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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*9
Tablet Refills:*0
2. GuaiFENesin 10 mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 10 ml by mouth every six (6) hours
Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tab-cap by mouth once a day Disp
#*30 Tablet Refills:*0
4. Naloxone Nasal Spray 4 mg IH ONCE Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray Nasal As needed for
heroin/opioid overdose Disp #*1 Spray Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute hypoxic respiratory failure
Aspiration pneumonia
Opiate use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to take care of you at ___.
Why was I here?
- You were admitted to the ICU with difficulty breathing and a
lung infection after CPR.
What was done while I was here?
- You needed a breathing tube which was removed when your
breathing improved.
- You were given medications to treat pneumonia.
- You were seen by the addiction psychiatry team to discuss
substance abuse resources and counseling.
What should I do when I get home?
- Please take all of your medications as prescribed. You will
need to continue taking the antibiotic (called cefpodoxime)
until ___.
- You are being provided a prescription for narcan which you
should make sure to have at home. Make sure those around you
know to use it in case of another overdose.
- It has been a pleasure to care for you. Your team sincerely
wishes you luck with your recovery. Please continue to work with
your outpatient providers in this regard.
We wish you the best,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Allopurinol ___ mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
7. Ranitidine 300 mg PO DAILY
8. Torsemide 20 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
10. Aspirin 81 mg PO DAILY
11. Dymista *NF* (azelastine-fluticasone) 137-50 mcg/spray NU
BID PRN swelling, irritation of the nose
12. Calcium Carbonate 500 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Lidocaine 5% Patch 1 PTCH TD DAILY
15. Artificial Tears ___ DROP BOTH EYES PRN dry eye
16. DiCYCLOmine 10 mg PO BID
17. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___)
18. Omeprazole 20 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic diastolic Congestive heart failure
Mitral stenosis
Acute on Chronic kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure taking care of you at ___.
You were admitted with shortness of breath and fatigue
consistent with your known congestive heart failure. You were
treated with an infusion of lasix (furosemide) to remove extra
fluid. Your breathing improved with this treatment. It is
possible that you may need another mitral valve replacement as
this may be causing the heart failure or fluid buidlup. You had
an echocardiogram through your esophagus to better evaluate the
valve and you will see Dr ___ in ___ to discuss the valve.
Please weigh yourself daiy and call Dr ___ your weight
increases more than 3 pound sin 1 day or 5 pounds in 3 days.
Your weight at discharge is 192 pounds.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. crutch Standard crutches miscellaneous as needed L knee pain
Duration: 13 Months
Diagnosis: M25.562.
Prognosis: Good.
Length of need: 13 months.
RX *crutch 1 set crutches as needed Disp #*1 Package Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain/fever
RX *acetaminophen 325 mg 2 tablets by mouth every 6 hours Disp
#*50 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet by mouth daily Disp #*30 Tablet
Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet by mouth daily
Disp #*30 Tablet Refills:*0
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir [Truvada] 200 mg-300 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
7. Darunavir 800 mg PO DAILY
RX *darunavir [Prezista] 800 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. RiTONAvir 100 mg PO DAILY
RX *ritonavir [Norvir] 100 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Sepsis
Pneumonia
Pericarditis
HIV
Lymphadenopathy
Secondary:
Reactive arthritis
Anemia
Alcohol abuse
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You came into the hospital with shortness of breath, cough, and
chest pain. You were found to have pneumonia and fluid in the
lining surrounding your heart. You were treated with
antibiotics. For the fluid surrounding your heart, you were
given colchicine throughout your hospital stay, but it was
discontinued once you were started on HIV medications due to
potentially severe drug interactions. You may take Tylenol or
ibuprofen as needed for pain.
You had pain and swelling in your left knee after falling. Knee
x-ray showed no fracture, which was confirmed by a CT scan. The
fluid in your knee was not obviously infected, but you were
treated with antibiotics until the Infectious Disease
specialists thought that your knee pain and swelling was most
likely not due to infection. You may continue taking ibuprofen
or Tylenol as needed for pain.
During your hospitalization, you were found to have HIV. You
were started on antiviral therapy for your HIV with medications
called Truvada, darunavir, and ritonavir. You must take these
medications every day as prescribed. If you don't, your HIV
virus may develop resistance to the medication, and the
medication would no longer be effective in fighting the virus.
You should keep in contact with ___, the case worker at
AIDS Action Committee ___ number ___ main number
___. Please notify AIDS Action Committee about any
location changes or any change in your living situation.
You were found to have swollen lymph nodes in your chest. One of
them was removed, which showed that the swelling was not due to
cancer or an infection called tuberculosis but was most likely a
reaction to your recent pneumonia and HIV infection.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___
___, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery.
Physical Therapy:
activity as tolerated; lumbar corset brace when OOB.
Treatments Frequency:
ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___ Spine
Specialists, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO TID
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. Colchicine 0.6 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Rivaroxaban 15 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Xtandi (enzalutamide) 40 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Multiple acute vs pathologic spinal fractures
#Spinal metastases
#Rhabdomyolysis
#Sacral decubitus ulcer
#Fall
SECONDARY DIAGNOSES:
#Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
You were admitted after you had a fall at home.
Your scalp laceration was repaired during your stay.
Additionally, you were diagnosed with multiple spinal fractures.
Orthopedic surgery assessed these fractures and thought that
they did not require surgery.
You are to wear your ___ J collar constantly for a total of 6
weeks, except you may remove it for eating and bathing. You do
not require a brace for the fractures in your lower back at this
time, and you can move as tolerated with assistance. If you have
lower back pain that is interfering with your ability to move,
then you may wear a TLSO brace as needed.
Please call your doctor or return to the Emergency Department
for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to mobilize with appropriate
assistance, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Warm regards,
Your ___ Surgery and Medicine Teams</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Gabapentin 800 mg PO TID
3. LaMOTrigine 300 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
5. OLANZapine 20 mg PO HS
6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
7. Paroxetine 60 mg PO QHS
8. Raltegravir 400 mg PO BID
9. Rifaximin 550 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Lactulose 30 mL PO Q2H
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*2 Liter Refills:*0
12. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour apply one patch to the skin daily
Disp #*30 Transdermal Patch Refills:*0
13. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -200 unit
Oral BID
14. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Fall with head strike
Secondary: Cirrhosis, Encephalopathy, Balance disturbance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking part in your care at ___
___. You were admitted following a fall at
home. You have had chronic problems with dizziness and balance,
and this is likely an interplay of both your liver disease and
the sedating medications that you are taking. While in the
hospital, we saw that you did not have an intracranial bleed. We
also gave you lactulose to help reduce the contribution of the
liver disease. Please follow up with your PCP, the ___,
and your neurologist after discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Creon 12 1 CAP PO TID W/MEALS
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. common bile duct stricture
2. dehydration
3. acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Stable.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
You are now being discharged from ___ after being admitted due
to nausea/vomiting, dehydration, hypotension and acute kidney
injury following exchange of your biliary drainage catheter. The
plan is for you to have a biliary stent placed next week by
Interventional Radiology, and they will call you to notify you
of when this will be. In the interim, please call your doctor
or nurse practitioner if you experience the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
PTBD Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Wash the area gently with warm, soapy water and place a drain
sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen (Liquid) 650 mg PO Q6H
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Diltiazem 30 mg PO QID
5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
hold for loose stool
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE Liquid 2.5-5 mg PO Q6H:PRN pain
9. Senna 8.6 mg PO BID:PRN constipation
10. Tamsulosin 0.4 mg PO QHS
11. Lisinopril 10 mg PO DAILY
12. Atorvastatin 10 mg PO QPM
13. Milk of Magnesia 30 mL PO Q12H:PRN no BM>24 hrs
14. dutasteride .5 mg ORAL QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C2 transverse process fracture
T1, T3, T5 vertebral body fracture
T9 fracture extending into disc space
Pelvic hemorrhage
Left parietal subdural hematoma
Left anterior column acetabular fracture
Right sacral fracture
Left ___ rib fractures
bilateral super pubic rami fracture
right inferior rami fracture
left anterior acetabular fracture
left iliac wing fracture with hematoma
sternal fracture and substernal hematoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to ___ on ___ after a fall. You had a
large bleed in your pelvis for which you went to interventional
radiology and had gel foam placed to stop the bleeding. You had
multiple blood transfusions and now your blood levels are
stable. You had a small bleed in your head. The neurosurgery
team was consulted and the bleed is stable and does not require
surgery. You have left rib fractures which will continue to heal
over time. You have a pelvic, sacral, and lumbar (spine)
fracture. You were taken to the operating room by the orthopedic
surgery team and had a screw placed in your hip. The orthopedic
team recommend non-weight bearing on the left leg and weight
bearing as tolerated on the right leg. For your lumbar
fractures, the orthopedic spine team recommended that you wear a
back and neck brace when you are out of bed for support.
During this hospitalization your breathing was assisted by a
ventilator. In order to help you breath on your own and better
clear your secretions, a tracheostomy tube was placed. You had
chest tubes placed to help drain extra fluid from your lungs
which are now removed. You are now able to cough and breath
effectively on your own.
You have a fast, irregular heart rate called atrial fibrillation
that is difficult to control. You were evaluated the the
cardiology team and a pace maker was placed to help regulate
your heart rate.
You had a foley catheter placed to measure your urine output.
After removal of this catheter you were initially unable to
urinate on your own. You are not urinating on your own without
difficulty. We recommend you follow up with a urologist if this
problem persists.
You are now breathing more comfortably, your pain is better
controlled, and you are ready to be discharge to a
rehabilitation center to continue your recovery.
Please note the following discharge instructions.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN
shortness of breath
2. Calcipotriene 0.005% Cream 1 Appl TP DAILY
3. Calcium Carbonate 500 mg PO BID
4. Fluoxetine 40 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Lorazepam 0.5 mg PO DAILY:PRN anxiety
8. Magnesium Oxide 800 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
11. Docusate Sodium 100 mg PO BID
12. Simvastatin 40 mg PO QPM
13. Spironolactone 200 mg PO DAILY
14. TraZODone 200 mg PO QHS:PRN insomnia
15. Ursodiol 300 mg PO BID
16. Vitamin D 4000 UNIT PO DAILY
17. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
18. B Complete (vitamin B complex) 1 pill oral DAILY
19. biotin 5 mg oral DAILY
20. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
21. canagliflozin 100 mg ORAL DAILY
22. Ferrous Sulfate 325 mg PO DAILY
23. insulin regular hum U-500 conc 500 unit/mL subcutaneous BID
24. Lisinopril 5 mg PO DAILY
25. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
26. nystatin 100,000 unit/gram topical BID
27. Vitamin B Complex 1 CAP PO DAILY
28. Vitamin E 400 UNIT PO DAILY
29. Lactulose 30 mL PO Q8H:PRN constipation
RX *lactulose [Enulose] 10 gram/15 mL 30 mL by mouth three times
a day Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Gastrointestinal bleeding
-Nonalcoholic steatohepatitis Cirrhosis complicated by ascites
Discharge Condition:
Hemodynamically stable, A&Ox3, no BRBPR. Able to ambulate with
cane (baseline at home).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
You were admitted to the hospital because of bleeding from your
GI tract while going to the bathroom. While in the hospital, you
underwent a colonoscopy which showed dilated veins in your
rectum and hemorrhoids, but no active bleeding. You had no
further bleeding while in the hospital, and your blood counts
were stable.
You were seen by physical therapy in the hospital. They
recommended physical therapy visit your home after discharge.
After discharge, because of your live disease, please weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Duloxetine 30 mg PO BID
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir [Truvada] 200 mg-300 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
3. Etravirine 200 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Fosamprenavir 2100 mg PO Q12H
RX *fosamprenavir [Lexiva] 700 mg 3 tablet(s) by mouth twice
daily Disp #*180 Tablet Refills:*0
6. Lorazepam 1 mg PO Q6H:PRN anxiety
RX *lorazepam 1 mg 1 tab by mouth every 6 hours Disp #*30 Tablet
Refills:*0
7. Maraviroc 300 mg PO BID
8. Metoprolol Tartrate 25 mg PO BID
9. QUEtiapine Fumarate 400 mg PO QHS
10. Raltegravir 400 mg PO BID
11. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 8 hours Disp #*90
Tablet Refills:*0
12. Zidovudine 300 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Glucometer
Please dispense 1 glucometer (whichever brand/make approved by
patient's insurance) with 1 month supply of testing lancets (for
testing qAC/HS) and test strips.
DX: 250.0
15. Miconazole Powder 2% 1 Appl TP TID
16. GlipiZIDE XL 2.5 mg PO WITH DINNER
RX *glipizide 2.5 mg 1 tablet(s) by mouth Please take 1 tablet
daily with dinner. Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: diabetes mellitus
Secondary diagnoses: HIV infection, CAD, sCHF (EF 50-55%), HTN,
HLD, IBS, MDD, vocal cord paralysis s/p reconstruction x2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
You were admitted to ___ for a fast heart rate. Your fast
heart rate was caused by dehydration. You were dehydrated
because of diabetes, which is a new diagnosis for you.
We rehydrated you and got your blood sugars under good control.
Your fatigue, body aches and joint pains, as well as changes in
your voice, are likely from a viral cold-type syndrome.
Your liver enzymes were found to be elevated while in the
hospital. We belive this is secondary to _________.
Please follow up with your doctors ___ appointments below).
It was a pleasure taking care of you! We wish you the very best.
-- Your inpatient team at ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Metoprolol Succinate XL 12.5 mg PO BID
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
3. Apixaban 2.5 mg PO BID
4. Colchicine 0.6 mg PO DAILY
5. Donepezil 5 mg PO DAILY
6. Doxazosin 4 mg PO HS
7. Ensure (food supplemt, lactose-reduced) 1 bottle oral DAILY
8. Finasteride 5 mg PO DAILY
9. Loratadine 10 mg PO DAILY
10. Phosphorus 250 mg PO TID
11. Psyllium Powder 1 PKT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Aspiration pneumonia
SECONDARY DIAGNOSIS
====================
Hypernatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you here at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were found to
have very low oxygen levels at your facility.
WHAT WAS DONE WHILE I WAS HERE?
- You were given antibiotics to treat a pneumonia.
- You were seen by our speech and swallow team to evaluate how
well you swallow foods and liquids; at first we didn't allow you
to eat, but then you tried eating pureed foods and thick liquids
and did well with those.
WHAT DO I NEED TO DO ONCE I LEAVE?
- Go to all your appointments and take all your medicines.
- All your food should be pureed and all your drinks should be
thickened to "nectar thick" consistency.
Best wishes,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 325 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. LeVETiracetam 1000 mg PO BID
4. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Furosemide 20 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Leukocytosis
- Atrial fibrillation
- HTN
- Abnormal LFT's
Secondary Diagnoses:
- History of CVA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted with concern
for a heart attack but were actually found to have a severe
infection. We are still not entirely sure what caused your
infection, but you improved on antibiotics.
During your hospitalization, you had elevated liver enzymes
which may be related to a medication reaction. You also had a
decrease in your kidney function, which is probably related to
being dehydrated from your infection. Your kidney function
returned to the normal range and your liver enzymes were
significantly improved at the time of discharge.
We made the following changes to your medications:
- STOP atenolol
- STOP cardizem (diltiazem)
- START metoprolol succinate (for atrial fibrillation and blood
pressure)
- START amlodipine (for blood pressure)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, headache
2. Amlodipine 10 mg PO DAILY HTN
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Docusate Sodium 100-200 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Sarna Lotion 1 Appl TP QID:PRN itching
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Simethicone 40-80 mg PO QID:PRN Gas/bloating
13. Sucralfate 1 gm PO BID
14. Tamsulosin 0.8 mg PO HS
15. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Take ___ tablets every 4 hours if you need it to control the
pain.
17. Senna 1 TAB PO BID:PRN constipation
18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H c. difficile Duration:
14 Days
Please take 3 times a day for 14 days.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Jejunitis
Anemia
Urinary retention
Clostridium difficile infection
Secondary Diagnoses:
Diabetes Mellitus Type 1
Hypertension
Hyperlipidemia
ESRD
Diabetic Retinopathy
Erectile Dysfunction
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were seen at the ___
for abdominal pain. You were found to have inflammation of your
small bowel on cat scan and also had a scope to look into you
small intestine, which also found inflammation and swelling,
which is likely the cause of your abdominal pain. On admission
your sugars were in the 600's and were quickly brought back down
to more normal levels. During your stay, you were unable to
urinate without the foley catheter, so we had to replace the
foley catheter and reschedule a follow up urology appointment
for further workup of your urinary retention. Finally, you were
anemic, and required one unit of blood to raise your reb blood
cells. Otherwise you were managed with pain medications and
continued on your ___ hemodialysis
schedule.
Please make sure to continue taking your medications as
prescribed and follow up with your outpatient providers. You
need to see your primary care provider, urologist, and the
diabetes specialists. All of the scheduled appointments are
listed below. Weigh yourself every morning, call MD if weight
goes up more than 3 lbs.
Thank you for letting us take care of you.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Please restart your rivaroxaban on ___. Otherwise, make sure
to follow up in the ___ clinic on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
8. Multivitamins 1 TAB PO DAILY
9. Nicotine Patch 14 mg TD DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth up to every 4 hours
Disp #*90 Tablet Refills:*0
11. Senna 8.6 mg PO BID
12. Thiamine 100 mg PO DAILY
13. urea 20 % topical DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Inflammatory arthritis
T5 Fracture
Alcohol use disorder
Anemia
Psoriasis
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
us after a fall. You were found to have a fracture in your
spine. Fortunately, there is no surgery that will be needed for
this.
You were also noted to have joint pains and fevers. For this,
you were seen by the Rheumatologists. You will need a biopsy of
your wrist to help the Rheumatologists determine how to best
treat you. Our hand surgeons will be communicating with your
rehab, and the Rheumatologists, to help schedule this.
Your rash was found to be due to Psoriasis, and will improve
slowly, over time, with treatment. You are scheduled to see the
skin doctors in ___.
We wish you all the best,
___ Medicine Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) g Intravenous Q24H (every 24 hours) for 14 days.
Disp:*28 g* Refills:*0*
2. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
5. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours).
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*50 Tablet(s)* Refills:*2*
8. nystatin 100,000 unit Tablet Sig: One (1) Tablet Vaginal HS
(at bedtime).
9. Saline Flush 0.9 % Syringe Sig: One (1) syrine Injection
every eight (8) hours for 14 days: flush ___ q8h.
Disp:*42 syringes* Refills:*0*
10. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
once a day for 14 days: please flush PICC qday and prn.
Disp:*21 flushes* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lap Band erosion with retained foreign body
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. brexpiprazole 0.5 mg oral DAILY
4. ClonazePAM 0.5 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
7. PARoxetine 30 mg PO DAILY
8. ValACYclovir 1000 mg PO Q8H
9. Vitamin A ___ UNIT PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS
12. HELD- Propranolol 10 mg PO DAILY This medication was held.
Do not restart Propranolol until you are seen by Dr. ___
___ Disposition:
Home With Service
Facility:
___
___:
PRIMARY:
=========
#Acute on chronic normocytic anemia
#Guaic positive stool
SECONDARY:
==========
#Chronic fatigue syndrome
#Depression/anxiety
#Arthritis s/p R TKA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were experiencing nausea, lightheadedness and palpitations
and you were found to have worsened anemia.
What did you receive in the hospital?
- You received 2 transfusions of red blood cells with
improvement of your anemia.
- You had a CT scan of you abdomen.
- You felt better and you were ready to leave the hospital.
What should you do once you leave the hospital?
- Please make sure you follow up with your gastroenterologist as
scheduled on ___.
- Please take your medications as prescribed and go to your
future appointments.
- You should call your doctor and return to the emergency room
if you experience any of the warning signs listed below.
We wish you all the best!
- Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin EC 325 mg PO DAILY
2. Ranitidine (Liquid) 150 mg PO BID
3. Nystatin Oral Suspension 5 mL PO QID:PRN pain
4. Diltiazem 30 mg PO TID
RX *diltiazem HCl [Cardizem] 30 mg 1 tablet(s) by mouth Three
times daily Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Unsteady gait/lightheadedness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___, it was a pleasure taking care of you during
your hospitalization at ___. You were admitted for evaluation
of unsteady gait, lightheadedness, and worsening tremor. You had
imaging of your head which did not show any signs of stroke. You
were seen by neurologist specialists who did not think you had
seizures and recommended outpatient follow up for further
evaluation. It is possible that some of your symptoms may be
from taking a long acting dilitiazem. Therefore you were
switched to short acting diltiazem. You were seen by physiacl
theapy who recommended home physical therapy at home but your
refused physical therapy. Please follow up with your primary
care physician, gastroenterologist and cardiologist for further
evaluation and discussion regading possibly starting you back on
metoprolol.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
3. Amlodipine 10 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Milk of Magnesia 30 mL PO Q12H:PRN constipation
10. Omeprazole 20 mg PO BID
11. Aspirin 325 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*45 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Gabapentin 200 mg PO BID
2. Lactulose 30 mL PO QID
3. Rifaximin 550 mg PO BID
4. Ursodiol 300 mg PO TID
5. Lantus (insulin glargine) 15 units/mL subcutaneous DAILY
6. tazarotene 0.1 % topical DAILY
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Outpatient Lab Work
ICD 10 K74.60 Cirrhosis
labs should be drawn on ___ CBC INR LFTs Chem10 and
faxed to ___ Hepatology ___ ___
10. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Sucralfate 1 gm PO QID Duration: 7 Days
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth four times
daily Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
-Hepatic encephalopathy
-Hypokalemia
-Leukocytosis
-Decompensated cirrhosis
Secondary
-Type 2 Diabetes
-Chronic Kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted due to confusion. Studies showed you had no
infection but you did have electrolyte abnormalities which we
corrected. We increased your lactulose to help you get rid of
extra toxins that were making you confused. If you notice any
confusion in the future, increase your lactulose so you have ___
bowel movements per day.
It is very important that you follow up with your liver doctor
as scheduled. You will also need to have your labs drawn ___
___.
New medications: omeprazole 40 mg daily, Carafate 1 mg four
times daily for 7 days (___).
Please drink only clear liquids today, ___, and a soft diet
tomorrow (___). On the ___, you can have a regular
diet.
It was a pleasure to care for you!
-Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
2. Gabapentin 600 mg PO QHS
3. Loratadine 10 mg PO DAILY
4. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenic Fever
Myxofibrosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You were admitted with a neutropenic fever. No source of
infection was found and your blood counts improved. You did not
have a fever while admitted.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
3. mupirocin 2 % Ointment Sig: as directed Topical twice a day:
Apply to open area on right ankle twice daily.
Disp:*60 grams* Refills:*0*
4. mupirocin 2 % Ointment Sig: as directed Topical once a day:
Apply to psoriatic area on scalp daily.
Disp:*60 grams* Refills:*0*
5. betamethasone dipropionate 0.05 % Lotion Sig: as directed
Topical once a day: Apply to psoriatic area on scalp daily.
Disp:*1 bottle* Refills:*0*
6. econazole 1 % Cream Sig: as directed Topical twice a day:
Apply to athlete's foot twice daily.
Disp:*60 grams* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Cellulitis
.
Secondary:
1. Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You came to the hospital with swelling and redness of your right
leg. You had an ultrasound, which was negative for blood clots.
You were treated for cellulitis with an intravenous antibiotic
called vancomycin, which was subsequently changed to two oral
antibiotics (Keflex and Bactrim). You should continue the oral
antibiotics for another 6 days.
You were seen by the dermatology service, who recommended
applying mupiricin ointment to the area of skin breakdown on
your right ankle. They also recommended using mupiricin ointment
and betamethasone lotion for your scalp psoriasis, and econazole
cream for your athlete's foot.
The dermatology service recommended that you be seen by Dr.
___ or by the resident who saw you here in the hospital (Dr.
___ within the next ___ weeks. Please call the
dermatology office on ___ to schedule an earlier appointment.
Please also call Dr. ___ office on ___ to schedule an
appointment to be seen within the next week.
Please do not take Humira until at least 1 week after your
infection resolve. Discuss restarting Humira with your
gastroenterologist once the infection resolves.
There are some changes to your medications:
START Keflex (cephalexin) and Bactrim
(trimethoprim-sulfamethoxazole) for another 7 days.
START mupiricin ointment for area of skin breakdown on right
ankle.
START betamethasone lotion and mupiricin ointment for psoriasis
on scalp.
START econazole cream for athlete's foot.
STOP Humira for now and discuss with your gastroenterologist
when it is okay to restart this.
Do not take the medications that you were prescribed in ___,
as one of them (metamizole) can cause severe bone marrow
problems and was banned in the ___ in ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 40 mg PO QPM
2. Lisinopril 5 mg PO DAILY
3. omeprazole 20 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
-Hypertensive Urgency
SECONDARY DIAGNOSIS/ES:
-Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital because you were having very
high blood pressures. You were closely monitored in the
intensive care unit because of these blood pressures. Please see
below for a more detailed account of your hospital course.
WHY WERE YOU ADMITTED TO THE HOSPITAL:
-You had very high blood pressures
-You were feeling nauseated, sweaty, and short of breath
WHAT WAS DONE FOR YOU IN THE HOSPITAL:
-You were given medications to lower your blood pressure quickly
-You had multiple scans of your head and your kidney to try and
figure out why your blood pressures were so high
-You had many blood tests run to try and figure out why your
blood pressures were so high
WHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:
-PLEASE follow up with your outpatient doctor
-___ pick up a 24-hour urine collection container at ___ on
the ___ floor of the ___ Building
-Please take your medications as prescribed
-Come back to the ED right away if you have another episode
Best Wishes,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Furosemide 20 mg PO DAILY
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
7. NPH 18 Units Breakfast
NPH 18 Units Dinner
RX *insulin NPH isoph U-100 human [Humulin N NPH U-100 Insulin]
100 unit/mL AS DIR 18 Units before BKFT; 18 Units before DINR;
Disp #*1 Vial Refills:*0
8. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff every 4 hours
Disp #*1 Inhaler Refills:*0
10. FLUoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times daily
Disp #*1 Bottle Refills:*0
12. Nadolol 40 mg PO DAILY
RX *nadolol 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine 14 mg/24 hour Apply 1 patch daily Disp #*30 Patch
Refills:*0
14. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
15. Spironolactone 25 mg PO BID
RX *spironolactone 25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic Cirrhosis
Alcohol Use Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you while you were admitted at
___,
Why was I admitted to the hospital?
-You were having dark black stools which were concerning for
bleeding. Your liver disease puts you at high risk for bleeding.
What was done while I was admitted?
-We performed several laboratory tests to confirm that you were
not bleeding.
-We monitored your blood pressure and heart rate very carefully
-We ensured that you would not have withdrawal symptoms from
alcohol.
What should I do when I go home?
-It is very important for you to stop drinking alcohol.
-Attend AA sessions to assist you in stop drinking alcohol
-See your primary care physician
-___ doctor. We have scheduled an appointment for you
(time and location are noted below)
-Continue taking all of your medications as prescribed in the
discharge paperwork.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
2. Aspirin 81 mg PO DAILY
3. Betimol (timolol) 0.5 % ophthalmic (eye) DAILY
4. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
8. Levothyroxine Sodium 150 mcg PO ONCE WEEKLY
9. LORazepam 0.5 mg PO BID:PRN anxiety
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until Your primary
care provider thinks it is nessesary again
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Syncope, Orthostatic Hypotension, Subarachnoid
Hemorrhage, Hypokalemia, Viral gastroenteritis
Secondary: Stage IB Grade 2 endometriod endometrial
adenocarcinoma, HTN, Asthma, Anxiety, Glaucoma, Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I ADMITTED?
- You came to us because you fainted and hit your head
WHAT WAS DONE FOR ME WHILE I WAS IN THE HOSPITAL?
- We performed a CT of your head to see if you had any bleeding
around your brain
- We performed an EKG and monitored your heart to see how your
heart was functioning
- We performed an echocardiogram to see if there was any
abnormality in the structure or function of your heart
- We performed a number of blood tests to monitor the
electrolytes in your blood
- We gave you IV fluid with potassium to hydrate you and
increase the level of potassium in your blood
- We stopped giving you your diuretic because it may have been
contributing to your low potassium levels
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed.
- Please stop taking your hydrochlorothiazide as this may have
reduced your potassium
- Please follow up with your primary care physician as described
in this summary
- If you have chest pain, shortness of breath, lightheartedness
or other danger signs listed below please call your PCP or come
to the emergency department
Best Wishes,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear ___,
You were admitted to the hospital because you were having some
unsteady gait and confusion. You were found to have new masses
in your brain from spread of your lung cancer.
While you were here, you were started on radiation therapy for
the masses in your brain. You were also seen by physical
therapy, who recommended you go to rehabilitation to help make
you stronger. You were discharged in good condition.
When you leave the hospital, it is important you continue to go
to your radiation appointments. It is also important you take
you medications as prescribed.
If you have any increasing confusion, nausea, vomiting,
headaches, or increasing sedation, it is important you go to the
ER immediately.
It was a pleasure to care for your, and we wish you the best of
luck!
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times
daily Disp #*40 Capsule Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. FoLIC Acid 1 mg PO DAILY
6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
7. Pregabalin 100 mg PO TID
8. Propranolol LA 60 mg PO DAILY
9. Venlafaxine 150 mg PO DAILY
10. Vitamin B Complex 1 CAP PO DAILY
11. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>___,
You were admitted to the hospital for a skin infection of your
left leg. This improved with antibiotics. You will be discharged
with antibiotic pills to complete two weeks of treatment.
Please keep your left leg elevated at all times while sitting
during healing process.
You will need to follow-up with your primary care provider after
hospital discharge.
It was a pleasure taking care of you!
Sincerely, your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Mr. ___,
It was a pleasure taking care of you while you were admitted at
___. You were admitted due to nausea and vomiting with low
blood pressure due to a viral gastroenteritis. You were given
IV fluids and managed with supportive care, and your blood
pressure came up to normal. Your symptoms resolved and you were
discharged the following day.
Some of your blood pressure medications were held while you were
in the hospital because your blood pressure had been low. We
restarted your metoprolol but not your lisinopril or
hydrochlorothiazide. You will talk to your primary doctor about
restarting these when you see him next ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
2. Enoxaparin Sodium 30 mg SC QHS
RX *enoxaparin [Lovenox] 30 mg/0.3 mL 1 (One) syringe
subcutaneous once a day Disp #*28 Syringe Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 (One) ml by mouth twice a day
Disp #*20 Tablet Refills:*0
5. Atenolol 50 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. Prazosin 2 mg PO DAILY
10. Quinapril 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower externally
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
ASSESSMENT/CLINICAL IMPRESSION: Pt is a ___ y/o F hospitalized
for
ankle fx, now POD ___ s/p ORIF. pt presents with progress
including: increased strength, endurance and functional
mobility,
however is limited by decreased endurance due to NWB status, and
inappropriate HDR to mobility. Due to patients strong home
supports, ability to live on 1 level, and progress demonstrated
so far with mobility, I recommend the patient DC to home with
home ___, a WC and commode. Family reports they can move a bed to
the ___ living level, and have 2 people assist with WC transfer
up/down her front stairs. patient will require ___ more ___
sessions for family education on WC management and stair
negotiation. patient may require rehab placement if family
unable
to comply.
Recommended Discharge: (X)see clinical impression
PLAN:
Progress functional mobility including bed mobility, transfers,
gait and stairs as tolerated.
Balance training
Pt/caregiver education RE: fall risk
D/C planning
Recommendations for Nursing: OOB for all meals and at least 3
hours a day no more than 1 hour at a time to prevent skin
breakdown.
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
6. Tiotropium Bromide 1 CAP IH DAILY
7. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing
8. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drive while on this medication
10. Albuterol Inhaler 2 PUFF IH Q4-6H:PRN chest
tightness/wheezing
11. Allopurinol ___ mg PO DAILY
12. brimonidine 0.2 % ophthalmic 1 drop in each eye 3 times a
day
13. Calcitriol 0.5 mcg PO 3 TIMES A WEEK (___)
14. Diltiazem Extended-Release 180 mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
18. Losartan Potassium 25 mg PO DAILY
19. Magnesium Oxide 500 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q24H
22. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE AS
NEEDED
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
cecal volvulus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You came to the hospital with abdominal pain and white blood
count of 15 on ___. You were found to have a cecal volvulus.
You underwent an emergent exploratory laparotomy with right
colectomy and primary anastamosis. Your abdomen was left open so
you were again brought to the operating room and underwent a
washout and closure on ___. After extubation on ___ you
had difficulty with phonation so otolaryngology was consulted to
assist with laryngeal exam. You started to feel better and were
advanced to a regular diet which you are now tolerating. You are
ready to be discharged to a rehabilitation facility. Please
adhere to the following instructions for discharge.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*20 Capsule Refills:*0
2. Pantoprazole 40 mg PO 2X/DAY
RX *pantoprazole 40 mg 1 tablet(s) by mouth 2X/DAY Disp #*60
Tablet Refills:*0
3. Sucralfate 1 gm PO QID
Please crush in 30 cc's of water to form a slurry.
RX *sucralfate 1 gram 1 tablet(s) by mouth four times daily Disp
#*40 Tablet Refills:*0
4. Periogard (chlorhexidine gluconate) 0.12 % mucous membrane
BID
Brush 15 mL on teeth 2x daily (dip toothbrush in solution and
brush on teeth, repeat until solution gone)
5. Cyanocobalamin 1000 mcg PO AM
6. Atenolol 25 mg PO QAM
7. Bengay Cream 1 Appl TP TID:PRN pain
Apply to left knee three times a day as needed for pain
8. Guaifenesin ___ mL PO Q4H:PRN cough, congestion
9. Tenofovir Disoproxil (Viread) 300 mg PO QAM
10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
11. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP HS
Apply a thin ribbon to toothbrush. Brush thoroughly for two
minutes at bed time.
12. Allopurinol ___ mg PO QAM
13. Acetaminophen 500 mg PO Q6H:PRN pain, fever
14. Phosphorus 500 mg PO DAILY
RX *sod phos,di & mono-K phos mono [Phospha 250 Neutral] 250 mg
2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
# Severe esophagitis c/b UGIB
# Duodenal stricture
# Fever/Cough/Leukocytosis
Chronic diagnoses:
# Chronic Hepatitis B
# CKD
# History of HCV
# HTN
# Gout
# Pernicious anemia
# Peridontal disease
# OA
Discharge Condition:
Mental Status: Clear and coherent (some communication
limitation).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
after vomiting blood and we also noticed you had a fever and
cough. We looked into your stomach with a camera and found that
you have irritation of the throat, called esophagitis. We gave
you some medications for the irritation. Your cough also
gradually improved with medications and we think it is from an
upper respiratory infection. We discharged you back to your
group home. When you return home, you do not have to return to
work right away; we have written you a letter for work.
Our GI doctors ___ be calling your home to set up a follow-up
appointment for an ultrasound. If you experience additional
episodes of vomiting blood, please call clinic right away or go
to the Emergency Department.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Cetirizine 10 mg PO DAILY
3. estrogens-methyltestosterone 1.25-2.5 mg oral DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 2 mg PO DAILY
Started lower due to elevated INR. Previous home dose: ___:
3.5mg, other days: 3mg
9. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Viral upper respiratory infection
Atrial fibrillation with rapid ventricular response
Weakness
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear ___ was a pleasure taking care of you. Thank you for choosing
___ for your care. You were admitted to the hospital with
weakness and trouble breathing. We found that you had too much
fluid in your body, and likely had a viral upper respiratory
infection.
Your heart rate was also fast, likely due to your atrial
fibrillation and your infection. We increased your heart rate
medication (metoprolol) to help better control your heart rate
as well. Your doctors ___ continue to increase your medication
as needed.
If you have trouble breathing, or other symptoms that worry you,
please let your doctor know or return to the hospital for
further care.
Thank you,
___, M.D.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet by mouth every twelve (12) hours Disp #*10 Tablet
Refills:*0
2. Renagel 1600 mg oral QID
3. AcetaZOLamide 250 mg PO Q12H
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. brimonidine 0.2 % ophthalmic (eye) TID
8. Cinacalcet 60 mg PO DAILY
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. GlipiZIDE 10 mg PO BID
12. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
13. Metoprolol Tartrate 12.5 mg PO BID
14. Nephrocaps 1 CAP PO DAILY
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
16. Ranitidine 150 mg PO BID
17. sevelamer CARBONATE 1600 mg PO QID
18. HELD- Doxercalciferol Dose is Unknown PO 3X/WEEK (___)
This medication was held. Do not restart Doxercalciferol until
you confirm with your PCP dose and duration
19. HELD- Epoetin Alfa Dose is Unknown IV Frequency is Unknown
This medication was held. Do not restart Epoetin Alfa until your
PCP confirms dose and duration
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right third toe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires heel weightbearing
surgical shoe
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the vascular surgery department at ___
and you were found to have osteomyelitis of the right toe. You
underwent a right third toe amputation and are now ready to be
discharged.
ACTIVITY
Keep your foot elevated to prevent swelling.
It is very important that you put no weight or pressure on your
toe to allow the wound to heal properly.
You may use the opposite foot for transfers and pivots, if
applicable.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the wound. If there is no drainage, you
may leave the incision open to air.
If used, any staples/sutures will remain in place until
follow-up with ___ clinic
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth at your amputation site.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
It has been a pleasure looking after you and we wish you a
speedy recovery.
Best,
Vascular Surgery Team at ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*25 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*37 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intra abdominal fluid collection due to perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with an drainable collection in your abdomen due to perforated
appendicitis. You were given IV antibiotics and taken to
Interventional Radiology for drainage of the infection. You are
now doing better, tolerating a regular diet, and pain is better
controlled.
You are now ready to be discharged to home with your 2 drains to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>You were admitted for further evaluation of abdominal pain due
to stones in your bile ducts and an inflammation of your colon
(diverticulitis). For this, you were monitored by the surgery
and GI teams. You were given antibiotic therapy with good
effect. In addtion, you underwent an ERCP where attempts were
made to remove the stones in your bile ducts. However, you were
found to have some large stones and these were unable to be
removed at this time. Therefore, you have a stent in place to
keep the area opened. You will need to return in 2 week's time
for repeat ERCP and stent removal. You will also need to follow
up with general surgery for consideration of having your
gallbladder out. Your symptoms improved and your diet was
successfully advanced.
.
Medication changes:
1.cipro/flagyl - take for another 5 days
2.stop asa and cilostazol - can be restarted in 5 days. You
should stop cilastazol 3 days before your next ERCP.
3. You were start on a PPI called omeprazole for GERD.
.
Please take all of your medications as prescribed and follow up
with the appointments below.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID opiod
dependence
home med
2. Risperidone 1 mg PO BID
home med
3. Nicotine Patch 21 mg TD DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Pyridoxine 25 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Aspirin 325 mg PO DAILY stroke secondary prophylaxis
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*100
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE ISSUES:
1. Left face tingling, word finding difficulties - suspect TIA
CHRONIC ISSUES:
1. Embolic right cortical stroke
2. Hepatitis C
3. Patent foramen ovale
4. Polysubstance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital for left-sided facial tingling
and mild word-finding difficulties concerning for a new stroke.
You had a CT scan and MRI, both of which were reassuring and
showed no new stroke. We checked some more labs to see whether
you have a coagulation disorder predisposing you to strokes,
which showed....
Please attend your previously-scheduled follow up appointment
with neurology with Dr. ___ cardiac surgeon with Dr.
___ below.
We made the following changes to your medications:
1. INCREASED aspirin from 81mg daily to 325mg daily</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*9
Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO/NG BID
RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp
#*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
septic abortion
hyperthyroidism
chlamydia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office
with any questions or concerns. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks.
* You may eat a regular diet.
You were admitted to the gynecology service after your
miscarriage. You had a procedure done in the operating room to
remove pregnancy tissue. You were found to have an infection.
Your infection was treated antibiotics.
Please complete your entire antibiotic course as instructed,
even when you start feeling better.
You were also diagnosed with hyperthyroidism during this
admission and had a high heart rate. You were started on a
medication called atenolol to help bring your heart rate down to
a normal range. Please continue taking it as instructed.
You were also diagnosed with chlamydia during this admission and
you were treated for it.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Mr ___,
It was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted because you had an infection in your finger. A
collection of fluid was drained by the plastic surgeons. You
were given antibiotics which you will need to continue for 12
more days. You will also need to soak your finger in betadine
three times a day.
We made the following changes to your medications
1. START Augmentin 500 mg daily for 12 more days
2. DECREASE simvastatin to 20 mg daily
3. START Tylenol ___ mg three times a day as needed for pain
You should continue to take all your other medications as
instructed. Please feel free to call with any questions or
concerns.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
2. Aspirin 325 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. Clopidogrel 75 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Paroxetine 20 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
11. Boniva (ibandronate) 150 mg oral Qmonthly
12. Cetirizine 10 mg PO DAILY
13. Estrogens Conjugated 0.625 gm VG DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Potassium Chloride (Powder) 40 mEq PO DAILY
Hold for K >
16. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
17. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
Qweekly
18. Supplemental oxygen
Portable oxygen delivery system, ___ titrate to O2 sats
>92%. ___: V46.2 (dependence on supplemental oxygen).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Neisseria meningitis
Oxygen dependence
SECONDARY DIAGNOSIS
asthma
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mrs. ___,
___ was a pleasure taking care of you at ___. You were
transferred for further management of neisseria meningitis. You
were continued on the correct dose of antibiotics and completed
the appropriate IV antibiotic course. You also took 2 days of
oral meds to clear any colonization in your upper airway. All of
your close contacts should take the prescribed prophylactic
antibiotics to prevent infection.
During your stay you were found to have episodes of low oxygen
when walking around. You have been told in the past that you
might benefit from oxygen at home and it was reordered while you
were here.
Of note, our radiologists commented on small nodularities on
your right upper lung, which is likely from an old infection.
This should be followed by a 3 month chest ___.
You should follow up with your primary doctor when you return to
___.
Wishing you well,
Your ___ Medicine Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, SOB
3. Ascorbic Acid (Liquid) 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. FoLIC Acid 1 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezes, SOB
9. Loratadine *NF* 10 mg Oral daily
10. Naphazoline-Pheniramine Ophth. Solution 2 DROP BOTH EYES
QID:PRN dry eyes
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. PredniSONE 15 mg PO DAILY
14. Promethazine 25 mg PO Q6H:PRN nausea
15. Thiamine 100 mg PO DAILY
16. Warfarin 5 mg PO DAYS (___)
17. Alendronate Sodium 70 mg PO QMON
18. Hydrocortisone Cream 2.5% 1 Appl TP BID
19. Oyst-Cal-500 *NF* (calcium carbonate) 500 mg calcium (1,250
mg) Oral daily
20. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q6H:prn wheezing
21. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth every six (6) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hip Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You were admitted because you were feeling unwell. You appeared
very dehydrated and we gave you lots of fluid and held your
lasix. The CAT scan of your abdomen did not reveal the cause for
your pain. You also complained of vision loss however the eye
doctors did not find a reason for this. At discharge you were
able to tolerate food. You will need to follow up with your
doctor to work this pain up further.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
2. Omeprazole 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily as
needed Disp #*60 Capsule Refills:*1
4. Lidocaine Viscous 2% 20 mL PO QID:PRN mouth pain
RX *lidocaine HCl 20 mg/mL 20 mL PO four times daily as needed
Disp #*1 Bottle Refills:*0
5. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*1
6. Indapamide 2.5 mg PO DAILY
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Ondansetron 8 mg PO Q12H:PRN nausea
10. Prochlorperazine 5 mg PO Q6H:PRN nausea
11. ValACYclovir 1000 mg PO Q12H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every ___ hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Febrile neutropenia
SECONDARY:
Breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___, you were admitted because of a fever. We thought
this was from a herpes outbreak because of your oral and vaginal
lesions. The lesions in your mouth are probably related to
chemotherapy because that can cause breakdown of mucous
membranes. We treated you with acyclovir for the outbreak and we
are sending you home with a prescription for this medication
which you should continue throughout the duration of your
chemotherapy unelss you hear otherwise from your oncologist.
We also had some concern that your port site could have an
infection but we monitored you carefully and it seemed to be
fine. Please call your doctor immediately if that site develops
any drainage or redness or tenderness.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Bisacodyl 10 mg PO BID:PRN constipation
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
7. Metoprolol Tartrate 100 mg PO TID
8. Montelukast Sodium 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Torsemide 60 mg PO DAILY
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN itch and
pain
13. Vitamin D 400 UNIT PO BID
14. Warfarin 5 mg PO DAILY16
15. Docusate Sodium 100 mg PO BID
16. Vancomycin 750 mg IV Q48H
17. Omeprazole 20 mg PO BID
18. Finasteride 5 mg PO DAILY
19. Aspirin 81 mg PO DAILY
20. Calcium Carbonate 500 mg PO BID
21. Outpatient Lab Work
Weekly CBC with differential, chem-7, vancomycin trough, and
ESR/CRP faxed to ___.
22. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
-Septic arthritis
-Septic shock
-Hemarthrosis
-Supratherapeutic INR
-Healthcare associated pneumonia
-Delirium
Secondary diagnoses:
-Diastolic heart failure
-Atrial fibrillation
-Hypertension
-Chronic kidney disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It has been a pleasure taking care of you in the hospital. You
were admitted for chest pain and trouble breathing. You were
treated with intravenous antibiotics for pneumonia and diuretics
for your heart failure. During your hospital course, you were
found to have an infection in your knee. You had surgery and are
now on antibiotics which will require treatment for several
weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID
hold for loose stool
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
please take stool softener or laxative with this med, it can
cause constipation
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. gabapentin 800 mg oral TID
7. lamoTRIgine 50 mg oral DAILY
8. OLANZapine 5 mg PO BID:PRN agitation
9. Venlafaxine XR 150 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Grade 1 liver laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ after
a car crash and you sustained a head laceration which was
repaired with staples, as well as a minor liver laceration.
Your blood levels were trended and have remained stable. Your
diet was advanced to a regular diet, which you are tolerating,
and your pain is better controlled with pain medication. You
are now ready to be discharged home to continue your recovery.
Please note the following discharge instructions:
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Cephalexin 500 mg PO Q6H Duration: 6 Doses
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*6 Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*1
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*20 Packet Refills:*0
6. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 by mouth once a day Disp #*20
Tablet Refills:*0
7. TraMADol 50 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*25 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Central cord syndrome
Complex right perineal and scrotal closure
Left inferior orbital floor fracture
Bilateral nasal bone fractures
Left lamina propecea fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ after a fall. You were experiencing
numbness, pain and tingling in your extremities, MRI obtained
was concerning for cord injury at C3/C4. You were seen by
Neurosurgery and they recommended hard cervical collar to be
worn at all times and outpatient follow-up. You also had facial
fractures, a scalp laceration, and a scrotal laceration. Plastic
Surgery evaluated you and recommended bacitracin to the scalp
laceration and non-operative management of the facial fractures.
Because you fractured the bones around your left eye,
Ophthalmology did an eye exam which was normal. If you do
experience any vision changes, you should have your eye
re-examined. Urology was consulted and determined the scrotal
injury did not involve the genitourinary system. You were taken
to the operating room for a washout and repair of this injury.
There is a surgical drain that will remain in place until your
follow-up in clinic.
You are regaining your sensation and are medically cleared for
discharge home. Please note the following:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. LevETIRAcetam 500 mg PO BID Duration: 10 Days
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
no greater than 4gram of APAP in 24 hours
6. Senna 17.2 mg PO HS
7. Acyclovir 400 mg PO Q8H
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough, SOB
9. amLODIPine 5 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Furosemide 20 mg PO DAILY
13. Metoprolol Tartrate 6.25 mg PO Q6H
14. Pravastatin 10 mg PO QPM
15. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Atrial fibrillation
Discharge Condition:
Stable
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures or staples along your incision dry
until they are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Onc:
- Will consider restarting chemotherapy after wound evaluation
at first follow-up.
- Check at least 1 CBC w/ diff at rehab per oncology team
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin, Xarelto) until cleared by the
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
4. lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___: Please get your blood level checked by your PCP and adjust
warfarin dose according to their direction.
Disp:*30 Tablet(s)* Refills:*0*
9. Tylenol ___ mg Tablet Sig: ___ Tablets PO every eight (8)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
deep vein thrombosis
pleural effusion
acute on chronic kidney injury
Secondary:
anemia of chronic kidney disease
polycystic kidney disease
congenital hepatic fibrosis
thrombocytopenia (low platelet count)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>It was a pleasure participating in your care at ___. You were
admitted to the hospital and found to have a blood clot in your
leg and possibly lungs. You have been treated with blood
thinning medicine for this. You were also found to have extra
fluid in your chest outside of the right lung called a pleural
effusion. You have decided to follow up with Interventional
Pulmonology as an outpatient for possible drainage of this
liquid.
REGARDING YOUR MEDICATIONS...
Medications STARTED that you should continue:
colace, senna, warfarin (blood thinner), tylenol
Medications STOPPED this admission:
lisinopril (given kidney function) - this should be addressed
with your primary care doctor regarding resuming this medicine.
Medication DOSES CHANGED that you should follow:
metoprolol succinate was decreased from 75mg daily to 25mg
daily.
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
** It is very important that you call your PCP or come into ED
for any changes in your breathing or for fevers given your
pleural effusion (fluid around the lung)**</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Pradaxa 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO once a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day prn as needed for leg swelling.
Discharge Disposition:
Home
Discharge Diagnosis:
unstable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ for
chest pain. We treated you with medications for your chest pain
and then you underwent a cardiac cath. You cardiac cath
revealed 2 blockages that will be treated with medications. You
will need to start new medications (see below for details).
Please follow up with your primary care doctor and your
cardiologist.
Medication Changes:
START taking dabigatran (pradaxa) 150mg by mouth every 12 hours
START taking clopidogrel (plavix) 75mg by mouth daily
START taking lisinopril 20mg by mouth daily
START taking isosorbide mononitrate (imudr) 30mg by mouth daily
START taking aspirin 81mg by mouth daily
START taking atorvastatin 80mg by mouth daily
INCREASE metoprolol succinate to 400mg by mouth daily
STOP taking Warfarin
STOP taking simvastatin
Continue taking sotalol 120mg by mouth daily
Continue taking Furosemid 40mg by mouth as needed for ankle
edema</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 5 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Haloperidol 5 mg PO BID
4. Lisinopril 10 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. LeVETiracetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
7. DiphenhydrAMINE 50 mg PO Q12H
8. Milk of Magnesia 30 mL PO QHS:PRN constipation
9. Mylanta 30 ml oral Q4H:PRN dyspepsia
10. Acetaminophen ___ mg PO Q8H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==================
Syncope
Orthostatic Hypotension
Fall
traumatic ___
Secondary Diagnoses
===================
C4 on C5 anterolithesis
Schizophrenia
Delirium
Abnormal EKG: RBBB, left anterior fascular block, ?nodal
conduction disease
Elevated CK
Hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking part in your care during your
hospitalization at ___. You underwent diagnostic work up
because you lost conciousness, fell, and struck your head while
at ___. Your fall was most likely
due to orthostatic hypotension, low blood pressure when you are
standing. We recommend that you drink plenty of fluids, and
that you rise slowly when changing from sitting to standing.
Because you struck your head, we did a CT-scan to look at your
brain. A small amount of blood was seen in your brain. Blood
can irritate the brain and cause seizures. We have put you on a
medication to prevent seizures for 1 week. You have already had
2 days of this medication and only need to take it for 5 more
days.
You have schizophrenia and were being seen at ___
for psychosis. It is important for you to continue in patient
treatment for pyschosis. Managing mental illness is
challenging, continue to take your antipsychotic medications and
keep intouch with your providers.
You had some abnormalities on EKG, a study of electrical
conduction in your heart, howevever, these do not seem to be
new. You had no evidence of a heart attack. You did not have any
symptoms while in the hospital, and an ECHO of your heart showed
normal heart function. You should discuss with your primary
care provider if you have questions about these findings.
It was a pleasure participating in your care.
We wish you the best of luck!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
2. Labetalol 100 mg PO TID
3. Lisinopril 40 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left frontoparietal intraparenchymal hemorrhage.
hyptertension
oropharyngeal dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were hospitalized due to symptoms of difficulty speaking
and right sided weakness resulting from an ACUTE HEMORRHAGIC
STROKE, a condition where there is bleeding in the brain. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High blood pressure
We are changing your medications as follows:
- continue lisinopril 40mg daily
- continue labetalol 100mg three times daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Atenolol 25 mg PO DAILY
3. Duloxetine 120 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Gabapentin 600 mg PO QID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lorazepam 0.25 mg PO Q8H:PRN Anxiety
8. Nortriptyline 75 mg PO HS
9. Omeprazole 40 mg PO BID
10. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
11. Simvastatin 10 mg PO DAILY
12. Tizanidine 4 mg PO TID
13. Zolpidem Tartrate 5 mg PO HS
14. CeleBREX (celecoxib) 200 mg ORAL DAILY
15. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
Do not take until you have stopped the liquid oxycodone
16. OxycoDONE Liquid 10 mg PO TID:PRN Pain
RX *oxycodone 5 mg/5 mL 10 ml by mouth Every 8 hours as needed
Disp ___ Milliliter Refills:*0
17. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Twice daily Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
# SIRS related to cellulitis
# Musculoskeletal chest pain
Secondary Dianoses:
# Chronic pain
# Anxiety
# Hypertension
# Hypothyroidism
# Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to manage an infection in
your legs. You were given antibiotics and your infection
appeared to resolve rapidly. We discharged you with a short
course of antibiotics to complete your therapy.
Please be sure to complete your antibiotic course and attend all
follow-up appointments.
Thank you for allowing us to be part of your care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Pravastatin 40 mg PO DAILY
7. Acetaminophen 650 mg PO TID
8. Diltiazem 30 mg PO TID
RX *diltiazem HCl 30 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Orthostatic Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital and found to have orthostatic
hypotension. Your blood pressure drops when you go from a lying
to standing position. We have adjusted your medications, and
you are now only on diltiazem 30mg three times per day for your
blood pressure.
When you go from a lying or sitting to standing we recommend
that you sit for ___ minutes before standing. Once you stand,
give yourself a minute before you begin walking. We have set up
a visiting nurse to come to the house and check your blood
pressures. If you continue to feel dizzy despite following
these recommendations please call our office, or your PCP, ___.
___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- NWB LLE
Physical Therapy:
NWB LLE
Treatments Frequency:
Splint: please leave splint on until follow-up appointmen with
Dr. ___ in ___ days.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Fexofenadine 180 mg PO DAILY
2. Sarna Lotion 1 Appl TP QID:PRN Itchiness
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg One tablet(s) by mouth Every 8
hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. SBO
2. ___ Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because of abdominal pain. You were found
to have a small bowel obstruction related to your ___
Disease. You were seen by the gastroenterology team and your
symptoms were treated conservatively. On hospital day ___ you
were passing gas and having stool. You tolerated a liquid diet
and we advanced you to a soft diet. You will need to follow-up
with gastroenterology about further treatment of your ___
Disease.
You wanted a prescription for flagyl to take home. Please take
500mg every 8 hours for 7 days. Do not drink alcohol while
taking this medication.
You should see your primary care doctor about receiving the
hepatitis B vaccine series. Your prednisone was being tapered
by your outpatient GI team. Your last dose was 5mg on ___.
You should not take more prednisone unless directed by your
outpatient gastroenterologists.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. budesonide-formoterol *NF* 160-4.5 mcg/actuation Inhalation
BID
2. Ferrous Sulfate 325 mg PO BID
3. Montelukast Sodium 10 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H
Use this three times a day for a week for leg pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
5. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4h sob
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*40
Tablet Refills:*0
7. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Capsule Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
9. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin [Lovenox] 80 mg/0.8 mL 80 mg SC twice a day Disp
#*20 Syringe Refills:*0
10. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
use this if ultram and tylenol are not sufficient
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*10 Tablet Refills:*0
11. Outpatient Lab Work
Please draw INR on ___ and FAX to the patient's
primary care physician:
___. attn: ___: ___ Fax: ___
12. Warfarin 2 mg PO DAILY16
take 2.5 tablets to make 5 mg dose
RX *warfarin [Coumadin] 2 mg 2.5 tablet(s) by mouth daily Disp
#*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: deep vein thrombosis
Secondary diagnosis: menorrhagia, iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ was a pleasure taking care of you in the hospital. You were
admitted for evaluation of calf pain and found to have a DVT -
deep vein thrombosis - a clot in your leg. You were started on
Lovenox and warfarin to thin your blood. You will need close
monitoring of your blood levels for the first part of treatment
until the levels stabilize. Please go to your primary care
physician's office on ___ morning to have your blood drawn
(see below). The office will help you adjust your dose. Use
the Lovenox injections until they tell you to stop. This will
be when your INR (warfarin level) is > 2.
You began to have bleeding again after your Provera was stopped.
We discussed your case with Dr. ___, and they
will see you on ___ during your scheduled appointment.
**Please call their office immediately if you have bleeding that
requires more than one pad per hour for more than one hour at
___
Please see the attached medication list for your updated
medication list.
Please STOP Provera.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Omeprazole 20 mg PO DAILY
2. Verapamil SR 360 mg PO Q24H
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth every night Disp
#*30 Tablet Refills:*3
5. Ascorbic Acid ___ mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Terazosin 8 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurology: subtle right pronation without drift
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were hospitalized due to symptoms of weakness resulting from
an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High cholesterol
- High blood pressure
We are changing your medications as follows:
- Start aspirin 81mg daily
- Start atorvastatin 20mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
You are being advised not to drive at this time. Please follow
up with a driving assessment as outpatient. You can get this
referral through your primary care doctor's office.
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Dabigatran Etexilate 150 mg PO BID
RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
2. Digoxin 0.125 mg PO EVERY OTHER DAY
RX *digoxin 125 mcg 1 tablet(s) by mouth every other day Disp
#*15 Tablet Refills:*0
3. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
4. Furosemide 60 mg PO DAILY
RX *furosemide 40 mg 1.5 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
5. Metoprolol Succinate XL 200 mg PO QHS
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Atrial fibrillation, paroxysmal, with rapid ventricular rate
-Acute left ventricular systolic heart failure with reduced
ejection fraction
-Right atrial thrombus
-Right calf acute deep vein thrombosis
-Hypertension
-Hyperkalemia
-Musculoskeletal chest pain
-Escherichia coli urinary tract infection
-Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital because you had chest pain and
felt short of breath. This is because your heart was not pumping
as well as it should, and so fluid built up in your lungs. You
were given a diuretic medication to help get the fluid out of
your lungs. Also, your heart was beating abnormally fast with an
abnormal rhythm called A Fib, and so we gave you medications to
slow down your heart rate. Finally, we found that you had a clot
in your heart and also in your leg. We started you on a blood
thinner to help the clots dissolve.
You were started on a number of new medications in the hospital.
Please continue to take these medications as prescribed when you
go home. Please weigh yourself every morning when you go home,
and call your doctor if your weight goes up by 3lb.
It was a pleasure taking care of you!
- Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
lung mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Please follow up with the appropriate studies. You will see the
interventional pulmonologists on ___. On ___ you should
see your primary care doctor and call Dr. ___ office
to discuss getting pulmonary function tests (spirometry and
DlCO), a PET scan and a VQ scan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Furosemide 40 mg PO DAILY Duration: 4 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
2. Zofran ODT (ondansetron) 4 mg oral q8h
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*15 Tablet Refills:*0
3. Potassium Chloride 20 mEq PO DAILY Duration: 4 Days
Hold for K >
RX *potassium chloride 10 mEq 2 tablets by mouth daily Disp #*8
Packet Refills:*0
4. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*50 Tablet
Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 gm by mouth daily
Disp #*10 Packet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- acute diastolic congestive heart failure
- atrial fibrillation
- constipation
Secondary diagnoses:
- atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ with shortness of breath and
vomiting. Fortunately, you did not have a blood clot as the
cause of your symptoms. You were instead found to have fluid in
your lungs that was treated with a diuretic, lasix (furosemide).
You urinated well after this and your breathing improved. You
should take oral lasix for 4 days, with some potassium tablets
as well to keep your potassium levels normal.
You were also very constipated. It will be important for you to
continue to take medications to help move your bowels especially
while taking narcotic pain medicines.
You should not resume taking your sotalol on discharge. You will
need to see Dr. ___ in 2 weeks to address whether you should
restart this or begin another medication.
If you should have worsening shortness of breath, chest pain, or
any other concerning symptom, please let your doctors ___.
Again, it was our pleasure participating in your care.
We wish you the best,
-- Your ___ Medicine Team --</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 975 mg PO Q6H
do not exceed 4g of acetaminophen in 24 hrs
2. Aspirin EC 325 mg PO DAILY
start in 2 weeks after you finish the lovenox prescription
RX *aspirin [Ecotrin] 325 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*14
Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
do not drink or drive while taking
RX *oxycodone 5 mg ___ capsule(s) by mouth q4 hr prn Disp #*30
Capsule Refills:*0
6. Amphetamine-Dextroamphetamine XR 30 mg PO DAILY
7. Amphetamine-Dextroamphetamine 30 mg PO DAILY:PRN inability
to focus
8. BuPROPion XL (Once Daily) 300 mg PO DAILY
9. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity in the splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 2 weeks then ASA 325mg for 2
weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. ClonazePAM 0.5 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. HydrOXYzine 50 mg PO QHS
8. Levothyroxine Sodium 75 mcg PO DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID
10. Sertraline 150 mg PO DAILY
11. Vitamin D 1000 UNIT PO BID
12. Warfarin 2 mg PO DAILY mechanical MV
Dose to change daily per Dr. ___ goal INR 2.5-3.5
13. Amiodarone 200 mg PO TID
RX *amiodarone 200 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
15. Magnesium Oxide 400 mg PO BID
RX *magnesium oxide 400 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Ranitidine 150 mg PO BID
17. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
AFib
- Mitral regurgitation
- Pulmonary Hypertension
- Hypertension
- Asthma with DLCO decrease, no recent PFTs
- Hyperlipidemia
- History of TIA ___ (thought to be secondary to tamoxifen)
- History of left temporal CVA ___ - reports ongoing mild
cognitive delays, difficulty focusing, and difficulty with
reading.
- GERD
- History of Hodgkin's Lymphoma ___, s/p radiation
- Diabetes, new diagnosis not yet started on any medications
- Chest pain syndrome
- LCIS / breast calcification- treated with Tamoxifen for
chemoprevention
- Anemia, no GI source identified, now resolved
- Depression/Anxiety
- Hypothyroid
st Surgical History:
s/p Splenectomy
s/p Hysterectomy
s/p Myomectomy
s/p C7 fusion
s/p Nissen fundoplication ___
s/p Tonsillectomy
s/p Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- trace
Followup Instructions:
___ [/INST] </s><s>Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gabapentin 200 mg PO BID
5. Levobunolol 0.5% 1 DROP BOTH EYES BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Lovastatin 20 mg oral DAILY
8. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Metoprolol Succinate XL 200 mg PO QAM
11. Metoprolol Succinate XL 100 mg PO QHS
12. Mirtazapine 7.5 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fatigue
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you.
You came to the hospital because you had a fall.
We did a workup, and you had no injuries.
You were safe to go home.
Please see you Doctor on ___ for followup</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Bisacodyl ___AILY constipation
2. Docusate Sodium 100 mg PO BID
3. Magnesium Oxide 400 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 40 %
topical QID:PRN
8. Diastat AcuDial (diazePAM) 2.5 mg Other Q12H:PRN seizure
9. Isosource 1.5 Cal (lactose-reduced food with fibr) 0.07
gram-1.5 kcal/mL Other Q12H
10. Ketoconazole Shampoo 1 Appl TP ASDIR
11. LACOSamide 150 mg PO BID
12. LevETIRAcetam ___ mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO Q3DAYS: PRN constipation
15. Senna 17.2 mg PO BID:PRN Constipation - First Line
16. Simethicone 80 mg PO QID
17. Trivora (28) (levonorg-eth estrad triphasic) 50-30
(6)/75-40 (5)/125-30(10) oral DAILY
18. Vitamin D 5000 UNIT PO EVERY 4 WEEKS (MO)
19. Vitamin D 400 UNIT PO DAILY
20. water 150 cc oral QID
21. Zonisamide 400 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
Gastroenteritis
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused - always.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You came to the hospital because you had breakthrough seizures
likely due to nausea and vomiting from a gastroenteritis.
Your seizure medicine was switched to IV formulation until you
could tolerate medicine in your enteral tube. You stopped
vomiting and your tube feeds were resumed. Then, your medicines
were switched back to enteral formulation.
Now that you are leaving the hospital, you will continue to take
your medicines as previously prescribed. Please follow-up with
your doctors, as listed below.
We wish you the best,
- Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Nystatin Oral Suspension 5 mL PO QID
5 more days
RX *nystatin 100,000 unit/mL 5 ml by mouth four times per day
Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Docusate Sodium 100 mg PO BID
4. FLUoxetine 20 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. LamoTRIgine 125 mg PO DAILY
7. LORazepam 1 mg PO BID
8. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Moderate
9. Omeprazole 40 mg PO BID
10. Polyethylene Glycol 17 g PO BID
11. Prazosin 3 mg PO QHS
12. Rexulti (brexpiprazole) 2 mg oral QHS
13. Sucralfate 1 gm PO QID
14. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Thrush
Odynophagia
Secondary:
Abdominal mass
Depression/Anxiety
Asthma
Sleep Apnea
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It was a pleasure caring for you at ___. You were seen in our
hospital for trouble swallowing. We found evidence of a fungal
infection, called "thrush," in your mouth. We also did an EGD
(endoscopy) to evaluate for any obstruction or mass or infection
to cause your trouble swallowing. Fortunately, this test did
not show any abnormalities.
Please continue all your medications as prescribed. Please
continue the Nystatin rinse for 5 more days. Follow up with your
surgeon, PCP, and GI doctors as ___. If you have a
question, do not hesitate to ask.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*31
Tablet Refills:*1
4. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*8 Tablet Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*31 Tablet Refills:*1
6. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate Duration: 7 Days
___ request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*31
Tablet Refills:*1
8. QUEtiapine Fumarate 25 mg PO QHS insomnia
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [Senna Laxative] 8.6 mg 1 tablet by mouth twice a
day Disp #*60 Tablet Refills:*0
10. Thiamine 200 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 2 tablet(s) by mouth once a
day Disp #*62 Tablet Refills:*1
11. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times a day
Disp #*1 Bottle Refills:*1
12. Diltiazem Extended-Release 120 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. Spironolactone 50 mg PO DAILY
15.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral acute-on-chronic subdural hematomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>#Brain Hemorrhage with Surgery
Surgery:
- You underwent a surgery called a left-sided mini craniotomy to
have blood removed from your brain.
- You underwent a surgery to embolize the vessels contributing
to the bleed in your brain
- Please keep your sutures or staples along your incision dry
until they are removed.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
This is to prevent bleeding from your groin.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
- You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
- Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
- You make take a shower.
Medications:
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
Care of the Puncture Site:
- Keep the site clean with soap and water and dry it carefully.
- You may use a band-aid if you wish.
What You ___ Experience:
- Mild tenderness and bruising at the puncture site (groin).
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and/or behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptoms after a brain
bleed.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
- Bleeding from your groin incision
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*12 Tablet Refills:*0
2. Creon ___ CAP PO QIDWMHS
RX *lipase-protease-amylase [Creon] 3,000 unit-9,500 unit-15,000
unit ___ capsule(s) by mouth Four times a day with meals and
snack Disp #*360 Capsule Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*9 Tablet Refills:*0
4. Midodrine 10 mg PO Q8H
RX *midodrine 10 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
5. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
6. ARIPiprazole 30 mg PO DAILY
7. Diazepam 5 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
10. Fluvoxamine Maleate 150 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
12. Milk of Magnesia 15 mL PO Q12H:PRN Constipation
13. Ondansetron 8 mg PO Q8H:PRN Nausea
14. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
15. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
16. Polyethylene Glycol 17 g PO DAILY
17. Prochlorperazine 10 mg PO Q6H:PRN Nausea
18. Senna 8.6 mg PO BID
19. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia
20.Bedside Commode
Bedside Commode
Limited mobility due to orthostatic hypotension (I95.1)
21.Shower chair
Shower chair
Orthostatic hypotension (I95.1)
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis
Acute Bacterial Colitis
Pancreatic insufficiency
Chronic hypotension / Orthostatic hypotension
Stage III Pancreatic Cancer
Portal Vein Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ were admitted because ___ had a severe infection to your
colon. We treated ___ with antibiotics and fluids. ___
fortunately improved and are feeling better.
Please continue your medications as explained further down. We
strongly recommended ___ to have a visiting nurse to help ___
with medications and home safety but ___ declined.
It was a pleasure to take care of ___.
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
It was our pleasure to care for you at ___.
You came to the hospital because of abdominal pain and low blood
pressures.
WHAT HAPPENED IN THE HOSPITAL?
- you had blood work done which showed a decrease in your liver
function which was suspected to be possibly from your cancer
treatment
- you were started on oral steroids to help your liver function
- your liver numbers started to improve
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with your oncologist
- continue taking all your medications as directed
- please continue taking your prednisone (steroid) at the
current dose until instructed to decrease it by your oncologist
We wish you all the best!
Sincerely,
Your care team at ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 5 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Paroxetine 20 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Acetaminophen 650 mg PO Q8H:PRN pain/HA
do NOT exceed 3gm in 24 hours
7. Docusate Sodium 100 mg PO BID
please hold for loose stools
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN sob
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms ___,
You presented to ___ on ___ after having an abdominal CT
scan at an outside hospital which was concerning for gallstones
and fluid collection. At ___, you had a MRI of abdomen which
was concerning for inflammation of your pancreas. You were
admitted to the Acute Care Surgery team and were transferred to
the surgery floor for further medical management.
On ___, you underwent an ERCP with sphincterotomy procedure
and your gallstones were removed. You tolerated this procedure
well. On ___, you underwent a laparoscopic cystectomy where
your gallblader was removed. You tolerated this procedure well.
You were given IV fluids for rehydration and bowel rest. You
were then advanced to a regular diet which you tolerated. You
tolerated oral medicine and ambulated and are now medically
cleared to be discharged to home to continue your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amiodarone 400 mg PO BID Duration: 1 Week
Tapered dose to maintenance 200 daily, see instructions on
prescriptions
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
2. Amiodarone 200 mg PO BID Duration: 1 Week
To begin after you complete week of 400 twice daily
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
3. Amiodarone 200 mg PO DAILY
To begin after finish 2 weeks of loading; this is your
maintenance dose
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Enoxaparin Sodium 100 mg SC Q12H
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Pantoprazole 40 mg PO Q12H
9. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
syncope
orthostasis
pulmonary embolism
pancreatic adenocarcinoma
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you. You were admitted because you
passed out. This was likely caused by a dehydration
("hypovolemia") which may or may not have led to atrial
fibrillation with rapid heart rate.
You got better with IV fluids and better oral intake, and
controlling your heart rate.
We wish you the best in your recovery!
Sincerely, your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital for abdominal pain and
management of your pain medications and constipation
medications. Your regimens were readjusted and you were started
on a fentanyl patch. You should continue to take your pain
medications and constipation medications as prescribed. You are
now safe for discharge home with close follow up.
It was a pleasure caring for you - we wish you all the best!
Sincerely,
Your ___ Oncology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate [iron] 325 mg (65 mg iron) 1 tablet(s) by
mouth twice daily Disp #*60 Tablet Refills:*0
3. NPH 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. MedroxyPROGESTERone Acetate 10 mg PO DAILY Duration: 7 Days
RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
vaginal bleeding
firboid uterus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted with heavy vaginal bleeding, likely
attributable to a fibroid. Please take the provera as prescribed
and continue your oral contraceptive pills. You also need to
take iron twice daily. If your bleeding increases or you feel
dizzy or lightheaded, please call your gyn provider or our
office at ___ right away.
You have a follow up appt with your primary gyn on ___, it is
important that you go to this appointment. If you have any
problems with this please feel free to call the ___ clinic at
___.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
standing dose
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
hold for SBP < 110, HR < 60
8. MetFORMIN XR (Glucophage XR) 1500 mg PO QPM
Do Not Crush
9. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP < 110, HR < 60
10. Senna 1 TAB PO BID
11. Tizanidine ___ mg PO HS:PRN pain, spasm
12. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
13. fenofibrate *NF* 160 mg Oral daily
14. testosterone cypionate *NF* 200 mg/mL Injection every 2
weeks
15. Aspirin 81 mg PO DAILY
16. Outpatient Lab Work
Check CBC/diff, ESR/CRP, BMP, LFTs
- Check weekly and fax results to ___
17. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
18. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
19. Calcium Carbonate 500 mg PO TID calcium repletion
20. Diazepam 10 mg PO Q6H:PRN pain
please encourage more PRN use if needed, patient only taken 1
tab today and 1 tab yesterday per pharmacy
21. DiphenhydrAMINE 12.5-50 mg PO/IV Q6H:PRN Insomnia/Pruritis
22. Gabapentin 600 mg PO Q6H
23. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
24. Milk of Magnesia 30 ml PO BID:PRN Constipation
25. Multivitamins 1 CAP PO DAILY
26. Nortriptyline 25 mg PO HS
27. CefePIME 2 g IV Q8H
28. Morphine Sulfate ___ ___ mg PO Q4H:PRN pain
29. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 capsule(s) by mouth every twelve (12) hours
Disp #*60 Capsule Refills:*0
30. Lidocaine 5% Patch 1 PTCH TD DAILY
31. Fluconazole 400 mg PO Q24H
32. Enoxaparin Sodium 40 mg SC DAILY
stop date is ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip osteoarthritis s/p total hip arthroplasty ___
Postoperative hematoma within right gluteus medius s/p ___ and
evacuation of hematoma on ___ ___ right total hip arthroplasty s/p ___, explant of all
components, cement spacer placement, and wound vac placement on
___ ___ and vac changes for septic right total hip
arthroplasty on ___ ___
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches that need to be removed will be
taken out at your follow-up visit.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Sutures will be removed at yoru follow-up
visit.
11. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, PICC line assessment, IV infusions.
Weekly labs - CBC/diff, Chem 7, LFTs and send to ID RNs at
___.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. No strenuous exercise or heavy lifting until follow
up appointment. Mobilize frequently.
Physical Therapy:
WBAT
Mobilize
Treatments Frequency:
dry, sterile dressing changes daily and as needed for drainage
wound checks
ice
TEDs
**staple removal will be at first follow up appt.**</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 10 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Doxazosin 4 mg PO HS
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- 1.3 cm cystic pancreatic head mass
- Biliary obstruction
Secondary:
- Hypertension
- Non insulin dependent diabetes mellitus
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for a mass in your pancreas. You had
a procedure to look in your bowels and there was a narrowing
found near your pancreas. This was opened up and sample were
taken. You also had an MRI (picture of your abdomen) to better
look at the lesion in your pancreas. After your procedure, you
had vomiting that was brown and concerning for blood. Your blood
count remained stable and you did not have any further episodes.
Because your blood pressure was well controlled while you were
in the hospital, we are only restarting Doxazosin upon your
discharge. Please talk with your PCP about restarting the other
medications. Please continue to take your current medications as
directed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: Home meds:
DEXTROAMPHETAMINE-AMPHETAMINE [AMPHETAMINE SALT COMBO] -
Amphetamine Salt Combo 30 mg tablet. 1 (One) tablet(s) by mouth
once a day - (Prescribed by Other Provider)
TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 (One) capsule(s) by
mouth once a day - (Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 (One) tablet(s)
by
mouth every six (6) hours as needed for pain - (Prescribed by
Other Provider)
ASCORBIC ACID [VITAMIN C] - Dosage uncertain - (Prescribed by
Other Provider)
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 (One)
tablet(s)
by mouth once a day - (Prescribed by Other Provider)
FLAXSEED - Dosage uncertain - (Prescribed by Other Provider)
FOLIC ACID - Dosage uncertain - (Prescribed by Other Provider)
MULTIVITAMIN [MEN\'S MULTI-VITAMIN] - Men\'s Multi-Vitamin
tablet. 1 (One) tablet(s) by mouth once a day - (Prescribed by
Other Provider)
OMEGA 3-DHA-EPA-FISH OIL [FISH OIL] - Dosage uncertain -
(Prescribed by Other Provider)
SAW-VIT E-SOD SEL-LYC-BETA-PYG [PROSTATE HEALTH] - Prostate
Health 160 mg-100 unit-100 mcg tablet. 1 (One) tablet(s) by
mouth
once a day - (Prescribed by Other Provider)
New meds:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary infection
Discharge Condition:
Good condition; ambulatory
Followup Instructions:
___ [/INST] </s><s>Return to ED for temperature > 101.5
Take cipro for 10 days</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Enoxaparin Sodium 70 mg SC Q24H
RX *enoxaparin 300 mg/3 mL 70 mg SC Daily Disp #*7 Vial
Refills:*3
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth Daily Refills:*3
5. Simethicone 40-80 mg PO QID:PRN gas
RX *simethicone 80 mg 1 tab by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
7. Acyclovir 400 mg PO 5X/DAY:PRN Herpes outbreak
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Common hepatic duct stricture
Occlusive thrombosis of the central portal venous system
Metastatic gallbladder adenocarcinoma
Fever related to malignancy
SECONDARY DIAGNOSES:
====================
Coagulopathy
Normocytic anemia
Thrombocytopenia
Dyslipidemia
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for recurrent fevers
What was done for me while I was in the hospital?
- You were treated with broad spectrum antibiotics while we
searched for a cause of your infection.
- Your fevers were determined to be caused by your cancer.
- A CT scan of your belly revealed a blood clot in one of your
veins. You were started on a blood thinner to help treat the
clot.
- You had an endoscopic biopsy of your lymph nodes to help guide
your chemotherapy regimen.
- You were started on FOLFOX chemotherapy.
- You were treated with stunting for a blockage in your biliary
drainage system.
- You improved and were ready to leave the hospital. You did
have a fever and elevated white blood cell count before you
left, but we believe this is related to your cancer rather than
a new infection.
What should I do when I leave the hospital?
- Take your medications as prescribed and go to the follow up
appointments that we have arranged for you.
We wish you all the best!
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Lisinopril 40 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: hypertension
secondary: left ventricular hypertrophy and aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ was a pleasure taking care of your during your stay here at
___.
You came to the hospital because of a headache and high blood
pressure. You were found to have a blood pressure in theh
200s/100s. We gave you medication to lower your blood pressure
which worked. We started you on a new medication which we would
like for you to take every day and follow up with your primary
care doctor about your blood pressure. It is also very important
that you avoid salty foods such as ___ sausage etc.
Please check your blood pressures while at home in the morning.
If the top number is above 180 please call your primary care
doctor.
The following changes have been made to your medication regimen:
START amlodipine</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Allopurinol ___ mg PO DAILY
2. Docusate Sodium 200 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Morphine SR (MS ___ 45 mg PO Q12H
RX *morphine [MS ___ 15 mg 3 tablet extended release(s) by
mouth every twelve (12) hours Disp #*90 Tablet Refills:*0
5. Omeprazole 40 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN
breakthrough pain
RX *oxycodone 5 mg ___ capsule(s) by mouth q3h Disp #*100 Tablet
Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 1 TAB PO BID
9. Benzonatate 100 mg PO TID
10. Bisacodyl ___AILY constipation
11. Dexamethasone 4 mg PO QAM
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheeze
14. Amlodipine 5 mg PO DAILY
15. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN rectal
irritation
16. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0.52 gram oral daily
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Lactulose ___ mL PO DAILY constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: pneumonia, malignant pleural effusion
Secondary: metastatic non small cell lung cancer, atrial
fibrillation with rapid ventricular rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital with a fast heart rate,
diarrhea and shortness of breath. It was found that you had some
fluid in your lungs which was drained. This fluid had cancer
cells in it that were consistent with your known lung cancer.
You also had a lung infection which was treated with antibiotics
and your symptoms improved. Your condition has improved and you
can be discharged to your facility.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ascorbic Acid ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. ClonazePAM 0.5 mg PO QHS:PRN anxiety
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Valsartan 160 mg PO DAILY
7. Vitamin D 50,000 UNIT PO DAILY
8. Acyclovir 400 mg PO Q12H
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Magnesium Oxide 400 mg PO ONCE
11. Meclizine 12.5 mg PO Q6H:PRN dizziness
RX *meclizine 25 mg 1 tablet(s) by mouth every 6 hours as needed
for dizziness Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Benign Paroxysmal Postional Vertigo
2. Hypertension
3. Hyperlipidemia
4. Diverticulitis s/p colon resection
5. Aortic insufficiency
6. Arthritis
7. Obstructive Sleep Apnea
8. History of head trauma as a teenager
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were hospitalized for work up of vertigo or dizziness. There
are 2 main reasons for dizziness. One reason is due to the
peripheral nerves in the inner ear and the other reason is due
to the brain such as a stroke. Due to the fact that you have had
many short episodes of dizziness before, it was improved with a
maneuver to dislodge the calcium crystals in your inner ear and
now you do not have any more symptoms, we believe that most
likely the cause of your dizziness is because of a nerve problem
and not because of a stroke. Your MRI did not show a stroke or
blood clot in your head.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for anxiety.
5. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 7 days.
Disp:*84 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
Right vertebral Artery Aneurysm
hydrocephalus / mild
Intraventricular hemorrhage
Headache
Alcohol withdrawal
Delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Angiogram with Embolization of Right Vertebral Artery Dissecting
Aneurysm
Medications:
Take Aspirin 325mg (enteric coated) once daily.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Ascorbic Acid ___ mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl ___AILY:PRN constipation/stool impaction
6. ClonazePAM 2 mg PO TID
7. Cyanocobalamin 1000 mcg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Ferrous Sulfate 325 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 800 mg PO TID
12. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
13. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
14. Lactulose 30 mL PO DAILY:PRN constipation
15. Methadone 80 mg PO DAILY
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Senna 17.2 mg PO QHS
21. Tamsulosin 0.4 mg PO QHS
22. Tiotropium Bromide 1 CAP IH DAILY
23. Torsemide 20 mg PO DAILY
24. Warfarin 2.5 mg PO DAILY DVTs
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic pain
Opioid Use disorder
Chronic DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. atenolol-chlorthalidone 100-25 mg oral daily
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
9. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Brain mass, likely metastasis
Lung mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure taking care of you during your recent
admission to ___. You were admitted after your MRI showed
three brain tumors. You were seen by our neuro-oncology,
neurosurgery and interventional pulmonary teams. You had a CT
scan of your body which showed a mass in your lung which is also
suspicious for cancer. You will need to have a sample of the
lung and possible brain surgery. You need to return to the
hospital on ___ at 10am. Do not eat or drink anything after
midnight on ___ night. You also have an MRI scheduled on
___ at 3pm.
Stop taking your Plavix.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) for 5 days: through ___, then increase by 25 mg
bid per week.
5. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
8. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 3 days.
10. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for HR < 55, SBP < 100.
11. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours.
12. levetiracetam 100 mg/mL Solution Sig: Two Hundred Fifty
(250) ML PO once a day: IN AM.
13. levetiracetam 100 mg/mL Solution Sig: 5 ML ML PO HS (at
bedtime): AND TAPER AS PER ___. ___, 250 MG/WEEK TAPER UNTIL
OFF.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspiration pneumonia
Dementia
Seizure disorder
Leukopenia, possibly related to anti-seizure medication
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound or out of bed with significant
assistance.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure to care for you during this admission. You
were treated for pneumonia. Your blood pressure was low when
you were admitted, and you were sleepy. These things improved
with intravenous fluids and antibiotics. We stopped the bladder
irrigation and this should not be restarted.
Medication changes:
Augmentin 875 mg po bid for 4 more days
Lamictal increased to 75 mg po bid
Keppra decreased to 250 mg/500 mg po bid</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Methimazole 2.5 mg PO EVERY OTHER DAY
5. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually every 5 min
Disp #*10 Tablet Refills:*0
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
10. GlipiZIDE 2.5 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Unstable angina, coronary artery disease
Secondary Diagnosis: Hyperlipidemia, hypertension, diabetes
mellitus II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ for
chest pain. In the Emergency Department there were some mild
changes in your EKG, which made us concerned about your heart.
Your chest pain resolved. To further evaluate your heart you had
a nuclear stress test on ___, which showed that some areas of
your heart could be at risk for a heart attack. On ___, we
planned to take you for a cardiac catheterization, however since
your pain had resolved, you preferred to go home. The risks of
not having a catheterization were described to you, however you
still wished to go home. Your medications were adjusted to
hopefully decrease your chest pain in the future.
Please take all medications as prescribed and follow-up at your
scheduled appointments. If you develop any chest pain while you
are at home you should present to the Emergency Department
immediately.
It was a pleasure taking care of you,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every 8 hours Disp #*40 Tablet
Refills:*0
2. Cholestyramine 4 gm PO BID
3. Duloxetine 90 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Fentanyl Patch 25 mcg/h TD Q72H
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
___ hours Disp #*60 Tablet Refills:*0
7. Psyllium Wafer ___ WAF PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Drainage from intraabdominal phlegmonous collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our institution
for your increased pain and drainage from a collection inside
your abdomen. Your antibiotics and parenteral nutrition were
maintained throughout your brief hospital course. We were able
to drain of your collections and sent the samples for
microbiological analysis. Upon evaluation by Infectious Disease
specialist, it was determined that you were not benefitting from
your current antibiotic therapy. We thus have stopped
antibiotics for the time being.
Upon stabilization and control of your pain, we now feel
comfortable sending you home provided you follow these
recommendations:
-You may resume all your medications
-Please continue TPN
-Follow-up with infectious disease specialists as indicated
-Call or come to the emergency department if you develop fever
to 101.3F, chills, persistent nausea and/or vomiting, increasing
pain not controlled with medications, increased drainage from
your wounds, or any other symptom of your concern.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
2. ALPRAZolam 1 mg PO BID:PRN anxiety
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
5. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
6. DULoxetine 60 mg PO BID
7. Enalapril Maleate 20 mg PO DAILY
8. Gabapentin 1200 mg PO QHS
9. Latuda (lurasidone) 40 mg oral DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Naproxen 500 mg PO BID:PRN Pain - Moderate
13. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
14. TraZODone 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Recurrent syncope
Seroma
Back pain
SECONDARY DIAGNOSIS
====================
Diabetes Mellitus II
Hypertension
Functional Neurologic Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for lower back pain and fainting.
What was done for me while I was in the hospital?
- You had imaging of your spine that showed no sign of
infection.
- You had imaging of your head that showed no sign of bleed.
- The Chronic Pain doctors saw ___ and helped us come up with a
good pain management plan.
What should I do when I leave the hospital?
- Please follow up with your chronic pain doctors ___.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Lacosamide 250 mg PO BID
RX *lacosamide [Vimpat] 50 mg 5 tablet(s) by mouth twice a day
Disp #*300 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital after havin several seizures
at home. We monitored you on EEG and you did not have any more
seizures. Per recommendation of Dr. ___ outpatient
epileptologist, we increased your dose of Vimpat to 250mg twice
per day.
On discharge, please follow up with Dr. ___ as scheduled
below.
It was a pleasure taking care of you, we wish you all the best!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Fluoxetine 20 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. LeVETiracetam 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID Duration: 6 Weeks
6. Acetaminophen 650 mg PO TID
7. Aspirin 81 mg PO DAILY
8. LORazepam 0.5 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
- Right displaced greater trochanter fracture
- Right sacral fracture
- Right inferior pubic ramus fracture
- Right superior pubic ramus fracture w/ extension into
acetabulum
- Right hip/upper thigh hematoma
- Anemia due to acute bleed (from hematoma) and nutritional
deficiency
- Acute kidney injury due to pre-renal azotemia
- Chronic kidney disease, Stage IV
- Acute toxic-metabolic encephalopathy
SECONDARY DIAGNOSIS/ES:
- Chronic Dementia
- History of stroke complicated by seizures
- Dyspohagia, unspecified
- Hypertension
- Hypercholesterolemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure meeting you and taking care of you. You were
admitted to ___ with a fracture of your right hip after you
had fallen at home. You also had low blood counts from bleeding
around the hip. You were evaluated by our orthopaedic surgery
service who felt that you did not need immediate surgery and
should be able to walk with a walker. We noted that your blood
levels dropped during your hospital stay which could be due to
your fractured hip and a collection of blood underneath your
skin which was stable. You were given IV fluids to improved
your blood pressure.
Please take your medications as prescribed and follow up with
your appointments as listed below.
It was a pleasure taking care of you at the ___
we wish you all the best
You ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. BuPROPion (Sustained Release) 100 mg PO BID
2. BusPIRone 30 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ranitidine 150 mg PO QHS
6. Sertraline 200 mg PO DAILY
7. TraZODone 100 mg PO QHS:PRN insomnia
8. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 grams
powder(s) by mouth twice a day Refills:*0
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg 1 tablet(s) by mouth twice a day Disp #*40
Tablet Refills:*0
10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every six
hours as needed Disp #*40 Tablet Refills:*0
11. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl [Ducodyl] 5 mg 1 tablet(s) by mouth every other
day as needed Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatic mass
2. Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with abdominal pain, nausea
and vomiting and were found to have a mass in the pancreas. You
had a biopsy of this mass, and results are pending at this time.
You will followup for this on ___. Please follow up at the
multidisciplinary conference on ___ and with your PCP. Our
palliative care doctors ___ help manage your pain and appetite.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 40 mg PO QPM
2. Lisinopril 2.5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Torsemide 80 mg PO DAILY
8. Apixaban 5 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
11. FoLIC Acid 1 mg PO DAILY
12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN Dyspnea
13. Levothyroxine Sodium 88 mcg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
15. Pregabalin 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
heart failure with reduced ejection fraction
atrial flutter (resolved)
SECONDARY DIAGNOSIS
Upper gastrointestinal bleed (stable)
Acute kidney injury (resolved)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you were short of breath and were
found to have excess fluid due to poor heart function and an
abnormal heart rhythm
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You received water pills through the IV to help with the extra
fluid
- You had a shock delivered to your heart to put your heart
back in normal rhythm. You had a special ultrasound (TEE) done
first to rule out the presence any blood clots in your heart
- You had a gastrointestinal bleed for a few days that
fortunately resolved without intervention
- Your heart failure medications were optimized
- You began to feel better and were ready to leave the hospital
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Your weight at discharge is 188 pounds. Weigh yourself every
morning, seek medical attention if your weight goes up more than
3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- If you are experiencing new chest pain please call the
heartline at ___
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
RX *triamcinolone acetonide 0.025 % apply to vaginal lesions
once a day Refills:*0
2. U-500 Conc 80 Units Breakfast
U-500 Conc 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Betamethasone Valerate 0.1% Cream 1 Appl TP QD
8. Carvedilol 12.5 mg PO BID
9. Clotrimazole Cream 1 Appl TP BID
10. Colchicine 0.6 mg PO BID:PRN Gout flare ups
11. Docusate Sodium 100 mg PO BID:PRN hard stools
12. Hydrocortisone Cream 2.5% 1 Appl TP QD
13. Ketoconazole Shampoo 1 Appl TP ASDIR
14. Levothyroxine Sodium 175 mcg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
16. psyllium husk (aspartame) 3 gram/5.95 gram oral DAILY:PRN
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. SITagliptin 50 mg oral DAILY
19. Torsemide 60 mg PO BID
20. Venlafaxine XR 75 mg PO DAILY
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
UTI
Vaginitis
Hyperglycemia
Constipation
Chest pain
Secondary Diagnoses
===================
Chronic kidney disease
Heart failure with preserved ejection fraction
Hypertension
Obstructive sleep apnea
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had high blood sugars,
vaginal irritation, and urinary symptoms
What happened while I was admitted to the hospital?
-Your insulin regimen was adjusted by ___
-You were given antibiotics for urinary tract infection and
completed your course while in the hospital
-Your given a steroid cream for her vaginal irritation
Your given an antifungal medication to treat your vaginal
infection
-Your lab numbers were closely monitored and you were given
medications
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs
-It is very important that you take your insulin as prescribed
and also use your sliding scale as discussed
-If you miss more than 2 doses of insulin or if your blood
sugars are >250 on 3 separate occasions, you should call your
diabetes doctor or your primary care doctor immediately
We wish you the very best!
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Multivitamins 1 TAB PO DAILY
3. Voriconazole 200 mg PO Q12H
4. Acyclovir 400 mg PO Q8H
5. moxifloxacin 400 mg ORAL DAILY
RX *moxifloxacin 400 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Ursodiol 300 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Presyncope
Secondary:
-AML
-Anemia
-Neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure to care for you. You were admitted due to a
fall at home. We did not find a specific cause for the fall.
Imaging and monitoring of your heart did not show any
significant abnormalities. You were given fluids. Your blood
counts were monitored, and you were given blood products to
increase your blood counts. You had a bone marrow biopsy to help
guide future treatment of your leukemia.
Please take your medications as prescribed and attend your
follow up appointments. You should no longer take amlodipine for
high blood pressure.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO MON/WEDS/FRI/SAT/SUN
5. Levothyroxine Sodium 44 mcg PO TUES/THURS
6. Valsartan 160 mg PO DAILY
7. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSES
Benign paroxysmal positional vertigo
Presyncope
SECONDARY DIAGNOSES
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at the ___. You were admitted
because you have been having lightheadness, spinning, and blurry
vision over the past few months. You had a scan of your head
done, and this did not show a cause for your symptoms. You were
evaluated by the neurology team (the brain doctors) and there
was no concern for a stroke or head bleed. Your symptoms are
likely a combination of your previous diagnosis of benign
vertigo, along with a side effect of taking extra blood pressure
medications. You should see an eye doctor about your blurry
vision, as you shared with us that you think this is because you
need new glasses.
You were also evaluated by physical therapy, and they determined
it's safest if you go to rehab to gain strength before you go
home. You and your family decided you preferred to go home, and
we strongly recommend you have someone at home with you at all
times.
Please take your medication as prescribed. It may be beneficial
to you to have a pillbox that helps lay out which medications to
take when. The medications alprazolam and meclizine have both
been stopped as these can cause lightheadedness, falls and
confusion.
Please go to your doctor's appointment this ___, this is
very important you follow up.
We wish you the best of luck with your health.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr ___,
It was a pleasure to care for you at ___. You were admitted to
the hospital because you had a drug overdose causing multiorgan
failure and hypothermia. You required a breathing tube for
respiratory failure, and your kidneys and liver failed. You also
had significant muscle breakdown (called 'rhabdo' or
rhabdomyolysis), which made your kidneys worse. You required
dialysis for 9 days, and because you were previously healthy,
you are very lucky, and your kidneys recovered, as did your
liver.
You should continue to eat a low potassium and low phosphate
diet while your kidneys recover.
You will need to follow up with Dr ___ kidney doctor)
in clinic in 2 weeks. They will call you with the follow up
appointment.
We wish you all the best! We hope that you will take care of
yourself.
-Your ___ care team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
6. QUEtiapine Fumarate 12.5 mg PO QHS
RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
7. Parnate (tranylcypromine) 20 mg oral BID
RX *tranylcypromine [Parnate] 10 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*0
8. Tranylcypromine Sulfate (tranylcypromine) 10 mg ORAL DAILY16
RX *tranylcypromine [Parnate] 10 mg 1 tablet(s) by mouth daily
at 3pm Disp #*30 Tablet Refills:*0
9. compression stockings
Venous compression stockings
Orthostatic hypotension 458.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Orthostatic hypotension
Secondary
HTN
CKD
Bipolar disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You were admitted because you became confused and had a fall. We
think your sleep medication dose was too high and made you
confused so we decreased this.
Also, your blood pressure drops when you stand up so we
recommend:
1. Drink eight 8-oz glasses of water daily to prevent
dehydration.
2. Wear compression stockings every day to help improve blood
flow
3. Do simple exercises before you get out of bed to help
increase your heart rate
You can keep these instructions by your bedside so you remember
these tips! We have also decreased your blood pressure
medications to help prevent falls.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Calcium Carbonate 1000 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Desonide 0.05% Cream 1 Appl TP BID
4. Ferrous Sulfate 325 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Ibuprofen 600 mg PO Q6H:PRN pain
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Methylprednisolone 10 mg PO DAILY
9. Metoprolol Succinate XL 75 mg PO DAILY
hold for HR < 55, SBP < 100
10. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain
11. Multivitamins 1 TAB PO DAILY
12. Mycophenolate Mofetil 1500 mg PO BID
13. Omeprazole 40 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nasuea
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. Torsemide 80 mg PO DAILY
hold for SBP < 100
17. traZODONE 50 mg PO HS:PRN insomnia
18. Warfarin 7.5 mg PO DAILY16
19. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, cough
20. Guaifenesin ___ mL PO Q6H:PRN cough
21. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN cough, SOB
22. Alendronate Sodium 70 mg PO QSUN
23. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
viral bronchitis
polymyositis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It has been a pleasure taking care of you at ___
___. You came to the hospital with symptoms
of a viral bronchitis, as well as increased mucle pain and
weakness. You rheumatologist is working on getting you rituximab
for your polymyositis, but for now we did not change your
medicines. We gave you breathing treatments for your cough,
which seemed to help.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Chest pain secondary to demand ischemia
SECNDARY DIAGNOSES
- Aortic stenosis
- Lung carcinoma with metastasis to multiple lymph nodes
- Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms ___,
It was a pleasure taking care of you. You were admitted to ___
___ for chest pain. While you were
here, you were evaluated by our cardiology team; you were not
having a heart attack, and you did not require a surgical
procedure for your chest pain. Your blood counts were very low,
so you received a unit of blood cells, and your counts
improved.
We also had an important family meeting with you, your son, and
our full team. You completed the MOLST form, which expresses
your wishes when you leave the hospital. We will set you up with
services at home so that you can get help with medications and
assistance around the house.
We wish you all the best in the future.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. oxycodone 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
3. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
BID (2 times a day).
5. chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for hiccups.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).
8. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. multivitamin Tablet Sig: ___ Tablets PO DAILY (Daily).
10. Ensure Liquid Sig: One (1) PO twice a day.
11. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
13. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
18. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Metastatic Renal Cell Cancer
Secondary Diagnosis:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted with altered mental status and fever.
Your mental status improved after decreasing your pain
medication doses. You were treated with antibiotics for a
possible pneumonia, and should complete a course of
Levofloxacin. You were discharged home with hospice services to
make you more comfortable at home.
The following medication changes have been made to your regimen:
START: Levofloxacin 750 mg by mouth daily until ___
DECREASE: Oxycontin 30 mg by mouth twice daily
CONTINUE: Oxycodone 10 mg every 4 hours as needed for pain
START: Acetaminophen 1000 mg every 8 hours
START: Ibuprofen 400 mg by mouth every 6 hours
STOP: Krill Oil
Please continue all other medication as prescribed.
Please contact your hospice team or primary oncologist if you
have any medical concerns while at home. It is important that
you take your pain medications as prescribed to avoid future
problems with confusion and lethargy. Your hospice team should
be contacted if your pain worsens and is not well controlled
with the current medication regimen.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Pt was discharged against medical advice. He and his wife
refused to wait for their discharge paperwork.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 80 mg PO QPM
2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
3. Levothyroxine Sodium 137 mcg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Omeprazole 20 mg PO DAILY
8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
9. glimepiride 2 mg oral QHS
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*3
12. Senna 17.2 mg PO HS
RX *sennosides [___] 8.6 mg 2 by mouth daily Disp #*60
Tablet Refills:*3
13. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
14. Aspirin EC 325 mg PO DAILY
15. Outpatient Lab Work
anemia ICD 285.0
Please repeat CBC.
16. Ferrous Sulfate 325 mg PO DAILY iron def anemia
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth once Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: hemoptysis
Secondary Diagnosis: hypertension, recent pulmonary embolism,
diabetes.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to the hospital for coughing
up blood and your pulmonary doctors wanted to take another look
at your lungs with a camera to assess for a source of bleeding.
During this procedure, a few oozing sites of bleeding were
identified and treated with electrocautery.
Each morning, we monitored your labs for signs of worsening
anemia from blood loss. At the time of discharge, we did not
feel that you needed a transfusion. Please be sure to schedule a
___ appointment with your Primary Care doctor within 1
week of discharge. You should have a repeat "Complete Blood
Count" at that visit.
Also, since you recently had bleeding, you should not take your
blood thinner coumadin for one month in order to allow your
lungs time to heal. After one month, it is advised that you
resume this medication due to your long term risk of developing
a clot, which may cause another pulmonary embolism or other
adverse event. Please follow closely with your outpatient
doctors regarding continued ___ of these issues.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Mesalamine 1000 mg PO QID
3. Pantoprazole 40 mg PO Q24H PRN heartburn
4. Vitamin D ___ UNIT PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
DAILY Disp #*30 Tablet Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
Acute blood loss anemia
Inflammatory bowel disease
Palpitations
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ was a pleasure taking care of you. You were admitted to the
hospital with palpitations and found to be extremely anemic.
This is most likely due to slow bleeding from your intestines.
We gave you blood transfusions to treat your anemia. Your blood
counts remained stable throughout your time here.
We did an EGD (endoscopy) that was normal. We also did a
colonoscopy that showed an obstruction at the end of your small
bowel, likely due to your colitis. We are not able to rule out
other causes for the obstruction, including cancer.
We recommended that you remain in the hospital for further
evaluation by the colorectal surgeons, but you declined and said
you prefer to follow up with your gastroenterologist at ___
___ prior to any surgical evaluation. You understood
the risk of leaving prior to completing this evaluation. With
your permission, we have contacted Dr. ___ at ___ to let her
know you were here and the details of your stay.
If you have blood in your stool, shortness of breath, chest
pain, or other symptoms that concern you, please contact your
doctor or return to the hospital for further care.
Sincerely,
Your ___ Team</s> |