ discharge. #Toe pain L foot/toe pain from fall. ___ was negative for fracture. Recommended rest, ice, elevation. #Renal Renal transplant team followed while inpatient. She was continued on home medications and Tacrolimus level was monitored. Renal function at baseline. She also has recurrent UTIs and was continued on Cipro (completed ___. She was instructed to follow up on ___ for routine labs. #DISPO She was cleared by ___ for discharge home with home ___ on ___. Tertiary survey was completed by ___ with no further injuries noted. At time of discharge pain was well controlled, she was tolerating PO diet without nausea or vomiting, she was ambulating, and voiding. Discharge instructions were reviewed with patient and daughter (translated) and all questions were answered. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is ___ with history of HIV on HAART, last CD4 count 875 viral count 2422, presenting with shortness of breath. He initially presented to his PCP's office today with complaint of hematuria and was found to be hypoxic (80%) on room air. The patient reports that for the past couple of days he has been short of breath. He also reports associated fever, chills and cough productive of greenish sputum and pleuritic chest pain on the R. Denies any abdominal pain, n/v, diarrhea, consipation, dysuria, frequency, palpitations, headache. He denies any recent travel. He lives alone in an apartment and is on disability. Radiology showed Widespread opacification of the right mid-to-lower hemithorax with mass effect, suspected to represent a pleural effusion at least in part, including a possible large loculated component; a mass could also be considered, in addition to widespread atelectasis or pneumonic consolidation. Radiology showed 1. Large loculated right pleural effusion; saccular bronchiectasis of the bilateral lower lobes and consolidation of the right middle and right lower lobes with heterogeneous hypoenhancement and rounded hypodensities that may represent either the underlying saccular bronchiectasis versus multifocal necrotizing pneumonia. 2. Cholelithiasis without cholecystitis. 3. Hilar lymphadenopathy may be reactive; follow up imaging after treatment is recommended to ensure resolution. Radiology showed 1. Decreased size of large right free-flowing pleural effusion, status post placement of a percutaneous pigtail catheter. Given anterior positioning of the pigtail catheter within the pleural space, right lateral decubitus patient positioning may be helpful in allowing further drainage of this effusion. 2. Slight improvement in right lower lobe aeration. Previously seen rounded hypodensities within the right lower lobe cannot be assessed on the present study given the lack of intravenous contrast. Of note, these rounded hypodensities were previously thought to be either mucous-filled saccular bronchiectasis or areas of parenchymal necrosis. 3. Markedly improved aeration of the right middle lobe. 4. Unchanged extensive left lower lobe bronchiectasis. Findings were discussed with Dr. ___ by Dr. ___ at 6:52 p.m. via telephone on the day of the study. Radiology showed Right basilar opacity consistent with empyema, unchanged from most recent imaging. Radiology showed AP chest compared to ___: Moderate volume of residual right pleural effusion, and attendant atelectasis or consolidation in the right lower lung have not improved since at least ___, despite the right pleural pigtail catheter in the lower chest laterally. No pneumothorax is present. There is new consolidation at the left lung base, which could be either atelectasis or new pneumonia. If the patient can tolerate conventional radiographs, these, rather than bedside studies, should be obtained. The heart size is normal. Findings were discussed by telephone with the resident physician caring for this patient at 9:03 a.m. Radiology showed New right-sided PICC in place with the tip in the low SVC, otherwise unchanged chest radiograph. These findings were communicated to ___ with IV nursing team at 11:36 a.m. by phone. Radiology showed Stable appearance of right pleural effusion. The patient was diagnosed with PLEURAL EFFUSION NOS, HYPOXEMIA, ASYMPTOMATIC HIV INFECTION. The patient was treated with Chest tube placement PICC. At the time of discharge, the patient had Empyema. The patient was given written instructions concerning 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 HIV on HARRT (CD4 count of 800), HCV (failed treatment), history of IVDU on methadone, who presented with dyspnea and was found to have pneumonia and empyema. He was treated with antibiotics and had a chest tube placed. The cultures from the sputum and pleural fluid returned and he was switched to IV cefepime and PO flagyl for a 4 week course. ID will follow as an outpatient. # Pneumonia with empyema: He had hypoxemia, pneumonia and a large empyema on chest CT. He was initially started on vancomycin, cefepime, and levofloxacin. Interventional pulmonology placed a chest tube on ___. The effusion was loculated and required tPA and ___ injections. The results of the pleural effusion cultures were strep milleri species. Sputum cultures grew Beta streptococcus group C, enterobacter aerogenes, acinetobacter baumannii complex, haemophilus influenza and beta lactamase negative (see results secontion). He improved with treatment and drainage and his chest tube was pulled on ___. He was seen by infectious disease specialists who recommended a 4 week course of cefepime and flagyl. He will need to continue this until ___ (and will need to be seen by ID prior to discontinuation). A picc line was placed. He should not be discharged from rehab with the ___ as he is at risk of IVDU. After completion of his antibiotics this should be removed. At the time of discharge he was on 1L NC. # Opioid dependence: He takes 91mg of methadone per day (Habit OPAC on ___.). He was continued on methadone 90mg per day. He is at risk of abuse of the PICC. This should be removed prior to discharge. He is also getting oxycodone as needed for pain. # Chronic CO2 retention: Likely secondary to COPD or obesity hypoventilation syndrome. He has been relatively stable with NC and has not required positive pressure ventilation. This should be evaluated further after discharge. He was treated with PRN nebulizers. # Hyponatremia: He had hyponatremia. Initially he was treated with IVF with some improvement in his sodium. However, the urine lytes were suggestive of SIADH. Thus, he was put on a fluid restriction. However, the patient was unhappy with this and refused to comply. His Na was stable at 132 without treatment. Sodium should be checked a couple of times per week to make sure it is stable at rehab. # HIV: His most recent CD4 count is 875 with a viral load of 2422. He should be continued on truvada and kaletra. # Hypertension: He was continue on amlodipine BID. Blood pressures largely controlled. # Anxiety: He was continued on his clonazepam. # Constipation: he was writted for a bowel regimen # Asthma: stable, continued on inhalers. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF THE PRESENTING ILLNESS: CT abdomen with contrast. showed 1. Cirrhotic liver without evidence of an enhancing lesion. 2. No evidence of portal venous thrombosis. 3. Large abdominal ascites. 4. Moderate lumbar spondylosis including age-indeterminate L4 compression deformity. Radiology showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Mild to moderate central bronchial wall thickening is most likely due to airway inflammation. 3. Mild to moderate bibasilar atelectasis. 4. Enlargement of the main pulmonary artery up to 3.5 cm raises the possibility of pulmonary arterial hypertension. 5. Large amount of simple ascites in the upper abdomen and bilateral gynecomastia. The patient was diagnosed with Abdominal distension (gaseous). The patient was treated with ___: large volume paracentesis (8L) ___: large volume paracentesis (10L). At the time of discharge, the patient had Primary diagnosis: decompensated cirrhosis, alcohol-induced Secondary diagnosis: chronic systolic heart failure, orthostatic hypotension, protein energy 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>SUMMARY: Mr. ___ is a ___ year old male who had not seen an MD in over ___ years prior to his presentation with volume overload which was eventually diagnosed as decompensated alcohol-induced cirrhosis. Patient had 48.5 lbs of fluid removed via a combination of multiple large volume paracentesis and diuretics, and further diuresis was limited by orthostasis, for which midodrine therapy was initiated. A screening EGD showed no gastro-esophageal varices. He did not display any signs of hepatic encephalopathy. He had obvious protein-energy malnutrition, for which Ensure Enlive with breakfast, lunch, and dinner was recommended. Given his elevated BNP on admission, an echocardiogram was ordered which showed an EF of 35-40% with diffuse LV dysfunction, suggesting a global cardiomyopathic process such as alcohol cardiomyopathy. Cardiology evaluated patient and deferred catheterization and recommended an outpatient ischemic/viability workup with possibily a cardiac MRI. Given his lack of elevated JVP, we tried to initiate beta blocker therapy but coreg 3.125 BID was poorly tolerated as he developed symptomatic orthostasis. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male w/ uncomplicated ___ presents s/p fall during a baseball game this evening in which he sustained a right ankle injury. He had immediate pain and inability to bear weight and was taken to ___ for further management. Radiology showed 1)Displaced comminuted fractures involving medial malleolus and posterior tibia tubercle. 5 mm intra-articular fracture fragment. 2) An oblique fracture involving the distal fibula with intra-articular extension. 3) Medial mortise is widened. There is likely disruption of the tibiofibular syndesmosis. 4) Some bony rarefaction at the base of the ___ metatarsal, without definite fracture line. Attention to this on follow-up films is recommended. Radiology showed 1. Interval reduction of previously seen tibiotalar dislocation, with persistent mild widening of the anterior tibiotalar joint space. Complex trimalleolar fractures, better evaluated in the concurrent CT study. 2. No acute fracture or joint effusion in the right knee. Radiology showed Multiple views of the right ankle. Status post bimalleolar ORIF. The hardware appears intact. Improved alignment of the ankle. Posterior malleolus fracture is again noted, mildly displaced. Total intraoperative fluoroscopic imaging time 146.4 seconds. Please see operative report for further details. The patient was diagnosed with FX TRIMALLEOLAR-CLOSED, OTHER FALL, ACTIVITIES INVOLVING BASEBALL. The patient was treated with Open Reduction Internal Fixation of Right Ankle trimalleolar fracture dislocation.. At the time of discharge, the patient had Right Ankle trimalleolar 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 was admitted to the Orthopaedic Trauma Service for repair of a right trimalleolar ankle fracture. The patient was taken to the OR and underwent an uncomplicated open reduction internal fixation right trimalleolar ankle fracture without fixation of the posterior malleolus. The patient tolerated the procedure without complications and was transferred to the PACU in stable condition. Please see operative report for details. Post operatively pain was controlled with a PCA with a transition to PO pain meds once tolerating POs. The patient tolerated diet advancement without difficulty and made steady progress with ___. Weight bearing status: Right lower extremity non-weight bearing The patient received ___ antibiotics as well as Lovenox for DVT prophylaxis. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 2 weeks post-operatively. All questions were answered prior to discharge home 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 F with history of type 2 diabetes, atrial fibrillation, chronic heart failure, and CAD who was found down in her home after EMS was called by her family, who had not heard from the patient. EMS arrived to find patient minimally responsive, laying on floor, and covered in stool. Patient reported to the ED that she normally sleeps in her recliner. She remembers falling asleep in recliner and does not know how she got to the floor. No chest pain at presentation, but did have some dyspnea. In the ED reportedly had some abdominal pain, nausea, vomiting and diarrhea. Radiology showed No pneumothorax. Mild edema. Radiology showed No acute intracranial process. Radiology showed No acute fracture or traumatic malalignment. Radiology showed 1. No acute pathology. 2. Redemonstration of chronic findings, including cholelithiasis and hemorrhagic left renal cyst. Evaluation of the patient with congestive heart failure, now with respiratory distress, re-assessment. Portable AP radiograph of the chest was reviewed in comparison to ___. As compared to the prior study, there is additional progression of vascular engorgement, vascular indistinctness, dilatation of the vascular pedicle and interstitial engorgement in the perihilar and lower lungs, finding consistent with progression of pulmonary edema. Heart size and mediastinum appear to be unchanged. Small pleural effusion is most likely present. There is no evidence of pneumothorax. was done. Evaluation of the patient after fluid resuscitation and shortness of breath concerning for pulmonary edema. AP chest radiograph. As compared to the prior study obtained on ___ at 9:32 p.m., there is interval improvement in interstitial prominence and vascular engorgement but unchanged appearance of the prominence of the azygos vein in vascular pedicle that is consistent with volume overload, substantial but improving pulmonary edema. was done. The patient was diagnosed with ALTERED MENTAL STATUS , DEHYDRATION, 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>Ms. ___ is a ___ yo F with history of type 2 diabetes, atrial fibrillation, diastolic heart failure and CAD who was found down in her home. Patient was found to have HONK with elevated lactic acidosis, initially admitted to the MICU.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: As per HPI by admitting MD: LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with no focal lesions identified. 2. Cholelithiasis and gallbladder sludge without findings of cholecystitis. 3. Interval increase in splenomegaly now measuring 16 cm, previously measuring 13 cm on MRCP from ___. MRI of the Abdomen showed 1. New gallbladder sludge and stones, with some sludge obstructing the gallbladder neck. Marked gallbladder distension is similar to ___. No evidence of acute cholecystitis or cholangitis. 2. Cirrhotic liver morphology, with sequela of portal hypertension including paraesophageal and perisplenic varices. No ascites or splenomegaly. 3. Slightly enlarged upper abdominal lymph nodes measuring up to 13 mm are likely reactive. The patient was diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction. At the time of discharge, the patient had #Primary Cholelithiasis #Secondary: Cirrhosis, unclear etiology Diabetes mellitus type II, insulin dependent. The patient was given written instructions concerning 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 female with a history of DM type II, HTN, HLD, GERD and NASH who presented with abdominal pain concerning for biliary colic, found to have cholelithiasis without cholecystitis or choledocholithiasis. Surgery evaluated and deferred given high surgical risk. She was managed medically with improvement in her pain. Additionally, imaging showed a new diagnosis of cirrhosis, etiology remains unclear but likely ___ NASH. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with PMH hypothyroidism, pAF (on flecainide and metoprolol) and AT presenting with palpitations and dyspnea. Patient states that she developed palpitations yesterday morning, intermittent in nature as well as brief shortness of breath and palpitations. States that she has had constant symptoms since 3pm ___, similar to prior AF. Endorses a chest tightness, non-pleuritic in nature. Denies recent travel, leg swelling. H/o DVT after surgery no longer on blood thinners. Denies fever or cough. Denies changes in medication recently. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. The patient was diagnosed with Unspecified atrial fibrillation, Palpitations. The patient was treated with Technetium-___ Thyroid Scan. At the time of discharge, the patient had Thyroiditis 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>Assessment: Ms. ___ is a ___ year old female with a h/o hypothyroidism (on home levothyroxine 50mcg daily), pAF (on flecainide and metoprolol) and AT who presented to ED ___ with palpitations and dyspnea since ___ at 1500. She was found to be in AF on EKG with HR 110bpm with no ischemic changes. Trop negative. TSH <0.01, T4 15. She is not on home anticoagulation therefore a heparin gtt was started in ED for possible TEE/DCCV today, ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of high grade SBO s/p ex-lap and SBR on ___, Aortic valve replacement/Afib on coumadin, CHF, DM, paranoid schizophrenia, transferred from nursing home with confusion/agitation and abdominal distention. Patient mumbling incomprehensibly, unable to obtain further history. Per transfer notes, patient has been receiving 500 mg levaquin qday since ___ for URI and had a cough productive of thick yellow sputum. At baseline is conversational, but was noted to be increasingly confused and agitated today. At nursing home, oxygen saturation 84-88% on room air, 94-95% on 4L NC. Temp 97. Per his daughter (via ACS), current mental status is nowhere near his baseline. Received nebulizing treatment x3 at nursing home. Otherwise had been doing well before today, no other symptoms. Radiology showed Mild pulmonary edema with small bilateral pleural effusions. Radiology showed Gaseous distension of large bowel without definite evidence for obstruction. Radiology showed No acute intracranial process. Radiology showed Tip of OG tube not included in field of view. Endotracheal tube positioned appropriately. Otherwise, no change allowing for differences in technique. Radiology showed 1. No evidence of bowel obstruction. 2. Large bilateral pleural effusions, right greater than left, which are new from prior exam with compressive bibasilar atelectasis. 3. Low lying ET tube at the level of the carina, requiring pull-back. Orogastric tube tip terminates within the stomach, with sideport at the GE junction and should be advanced. 4. Ascending aortic aneurysm to 5.7 cm. 5. Evidence of third spacing, including anasarca and periportal edema. 6. Mediastinal lymphadenopathy, likely reactive. Radiology showed AP chest compared to ___, substantial worsening of both moderate-to-large bilateral pleural effusions and moderately severe pulmonary edema is evident since ___, 2:18 p.m. ET tube in standard placement. Nasogastric tube would need to be advanced 10 cm to move all the side ports into the stomach. I do not believe there is no pneumothorax, but an upright chest radiograph would be very helpful in making that determination. Radiology showed 1. Persistent distention of large bowel without definite evidence of small bowel obstruction. 2. Deep sulcus sign on the left raises concern for left-sided pneumothorax. Recommend upright frontal chest radiograph for further assessment, if clinically indicated. 3. ___ tube is see with the tip terminating in the stomach and the last side port above the GE junction. Recommend advancement of NGT by 4-6 cm. COMMENTS: These findings were discussed with Dr. ___ by Dr. ___ telephone at 3:20pm on ___, 20 minutes after their discovery. Radiology showed 1. Ongoing gaseous distention of large bowel without definite evidence of small bowel obstruction. Recommend CT of the abdomen and pelvis for further evaluation of obstruction if clinically indicated. 2. Nasogastric tube seen with tip in stomach and last side port above the GE junction. Recommend advancing NGT 4-6 cm. Chest AP portable single view. was done. Radiology showed All the monitoring devices have been removed. The bibasilar atelectasis with pleural effusion is minimally improved, mainly for reduced pleural effusion especially on the left base. Persistent bibasilar atelectasis with large atelectasis of the right middle lobe. Radiology showed Ongoing gaseous distention of multiple loops of large bowel without evidence of small bowel obstruction. Radiology showed 1. Possible increase in size of right pleural effusion, however may be positional. No definitive evidence of loculation, however this is difficult to exclude on plain frontal radiograph. A lateral view would be helpful if the condition of the patient permits. A right lateral decubitus radiograph could demonstrate the extent of free pleural fluid. Nevertheless, to definitely determine whether there is a loculated fluid collection, CT would be necessary, especially since the appearance could be compared with the study of 1 week previously. 2. Pulmonary edema appears unchanged. Results were conveyed via telephone to Dr. ___ by Dr. ___ ___ on ___ at 11:30 a.m. within 10 minutes of results. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ M h/o SBO s/p SBR, AVR on coumadin, CHF, DM, paranoid schizophrenia, transferred from nursing home with confusion/agitation and abdominal distention complicated by acute decompensated dCHF and pulmonary edema.</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 h/o CAD s/p 2 x stents to RCA and LCX in ___ and recurrent CP in ___ with moderate CAD throughout. He has been chest pain free after his last cath and his artherosclerotic risk factors have been well controlled. He continues however to smoke cigarettes. Today he noticed to have chest pain with exercise that radiated into the left arm. He presented to the ED after contacting his cardiology office (Dr ___. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with INTERMED CORONARY SYND. The patient was treated with Cardiac catheterization. The patient was given written instructions concerning 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 man with h/o CAD (s/p 2 x stents to RCA and LCX in ___ and recurrent CP in ___ with moderate CAD noted throughout and mod single vessel disease of LAD) and heavy tobacco use who presented w/ chest pain concerning for ACS ACTIVE ISSUES ==================== 1. CHEST PAIN Given his known hx of CAD, pt's severe chest pain on admission was concerning for unstable angina. Though his EKG did not show any clear e/o ischemia and his cardiac biomarkers were negative, he was treated empirically for ACS w/ ASA, Atorvastatin 80 and Fondaparinux. Aortic Dissection was considered given the "tearing quality" of his chest pain but his mediastinum was not widened on CXR, and his vital signs remained stable. Chest pain was initially treated with IV dilaudid and a nitroglycerin drip, but pt became hypotensive requiring IVF, so the nitroglycerin was discontinued, and further pain control was achieved with IV Dilaudid alone. Notably, pain relented soon after being transferred to the medicine ward. Given his hx of extensive CAD, he was continued on Fondaparinux anticoagulation pending cardiac catheterization, which revealed stable coronary artery disease, not requiring percutaneous coronary intervention, and no e/o vasospasm. LAD with proximal tubular 40% stenosis; mid-LAD 50% lesion between S1/D1 and S2/D2; first diagonal with 50% lesion proximally; 45% stenosis proximally in the long modest caliber fourth obtuse marginal; patent stent in the major fifth obtuse marginal/LPL; RCA with 20% proximal stenosis and 20% distal stenosis; PDA with diffuse plaquing to 40%. Given concern for aortic dissection he had supravalvular aortography done in the catheterization lab which did not show any e/o dissection. Initiation of isosorbide mononitrate or caclium channel blocker was considered, but his blood pressure (90s-100s systolic) did not permit during this admission. Since the findings on cardiac catheterization did not require any intervention, he was informed of the importance of managing his risk factors for CAD. Specifically, the team spent much time with the pt educating him regarding the risks of smoking, and potential methods for quitting. He was discharged chest pain-free in stable condition, w/ appropriate follow up appointments. He was instructed to continue Aspirin 81mg daily.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male w/ PMH significant for Type-1 diabetes who presents with an ~6-hour history of abdominal pain. Pain started ___ AM on day of admission and was diffusely present around the umbilicus. The pain then migrated to the RLQ pain. He denies any fevers or chills. He had not had any nausea/vomiting until getting a dose of morphine in the ED and then develop some mild nausea. He does report having an appetite. He has had normal bowel habits. Denies urinary symptoms. US APPENDIX showed Nonvisualization of the appendix. No free fluid. CT ABD AND PELVIS WITH CONTRAST showed Acute appendicitis. No drainable fluid collection or extraluminal air. The patient was diagnosed with ACUTE APPENDICITIS NOS. The patient was treated with Laparoscopic appendectomy. At the time of discharge, the patient had Acute 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 General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis, no drainable fluid collection or extraluminal air. WBC was elevated at 15. The patient underwent laparoscopic appendectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquids, on IV fluids, and PO/IV analgesia for pain control. The patient was hemodynamically stable. . When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. He was noted to have a high post void residual and was given a dose of Tamsulosin. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. ___ was consulted to help manage the patient's juvenile diabetes, for which he was on an insulin pump for. During the hospitalization, the patient's blood sugars were well controlled. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o ESRD on MWF HD, CAD w/ prior MI, CVA, stable angina presenting from HD with chest pain. Ms. ___ was otherwise well this morning when she developed acute onset of stabbing chest pain under her left breast unlike any other pain she had felt before. Patient denied SOB, nausea, diaphoresis. Of note, patient's usual stable anginal pain is described as left sided chest pressure with SOB, diaphoresis and nausea. At HD, patient was given SL NTG x1 with complete relief of her pain. Due to her chest pain, HD was deferred and patient was transferred to the ED. On arrival to the ED, patient remained pain free. Initial vitals: 98.5 83 189/101 12 100% 2L. Labs notable for: H/H 10.4/31.7 (baseline), BUN 24, Cr 3.9, trop 0.04 (baseline 0.02-0.07) Imaging notable for CXR with mild pulmonary edema and very small b/l pleural effusions. EKG showed SR with LAFB, no i/i/i, c/w previous. Due to lack of HD today, decision was made for admission for HD and rule out given need for complex rule out. Prior to transfer, patient's blood pressure elevated at 196/75. Patient given home labetalol 300mg PO and transferred to the floor. Vitals on transfer: 93 199/ 18 100% RA On arrival to the floor, vitals: 98.4 173/79 82 18 100%RA FSBG 153, weight 65.9kg. ROS: Full 10 pt review of systems negative except for above. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. CHEST (PA AND LAT) showed Mild pulmonary interstitial edema with tiny bilateral pleural effusions. The patient was diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, HYPERCHOLESTEROLEMIA. The patient was treated with ___ HD. At the time of discharge, the patient had - Atypical chest 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 ___ with known CAD who developed sharp left sided chest pain at HD that felt different than her prior anginal symptoms but did respond to SL NTG x 1. She was transferred to ___, where three sets of cardiac enzymes were at baseline and EKG showed no acute ischemic changes. Last stress test was ___ and showed no symptoms or EKG changes. There were WMA's at rest but no inducible ischemia. She underwent HD. During HD, chest pain briefly recurred, then resolved again. It is unclear what caused pain, as it was not reproducible to suggest classic MSK pain, and she did not have reflux or other GI symptoms to suggest clear GI etiology. Given lack of acute EKG changes or enzyme elevation, patient will follow-up as an outpatient with Cardiologist Dr. ___. Please consider utility of repeat outpatient stress test at next visit. During stay, patient was persistently hypertensive to high 170's, even after HD, which diuresed her to just below dry weight. Labetolol was increased from BID to TID, and blood pressure will be rechecked at HD session tomorrow. # Chest pain: Patient with acute onset of sharp, stabbing chest pain unlike prior history of stable angina which resolved with single dose of nitro. While pain could certainly represent unstable angina, does not meet criteria for NSTEMI given trops at baseline (likely elevated chronically due to CKD). Three sets of cardiac enzymes were negative. EKG showed no acute ischemic changes. We continued her aspirin, statin, and beta blocker. # Hypertension: baseline HTN with SBPs 140s-160s per patient. She remained persistently hypertensive here with SBPS in the 170s, even after dialysis to dry weight. We increased her labetolol 300 mg BID to TID. # ESRD: Low phos, low K diet. She received dialysis on ___. # Diabetes: Type II, currently off of insulin and oral agents given symptomatic on medications with hypoglycemia. We maintained her on a conservative ISS while in house. #CAD s/p MI, BMS, with dCHF: EG 55% in ___. We continued aspirin and simvastatin. # Peripheral Vascular Disease: Continued aspirin # HLD: Continued simvastatin # Depression/Anxiety: Continued ___ Mirtazapine #Seasonal Allergies: Continued home loratadine TRANSITIONAL ISSUES - Follow-up with Dr. ___ consideration of outpatient stress test - Monitor BP on increased dose of labetolol (next BP check tomorrow, ___, at HD) -Consider d/c plavix (not clear indication given remote h/o bare metal stent) </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with developmental delay, bipolar disorder, morbid obesity, diabetes who presented to ___ ED with nausea, vomiting, diarrhea, abdominal pain for about 24 hours prior to presentation. She reports at least 6 bouts of NBNB emesis as well as diarrhea. She states that she has been feeling very weak, with dizziness and vertigo and multiple falls as a result of being very unsteady on her feet. Per patient, first symptom was abdominal pain but is not sure. She reports periumbilical and lower abdominal tenderness. Denies any vaginal bleeding or complaints, hCG negative in ED. Denies dysuria or frequency. CT abdomen and pelvis showed A normal appendix is visualized. Normal CT abdomen and pelvis. The patient was diagnosed with Acute pancreatitis, unspecified, Nausea with vomiting, unspecified, Diarrhea, unspecified. At the time of discharge, the patient had # Benign Positional Paroxysmal Vertigo # Viral Gastroenteritis / Abdominal Pain / Nausea # Type 2 Diabetes with neurologic complications # Bipolar disorder # Hyperlipidemia # GERD # 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>This is a ___ year old female with past medical history of developmental delay, type 2 diabetes, bipolar disorder admitted ___ with abdominal pain, nausea and vomiting secondary to a viral gastroenteritis, course complicated by a peripheral vertigo (potentially BPPV), GI symptoms treated conservatively and now tolerating a regular diet, vertigo symptoms improving with meclizine and maneuvers, ready for discharge home with close PCP ___ and outpatient physical therapy. # Viral Gastroenteritis / Abdominal Pain / Nausea / Dehydration - patient admitted with abdominal pain with nausea, vomiting and diarrhea x 1 day; CT abd/pelvis without focal process; labs notable only for mildly elevated lactate (resolved with fluid resuscitation) and elevated lipase (less than 3x the upper limit of normal). Patient rapidly improved with conservative management, most consistent with viral gastroenteritis (and not acute pancreatitis). # Peripheral Vertigo - patient reported onset of symptoms around time of her GI symptoms above-reported sensation of room spinning, worse with changing of position; no tinnitus or hearing deficit; no focal neuro findings; no orthostasis and did not improve with volume repletion. Given onset with viral infection felt to be possible related peripheral vertigo versus potential BPPV. Symptoms resolved with trial of PO meclizine treatment. Patient was seen by physical therapy for maneuvers, who recommended outpatient ___ ___. At time of discharge, patient was safely ambulating. # Type 2 Diabetes with neurologic complications - continued home oral glimepiride, Invokana, liraglutide, metformin. Continued home gabapentin. # Bipolar disorder - continued oxcarbazepine # Hyperlipidemia - continued statin, ASA # GERD - continued PPI # Hypertension - continued lisinopril TRANSITIONAL ISSUES - Discharged home - Contact - Legal Guardian ___ ___ - all medical details relayed to her - Discharged on trial of meclizine--given prescription for 1 weeks supply to get her to upcoming PCP ___ < 30 minutes spent on this discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/men___ disease presents with unsteady gait. Pt reports sx for 1 week, also with N/V/D for 1 week. She lives in ___ and was admitted to ___ twice in the past week due to GI illness and dehydration. Pt now with increased difficulty ambulating, and weakness. States n/v has resolved but has low PO intake. Still with intermittent diarrhea. In ED pt received IVF. CT head wnl. Seen by neuro who stated pt was improved with fluids and OK to d/c home with daughter. Pt also with dirty UA, given macrobid. On arrival to floor pt reports feeling dehydrated prior to admission and now feels better since getting fluids. Felt much more steady on her feet when she transferred from ambulance gurney to bed just a few minutes ago. She has no other complaints. Radiology showed 1. No evidence of acute infarction or hemorrhage. 2. Tiny left frontal subacute infarcts. 3. Cortical atrophy is evidence of chronic small vessel ischemic disease. Findings were conveyed by Dr. ___ to Dr. ___ telephone at 5:15pm on ___, 5 minutes after interpretation. The patient was diagnosed with VERTIGO/DIZZINESS, ABNORMALITY OF GAIT, HYPERTENSION NOS. At the time of discharge, the patient had Recent viral gastroenteritis. The patient was given written instructions concerning 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 with recent GI illness and dehydration presents with difficulty ambulating and general weakness Ataxia/Weakness: improved, likely ___ dehydration and possible component of UTI, no focal neuro symptoms - change macrobid to cipro based on prior culture data and multiple allergies will have to monitor closely for medication induced delerium - consult ___ - f/u urine culture Bladder Cancer:chronic hydronephrosis of R ureter - monitor renal function HTN: poorly controlled, not on home meds - start HCTZ and lisinopril COPD: no acute exacerbation, not on home meds Dyslipidemia: cont home meds FEN: gen diet PPX: heparin ACCESS: piv FULL CODE: presumed CONTACT: daughter DISPO: medicine, pending above ___, ___ signed electronically</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH DM, Afib, pacemaker, Total shoulder arthroplasty on ___ presenting with shortness of breath of ___ days. Began on exertion, worsening over the past few days. Patient states he is retaining a lot of fluid and has been monitoring his weight over the past few months. He was on dialysis through ___ and ___, last HD ___, discharged to ___ ___ but never needed HD there. Discharged home ___. He still has his dialysis line in. He believes his urine output has decreased recently. Was on furosemide 80 mg bid at home, but last week dose increased to 120mg bid by his nephrologist, Dr. ___ worsening edema in legs, without any effect. Denies any changes in diet, medications. Denies an n/v/f/c/chest pain. ED initial vitals were: T:97.9, HR:88, BP:95/57, RR:22, 99% RA. ED exam: 2+ BLE edema, faint bibasilar rales, but breathing comfortably. Imaging: CXR no acute cardiopulmonary process. Labs were notable for * Cr 3.2 (Cr at discharge 4.2), K 4.2, HCO3 20. *Troponin 0.07, BNP 9907 (18673 on last admission, previously 1100-5000 range) *Hb 8.5, plt 79, INR 2.3. Renal was consulted -did not think fluid overload related to renal function but rather to heart failure. *Pt was given 160 mg iv Lasix in the ED and admitted for management of fluid overload. Radiology showed No acute fractures or dislocations are seen. There are extensive vascular calcifications. There are degenerative changes spurring worse within the patellofemoral compartment. Chondrocalcinosis is seen. Corticated density is seen adjacent to the superior aspect of the patella which may represent a large osteophyte.No bony erosions are seen. DIALYSIS REMOVAL showed Successful removal of right internal jugular vein tunneled dialysis catheter. No complications. Lower extremity arterial duplex US. was done. Radiology showed Low lung volumes without definite acute cardiopulmonary process. The patient was diagnosed with Shortness of breath. The patient was treated with ___ Cardioversion ___ Cardioversion. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Acutely Decompensated Heart Failure with preserved Ejection Fraction Atrial fibrillation Acute on chronic kidney disease SECONDARY DIAGNOSIS Coronary artery disease Diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old gentleman with HFpEF, CKD, AF on warfarin, s/p PPM for sick sinus who presented with dyspnea on exertion and significant edema consistent with a diastolic HF exacerbation, with concern for recurrent atrial fibrillation as precipitating factor. #Acutely Decompensated Heart Failure With Preserved Ejection Fraction: LVEF = 50%. Unclear precipitant given non-ischemic EKG with TnT elevation in proportion to renal dysfunction and no history of medication non-compliance or dietary indiscretion. Pt in atrial fibrillation, possibly contributing to exacerbation, though his rates were generally in the ___ to 110s. On admission he was significantly volume overloaded with 3+ pitting edema to thighs and sacrum. Admission weight was 86.9 kg compared to discharge weight of 88.2 on ___ (although the latter likely did NOT represent his true dry weight). He was started on lasix gtt upon admission and titrated up to 20 mg/h. He was resistant to diuresis and dobutamine gtt 2.5 was added on ___. With inotropic support he diuresed effectively. Patient was cardioverted x2 from AF into NSR (see below). A pyrophosphate scan performed on ___ to r/o amyloidosis as the etiology of his heart failure but this was negative. Given his mod-severe TR and MR on prior TTE (___), and the need for dobutamine to diurese, a right heart cath (___) was performed to evaluate for RV dysfunction and the possibility of high output heart failure in the setting of a known right femoral AV fistula (iatrogenic from prior caths at that site). The RHC revealed normal right and left heart filling pressures and normal cardiac output (no evidence of high output state). The patient was successfully weaned off dobutamine following the cessation of Lasix and cardioversion. He was transitioned to torsemide 40mg BID and remained euvolemic on PO diuretics at discharge. Admission weight: 86.9 kg Discharge weight: 66.3 kg #Atrial fibrillation with normal ventricular rates: HRs ___ in the hospital, and pt was asymptomatic. Pt previously on dofetilide but this was discontinued prior to admission ___ renal failure. He was admitted on carvedilol but beta blockers were discontinued during this admission for hypotension. INR was therapeutic at 2.3 on admission. He was placed on heparin gtt for better anticoagulation control in preparation for cardioversion and cath, and then bridged back to warfarin, again with a therapeutic INR on discharge. The patient was amiodarone loaded and then cardioverted on ___. He maintained NSR for several days but then on ___ he had recurrence of his atrial fibrillation. He was continued on Amiodarone 200 mg PO/NG DAILY and re-cardioverted on ___. At time of this second cardioversion his rhythm pre-shock was actually atrial flutter with 2:1 block (rather than atrial fibrillation). Post-shock on ___ he, again, was in normal sinus rhythm. EP recommended continuing amiodarone 200mg PO qday (no change in anti-arrhythmic therapy). Discharged on a warfarin dose of 7.5mg daily with an INR of 2.8. He monitors his own INR at home and calls in the results to his PCP who manages his warfarin dosing. #Valvulopathies: moderate to severe MR and TR noted on TTE in ___ in the setting of significant volume overload. It is less likely this represents a primary structural event but rather was secondary to dilation of the valvular rings while overloaded given the normal filling pressures observed on right heart cath when dry. A follow-up TTE while dry could be performed as an outpatient if warranted. #Acute on Chronic Kidney Disease, Stage 4: Pt was on dialysis through ___ and ___ subsequent to an episode of ATN precipitated by volume overload after L shoulder arthropathy. His last HD was ___ and the HD line was removed ___. as it was no longer needed. He was able to diurese effectively on lasix gtt with inotropic support and then on PO diuretic after the dobutamine was discontinued. Cr prior to shoulder surgery and ATN was 0.9-1.1, Cr in house ranged from 2.5-3.2, with most values prior to discharge between 2.8 and 3.2. His renal function changed little during diuresis, with his Cr hovering around 3, and this likely represents a new baseline for him. He will follow up with nephrology as an outpatient for ongoing management. CHRONIC ISSUES: ================ # Coronary artery disease s/p CABG: No chest discomfort or angina equivalent was noted with no ischemic changes seen on EKG. TnT elevation in proportion with renal dysfunction. Pt was transitioned to rosuvastatin 20mg PO QPM and continued on aspirin 81 mg daily. All beta blockers were discontinued ___ hypotension and not needed for rate control (nor for heart failure since he has preserved EF). # Diabetes Mellitus Type 2, controlled: Recent A1c 6.8%, and patient has stopped using glargine--uses a carbohydrate scale at home. Humalog sliding scale while in hospital and at discharge. # Macrocytic anemia/Thrombocytopenia: Chronic, followed by Dr. ___. Platelets are lower than usual without use of antibiotics, previously thought to be the culprit. SPEP was normal in ___. He had gastric bypass in ___ with resulting iron and B12 def and is on monthly B12 injections. Retic 2.7. Normal B12, folate, LDH, hapto. Light chains assay w/ high free kappa and lambda but with normal K:L ratio. TSH normal. MMA wnl. ___ recommended the initiation of EPO for Hgb < 9, which may be started as an outpatient. The patient will follow-up with Dr. ___ discharge. # GERD: Pt was continued on pantoprazole </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ h/o diastolic CHF and PAH (idiopathic vs. ___ hypoxia) presents with progressive weight gain and edema despite escalating of PO Lasix as outpatient. Seen by ___ cardiology and ___ today. She was markedly volume overloaded on exam and w/ ___, so they recommended admission for IV diuresis. Patient has noted progressive lower extremity edema over the past several months. She states that her respiratory status is essentially at baseline. She is able to get around her home and perform her normal daily activities w/o too much dyspnea. She does not really leave the home except for doctor appointments because she is concerned that she will fall. In the ED initial vitals were: 98.6 79 81/42 18 93% - Labs were significant for BNP ___ Cr 1.9 - Patient was given 80mg IV Lasix Vitals prior to transfer were: 75 110/34 17 100% Nasal Cannula On the floor, patient is comfortable and has no acute complaints. Chest radiograph. showed Small right pleural effusion. Stable cardiomegaly. No evidence of parenchymal edema. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PULMONARY HTN-SECONDARY, CHRONIC AIRWAY OBSTRUCTION. At the time of discharge, the patient had Primary: Heart failure exacerbation Secondary: Chronic obstructive pulmonary disease Obstructive sleep apnea Atrial fibrillation, anticoagulated for at least last ___ years Hypertension Hyperlipidemia Gout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ h/o moderate-severe PAH (presumed idiopathic, but also w/ h/o COPD, OSA, and hypoxemia), as well as diastolic CHF, presents for persistent edema, fatigue, and dyspnea despite increasing doses of oral diuretics; also found to have ___. # Acute on chronic diastolic, biventricular CHF: Pt. w/ diastolic left-sided CHF as well as severe PAH (idiopathic vs. ___ hypoxia). She has had progressive volume overload despite escalating doses of PO Lasix. It is possible that she is not absorbing PO Lasix consistently due to gut edema. Patient diuresed initially with IV lasix, transitioned to PO torsemide, and euvolemic with dry weight of 75.1kg at discharge. Continued home sildenafil and macitentan for PAH. Started low dose metoprolol. Continued lisinopril. Discontinued lasix and started torsemide. # ___: Cr 2.0, up from baseline of 0.7. Given her overall clinical presentation, this is likely due to renal venous congestion w/ decompensated right heart failure. Creatinine improved somewhat with diuresis to 1.7 at discharge. # Macrocytic anemia: 9.8 from baseline of 11.8. No evidence of active bleeding. B12 and folate were normal. #Gout: Patient complained of right foot pain on ___, improved with colchicine x1. ___ right foot pain resolved, but new left ankle pain, now somewhat improved with repeat dose of colchicine. Patient able to ambulate with ___ and with RN. # COPD: stable. Continue home bronchodilators # A-fib: rate within target range with metoprolol 25mg daily. INR sub-therapeutic at 1.3 at the time of discharge. She received one increased dose of 3mg on ___ and was discharged on 2.5mg daily.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with history of recent transurethral resection of the prostate in an outside hospital who has had two prior episodes of gross operative bleeding who presented to the Emergency Department overnight with clot retention and ultrasound showing organized clot in the bladder. RENAL U.S. showed 1. Mild right-sided hydronephrosis. 2. 6.8 x 8.2 x 7.4 cm avascular mass within the bladder lumen likely represents residual clot. The patient was diagnosed with Hematuria, unspecified. The patient was treated with Cystoscopy, evacuation of clot and fulguration of prostate bed.. At the time of discharge, the patient had Hematuria, gross retention, clot urinary. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to urology with hematuria and clot retention and underwent cystoscopy, evacuation of clot and fulguration of prostate bed. No concerning intraoperative events occurred; please see dictated operative note for details. He patient received ___ antibiotic prophylaxis. Patient's postoperative course was uncomplicated. He received intravenous antibiotics and continuous bladder irrigation overnight. On POD1 the CBI was discontinued and his Foley was removed after active voiding trial and post void residuals were checked. His urine was clear yellow and without clots. He remained a-febrile throughout his hospital stay. At discharge, the patient's pain well controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. He is given pyridium and oral pain medications on discharge and explicit instructions to follow up in clinic. </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/ PMHx of CAD c/b STEMI s/p BMS, IE of AV s/p ___ porcine valve replacement, pulmonary hypertension, HTN, OSA not on CPAP who p/w hyperkalemia. He was recently discharged in ___ for melena of unclear etiology. At the time of discharge, his lisinopril and lasix had been discontinued during that hospitalization but then re-started at a post-discharge f/u appt with his PCP ___ ___. He returned for f/u with his PCP ___ ___ and repeat labs were drawn and his K+ returned at 5.9. He was instructed to re-draw his labs on ___ and his K+ returned at 6.8. His creatinine during this time went from 1.56->1.93. At the time of discharge from ___ on ___, his creatinine was 1.3. Mr. ___ states he has had poor PO intake over the past several weeks because of an anal fissure. He is scheduled for anal fissure repair next week. He also states he had problems with low potassium earlier and started drinking more orange juice. He denies NSAID use. He has been urinating the usual amounts. There has been no change to his urine either - it is not foamy, there is no blood, he has no dysuria or frequency. In the ED initial vitals were: 98.2 108 102/57 16 95%RA - Labs were significant for K+ 5.4, BUN/Cr 44/2.0, phos 4.8 - Patient was given nothing and admitted to medicine for further management. Vitals prior to transfer were: 98.1 104 101/56 25 98%RA. On the floor, the pt states he is feeling great and hoping to leave tomorrow. RENAL U.S. showed No hydronephrosis. Small simple left renal cortical cyst noted. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Hyperkalemia and ___ of multifactorial 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>Mr. ___ is a ___ y/o man with a hx of a flutter (on coumadin, recently stopped for upcoming surgery), CAD c/b STEMI s/p BMS, IE of AV s/p AVR with ___ porcine valve replacement, pulmonary hypternsion, HTN, OSA not on CPAP who presented to our hospital for concerning lab finding of hyperkalemia and ___. He had bloodwork in the ED which showed a downtrend in potassium. He was given IVF and monitored overnight. Repeat blood work in the AM and ___ showed downtrending potassium and creatinine. He was then discharged to outpatient follow up with his PCP. ___-- The patient was discharged from our hospital in ___ for melena of unclear etiology, at the time of discharge his lasix and lisinopril which had been d/c'd for the admission were restarted. Because of his improved leg edema, lasix was discontinued by one of his outpatient physicians. The patient reports increasing his potassium intake with orange juice because he thought he was previously low. He went to his PCP ___ ___ and was found to have a K of 5.9 with repeat testing on ___ up to 6.8. There was also a change of 1.56->1.93 in his creatinine over that time (at previous discharge in ___, as 1.3). he was admitted to the floors and given IVF (2 L NS @ 150 mL/hr). His labs improved during admission, from ED: Creatinine 2.0, K 5.4-->AM Crea 1.6, K ___ Crea 1.2, K 5.3. The patient was discharged to ___ with PCP on ___. He should have a CBC and CHEM7 (Na/K/Cl/Bicarb/BUN/Creat/Glucose) drawn ___ and faxed to his PCP's office ___. TRANSITIONAL ISSUES -Patient told to start lovenox for anticoagulation (while holding Warfarin) on discharge per recommendation of his cardiologist for upcoming colorectal surgery for anal fissure. -Patient to have labs drawn ___ to be faxed to PCP for ___ lisinporil during visit and told to stop at home for the time being, please discuss restarting with PCP/cardiologist</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ old woman with no PMH, who presented from ___ for evaluation of incidental finding of hypercalcemia. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. PARATHYROID US showed The three visualized) is 2 right, 1 left) parathyroid glands demonstrate enlargement, consistent with parathyroid hyperplasia. However, a fourth left parathyroid gland could not be identified on current study. A follow-up sestamibi parathyroid or 4D CT scan may be considered to search for a fourth left parathyroid gland. RECOMMENDATION(S): The follow up sestamibi parathyroid or 4D CT scan may be considered search for a fourth left parathyroid gland. 4DCT NECK W AND W/O CONTRAST showed 1. Incidental findings as indicated above. 2. The 2 small nodules identified on ultrasound at the lower poles bilaterally are not really confirmed on the 4DCT. In addition, the more superior nodule is demonstrated as a low-density defect within the enhancing thyroid rather than hyperenhancing nodule. In addition, although it is possible that this is an extrathyroidal nodule invaginating into the thyroid tissue, it could be actually intrathyroidal (subcapsular). Review of the ultrasound does tend to suggest that the 3 lesions suspicious for parathyroid gland enlargement. The lower pole nodules could represent small lymph nodes on the bases are non enhancement. As discussed with Dr. ___, there is no evidence to suggest an unusual ectopic parathyroid adenoma, either undescended or within the mediastinum. As result, a 4 gland exploration may be warranted. The patient was diagnosed with Hypercalcemia. The patient was treated with Parathyroidectomy ___. At the time of discharge, the patient had -Hypercalcemia -Primary hyperparathyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH of microcytic anemia who presents from PCP at ___ for evaluation of incidental finding of hypercalcemia. Likely primary hyperparathyroidism given elevated PTH and enlarged parathyroid glands on imaging. Underwent parathyroidectomy on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is an ___ year-old right-handed woman with atrial fib on prodaxin, HTN, HLD, and history of GI bleed on coumadin who was transferred to ___ ER from ___ for a concern for acute stroke. Patient was last seen well at 22:30 on ___ by her daugher who was having a conversation with her and noted that she was fully alert, oriented and interactive with no notable deficits. However, at 11:15, as the daughter went by her mother's room she noted that the patient's TV was on at a show that she didn't watch and when she went in she noted that Ms. ___ was lying down on her bed mumbling something. As per her daughter, "she was trying to say something but the words would not come out." The daughter also noted that the patient was not moving the right side of her body. She called ___ and Ms. ___ was taken to ___ where a CT head was done. The CT was degraded by motion but read as negative for any acute process including bleed or infarct. Her ___ stroke scale there was 20. She was not considered a candidate for Tpa at that time since she has been on prodaxin. Chemistry panel was done and was normal and coagulation panel was also normal. She was transferred to ___ for futher management. Radiology showed Occlusion of the left distal cervical and intracranial ICA as well as the left MCA. Left MCA acute infarct. Radiology showed Persistent occlusion of the left middle cerebral artery and its distal branches. Expected progression of the large left middle cerebral artery infarction, without significant mass effect at this time. No evidence for hemorrhagic transformation. Evaluation of the patient with MCA stroke, new Dobbhoff placement. COMPARISON: Chest radiograph obtained the same day earlier at 11:30 a.m. The Dobbhoff tube is coiled in the oropharynx with its tip being in the distal esophagus. Cardiomegaly is unchanged as well as bilateral hilar enlargement. No pneumothorax is seen. was done. Evaluation of the patient with MCA stroke after Dobbhoff placement. AP radiograph of the chest was reviewed in comparison to ___. The NG tube is coiled within the esophagus and should be re-positioned. There are two radiographs obtained demonstrating overall similar appearance of the coiled NG tube. Bilateral pleural effusions, cardiomegaly and tortuous aorta are re-demonstrated. was done. Assessment of the upper thoracic air-containing abnormality seen on the prior radiograph. AP radiograph of the chest was reviewed in comparison to prior study obtained at 5:50 p.m. on the same day. The NG tube has been removed. There is cardiomegaly, vascular engorgement, bilateral pleural effusions and potentially bibasal atelectasis. The prior study was obtained on an abnormal angle that the appearance of the esophagus might be increasing concerns. On the current study, no definitive abnormal air collection is demonstrated. If clinically warranted, correlation with CT of the chest might be considered. was done. Radiology showed 1. Evolving extensive "early subacute" infarction involving the entirety of the left middle cerebral arterial territory. 2. Evidence of extensive hemorrhagic conversion involving the deep gray and white matter structures within this territory; there is an intraventricular hemorrhagic component. 3. Associated subfalcine herniation, new since the most recent CT examination. COMMENT: Discussed with Dr. ___, via telephone, at ___, ___, the time of study interpretation. Radiology showed 1. Large hiatal hernia with the majority of the stomach in an intrathoracic location. 2. Left adrenal nodule with indeterminate characteristics. Dedicated adrenal CT may be obtained for further characterization. 3. Small right pleural effusion. 4. Incidental findings, including diverticulosis and renal hypodensities which are too small to characterize. Radiology showed Left MCA infarct with hemorrhagic conversion and associated mass effect, including effacement of the sulci and left lateral ventricle and rightward midline shift, all unchanged from prior exam. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. At the time of discharge, the patient had Primary diagnosis: Large left MCA stroke with hemorrhagic conversion Cause of death: Cardiopulmonary arrest. The patient was given written instructions concerning 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: ___ year-old right-handed woman wit a fib on pradaxa, HTN, HLD, and history of GI bleed on coumadin who presents to us with dense right hemiparesis. Found on head CT to have a large MCA stroke/ left carotid occlusion. # Neuro: Held home pradaxa. Assessed vascular risk factors: HbA1c (6.1%) and lipid panel (LDL 112). Patient underwent MRI/MRA which showed hemorrhagic conversion involving deep gray and white matter structures and some IVH components with associated subfalcine herniation. Initially continued Aspirin, which was held on ___ given hemorrhagic conversion. Repeat Head CT showed stable hemorrhage. Patient became comfort measure only on ___ after discussion with family members and further interventions held. # Cardiovascular: We rule-out MI with repeat cardiac enzymes which showed negative troponins. Held home antihypertensives. Patient placed on telemetry, which was discontinued once patient became comfort measures only. # Pulmonary: CXR revealed cardiomegaly, enlarged pulmonary arteries, pulmonary edema and Right lower lobe consolidation consistent with pneumonia. Started on antibiotic treatment for pneumonia, which was discontinued once decision was made for comfort emasures only. # FEN: Patient with significant difficulty with NG placement so NPO on IVF. Found to have hiatal hernia confirmed on CT chest/abdomen/pelvis. Initially plan had been to place PEG for long term feeding plan. However, after family meeting, plan became comfort measures only and PEG placement was cancelled. Withdrew IVF. # Social: On ___ around 2pm, discussion with family regarding goals of care determined that patient should be comfort measure only. Palliative care team was consulted and recommended IV Morphine for pain, Ativan po for anxiety/agitation, Tylenol PR for fever/chills, Atropine SL drops for excessive secretions and Lasix for comfort with shortness of breath. Other interventions were withheld. Around 9PM, patient passed peacefully, cause of death likely cardiopulmonary arrest. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ speaking male with a history of mixed connective tissue disease with features of Sjogren's, systemic sclerosis (sclerodactyly and achalasia s/p endoscopic myotomy) and SLE with class V membranous nephritis, who presented with abdominal pain. CT ABD AND PELVIS WITH CONTRAST showed Moderate amount of fluid within the small bowel could suggest nonspecific enteritis, without CT signs to suggest IBD. The patient was diagnosed with Epigastric pain. At the time of discharge, the patient had PRIMARY DIAGNOSES Gastroenteritis Acute kidney injury Hypovolemic hyponatremia Hypotension Bright red blood per rectum SECONDARY DIAGNSES Mixed connective tissue disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>==================== PATIENT SUMMARY: ==================== ___ ___ speaking male with a history of mixed connective tissue disease with features of Sjogren's, systemic sclerosis (sclerodactyly and achalasia s/p endoscopic myotomy) and SLE with class V membranous nephritis, who presented with abdominal pain and N/V, found to have likely gastroenteritis as per CT. ==================== TRANSITIONAL ISSUES: ==================== [ ] Ciprofloxacin and Flagyl - 7 day course to be completed ___ [ ] Please follow up stool cultures [ ] Please follow up blood cultures - no growth to date [ ] Restarted home lisinopril at discharge given resolution of ___ [ ] Discharge Cr 0.8 [ ] Noted to have sinus bradycardia to 40-50s while in hospital, asx. Can consider further workup as needed as this does not appear to be his baseline #CODE: presumed full #CONTACT: ___, Phone: ___ ============</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ RHD M ___ speaking, who was ___ around 11am this morning. Patient put hand on table by accident in the area of the saw blade while picking up a piece of wood. Patient was transferred from ___. Patient is accompanied by his daughter. At the OSH patient had hand x rays which revealed fractures of the long metarcarpal head, as well as digital fracture of index and long finger. Patient has multiple full thickness lacerations with exposed tendons and partial amputation of distal index finger. Currently patient only had some moderate pain to right hand. Overall he states he doing well. Denies f/c/n/v Radiology showed Low lung volumes. No acute cardiopulmonary process. The patient was diagnosed with Partial traumatic trnsphal amputation of r idx fngr, init, Contact w powered woodworking and forming machines, init. The patient was treated with PROCEDURES: 1. Irrigation and debridement of open fractures of the index and middle fingers. 2. Primary arthrodesis of the ___ metacarpophalangeal joint using autograft. 3. Open reduction, internal fixation of index finger proximal phalanx. 4. Open reduction, internal fixation of index finger middle phalanx. 5. Revision amputation of index finger at the level of distal interphalangeal joint. 6. Excision of index finger flexor digitorum profundus from zone 2 to zone 4. 7. Middle finger flexor digitorum profundus reconstruction from zone 3 to zone 4 using tendon graft. 8. Open carpal tunnel release. 9. Allograft nerve reconstruction of middle finger radial digital nerve. 10.Primary repair of superficial palmar arch under operating microscope. 11.Skin graft reconstruction of middle finger volar radial defect (1 x 2 cm). 12.Complex repair of volar skin and dorsal index finger wound (combined length of 8 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>Hospitalization Summary (ED Admit) The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have right hand table saw injury and was admitted to the hand surgery service. The patient was taken to the operating room on ___ for fixation of hand fractures and revascularization, 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 OT was appropriate. The hospital course is notable for: 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 nonweight bearing in the right extremity, and will be discharged on aspirin 121.5mg daily for DVT prophylaxis. The patient will follow up with Dr. ___ per 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: Ms. ___ is a ___ F with PMHx notable for osteopenia, HTN, CKD stage III, multiple recent falls with cognitive decline per family who presents as transfer from OSH for evaluation of bowel and urinary incontinence over past ___ days. Chest radiograph. showed No evidence of acute cardiopulmonary process. CT ___ W/O CONTRAST showed 1. Near complete compression fracture of the L1 vertebral body with a combination of posterior osteophytosis and bony retropulsion into the canal at this level, causing moderate-severe canal narrowing. 2. Comminuted fracture of the superior endplate of the L2 vertebral body. 3. Moderate-severe multilevel degenerative changes of the lumbar spine, most significant at L4-5 with severe spinal canal and bilateral neural foraminal narrowing. CT HEAD W/O CONTRAST showed No acute intracranial hemorrhage or large vascular territory infarction. The patient was diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL, BACKACHE NOS, URINARY INCONTINENCE. At the time of discharge, the patient had Primary: Acute toxic metabolic encephalopathy L1 spinal compression fracture with retropulsion Secondary: Hypertension Chronic kidney disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ F with PMHx notable for osteopenia, HTN, CKD stage III, multiple recent falls with cognitive decline per family who presented as transfer from OSH for evaluation of bowel and urinary incontinence over ___ days after a fall, found to have L1 compression fracture on MRI being managed non-operatively, subsequently developed AMS. # L1 compression fracture with retropulsion: Circumstances around fall, including exact timing, remain unclear. Per family patient lives alone and has been falling frequently lately. Pt did not seek care immediately, likely due to baseline cognitive dysfunction. Pt initially sought care at ___ for symptoms of bowel and bladder incontinence. She was transferred to ___ given concern for cord compression. Initial exam did not reveal any acute neurological changes. MRI here revealed acute on chronic L1 compression fracture without evidence of compression of cord to explain her symptoms. Pt has history of osteopenia, which likely predisposed her to fracture. She was evaluated by the Orthopedic Spine team, who recommended non-operative management. She was fitted with a Jewitt brace for spine stabilization to wear with ambulation. She was evaluated by ___ and OT, who recommended SNF for further recovery. If medication is needed for pain prefer tylenol given AMS likely caused by narcotic pain medication. Pt will need to follow up with Ortho Spine clinic ___ weeks after discharge. Vitamin D and multivitamin should be continued. # Toxic metabolic encephalopathy: Pt's family reports progressive cognitive decline over the past year. She continues to lives alone, however has had several recent falls as above. Initial exam after admission to medicine was consistent with acute delirium given lack of orientation, attention and concentration. Her symptoms were most likely caused by narcotic pain medication given urine tox positive for opiates and/or hospital setting on baseline dementia. Infectious work-up negative. CT head revealed no acute intracranial abnormality. She was found to be Vitamin B12 deficit, however this is not likely to explain the acute change. TSH was normal. She required Zyprexa in ED and additional 5mg PO on AM of ___ for agitation, none thereafter. Over the next several days pt's mental status gradually cleared. Prior to discharge she was alert and oriented x 3 and able to form concentration tasks, per family approaching her baseline. Will need to continue environmental measures to reduce delirium, especially while at ___, and continue vitamin B12 supplementation. # Candidal intertrigo: Rash noted in right groin area during admission. It was not itchy, painful or otherwise bothersome to patient. She was started on nystatin cream with some improvement prior to discharge. She should continue a 2 week course. To prevent infection from recurring, make sure to pat area dry after showers. # Bowel/bladder incontinence: Resolved. Reported by pt over several days prior to admission to ___. Initial evaluation in ED revealed normal rectal tone. MRI was negative for acute cord compression as above. Pt voided urine spontaneously and had normal bowel movements during admission without incontinence. # Hypercalcemia: Noted to have elevated Ca to 10.6 on ___ that quickly returned to normal. Albumin and PTH were normal. Encouraged PO intake, likely dry. # HTN: Remained well-controlled. Home lisinopril was continued. # CKD: Cr stable at 1.0-1.1. CKD stage III per records, likely due to chronic HTN. Medications were renally dosed. # Glaucoma: Continued home eyedrops. # Primary prevention CAD: Continue home ASA 81mg.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with history of Rheumatoid Arthritis (wheelchair bound, was was seen in the ___ ED 4 days PTA for left flank pain and subsequently had a negative CT scan. Patient was given a prescription for bactrim for a UTI. She re-presents with with bilateral flank pain, lower back pain, and abdominal pain that has been present for the last 8 days and progressively getting worse. . In the ED, initial vs were: 98.2 90 143/58 16 94%. Patient was given 1 dose of azithromycin, 1LNS, and benadryll. Patient had a CXR that demonstrated bibasilar minimilar atelectasis (less concern for PNA), and mild cardiomegaly. Her labs were notable for hyponatremia 125, trop neg x1, Hb 10.4. . Prior to transfer vitals were 99.0, 80, 147/74, 18, 94%RA. . On the floor, patient's vitals were 98.4 83 143/60 18 93%RA. She is a difficult historian. On further history, patient reports that she has had progress worsening pain that starts at her lower breasts bilaterally and goes down into her abdomen that has been going on for 8 days. She says that she also has back pain associated with this, which is also bilateral, mainly located in her lower back but also at times closer to her spinal column. She denies any recent trauma or falls. She denies any recent illnesses, fevers/chills. She qualifies the pain as being constant, located all around her abdomen at times, only alleviated by laying still, and aggravated with movement. She also reports a decrease in her appetite, and associated nausea. She was able to tolerate a meal last night, beans with vegetables, she ate half her plate and did not have any emesis. She also reports constipation, as she had a suppository placed yesterday with small BM, but previously had not had BM since seeing her PCP last ___. Patient also reports small cough, clear sputum production, but no sore throat or rhinorrhea. Patient denies dysuria, increased frequency, change in color/odor of her urine (she was recently seen in ED with UTI and given bactrim). . Of note, patient had CXR at outside facility demonstrating subtle minimally displaced fractures of left ___ and 9th ribs on ___. . In addition patient reports numbness/cramping in her hands, this has been present for quite some time ___ year) with also weakness in her legs that has also been more chronic. She is wheelchair bound. Patient reports that she has been dropping objects more recently in the last 3 weeks and has difficulty holding them in her hands. She has had urinary incontinence, which is not new, and denies any bowel incontinence. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Has cough at times, clear sputum production. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied vomiting, diarrhea. Radiology showed 1. Mild congestive heart failure. The patient was diagnosed with HYPOSMOLALITY/HYPONATREMIA, ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had Rheumatoid Arthritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with hx of Rheumatoid Arthritis and HTN who presented with abdominal and bilateral flank pain of 8 days duration, with no other GI symptoms apart from her progressively worsening pain. In summary, she had a negative CT on ___ and workup was otherwise negative. She continues to have a chronic left otitis, for which ENT follow up is recommended. # Flank/Back Pain/Abdominal Pain: Pt had normal lipase, LFTs, clean UA, negative urine cultures and legionella antigen, negative blood cultures, no leukocytosis; as such, UTI/pyelo or other infection as well pancreatitis both seemed unlikely. Her CT showed no evidence of compression fracture. Her pain was unchanged throughout her admission; she took acetaminophen and reported some small pain relief, but refused any narcotic pain medication. . # Wheezing: Pt had some wheezing on admission, with no SOB or respiratory distress, adequate O2 sat, and normal resp rate. She received an albuterol nebulizer treatment on ___, and had resolution of her wheezing. Her lungs were clear at the time of discharge on ___. . # L ear discharge: The presentation of the ear is concerning for otitis media or externa; unable to adequately visualize TM due to purulent discharge. As such, perforated TM could not be ruled out, which led team to hold off on antibiotic drops. This otitis is likely chronic and was seen by her PCP, who obtained a cx sample on ___ (grew S aureus). It is unclear where exactly this sample was obtained from. Pt was discussed with ENT, who felt that pt should be seen for outpatient f/u for repeat culture from within ear canal and appropriate therapy. . # Social: Patient was seen by SW to follow up on issues that came up, including that her husband is her sole caretaker but also works; therefore, the patient spends the majority of her time alone. She pays for some private home help. Patient also reports verbal abuse, but denies phsyical abuse from husband. ___ provided support and also contacted Ethos Elder Services on her behalf given her isolation, to discuss further resource availability. . # Psych: Psychiatry was consulted given the patient's numerous psychosocial stressors and question of difficulty coping and safety going home, as well as some mention in previous PCP notes about pt seeing demons. Psychiatry corraborated some possible delusional aspect to her thinking as well as prominent mood symptoms (though the patient firmly opposed the label of depression), but psychiatry felt that her primary treatment concerned her underlying delusional disorder with psychotic symptoms. They recommended some additional laboratory workup that is detailed elsewhere for possible organic causes of her symptoms(negative RPR); brain MRI was not obtained. Pt declined any treatment for mood symptoms. . # Hyponatremia: Pt's Na was 125 on presentation, but resolved overnight with NS and remained normal throughout her admission. Previous treatment with bactrim may have contributed to her hyponatremia, though this is unclear. . # HTN - Patient was continued on her home amlodipine 5 mg with good effect. . # Rheumatoid Arthritis: Patient is not currently on and has never taken DMARDS, and does not like to take muliple medications at home. She refused pain medication stronger than acetaminophen, which she reported provided only a small amount of pain relief. . . . 1. Left-sided otitis: for ENT follow up. 2. Patient will go to rehab following discharge to receive physical therapy. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: DX HIP AND FEMUR showed Periprosthetic fracture of the proximal right femur shaft with 1.7 cm of dorsal displacement of the distal fracture fragment. Radiology showed 1. No acute cardiopulmonary process. 2. Although no acute fracture or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of such abnormalities. If the demonstration of a fracture or other trauma is clinically warranted, the location where there are focal findings should be clearly marked and imaged with either bone detail views or CT scanning. 3. A rounded area of increased density is seen projecting over the medial left lung base. This finding is most consistent with a hiatal hernia. NOTIFICATION: Updated impression was discussed with Dr. ___ by Dr. ___ telephone at 9:20am on ___, 90 minutes after discovery. Intraoperative radiographs for surgical guidance. showed Intraoperative images were obtained during operative fixation of right femoral fracture. Please refer to the operative note for details of the procedure. The patient was diagnosed with FX FEMUR SHAFT-CLOSED, JOINT REPLACEMENT-HIP, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING. The patient was treated with left periprosthetic hip fracture ORIF on ___ ___. At the time of discharge, the patient had Left hip periprosthetic fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left hip periprosthetic hip fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF of the left hip periprosthetic hip fracture which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. On POD3, patient had a bloody bowel movement, with another one the folowing day. His lovenox dvt prophylaxis was held for two days. He received 1uPRBC for a hct of 23, which bumped up appropriately to 27 and remained stable prior to discharge. Gastroenterology was consulted who recommended a colonoscopy, which he underwent on ___ which revealed diverticulosis without any other concerning masses. They cleared him for discharge on ___. 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 TDWB in the LLE, and will be discharged on lovenox x 2 weeks for DVT prophylaxis. The patient will follow up in two weeks with Dr. ___ team in 2 weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old man with a history of recurrent PE on coumadin, HTN, and hyperlipidemia who presents with head pressure/ache and diplopia. MRI AND MRA BRAIN showed No significant abnormalities are seen on MRI of the brain with and without gadolinium. No evidence of venous sinus thrombosis. The patient was diagnosed with DIPLOPIA, HEADACHE, PERSONAL HISTORY OF PULMONARY EMBOLISM, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had Primary: idiopathic headache, diplopia Secondary: hypertension, pulmonary embolisms on coumadin, 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>___ M w diplopia and headaches. Headaches described as "fullness". Fundoscopic exam w/o e/o papilledema. Diplopia on far lateral gaze bilaterally - appear to be consistent w mild bilateral ___ nerve palsies. CT head benign. MRI+/MRV benign. Will follow closely in neurology and neuro-ophtho clinics. Will follow in ___ clinic on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ M with history of severe COPD (per pulmonary note dated ___ baseline FEV1 has been 0.8-1.0L for the past ___, s/p LVRS in ___, who was treated for pneumonia one month ago with levaquin and high-dose steroids, sent to the ED from pulmonary clinic with worsening cough, dyspnea, weight loss, and exertional hypoxia over the past month. Radiology showed Increased lingular and left lower lung opacities, compatible with worsened infection since ___. Small left pleural effusion. Radiology showed 1. Increasing consolidation and ground-glass opacification in the residual left lingula and left upper lobe. This is most concerning for a worsening infectious process. 2. Stable mildly enlarged left hilar and mediastinal lymph nodes are likely reactive. 3. Stable severe pan-lobular emphysema. 4. Multiple stable pulmonary nodules. These are unchanged dating to ___. Radiology showed Right PICC terminating in upper SVC. Left lingular and lower lobe opacification more prominent on this exam due to lower lung volumes compared to prior. Otherwise, stable chest radiograph. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. The patient was treated with ___ Line placement. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Multilobar Pneumonia 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>___ with history of severe COPD who was treated for bacterial pneumonia one month ago with levofloxacin and PO steroids, sent to the ED from pulmonary clinic with worsening cough, dyspnea, and exertional hypoxia over the past month. HOSPITAL COURSE BY PROBLEM #. Dyspnea, cough, and hypoxia. Given his risk factors of older age, severe obstructive disease, and failure of recent antimicrobial therapy, the patient was started on vancomycin and cefepime for pneumonia. PE was felt to be less likely given that the patient had no other signs or symptoms suggesting this (no chest pain, not tachycardia, no history of immobilization, Wells score of zero). A chest CT was obtained which showed increasing consolidation in the lingula and left upper lobe compared to prior CT, concerning for a worsening infection. The patient was continued on his home impratroprium and albuterol nebulizers. A cardiac etiology of his dyspnea was thought to be less likely given that he had no cardiac history, did not appear volume overloaded on exam, and recent normal LV and RV function on TTE from ___. His EKG on arrival was negative for acute ischemic changes, though troponin in ED slightly elevated to 0.02. His subsequent cardiac markers were negative and an AM EKG showed no acute changes. A urine legionella antigen was obtained and found to be negative. Beta-glucan and galactomannan were also checked and were found to be negative. Alpha-1 antitrypsin levels were also checked and were also pending at the time of discharge. The inpatient pulmonology team was consulted and recommended that he be discharged on IV vancomycin and cefepime and that he begin taking fluticasone with a spacer. The patient was discharged on IV vancomycin and cefepime; follow-up with his outpatient pulmonologist was being arranged by Dr. ___. #. Elevated troponin. The patient's troponin was elevated in the ED to 0.02, which was attributed to a hemolyzed specimen. His EKG showed no acute ischemic changes, and his cardiac markers were cycled and found to be negative x2. He was placed on telemetry overnight, which was discontinued the morning after a morning EKG showed no acute ischemic changes. The patient denied any chest pain throughout his admission. #Creatinine bump. On day four of his admission, the patient's serum creatinine bumped from 1.1 to 1.4. Urine electrolytes were consistent with an intrinsic renal process, likely contrast-induced (as he received a chest CT with contrast) vs. antibiotic-induced. The patient's AM and ___ doses of vancomycin were held for one day. His serum creatinine was monitored and remained stably elevated on the day of discharge. Upon discharge, the patient will have a serum creatinine check along with Vancomcyin trough checked upon discharge by ___ services; patient was provided with presciption for outpatient lab check. #. Hyperkalemia. On admission the patient was found to be hyperkalemic, withou acute EKG changes. An AM K was checked and found to be within normal limits. #. Hyponatremia Mild, asymptomatic. Thought to be secondary to poor PO intake versus SIADH in light of the patient's history of lung disease. Urine electrolytes were checked and found to be consistent with SIADH. The patient was initially fluid restricted; however this was discontinued per the patient's request. His sodium was trended and his hyponatremia resolved. #. Urinary symptoms: Patient with PSA of 9 as an outpatient; he is awaiting Urology follow-up at ___. Tamsulosin was started. Patient tolerated this well, denying symptoms of orthostatics. The patient was provided with prescription for this medication and encouraged to follow-up with Urology as an outpatient as per plan prior to admission. Transition of care issues: - follow-up alpha 1 antitripsin level (pending at time of discharge) - continuation of IV antiboitics through ___ line - outpatient pulmonology follow-up</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: presented with left eye pain and swelling after she manually lanced it and the pain/swelling has been getting and she came to the ED where ophthalmo Fellow saw her and he stated that it is not orbital cellulitis but it is pre-septal cellulitis. Patient was hard to establish IV access and picc line was placed for her. Patient is very eager to leave although her cellulitis was not completely resolved. I discussed with her the risk of leaving AMA including worsening of her infection to extend to her neurological system or the risk of losing her eye but she insisted on leaving and she does not want to stay in the hospital. I informed her that her abscess around her eye need to be drained and she refused any further treatment and she does not want to stay, a prescription of Bactrim has been given and she was informed that it is not full treatment for her eye infection and she is aware and understands the risks CT ORBITS, SELLA AND IAC W/ AND W/O CONTRAST Q1216 CT HEADSUB showed 1. Preseptal soft tissue swelling and edema of the medial and lateral left orbit. The appearance appears somewhat improved in comparison to the prior exam. However, post-septal orbital cellulitis remains a clinical diagnosis. 2. Paranasal sinus disease as described above. Radiology showed Successful placement of a right 37 cm brachial approach single lumen PowerPICC with tip in the distal SVC. The line is ready to use. The patient was diagnosed with Periorbital cellulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>presented with left eye pain and swelling after she manually lanced it and the pain/swelling has been getting and she came to the ED where ophthalmo Fellow saw her and he stated that it is not orbital cellulitis but it is pre-septal cellulitis. Patient was hard to establish IV access and picc line was placed for her. Patient is very eager to leave although her cellulitis was not completely resolved. I discussed with her the risk of leaving AMA including worsening of her infection to extend to her neurological system or the risk of losing her eye but she insisted on leaving and she does not want to stay in the hospital. I informed her that her abscess around her eye need to be drained and she refused any further treatment and she does not want to stay, a prescription of Bactrim has been given and she was informed that it is not full treatment for her eye infection and she is aware and understands the risks </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CT ABD AND PELVIS WITH CONTRAST showed 1. Findings consistent with acute interstitial edematous pancreatitis. The pancreas appears to enhance homogeneously. No peripancreatic fluid collections are identified. 2. Peripancreatic fat stranding extends into the lesser sac abuts the lesser curvature of the stomach and duodenum with reactive lymphadenopathy as described above. 3. Hepatic steatosis. The patient was diagnosed with Other chronic pancreatitis. At the time of discharge, the patient had pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with h/o alcohol use disorder, previous admissions for alcohol withdrawal requiring IV phenobarbital as well as previous admissions for necrotizing pancreatitis presents with alcohol withdrawal, alcoholic hepatitis, and acute pancreatitis. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with a history of hypertension, GERD, dyslipidemia, remote bowel resection for colonic lipoma and peptic ulcer disease s/p vagotomy (in ___ who presents with abdominal pain. 2 weeks ago, the patient developed gradual onset abdominal pain which is been waxing and waning but overall constant per report. He says it is been nonradiating. The pain is intermittently on the left, right and center, but typically is around the umbilical level. The pain is not associated with p.o. intake or improved by p.o. The pain is not improved or worsened by movement or exercise. The pain is typically dull but gets sharp when he presses and he occasionally has sharp pains that have woken him from sleep. He has had nausea without vomiting. He intermittently has small bowel movements which are at his baseline and he denies any hematochezia or melena. He has also had intermittent fevers for the past 3 days up to 38.5 °C yesterday. He has had no difficulty with urination or blood in his urine. Denies chest pain, shortness of breath, palpitations, cough, or lightheadedness. He denies any headache or double vision. He denies any testicular pain or penile discharge. No recent travel and no sick contacts. He has been taking Aleve for the pain, which is mildly effective. CT ABD AND PELVIS WITH CONTRAST showed 1. Marked wall thickening of the terminal ileum in very distal ileum and wall thickening to a lesser extent involving the cecum and proximal ascending colon. 5 x 4.0 cm region of likely phlegmon superior to the thickened terminal ileum. Numerous associated mildly prominent likely reactive right abdominal ileocolic lymph nodes. Consultation of findings most compatible with terminal ileitis and associated phlegmonous change. Differential diagnosis includes inflammatory bowel disease, including Crohn's disease, other inflammatory process, versus infectious ileitis. No free air or extraluminal oral contrast seen. No drainable collection. 2. Normal caliber appendix. RECOMMENDATION(S): Recommend follow-up CT or colonoscopy once the acute process resides to ensure resolution and exclude an underlying mass. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Normal appearance of the liver parenchyma. No focal liver lesions are identified. 2. Nondistended gallbladder with trace wall edema versus pericholecystic fluid. Findings may be related to third spacing. No other sonographic findings to suggest cholecystitis. The patient was diagnosed with Crohn's disease of small intestine without complications. At the time of discharge, the patient had PRIMARY DIAGNOSIS =================== Terminal Ileitis SECONDARY DIAGNOSIS ====================== Peptic Ulcer Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY =============== ___ male with a history of GERD, peptic ulcer s/p vagotomy, and sigmoid lipoma s/p partial sigmoid colectomy (___) who presented with fevers and abdominal pain with features of enterocolitis noted on imaging. He was started on ciprofloxacin and flagyl with improvement in his symptoms. He was seen by gastroenterology, who recommended outpatient colonoscopy for further follow up. TRANSITIONAL ISSUES ===================== [] At time of discharge, patient did not have an outpatient colonoscopy scheduled but had been ordered. Please confirm with patient that this has been scheduled for the next few weeks after he completes course of antibiotics. [] Patient with " Marked wall thickening of the terminal ileum in very distal ileum and wall thickening to a lesser extent involving the cecum and proximal ascending colon. 5 x 4.0 cm region of likely phlegmon superior to the thickened terminal ileum." found on CT A/P. Recommend that patient has a follow up CT or colonoscopy once the acute process resides to ensure resolution and exclude underlying mass. [] Patient discharged on ciprofloxacin and flagyl for a 10 day course scheduled to end ___. [] Patient found to be CMV IGM and IGG positive. Per GI, there was no indication for antiviral treatment or colonoscopy at this time because patient is immunocompetant. GI will follow with outpatient colonoscopy. [] Recommend outpatient vaccination for hepatitis. ACUTE ISSUES ================= # Terminal ileitis He presented with 2 weeks of abdominal pain and intermittent fevers and was found on imaging to have findings consistent with terminal ileitis. This is typically associated with Crohn's disease although there are other associated conditions such as ulcerative colitis, infection or less likely NSAID ileitis. CRP at admission was elevated to 179. He was started on cipro and flagyl with improvement in his abdominal pain. GI was consulted and recommended sending off serologies. At the time of discharge, patient was noted to be CMV IgM positive, IgG positive, EBV IgG positive. Per GI, since patient was immunocompetant, they believed this was likely infectious and recommended continuing antibiotics and setting up an outpatient colonoscopy once the infection resolved. # Mild normocytic anemia Suspect reactive from illness however pt has prior hx of BRBPR iso lipoma. Low iron. Hemolysis labs negative. No evidence of active bleeding. # Mild transaminitis Initially presented with transaminitis that improved by discharge. RUQUS negative for biliary process. Likely secondary to infection as above. Hepatitis panels negative.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male who presented as a trauma patient after a syncopal episode. He had been on a prolonged bikycle ride with his wife. Per report, he was standing and talking in the driveway after the ride when he suddenly lost consciousness and fell forward, striking his face. He had no prodromal symptoms. He has not had prior syncope. At the time of presentation, he complained of pain and bleeding and loss of multiple teeth. Patient denies any medical history however he has not seen a physician in several decades by his estimate. Radiology showed Low lung volumes. Left basilar opacity may be secondary to atelectasis. Consider repeat with improved inspiratory effort to further assess. Radiology showed 1. No evidence of acute intracranial process. 2. For details regarding the extensive facial fractures, please see dedicated facial bone CT Radiology showed 1. Bilateral ___ Fort I, right ___ ___ and left ___ ___ fractures as described above with involvement of the bilateral cribriform plates, the lacrimal duct on the left and the lacrimal fossa on the right. 2. Comminuted fractures through the hard palate with teeth 9 and 11 missing and fractures involving the roots of multiple left maxillary teeth. 3. Vertically oriented mandibular fractures in the parasymphyseal region on the right and the left with a horizontally oriented fracture extending through the body of the mandible on the right paralleling the course of the inferior alveolar canal. Findings were discussed with Dr. ___ by Dr. ___ in person at 8:30 p.m. on ___, 20 minutes after review of the study. Radiology showed No evidence of acute fracture or traumatic malalignment in the cervical spine. CHEST (PORTABLE AP) showed In comparison with the study ___, the lung volumes have slightly improved. Opacification at the left base most likely represents the combination of a small effusion and compressive atelectasis. Radiology showed mpression: Right ICA with <40% stenosis. Left ICA with no stenosis. 3D reconstructions of facial bone CT showed Please see report under clip ___. Radiology showed 1. Numerous facial fractures, status post repair. 2. Persistent comminuted fracture of the lateral wall of the right maxillary sinus with now an angulated linear fracture fragment present inside the sinus cavity surrounded by increased hematoma. There is also increased hemorrhagic opacification of the right maxillary sinus and ethmoid air cells. 3. Persistent subluxation of the right temporomandibular joint. NOTE ADDED AT ATTENDING REVIEW: Unchanged comminuted mandibular fractures. Radiology showed Focal thrombosis of the right cephalic vein at the prior line insertion site. No deep vein thrombosis identified in the right upper extremity. The patient was diagnosed with FX MALAR/MAXILLARY-CLOSE, MULT FX MANDIBLE-CLOSED, TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA), WITHOUT MENTION OF COMPLICATION, OPEN WOUND OF LIP, SYNCOPE AND COLLAPSE, OTHER FALL. The patient was treated with ORIF of facial fractures. At the time of discharge, the patient had Bilateral LeFort I fractures, right LeFort II fracture, and left LeFort III 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>Mr. ___ was admitted to the ACS service with HPI as stated above. He underwent imaging which revealed bilateral ___ I fractures, right LeFort II fracture, and left LeFort III fracture. OMFS and ophthalmology were consulted. OMFS determined that operative repair would require a substantial block of OR time and so scheduled the case for ___. Ophthalmology evaluated the patient and determined that no acute ophthalmologic operative intervention was indicated but that the patient should follow up with the Mass Eye and Ear Institute department of occuloplastics. He was given a full liquid diet as he was not expected to go to the OR immediately. On ___, the patient was noted to have substantial facial swelling secondary to his injuries and so he was placed on continuous O2 saturation monitoring and transferred to the SICU; his condition did not worsen and he required no additional interventions. A tertiary survey on that day did not reveal any new injuries. He returned to the floor on ___ and was kept on full liquids. On ___, a syncope workup was initiated. EKG and CXR on ___ were not acutely concerning for evidence of a cause for his syncopal episode. A carotid ultrasound was similarly non-concerning. Ancef was initiated on that day per ___ recommendations. A TTE on ___ did not reveal any clear cause of his syncope but was reassuring for his appropriateness as an operative candidate. Mr. ___ went to the OR on ___ and underwent ORIF of facial fractures of his facial fractures and he tolerated the procedure well; for full details please see the operative report. He remained intubated for airway protection in the context of edema and went to the ICU post-op; he was extubated on POD#1, went to the floor in good condition, and was resumed on a full liquid diet. He initially was unable to tolerate the liquid diet due to difficulty swallowing as a consequence of the packing in his nose. He remained on IV fluids for hydration. ___ was involved in discussion of disposition and it was decided to keep Mr. ___ in the hospital for the time being. Ultimately, packing was discontinued by ___ on ___ in the early afternoon and the patient tolerated a full liquid diet very well after this action. On the day of his discharge, foley was removed and the patient voided multiple times successfully. It was noted that his right antecubital fossa was inflamed and indurated at his former IV site and so an ultrasound was ordered which revealed superficial clot but no DVT; he was advised to apply moderate comfortable heat to the area. Discharge meds were prescribed and follow-up with ___ and ophthalmology services in accordance with the recommendations of these services. He will remain on chlorhexadine mouth rinse and PO Keflex for 1 week. Mr. ___ was discharged to home on ___ with appropriate information, warnings, prescriptions, and follow-up. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of presumed ETOH cirrhosis, GERD, BPH, biliary colic s/p ERCP in ___ who presents with right upper quadrant pain. Records suggest that he has had several previous admissions with similar complaints, including in ___, and most recently, he was admitted to ___ ___ in late ___ for RUQ pain and was thought to have cholecystitis, so he underwent ERCP with balloon sweep, which did not reveal further stones. He was ultimately discharged to rehab with outpatient surgical follow up. Radiology showed No visualized metallic objects. MRI abdomen with and without contrast showed Morphologic appearance of the liver consistent with cirrhosis. Non-specific, sub-centimeter focus of arterial hyperenhancement. Particular attention to this lesion on future surveillance imaging is recommended. Evidence of portal hypertension based on ascites, splenomegaly, and varices. Given degree of motion degradation of this examination, consideration may be given to acquiring future surveillance imaging with multiphase CT. Cholelithiasis, biliary sludge and likely fundal adenomyomatosis. Small pleural effusions and bibasilar atelectasis. The patient was diagnosed with ABDOMINAL PAIN RUQ, ALCOHOL CIRRHOSIS LIVER. The patient was treated with ERCP ___ EGD ___. At the time of discharge, the patient had Primary Diagnosis: Cholangitis Biliary obstruction (choledocholithiasis) Secondary Diagnosis: Esophageal varices, grade I-II. The patient was given written instructions concerning 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 Narrative (more details below): ___ with history of presumed ETOH cirrhosis, GERD, BPH, biliary colic s/p ERCP in ___ with sphincterotomy admitted ___ for recurrent right upper quadrant abdominal pain with initial concern for cholecystitis. Given his Child ___ Class C, he was deemed a high-risk surgical candidate and was therefore managed medically with IV antibiotics. His pain persisted and he began to develop low-grade fevers with rising T bili, so he went for ERCP which revealed 2 stones in the Common Bile Duct which were successfully removed with good drainage. Given these findings and his clinical presentation, he was diagnosed with cholangitis. He improved significantly after ERCP and with IV unasyn and was subsequently narrowed to po ciprofloxacin. He should continue on this ciprofloxacin through ___. His blood pressure while inpatient was in the 90-100 systolic range after resolution of his infection - likely due to poor nutritional intake while hospitalized and amidst his acute illness. For this reason, though, his home lasix/spironolactone regimen and his new nadolol were NOT CONTINUED on discharge - these should be re-addressed and possibly restarted at his upcoming appointment on ___ ___. Of note, he also underwent routine screening EGD for varices while inpatient which discovered Grade I-II varices, no intervention needed, with recommendation for nadolol prophylaxis. He also underwent routine MRI screening which was negative for HCC. ** TRANSITIONAL ISSUES **: - continue ciprofloxacin 500mg po q12h through end of ___. - check full labs (CBC, basic chemistries, LFTs) on ___ ___ - ensure stable liver function and also renal function. - on ___ ___ blood pressure should be assessed to determine whether he is safe to restart his normal lasix 40mg daily and spironolactone 25mg daily, as these are HELD on discharge. Nadolol prophylaxis can also be re-addressed since this was NOT STARTED on discharge due to his BP - his home potassium supplements were HELD since his lasix is being held as above. re-evaluate with his labs and if restarting lasix as above as outpatient - initiated HBV vaccine series on ___ - should complete routine initial vaccination series with 2 more administrations - iron/TIBC ratio noted to be elevated (116/174) - hereditary hemochromatosis panel was ordered and should be followed-up ================================================================ ___ with history of presumed ETOH cirrhosis, GERD, BPH, biliary colic s/p ERCP in ___ who presents with right upper quadrant pain found to have radiographic evidence equivocal for acute cholecystitis, initially admitted to surgery service but subsequently transferred to the liver service given high surgical risk with subsequent development of cholangitis.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with abdominal pain since started last night (10 hours ago) which she describes as right sided and crampy. She has associated nausea but denies emesis. She had a bowel movement yesterday and continues to pass gas. CT ABD AND PELVIS WITH CONTRAST showed Appendix is fluid-filled and dilated to 1 cm demonstrating wall thickening and adjacent fat stranding consistent with acute appendicitis (601b:24). There is no extraluminal air; however, a small amount of free fluid along the distal appendix may represent early changes after perforation (2:46). No drainable fluid collection or abscess. The patient was diagnosed with ACUTE APPENDICITIS NOS, HX OF BREAST MALIGNANCY. 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>Ms. ___ was admitted to ___ for abdominal pain. At CT scan showed Appendix is fluid-filled and dilated to 1 cm demonstrating wall thickening and adjacent fat stranding consistent with acute appendicitis. She was taken to the operating room that night for a laparoscopic appendectomy. She improved through out the night. By morning she was able to tolerate a regular diet. Her pain was well controlled. Upon discussion with the pt concerning discharge it was noted the her left pupil was dilated compared to the right. She had no visual complaints at the time. A cranial nerve exam showed that both pupils were reactive to light, with the left less so than the right. Neurology was notified, and she was scheduled to visit the neurology clinic as an outpatient. At the time of discharge she was doing well. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ dementia who presents from home because patient has been less willing to walk, eat, drink, or take meds. Patient has had subacute decline over the past several months with increased fatigue, weight loss, decreased appetite, refusal to take certain medications, and unwillingness to get out of bed. Also newly incontinent of urine. On day of admission, pt complained of neck and shoulder pain, which is chronic, but was unwilling to take tylenol. Daughter, ___, who lives with patient feels she has become deconditioned and needs a higher level of care, at least temporarily. Initial VS in the ED: 98.6 94 181/68 18 98% Labs notable for K 2.7, Mg 1.6, P 2.2, normal creatinine. Patient was given 800mg MgOxide, 40mEq PO K, 40mEq IV K, 2 packets neutraphos, 1L IVF. Radiology showed Chronic fibrotic changes with bilateral calcified pleural plaques compatible with asbestosis, similar compared to the prior exam. No new areas of focal consolidation identified. The patient was diagnosed with HYPOKALEMIA, FAILURE TO THRIVE,ADULT, HYPERTENSION NOS. At the time of discharge, the patient had advancing dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with dementia here with FTT and hypokalemia. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ Stroke Scale - Total [1] 1a. Level of Consciousness -0 1b. LOC Questions -0 1c. LOC Commands -0 2. Best Gaze -0 3. Visual Fields -0 4. Facial Palsy - 0 5a. Motor arm, left -0 5b. Motor arm, right -0 6a. Motor leg, left - 0 6b. Motor leg, right - 0 7. Limb Ataxia - 0 8. Sensory -1 9. Language - 0 10. Dysarthria - 0 11. Extinction and Neglect - 0 CHEST (PA AND LAT) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed No evidence of acute hemorrhage or fracture. MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ showed 1. No evidence of hemorrhage, infarction, or edema. 2. No evidence of stenosis, occlusion, or aneurysm formation. The patient was diagnosed with Transient cerebral ischemic attack, unspecified. At the time of discharge, the patient had 1)Left lumbar radiculopathy 2) Meralgia paresthetica or lateral femoral cutaneous neuropathy is numbness or pain in the outer thigh caused by injury or irritation to a nerve that extends from the spinal column to the thigh. Patient did not have a TIA or 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>Mrs. ___ is a ___ woman with a past medical history and recent admission for dyspnea and chest pain, who presents with a generalized feeling of being unwell, some dyspnea on exertion, and acute onset of left V2 to V3 facial and hemibody paresthesias that progressed into 50% decrease in sensation. NIHSS was 1 for her sensory changes, otherwise patient demonstrated good strength, no language deficits, no dysarthria, and no cortical signs such as extinction or neglect. Patient also has full visual fields and no asymmetry in her smile. Given the acute onset of paresthesias and numbness in the hemibody distribution, she was worked up for TIA versus stroke which was negative. No concern for metastasis to the brain. There was no other evidence to suggest that the patient was experiencing a seizure as there was no alteration in consciousness nor any abnormal movements. The patient denied paresthesias at the time of discharge. Patient's left iliopsoas was slightly weak with signs of left lumbar radiculopathy. There was numbness of the left lateral thigh concerning for left lateral cutaneous neuropathy of the thigh (otherwise known as meralgia paresthetica). Hospital course by system </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is an otherwise healthy ___ year-old female with a one-day history of abdominal pain. Patient reports having felt mild periumbilical discomfort last night that migrated to the right lower quadrant earlier this morning and became sharp, of moderate intensity (___), non-radiated, with no known alleviating factors, worsened with movements. Concomitantly, she endorsed intermittent nausea but no emesis, as well as headache. She denies fever, chills. PELVIS U.S., TRANSVAGINAL showed Normal pelvic ultrasound. CT ABD AND PELVIS WITH CONTRAST showed Slightly prominent size of the appendix up to 7 mm with slight wall thickening and mild surrounding stranding. In the proper clinical setting this may represent acute appendicitis. US APPENDIX showed The appendix was not reliably identified. If there is concern for appendicitis, a CT should be performed. 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 hospital with abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging. A cat scan of the abdomen was done which showed a 7 mm appendix with slight wall thickening and mild surrounding stranding. These findings were suggestive of acute appendicitis. The patient was taken to the operating room where she underwent an appendectomy. The operative course was stable with minimal blood loss. The patient was extubated after the procedure and monitored in the recovery room The post-operative course was stable. The patient was started on clear liquids and advanced to a regular diet. Her vital signs remained stable and she was afebrile. She was transitioned to oral analgesia for management of her incisional pain. The patient was discharged home on POD # 1 in stable condition. Follow-up appointments were made with the acute care service. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with IDDM, HTN, right BKA presenting with abdominal pain x 1 week. Pain is not related to eating or to bowel movements. Has had a poor appetite. Denies fevers/chills. Denies N/V or diarrhea/constipation. Last BM was on morning prior to presentation to ED and normal in appearance. He has been taking pepcid at the advice of his PCP but this has not improved symptoms. He states that several people he knows are sick with N/V and diarrhea. . In the ED, initial VS: 98 90 158/96 16 100% RA. CT abdomen/pelvis was performed that showed mild mesenteric stranding between the uncinate process and third part of the duodenum is nonspecific and could represent a focal pancreatitis or duodenitis. He was given IV cipro and IV flagyl, 1 tab percocet, as well as 1L normal saline. He was also found to have an abscess in his right lower quadrant that was drained at the ED. However, cultures were not sent. Radiology showed No pneumonia, edema or effusion. Radiology showed 1. Mild mesenteric mistiness between the uncinate process and the third part of the duodenum is nonspecific but may represent a focal pancreatitis or duodenitis in the appropriate clinical setting. An adjacent borderline enlarged lymph node is likely reactive. 2. Mild diverticulosis without diverticulitis. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, LUMBAGO, DIAB W MANIF NEC ADULT, CELLULITIS/ABSCESS OF TRUNK, HYPERTENSION NOS. The patient was treated with Incision and drainage of abscess. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with hx of HTN, IDDM, and R. BKA who presents with abdominal pain x ___bdomen only showing mild mesenteric stranding. . # Abdominal pain: Patient presented with abodminal pain x 1 week with no associated n/v/d. In the emergency department, he underwent CT abdomen which showed mild mesenteric stranding and was given a dose of intravenous cipro and flagyl. Patient remained afebrile without leukocytosis. Other labs including lipase and liver function tests were within normal limits. Upon arrival to the flood antibiotics were discontinued. Abdominal pain thought to be due to viral etiology given known sick contacts with GI symptoms. Also given the location and nature of the pain, PUD vs gastritis was considered. He was treated with IVF on the floor and his lactate improved. He was given a GI cocktail and percocet for pain. H. pylori antibody was sent. At time of discharge pain improved and he was able to tolerate diet. He was discharged with maalox and omeprazole with plans to follow up with his primary care physician. . # Cellulitis - Patient found to have small abscess on his RLQ that was drained in ED, however cultures were not sent. The surrounding skin was erythematous and warm. Given that patient is a diabetic and that there was purulent drainage, clindamycin was started for MRSA coverage. He was discharged with plans to complete a ___nd follow up with his PCP. . # back pain - Patient with known chronic back pain. There were no concerning symptoms for acute process on presentation. He was continued on his home percocet. . # Hypertension - Patient remained normotensive during admission. He was continued on his home lisinopril and amlodipine. . # IDDM - Blood sugars were controlled with sliding scale during admission. . Transitional Issues - H. pylori and blood cultures pending at time of discharge - patient was full code on this admission - contact: ___ (brother, HCP) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old man with a PMH significant for ESRD ___ Alport syndrome s/p LURT in ___ from his wife complicated by BK viremia, proteinuria and biopsy showing both BK viral inclusions as well as evidence of chronic humoral rejection who presents with nausea and vomiting. Of note, the patient was recently admitted ___ for N/V and diarrhea after recently starting MMF, found to have severe C.diff infection for which he was discharged on PO vanco, with the rest of w/u for infectous causes of diarrhea unrevealing (including stool cultures, CMV, adenovirus and norovirus). Patient went in for routine labs yesterday, which returned with Cr up to 2.9 (from 1.7 on discharge), so he was referred into ___ ED. He also reports 2 episodes of vomiting this morning. In general, however, he feels overall significant improved compared to his last hospitalization. Diarrhea as resolved (currently only 1 formed stool per day), and N/V significant improved as well. Denies fevers, chills, abdominal pain, chest pain, SOB. In the ED, initial vitals were 99.8 89 168/104 16 100%. Labs notalbe for Chem-7 with Cr 2.8 (Cr 1.7 baseline, 2.7 on last discharge), CBC with WBC 3.3 H/H 9.1/27.3 plts 117, lactate normal. Renal US showed a normal transplant. Transplant Nephrology team recommended admission for IVF overnight. VS on transfer 98.7 88 180/120 16 100% RA. On arrival to the floor, VS 98.8 108/54 91 18 99%RA, The patient is well-appearing and without complaints. RENAL TRANSPLANT U.S. showed Normal appearance and vascularity of the transplant kidney. Less elevated peak systolic velocities in the remaining renal artery continue to reflect the tortuosity of this vessel. Small amount of perinephric simple fluid. Ultrasound guidance for percutaneous kidney biopsy by nephrology showed Ultrasound guidance for percutaneous transplant kidney biopsy. CHEST (PA AND LAT) TECHNIQUE: Chest radiograph, PA and lateral views COMPARISON: Chest radiograph ___ FINDINGS: There is a new small left pleural effusion. There is a new irregular opacity at the left lung base laterally, which could be an infectious process or atelectasis. A calcified granuloma in the left mid to upper lung is unchanged. Cardiomediastinal silhouette is normal size. IMPRESSION: New small left pleural effusion and left lung base opacity could be an infectious process or atelectasis. If clinically indicated, CT is recommended for further evaluation. showed New small left pleural effusion and left lung base opacity could be an infectious process or atelectasis. If clinically indicated, CT is recommended for further evaluation. CT CHEST W/O CONTRAST showed Suspected aspiration or pneumonia involving the dependent aspect of both lower lobes. Given the history of immunosuppression, invasive aspergillosis cannot be excluded. Although the bronchiolar nodules measuring up to 7 mm in the dependent right lower lobe are likely infectious or inflammatory, a short-term followup chest CT following appropriate antibiotic treatment is advised. Mild pulmonary edema. Small layering nonhemorrhagic left pleural effusion with mild associated partial passive atelectasis of the left lower lobe. Trace right pleural effusion. Mild coronary artery calcification involving the proximal LAD is atypical in a young patient. However, this patient may be at increased risk of coronary artery disease given the history of chronic renal disease in the setting of Alport syndrome. Anemia. Radiology showed Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Fluoroscopy showed Intraoperative images were obtained during left bronchoscopy. Please refer to the operative note for details of the procedure. Total fluoroscopic time is 161.8 seconds and total dose is 25 mGy CHEST (PORTABLE AP) showed In comparison with the study of ___, there has been placement of a hemodialysis catheter that extends to the cavoatrial junction or right atrium. Otherwise, little change. Specifically, no evidence of pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is no evidence of post-procedure pneumothorax or other change. Radiology showed 1. Bilateral atrophic kidneys with a right pelvic renal transplant identified. While there is no perinephric fluid or fluid collection, there is trace pelvic free fluid noted. No hydronephrosis or perinephric stranding. 2. No evidence of retroperitoneal bleed. 3. Mild diverticular disease without evidence of diverticulitis. 4. Diffusely dense liver, presumably hemosiderosis. CT CHEST W/O CONTRAST showed Bibasilar consolidations have increased in size and become more consolidated within the left lower lobe concerning for aspiration or alternatively pneumonia in the correct clinical setting. Several bronchiolar nodules within the right lower lobe are thought likely infectious or inflammatory, stable when compared to prior CT 3 days prior, though deserve followup chest CT up on termination of treatment. Small bilateral nonhemorrhagic and layering pleural effusions have increased since prior study. Trace pericardial effusion is unchanged. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. CHEST (PA AND LAT) TECHNIQUE: Chest radiograph, PA and lateral views COMPARISON: CT chest ___. Chest radiograph ___ FINDINGS: There is small bilateral pleural effusions, left larger than right. The opacification at the left lung base is possibly pneumonia in correct clinical setting. Compared to the prior radiograph from ___, left lung base opacification and pleural effusion is increased. There is no pneumothorax. Cardiomediastinal and hilar silhouettes are normal size. Right-sided dialysis catheter terminates in the right atrium, unchanged in position. IMPRESSION: Mild left lower lobe opacification is increased compared to ___. This may represent progressive pneumonia in correct clinical setting. showed Mild left lower lobe opacification is increased compared to ___. This may represent progressive pneumonia in correct clinical setting. RENAL TRANSPLANT U.S. showed In the lower pole of the transplant kidney, likely in similar location to recent biopsy, vascular aliasing and turbulent flow with increased peak systolic velocity worrisome for AV fistula. Findings discussed with Dr. ___ on ___ at 7:35pm via telephone. Chest CT showed INTERVAL RESOLUTION OF THE CAVITATED LESION IN THE LEFT LOWER LOBE. INTERVAL INCREASE IN BILATERAL CURRENTLY MODERATE PLEURAL EFFUSIONS EVIDENCE OF ANEMIA. SMALL PERICARDIAL EFFUSION, UNCHANGED VENOUS DUP UPPER EXT BILATERAL CLINICAL HISTORY ___ year old man with h/o kidney transplant s/p acute rejection, on dialysis // vein mapping for AVF vein mapping for AVF FINDINGS: Duplex was performed of bilateral upper extremity veins and limited views of the brachial and radial arteries were obtained also. Right colon phasic flow is seen in the subclavian vein. The cephalic vein is patent throughout with diameters ranging from 1-3 mm in the forearm and 3 mm throughout the upper arm. The basilic vein is patent with diameters ranging from 2-3 mm in the forearm from 3-4 mm in the upper arm. The brachial and radial arteries are patent with triphasic waveforms no significant calcification and diameters of 5 and 2 mm respectively. Left colon phasic flow is seen in the subclavian vein. The cephalic vein is patent throughout with diameters from 1-2 mm in the forearm and 3 mm throughout the upper arm. The basilic vein is patent with diameters ranging from 1-2 mm in the forearm pain from 5-6 mm in the upper arm. The brachial radial arteries are patent with triphasic waveforms. No significant calcification and diameters of 5 mm and 2 mm respectively. IMPRESSION: Pain bilateral cephalic and basilic veins with diameters as noted. showed Pain bilateral cephalic and basilic veins with diameters as noted. The patient was diagnosed with NAUSEA WITH VOMITING, ABDOMINAL PAIN UNSPEC SITE, KIDNEY TRANSPLANT STATUS. The patient was treated with Kidney biopsy Bronchoscopy Plasmapheresis Tunnelled HD Line Placmeent. At the time of discharge, the patient had PRIMARY DIAGNOSIS 1. Acute Kidney Rejection 2. BK nephropathy and viremia SECONDARY DIAGNOSIS: 1. Alport 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>___ year old male, with a history of ESRD ___ Alport Syndrome, s/p LURT in ___ (from his wife), presenting with ___. Hospital course complicated by BK viremia, and biopsy proven acute humoral rejection. . >> ACTIVE ISSUES: # Acute Humoral Rejection: Patient initially presented with an increased creatinine, and there was question of rejection given outpatient testing which was significant for low titer of donor specific antibodies. Patient underwent a renal biopsy, and repeat donor specific antibody testing, which revealed a > test MFI. Further, BK testing done at that time also showed an increasing BK viremia in both the serum and urine. Biopsy results included a multitude of findings, including an acute on chronic humoral rejection, with multiple crescenteric glomeruli. Further, in the background of his acute rejection was BK positivity on biopsy (SV40) as well. After much discussion regarding treatment options, it was thought that patient should be placed on high dose immunosuppression with both tacrolimus and MMF. With increasing immunosuppression, patient started to have increased hemolysis as well and thought to be ___ to tacrolimus microangiopathy. Peripheral smears did show ___ schistocytes/HPF. Per acute rejection guidelines, patient was initially started on plasmapheresis to remove donor specific antibodies, and was replaced full FFP instead of half albumin because of risks of bleeding with renal biopsy. Patient also was started on high dose steroids at that time, and during plasmapheresis sessions patient started to develop a cough (reported below). Given concerns for aspergillus, and the risk for invasive disease with higher immunosuppression, patient underwent plasmapheresis and was transitioned to an IVIG load of 2 grams, with lower immunosuppression. Tacrolimus was also discontinued in the setting of increased TMA with severely elevated levels ___ to initiation of voriconazole. Patient started to undergo dialysis sessions ___ to increased volume, although urine output consistently stayed between 500-1L per day. Patient eventually was transitioned to permanent dialysis, with loss of his graft function, and was transitioned to a regimen including low dose prednisone and MM sodium. . #ESRD s/p LURT : As described above, patient was transitioned to dialysis during hospital stay after acute humoral rejection. Patient underwent transplant evaluation for AVF, with vein mapping bilaterally, and scheduled to undergo AVF after hospital discharge. Plans for patient include home hemodialysis set up as well in the future. Patient was discharged with negative Hepatitis Serologies, and pending quantiferon gold for dialysis placement. . # Pneumonia: As indicated above, patient started to develop a cough during his plasmapheresis sessions, and initial imaging showed a possible cavitary lesion. Patient was started on broad spectrum antibiotics, however given concerns for invasive aspergillus in the setting of higher dosed immunosuppression for acute rejection, confirmatory testing with bronchoscopy was performed. Patient's BAL did not show any evidence, and no serologic evidence of fungi either. Patient was originally started on amphotericin given interactions of voriconazole with immunosuppression, however this was discontinued as suspicion was low after testing. Patient was continued on Zosyn for 7 day course, with resolution of cough and CT imaging showed resolution of cavitary lesion. . # Hypertension: Patient was up-titrated to labetolol 200 mg TID for better control as started to have both elevated diastolic and systolic pressures. Patient tolerated dose adjustment well. . # Chest Pain: Patient was found to have acute chest pain, with respiratory difficulty after bronchoscopy. He described this pain as chest pressure, and since no DVT prophylaxis as risk of bleeding with renal biopsy, initial concerns for PE. ABGs at that time were significant for a resppiratory alkalosis (pH 7.8, CO2 15). Patient underwent V/Q scan which showed low likelihood, and LENIs which were negative for DVT. Patient also started to have resolution with anxyiolitic, thought to be more panic attack with pain ___ bronchoscopy. . # Gout: Patient was continued on allopurinol renal dose without flare. . # History of C. diff: Patient would be classified as severe C. diff in the past, and was finishing a course of PO vancomycin to prevent recurrence. His course was extended given antibiotics while inpatient and higher dose immunosuppression, and was continued until ___ per ID recommendations. Patient did not have diarrhea while inpatient and reported resolution of symptoms. . # Anemia: Patient was found to be anemic several times during hospital stay, requiring multiple transfusions. Anemia was thought to be ___ to TMA evidenced by hemolysis and peripheral smear findings. Further, patient's renal biopsy also demonstrated thrombi as well. Patient also encountered a dialyzer reaction, and therefore had an acute blood loss as well. Patient's renal biopsy site was ultrasounded given increased pain, but not significant for bleeding as well. Patient remained hemodynamically stable, and will require checks as an outpatient. . >> TRANSITIONAL ISSUES:# Dialysis: Set up ___. Plan for transition to home HD # TMA?: Concerns while inpatient for hemolysis, stable H/H. Continue to trend as outpatient. # C. diff: Patient completed course with PO Vanc, CTM for diarrhea. # CT Chest Imaging: Several bronchiolar nodules, f/u in 3 months for resultion and tracking to compare (___) # AVF: Patient to have AVF on ___ for planned hemo-dialysis. # HTN: Up-titrated Labetolol 200 TID. # Dialysis Placement: Quantiferon Gold pending upon discharge. # ? Dialysis Rxn: Possible Dialysis Rxn to optiflux 180, but not definitive. Please monitor.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M crossing a crosswalk in a motorized wheelchair when struck by a car, thrown 30ft. +LOC. Radiology showed Emphysema, subtle nodularity in the right upper lung better assessed on subsequent CT. No definite traumatic injuries. NOTIFICATION: Radiology showed 1. No evidence of a large hemorrhage or vascular territorial infarction, although the exam is somewhat limited by motion. 2. Stable bifrontal encephalomalacia, worse on the left than the right. Radiology showed Extremely limited by motion, but within the limitations, no evidence of fracture or malalignment. Radiology showed 1. Left flank subcutaneous hematoma with evidence of active extravasation. 2. Consolidation in the right upper lobe is new from ___ and has the appearance of a mass. Recommend evaluation with PET-CT to exclude a malignancy. 3. Stable pulmonary nodules in the left upper and left lower lobes. These also can be further evaluated on PET-CT. 4. Collapsed left renal cyst, likely subacute. 5. Severe bullous emphysema. 6. No solid organs injury. 7. No acute fracture. Results were communicated with the surgery resident, Dr. ___, at the time of the wet read was updated at 2:30 p.m. on ___ via telephone by Dr. ___. Radiology showed Minimally displaced fracture of the proximal left fibular shaft. Findings were communicated via phone call by Dr. ___ on ___ at 15:43 via phone call to ___, M.D. Radiology showed Unremarkable left elbow radiographs. Radiology showed Fracture of the proximal fibular shaft. Findings suggestive of bony demineralization. Radiology showed No evidence of fracture, acute alignment abnormality, or prevertebral soft tissue abnormality. Chest, AP portable single view. showed No acute new abnormalities on portable chest examination 24 hours followup. The patient was diagnosed with FX ANKLE NOS-CLOSED, OPEN WOUND OF FOREHEAD, MV COLL W PEDEST-PEDEST, POSTCONCUSSION SYNDROME, CHEST SWELLING/MASS/LUMP, CHRONIC AIRWAY OBSTRUCTION. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>He was monitored closely in the TSICU. He was alert and responsive. He had a L flank hematoma and his hct was monitored closely, it was stable. His diet was advanced but he had a possible aspiration event. His o2 sats remained stable, however, in the low ___. He was placed on metoprolol for his tachycardia. He was restarted on his home anti-seizure medications. He had a speech and swallow consult. Patient was transferred to the floor once stable. He remained on the floor and was doing well until the evening of ___ when he began to become agitated, stating "I've had enough," and warning that he would leave that night despite knowing that his primary team did not think it was wise. Pt was also aware that he was likely to be discharged to rehab the following day. The intern on call had multiple conversations with him totaling about 30 minutes explaining the risks of leaving against the team's advice in his condition (requiring 4L of oxygen d/t severe COPD and incomplete transition to rehab). As patient was ambulatory at this time, he proceeded to walk out of floor despite advice, after all lines were d/c'd. He was directed towards the lobby at this time and left hospital. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Time (and date) the patient was last known well: 22:00 on ___ (24h clock) SECOND OPINION CT NEURO PSO1 CT showed 1. Normal CTA head. No aneurysm. 2. Subarachnoid hemorrhage is not as well seen secondary to contrast. CHEST (PORTABLE AP) showed Hypoinflated lungs without acute cardiopulmonary process. PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD showed Decreased conspicuity of the pre-existing right sylvian fissure subarachnoid hemorrhage. No new hemorrhage. No evidence of large territorial infarct, though detection is somewhat limited on the noncontrast head CT. DX CHEST PORTABLE PICC LINE PLACEMENT showed Interval placement of a right PICC with the tip seen in the right atrium. Otherwise, stable appearance of the heart and lungs RECOMMENDATION(S): Recommend retraction by approximately 4-5 cm for optimal positioning. Cerebral angiogram to evaluate for vascular lesion patient was subarachnoid hemorrhage The following vessels were selectively catheterized and angiography was performed. Right common femoral artery Right common carotid artery Three-dimensional rotational angiography of the Left internal carotid artery circulation requiring post processing on an independent workstation and concurrent attending physician interpretation and review Right vertebral artery Left common carotid artery showed Extradural origin left posterior inferior cerebellar artery Negative cerebral angiogram for intracranial vascular lesion RECOMMENDATION(S): 1. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. Punctate, 1-2 mm areas of slow diffusion in the left cerebellum likely representing acute embolic strokes. 2. Focus of slow diffusion in the right frontal lobe in the periphery could be due to subarachnoid blood or acute infarcts. 3. Trace amount of right sylvian fissure subarachnoid hemorrhage. No new or enlarging hemorrhage. 4. 3.0 cm left parotid lesion, better seen on the neck CT from ___. Differential includes pleomorphic adenoma and Warthin's tumor. NOTIFICATION: The findings were discussed with ___. by ___ ___, M.D. on the telephone on ___ at 4:17 pm, 5 minutes after discovery of the findings. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed The tip of the enteric tube projects over the stomach. Unchanged cardiopulmonary findings. CHEST (PORTABLE AP) showed Support lines and tubes are unchanged. Cardiomediastinal silhouette is stable. Lungs are low volume with mild pulmonary vascular congestion. Surgical clips are seen in the left axilla. No pneumothorax is seen. Oropharyngeal swallowing videofluoroscopy showed 1. No evidence of aspiration. 2. Penetration with thin and nectar thick liquids. 3. Mild vallecular residue with solids. 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). CHEST (PORTABLE AP) showed ETT tip is 3.4 cm above the carina. Enteric tube tip is at least within the stomach. ET tube in standard placement. Borderline cardiac decompensation. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Acute subarachnoid hemorrhage right sylvian fissure. 2. Indeterminate 2.4 cm left parotid gland mass, ENT consult recommended. RECOMMENDATION(S): ENT consult, left parotid mass CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Re-demonstrated subarachnoid hemorrhage layering along the posterior right sylvian fissure, unchanged from prior head CT. No new bleed. 2. Re-demonstrated partially imaged indeterminate 2.4 cm left parotid gland mass. As reported on prior, ENT evaluation advised. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus, Weakness, Nontraumatic subarachnoid hemorrhage, unspecified, Urinary tract infection, site not specified, Altered mental status, unspecified. At the time of discharge, the patient had Subarachnoid hemorrhage 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>Ms. ___ is a ___ year-old woman with diabetes, HTN, and HLD who presented from ___ after she was found down with left sided weakness, aphasia, and forced left gaze followed by convulsions consistent with GTC. #Neuro: Subarrachnoid hemorrhage with GTC: At OSH stroke code called followed by telestroke. While on telestroke, observed to have GTC. She was given Ativan with resolution, loaded with fosphenytoin, and given IV labetalol for SBP >220. She was intubated and transferred to BI. Initial CT head showed no hemorrhage. Repeat head CT in ICU showed she had a right frontal subarachnoid hemorrhage in the right sylvian fissure. CTA negative for any large vessel occlusion. Conventional angio done with no vascular malformation found. MRI done with no evidence of metastatic disease given history of breast cancer. She was hooked up to EEG with no further epileptiform discharged. She was started on keppra 750mg BID for further seizure prevention. Etiology likely underlying CAA causing SAH which then led to seizure. She was transferred out of the ICU to the floor. Initially issues passing swallow study therefore requiring NG feeds for a few days. Video swallow was passed and diet was advanced. She continued to improve with ___ and OT on the floor and was deemed ready for DC to ___ rehab. #Uncontrolled Diabetes: While in the ICU she was put on an insulin drip given uncontrolled blood glucose. She was transitioned to standing glargine dose with Joseline Diabetes team following closely. Glargine dose with increased periodically given persistently elevated blood glucose. #HTN: Elevated BPs above 200 and nicardapine drip in ICU. BPs regulated and home losartan restarted at 50 then increased to 100. Coreg added for additional BP control. # UTI: found to have leukocytosis while in ICU. Started on CTX empirically. Found to have an E. coli UTI. Switched to nitrofurantoin and completed a 7 day course. # vaginal discharge: found to have significant vaginal discharge while in ICU. Started on 7 day course of miconazole nitrate vaginal cream.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ with a history of HTN, atrial fib/flutter s/p pacemaker, and multiple DVTs on lifelong coumadin who presents with right lower leg erythema, swelling, and pain that began earlier this evening. He was in his usual state of health until this subacute pain began, and he later described an intense cold feeling as well as trembling. This prompted an ED visit. . He immediately triggered on admission to the ED with a BP of 63/38, though he was otherwise afebrile with tachycarida to 100. His BP was checked several times in the left arm, yielding ___ on each of these assays. He states that he's had similar swelling and pain before, and that he had to do "shots in the belly." He maintained normal mentation throughout. Labs were notable for bandemia to 19%, lactate to 2.9, ___ to cr 1.6, and an INR of 3.6. Trauma ultrasound revealed no bleed. CTA chest revealed no massive PE, and no intraabdominal acute pathology. CVL was placed and he was resuscitated with 4LNS. Got one gram vancomycin. Placed on low dose norepinephrine with bolstering of pressure to mid-90s systolic prior to transfer. . Upon arrival to the MICU, his initial vitals were T:96.3 BP:99/43 P:78 R:22 O2: 99RA. He is currently in no pain and has no complaints. He claims to have been asymptomatic during his hypotension, though his wife found him to be more confused than usual. With regard to his RLE erythema, he denies previous episodes of cellulitis. He has baseline edema without erythema or pain bilaterally. He also mentioned urinary frequency over the preceding ___ days without dysuria or hematuria. Radiology showed 1. Suboptimal contrast bolus with mixing artifact limits evaluation for PE. Within this limitation, there is no evidence of central pulmonary embolism. 2. No acute aortic injury. 3. Approximate 9.3 cm x 3.2 cm x 7.5 cm anterior mediastinal cystic lesion without enhancement and with fluid density and extending to the base of the heart. This is most consistent with a pericardial cyst. 4. Right adrenal lesion, previously characterized as myelolipoma or adenoma, is unchanged since ___. 5. Uncinate process small cystic lesions as above, unchanged since prior examination, likely represents a small focus of side branch IPMN. 6. Persistent cholelithiasis. 7. Unchanged fat-containing left inguinal hernia. 8. Unchanged enlarged prostate. 9. Small hiatal hernia. Findings discussed with Dr. ___ at 1:53 am on ___ via telephone. Radiology showed AP chest reviewed in the absence of recent prior chest radiographs: Right internal jugular line tip projects over the mid SVC. No pneumothorax, mediastinal widening or pleural effusion. Lungs grossly clear. Heart size normal. Transvenous right atrial and right ventricular pacer leads in standard placement. Radiology showed 1. Bilateral pleural effusions. 2. No evidence of pulmonary edema. No focal consolidations. Radiology showed No right lower extremity DVT. The patient was diagnosed with HYPOTENSION NOS, ATRIAL FLUTTER, CELLULITIS OF LEG. The patient was treated with R IJ central line placement. At the time of discharge, the patient had Primary: Septic shock due to cellulitis and urinary tract infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Assessment and Plan: Mr. ___ is a ___ with afib/flutter, and ?previous DVTs who presents with RLL pain/erythema and who was found to be profoundly hypotensive with bandemia and ___. # SEPTIC SHOCK: Felt to be due to cellulitis and possible UTI. Received ~ 8 liters NS for fluid resuscitation and was on norepinephrine briefly. Started on vanc/cefepime for cellulitis and presumed UTI. Urine culture was negative, but tx for seved days with Ciprofloxacin as culture was obtained after antibiotic administration. He remained in intensive care unit overnight only. # Cellulitis. Initially well responded to vancomycin, however given negatie nasal swab and no evicence of abcess, was changed to ___ was negative. Slow but steady improvement in erytheme and induration was made and he was transition to PO Keflext on ___. He was diuresed with lasix for lower extremity edema and was discharged on a week's course of lasix. ACE bandages are to be applied on daily basis at time of discharge. # ACUTE KIDNEY INJURY: due to hypoperfusion. Improved to 1.2 (baseline 1.1 with IVF). Lisinopril was held at discharge until patient completes course of lasix at which point it can be reinstituted. HCTZ was likewise held at discharge. # ATRIAL ARRHYTHMIA: has both atrial flutter and fibrillation patterns in previous EKGs/telemetry. According to cards notes, spends about 35% time in atrial arrhythmia. During his ICU stay, he remained often in atrial fibrillation although occasionally was atrial paced or venticular paced. As patient was diuresed his rate normalized and he remained in SR vast majority of the time.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with atrial fibrillation on apixaban, CML in remission, DMII, CVA with left hemianopia, HTN, PVD s/p bilateral lower extremity interventions, and history of C diff who presents with generalized malaise, weakness, and poor PO intake. CHEST (PA AND LAT) showed Small bilateral pleural effusions. No other acute cardiopulmonary process CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormalities. 2. Unchanged appearance of right temporo-parieto-occipital encephalomalacia with ex vacuo dilatation of the right lateral ventricle. CT ABD AND PELVIS WITH CONTRAST showed 1. Persistent nonspecific mild wall thickening of the ascending colon. The remainder of the colon is unremarkable. 2. Findings of volume overload, with new bilateral small pleural effusions, diffuse retroperitoneal edema which has slightly worsened, and anasarca of the body wall. 3. Reflux of contrast into the IVC and hepatic veins suggests right-sided heart failure. Cardiomegaly. 4. Sigmoid diverticulosis without evidence of acute diverticulitis. CHEST (PORTABLE AP) showed No evidence of pulmonary edema. Small bilateral pleural effusions. Enlargement of the cardiac silhouette, unchanged ABDOMEN US (COMPLETE STUDY) showed 1. Cholelithiasis without evidence of cholecystitis. No biliary dilation. 2. Patent portal vein. 3. Bilateral small pleural effusions and trace ascites. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, there is an placement of right IJ catheter. The precise position of the tip is difficult to demonstrate, though it appears to be in the lower SVC. No evidence of post procedure pneumothorax. The continued substantial enlargement of the cardiac silhouette with some elevation of pulmonary venous pressure and left pleural effusion with volume loss in the left lower lobe. No evidence of acute focal pneumonia. CHEST PORT. LINE PLACEMENT showed 1. Left internal jugular dialysis catheter terminates in the upper right atrium near the cavoatrial junction. No pneumothorax. 2. Improved pulmonary edema. Stable small left greater than right pleural effusions and moderate cardiomegaly. NOTIFICATION: The findings were discussed with the clinical team, M.D. by ___, M.D. on the telephone on ___ at 12:31 am, 2 minutes after discovery of the findings. The patient was diagnosed with Adult failure to thrive. The patient was treated with R IJ CVL ___, swapped for PA line ___ L IJ HD line ___. At the time of discharge, the patient had Primary Diagnosis: HFrEF exacerbation Secondary Diagnoses: Acute renal failure Atrial fibrillation with rapid ventricular response. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ year old female with atrial fibrillation on apixaban s/p multiple DCCVs and recent PPM placement, CML in remission, DMII, CVA with left hemianopia, HTN, PVD s/p bilateral lower extremity interventions, and history of C diff who presents with diarrhea, generalized malaise, weakness, and poor PO intake and was found to have heart failure exacerbation and uncontrolled afib. She was treated in CCU for cardiogenic shock and renal failure with improvement in cardiac function and hemodynamics. She will be discharged to rehab for treatment of deconditioning. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ Hx of IVDU and migraines, who had presented ___ w/ serratia bacteremia and aortic valve vegetations causing severe AR, s/p Aortic Valve replacement (___) and discitis/osteomyelitis on MRI (___), currently on 8xwk course of Meropenem/Gent (through ___, re-presenting today w/ L pleuritic chest pain, found to have PE on chest CTA (w/ negative ___. Radiology showed 1. Probable acute subsegmental pulmonary embolus within the right basilar branch, noting motion artifact, but fairly convincing morphology. 2. Patient is status post aortic root repair with no evidence of dissection on this non-gated examination. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change. Left subclavian PICC line extends to the upper portion of the SVC. No evidence of acute cardiopulmonary disease. VENOUS DUP UPPER EXT UNILATERAL showed No evidence of deep vein thrombosis in the left upper extremity. PICC in place via left basilic vein. The patient was diagnosed with PULM EMBOLISM/INFARCT. At the time of discharge, the patient had PRIMARY: -Acute subsegmental pulmonary embolism SECONDARY: -Spinal discitis / osteomyelitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ Hx of IVDU who presented in ___ w/ serratia bacteremia and aortic valve vegetations causing severe AR, s/p Aortic Valve replacement (___) and discitis/osteomyelitis on MRI (___), on 8wk course of Meropenem/Gent (through ___, who re-presented on ___ w/ L pleuritic chest pain, found to have small right subsegmental PE.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M s/p elective lap ccy (___) on ___ presents with abdominal pain since ___. Vomited X 1 ___ (no hematemesis). No bowel movements since yesterday but is passing gas.No fevers. Per the op report, his cholecystectomy was uneventful aside from some minor bleeding from the liver bed and a large cystic duct that was taken with an Endo ___ stapling device. Post operatively he did well and was discharged the following day. Pathology showing chronic cholecystitis and cholelithiasis, mixed type with embedded calculus fragments. Radiology showed 1. Post-cholecystectomy. No free fluid detected. The CBD could not be visualized. 2. Echogenic liver, compatible with steatosis. More advanced disease such as fibrosis and cirrhosis cannot be excluded. 3. 2.9 cm mass appears to be adrenal, and may reflect an adenoma or myelolipoma, incompletely imagedon the ___ chest CT examination. This lesion could also be hepatic. Further assessment of this mass and of the CBD can be performed with MRCP or CT. The patient was diagnosed with ACUTE PANCREATITIS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. The patient was treated with ___: ERCP. At the time of discharge, the patient had Choledocholithiasis, gallstone pancreatitis.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the hospital for ERCP after having acute pancreatitis episode related to choledocholithiasis. He underwent ERCP and had stone and sludge extracted from the CBD. After ERCP his labs trended down appropriately and his pain was much improved. He was started on a diet the day after the ERCP and was discharged after tolerating this. At time of discharge he was voiding, had no abdominal pain, and was voiding.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENTING ILLNESS This patient is a ___ year old male s/p fall from ladder down approx 2 flights of stairs just prior to arrival. He complains of head strike w/ LOC. He has a headache but denies any other complaints. TRAUMA #3 (PORT CHEST ONLY) showed No previous images. The cardiac silhouette is within upper limits of normal in size and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. No evidence of fracture or pneumothorax. CT HEAD W/O CONTRAST showed -No acute intracranial hemorrhage or fracture identified. CT C-SPINE W/O CONTRAST showed No cervical spinal fracture or traumatic malalignment. Radiology showed Moderate compression fracture of the L5 vertebral body, burst component difficult to entirely exclude radiographically. CT CHEST/ABD/PELVIS W/ CONTRAST showed Compression fractures of the L3 and L5 vertebral bodies with no significant loss of height of the L3 vertebral body and with mild to moderate loss of height of the L5 vertebral body. No retropulsion seen. No evidence of acute visceral or vascular injury in the chest, abdomen, or pelvis. LUMBO-SACRAL SPINE (AP AND LAT) showed Stable short term appearance of the L5 fracture. The patient was diagnosed with Unsp intracranial injury w LOC of unsp duration, init, Oth fracture of fifth lumbar vertebra, init for clos fx, Fall on and from ladder, initial encounter. At the time of discharge, the patient had Compression fracture of L5 and L3 vertebrae. The patient was given written instructions concerning 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, Mr. ___ was admitted to ___ after falling from the ___ step of a ladder. He was found to have L3 and L5 vertebral compression fractures on imaging, was evaluated by the orthopaedic spine team, and had serial lumbar spine films which showed stable fractures on imaging. He was initially placed on bedrest, his activity was advanced after his spinal injuries were cleared by the spine team. He was tolerating a regular diet, and he had a stable pain control regimen on oral medication. He was discharged in good condition after being cleared by both ___ and OT with follow-up scheduled in the outpatient spine clinic.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with MGUS and prior uterine cancer presenting with dyspnea. She was seen at ___ urgent care for evaluation of acute onset of cough and shortness of breath for 4 days. She was noted in clinic to be tachypneic with RR 36. She had wheezing which did not improve with albuterol inhaler. On exam in urgent care, she was tachypneic with a respiratory rate of 36. O2 sat of 95 and dropped to 93% when walking to the elevator. Peak flow was 270. She also has had decreased appetite. She had some sore throat, just after coughing, but has no nasal symptoms, rhinorrhea or congestion. No earache. She feels weak. No GI or urinary symptoms. She did not receive flu vaccine. She has no known history of smoking or asthma. In the ED, initial vitals were: 100.9 99 146/71 28 94% RA - Exam notable for diffuse wheezing, decreased air entry bilaterally. - Labs notable for: Cr 1.1 CBC unremarkable Trop <0.01 FluA positive Lactate 2.2->1.7 VBG with pH 7.33, pCO2 48, HCO3 26 - Imaging was notable for: CXR with no evidence of pneumonia. CTA showed multiple bilateral segmental/subsegmental PEs. - Patient was given: ___ 18:46 IH Albuterol 0.083% Neb Soln 1 NEB ___ 18:46 IH Ipratropium Bromide Neb 1 NEB ___ 18:46 PO Azithromycin 500 mg ___ 18:46 PO PredniSONE 40 mg ___ 19:45 IH Albuterol 0.083% Neb Soln 1 NEB ___ 19:45 IH Ipratropium Bromide Neb 1 NEB ___ 19:45 IVF NS ___ 19:45 PO/NG OSELTAMivir 75 mg Vitals prior to transfer: 99.8 79 161/50 22 96% RA Upon arrival to the floor, patient reports bilateral ankle / calf pain at baseline, which she attributes to gout (she stopped her gout medications per her own preference, says she leaves this untreated). Currently left calf hurts more than right calf). Of note she has not had recent plane travel, and has not been on hormone-containing medications. Never smoker. She does lead a sedentary lifestyle and spends long periods of time sitting during the day. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI CHEST (PA AND LAT) showed 1. Widening of the upper mediastinum likely represents prominent upper mediastinal fat/prominence of the great vessels though thyromegaly is possible given the patient's documented history of goiter seen on thyroid scan ___. Possibility of lymphadenopathy or mediastinal mass cannot definitely be ruled out. 2. No evidence of pneumonia. CTA CHEST WITH CONTRAST showed 1. Multiple bilateral segmental and subsegmental pulmonary emboli without evidence of right heart strain. 2. Enlarged multinodular thyroid gland with substernal extension. Recommend thyroid ultrasound for further evaluation if not previously evaluated. 3. Multiple sub 6 mm pulmonary nodules within the lungs. Per ___ criteria guidelines, if patient is at low risk for lung malignancy no follow-up is recommended. If patient is at high risk for lung malignancy, optional CT in 12 months can be obtained. 4. Mild diffuse airway wall thickening suggests chronic airways disease. RECOMMENDATION(S): 1. Enlarged multinodular thyroid gland with substernal extension. Recommend thyroid ultrasound for further evaluation if not previously evaluated. 2. Multiple sub 6 mm pulmonary nodules within the lungs. Per ___ criteria guidelines, if patient is at low risk for lung malignancy no follow-up is recommended. If patient is at high risk for lung malignancy, optional CT in 12 months can be obtained. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:15 pm, 5 minutes after discovery of the findings. Radiology showed 1. No evidence of local recurrence or metastatic disease. No evidence of intra-abdominal or intrapelvic primary malignancy. 2. No acute intra-abdominal or intrapelvic process. 3. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. CT CHEST W/CONTRAST showed -Less than 3 mm multiple pulmonary nodules in the setting of known malignancy. Follow-up in 3 months is recommended to establish stability. -Left lower lobe ground-glass opacities, suggestive aspiration. Attention on follow-up for interval resolution is recommended. -No significant interval change in pulmonary embolism, better seen on the prior study. No new clot burden. -Multiple multinodular, enlarged thyroid, previously evaluated with thyroid uptake nuclear medicine study in ___. RECOMMENDATION(S): Less than 3 mm multiple pulmonary nodules in the setting of known malignancy. Follow-up in 3 months is recommended to establish stability. THYROID U.S. showed Confluent multinodular goiter. All of the nodules have an appearance similar to each another, and none have overtly suspicious architecture. This patient has had a known multinodular goiter for at least 10 or more years having had a radionuclide thyroid scan in ___. RECOMMENDATION(S): Given the long history and similar appearance of all of the multiple thyroid nodules, there are no specific indications for biopsy at this time. If prior US studies are available we would be happy to make a comparison. Otherwise follow-up imaging in ___ year is recommended. The patient was diagnosed with Flu due to ident novel influenza A virus w oth resp manifest. At the time of discharge, the patient had Primary Diagnosis ================= Asthma exacerbation secondary to influenza A Pulmonary embolus Secondary Diagnoses =================== Monoclonal gammopathy of undetermined significance Multi-nodular thyroid Gastroesophageal reflux disease Peripheral vascular disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with MGUS and Stage 1a uterine cancer s/p hysterectomy who presented to the ED with dypnsea and tachypnea. She was found to have influenza A and multiple segmental/subsegmental pulmonary emboli. She was treated for an asthma/COPD exacerbation with prednisone and azithromycin. She was treated for influenza A with apixaban 10mg BID. She will be transitioned to abixipan 5mg BID after the 1 week loading dose. Given concern for malignancy causing pulmonary embolus with patient's prior history of malignancy she underwent CT torso without evidence of malignancy. Also had repeat FLC that showed slightly increased levels compared with ___ with increased Fr-K/L ratio. She will have follow up with oncology as an outpatient, but no active signs of malignancy. # Asthma exacerbation ___ Influenza A: Patient with influenza A which has likely triggered asthma exacerbation with diffuse wheezing. Also found to have pulmonary embolism on CTA. She was treated with oseltamivir, azithromycin and prednisone, each for a 5 day course. She was also treated with duonebs and albuterol. She should continue nebulizer treatments as an outpatient. - oseltamivir for 5 days [___] - azithromycin for 5 days [___] - prednisone 40mg daily [___] - duonebs PRN - albuterol PRN # Pulmonary emboli: Noted on CTA to have multiple segmental and subsegmental emboli. History of MGUS and uterine cancer, but denies prior thrombosis, family history of blood clots, personal history of spontaneous abortions, or recent travel. Admits to sedentary lifestyle. CT torso without evidence of active malignancy. SPEP with elevated serum FLC compared to prior with elevated Fr K/L ratio. Appears trending towards smouldering myeloma. A skeletal survey was deferred given absence of bone pain. She will be continued on apixaban 10mg BID for 7 day loading dose to end on ___, followed by apixaban 5mg daily. # MGUS: Patient with M-spike on SPEP from ___ with free kappa 37.6 and free lambda 29.7, increased from ___. Concern for progression given bilateral segmental/subsegmental pulmonary embolism. Will have follow up with oncology as an outpatient. FreeKap ___ FreeLam ___ Fr-K/L: 1.69 IgG 1059 IgA 429 IgM 33 # Multi-nodular thyroid: CTA showed enlarged heterogeneous thyroid gland containing calcification and extending to the upper mediastinum. Had prior u/s in ___ that was unchanged along with iodine uptake scan in ___ that was not concerning for cancer. Thyroid ultrasound during this admission without suspicious imaging with recommendation for f/u in ___ year. # GERD Continued on omeprazole # PVD Continued on aspirin Transitional Issues ==================== [] Started on apixiban for treatment of pulmonary embolism. Will continue on 10mg BID for 7 day load to end on ___ followed by 5mg BID. She should be treated indefinitely given unprovoked PE. [] C/w azithromycin, prednisone, oseltamivir for 5 day course to end on ___ [] Patient will follow with her oncologist regarding progression of MGUS with increasingly elevated Fr-K/L ratio. [] Repeat thyroid ultrasound in ___ year to assess for stability [] Follow-up CT chest in 3 months is recommended to establish stability given less than 3 mm multiple pulmonary nodules in the setting of known malignancy. [] Patient had significant hypertension in house and was discharged on lisinopril 10mg daily Greater than 30 minutes were spent on this patient's discharge day management.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Male with isolated plasmacytoma and spinal stenosis who presents with increasing back pain over several weeks and an acute delirium the morning of admission. The patient has had long-standing lumbar stenosis with chronic back pain for the past ___ years. He has also had a T12/L5 kyphoplasty approximately 2.5 months prior to admission. During this admission operation a lytic bone lesion at L3 was biopsied and found to be multiple myeloma. He had an x-ray of the lumbar spine which was reportedly negative for lytic lesions for lytic lesions in the ___ ED prior to transfer. Per his daughter, he is receiving XRT for his plasmacytoma and has completed 7 treatments. The morning of admission his daughter was called by the nursing home where he lives and was told he was acting somewhat withdrawn, and appeared groggy and which was an acute change from his baseline mental status. Per the daughter little workup was done at ___ in the ED and she believed that his pain was not being well controlled, so she requested tranfer to ___. Failure to thrive, weakness. No prior studies available for comparison. PA and lateral upright chest radiographs were reviewed. The patient is after median sternotomy, reason unclear since no evidence of CABG is definitely seen. Mediastinum is shifted to the left. Cardiac silhouette is difficult to assess due to obscuration of the left heart border by pleural effusion, partially layering and most likely partially loculated, moderate. There is left lower lobe opacity, most likely reflecting atelectasis, unclear if secondary to the effusion or due to other reasons. The right lung is essentially clear except for minimal atelectasis. Left upper lung is clear as well. No pneumothorax is seen. No evidence of pulmonary edema is present. Vertebroplasty of the lower thoracic vertebral body, most likely T11 is noted. Comparison with prior study is recommended. Otherwise, assessment of the patient with CT chest preferably with contrast for precise determination of left lower lobe and pleural effusion appearance might be considered. Findings submitted to Radiology Dashboard for communication of critical results by dr ___ on ___ at 1:50 pm was done. Radiology showed 1. Diffuse infiltration of the bone marrow of the lumbar spine, sacrum, and coccyx, likely by the known myeloma. Discrete expansile mass in the L3 spinous process involves the adjacent posterior paravertebral muscles and the overlying fascia, but does not extend into the spinal canal. No evidence of epidural or foraminal masses. 2. Superior endplate deformities at T12, L1, L2, and L5, without evidence of edema to suggest acute fractures. No retropulsion. 3. Abnormal signal in the presacral and pre-coccygeal space. An infiltrative soft tissue process cannot be excluded. Suggest further evaluation by contrast-enhanced CT or MRI of the pelvis. 4. Multilevel lumbar degenerative disease. Moderate-to-severe spinal canal stenosis at L4-5 with compression of the traversing L5 nerve roots. Narrowing of the subarticular recesses at L3-4, with abutment of the traversing L4 nerve roots. 5. Partially imaged cystic lesions in the kidneys. Recommend sonography for further evaluation. Radiology showed 1. No definite lytic lesions identified. Lucencies are seen within humeri, likely due to bone mineralization. If further evaluation is needed for a specific region, recommend further evaluation with MRI which is more sensitive to detect myelomatous lesions. 2. Cholelithiasis. Radiology showed 1. No evidence of hemorrhage or infarction. 2. Small vessel ischemic disease and age-related involution. Mental status changes in a patient with history of multiple myeloma and new loculated pleural effusion on chest radiograph. COMPARISON: Chest radiograph from ___. TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to upper abdomen with subsequent 1.25- and 5-mm collimation. Axial images reviewed in conjunction with coronal and sagittal reformats. FINDINGS: Several mediastinal lymph nodes ranging up to 7 mm in the right lower paratracheal area, 6 mm in the prevascular area with no pathologically enlarged mediastinal, hilar or axillary lymph nodes seen. The aorta is normal in diameter. Main pulmonary artery is normal, 3.2 cm but the right pulmonary artery and left pulmonary arteries are enlarged up to 3.1 and 3 cm respectively that might reflect pulmonary hypertension. Extensive coronary calcifications are present. Heart size is normal. The patient is after mitral valvuloplasty. Calcifications within the papillary muscles might reflect prior infarction. There is no pericardial effusion. The imaged portion of the upper abdomen reveals calcified gallstones and pancreatic atrophy and otherwise is unremarkable. Airways are patent to the subsegmental level bilaterally. Partially loculated left pleural effusion is demonstrated, small to moderate. Consolidation in the left lower lobe with subsequent volume loss, most likely reflects rounded atelectasis given the appearance of the vessels and airways. Internal calcifications are also noted in this loculation. The assessment of lung parenchyma is somewhat limited due to motion artifact. Loculated pleural effusion on the right along the major fissure is demonstrated, 4:89, approximately 5 x 2 cm. At the right lung base, several ground-glass and solid nodules are noted, might potentially reflect infectious process such as right lower lobe pneumonia. No definitive evidence of pneumonia is seen on the left. Within the limitations of this non-contrast study, no pleural masses are noted. The patient is after T12 vertebroplasty. Some irregularity within the bones might be consistent with known history of myeloma. Left upper lobe posterior segment atelectasis is most likely related to pleural effusion and unlikely to represent infectious process. IMPRESSION: 1. Small to moderate loculated left pleural effusion, chronicity unknown, most likely chronic given the presence of relatively large left lower lobe rounded atelectasis and left upper lobe posterior segment atelectasis. Small loculated right pleural effusion along the fissure. 2. Suspected right lower lobe developing / resolving infectious process, assessment is limited due to motion artifacts. 3. Extensive coronary artery disease. 4. Status post mitral valvuloplasty. 5. Dilated pulmonary arteries that might reflect pulmonary hypertension. Correlation with echocardiography is suggested if clinically warranted. showed 1. Small to moderate loculated left pleural effusion, chronicity unknown, most likely chronic given the presence of relatively large left lower lobe rounded atelectasis and left upper lobe posterior segment atelectasis. Small loculated right pleural effusion along the fissure. 2. Suspected right lower lobe developing / resolving infectious process, assessment is limited due to motion artifacts. 3. Extensive coronary artery disease. 4. Status post mitral valvuloplasty. 5. Dilated pulmonary arteries that might reflect pulmonary hypertension. Correlation with echocardiography is suggested if clinically warranted. Radiology showed 1. Interval placement of a left-sided PICC line with the tip terminating in the proximity of the cavoatrial junction. 2. A new rounded opacity is seen projecting over the mid right lung possibly representing a foreign object. The patient was diagnosed with OTHER CHRONIC PAIN , LUMBAGO, ALTERED MENTAL STATUS , MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION. The patient was treated with ___ line placement. At the time of discharge, the patient had Primary: Pneumonia, Multiple Myeloma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/PMHx multiple myeloma, arthritis, and spinal stenosis presenting with complaints of poorly controlled back pain, acute changes in mental status and failure to thrive, now with chest CT showing consolidation vs. atelectasis on left, with possible evolving right infectious process on right. ACTIVE ISSUES 1 Goals of care: After extensive discussion with the patient's son ___ and daughter (and HCP) ___, the decision was made to transition to comfort measures only. Antibiotics were discontinued and medication list was reviewed with unnecessary medications removed (Simvastatin, vitamin D). The patient was discharged to skilled nursing with inpatient hospice care. Goals of care are comfort measures only, DNR/DNI, do not hospitalize unless symptoms are not controlled with hospice care. 2. Healthcare Associated Pneumonia: Left pleural effusion discovered on chest x-ray early in admission. After review of patient's outside CT scans, no effusion was present in CT of ___, only an area of rounded atelectasis on the right. With these findings, chest CT was performed and possible infectious process was found on the right, with large areas of consolidation vs. atelectasis on the left. It was thought that these areas could likely represent pneumonia in the setting of this patient who had been persistently delirious and has a history of stay in a ___ care facility for the last several months, who is likely to have aspirated, and likely does not mount a large immune response. He was started on treatment for presumed HCAP with vancomycin, cefepime, and metronidazole to be continued for an 8 day course starting ___. After goals of care discussion, antibiotics were discontinued ___. PICC line was removed prior to discharge. 3. Altered mental status: Per the patient's family, he had experienced a decline in mental status after his kyphoplasty several months ago with a possible history of stroke, however, his mental status had become acutely worse over the week prior to admission. CT of the head revealed no acute process, but did show evidence of chronic ischemic changes. Narcotics were minimized with the thought that these were contributing to his delirium. The patient was found to be hypercalcemic to 10.7 and this was thought to be a possible cause of AMS. Oncology was consulted and noted that this level of hypercalcemia was not dramatic enough to cause AMS of the degree seen in this patient. Other oncologic causes, including hyperviscosity and uremia were also ruled out. Per oncology, there was no clear indication that myeloma could be causing this AMS. Medication effect from over sedation with oxycodone was thought to be a large part of the etiology for delirium and the patient was treated conservatively for pain, limiting narcotics. 3. Mutiple myeloma: The patient and family history on this topic were vague; the outside oncologist Dr. ___ was called to clarify. Per Dr. ___ patient was discovered to have an isolated plasmacytoma at L3 in ___, which he was treating with palliative radiation, with the possibility of definitive treatment as this was thought to be his only lesion, and he was thought to be free of systemic disease based on an unremarkable skeletal survey. The patient had never received chemotherapy for myeloma, nor had he had bone marrow biopsy. IgG on ___ was 2500 with elevated kappa spike 27.2. However, on lumbar MRI performed to evaluate back pain on this admission, systemic disease was suggested by infiltration of the spine consistent with extensive myeloma. Oncology was consulted who noted that there was no urgent indication to treat the patient for myeloma at this time and that myeloma was not likely to be a contributing factor to his AMS. Repeat IgG was 2665 and Beta 2 microglobulin was elevated at 3.4. Skeletal survey showed no definite lytic lesions. At the time of discharge, UPEP, serum viscosity, and Free kappa and lambda light chains were still pending and should be followed by the outpatient oncologist depending on goals of care. 4.Back pain: The patient has a longstanding history of back pain as well as surgery on the spine with most recently being kyphoplasty in ___. However, this pain seemed worse. Lumbar MRI was performed which did not reveal any obvious cause for his pain but did show an ill-defined region of abnormal density in the pre-coccygeal/pre-sacral area. The spine service was consulted who reviewed the MRI with the neuroradiologist and found no involvement of the spine by the presacral tissue abnormality. The chronic pain service was also consulted. For pain, the patient received: tylenol ___ tid, gabapentin 300mg TID, oxycodone 5mg q6hours PRn, as well as morphine ___ IV prn q8hrs for breakthrough pain. Narcotics were minimized due to contribution to delirium. His neuropathic pain with sciatica-like features improved. However, the patient had difficulty communicating his overall pain effectively due to delirium and consistently rated his pain low on a severity scale. 5. Aspiration: Nursing raised concern for aspiration. Speech and swallow study was performed with recommendations for nectar-thick liquids and ground solids. CHRONIC ISSUES 1. Glaucoma-stable on brimonidine and dorzolamide. 2. ___ esophagus-stable on omeprazole. TRANSITIONAL ISSUES UPEP, serum viscosity, and free kappa/lambda light chains are still pending at discharge and should be followed up by the outpatient PCP and oncologist CODE STATUS DNR/DNI, Comfort measures only. Do not hospitalize.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with history of hypertension, hyperlipidemia, atrial fibrillation on apixaban, type 2 diabetes c/b neuropathy with diabetic foot ulcers, chronic diastolic CHF, and CKD Stage III who was brought to the ED by her niece for cough and reduced PO intake. CHEST (PA AND LAT) showed No definite radiographic evidence of pneumonia. Stable mild cardiomegaly. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial hemorrhage or large territory infarction. 2. Air-fluid level in the left sphenoid sinus may be due to prolonged supine positioning, although acute sinusitis cannot be excluded. 3. Stable chronic microvascular ischemic disease. The patient was diagnosed with Flu due to unidentified influenza virus w oth resp manifest. At the time of discharge, the patient had Primary Diagnoses ============== Acute influenza A infection Hypoxemia Hypernatremia Altered mental status. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is a ___ with history of atrial fibrillation on apixaban, type 2 diabetes c/b neuropathy with diabetic foot ulcers, chronic diastolic CHF, and CKD Stage III who presented with fever and hypoxia, found to have acute influenza A infection, course complicated by altered mental status (most likely toxic metabolic encephalopathy), hypernatremia, and recurrent fevers/persistent hypoxia with supplemental oxygen requirement. Now completed Tamiflu and on room air. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo man with esophageal cancer on chemo and s/p XRT with plans for esophagectomy at some point who presenting with chest pain and dysphagia found to have radiation esophagitis, s/p J-Tube placement who was just discharged yesterday ___ where his prior course was complicated by HA-PNA s/p completed course of ABx and complicated by intractable nausea and vomiting and intolerance to tube feeds who was discharged to rehab facility for ongoing care and ___ and readmitted for recurrent abdominal pain, nausea, vomiting and an isolated fever. ___ reports that he was feeling fine yesterday when he was discharged and when he arrived to the rehab immediately "it was was a horrible place". He reports that the "woman just sat there on her phone not caring at all" and that when he started having pain and nausea again "it was 5 or 6 hours before someone came" and that "they didn't have the medications to give me", he became frustrated angry and decided "Im getting out of this place." He reports then his pain became worse, he started having vomiting and then the pain became so severe that "I was hot all over", per report he had a fever to 101 so was sent back to ___ ED for evaluation. Chest: Frontal and lateral views showed Linear opacity at the left lung base likely represents atelectasis or sequela of infection seen in ___. No new focal consolidation. CT abdomen and pelvis with contrast showed No acute process in the abdomen or pelvis. Radiology showed Successful exchange of clotted J tube with 12 ___ ___ tube. The tube is ready for use. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had Active: - Radiation esophagitis - Esophageal cancer s/p XRT - Nausea with Vomiting - GERD - Moderate 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>___ yo man with esophageal cancer on chemo and s/p XRT with plans for esophagectomy at some point who was just discharged from my service yesterday ___ after a 5 week hospitalization where he was managed for radiation esophagitis, s/p J-Tube placement, HA-PNA s/p completed course of ABx and intractable nausea and vomiting with intolerance to tube feeds who was readmitted from nursing facility <12 hours from discharge with recurrent symptoms and isolated fever. # Fever # Abdominal pain One isolated fever to 101 without new or focal symptoms. Seems that the fever was an adrenergic response to severe abdominal pain and nausea while at ___. During his course he had no focal findings on exam and no localizing symptoms other than chronic issues and with stable labs without leukocytosis. CT A/P, CXR, UA, Flu swab and Cdiff PCR all negative. BCx and stool Cx NGTD. He remained hemodynamically stable without signs of sepsis throughout his course without need for antibiotics. # Radiation Esophagitis # Stage III-IV esophageal cancer on chemo s/p XRT # Moderate Malnutrition: No PO intake, albumin 3.0 during prior admission, peripheral muscle wasting on exam. # Nausea with vomiting Overall he appeared stable, pain and nausea controlled and at baseline from prior to last discharge. As per prior work up and documentation from last admission, radiation esophagitis was confirmed on biopsy EGD ___. His last admission pain was very difficult to control following J tube placement and he required high dose IV Morphine which was changed to PO solution AND SC morphine. Prior to discharge he was only requiring oral morphine solution. Recurrent severe pain at ___ was likely related to missing several doses of morphine and being underdosed from what he was receiving at ___. Furthermore, nausea and vomiting were best controlled at ___ when zofran and compazine were staggered Q4 Hr. While at ___ seems he did not receive any antiemetics, this likely accounted for worsening symptoms rather than new acute pathology. During his admission he had no evidence of worsening diarrhea, fevers, chills or leukocytosis to support infectious etiology. No abdominal tenderness on exam and normoactive bowel sounds, CT A/P negative and passing flatus, SBO highly unlikely. Cdiff and stool cultures all negative. Continued continuous tube feeds at 70ml/hr as per prior hospitalization, restarted Ondansetron Q8H and Compazine Q8H standing and stagger within 4 hours of each other. EKG monitored and QT remained around 425. Continued Fentanyl 25 mcg/patch for basal pain control, Omeprazole, liquid acetaminophen, sucralfate slurry, lidocaine patch as during prior admission. Continued also Maalox/diphenhydramine/lidocaine/levsin. Continued 10 mg oral morphine solution q2hrs initially as recommended by palliative care which was tapered to Q3HRS:PRN in conjunction with palliative care recs. On discharge the plan was to continue weaning to Q4HRs:PRN, this was communicated to outpatient providers by palliative care. # Hyponatremia Mild and consistent with prior values during last admit. Likely hypovolemic from vomiting, resolved with IVFs. # Anemia: # Leukpenia Stable on admission from prior to discharge, downtrended in setting of IVFs but remained stable therafter. Likely related to chemotherapy, radiation and chronic disease, not neutropenic and without signs of blood loss. # Opiate use disorder: History of and no longer active. For now priority is achieving pain control for his severe esophagitis as before then discuss weaning opiates in conjunction with palliative care. Morphine tapering should continue as discussed in notes and in discussion with palliative care, high risk for addiction.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male h/o SCLC s/p XRT and radiation, HTN, afib, gout recently admitted with R sided empyema s/p chest tube placement, ___ currently on CTX who presented to ___ clinic with worsening hydropneumothroax and loculation. Pt not feeling more dyspneic than usual. Denies fevers, chills, N/V, chest pain, pleuritic pain. Endorses mild productive cough and congestion. Reports only having 25cc drained daily from chest tube. Patient had a recent admission to the MICU for right sided pleural effusion and dyspnea. He had chest tube placed at that time In the ED, initial VS were 98.3 ___ 24 98/RA. Exam notable for: Decreased breath sounds over R lung field. Mild diffuse wheezing Tachycardic. RRR. S1, S2. Chest tube dressed anteriorly. No tenderness Labs showed: 11.8 > 9.3/30.5 < 482 133 | 95 | 11 --------------< 88 4.9 | 27 | 0.5 phos 5.4 INR 1.5 Imaging showed CXR: persistent large, loculated right pleural effusion with associated air fluid level and locules of pleural gas CT chest: -Increase in fluid volume of large probably multiloculated right hydro pneumothorax, most of which is remote from the plane of the lateral and anterior position of the tunneled right pleural drainage catheter. -New epicardial edema. Even though the volume of right pericardial effusion is small, it should be monitored with echocardiography to detect any evidence of developing purulent pericarditis. -The bronchus intermedius is stented. Narrowing of the right main and upper lobe bronchi has improved. Right hilar mass still occludes right middle and lower lobe bronchi and those lobes are collapsed. Interventional Pulmonology was consulted and put tPA through the chest tube. Received intrapleural alteplase and dornase Alfa through the chest tube. Patient also received metoprolol for tachycardia. Also received 75 cc/hr IVF. Transfer VS were 98.5 114 108/68 20 96% RA. Decision was made to admit to medicine for further management. CT CHEST W/O CONTRAST showed Increase in fluid volume of large probably multiloculated right hydro pneumothorax, most of which is remote from the plane of the lateral and anterior position of the tunneled right pleural drainage catheter. New epicardial edema. Even though the volume of right pericardial effusion is small, it should be monitored with echocardiography to detect any evidence of developing purulent pericarditis. The bronchus intermedius is stented. Narrowing of the right main and upper lobe bronchi has improved. Right hilar mass still occludes right middle and lower lobe bronchi and those lobes are collapsed. CHEST (PA AND LAT) showed In comparison to ___ radiograph, a pleural catheter is in place in the right hemi thorax, with a persistent large, loculated right pleural effusion with associated air fluid level and locules of pleural gas, more fully evaluated by recent chest CT performed less than 1 hr earlier. Postoperative and post radiation changes in the right hemi thorax are more fully evaluated by CT. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Left PIC line ends in the upper SVC. Restrictive right pleural thickening persists but there has been a decrease in the volume of dependent pleural effusion. I cannot tell whether this has been replaced by pleural air or re-expanded lung. Basal pleural drainage tube is still in place. Heart size top-normal. Left lung clear. CT CHEST W/O CONTRAST showed Slight decrease in overall volume and in the fluid component of multiloculated right hydro pneumothorax. No change in position of course of the right pigtail drainage catheter. Bronchus intermedius stent unchanged in position. Improved patency to right middle lobe bronchus and right lower lobe segmental bronchi. The patient was diagnosed with Other pneumothorax. The patient was treated with Placement of TPA in Chest Tube. The patient was given written instructions concerning 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 h/o SCLC s/p XRT ___ years ago, HTN, afib on apixiban, gout recently admitted with complicated R-sided empyema and presented from ___ clinic for management of worsening hydropneumothorax and new loculations of this known empyema. He was recently treated with 6 week course of ceftriaxone and placement of a chest tube for drainage of the empyema. Previous pleural fluid culture grew S. pneumo. CT scan obtained in ___ clinic on the day of admission showed loculations of the empyema, and he was sent to ___ ED. ___ was held and TPA placed in the chest tube X 3 with good effect. He was restarted on a 6 week course of CTX. He was mildly tachycardic on admission but this resolved with home metoprolol. Plan for patient to follow-up in clinic regarding continued care of this complex loculated hydropneumothorax. Active Medical Issues ====================== #Empyema: Patient presented from ___ clinic for management of worsening hydropneumothorax and new loculations of this known empyema. He was recently treated with 6 week course of ceftriaxone and placement of a chest tube for drainage of the empyema. Previous pleural fluid culture grew S. pneumo. CT scan obtained in ___ clinic on the day of admission showed loculations of the empyema, and he was sent to ___ ED. The patient was evaluated by Infectious disease who recommended repeat 6 week course of CTX (anticipated end date ___. Apixiban was held and TPA placed in the chest tube X 3 with good effect. Of note, chest CT showed a new mass highly suspicious for recurrence of small cell lung cancer, which may explain the etiology of the patient's persistent empyema. Plan for patient to follow-up in clinic regarding continued care of this complex located empyema and further workup of lung mass. #Sinus tachycardia: Patient with history of sinus tachycardia and Afib. Had afib and pauses on telemetry ___ seconds) on his last admission at ___. On this admission, found to be in sinus tach, resolved with resumption of home metoprolol. HD stable. Home ASA and apixaban were initially held iso tPA infusion, restarted upon discharge. Home diltiazem was stopped given patient had intermittent low BPs during hospital course. #Pericardial effusion: Pt w/ persistent small pericardial effusion since at least ___, per previous notes. Patient with tachycardia, however pressures normal and stable w/ negative pulsus paradoxus. TTE on ___ and ___ also showed very small pericardial effusion, without echocardiographic signs of tamponade. Patient did show evidence of new epicardial edema on CT scan ___ concerning for pericarditis, but patient asymptomatic and EKG w/ no e/o pericarditis. Chronic Medical Issues: ======================= #Gout: Patient notes several acute gout exacerbations per year, most recently involving L knee. Continued home allopurinol. #COPD: continued home inhalers, albuterol prn #HLD: continued home simvastatin, home fenofibrate #HTN: continued home quinapril, continued home spironolactone. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male, with past history of CAD s/p CABG, aspirations, presenting with increased dyspnea, shortness of breath and respiraotry distress. Patient was initially hypoxic to the ___ by EMS, and placed on NRB with improvement to 93%. Patient is admitted to the FICU for hypoxemic respiratory distress. CHEST (PORTABLE AP) showed Substantial iimprovement in bibasilar opacities since 1 day ago. CHEST (PORTABLE AP) showed Minimal interval improvement in bibasilar left-greater-than-right opacities. The patient was diagnosed with RESPIRATORY ABNORM NEC, VOMITING. At the time of discharge, the patient had Aspiration ___. The patient was given written instructions concerning 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 prior history of aspirations by history, CAD s/p CABG, who presented to ___ acute respiratory distress and hypotension after vomiting. ACUTE ISSUES # Sepsis ___ Aspiration Pneumonia: Patient briefly febrile with leukocytosis on admission. Lactate elevated and there was a new infiltrate noted in b/l bases concening for aspiration pneumonia vs pneumonitis. Hypoxic on arrival, briefly requiring NIPPV, but rapidly down-titrated to NRB and then NC. Initially treated with vancomycin/zosyn. Zosyn later changed to cefepime/metronidazole given a penicillin allergy and vancomycin discontinued. After 24 hours, patient no longer had on oxygen requirement, was afebrile, had appropriate urine output and lactic acidosis had resolved. Patient's blood pressures remained lower than reported baseline however improved and home bblocker was restarted. He was called out of the ICU where he was transitioned to levo/flagyl with continued improvemnt. ___ompleted while in the hospital. # Aspirations: Patient with aspiration pneumonia in the setting of recurrent aspiration and dysphagia. Originally evaluated by speech and swallow who recommended he remain NPO, but on re-evaluation he was deemed safe to place on a modified diet. On further discussion with the patients family, they do not want to pursue further w/u for this. Per family request, patient was seen by palliative care in the hospital for discussions about end of life and DNH, however ultimately pt was discharged to rehab with ongoing discussions about goals of care. # Delerium: pt with AMS while in the hospital, likely due to infection. Pt was aaox 3 throughout and was improved at the time of discharge although is intermittently somnolent. # Heart Failure with preserved EF: Patient appeared euvolemic on examination. BNP 465 on admission, not concerning for exacerbation of diastolic CHF. # ___ on CKD: Patient with baseline creatinine of 1.3, presented with 1.8. Improved with IVF hydration to 1.4. # Paroxysmal Atrial fibrillation: Occured in the setting of infection, no recurrent tachycardia.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old left handed male with a history of ? epilepsy and a-fib c/b strokes now presenting with recurrent aphasia. CTA HEAD AND NECK WITH PERFUSION showed 1. No evidence for acute intracranial abnormalities on noncontrast head CT. Nondiagnostic CT perfusion study due to technical factors. 2. Multiple chronic infarcts are again seen in the right thalamus, left caudate, and left lentiform nucleus/corona radiata/external capsule. 3. No flow-limiting arterial stenosis in the neck. 4. Unchanged atherosclerotic occlusion of the distal V4 segment of the non dominant right vertebral artery. 5. Bronchiectasis in the visualized upper lungs with apparent new bronchial wall thickening compared to ___, which may represent superimposed infectious/inflammatory process versus technical differences. Clinical correlation is recommended. 6. Severe cervical spinal stenosis, previously assessed by MRI in ___. RECOMMENDATION(S): MRI would be more sensitive for an acute infarction, if clinically warranted. MR HEAD W AND W/O CONTRAST showed 1. Small 6 mm acute to subacute infarct of the left temporal lobe. No associated mass effect. 2. Numerous chronic infarcts of the cerebral white matter, bilateral basal ganglia, and thalami. Severe chronic microangiopathy. 3. Moderate generalized parenchymal volume loss. 4. Asymmetric enlargement of the right temporal horn, although this appears to be due to adjacent temporal lobe volume loss rather than specifically volume loss of the right hippocampus. 5. Occlusion of the V4 segment of the right vertebral artery, unchanged from CTA on ___. The patient was diagnosed with OTHER SPEECH DISTURBANCE, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had Subacute to Acute Stroke History of prior strokes Seizures Atrial Fibrillation Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year old left handed man who presented with isolated global aphasia similar to a prior MRI-negative episode in ___ thought to be seizure vs stroke. Initially, given the exam and the identical nature of his current aphasia to an MRI-negative spell in ___, seizure was higher consideration than stroke. However, EEG showed no epileptiform activity. It showed left greater than right slowing. Previous EEG showed right greater than left slowing. However, due to the clinical suspicion for seizure, whether of unknown etiology or secondary to stroke, we have increased his Keppra 1000mg BID. Although the initial CT was negative, an MRI showed a small posterior insular cortex. His stroke risk factors have been assessed. He is currnetly on Atorvastatin 40mg qday. His last LDL was 66. He has afib and is currently on Coumadin 2mg with theurapeutic INRs. His INR on discharge was 3.1. His INR will continue to be trended by his primary care doctor. We were going to obtain an Echo since his last Echo was ___, however, the result will not change management. He will follow up with his outpatient Neurologist. In regards to pulmonary, Mr. ___ had some wheezing on inital exam that improved throughout the hospital course. He had a CTA that showed bronchiectasis visualized in the upper lungs with apparent new bronchial wall thickening compared to ___, which may represent superimposed infectious/inflammatory process. Mr. ___ did endorse a recent viral illness. Additionally, Mr. ___ was found to have pancytopenia of unknown etiology. The pancytopenia improved over the course of the hospitalization. He will follow up with his outpatient primary care doctor.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ on warfarin for AF, stroke, HTN presenting with falls and injury to left arm. Patient's son states she was recently hospitalized for high INR and was discharged two weeks with decreased mental status. He states that for the last week or so she has had several falls with one wound on her left elbow which he noticed ___. He states that the arm and hand were swollen with some redness. He states that he has been putting ice packs on the arm for the past couple of days. He states that this morning the arm and hand were much more swollen with redness and blister extending through the whole forearm. Radiology showed Osteopenia. No acute fracture. Radiology showed Diffuse osteopenia. Degenerative changes, as above. No acute fracture seen. Subtle linear tract of relative lucencies along the lateral aspect of the partially imaged forearm could be due to subcutaneous edema but soft tissue gas is not excluded. Consider CT for more sensitive evaluation. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. An area of hypodensity in the left occipital lobe is new from ___, and may represent a subacute to chronic infarct. MRI is more sensitive in detecting acute ischemia. 2. No acute intracranial hemorrhage. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed Please note that this study is degraded by patient motion artifact. Allowing for this limitation, there is no definite acute fracture or traumatic malalignment. Radiology showed Extensive soft tissue stranding and fluid within the subcutaneous and deep tissues of the left forearm. No foci of soft tissue gas identified. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is now an endotracheal tube in place with its tip approximately 4.4 cm above the carina. Opacification at the left base obscures the hemidiaphragm, most likely relating to small pleural effusion and volume loss in the left lower lobe. No evidence of pulmonary vascular congestion and the right lung is essentially clear. CHEST PORT. LINE PLACEMENT showed OG tube side port lies above the diaphragm in the esophagus, and should be advanced into the stomach. A right IJ catheter terminates in the low SVC. RECOMMENDATION(S): OG tube should be advanced so that side port lies within the stomach. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephoneon ___ at 12:18 ___, 45 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Since ___ the patient is been extubated and although lung volumes are lower, there is no discernible atelectasis, however there may be new mild edema at least at the right lung base. Severe cardiomegaly is long-standing. Small pleural effusions are new or newly apparent. No pneumothorax. Right jugular line ends in the low SVC. DX CHEST PORTABLE PICC LINE PLACEMENT showed New right PICC line. The tip of the line is slightly coiled in the mid to low SVC. If fully deployed, the tip would be located at the cavoatrial junction. No complications, no pneumothorax. The previous right internal jugular vein catheter was removed. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the earlier study of this date, the subclavian PICC line is been pulled back so that the tip lies at or just above the cavoatrial junction. Otherwise little change. The patient was diagnosed with Cellulitis of right upper limb. The patient was treated with - Debridement of left arm necrotizing fasciitis - Irrigation and placement of VAC dressing - Split-thickness skin graft reconstruction of left upper extremity wound - Bilayer skin substitute matrix reconstruction - Wound vacuum takedown. The patient was given written instructions concerning 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 ============= Ms. ___ is a ___ with a PMH of A-fib on warfarin, R MCA stroke, HTN, and dementia who presented to ___ with falls and injuries to her left arm. She was found to have evidence of necrotizing fasciitis of the left arm likely secondary to a wound sustained after a recent fall. She was admitted to the plastic surgery service and underwent significant debridement of the left arm from above the elbow to the dorsum of the hand, with a washout several days later and skin grafting a few days later. Her initial operation was complicated by Afib w/ RVR, and she required an ICU stay for BP support. After achieving stable vitals, she was transferred to the floor. For the supratherapeutic INR, she was given FFP and vitamin K. She was continued on her metoprolol for her Afib, but subsequently developed bradycardia, which held stable until discharge. She was started on Apixaban for anticoagulation and was discharged to rehab after her wound vac was taken down. ACUTE ISSUES ============ #L elbow necrotizing fasciitis: The patient was recently hospitalized at ___ for a supratherapeutic INR ___ the setting of poor PO intake. After discharge, she suffered several falls resulting ___ a wound on her left elbow, which became progressively more reddened and swollen. The day prior to presentation, she noted blisters on her forearm and was taken to the ED. ___ the ED, she was noted to have e/o necrotizing soft tissue infection on exam. She was started on vancomycin, clindamcyin, and meropenem and taken to the OR, where the L arm was extensively debrided. Her OR course was complicated by A-fib w/ RVR requiring multiple doses of esmolol. She was briefly admitted to the TSICU w/ intubation, pressor support, and close monitoring, then transferred to the plastic surgery service. Her wound cultures revealed group A strep, and her antibiotics were switched to clindamycin and ceftriaxone per ID. The patient was subsequently transferred to the medicine floor, and was taken back to the OR for a washout, again for a skin graft placement, and then again for wound vac takedown (done at bedside). Her clindamycin was discontinued with plans to continue her Ceftriaxone for 2 weeks post-debridement. She remained afebrile with negative cultures and was discharged to rehab. SURGICAL/ICU COURSE: Data upon admission: WBC 23, Cr 2, Na 147, lactate 5.5, fascial plane air on plain films, and necrotic bullae formation. INR was 7 and she was given 2 units FFP and IV vitamin K x 1. She was taken to the OR once INR down to 2.4 a few hours later. Patient was tachycardic and somnolent ___ the ED, but maintaining her pressure. ___ OR, she developed A-fib w/ RVR requiring multiple bouts of esmolol before starting the case. She was maintained on neo throughout case. The patient was taken to the OR and circumferentially debrided soft tissue of entire left forearm, dorsal and including some digital soft tissue, down to the elbow proximally. Much of the dorsal tendons paratenon had to be removed, adaptic placed on this before the VAC. Circumferential VAC applied on 75 mmHg, intermittent suction. The patient was transferred to the ICU post-surgery for blood pressure support with pressor therapy. Pressor therapy was discontinued on hospital day #2. Patient given digoxin load for a-fib with RVR. Patient restarted her amlodipine on hospital day #4 and she was also started on PO Lopressor with good control. The patient was maintained intubated and on ventilator until she was able to be weaned from vent on hospital day #2. Post-operatively, the patient was given IV fluids. An NG tube was inserted and coffee ground gastric contents were drained, guaiac positive. Patient was started on IV pantoprazole and monitored closely. On hospital day#4, patient pulled out her NG tube. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Wound cultures revealed beta streptococcus group A and patient's antibiotic therapy to changed to ceftriaxone and clindamycin per Infectious Disease. #A-fib with RVR: At home, the patient is controlled with metoprolol 25 mg BID and anticoagulated with warfarin 5 mg. The patient was noted on admission to have a supratherapeutic INR, requiring vitamin K and FFP. As noted above, the patient developed A-fib with RVR during her initial OR course, requiring several doses of esmolol, with subsequent hypotension and pressor requirement ___ the ICU. On the medicine floor, she was noted to be ___ A-fib with controlled rate on metoprolol 25 mg BID, however she subsequently converted to sinus rhythm with bradycardia. Her metoprolol dose was decreased to 12.5 mg BID for this. Regarding her anticoagulation, because of her need to go to the OR several times, the patient was maintained on a heparin drip. After a discussion with her son (HCP), he felt that the risks of anticoagulation ___ the setting of her falls were outweighed by the risks of stroke, so felt that she should be anticoagulated at discharge. Given her INR lability, she was started on Apixiban on the day of discharge. She was discharged on 12.5 bid metoprolol with holding parameters (to be administered if HR ?60). #Supratherapeutic INR: The patient was hospitalized ___ ___ for a supratherapeutic INR ___ the setting of poor PO intake, and was again found to have a supratherapeutic INR during this admission. See above two problems for further detail. #Sinus bradycardia: Patient ___ A-fib at admission which converted to sinus rhythm during her floor course. Bradycardia likely due to metoprolol effect. She was also noted to have occasional atrial and ventricular ectopy on telemetry. She remained asymptomatic during her course. Metoprolol adjusted per above. #Anemia: Likely secondary to post-op blood loss combined with dilutional effect. H/H slowly trended down and required a transfusion of 1 u pRBCs on the day of discharge. #Malnutrition: The patient was noted to have poor PO intake with no dysphagia. Nutrition was consulted, and recommended supplements and possible feeding tube placement. Given her functional ability to eat and difficulty with rehab placement ___ the setting of feeding tube placement, we opted to continue her on a PO diet with supplements and assistance with eating. She will eat well with one-to-one assistance with feeding and this should be encouraged. #new diagnosis of systolic CHF: The patient had a TTE during this admission showing an EF of ___ with moderate (2+) aortic regurgitation, mild to moderate (___) mitral regurgitation, and moderate to severe [3+] tricuspid regurgitation. After talking with the PCP, this is a new diagnosis, and according to the PCP the patient has never experienced CHF symptoms. ___ consider starting ACE/statin ___ the future after further discussion regarding patient goals. #Chest pain: The patient reported chest pain on two occasions, once while working with ___. Pain was described as dull and intermittent, ___ the ___ her chest. No SOB. EKG showed no evidence of ischemia. CHRONIC ISSUES ============== HTN: Patient is on metoprolol and amlodipine at home, these medications were continued and her BPs remained stable. TRANSITIONAL ISSUES =================== -Ms. ___ need a CBC checked on ___ to ensure that her Hgb/Hct is stable (she required 1U PRBC's on ___. -Patient was discharged on ceftriaxone only with her course ending on ___. -Patient's metoprolol should be administered only if HR is >60 to avoid bradycardia; it is important to continue this medication when possible, however, to prevent A-fib with RVR. -Patient needs assistance with feeding and should be encouraged to take po's. -The patient was started on Apixaban due to INR lability on warfarin. Will need to continue discussions as an outpatient with the patient's son regarding risks and benefits. - She was noted to have an EF of ___, however we have no previous ECHOs on record and her PCP was unaware of any previous reports. - ___ consider starting ACE-I given reduced EF - ___ Consider statin therapy, although risks and benefits will need to be assessed given patient's goals. -Patient will f/u with plastic surgery</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. Large anterior midline extra-axial mass with surrounding edema exerting mass effect the bilateral frontal lobes and causing effacement of the anterior horns of the lateral ventricles and 5 mm of leftward midline shift, unchanged from prior CT, likely representing an olfactory groove or planum sphenoidale meningioma. 2. Superior and posterior displacement of the bilateral A1 segments, and superior and left lateral displacement of the bilateral A2 and A3 segments without evidence of stenosis or occlusion. An A-comm is not visualized. 3. No evidence of intracranial arterial stenosis or occlusion. Radiology showed Cardiomediastinal silhouette is within normal limits. There are no focal consolidations, pleural effusion, or pulmonary edema. There are no pneumothoraces. Right common carotid artery angiogram. Left common carotid artery angiogram. Right common femoral artery angiogram. showed Bilateral common carotid artery angiograms demonstrated no significant arterial supply from the anterior circulation that could be successfully embolized. RECOMMENDATION(S): We will communicate this information with Dr. ___. PRE-SURGICAL PLANNING WAND STUDY ___ MR HEAD showed 1. No interval change appearance of a 6.0 cm likely olfactory groove/planum sphenoidale meningioma. 2. The inferior aspect of the lesion appears to contact the optic chiasm (series 600, image 79). CT HEAD W/O CONTRAST showed Post surgical changes following meningioma resection including 6 mm leftward shift of midline structures, small amount of subdural blood along the falx, small hemorrhage along the resection bed and pneumocephalus. MR HEAD W AND W/O CONTRAST showed Expected postsurgical changes are seen without evidence of an obvious area of residual nodular enhancement. CHEST (PORTABLE AP) showed Comparison to ___. Mild cardiomegaly. No pneumonia, no pulmonary edema, no pleural effusions. Lung volumes are normal. CTA CHEST showed 1. No evidence of pulmonary embolism or aortic abnormality. 2. 2.4 cm hypodense left thyroid nodule. Heterogeneous appearance of the right lobe of the thyroid without distinct nodule. Recommend further evaluation with nonurgent thyroid ultrasound, if this has not already been performed. 3. Incompletely evaluated left upper pole renal lesion measures less than 1 cm. Recommend further evaluation with nonurgent renal MRI. RECOMMENDATION(S): 1. 2.4 cm hypodense left thyroid nodule. Heterogeneous appearance of the right lobe of the thyroid without distinct nodule. Recommend further evaluation with nonurgent thyroid ultrasound, if this has not already been performed. 2. Incompletely evaluated left upper pole renal lesion measures less than 1 cm. Recommend further evaluation with nonurgent renal MRI. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with ___: Embolization of vasculature to known ___ mass, Dr. ___ ___: tumor resection, Dr. ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with PMH significant for HTN, DM, HLD, visual hallucinations, and blindness who was recently diagnosed with intracranial mass. Now she presents with acute on chronic worsening of visual hallucinations.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with PMH significant for DM type II on insulin, hypercholesterolemia, hypertension, NAFLD, and hx. of pulmonary embolism at ___ y/o on OCPs who presents with acute onset headache, blurred vision, and chest pain. Radiology showed No evidence of acute cardiopulmonary process. Radiology showed No evidence of acute intracranial process. Radiology showed Less than 40% stenosis on the right and no atherosclerotic plaque noted on the left. The patient was diagnosed with HEADACHE, DIPLOPIA, CHEST PAIN NOS, OTHER NONSPECIFIC FX ON EXAM, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Primary 1. Hypertensive Emergency 2. Reduced Ejection Fraction Secondary 1. Diabetes Mellitus - Type 2, Insulin Dependent 2. Chronic Cough - Secondary to lisinopril 3. Hypertension 4. Hyperlipidemia 5. Gastroesophageal Reflux Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ year old female with PMH significant for DM type II on insulin, hypercholesterolemia, hypertension, NAFLD, and hx. of pulmonary embolism at ___ y/o on OCPs who presents with acute onset headache, blurred vision, and chest pain. The patient's symptoms occured in the setting of elevated blood pressures likely consistent with an episode of hypertensive emergency. # Chest Pain: The pt. has history of similar type of chest pain, not necessarily related to activity and more related to anxiety type events. On this admission, her chest pain occurred in the setting of elevated blood pressures in the 220s/120s. Her chest pain slowly improved as her blood pressures improved. She was found to have a mildly elevated troponin at 0.02. Her troponin peaked at this level and slowly returned to normal. It was thought that the mechanism of her chest pain is related to transient ischemic injury from increased cardiac demand in the setting of high afterload with significantly elevated blood pressures. This type of mechanism supports an episode of hypertensive emergency as there is evidence of end organ damage. The patient's EKG was without significant change (Sinus rhythm with LBBB) other than a slight change in QRS morphology in the lateral leads likely attributable to lead placement. Stress test showed possible anginal type symptoms in the setting of Persantine infusion, with uninterpretable ST segment changes for ischemia in the setting of LBBB. Nuclear perfusion test showed decreased cardiac output of 47%, down from 70% previously. The patient was asymptomatic during her stay. She will follow up with cardiology as an outpatient. # Headache and Blurry Vision: The patient presented with acute onset left-sided supraorbital sharp pain associated with blurry vision that lasted approximately 5 minutes. The quick onset and remission of these symptoms in the setting of significantly elevated blood pressures is consistent with hypertensive emergency causing end organ damage manifested in this case by blurry vision and headache. Other diagnoses we considered were transient ischemic attach from sometype of embolic event. The patient was noted to be in sinus rhythm without evidence of atrial fibrillation. A carotid ultrasound was performed which showed Less than 40% stenosis on the right and no atherosclerotic plaque noted on the lef. This made an embolic event less likely. Her neurologic exam remained non-focal and she remained hemodynamically stable throughout admission. # Hypertension: The patient's blood pressure at home before admission was in the 220s. However, during admission the patient's blood pressure was well controlled. The patient was continued on lisinopril 40mg PO daily and HCTZ 12.5mg PO daily. CHRONIC ISSUES # Diabetes Mellitus: Stable. The patient was continued lantus 34 units in the AM and on a humalog insulin sliding scale. # Constipation with Right upper quadrant pain: The patient reported a chronic history of stable abdominal pain since antibiotic treatment several months ago for her pneumonia. She denied a history of diarrhea, however she does endorse significant constipation associated with RUQ abdominal pain. This was managed with constipation regimen. # Chronic Cough: Likely related to the lisinopril. The patient was tried on losartan in the past and was not able to tolerate secondary to GI upset. As such, will continue lisinopril. # Hyperlipidemia: Pt. with known history however is no longer taking statin ___ myalgias. She is also not taking primary prophylaxis with aspirin ___ gastric intolerance # GERD: Stable. Continued on omeprazole TRANSITIONAL ISSUES #Hypertension Management: We discharged the patient on her home regimen; however it is unclear why the patient's blood pressure was in the 220s at home before admission. She may need increased blood pressure control and should be monitored.</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 ESRD on HD, T2DM, CHF, HTN, HLD, Afib (not anticoagulated ___ history of GI Bleed) presenting with fever, cough x1 day, and shortness of breath. He reports that yesterday morning he felt very hot, also had chills, fever to 103, and had strong, non productive cough starting that morning. Sent in from rehab for temp 103 and hypoxia. Pt reports cough since yesterday, worse when supine. Last dialysis ___ (HD ___. In the ED initial vitals were: 20:31 100.4 109 118/53 20 91% ra. Tmax was 103.1, at that time HR was 112, BP 110/67, RR 30. 95 on 3L. - Labs were significant for BNP of 21,569 (last BNP 30,950 ___, creatinine of 6.0 (baseline ___, on HD), leukocytosis to 11.1, microcytic anemia of 35.5 (baseline ~30) - Patient was given Ceftriaxone and Vancomycin 1g. At rehab (___) also had low sat 85 on 3L. Digoxin recently discontinued in ___ clinic ___ ESRD on ___. Radiology showed Mild pulmonary edema and persistent right effusion, similar to prior. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Primary: healthcare associated pneumonia Secondary: ESRD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old gentleman with ESRD on HD, T2DM, CHF, HTN, HLD, Afib (not anticoagulated ___ history of GI Bleed) presenting with fever, cough x1 day, and shortness of breath. # Fever, leukocytosis, cough, hypoxia - Concerning for pneumonia vs ILI. Given his recent hospitalizations, rehab residence, and dialysis, patient was started on HCAP coverage with vancomycin and cefepime. Sputum cultures did not grow a specific pathogen and viral DFA and culture was negative. Patient's symptoms improved with empiric HCAP coverage. Vanc/cefepime was changed to vanc/ceftazadime at discharge for ease of dialysis dosing. Patient will complete a 7d course of antibiotics, last dose of vanc and ceftazadime to be given after dialysis session on ___. # Diastolic CHF: BNP is lower than recent admissions, though pt does have bilateral lower crackles, concerning for contribution of mild fluid overload. Echo in ___ with EF 55-60%. Patient was maintained on a low-sodium diet with a 2L fluid restriction. Patient was dialyzed as per outpatient schedule, supplemental 02 was weaned and patient remained comfortable on room are for >___. CHRONIC ISSUES # History of GI bleed. Per GI Dr. ___ was pursued in ___ given hx of GI bleed requiring transfusions, and the study indicated single non-bleeding pseudopolyp in the proximal jejunum. Otherwise normal EGD to mid jejunum. Patient has f/u with GI. Hematocrits were stable throughout his course without signs of active bleed. # ESRD on HD: outpatient schedule ___. Nephrology was consulted, continued sevelamer, nephrocaps. Nephro recommended holding cinacalcet at discharge as patient's calcium was low. Recommend following calcium and PTH at outpatient dialysis and restarted cinacalcet as per outpatient nephrologist. # T2DM: Last HbA1c 10.7 on ___. Repeat during this admission was 7.4. Multiple complications including peripheral neuropathy, retinopathy, nephropathy. He was continued on his home insulin regimen. # Atrial fibrillation/AFlutter (s/p ablation ___ s/p ablation x 2 in ___, EPS for atach in ___ (thought to be trigger vs. reentrant) not on warfarin due to history of GIBs. Continued diltiazem. # Hypertension. Stable. Continued home diltiazem and imdur. TRANSITIONAL ISSUES # Code: Full, confirmed # Emergency Contact: ___ (girlfriend/HCP) ___ Cell ___. Alternate HCP is son ___ ___/ home ___. # cinacelcet held on discharge due to low calcium, recommend following calcium and PTH at outpatient dialysis and restarting as per outpatient nephrologist # needs to complete course of antibiotics for HCAP (vanc and ceftazadime, last dose after dialysis session ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ Yo M with PMH of GERD, CVA, HIV, DMII, Celiac disease, Pressure ulcer on coccyx, depression and poor hearing who presented to the ED with GI bleeding. History is obtained from the chart. He had a labs performed by his ___ (___ ___) today which was remarkable for WBC 13.8, Hgb 5.9, Glucose 319 and BUN 38. He was then transported to ___. At ___, he was tachycardic to 108 and BP was 95/52. Physical exam revealed dark red, almost maroon blood per rectum, guaiac positive. Hgb was 6.1, BUN 33, WBC 13.9 and INR 1.15. According to note, most recent available Hct was 25 from ___. On evaluation there, he had no complaints and no history of GI bleeding. No blood thinner on medication list. According to notes, he has a DNR/DNI order but wanted a transfusion and "care for GI bleed". He received emergency release blood products: 2u pRBC and 1u FFP. He also received protonix 80mg IV x1. The case was discussed with GI on call at ___ who recommended transfer to ___ in case his GI bleed worsened overnight and necessitated more immediate attention as this is not available overnight at ___. He was then transferred to ___. CHEST (PORTABLE AP) showed No previous images. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion. There is suggestion of asymmetric opacification in the left suprahilar region and possibly the left base, which given the clinical history could be a manifestation of consolidation. NOTIFICATION: Dr. ___, immediately by telephone on identification of this appearance at 10:12 on ___. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with EGD ___. At the time of discharge, the patient had ================== Primary Diagnosis ================== Lower GI bleed secondary to stercoral ulcer =================== Secondary Diagnosis =================== Anemia secondary to acute blood loss Ascending colon polyp Hypernatremia 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>========= Summary ========= ___ year old man with PMH of GERD, CVA, DMII, celiac disease, pressure ulcer on coccyx, depression and poor hearing who presented with GI bleeding. Colonoscopy revealed stercoral ulcer. Hgb stabilized, no further bleeding. ============================= Acute Medical/Surgical Issues ============================= # GI Bleed: # Acute blood loss anemia Patient presented with hgb drop in the setting of dark stools without hematemesis with a history of GERD on daily aspirin. No history of liver disease, malignancy, trauma. Required 3 units pRBC and 1 unit FFP and H/H stabilized with no further melena/hematochezia. BPs recovered with blood and fluid. EGD unrevealing. Colonoscopy on ___ revealed a stercoral ulcer in the rectum with no signs of bleeding. Biopsies were take which are pending at discharge. His home aspirin 81 was held but restarted at discharge. # Hypotension: initially hypotensive to ___ (baseline is 100s systolic), felt to be related to hypovolemia/blood loss. He was pancultured without revealing infectious source to contribute to a sepsis etiology of hypotension. BP improved to 95-105 systolics which appears to be his baseline. #DMII: Hyperglycemic on admission, unclear etiology but could be due to stress of infection or bleed. Given that he is NPO, dosed reduced home insulin regimen of glargine 14U qHS with ISS while on clear liquid/NPO diet here. Once diet resumed, restarted on home dose. CHRONIC # Coccyx wound: in the setting of bedbound status and potential malnutrition. Wound does not currently look infected on admission. CRP low making osteo less likely. Wound care was consulted and recommended pressure relief per pressure ulcer guidelines with turn and reposition every ___ hours and prn off affected area. Nutrition consulted and given celiacs disease, started on supplementation with vitamin C, zinc sulfate for 14 days, vitamin D, and calcium carbonate. # Potential HIV Chart diagnosis without labs or medications by history. Patient confused and does not know if he has diagnosis. CD4 and HIV viral load negative making HIV unlikely. Would remove from past medical history #CAD primary prevention: continued Atorvastatin 20 mg PO QPM and restarted ASA at discharge. #Constipation: Stercoral ulcer likely developed in setting of chronic constipation. Would put patient on standing bowel regimen with Senna 8.6mg PO daily and Miralax. Would continue PRN regimen of Bisacodyl ___AILY:PRN constipation; Milk of Magnesia 30 mL PO DAILY:PRN constipation; and Fleet Enema (sodium phosphates) ___ gram/118 mL rectal DAILY:PRN if patient without stool for 2 days. #Rhinitis: continued home Fluticasone Propionate 110mcg 1 PUFF IH BID; GuaiFENesin 10 mL PO Q6H:PRN cough; Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea #Depression/insomnia: continued home Sertraline 12.5 mg PO DAILY, Mirtazapine 15 mg PO QHS #Nutrition: continued Multivitamins W/minerals 1 TAB PO DAILY and started on supplementation with vitamin C, zinc sulfate for 14 days, vitamin D, and calcium carbonate given history of celiacs disease. #Dyspepsia: Restarted Sodium Bicarbonate 650 mg PO BID heartburn at discharge. ================== Medication Changes ================== - Started vitamin C 250mg BID - Zinc sulfate 220mg daily for 14 days (D1: ___ - Vitamin D 800U daily - Calcium Carbonate 1000mg daily ===================== Transitional Issues ===================== [] Constipation: important in preventing further stercoral ulcers. Place patient on standing bowel regimen with senna 8.6mg PO daily and miralax daily. Would try PRN medications in this order if no stool in 2 days: Bisacodyl ___AILY:PRN constipation; Milk of Magnesia 30 mL PO DAILY:PRN constipation; and Fleet Enema (sodium phosphates) ___ gram/118 mL rectal DAILY:PRN [] Ascending colon polyp: Will schedule follow-up appointment with GI to consider EMR for ascending polyp at a later date and follow-up stercoral ulcer pathology [] History of Celiac's Disease: Please have patient on gluten-free diet. Nutrition recommendations are supplementation with vitamin C, zinc sulfate for 14 days, vitamin D, and calcium carbonate as patient likely malnourished. [] Coccyx wound: Wound care was consulted and recommended pressure relief per pressure ulcer guidelines with turn and reposition every ___ hours and prn off affected area. Please have on gluten free diet and continue supplementation as above as malnutrition will impair wound healing. [] Continue aspirin 81mg here at discharge. Given patient's age and functional status, would continue to evaluate risk of bleeding vs cardiovascular benefit and consider stopping if indicated. # Communication: HCP: ___, sister - ___ # Code: DNR/DNI, confirmed </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a PMH of HTN and treated Hepatitis C (previously followed by GI at ___ who initially presented to ___ with a 2-day history of vomiting and diarrhea. The vomiting was reportedly non-bloodly-non-bilious and there was no blood in her stool. She also described new heartburn, described as burning sensation after drinking ginger ale, nonradiating, felt in her "throat." Felt like prior episodes heartburn. Lasted about 1 hour, the self-resolved. Her grandson is ___ years old, who does not live with her but who she sees twice weekly, had an illness with GI symptoms approx 2 weeks prior to her presentation. Has had intermittent periumbilical pain, relieved with emesis and defecation, max ___, nonradiating, now resolved. Last time she was able to take POs was ___, had oatmeal. At ___, she was unable to tolerate po's. CT abdomen showed enteritis and an EKG showed NSR at ___epressions (v4-6), TW III, and no STE. Last prior EKG in ___epressions. Her cTnI was 0.07. She denied any chest pain, SOB, diaphoresis. She was given a full dose ASA, morphine for pain, and transferred to ___ for further work-up. In the ED, initial vitals were: 98.6 110 134/80 18 96%. Her nausea, vomiting, and diarrhea had improved by the time she arrived in the ED. Labs were significant for: BUN 1.6/Cr 1.6, HCO3 19, and lipase ___. Her CBC, LFT's, and UA were WNL. Her lipase was then repeated several hours later (on ___ and had increased to 3208. Troponins x 2 were <0.01. Liver US showed hepatic ductal dilatation, gallbladder sludge but no stones, pancreas not visualized. She received 2L IVF and a dose of 1g CTX. She was then transferred to medicine for further work-up of her likely pancreatitis/question choledocholithiasis/enteritis, ___, and possible unstable angina. On the floor, pt reports that her symptoms are improving. She does continue to have diarrhea, but no further episodes of emesis. She denies CP, ___ edema, orthopnea, diaphoresis, weight gain or loss, night sweats, rash, hematuria, hematochezia, melena, dysuria. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Mild intrahepatic ductal dilatation within the left hepatic lobe. The common bile duct and pancreatic duct are within normal. Visualized portions of the pancreas are unremarkable. MRCP is advised for further evaluation of the dilated left intrahepatic duct. Cholelithiasis and sludge without evidence of cholecystitis. NOTIFICATION: Recommendations for MRCP communicated to Dr. ___ readout via telephone by A. Trotter at 8:41 am on ___. The patient was diagnosed with ACUTE PANCREATITIS. The patient was treated with EGD and colonoscopy. At the time of discharge, the patient had Gastroenteritis Mild demand ischemia Lower GI 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>___ yo woman with a PMH of HTN and treated Hepatitis C w/SVR (previously followed by Liver clinic at ___ presenting with 2-day history of vomiting and diarrhea, admitted for inability to tolerate POs, went initially to ___ had CT demonstrating likely gastroenteritis as well as elevated lipase level without clinical evidence of pancreatitis and very mild troponin elevation with non specific ECG changes in setting of ___. Transferred to ___ and over course of hospitalization developed maroon stools from likely diverticular bleed. # Vomiting/diarrhea: Resolved, likely from gastroenteritis # Elevated lipase: Unclear etiology. Clinically does not have pancreatitis and never had pain. ___ have had transient obstruction in panc duct, but presentation is odd. ? related to gastroenteritis. Will need follow up lipase level # GI bleed: Maroon stools. No evidence of hemodynamic instability or HCT drop. Likely from diverticulosis seen on ___. No active bleeding found. EGD also performed with insignifcant AVM in duodenum. The bleeding only took place over the course of one morning then resolved. # Potential demand ischemia: Trop I at OSH 0.07 (nl <0.03). EKGs with Nonspecific ST-T changes, pt denies CP, SOB, ___ edema, orthopenia, diaphoresis to suggest active ischemia or failure. Pt with serial cardiac enzymes here which were negative. Possible demand in setting of dehydration, illness and ___. Pt may benefit from ETT as OSH. Discussed with PCP. Pt continued on beta blockade and started on baby aspirin after resolution of GI bleed. # Rising LFTs: Pts LFTs initially normal. Over the last two days of admission had rise in LFTs to 100 Asymptomatic. Should f/u as outpt. Potentially from stone although no symptoms, no pain. ? recurrence of hep C. ? autoimmune hepatitis. ? associated with viral infection. Pt should have follow up LFTs at outpt appt next week. If rising or still elevated should have follow up HCV viral load level and should be referred to liver. Also needs outpt MRCP # Mild intrahepatic ductal dilatation within the left hepatic lobe: Needs MRCP # Hypertension: Currently well controlled # Hypothyroidism: - Continue home levothyroxine - med dosing confirmed with pt's pharmacy </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of breast cancer stage ___ s/p R partial mastectomy and sentinel LN biopsy previously on adjuvant letrozole now discontinued, hypertension, HLD and hypothyroidism, recently diagnosed Stage 4 metastatic lung adenocarcinoma on palliative chemo (last session ___ presenting with fevers, acute on chronic dyspnea on exertion, cough. CHEST (PORTABLE AP) showed 1. Increased consolidative opacity within the left lung base concerning for pneumonia. 2. Diffuse metastatic nodules, many which are cavitary, and dominant left perihilar mass are re-demonstrated and better assessed on prior CT. 3. Probable small left pleural effusion. Chest CTA. showed 1. No evidence of pulmonary embolism. 2. Confluent regions of consolidation in the lungs bilaterally, more extensive on the left than on the right as above worrisome for multifocal pneumonia. 3. Small left pleural effusion. 4. Innumerable bilateral cavitary lung lesions as seen previously worrisome for cavitary lung metastases without definite new lesion noting that significant portion of the lung is obscured by consolidation. Radiology showed Consolidation in the left lung appears to have progressed since two days prior. Chest radiograph, portable AP semi-upright view. showed Status post endotracheal intubation, orogastric tube placement, and placement of right internal central jugular venous catheter. Unchanged multifocal opacities suggesting widespread pneumonia. Radiology showed No significant interval change. CHEST (PORTABLE AP) showed ET tube tip is 6 cm above the carina. NG tube tip is in the stomach. Right internal jugular line tip is at the level of lower SVC. Port-A-Cath catheter tip is at the level of the proximal right atrium. There is minimal interval additional progression and left middle lower lung consolidations and right widespread parenchymal opacities compared to previous examination. No interval increase in pleural effusion. No pneumothorax. CHEST (PORTABLE AP) showed Comparison to ___. The lung volumes have minimally increased, potentially reflecting improved ventilation. These increase is more obvious on the right and on the left. However, the very extensive bilateral parenchymal opacities, left more than right, are not substantially changed in extent and severity. Stable position of the monitoring and support devices. CT CHEST W/O CONTRAST showed Improving multifocal bilateral consolidative opacities consistent with resolving pneumonia. Stable small left pleural effusion. Numerous bilateral pulmonary metastasis with evidence of cavitation. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Predominantly interstitial abnormality right lung mildly worsened since ___. More severe infiltrative process in the left lung improved since ___, unchanged since ___, includes a component of volume loss explaining leftward mediastinal shift. Small left pleural effusion is underestimated on the conventional radiograph. No pneumothorax. Indwelling cardiopulmonary support devices in standard placements. CHEST PORT. LINE PLACEMENT showed Compared to chest radiographs ___ through ___. Component of acute pulmonary edema has almost resolved from the right lung. Severe infiltration on the left has not changed. Pleural effusions small on the left if any. No pneumothorax. Heart is not enlarged but the borders are obscured by severe parenchymal abnormality in the left lung. ET tube in standard placement. Right jugular line and left supraclavicular central venous infusion catheter both end in the low SVC. Nasogastric drainage tube passes below the diaphragm and out of view. CT CHEST W/O CONTRAST showed Continued improvement in previously severe predominantly left-sided pneumonia, initially dense consolidation on ___, improved to generally ground-glass involvement on ___. Progressive, severe interstitial abnormality, also left greater than right is probably an organizing phase of the previous insult, and is more typical of drug-induced reaction than infection. Lymphangitic carcinomatosis is less likely. Multiple cavitary pulmonary metastases right lung. Residual and residual left suprahilar mass unchanged since ___. Small to moderate left pleural effusion is smaller, probably layering. Radiology showed No significant interval change since the chest radiograph dated ___. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with intubation ___ and extubation ___ temporary central venous line placement and removal. At the time of discharge, the patient had Primary diagnosis: Drug induced pneumonitis Acute Hypoxic Respiratory Failure Secondary: Anxiety Pulmonary Embolism Metastatic Lung Adenocarcinoma Steroid-Induced Hyperglycemia Hyponatremia Leukocytosis Anemia 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>SUMMARY: ___ female with history of breast cancer, hypertension, HLD, hypothyroidism, now recently diagnosed with metastatic lung adenocarcinoma, on palliative chemotherapy, presented with fevers and acute on chronic dyspnea on exertion. Imaging on admission notable for extensive consolidation consistent with multifocal pneumonia superimposed on underlying malignancy. She was started on broad antibiotics. She was admitted to ICU for hypoxic respiratory failure and intubated ___. Infectious workup was unrevealing. CT showed pulmonary embolisms for which she was started on heparin and ultimately lovenox. Her respiratory failure was attributed to penbrolizumab induced pneumonitis. She was treated with high dose steroids and IVIG with improvement, and was extubated on ___ and weaned to nasal cannula. She had persistent dyspnea on exertion and desaturations but her respiratory status was improving by time of discharge. She was discharged on prednisone 80mg with plan for long steroid taper. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who experienced a mechanical fall while showering this morning. She fell backwards and struck her head, but was able to crawl over to the "help cord" in her assisted living residence. Denies LOC. Only complains of right elbow pain. Radiology showed Increased interstitial markings at the lungs, potentially in part due to technique with possible chronic underlying parenchymal disease. Region of increased opacity at the right lung base medially for which dedicated two-view chest x-ray suggested to further characterize. Radiology showed Acute fracture through the olecranon process with associated elbow joint effusion. Radiology showed No acute fractures. Radiology showed No definite acute cardiopulmonary process. Right basilar opacity on portable x-ray likely due to confluence of shadows from costochondral calcifications and suspected bibasilar scarring and bronchiectasis. Suspected ___ thoracic/lumbar compression deformity, age indeterminate without prior. The patient was diagnosed with TRAUMATIC SUBDURAL HEM, FX OLECRAN PROC ULNA-CL, UNSPECIFIED FALL, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS. At the time of discharge, the patient had R SDH R olecranon 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>Ms. ___ was admitted to the ___ service for her injuries. Orthopedic surgery was consulted and placed her R elbow in a splint. She is to follow-up with them in 2 weeks in clinic. Neurosurgery was consulted for her SDH. Her neurological exam remained stable and no further imaging was performed. She remained hemodynamically stable. She was given a regular diet, which she tolerated. She worked with physical therapy and occupational therapy. She voided without difficulty. She was ready for discharge to her assisted living facility with services on HD3.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o dementia, aortic stenosis on plavix, and hypertension who sustained a fall at her nursing home. The patient was taking a shower with the help of an aide when she fell face forward while attempting to pick up a bar of soap. She struck her face and per the aide who witnessed her fall did not have any loss of conciousness or change in mental status after the fall. She did have signs of facial trauma and was taken to ___ for evaluation. There, her workup showed a left sided sub-dural hematoma, left posterior intra-parenchimal hemorrhage, and interpeduncular subarachnoid hemorrhage. She was neurologically at her baseline of dementia oriented to self only and was having a laceration on her lip sutured when she began vomiting what appeared to be old blood. She then had a decline in her respiratory status and was intubated for airway protection. She was then transferred to ___ for further management. Upon arrival she was intubated, sedated, and had visible diffuse facial ecchymosis and a lip laceration. Radiology showed Marked enlargement of the aortic contour, particularly the ascending aorta over the last 24 hours. A CTA of the chest should be considered to exclude acute aortic process. Discussed with Dr ___ phone at approximately 0830 on ___. Radiology showed No pneumonia. Continued but improved vascular congestion possibly related to better aeration. Radiology showed 1. Standard positioning of the endotracheal and enteric tubes. 2. Right ___ and ___ acute lateral rib fractures. Radiology showed 1. Interval enlargement of the subarachnoid hemorrhage involving the perimesencephalic cistern, as well as the pre-pontine and pre-medullary cisterns. 2. Small intraventricular hemorrhage within the bilateral occipital horns of the lateral ventricles and fourth ventricle without evidence of hydrocephalus. 3. Stable 6 mm left occipital subarachnoid hemorrhage. 4. Stable small subdural hemorrhage layering along the left cerebellar tentorium. Radiology showed No change in intracranial hemorrhage compared to ___. No evidence of new intracranial abnormalities. The patient was diagnosed with TRAUM SUBARACHNOID HEM, TRAUMATIC BRAIN HEM NEC, UNSPECIFIED FALL, TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA), WITHOUT MENTION OF COMPLICATION, OPEN WOUND OF LIP, TETANUS TOXOID INOCULAT, FRACTURE ONE RIB-CLOSED. At the time of discharge, the patient had Fall. The patient was given written instructions concerning 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 our institution after being transferred from an outside hospital where she was brought in by ambulance after sustaining mechanical fall face forward while showering. Reportedly, patient was intubated at OSH for airway protection after an episode of bloody emesis. Upon arrival she was sedated and had visible diffuse facial ecchymosis and a lip laceration. Repeat imaging studies showed interval increase in prepontine and interpeduncular subarachnoid hemorrhage tracking inferiorly, and confirmed the presence of a small intraventricular and a left subdural hemorrhage. Given findings, the neurosurgery team was consulted and recommended conservative management and monitoring for further interval changes. Patient was thus admitted to the ___ for further care. Regarding her facial injuries, the ___ team was consulted to assess the lip laceration and dental injuries. Evaluation and repair was initially difficult given the presence of an endotracheal tube. A repeat head CT scan showed no interval changes 24 hours later. Upon stabilization of her respiratory status, patient was extubated on hospitalization day #1. A tertiary survey revealed no further injuries. At this point, ___ was able to repair the lip laceration. There was avulsion of tooth #9, as well as mild mobility in teeth #8 and 10. At this point, decision was made not to place a dental splint given time elapsed from injury and questioned benefit from it. She was advised to stay on a full-liquid diet and follow-up with outside dentist once medically stable for definitive care. On hospitalization day #2 patient was started on ciprofloxacin for a urinary tract infection (confirmed by urinalysis and cultures positive for Klebsiella). Home medications were restarted upon diet tolerance, except for Plavix, to be held for one week post-injuries per neurosurgery recommendations. Given favorable response, she was transferred to the floor on hospitalization day #4. Foley catheter was then removed and patient had several episodes of incontinence. Anticipating discharge, physical therapy was consulted and determined need for extensive ___ rehab. Case management was involved in the rehab selection process. At the time of discharge, the patient was doing well, afebrile with stable vital signs. She was tolerating a full-liquids diet, and pain was well controlled. The patient's family members and aide 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: ___ is a ___ year-old right-handed obese ___ man with atrial fibrillation (longstanding A/C, but subtherapeutic INR this past week & just finished Lovenox bridge, now INR back up to 2.3), HTN, DM, HL, ?OSA, CKD-III (but no known Neurologic history). He was transferred from a scheduled office visit to our ED today due to his PCP's concern that he had a stroke or TIA yesterday. We (Neurology) were consulted to evaluate after the ED got a story of LUE weakness (since resolved) and found a facial droop on exam. Radiology showed Normal head CT. Radiology showed 1. Mild cardiomegaly. 2. Bibasilar atelectasis, left greater than right. 3. No evidence of pneumonia. Radiology showed 1. No evidence of infarct. No vascular occlusion in the head or neck. 2. Mild generalized brain volume loss. White matter signal changes, which are nonspecific, but likely reflect the sequela of chronic small vessel disease. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, FACIAL WEAKNESS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS. At the time of discharge, the patient had Transient Ischemic Attack. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>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 = pending at time of discharge) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? x() Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A ___ right-handed obese ___ man with past medical history significant for afib (with subtherapeutic INR this past week just finished Lovenox bridge,) also HTN, DM, HL, OSA, CKD-III, who presented with transient left-hand weakness which has since resolved. # Neurologic: likely had a TIA - head CT normal - MRI/MRA head and neck showed No evidence of infarct. No vascular occlusion in the head or neck. Mild generalized brain volume loss. White matter signal changes, which are nonspecific, but likely reflect the sequela of chronic small vessel disease. - TTE showed no cardiac source of embolus identified other than atrial fibrillation. However, views were suboptimal secondary to obesity. - telemetry stable throughout admission - EEG was considered on admission due to intermittent speech arrest episodes, but by the following day this was no longer evident and so EEG was not pursued - BP was 100/Doppler on AM on ___, held valsartan and amlodipine and BPs normalized shortly thereafter - AM fasting lipids were drawn and are pending, (as he was already on Lipitor 80; we would recommend Crestor if LDL is still high) - tox screens WNL, TSH pending at time of discharge - continue carbamazepine (200mg BID) and gabapentin (300/300/1200mg) - held baclofen overnight for somnolence, this was improved by the next day so restarted on ___ - We left a message with his PCP ___: recs for follow up with ___ Neurology # Pulmonology: severe OSA, obesity hypovent/restrictive etiology - stable overnight without CPAP but would likely benefit from this in the future # Infectious Disease: no active issues (non-toxic, afeb, no leukocytosis) - CXR showed no evidence of pneumonia # Cardiovascular: - Troponin normal # Hematology/Oncology: no active issues - CBC stable on admission # Endocrine: IDDM - Gave half dose of insulin glargine (Lantus) first night of admission to prevent hypoglycemic worsening of TIA, but as his symptoms did not return he was sent home on full dosing - DM diet - HbA1C quite elevated 11 # Nephrology/Urologic: - Stage 3 CKD, Cr at baseline 2.0 during admission # GI/Liver: no active issues - Took in enteric feeds (DM diet), passed dysphagia screen # Prophylaxis: - DVT: boots; already A/C (continued warfarin INR goal ___, INR on d/c was 2.1) - ___ Eval --> safe for home</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is an ___ male with PMHx HTN who is presenting with altered mental status. The night of admission, his grandson visited the patient and saw that he was not ambulating and appeared to be very weak, which differs greatly from his baseline independent functional status. His grandson last saw him 1 week ago and spoke with the patient's wife ___ days ago and she stated he was fine at that time. Per patient's wife, the patient has not been eating or drinking for the last two days, nor did he take his medications. The patient himself is a poor historian. CT abdomen/pelvis without contrast showed 1. No retroperitoneal hematoma. 2. Dense calcification at the splenic hilum is likely the sequela of prior granulomatous infection. 3. Bilateral renal cysts. RENAL U.S. showed 1. Mild right hydronephrosis and mild fullness of the left renal pelvis. 2. Nonobstructing left kidney stones, measuring up to 2 mm. 3. Significant bladder wall thickening with debris in the urinary bladder likely hemorrhagic material in the setting of hematuria. The patient was diagnosed with Acute kidney failure, unspecified, Hyperkalemia. The patient was treated with Femoral dialysis line placement Dialysis. At the time of discharge, the patient had PRIMARY DIAGNOSIS - obstructive uropathy SECONDARY DIAGNOSES - 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>___ male with PMHx HTN who is presenting with altered mental status, found to have acute renal injury and was emergently dialyzed for uremia and hyperkalemia. # Acute renal injury: Patient presenting with acute kidney injury (BUN 184, Cr 41). Patient's Cr has been trending up over the past ___ years (1.1 in ___, 1.5 in ___. In the ED he was underwent a bedside ultrasound, which showed bilateral hydronephrosis, an enlarged prostate, with 3+ liters in his bladder. Given that he had a PSA of 30 in ___, most likely cause thought to be obstructive uropathy secondary to enlarged prostate or prostate malignancy. Patient had foley placed by urology which initially revealed clear urine which quickly become bloody, consistent with hemorrhagic decompression. Patient emergently dialyzed overnight for uremia and hyperkalemia with improvement in electrolyte abnormalities. He was started on tamsulosin. Following emergent dialysis, renal function ultimately improved with discharge Cr of 1.2 and normal electrolytes. Though patient previously declined work up for prostate cancer, he will follow up with urology as an outpatient. # Altered Mental Status: Patient's altered mental status initially alert and oriented only to person likely secondary to toxic metabolic encephalopathy in the setting of uremia and gross electrolyte abnormalities. Following treatment of obstructive uropathy with dialysis and foley placement, his mental status significantly improved. Patient was alert and oriented x3 at time of discharge. # Hypertensive Urgency: Patient severely hypertensive on admission, BP 234/101. Patient had not taken meds in a couple of days prior to admission and it is unknown how long patient has been hypertensive. Patient was given 10 mg IV Hydralazine overnight and was started on Amlodipine in the ICU. Patient's BPs stabilized with amlodipine 5mg daily. His lisinopril was held in the setting of ___, and his home hydralazine was stopped with the initiation of tamsulosin. # Social Issues: At baseline, patient was living at home independently and taking care of sick wife. During admission, family raised concerns for safety to care for himself at home alone. Reportedly, family went to the home and saw blood and garbage and disarray that was concerning. Social work was consulted and their team began filing documentation to Elder Protective Services. ====================== TRANSITIONAL ISSUES ====================== - Patient will have followup with urology for workup of enlarged prostate and possible cystoscopy. - Patient's foley should remain in place until urology followup. - Patient was found to have anemia in the setting of hematuria. He should have a repeat h/h on ___. - The patient's electrolytes have largely normalized, but he continues to have low phosphorus levels. Lytes, including phos, should be checked on ___ to assess levels. - Due to concern for inadequate housing situation, Elder Services was notified, and will follow up on any need for increased services. - The patient's lisinopril was held in the setting of ___, and hydralazine was held after he was started on tamsulosin. He was started on amlodipine and tamsulosin in the hospital. He may need additional blood pressure medication titration in the outpatient setting. # CONTACT: wife ___ ___ # CODE STATUS: Full (confirmed)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old with history of Brugada, VT arrest (thought to be secondary to Brugada syndrome), s/p AICD placement ___, and recent admissions ___ and ___ for CHF exacerbation who initially presented to ___ with dyspnea and left sided chest pain radiating to his back. Of note, he has been planning to have a cardiac cath done as an outpatient, but due to the risk of kidney injury he has been delaying. He states that roughly one week ago he developed worsening dyspnea on exertion, orthopnea, and ___ edema. He states that he continued to take his home Lasix 20mg daily and was largely adherent to a low sodium diet. Starting three days ago he developed sharp left sided chest pain that started at rest and was not related to exertion. He states the pain radiated to his left arm, left side of his neck, and to his back under the shoulder blade. He states that pain was nearly constant, and after three days he decided to present to ___ for evaluation ___. At ___, EKG was performed and did not demonstrate evidence of active ischemia. CXR demonstrated pulmonary vascular congestion. Labs were notable for ___ ___, troponin T 0.02, and Cr 2.04. Pt received Zofran, morphine, and Lasix 40mg IV x 1. He was transferred to ___ for management of CHF and cardiac catheterization. Catheterization was obtained and revealed three vessel disease. He is now being referred to cardiac surgery to evaluate for surgical revascularization. CHEST (PORTABLE AP) showed In comparison to previous radiograph of 2 days earlier, pulmonary vascular congestion persists, but mild edemahas resolved in the interval. There are no areas of consolidation to suggest the presence of pneumonia, and no pleural effusion or pneumothorax is detected. CHEST (PRE-OP PA AND LAT) showed Previous mild edema has improved. No focal consolidation. CHEST PORT. LINE PLACEMENT showed Compared to prior chest radiographs ___ through ___, 12:13. Normal postoperative cardiomediastinal silhouette, including small pneumopericardium. Lungs clear. No pleural abnormality. No pneumothorax. Lines and tubes in standard placements. CHEST (PORTABLE AP) showed Comparison to ___. The nasogastric tube, the endotracheal tube, and the Swan-Ganz catheter were removed. Moderate cardiomegaly. No overt pulmonary edema. No larger pleural effusions. Stable alignment of the sternal wires. CHEST (PORTABLE AP) showed Comparison to ___. Removal of the mediastinal drains. No evidence of pneumothorax. Unchanged moderate cardiomegaly. Pacemaker leads in stable position. The right venous introduction sheet is also stable. No larger pleural effusions. CHEST (PA AND LAT) showed Small bilateral effusions, left greater than right. Radiology showed Normal bowel gas pattern. The patient was diagnosed with Cardiomyopathy, unspecified, Heart failure, unspecified. The patient was treated with 1. Coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery, and saphenous vein grafts to diagonal and obtuse marginal arteries. 2. Endoscopic harvesting of the long saphenous vein.. At the time of discharge, the patient had 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>The patient was admitted to the hospital and brought to the operating room on ___ where the patient underwent CABGx3. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable requiring Neosynepherine for hypotension, that was weaned off by POD#1. He developed acute on chronic renal failure, with significant acidosis/hyperkalemia, required bicarbonate gtt. His PPM was interrogated in the post-op period and it was determined that his A wire was not working. His device was changed to VVI. He has been in SR/SB with occasional pacing and prolonged QTC. He will need to have his PPM lead revised as determined by cardiology as an outpatient. He is tolerating Beta blocker. He was followed by the renal service for his acute on chronic renal failure and was gently diuresed. His creat peaked at 3.6 and is currently downtrending. He is being discharged on daily Lasix and will f/u with Dr. ___ in 2 weeks. The patient was transferred to the telemetry floor POD#3 for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home 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: This is a ___ year-old female with the history below who presented to the ___ Emergency room complaining of poor po intake, weakness, malaise, and pain in the mouth related to known cancerous lesion, over the past week. She has been undergoing chemo/radiation for SCC of the floor of the mouth, and has been having sig difficulty eating foods over the past ___ weeks. Her appetite is present, but foods taste unusual and she cannot eat them as a result, she also has pain in her mouth limiting the intake. She reports being able to take liquids, but was dehydrated on presentation and has clinically improved after mult litres of ivf in the ED She was advised to present to the ED for IV hydration, and for evaluation, including for possible enteral tube placement (suspect PEG given mouth cancer and xrt to area..) ABDOMEN (SUPINE AND ERECT) showed Nonobstructive bowel gas pattern. Colonic stool burden is mild. The patient was diagnosed with Dehydration, Nausea. The patient was treated with PEG placement ___. At the time of discharge, the patient had PRIMARY: Squamous cell carcinoma of the soft palate, uvula and tonsils, moderate malnutrition, Dehydration, anxiety SECONDARY: 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>___ is a ___ female with a history of head and neck cancer, squamous cell carcinoma of the soft palate, uvula and tonsils who presents with malnutrition and dehydration. # Malnutrition, moderate # Dehydration # Squamous cell carcinoma of soft palate, uvula, tonsils At this point in time it appears that she is failing oral nutrition and hydration and needs enteral feeding via PEG tube. After multidisciplinary discussion with oncology, radiation oncology, patient's daughter/healthcare proxy and patient herself, decision was made to pursue PEG placement. PEG was placed uneventfully, and she was started on cycled tube feeds that were gradually transitioned to bolus feeding. The patient was discharged on self-administered bolus TFs (Jevity 1.5, one can (240mL), 5 times daily), which she was tolerating well prior to discharge. # Pancytopenia: Chemo related, monitoring CBC/Diff to evaluate for ANC, which nadired at 1020 during this hospitalization. In discussion with her outpatient oncologist, decision was made to hold off on her last scheduled chemotherapy cycle and re-evaluate in the outpatient setting. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ y.o with history of hypopharyngeal SCC s/p trach, subsequently removed, G-tube dependent, with recent ___ guided exchange presenting with epigastric pain, elevated lipase, and imaging significant for choledocholithiasis. He first went to an OSH where he was found to have evidence of choledocholithiasis. He was given zosyn and flagyl and transferred to ___ for ERCP evaluation. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Collapsed gallbladder with cholelithiasis. No acute cholecystitis. 2. The common bile duct is not definitively visualized on this exam, but was better seen on the same-day CT exam demonstrating choledocholithiasis. The patient was diagnosed with Acute pancreatitis without necrosis or infection, unsp. The patient was treated with ERCP ___. At the time of discharge, the patient had gallstone pancreatitis choledocholithiasis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old male with past medical history of head/neck squamous cell cancer s/p chemo and XRT, previously trach dependent, s/p G-tube, admitted ___ with choledocholithiasis and gallstone pancreatitis, status post ERCP w sphincterotomy and stone extraction. # Gallstone pancreatitis / Choledocholithiasis – Patient presented with abdominal pain with lipase of 3k, and abnormal LFTs. Imaging was concerning for choledocholithiasis. Patient was made NPO, started on IV fluids, and given concern for cholangitis on OSH CT scan, started on antibiotics. Patient underwent ERCP with sphincterotomy and stone extraction without signs of purulence or cholangitis. He was recommended to take cipro for 5 days post procedure. Last day ___ AM. He was evaluated by the surgical team during admission and they did not recommend any surgery during admission but recommended short interval outpt f/u (arranged). # Esophageal Stricture ERCP incidentally found a "A benign intrinsic 9 mm stricture" at 20cm, which was subsequently dilated. Per advanced endoscopy; no follow-up is necessary unless patient were to develop dysphagia in the future--if so, the would recommend repeat endoscopy. # Hyperlipidemia Held home atorvastatin pending normalization of LFTs. Would repeat LFTs in outpt setting and resume when able. # Anxiety Continued Bupropion, trazodone # Hypothyroidism Continued Levothyroxine # Oropharyngeal squamous cell cancer s/p prior radiation therapy Continued scopolamine patch for help with secretions. Outpt f/u. Resumed tube feeds. Would consider need for repeat speech and swallow study as outpt. # BPH Continued tamsulosin </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male who was brought to the ___ ED by ambulance from ___, he presents with a complaint of 2 weeks of intrascapular back pain with accompanying left arm and chest "discomfort". He describes the pain ___ his back as dull and "like a screwdriver" boring into his muscle. The pain started between his scapulae approximately 2 weeks ago, on ___, was initially non-radiating and then progressed to include the dorsum of his left upper extremity and axilla and a discrete area ___ the midclavicular line, spanning from the 2nd rib to the ___ intercostal space on the left side, where there is an area of soft tissue swelling. He took 4 x ___ mg advil ~q8h for the first 5 days of this pain, which relieved his symptoms. The pain continued and he began to feel nauseated on ___ of the ___ week. On that day he saw a nurse practitioner at ___ who performed an EKG, which was normal, and gave him a prescription for cyclobenzaprine for muscle pain/spasm. He also noticed that lying down was uncomfortable from that time forward. Mr. ___ states that he used cyclobenzaprine through the weekend and also began taking advil 4 x ___ mg tabs combined with tylenol 2 x ___ mg tabs q 2h, every day from ___ for most of the day. Radiology showed Successful CT guided aspiration of anterior mediastinal inflammatory collection. Sample has been sent for microbiology. Radiology showed Somewhat widened appearance of the mediastinum, with a vague opacification overlying the anterior mediastinum. No evidence of pneumothorax. Radiology showed AP chest compared to preoperative chest radiograph, ___: Left hemithorax is relatively stable, no pneumothorax or pleural effusion, three pleural tubes in place. New atelectasis and small effusion at the base of the right chest. Heart size normal. Radiology showed AP chest compared to ___: New edema or hemorrhage has developed in the left lung. Small left pleural effusion is larger. No pneumothorax. Right lung is low in volume but grossly clear. Stomach is severely distended with gas. Two left apical pleural drains, unchanged. Heart size and mediastinal contours are partially obscured, but there may be widening in the region of the aortic arch. Dr. ___ was paged to discuss these findings. Radiology showed 1. Normal-appearing liver not grossly enlarged and without focal lesion. 2. Poor visualization of the spleen and left kidney secondary to overlying bandages. On comparison CT of the chest limited view of the left spleen maximally measured 15 cm. Radiology showed 1. Interval decrease of left anterior mediastinum collection with questionable involvement of the first anterior costochondral cartilage. 2. New left lower lobe disease is likely a combination of atelectasis and aspiration/pneumonia. Right lower lobe abnormality is likely atelectasis. 3. Increased density of the left lung is due to mild pulmonary edema, 4. Small left anterior pneumothorax is postprocedural. 5. Small left base pleural effusion Findings were reported to Dr. ___ at 8:30 p.m. by Dr. ___. PICC line placement. AP radiograph of the chest was reviewed in comparison to prior study obtained at 5:55 p.m. on ___. The right central venous line tip is at the level of low SVC/cavoatrial junction. Bibasilar atelectasis is present, unchanged. No definitive pneumothorax is seen. was done. The patient was diagnosed with CHEST SWELLING/MASS/LUMP. The patient was treated with ___ ___ aspiration of mediastinal mass ___ Left video-assisted thoracoscopic surgery (VATS) and debridement of mediastinal abscess ___ Right PICC line. At the time of discharge, the patient had MSSA anterior mediastinal abscess Acute renal 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>Mr. ___ was admitted to the hospital and taken to Interventional Radiology for CT guided drainage of his anterior mediastinal abscess. Yellow pus was aspirated and he was placed on broad spectrum antibiotics. MSSA grew from that sample and he was scheduled for surgical washout. His WBC was 14K and he continued Vancomycin and Zosyn therapy. His admission blood and urine cultures were negative. On ___ he underwent a left video-assisted thoracoscopic surgery (VATS) and debridement of mediastinal abscess. He tolerated the procedure well and returned to the PACU ___ stable condition with 3 chest tubes ___ place for drainage. Following transfer to the Surgical floor he had adequate pain relief and his chest tubes remained ___ place. His WBC gradually trended down but he developed acute renal failure to a maximum creatinine of 2.7. His urine output was adequate and the renal service was consulted. They felt it may be due to a combination of multiple contrast studies as well as the use of high dose Ibuprofen during his episodes of severe pain. With adequate hydration his creatinie gradually decreased and he will remain off of NSAIDS and not receive contrast until his kidney function is back to normal. The Infectious Disease service followed him closely during his admission and ___ addition to pan culturing also recommended a cardiac echo which showed no vegetations. His antibiotics were tapered to Cefazolin with plans to change to Nafcillin once his renal function returned to normal. His chest tubes were gradually removed and he felt much better. He was afebrile and his WBC was normal. He had a palm sized area above his waist along the left posterolateral area which was minimally erythematous. It was well below the incisions or chest tube sites but was watched closely and remained stable. He underwent a chest CT on ___ which showed a decreased fluid collection. The plan will be to treat him with 6 weeks of IV antibiotics via a right PICC line which was placed on ___. His creatinine gradually decreased and on ___ was 1.6. At that time he was switched to Nafcillin for better coverage. he will receive this at home at 2 Gm every 4 hours which will continue through ___. The ___ will draw labs twice a week including CBC w/diff, chem 7, LFT's, ESR, CRP. If there is any trouble with his renal function the Infectious Disease service will adjust the medication. He will have an MRI of the chest on ___ to evaluate the collection and R/O any evidence of osteomylitis and will then follow up with Infectious Disease and Thoracic Surgery. After a long hospital course he was discharged to home on ___ aqnd will have ___ services to help with home IV antibiotic therapy and wound assessment.</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 PMH of HTN who presents with 3 days of L sided pleuritic CP. Patient was in his USOH until 3 days prior to admission. Noted the sudden osnet of L sided CP that was worse with activity or lying flat. No known trauma to the area. Never had this pain before. Denies dyspnea or palpitations. The patient also c/o N/V which coincided with the onset of CP. Vomit is described as green but non-bloody. Endorses diffuse abdominal pain and has been unable to take POs. While in the ED, the patient had watery diarrhea x1. He endorses ongoing alcohol use with ___ of gin on weeekend days and 4 beers a night during the week. Last drink 3 days ago. No h/o DTs or seizures. No known sick contacts or recent travel. In the ED, initial VS were 8 98.2 78 152/105 16 96% RA. EKG significant for ST depressions and TWI in anterolateral leads. Labs, including troponin x1, were largely unremarkable. Patient was given 0.4mg SL nitroglycerin and 5mg IV morphine with relief in symptoms. Plavix load given in the ED as patient reports itchiness with ASA. Given valium for agitation and clonidine for elevated BP. Decision made to admit to medicine for r/o MI and detox. ROS: (+) as per HPI. A 12-point ROS was otherwise negative. Radiology showed Low lung volumes with mild bibasilar atelectasis. Radiology showed No acute findings to explain the patient's abdominal pain. The patient was diagnosed with CHEST PAIN NOS, ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING, ALCOH DEP NEC/NOS-UNSPEC. At the time of discharge, the patient had primary: constipation, abdominal pain, possible alcohol gastritis secondary: alcohol abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M with h/o alcohol abuse p/w positional CP and abdominal pain that he feels is related to alcohol. Pt was intiially on the ___ service and they cardiologist felt this was unlikely cardiac related and more likely abdominal pain related and pt was transferred to medicine service for further workup. . #abdominal pain - Etiology likely from constipation (CT imaging showing lots of stool in colon) vs alcohol gastritis vs PUD. ACS was ruled out by serial EKGs while on the cardiology service. Lipase/LFTs WNL. CT abdomen showing no acute findings except for stool on colon. On exam he was diffusely tender and abdoinal exam did not change while here but he was able to tolerate PO. No fever/leukocytosis to suggest major infectious process. He was started on ranitidine, was given bowel regimen with miralax, senna, docusate, bisacodyly. H pylori serologies sent were neg. He had BM day of d.c and was tolerating PO. He still had abdominal pain when he was discharged and knows to follow up with PCP for further workup if this persisits. . #. EtOH abuse - No reported h/o withdrawal seizures. Last drink 3 days prior to admission. Has did not score on CIWA. was given Thiamine, folate, MVI. Social work saw him and pt showed no interest in stopping alcohol . #. HTN - Continued home medication regimen </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old right-handed man with a history of myoclonic and abdominal seizures, undifferentiated mitochondrial disorder, migraines, and radiculoneuropathy, recent prolonged hospitalization in ___ for perforated diverticulitis s/p ___ repair and stomal retraction, now s/p reversal of colostomy who presents for evaluation of an 11 day history of progressively severe headache and left arm weakness. History provided by the patient. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CTA HEAD AND CTA NECK Q16 CT NECK. showed 1. Essentially normal head and neck CTA. 2. Please note that MRI is more sensitive for evaluation of acute/subacute ischemic changes. 3. Mild mucosal thickening identified in the ethmoidal air cells bilaterally, no air-fluid levels are seen. MRI AND MRA BRAIN AND MRA NECK PT11 MR HEAD NECK. showed 1. No significant intracranial abnormality. No evidence of acute infarction, hemorrhage or mass. 2. Patent intracranial and cervical vasculature without evidence of dissection, stenosis, occlusion or aneurysm formation. The patient was diagnosed with Headache, Weakness. At the time of discharge, the patient had 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>Mr. ___ is a ___ year-old right-handed man with a history of myoclonic and abdominal seizures, undifferentiated mitochondrial disorder, migraines, and radiculoneuropathy, recent prolonged hospitalization in ___ for perforated diverticulitis s/p ___ repair and stomal retraction, now s/p reversal of colostomy who presents for evaluation of an 11 day history of progressively severe headache and left arm weakness. Given his history and constellation of symptoms, he was admitted for neuroimaging to evaluate for central process. MRI was negative for stroke or other CNS lesion. Exam was notable for give-way weakness on left side with normal proprioception and sensation. His headache improved moderately with a migraine cocktail. He endorsed significant musculoskeletal discomfort and was seen by ___. He will be discharged home with a cervical soft collar and will follow-up with Dr. ___ week. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F h/o HCC presenting from clinic with portal vein thrombus. Pt presented to ___ oncology appt at ___ today. Pt c/o non-radiating epigastric pain ___, worsening over the past 2 weeks. Denies associated n/v/d. U/S in clinic showed new non-occlusive portal vein thrombosis and was sent in to the ED. . Pt first diagnosed with HCC last year. She had been followed for chronic hep C by GI. AFP noted to be elevated and pt had MRI which demonstrated 18 mm liver mass. s/p cyberknife ___. AFP has continued to rise. This was discussed with ___ GI who felt this may be ___ thrombus vs infiltrative malignancy. . In the ED: af/vss. RUQ u/s with dopplers showed apparent thrombus in the right anterior portal vein. ALT/AST 132/125, ap 143, tbili 0.6.Given lovenox and admitted to omed. . ROS: as above, otherwise complete ROS negative. Radiology showed 1. Reversal of flow in the right portal vein and apparent thrombus in the right anterior portal vein with either some peripheral flow in the setting of non-occlusive thrombus or collateralization around the thrombosed vessel. 2. Large gallstones in a prominent but otherwise normal gallbladder. The patient was diagnosed with PORTAL VEIN THROMBOSIS. At the time of discharge, the patient had Portal vein thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with HCV cirrhosis and ___ s/p cyberknife sent in for evaluation of portal vein thrombosis. # PORTAL VEIN THROMBUS: Etiology of thrombus is either due to tumor vs clot. She was initially started on anticoagulation x 1 (Lovenox and warfarin) which was stopped after review of images revealed this could be tumor clot, which would not need anticoagulation. Hepatology was consulted. She has also never had an EGD despite known cirrhosis, and she will require outpatient EGD to rule out varices prior to discussion of anticoaguation. She will be discussed at upcoming Liver Tumor conference. # HCC: s/p cyberknife. There is concern for possible progression of her tumor. LFTs were stable in obstructive pattern. She did not have jaundice or asterixis on exam. She was asymptomatic and will need outpatient hepatology followup. # CIRRHOSIS FROM CHRONIC HEP C. No evidence of decompensation. No ascites or asterixis on exam. # DM2: Initially hypoglycemic in ___ and complained of presyncope, which resolved after dextrose administration. Continue home glargine and ISS. # HYPERTENSION: Orthostatics negative. Continue home amlodipine and atenolol. # CKD: Cr stable in 1.0-1.2 range. # HYPOTHYROIDISM: Cont home levothyroxine #CODE: Full #CONTACT: neighbor ___ (___) ### ___ ISSUES ### -No medication changes -Will need outpatient EGD to rule out varices -Needs hepatology followup</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a right handed man with history of chronic labyrinthitis, HLD, diabetes, R caudate infarct, CAD s/p CABG who presents with vertigo and a code stroke was called. Today, he had laser eye surgery on the left at 1pm. At 3pm, he developed dizziness. He describes a "wave like" sensation, not quite room spinning. There was associated nausea, no vomiting. Symptoms improved with closing his eyes. He took ativan (what he usually takes) without relief. He denies associated diplopia, clumsiness, focal weakness, headache. There was gait unsteadiness but due to the dizziness. This was identical to his typical episodes of dizziness in quality, but increased in severity. As his symptoms persisted, his great niece called ___. Here, he was treated with zofran and had improvement of symptoms. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. MR CERVICAL SPINE W/O CONTRAST showed 1. Multilevel, multifactorial degenerative changes as described above. At C5-6 a large disc osteophyte complex flattens the cord without underlying cord signal change. In addition, there is severe left neural foraminal narrowing and moderate to severe right neural foraminal narrowing. 2. At C4-5, there is osteophyte which minimally remodels the ventral aspect of the cord. There is severe right neural foraminal narrowing and moderate left neural foraminal narrowing. 3. At C6-7 there is severe left neural foraminal narrowing and moderate right neural foraminal narrowing. 4. Additional less prominent multilevel and multifactorial spondylosis as described above. 5. Incompletely characterized are T2 hyperintense nodules within expected location of the thyroid gland measuring up to 1.2 cm on the sagittal images. Correlation with clinical history and prior imaging if available. Recommend further evaluation with thyroid ultrasound if clinically indicated. The patient was diagnosed with VERTIGO/DIZZINESS. At the time of discharge, the patient had Primary diagnosis: chronic vertigo, cervical stenosis, macular degeneration. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a right handed man with past medical history including chronic labyrinthitis, hyperlipidemia, diabetes mellitus (type 2), prior right caudate infarct, and coronary artery disease status post CABG who presented to the ___ ED ___ with acute worsening of his chronic vertigo. NCHCT was unremarkable. Due to pt's inability to ambulate independently, he was admitted to the stroke neurology service for further management. While on the floor, pt was noted to have loss of vibration and proprioception in the right > left lower extremity. He denied any recent urinary incontinence or saddle anesthesia. Due to these exam findings, pt underwent an MRI of the cervical spine which showed cervical spondylosis. There was no cord compression. Physical therapy worked with patient who recommended home with outpatient physical therapy. TSH, RPR, B12, and folate were all normal. During hospital stay, pt's vertiginous symptoms greatly improved. Pt will undergo ___ rehab as an outpatient to further treat his chronic labyrinthitis. Otherwise, pt was continued on home medications for his chronic medical conditions while in the hospital. ========================== TRANSITIONS OF CARE ========================== -MRI cervical spine incidentally showed: "Incompletely characterized are T2 hyperintense nodules within expected location of the thyroid gland measuring up to 1.2 cm on the sagittal images. Correlation with clinical history and prior imaging if available. Recommend further evaluation with thyroid ultrasound if clinically indicated." -Will need ___ rehab and physical therapy as an outpatient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old right-handed female with history of ADHD on stratera who presents with onset of slurred speech and left sided speech this afternoon. She was in her usual state of health until this afternoon/this morning when she was with friends in a car smoking K2. She felt like she was having an "anxiety attack" and went home. ___ describes shortness of breath, palpitations and says she "felt like [she] was going to die of a heart attack". She went home and tried to take deep breaths, count backwards from 10, take a drink of cold water which helped a little. The history is then unclear as to when she developed the slurred speech and weakness. . Per the history mom was given, her friend was at her apartment with her and she came out of her room some time around 2 or 3pm. At that time her speech was slurred and she had difficulty standing up. He had her sit on the couch and she fell to the ground. This friend then called her boyfriend who was at work and unable to come see her. He called another friend who picked her up and took her to the ED in ___. Per mom, she thinks she was left at the ED without much of a history being given. . In the ED at ___, she was combative and agitated. Unable to perform NIHSS due to agitation. There she had a CT head which was reportedly unremarkable. MRI performed after ativan. Radiology showed No evidence of lower extremity deep vein thrombosis. Radiology showed There is expected further evolution of the large right MCA territorial infarct with a minimal increase in leftward shift of normally midline structures and no evidence of significant central herniation. Radiology showed Stable appearance of large right MCA infarct with leftward shift of normally midline structures. Radiology showed 1. No evidence for a pelvic venous thrombus. 2. 3.6 cm minimally complex right ovarian cyst, probably within physiologic allowance in a patient of this age, followup pelvic ultrasound suggested in six weeks to ensure stability or resolution. Radiology showed Redemonstration of the extensive subacute right middle cerebral arterial territorial infarction, with similar degree of subfalcine but no more central herniation. There is evidence of hemorrhagic conversion in the involved deep gray matter structures of the striatum, as well as likely early dystrophic mineralization related to cortical pseudo-laminar necrosis. Radiology showed 1. Very large relatively acute infarct involving much of the right middle cerebral arterial distribution, with only slight mass effect upon the overlying gyri and subjacent body of the right lateral ventricle, and no subfalcine or more central herniation. 2. No evidence of hemorrhagic conversion. 3. Abrupt occlusion of the right MCA at its mid-M1 segment, which may relate to thrombosis, given the hyperattenuating material in the immediately more distal portion as seen on the NECT or, alternatively, to focal dissection or vasospasm, or some combination of these. There is minimal distal flow, largely provided by meningeal collateral vessels. 4. Otherwise, unremarkable intracranial circulation and cervical vessels; specifically, there is a normal appearance to the right common and internal carotid arteries, without significant plaque or flow-limiting stenosis. COMMENT: A preliminary interpretation to this effect was posted to RIS-web and PACS by Dr. ___ at 5:51 a.m. on ___. Radiology showed Lungs volumes are slightly diminished but no focal airspace consolidation, pleural effusions, or pneumothorax is seen. Incidental note is made of an azygos lobe. Overall, cardiac and mediastinal contours are within normal limits given portable technique. No pneumothorax. No evidence of pulmonary edema. No acute bony abnormality. Radiology showed 1. New mild (4 mm) leftward parafalcine herniation, with associated mild effacement of the right lateral ventricle. 2. Evolving large right MCA territory infarct, with no evidence of hemorrhagic conversion. 3. The suprasellar and quadrigeminal cisterns remain preserved. Radiology showed Overall, no significant change in mass effect on the right lateral ventricle compared to the prior study of ___. No hemorrhage seen. No evidence of herniation. Radiology showed Unchanged appearance of a large right MCA territory infarct, with continued mild effacement of the right lateral ventricle. Slight deformity on the right uncus. Consider close followup. No new mass effect or hemorrhagic conversion. Asymmetry in the lateral atlanto-axial distances is likely positional and can be correlated clinically for significance. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, UNSPEC HEMIPLEGIA UNSPEC SIDE, DRUG ABUSE NEC-UNSPEC. The patient was treated with PICC line placement.. At the time of discharge, the patient had Right middle cerebral artery 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>This is the brief hospital course for a ___ year old woman with ADHD on atomoxetine, on oral contraceptive therapy, and a history of tobacco use who presented with dysarthria and left sided weakness with a subsequent finding of a large right MCA territory. This notably occurred in the setting of synthetic cannabis abuse (smoking K2). She was found to have a mid-M1 occlusion of unknown etilogy with otherwise normal blood vessels of the neck and head. She was initially admitted to the SDU but overnight developed a headache. An NCHCT revealed 4mm of parafalcine herniation and she was started on hyperosmolar therapy with mannitol. She was transferred to the ICU for closer monitoring. . Her NCHCTs remained stable for the next few days (except for small amounts of hemorrhagic transformation), and her exam continued to improve with more wakefulness, attention, and improved speech. She remains hemiplegic with no movement on the LEFT side, including to noxious stimuli. . She was found to have a PFO on her TTE, but negative lower extremity dopplers and an MRI of her pelvic region did not reveal any venous clots (anticoagulation is not an option for her at this time). Hypercoagulability labs were sent, and some remain pending at the time of discharge (see above results section). These can be followed up at her appointment with Dr. ___ in a few weeks. . She conditionally passed her bedside dysphagia screen but requires 1:1 supervision and soft consistency solids. She was left-sided plegic when initially starting physical and occupational therapy, and remained this way throughout her stay with us. . At discharge, she will be continued on ASA 325mg daily, a daily statin, and prozac. Until she is more mobile, Heparin SC 5000U TID should be continued. . She was discharged to rehab for rigorous physical, speech, and occupational therapy when medically stable by the neurology team. She will have follow-up with Dr. ___ on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with reported h/o CAD, hypertension, hyperlipidemia, "CHF", s/p AVR (per patient in ___ presenting with chest pain and shortness of breath. CHEST (PA AND LAT) showed Trace pleural effusion or thickening. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had - Moderate to severe stenosis of bio-prosthetic aortic valve - Non-ST segment elevation myocardial infarction - Chronic obstructive pulmonary disease - Depression - Hypothyroidism - 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>This is a ___ with a reported h/o CAD (unknown anatomy), hypertension, hyperlipidemia, "CHF," s/p AVR (severe stenosis of a bicuspid AV that was repaired at ___ ___ with a 19 mm ___ Pericardial Magna Ease valve) who presented with chest pain and shortness of breath with concern for worsening prosthetic aortic stenosis. An echocardiogram revealed LVEF 70%, AV peak gradient of 45 mm Hg, mean of 25 mm Hg and valve area of 1.2 cm2 consistent with moderate to severe prosthetic aortic stenosis (vs. ___ ___ 0.8 cm2 with peak gradient 42 and mean gradient 28). Given level of AS so early after SAVR, there is concern for early valve failure. Plan at discharge was for the patient to follow up with outpatient cardiologist for planning of revision/replacement at ___ of his bio-prosthetic aortic valve. Troponin-T 0.02 twice followed by 2 normal values with normal CK-MB consistent with a tiny NSTEMI. Exercise MIBI provoked no symptoms and showed no perfusion defects, but poor functional capacity to only ___ METs. Based on patient's course and exercise stress, patient's chest pain was deemed to be unlikely a result of his aortic stenosis. Patient was discharged without coronary angiography as there was no objective evidence of residual ischemia. Dose of atrovastatin was increased from 40 mg to 80 mg in light of his history and risk factors for CAD.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with history of ESRD from IgA nephropathy s/p failed LRRT in ___ on HD ___ via tunneled line (and previously on PD, stopped ___ and recent acute necrotizing pancreatitis with pseudocysts in ___, who presents to the ED with abdominal pain and nausea. Radiology showed Nasogastric tube courses into the stomach and out of the field of view. Radiology showed The nasogastric tube courses past the pylorus likely into the region of the proximal jejunum The patient was diagnosed with ACUTE PANCREATITIS, KIDNEY TRANSPLANT STATUS, PANCREAS TRANSPLANT STATUS. At the time of discharge, the patient had Abdominal pain, 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>Mr. ___ is a ___ year old male with prior failed LRRT subsequently requiring peritoneal dialysis who is well-known to our service after his recent episode of necrotizing pancreatitis in ___ complicated by pseudocysts. Now on HD via RIJ tunneled line and on tube feeds via a post-pyloric dophoff tube. He is otherwise NPO. Recent imaging in late ___ showed improvement in the size of his known pseudocyst and fluid collections. He returned to the ED on ___ with band like abdominal pain, vague nausea, and a few episodes of diarrhea. His lipase was 290, minimal LFT elevation, normal WBC, and normal vitals. He was admitted to the transplant surgery service for hydration and observation. His pain resolved after one dose of dilaudid in the ED. His cdiff specimen was negative and his diarrhea stopped after an episode in the evening of hospital day 1. His vitals remained stable, his lipase came down to 190. His peritoneal dialysis catheter and his blood were cultured, both of which are no growth to date at the time of discharge. On HD2, the patient underwent routine HD via his RIJ tunneled line. He was run even for 3.5 hours. The session was stopped 30 minutes early because he had some heaviness in his chest that lasted for about 3 minutes. It self resolved, he had normal vitals during the episode, and an EKG was performed which was within normal limits and stable in comparison to the EKG that he had on ___. He was observed for a few hours and did not have recurrence of the chest or abdominal pain. The patient notes that he gets leg and chest symptoms on and off pretty regularly during his HD sessions. After HD, his tube feeds were restarted which he tolerated without difficulty and he was discharged home to follow up with Dr. ___ week in clinic. No new medications were prescribed during this admission. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ Afib, CAD, ___, CVA on aggrenox, HTN, and dementia who presents with fatigue. Per assisted living, last night was having acute AMS, confusing elevator for a bathroom and trying to wear her bra on her feet. Reportedly staff found drops of feces and blood on bedroom floor, but unknown source. Today, more fatigue in the AM. No fever/chills/cough, no neuro deficits, no chest pain, no abdominal pain. Almost couldn't wake up this AM. Per patient report, she does endorse feeling more fatigued this morning however does not recall any episodes of confusion. Currently, she feels she is in her usual state of health and surprised that she was taken to the hospital. Radiology showed No evidence of acute cardiopulmonary disease. Radiology showed No evidence of acute process. The patient was diagnosed with ALTERED MENTAL STATUS . At the time of discharge, the patient had Primary Diagnosis: Confusion, self-resolved, possibly medication effect. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRINCIPLE REASON FOR ADMISSION: ___ w/ Afib, CAD, dCHF, CVA on aggrenox, HTN, and dementia who presents with self-limited episode of fatigue and confusion. # Fatigue/Confusion: Patient reported to have acute confusion night prior to admission, and to be lethargic morning of presentation. Apparently self-resolved spontaneously, as patient was at her baseline cognitive status on arrival to the medicine floor. Delirium in this patient with reported dementia has a wide differential and most commonly may include medication effect, infectious etiology, electrolyte abnormality or other metabolic disturbances, seizures also considered. No new medications per report, however patient is on clonazepam which certainly could cause delirium in the elderly as well as amitriptyline. These medications were held and should be used cautiously or at decreased doses if indicated. Dig level was also checked and was normal. She had no symptoms or signs of infection including clean u/a and negative CXR along with any clinical symptoms of infection. The rash on her abdomen appears more consistent with irritation dermatitis or candidal rash rather than cellulitis. Basic chem panel was all within normal limits. Patient lacked any reported worrisome symptoms for seizures such as myoclonus, tongue biting, urine incontinence, though difficult to know whether post-ictal state was possible. Given the past concern for seizure activity, could consider EEG as outpatient to further evaluate. # Ostomy leak: Patient noted to have some leakage from her ostomy on arrival. Also with bright red rash around ostomy site concerning for a irritation dermatitis or perhaps candidal rash. Would recommend careful ostomy nursing to minimize leakage. Could consider empiric topical antifungal if rash does not improve with improved hygeine.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F child psychiatrist w/ complicated PMH significant for type 1 IDDM (s/p revision renal and pancreas transplants, ___ and ___, diastolic CHF (Echo 35-40%, ___, recurrent MDR E coli UTIs, chronic anemia, currently on dialysis for repeated hyperkalemia, who developed fevers during dialysis on ___. . Pt states that she was feeling completely normal up until dialysis. Over the last three months, she has had a complicated course w/ multiple admissions, most recently ___, w/ HCAP and worsening CHF during which she was intubated. Pt has since been at ___ since than and recently discharged to ___ in ___, where she has slowly been making progress in her recovery. . Pt received dialysis on ___, as usual and was found to be febrile and have chills. Dialysis was terminated early. Per her most recent nephrology note from ___, her renal graft seemed to be working better, with Cr 2.0, and a tentative plan to wean off dialysis. Pt denies any localizing symptoms prior to ___. . In the ED, Pt was initially not very responisve and triggered on arrival for altered mental status with fever 103 and HR 130. UA was bland, UCx and Blood Cx pending. Pt was given Vancomycin 1g, Levofloxacin 750mg, and Metronidazole 500mg, stress dose steroids (methylprednisolone 125mg) and fluid bolus (amount not documented). Pt had a good response w/ lactate correcting from 2.9 to 2.2, HR 90, and marked improvement in mental status. By report, she had nausea, lower abdominal pain and dysuria. Pt's CXR was significnat for small bilateral pleural effusions and interval marked enlargement of the cardiac silhouette. Bedside Echo did not show any significant pericardial effusion. Pt had a non-contrast CT abd which showed dilated fluid-filled loops of small bowel in RLQ and midline pelvis w/ some fecalized loops concerning for partial small bowel, colon full of stool, and normal appearing LLQ transplanted kidney. Transplant surgery was called and had low suspicion for obstruction w/ recommendation of serial abdominal exams and repeat imaging w/ po contrast if worsening exam or symptoms. Pt was admitted for fever of unknown origin workup. . On arrival to the floor, Pt's vitals were 99.2F, 117/60, HR 94, RR 18, sat 100% 2L. Pt has no pain at all, except for a "sharp pain" near her urethra. Radiology showed 1. Fluid-filled dilated loopss of small bowel in the right lower quadrant and midline pelvis with areas of fecalized small bowel concerning for partial small-bowel obstruction, of uncertain etiology. Clear transition point is difficult to identify given the lack of both oral and intravenous contrast. 2. Small right pleural effusion. 3. Normal appearance of the appendix. 4. Normal appearance of the transplanted kidney in the left lower quadrant. Evaluation of the patient with history of kidney and pancreas transplant and currently with sepsis and bacteremia and new oxygen requirement. Portable AP chest radiograph was compared to ___. As compared to the prior study, there is interval minimal increase in vascular congestion. Cardiomediastinal silhouette is stable. There is no change in the appearance of the dialysis catheter. Small bilateral effusions are most likely present. There is no pneumothorax. No new consolidations to suggest infectious process demonstrated. was done. Radiology showed Findings consistent with significant posterior tibial disease in the right lower extremity. Radiology showed Placement of a 15.5 ___ tunneled dual-lumen hemodialysis catheter via a right IJ approach, with the tip terminating in the right atrium. The tip-to-cuff length is 23 cm. The line is ready for use. The patient was diagnosed with SEVERE SEPSIS , ADV EFF MEDICINAL NOS, DIABETES UNCOMPL ADULT, KIDNEY TRANSPLANT STATUS. The patient was treated with interventional radiology hemodialysis catheter removal interventional radiology tunneled hemodialysis catheter placement. At the time of discharge, the patient had Primary: E coli septicemia (suspected HD line infection) Secondary: s/p pancreas and renal transplant chronic renal failure diastolic and systolic congestive heart failure severe mitral regurgitation peripheral neuropathy glaucoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F child psychiatrist w/ complicated PMH significant for type 1 IDDM (s/p revision renal and pancraes transplants, ___ and ___, diastolic CHF (Echo 35-40%, ___, recurrent MDR E coli UTIs, chronic anemia, currently on dialysis for repeated hyperkalemia, who developed fevers during dialysis and later septic shock. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is reliable historian Radiology showed Normal examination. Radiology showed Acute severe bilateral pyelonephritis. No abscess. The patient was diagnosed with ABDOMINAL PAIN EPIGASTRIC. At the time of discharge, the patient had Pyelonephritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F with no prior PMHx presents with 1 day suprapubic discomfort (likely cystitis), polyuria, abd pain, N/V and CVA tenderness (with ascending pyeloonephritis) with CT findings suggestive of bilateral pylenopnephritis. #Pyelonephritis: -Treated with ciprofloxacin during her hospitalization, and her symptoms of flank pain improved, as did her nausea. Although final culture grew out 3 species of bacteria, ___ d/w ___ medical director continuation of antibiotics for now. Discharged with oral anti-emetics, tylenol and oxycodone prn for flank pain. She also had pain in her pelvis - ? from cystitis or menstruation. Prescribed three days of pyridium # ___: (Cr = 1.3, likely higher than baseline given weight, age, build) Creatinine improved to 1.0 on discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ woman with a history of recurrent acute idiopathic pancreatitis with extensive work up without clear cause, followed by Drs. ___ who presents with recurrent symptoms concerning for recurrent acute pancreatitis. She reports that she has been suffering from recurrent acute pancreatitis for more than ___ years. She has had an extensive work up which has been unrevealing for an underlying cause despite being followed by pancreas specialists here at ___. She typically has ___ episodes per year and last admission was this past ___ for the same symptoms. Her symptoms consistently occur the same way. She has been doing well until last evening when her typical symptoms began. She first experienced abdominal pain located around her "naval" which then spreads in all direction to her entire abdomen and finally begins radiating diretly to her back. The pain is associated with nausea but no vomiting. She was awake most of the night with worsening pain so went to ___ for evaluation. What worries her this time is that her pain recurred so quickly from her last attack in ___ (was not admitted for this), usually she can be symptom free for several months. Otherwise her symptoms are fairly typical. She denies fever, chills, vomiting, chest pain, shortness of breath, diarrhea, recent travel. She does not drink nor has she drank alcohol in ___ years, she maintains a strict low fat, health diet. She presented to ___ where her labs revealed a lipase ___ (> assay). She was given IV Dilaudid, IVFs and transferred to ___ for eval. In the ED, initial vitals were: ___ pain 97.2 74 135/50 20 98% RA. Exam was reassuring with mild abdominal tenderness. Labs largely normal except for lipase >4000. CXR was negative. She was given IV Dilaudid, IVFs and admitted to medicine. On the floor, she reports her pain is reasonably controlled but she does not " want to take anything else" she reports feeling "queasy" but no vomiting. No SOB, chest pain, cough, sputum production. No fevers or chills. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. No dysuria. Denies arthralgias or myalgias. Otherwise ROS is negative. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CTA PANCREAS (ABDOMEN AND PELVIS) showed 1. Progressive changes related to chronic pancreatitis since ___, with increased irregular dilation of the pancreatic duct and increased atrophy of the body and tail. Mesenteric stranding centered around the pancreatic head suggests acute pancreatitis. No evidence of pancreatic necrosis. No peripancreatic collection. 2. Moderate simple free fluid in the pelvis, likely reactive. 3. No focal pancreatic mass. 4. Conventional arterial anatomy. The patient was diagnosed with Acute pancreatitis without necrosis or infection, unsp. At the time of discharge, the patient had Active: - Acute idiopathic pancreatitis - Chronic Pancreatic Insufficiency. The patient was given written instructions concerning 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 ___ woman with a history of recurrent acute idiopathic pancreatitis with extensive work up without clear cause, followed by Drs. ___ and ___ who presents with recurrent symptoms concerning for recurrent acute pancreatitis. # Acute pancreatitis, idiopathic # Chronic pancreatic insufficiency # Post procedure pancreatitis History of chronic recurrent acute pancreatitis with extensive negative work up followed by Drs. ___ and ___. At one point considered radical pancreatectomy though after review with multi-disciplinary pancreas board decision not to pursue that line of treatment given friable pancreas and her chronic pain syndrome had resolved. On admission, BISAP score was 1 (for age) portending favorable prognosis and lipase downtending rapidly. With conservative care including NPO, IVFs, pain and nausea control her symptoms abated and she was tolerated a clear liquid diet. CTA showed widened PD that would allow advanced endoscopic intervention. On ___, she underwent ERCP and received a PD stent across the minor papilla in an effort to keep the PD patent. Post-procedure on ___, she developed abd pain and nausea with lipase elevated to 2400. The pain has been waxing and waning since then with fluctating lipase levels of unclear significance. Continued Pancrelipase (usually on Viokace at home) at an approximate dose, which she takes for pancreatic insufficiency # Seizure disorder s/p temporal lobectomy, without seizures for many years. Continued Lamotrigine and Levetiracetam</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y.o lady with a history of hypothyroidism and depression, who presented with 1 day history of sore throat, odynophagia and difficulty with secretions. She denies any ear pain. She reports she has to push on her TMJs bilaterally to assist with swallowing due to the pain. No fever. No cough. No difficulty breathing or SOB. Immunizations up to date (except Hep B. She endorses chills at home over the last day. In the ED, initial vitals: 99.1 107 151/85 18 99% RA Physical exam significant for Oropharynx without significant swelling, no stridor, left tender adenopathy. Bedside laryngoscopy with erythema and inflammation of the vocal chords. She was given 10 mg IV dexamethasone. ENT scoped and agreed with epiglottitis. They recommended continuing 10 mg IV dexamethasone q 8 hours, unasyn 3g q6h, Benadryl 25mg q6h, continuous face mist/humidification at all times, page them for stridor/stertor, inc WOB or worsening airway complaints/signs. She should be in the ICU for airway monitoring. ENT notes: "beefy, red and edematous epiglottis w/ edema and erythema extending to AE folds and arytenoids. TVF still visualized with no glottic edema. No stridor/stertor." She received 30 mg IM ketorolac, 1 mg IM lorazepam, magic mouth wash, 3g ampicillin-sulbactam, 10 mg dexamethasone, 25 mg diphenhydramine, 2L NS. Labs significant for lactate 2.1. CHEST (PORTABLE AP) showed ET tube tip is relatively low, 2 cm above the carina and should be pulled back. NG tube is coiled within the stomach. Bibasal consolidations are present, might potentially represent atelectasis due to low lung volumes but infectious process is a possibility. Small bilateral pleural effusions are most likely present as well. The patient was diagnosed with Acute epiglottitis without obstruction. The patient was treated with ___ Fiberoptic nasopharyngeal intubation ___ Midline placement. At the time of discharge, the patient had Primary diagnosis: Pasteurella epiglottitis Pasteurella bacteremia Primary herpes simple I infection Secondary diagnosis: Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o woman who presented with sore throat and was found to have pasteurella epiglottitis and bacteremia. ===================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with PMH of well controlled asthma presenting with left hand pain and swelling. He was in his usual state of health until he woke up on ___ at 5 AM with pain in his left hand going up towards his left shoulder. The pain was worse with extending his fingers and he was unable to fully extend his fingers. He then developed swelling mostly of the left third finger and forearm. He called his doctor and was instructed to go to the ED. He denies any bites, scratches, trauma, sick contacts, recent travel. In ED labs and upper extremity Doppler were unremarkable, hand X-ray showed no fracture but did show soft tissue swelling along long finger. Hand surgery was consulted, concern for early flexor tenosynovitis, he was started on Vancomcyin and Unasyn, was put in a splint and his hand was kept elevated. He had improvement in the pain and swelling and was able to fully extend his fingers but still had some pain. Radiology showed No fracture or focal osseous abnormality. Soft tissue swelling involving the long finger. VENOUS DUP UPPER EXT UNILATERAL LEFT showed No evidence of deep vein thrombosis in the left upper extremity. The patient was diagnosed with Other synovitis and tenosynovitis, left forearm. At the time of discharge, the patient had left third finger flexor tenosynovitis. The patient was given written instructions concerning 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 PMH of well controlled asthma presenting with left hand pain and swelling. #Flexor tenosynovitis of left hand. Hand surgery was consulted in the ED. No obvious inciting cause of inflammation. Significant improvement on Vanc/Unasyn and elevation. With Vancomycin he developed some redness at the injection site and some tingling in his mouth/throat, Vancomycin was discontinued. -Transitioned to Bactrim DS for a 14 day course -Follow with hand surgery in ___ days. #Asthma: No signs of exacerbation, continue PRN albuterol #FEN/PPX: regular, ambulatory Full code</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is an ___ with history of A. fib on Coumadin, hypertension, presenting with an unwitnessed fall today. Patient himself has no recollection of the fall. Per ED documentation, the patient was found by security on the ground immediately outside of his apartment unit where he lives with his wife. He states that he woke up this morning, went to a meeting downstairs and was in his usual state of health until he found himself on stretcher by EMS. Has no recollection of intervening events. States that occasionally gets lightheaded when he takes his BP meds (sometimes takes QDay vs BID, one pill or two pills), but does not recall feeling so this morning. He denies CP, palpitations, SOB. No h/o seizures. Reports possible URI a few days ago but no persistent cough or fevers. Denies HA, focal weakness, numbness, HA, blurry vision, dysphagia, abd pain, n/v, poor PO intake, dysuria, hematuria (past hx but no recent issues), melana/hematochezia, paresthesias. Radiology showed No acute cardiopulmonary process. Radiology showed No evidence of acute intracranial process. Small left frontal scalp hematoma. Radiology showed 1. No fracture or traumatic malalignment of the cervical spine. Mild degenerative changes. 2. Enlarged heterogeneous multi-nodular left thyroid gland. Non-emergent thyroid ultrasound would be helpful for further evaluation if not previously done. 3. Pulmonary edema noted at the lung apices. Chest x-ray may be performed if clinically indicated for further evaluation. The patient was diagnosed with SYNCOPE AND COLLAPSE, URIN TRACT INFECTION NOS, TETANUS TOXOID INOCULAT, UNSPECIFIED FALL. At the time of discharge, the patient had Syncope. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is an ___ with history of A. fib on Coumadin, hypertension, presenting with an unwitnessed fall/syncope. # Fall Patient with syncopal episode of unclear etiology. No clear mechanical cause for fall and no h/o prior falls. Patient denied any ___ symptoms. No neurologic deficits on exam to suggest CVA and NC head CT neg for bleed or acute stroke. No h/o seizures. ___ revealed LBBB on EKG, which was later confirmed to be present on EKG in ___. Cardiac enzymes were neg x 3. Monitored on telemetry with no arrhythmias. Echocardiogram with normal EF, no e/o valvular disease and no wall motion abnormalities. Syncope likely occurred in setting of UTI for which patient will complete a ten day course of antibiotics. If recurrent episode, would consider event monitor. Patient evaluated by ___ who recommended regular use of a cane and home ___ for balance training. # UTI Patient reported h/o BPH and prior UTIs. Denied dysuria or recent difficulty urinating. Urinalysis for w/u of fall showed pyuria and bacteriuria. Initially treated with Ceftriaxone IV, then transitioned to PO Bactrim to complete a ten day course. Urine culture grew ___ E.coli. (Of note, patient had foley placed in ED as part of trauma protocol. Removed on arrival to the floor with few subsequent self limited episodes of hematuria. Reported clear urine prior to discharge. Has had h/o intermittent hematuria in past and this is not uncommon for him). # PAfib In SR throughout course. Continued Atenolol. Patient anticoagulated on warfarin with INR 1.6 on admission. Patient reported goal ___, confirmed with ___ ___ clinic that goal has been ___. Given above antibiotics, discharged on lower dose of warfarin 2.5mg daily with INR ___ on ___. INR on day of discharge 1.5. # Incidental finding: CT noted ___ left thyroid gland. TSH WNL. Recommend outpatient ultrasound for further evaluation. # HTN BP elevated on arrival to 190/90. Treated acutely with Labetolol, then resumed home Atenolol. # CKD III ___ ~ 1.3. GFR 53. Remained at baseline. # BPH Continued finasteride.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female who reports that yesterday morning she had oatmeal w/ milk as she usually does; around noon had some popcorn and then 15 minutes later, started having periumbilical pain, as if someone tied a knot at the belly button and was pulling it down but pain more diffuse as well. Took Tums and still wasn't feeling well; then took some Motrin 400 mg, continued to feel pain. Improved w/ lying down but feeling nauseous the whole time. Loss of appetite. Vomited up water when tried to drink. Around 9pm took more Motrin. Then today, vomited all day. Tried to drink apple cider, vomited this 10 minutes later along with medication. Middle of the night--no one to take care of kids as husband was away--tossing and turning--finally around ___ am made toast with jam, this finally stayed; took some Tums; felt better; slept from 3 to 7. Took more medication, vomited this again. Called HCA around noon, ate half an avocado, took a couple of Motrin. Staying in one position as much as possible. Pain continues unabated. Hurt to go over bumps in the car, even little bumps. Hurts to change position. Family history of gallstones, cholecystectomy among several of her female relatives. Radiology showed 1. Acute appendicitis. No drainable fluid collection or extraluminal gas. 2. Intestinal malrotation without current midgut volvulus. These findings were discussed with Dr. ___ by Dr. ___ by telephone at 9:30 p.m. on ___ and by Dr. ___ by telephone at 10:25 p.m. on ___. The patient was diagnosed with ACUTE APPENDICITIS NOS, INTESTINAL FIXATION ANOM, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. 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 Surgery team and underwent CT imaging of her abdomen showing acute appendicitis with intestinal malrotation. She was consented and taken to the operating room for laparoscopic appendectomy. There were no complications. Reader referred to operative note for full details. Postoperatively she progressed well; her diet was advanced on the morning following her surgery and her home medications were restarted. She was able to tolerate her diet without problems and is ambulating independently with adequate pain control. She is being discharged to home and will follow up with her PCP and in ___ Care Surgery clinic in the next few weeks.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with unknown PMH found down with a bottle of alcohol at side with pinpoint pupils on the side walk with heavy odor of EtOH per EMS. He was given 2 mg of Narcan x2 in ED without response. Pt became hypoxic to ___ with episodes of apnea and was intubated. There was a queston of trauma from OG tube placement d/t blood vs GI blood. Pt was guaiac negative in ED. He is being transferred intubated and sedated. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was treated with Intubation. The patient was given written instructions concerning 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 unknown PMH found unresponsive with serum EtOH level of 131 now intubated and sedated after apneic episode with respiartory failure likely secondary to toxic metabolic encephalopathy. #Hypercarbic Respiratory Failure Patient with respiratory failure secondary to altered mental status and inability to protect the airway. Hypercarbia now improved with intubation with normal pH and pCO2. Patient was quickly weaned from mechanical ventilation and extubated successfully and on RA prior to discharge. #Toxic Metabolic Encephalopathy Patient found down with bottle of EtOH with pinpoint pupils unresponsive to narcan. Serum EtOH level of 131 supports EtOH intoxication. Tox screen otherwise negative with negative CT head. Upon awakening patient endorsed taking a half tab of suboxone with alcohol. Infectious etiology also less likely given absence of leukocytosis, normal UA, and normal CXR. Mental status improved post-extubation. #Alcohol intoxication Patient with elevated serum EtOH level to 131. LFT's and INR all within normal range. Patient denied history of DT's or complicated alcohol withdrawel. Social work evaluated patient. Additionally patient monitored with CIWA scale for withdrawal. Thiamine, folate, and MVI given. Counseled regarding ETOh abuse and also seen by SW prior to discharge. #Pancytopenia Patient noted to develop pancytopenia on labs while in the ICU likely secondary to bone marrow suppression from alcohol use and dilutional effect from IVF since all counts were down.We requested that patient stay to have repeat CBC to ensure stability but patient refused to stay for blood draw. Otherwise was stable without bleeding so recommended he should have this rechecked upon follow up as outpatient if not willing to stay. #Hematemesis Questionable hematemsis vs. trauma from OG tube placement in ED. Differential included gastritis and ___ tear though patient was without any evidence of ongoing bleeding in the ICU. #Lactic Acidosis Patient with evidence of lactic acidosis initially with lactate of 3.4 on arrival. Elevated lactate likely secondary to poor PO intake in addition to EtOH effect favoring preferential conversion of pyruvate to lactate. Lactate improved with IVF to 1.1 prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with hx of weakness and guaiac positive stools. She presented to her PCPs office after feeling weak for 4 days. A few days ago she had some stomach discomfort after drinking old milk and had subsequent n/v. She had some abdominal cramping and noticed that her stools were black today (___). She went to her PCPs office and was noted to have a hgb of 11 down from 14 and black guaiac positive stool. Her BP was noted to be in the ___. She was transferred to the ED for further care. She was unable to get EGD done, as platelets result was 22. She reports that she has been taking NSAIDs recently for shoulder pain. She does have heartburn and takes ranitidine. She has never had any GI bleeding in the past. No EGD before. Last colonoscopy was in ___ and showed diverticulosis but was otherwise normal to the cecum. She denies chest pain or shortness of breath. ROS: A 10 point review of systems was performed in detail and negative except as noted in the HPI. In the ED, initial VS were 99.4 91 98/42 16 96% ra Exam notable for Heme Positive, dark stools, not tarry Labs showed WBC 3.3, Plts 20 3.3 10.1 20 32.0 Ret-Aut: 0.7 Abs-Ret: 0.02 ___: 11.0 PTT: 34.0 INR: 1.0 Lactate:2.2 Heme/onc was consulted. Decision was made to admit to medicine for further management, with heme/onc following and BM biopsy performed 2 showed No acute cardiopulmonary abnormality. CT ABD AND PELVIS WITH CONTRAST showed 1. Multiple pathologically enlarged retrocrural, retroperitoneal, and mesenteric lymph nodes are concerning for lymphoma. 2. 13.4 cm simple appearing left adnexal cystic structure displaces the uterus to the right. This was likely present in ___, but was incompletely imaged and smaller. If clinically indicated, consider MRI of the pelvis for further evaluation. 3. Top-normal spleen size, with 2 wedge-shaped hypodensities concerning for splenic infarcts. 4. Compression fracture of the T10 vertebral body was also present on the MR ___ from ___. RECOMMENDATION(S): If clinically indicated, consider MRI of the pelvis for further evaluation of the 13.4 cm simple appearing left adnexal cystic structure. The patient was diagnosed with GASTROINTEST HEMORR NOS. The patient was treated with bone marrow biopsy on ___. At the time of discharge, the patient had Primary diagnosis: anaplasma lymphadenopathy. The patient was given written instructions concerning 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 PRESENTATION: ___ yo woman with hx of GERD who presented with weakness and fatigue, with melena in setting of likely UGIB with associated pancytopenia. She has elevated LDH with lymphadenopathy seen on CT abdomen concerning for lymphoma, along with heme workup revealing anaplasma. She also likely had gastritis from NSAIDS use, leading to bleeding in setting of severe thrombocytopenia. She underwent bone marrow biopsy on ___ that showed anaplamsa with final stains for lymphoma pending at time of discharge. ACTIVE ISSUES #Lymphocytosis and Thrombocytopenia, concerning for CLL vs Mantle cell: Per ___ report, the lymphocytosis is concerning for CLL, however may need further investigation. Patient was aware of working diagnosis, and had follow up with oncology outpatient. Patient did not have any repeat episodes of melena after initial admission ___ and on ___, with her Hgb/Hct remaining stable and thrombocytopenia remained stable with slight improvement during hospitalization. It was recommended that she remain hospitalized until final pathology was determined, in the event that an aggressive lymphoma were identified and needed to be treated urgently. The patient, her husband, and in consultation with her PCP preferred discharge home with follow-up with hematology/oncology once her final pathology was back. These results were communicated over the phone by the resident physician and confirmed her follow-up appointment with heme/onc. # Anaplasma: Anaplasmosis or other tick borne illness could explain thrombocytopenia and subsequent bleeding, but prominent lymphadenopathy was thought to be less likely due to the infection. Her CBC was closely trended, and she was treated with Doxycycline 100mg TID, Day 1: ___, with plan for a ___ day course on discharge. #Upper GI Bleed from gastritis in setting of severe thrombocytopenia: Patient's Hgb/Hct remianed stable over admission. Patient was on Pantoprazole 40 mg IV twice a day inpatient. An upper endoscopy was not performed given presenting symptoms and thrombocytopenia. On discharge, she was given ranitidine 150 mg PO BID and Pantoprazole 40 mg PO twice a day. H. pylori antibody was negative, checked prior to admission. CHRONIC ISSUES #Cough/Asthma: Patient complained of mild cough, and audible "wheezing", correlated with physical exam. Patient was continued on home Symbicort, with sympotamtic relief with Guaifenesin. She remained stable on room air and did not require any supplemental oxygen therapy. #Osteoporosis: Patient was continued on home medications of Calcium Carb-Vit D3 600mg-400mg, with advil held in setting od inpatient GI bleeding. #Hyperlipidemia: Patient continued on home Lipitor 10 mg daily TRANSITIONAL ISSUES -------------------- - Follow up H. pylori serum antibody: negative - Follow up bone marrow biopsy: report as of ___ consistent with Chronic Lymphocytic Leukemia - Continue doxy for total 14 day course - Please recheck CBC + diff on ___ - Full code </s>