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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ertapenem 1 gram intramuscular DAILY Duration: 6 Days
___ through ___ for full ___onsider treating for
14 days if UA still positive or if pt is symptomatic.
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Lactulose 30 mL PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Omeprazole 20 mg PO DAILY
12. Phenytoin Sodium Extended 400 mg PO 4X/WEEK (___)
13. Phenytoin Sodium Extended 300 mg PO 3X/WEEK (___)
14. Senna 17.2 mg PO BID
15. Tamsulosin 0.8 mg PO QHS
16. Vitamin D ___ UNIT PO 1X/WEEK (WE)
17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until You meet with Dr. ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Chronic stable Subdural hematoma, urinary tract
infection
Secondary: CAD s/p CABG in ___, NSTEMI, systolic CHF (EF
35-40%), PVD s/p bypass, CKD stage III, history of LLE DVT s/p
IVC filter, chronic SDH, dementia
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 Mr. ___,
It was a pleasure taking care of you.
Why you were admitted?
-You were admitted to the hospital because you fell.
What was done for you?
-You had a CT scan of your head which showed a bleed in your
head that was stable from your previous CT scan. Nothing needed
to be done. Your asprin was held while you were here.
-You were found to have urinary tract infection.
What should you do when you leave the hospital?
-You should continue taking the antibiotic Ertapenem (last day
___ to complete a 7 day course.
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. QUEtiapine Fumarate 25 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. amLODIPine 10 mg PO DAILY
4. Bisacodyl ___AILY:PRN Constipation - Second Line
5. Bisacodyl 10 mg PO DAILY
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Docusate Sodium 200 mg PO BID
8. Melatin (melatonin) 3 mg oral QHS
9. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
10. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Hypernatremia
Malnutrition
Failure to thrive
Advanced dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>You admitted to ___. The follow
is a summary of your hospitalization and instructions for after
discharge from the hospital.
Reasons for hospitalization:
1) Dehydration
2) High sodium levels
3) Poor appetite
4) Malnutrition</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
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*30 Tablet
Refills:*0
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
3. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right foot infection
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___ [/INST] </s><s>These are the discharge instructions for post-operative
discharge instructions.
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, severe increase ___ pain to operative site or pain
unrelieved by your pain medication, nausea, vomiting, chills,
foul smelling or colorful drainage from your incisions/wounds,
redness or swelling around your incisions, or any other symptoms
which are concerning to you.
Diet: regular diet
Medication Instructions:
Resume your home medications.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. If you were prescribed antibiotics, it is critical for you
to take them as prescribed and for the full course of the
regimen.
Activity:
Please, remain nonweightbearing to your right foot. This is
crucial to increase healing potential.
Wound Care:
You may shower but please keep dressings clean, dry, and intact.
Do not submerge your foot/leg ___ water.
Please call the doctor or page the ___ pager, if you have
increased pain, swelling, redness, or drainage to the operative
sites.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
6. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. lamivudine 10 mg/mL Solution Sig: ___ (25) mg PO
DAILY (Daily).
9. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. sirolimus 1 mg Tablet Sig: One (1) Tablet PO Every ___.
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
19. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
20. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
21. Lantus 100 unit/mL Solution Sig: Ten (10) u Subcutaneous at
bedtime.
22. Humalog 100 unit/mL Solution Sig: as per home sliding scale
Subcutaneous four times a day.
23. vancomycin in 0.9% sodium Cl 1 gram/250 mL Solution Sig: One
(1) Intravenous with HD for 7 days.
24. Outpatient Lab Work
Please obtain CBC, Chem 7 and Rapamycin level on ___ in AM
before taking your dose of Rapamycin. Please fax resutls to
your Dr. ___ ___, Fax: ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Graft cellulitis AND seroma of graft
Secondary: End stage renal disease, HIV, liver transplatation.
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 having been found a falsely
abnormal lab value and worsening left arm pain at site of your
graft. You were treated with antibiotics for suspected
infection in your arm. You were found to have enlarging fluid
collections at your arm which were felt to be seromas.
Aspiration of fluid from the collection closest to your arm pit
did not show infection. You were treated for cellulitis
(infection of the skin) over your graft.
In addition, you had worsening fluid swelling and low sodium due
to having taken too much fluid by mouth. In addition, there was
scrotal and penile swelling. This resolved with dialisys and
fluid restriction. Please do not drink more than 1.5 liters of
fluids daily.
The following changes were made to your medications:
STARTED:
- Sevelamer
CHANGED:
Sirolimus 1mg every ___
STOPPED:
None
You were discharged home.
Should you develop any symptoms concerning to you, please call
your liver doctor, primary care doctor or go to the emergency
room.
You underwent hemodialisis during your hospital stay.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acyclovir 400 mg PO Q12H
2. Aspirin 325 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Gabapentin 100 mg PO QAM
5. Gabapentin 200 mg PO HS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Vitamin D 800 UNIT PO DAILY
10. Dexamethasone 10 mg PO 1X/WEEK (___)
11. Levofloxacin 750 mg PO Q48H Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48H Disp #*3
Tablet Refills:*0
12. Lenalidomide 10 mg PO DAILY
13. OxycoDONE (Immediate Release) ___ mg PO QHS:PRN pain
do not take if sedated, do not take if driving
RX *oxycodone 5 mg ___ capsule(s) by mouth at bedtime Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pneumonia
Secondary: multiple myeloma
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 ___. You were
admitted for right sided chest pain. This was likely due to
your resolving pneumonia. You were treated with antibiotics and
were feeling better.
Please see below for changes to your medications and
appointments.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 5 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily as needed for constipation Disp #*20 Capsule Refills:*0
5. Loratadine 10 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed for pain control Disp #*60 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
8. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L greater troch 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>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.
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
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated left lower extremity with minimal
abduction of the leg until follow up.
Physical Therapy:
Weight bearing as tolerated in left lower extremity with
restrictions on abduction of the leg until follow up due to
greater troch fracture
Treatments Frequency:
None</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cefpodoxime Proxetil 200 mg PO Q12H pneumonia
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
2. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*5
3. Aspirin 81 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizure
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 ___,
You were admitted for seizure. You were started on a new
anti-seizure medication called Keppra. You should continue
taking this everyday to help prevent seizure.
You were also found to have a pneumonia while you were in the
hospital. You will take 2 more days of antibiotics at home to
complete your treatment course.
Memantine was stopped during this hospitalization due to
ineffectiveness.
There were no other changes to your medications. You should
follow up with your neurologist, Dr. ___.
It was a pleasure caring for you.
Sincerely,
___ Neurology</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. amLODIPine 10 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Lisinopril 7.5 mg PO DAILY
5. NiMODipine 60 mg PO Q4H
Last dose on ___.
6. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
7. Ondansetron 4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Reversible cerebral vasoconstriction syndrome
Intracranial Hemorrhage
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 ___,
You were hospitalized due to symptoms of headaches and
resulting from an acute brain hemorrhage likely due to a
syndrome called reversible cerebral vasoconstriction syndrome.
Reversible cerebral vasoconstriction syndromes (RCVS) are a
group of conditions characterized by reversible narrowing and
dilatation of the cerebral arteries. The cause of this syndrome
is unknown, though the reversible nature of the vasoconstriction
suggests an abnormality in the control of cerebrovascular tone.
RCVS can cause brain hemorrhages and cerebral edema. You have
received supportive therapy directed towards managing your
intracranial pressure, blood pressure and headaches. We have
started you on oral calcium channel blockers to treat
vasoconstriction. Recurrence of an episode of RCVS is rare. You
require rehabilitation with physical-, occupational and speech
therapy to recover from your neurological deficits.
Please continue taking nimodipine, the last dose is on ___.
Please continue taking amlodipine and lisinopril
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 1000 mg PO Q4-6H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth q4-6h Disp #*60
Tablet Refills:*0
2. Donepezil 10 mg PO QHS
RX *donepezil 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Bumetanide 1 mg PO DAILY
Increase to 1mg twice a day if more short of breath. Decrease to
1mg if breathing improves
RX *bumetanide 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 17 mcg
HFA every six hours as needed Disp #*1 Inhaler Refills:*0
7. Levofloxacin 500 mg PO Q48H
RX *levofloxacin 500 mg 1 tablet(s) by mouth every 48 hours Disp
#*2 Tablet Refills:*0
8. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride [Klor-Con] 20 mEq 1 packet(s) by mouth
daily Disp #*30 Packet Refills:*0
9. ValACYclovir 1000 mg PO Q12H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 12 hours
Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Dyspnea
Secondary Diagnoses:
Atrial Fibrillation
Hypertension
Coronary Artery Disease
Dysphagia
Urinary Retention
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 Mr. ___,
it was our pleasure caring for you during your admission to ___
___ ___. You were admitted for shortness
of breath. We think this was due to extra fluid that collected
in your lungs from your heart disease. We treated you with a
water pill and this resulted in an improvement in your symptoms.
Your discharge weight was 95.2 kg. You should weigh yourself
daily. If you notice weight gain of 3 lbs in 2 to 3 days you
should call your doctor.
We also noticed a rash on your buttocks that was concerning for
shingles. We sent a few tests to confirm this diagnosis. We are
giving you a prescription to treat shingles called valacyclovir.
We will have the results of the tests we sent in the next ___ to
48 hours and we will call you with the results. You should take
this medication as prescribed until we call you with the
results.
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. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg one tablet(s) by mouth twice daily
Disp #*30 Tablet Refills:*2
2. Atorvastatin 40 mg PO QPM
3. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg
oral DAILY
4. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch daily Disp #*30 Patch
Refills:*0
5. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at night Disp #*30
Capsule Refills:*0
6. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
7. NexIUM (esomeprazole magnesium) 40 mg oral BID
8. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation BID
9. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
10. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
11. glimepiride unknown ORAL Frequency is Unknown
Please resume the dose you were previously taking.
12. Metoprolol Tartrate 75 mg PO TID
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Encephalopathy
Central Sleep Apnea
Atrial Fibrillation
Benign Prostatic Hyperplasia
Chronic Obstructive Pulmonary 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 presented to the hospital with poor sleep and agitation. You
were treated initially with Haldol and then transitioned to
Seroquel. You were seen by the neurologists and the
psychiatrists. Many of your sedating medications, including
Xanax and Ambien, were stopped. You were also seen by the sleep
specialists for your central sleep apnea and will follow up with
them as an outpatient.
You were also found to have new atrial fibrillation, for which
you were started on metoprolol with improvement in your heart
rates. You were started on a blood thinner, called Apixaban, to
help prevent strokes. Your aspirin and Plavix were stopped to
decrease the risk of bleeding. You had an ultrasound of your
heart which showed no concerning findings.
You were also started on Flomax for symptoms of urinary urgency.
You were seen by our physical therapists. Your oxygen levels
were noted to decrease significantly with walking; however, you
reported that this is not very different from your baseline. We
recommended that you be discharged to rehab; however, you
insisted to be discharged home. It is very important that you
follow up with your physicians as instructed below.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 650 mg PO TID
RX *aspirin 650 mg 1 tablet(s) by mouth three times a day Disp
#*36 Tablet Refills:*0
2. Desipramine 250 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Methocarbamol 750 mg PO BID:PRN pain
5. Omeprazole 20 mg PO DAILY
6. Outpatient Lab Work
Please check CBC, chem-7, and LFTs including: Na, K, Cl, HCO3,
BUN, Cr, Glc, AST, ALT, ALP, tbili
Fax results to: ___. fax #: ___
7. Colchicine 0.6 mg PO BID Duration: 48 Hours
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
viral pericarditis
Secondary diagnosis:
rheumatoid arthritis
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 during your stay at ___. You
were admitted for an expedited workup of multiple issues,
including your shortness of breath, elevated ALP, and for fluid
around your heart. You underwent several diagnostic tests,
including a liver ultrasound, an MRI of your liver, an
echocardiogram, and x-rays of your foot. These showed that you
do not have any life-threatening conditions that we can
identify. You were also evaluated by our rheumatology team, who
did not believe your symptoms were related to your underlying
rheumatoid arthritis. We sent a number of studies that are
pending at discharge. Please follow-up with your PCP within the
next week to continue monitoring your symptoms.
Please continue to take your aspirin three times a day for 2
weeks and colchicine twice a day for 3 months to help with the
chest pain. Please have your labs drawn on ___ next week so
your PCP can closely monitor your progress.
We recommended iron supplementation to help with your anemia but
understand you do not wish to take it. Please re-consider this
decision as treating your anemia may make you feel better and
less tired.
It was a pleasure taking care of you.
Best wishes,
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 - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN dry nasal mucosa
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Oxazepam 10 mg PO QHS:PRN imnsonia
8. Verapamil 20 mg PO Q8H
9. Warfarin 2.5 mg PO ONCE Duration: 1 Dose
follow-up with PCP for repeat ___ and dosing of coumadin
10. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoperitoneum status post laparoscopic cholecystectomy.
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 Acute Care Surgery Service on ___
with abdominal pain after a recent laparoscopic procedure. You
were found to have a bleed in your abdomen. Initially we
attempted to monitor the bleed and slowly restart your
anticoagulation medication. Unfortunately you continued to bleed
and therefore you were taken back to the operating room and an
arterial bleed was found and stopped. After surgery your blood
levels were closely monitored and remained stable. Your
anticoagulation was again restarted which you tolerated well.
You are now doing better, tolerating a regular diet, and ready
to be discharged to home 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.
Please follow-up with your PCP ___ 24 hours after discharge to
review Coumadin dosing
If you have any questions about your recovery, please call the
Acute Care clinic at ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Fluoxetine 20 mg PO DAILY
2. Lorazepam 0.5 mg PO Q4H:PRN nausea
RX *lorazepam 0.5 mg 1 tab(s) by mouth every four (4) hours Disp
#*20 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO BID
5. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
6. Acidophilus *NF* (L.acidoph &
___ acidophilus) 1 capsule ORAL
DAILY
As directed
7. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*45 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, nausea, vomiting
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 ___
___. As you know, you were hospitalized for nausea
and abdominal pain. We consulted our gastroenterology team who
recommended we checked a barium swallow with small bowel follow
through as well as a gastric emptying study. Both of these were
normal, and did not provide an explanation for your nausea and
abdominal pain. Our gastroeneterology team's recommendation is
that you follow up as an outpatient for continued investigation
and management of your nausea and abdominal pain. At the time of
discharge we have controlled your symptoms adequately with oral
medications.
You should follow up with your GI doctor as directed. Our GI
team will attempt schedule you an appointment with one of our GI
specialists, here at ___ who may be able to evaluate your
symptoms better. They will also contact you to set up an
appointment in our GI Clinic with one of our Gastroenterology
Fellows in the next ___ weeks to check up on your symptoms.
We have made the following changes in your medications:
START
Ondansetron (Zofran)
lorazepam (Ativan)
Oxycodone
Acetaminophen
STOP
hydromorphone (Dilaudid)</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
2. Docusate Sodium 100 mg PO BID
Hold for loose stool
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute 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 ___ with
acute appendicitis. You were taken to the operating room and
had your appendix removed laparoscopically. This procedure went
well. You are now tolerating a regular diet and your pain is
better controlled. You are now ready to be discharged home to
continue your recovery. Please note the following discharge
instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
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 You have Dermabond adhesive applied to your incisions and this
will dissolve on its own over the next couple of weeks.
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. Simvastatin 40 mg PO QPM
2. Metoprolol Succinate XL 125 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Eplerenone 25 mg PO DAILY
5. Eliquis (apixaban) 2.5 mg oral BID
6. Acetaminophen 500 mg PO Frequency is Unknown
7. Furosemide 20 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 108 mcg inhalation prn
9. Fluticasone Propionate 110mcg 1 PUFF IH BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute on chronic heart failure with reduced ejection fraction
Exacerbation
Dyspnea
Atrial Fibrillation
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 Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had extra fluid in your body related to your heart
disease. We gave you medicines through your IV to take that
fluid off. It is very important that you take all of your
medicines as prescribed and go to all of your follow up
appointments.
We wish you the best of health,
Your ___ Care 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. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
please hold for loose stool
5. Finasteride 5 mg PO DAILY
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain, fever
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Closed loop bowel obstruction
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 Mr. ___,
You presented to the ___ on
___ after with abdominal pain and were found to have a
small bowel obstruction. You were admitted to the Acute Care
Surgery team for further medical care. You were taken to the
Operating Room and underwent surgical repair of your bowel
obstruction. You tolerated this procedure well and were
transferred to the surgical floor for pain control and to await
the return of your bowel function.
You are now tolerating a regular diet, you pain is well
controlled and you have worked with Physical Therapy. The
Physical Therapy team evaluated you and recommended that you
continue your recovery at a rehabilitation facility.
You were also evaluated by the Medicine team given that you
reported fainting and losing consciousness at home prior to
being admitted to the hospital. There are no acute concerns and
it is recommended you
follow-up with your outpatient Cardiologist and have an
outpatient ECHO.
You are now medically cleared to be discharged. 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.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
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.
*Your staples will be removed at your follow-up appointment.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Diazepam 10 mg PO HS
2. Divalproex (EXTended Release) 1500 mg PO DAILY
3. Doxepin HCl 20 mg PO HS
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Ibuprofen 800 mg PO Q8H:PRN arthritis pain
7. Lisinopril 40 mg PO DAILY
8. Lithium Carbonate CR (Eskalith) 900 mg PO DAILY
Eskalith CR
9. Lorazepam 1 mg PO DAILY:PRN anxiety
10. lurasidone 80 mg oral DAILY
11. QUEtiapine Fumarate 400 mg PO QAM
12. QUEtiapine Fumarate 800 mg PO QPM
13. Tiotropium Bromide 1 CAP IH DAILY
14. Enoxaparin Sodium 110 mg SC Q12H Start: ___, First
Dose: Next Routine Administration Time
RX *enoxaparin 120 mg/0.8 mL 120 mg SQ Two (2) times a day Disp
#*20 Syringe Refills:*0
15. Warfarin 5 mg PO DAILY16
Take as directed by the ___ clinic.
RX *warfarin 5 mg 1 tablet(s) by mouth daily as directed by your
___ clinic Disp #*30 Tablet Refills:*0
16. esomeprazole magnesium 40 mg oral DAILY
17. ipratropium-albuterol ___ mcg/actuation inhalation
Q6H:PRN sob, wheeze
18. MetFORMIN (Glucophage) 500 mg PO BID
19. Warfarin 2 mg PO DAILY16
Take as directed by the ___ clinic
RX *warfarin 2 mg 1 tablet(s) by mouth daily as directed by the
anticoagulation clinc Disp #*30 Tablet Refills:*0
20. Outpatient Lab Work
Pulmonary Embolism
ICD-9 415.19
___ to be drawn on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: lobar and segmental pulmonary emboli
Secondary: hepatitis C, schizophrenia, seizure disorder
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 ___ with worsening chest pain and
shortness of breath. You were found to have blood clots in your
lungs. You were started on a medication called warfarin to thin
your blood and prevent the blood clots from getting worse. It
takes at least ___ days for this medication to work properly, so
you need to take an additional injectible medication called
enoxaparin (Lovenox) until your blood levels of warfarin are
appropriate.
You will take 5mg of warfarin daily. You need to have your
bloodwork done on ___ to see if the warfarin levels become
therapeutic. At that time, the ___ clinic
nurses ___ advise you if you need to change this regimen.
You should not get your tooth pulled for at least the next month
while your blood thinner dose is being adjusted. Overall, you
will need to take the warfarin for ___ months.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. BuPROPion 100 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 100 mg PO BID
9. Lactulose 15 mL PO TID
10. Lorazepam 0.5 mg PO Q6H:PRN anxiety
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO Q12H
13. Sertraline 100 mg PO DAILY
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Vitamin D 1000 UNIT PO DAILY
16. Bisacodyl 5 mg PO DAILY:PRN constipation
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Reguloid (psyllium husk;<br>psyllium seed (sugar)) 0.52 gram
oral BID
20. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Viral gastroenteritis
Acute kidney injury
Constipation
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. ___,
It was a pleasure caring for you at ___. You were admitted
with a gastrointestinal infection. You were treated with IV
fluids and nausea medications. Your kidney function was
decreased on admission, but improved with IV fluids. We are glad
you are feeling better.
Best wishes,
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. Aspirin 81 mg PO DAILY
3. Amlodipine 10 mg PO EVERY ___ AFTER DIALYSIS
4. Nephrocaps 1 CAP PO DAILY
5. Senna 8.6 mg PO QHS:PRN constipation
6. HydrOXYzine 10 mg PO BID:PRN Itch
7. Vitamin D 1000 UNIT PO BID
8. Ciprofloxacin HCl 500 mg PO Q24H
9. Labetalol 200 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multifactorial hypertensive and toxic/metabolic encephalopathy
ESRD on HD
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. ___,
You were admitted for evaluation of a brief episode of
unresponsiveness you had during dialysis. We performed extensive
evaluation and found that you likely had a urinary tract
infection. Your blood pressure was also high, likely as a result
of stopping your clonidine patch recently. We think the
combination of these factors was the likely cause of your
episode, and we treated you with antibiotic medications and high
blood pressure medications.
You should continue dialysis (___) at rehab, and continue
to adjust BP medications in conjunction with the Renal team.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY
RX *clobetasol 0.05 % Apply to erythematous lesions twice a day
Refills:*0
2. Enoxaparin Sodium 80 mg SC Q12H
3. FoLIC Acid 5 mg PO DAILY
RX *folic acid 1 mg 5 tablet(s) by mouth once a day Disp #*150
Tablet Refills:*0
4. LevoFLOXacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
5. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
6. Tacrolimus 0.5 mg PO QPM
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
7. Tacrolimus 1 mg PO QAM
RX *tacrolimus 0.5 mg 2 capsule(s) by mouth QAM Disp #*60
Capsule Refills:*0
8. Acyclovir 400 mg PO Q8H
9. Atovaquone Suspension 1500 mg PO DAILY
10. BuPROPion XL (Once Daily) 450 mg PO DAILY
11. Cyanocobalamin 250 mcg PO DAILY
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Fluconazole 400 mg PO Q24H
14. FLUoxetine 80 mg PO DAILY
15. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
16. Magnesium Oxide 400 mg PO BID
17. Multivitamins W/minerals 1 TAB PO DAILY
18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
19. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting
20. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
- Superior vena cava syndrome
- Pulmonary emboli
SECONDARY
=========
- DLBCL s/p allogenic SCT
- Neutropenia
- Erythema nodosum
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 came into the hospital because you were having flushing of
your face and a sensation of fullness in your chest, as well as
difficulty breathing. You were found to have a clot in the main
vein near your heart and in the vessels in your lungs. You had
this clot and your port removed and were started on blood
thinners. Additionally, you had low white blood cell counts ***.
You had some rashes on your legs that suggest an inflammatory
condition. Therefore, you were started on corticosteroids
(anti-inflammatory medication).
When you leave the hospital you should:
- Take all of your medications as prescribed.
- Attend all scheduled clinic appointments.
- Clean biopsy site with soap, water, then pad dry every day for
2
weeks. Cover with a thin layer of vaseline and perform dressing
change
every day for 2 weeks. Sutures can be removed on ___.
It was a pleasure taking care of you,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen ___ mg PO Q6H:PRN pain
do not exceed 4000 mg in 24 hours
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
take while using oxycodone for pain
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN Pain
RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive while taking, use with a stool softener
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every 4 hours
Disp #*35 Tablet Refills:*0
5. LaMOTrigine 200 mg PO QHS
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lithium Carbonate SR (Lithobid) 900 mg PO QHS
Lithobid SR
Discharge Disposition:
Home
Discharge Diagnosis:
Mesosalpinx inclusion cyst
Final pathology pending
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 gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. If they are still on
after ___ days from surgery, you may remove them.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*2
Tablet Refills:*0
2. OSELTAMivir 75 mg PO BID Duration: 9 Doses
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*2 Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. Aspirin 81 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Citalopram 40 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. dulaglutide 1.5 mg/0.5 mL subcutaneous q week
9. Ferrous Sulfate 325 mg PO BID
10. Furosemide 40 mg PO BID
11. linaGLIPtin 5 mg oral daily
12. Lisinopril 40 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
16. Pregabalin 200 mg PO BID
17. Rosuvastatin Calcium 20 mg PO QPM
18. Tamsulosin 0.4 mg PO QHS
19. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
#Pneumonia
#Influenza
#Hypoxia
#Diarrhea
#Nausea
#HFrEF
#Elevated Troponin
#Elevated Pro-BNP
#Acute kidney injury
#Insomnia
#DMII
#Microscopic Hematuria
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 at the ___
___!
Why was I admitted to the hospital?
===================================
- You were admitted because you had 2 days of cough,
fevers/chills, malaise, worsening fatigue as well as chest pain
and worsening shortness of breath.
What happened while I was in the hospital?
==========================================
- We did blood work and imaging to figure out what might be
causing this and found out you had the flu as well as a lung
infection.
- You were initially admitted to the intensive care unit for
close monitoring in the setting of infection but improved and
were on the regular hospital floor.
- We started you on antibiotic and antiviral and monitored your
heart.
- We manged your lack of sleep and nausea with medication.
What should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*10 Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Amitriptyline 10 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Venofer (iron sucrose) 200 mg/10 mL iron INJECTION Q4WEEK
7. Lidocaine 5% Patch 1 PTCH TD QPM knee pain
8. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach discomfort
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Congestive Heart Failure
Polyvalvular Heart Disease
Acute on Chronic Kidney Disease
Chronic Anemia
Mechanical Left Knee Pain
Neck Muscle Stiffness
SECONDARY DIAGNOSES:
Hypertension
Hyperlipidemia
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 at ___
___. You were admitted for shortness of breath. We
believe your shortness of breath was due to your heart not
working as efficiently as it used to. This caused fluid to back
up into your lungs, making it difficult for you to breathe. We
gave you a water pill to help remove this extra fluid in your
lungs. However, because your kidney function worsened, we
stopped giving you the water pill. Your breathing improved and
you did not need any extra oxygen by the time you were ready to
leave the hospital. We put in a catheter to help empty your
bladder and monitor your urine output. You developed a fever on
a few occasions. Because of your loose stools, we thought your
fevers were due to a infection in your bowels but we did not
find one. We initially treated you with antibiotics but stopped
them since we did not find an infection. Your left knee pain and
neck pain improved with pain medications and were not concerning
for any infection. Due to your chronic anemia, we gave you two
units of blood. Once your kidney function returned to normal and
your left knee and neck pain improved, we discharged you to
rehab. It will be important to see your primary care doctor
within ___ weeks of leaving the hospital. You should also ask
your primary care doctor about seeing a cardiologist to better
manage your heart conditions. Please remember to weigh yourself
at home everyday and let your primary care doctor know if you
have unexpected weight gain.
Thank you for letting us take part in your care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CeftriaXONE 2 gm IV Q 12H
2. Tizanidine 4 mg PO TID
3. traZODONE 50 mg PO HS:PRN insomnia
4. LeVETiracetam 1000 mg PO BID
5. Nicotine Patch 14 mg TD DAILY
6. Ibuprofen 600 mg PO Q6H:PRN pain
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
if not responding to ibuprofen or tizanidine
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Streptococcus pneumoniae bacterial meningitis, 2) Status
epilepticus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro Exam: MS notable for disinhibition, Mild UMN weakness in
UE and ___ L > R.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ on
___ after you developed fever and headache at home and
subsequently developed seizures. You were found to have
bacterial meningitis, an infection in the membranes surrounding
your brain. You were admitted to our ICU for close monitoring
and improved with antibiotics and anti-seizure medications.
We made the following changes to your medications:
Keprra 1000 mg twice daily to continue for 6 months.
Trazadone was also added as needed for sleep. You may not need
this outside of the hospital.
You have been treated for back, leg pain and headache with
muscle relaxants (tizanidine) and ibuprofen. You were given
tylenol, but had an increase in your liver function tests,
therefore you should avoid taking tylenol for the time being.
Instructions for Rehab:
1. Please treat headache, back and leg pain with tizanidine 4 mg
three times daily as needed or ibuprofen 600 mg every 6 hours as
needed.
2. Please avoid tylenol.
3. Reserve oxycodone for severe pain only and avoid if possible.
4. Please continue Ceftriaxone 2 grams twice daily through ___, to complete a 14 day course. The PICC line may be pulled
following the last dose of ceftriaxone.</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 #*25 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*5 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth once a
day Refills:*0
4. Acyclovir 400 mg PO Q12H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left incarcerated inguinal hernia
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. CT scan
revealed a left inguinal hernia. You were taken to the operating
room and had a left inguinal hernia repair with mesh. You
tolerated the procedure well and are now being discharged home
to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
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 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. Acetaminophen 650 mg PO Q6H
2. Diazepam 5 mg PO Q8H:PRN muslce spasm
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
6. Senna 8.6 mg PO BID:PRN constiaption
7. Allopurinol ___ mg PO DAILY
8. Famotidine 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
L1 superior wedge fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Activity
- Please wear your TLSO brace at all times when at edge of bed
or out of bed, Please ___ your brace at your bedside.
- Ok to take TLSO brace off when lying in bed
- Please shower while wearing your TLSO brace
- 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. ___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- No contact sports until cleared by your neurosurgeon.
Pain Control
· You may take Ibuprofen/ Motrin for pain.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
· It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· New weakness or changes in sensation in your arms or legs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Enoxaparin Sodium 110 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL ___very twelve (12) hours Disp
#*60 Syringe Refills:*5
2. Outpatient Physical Therapy
please evaluate and treat
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. exemestane 25 mg Oral daily
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Gabapentin 600 mg PO TID
9. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
10. Lorazepam 2 mg PO QHS:PRN insomnia
11. Omeprazole 20 mg PO DAILY
12. Ranitidine 300 mg PO QHS
13. Senna 8.6 mg PO BID:PRN constipation
14. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
pain
RX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every six (6) hours Disp #*60 Tablet Refills:*0
15. Ibuprofen 400 mg PO Q8H:PRN knee pain Duration: 3 Days
Please use sparingly
16. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pulmonary embolism
Left lateral meniscus tear
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 looking after you, Ms. ___. As you know, you
were admitted with shortness of breath and was found to have an
acute pulmonary embolus (clot in the lung). You were treated
with lovenox to help thin the blood and prevent progression of
old clot or development of new clot.
To identify a reason for why this clot developed, a lower
extremity ultrasound and abdominal CT scan was performed. It
did not show a clot in the legs - moreover, there was no sign of
recurrence of cancer which would potentially increase the risk
of developing a pulmonary embolus. You did not require oxygen
during this hospitalization.
You also had left knee pain. MRI of the knee revealed a tear
in the lateral meniscus - and this will be managed
conservatively (physical therapy). Please continue with home
physical therapy. You can continue to take ibuprofen as needed
for pain, but please use this sparingly as this can cause
stomach ulcers which would put you at risk of bleeding while you
are on Lovenox. You can also take vicodin as needed for pain.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb IH every six
(6) hours Disp #*1 Unit Refills:*1
2. Citalopram 40 mg PO QAM
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Ferrous Sulfate 325 mg PO QAM
5. Gabapentin 1200 mg PO TID
6. HydrOXYzine 25 mg PO Q6H:PRN itch
7. Glargine 50 Units Bedtime
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
9. Lisinopril 30 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Promethazine 25 mg PO BID:PRN nausea
14. RISperidone 1 mg PO QAM
15. RISperidone 4 mg PO HS
16. Rosuvastatin Calcium 10 mg PO HS
17. Tizanidine 4 mg PO TID
18. TraZODone 150 mg PO HS:PRN insomnia
19. Azithromycin 500 mg PO Q24H Duration: 3 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth Q24H Disp #*3
Tablet Refills:*0
20. PredniSONE 60 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
21. ammonium lactate *NF* 12 % Topical BID
22. Clindamycin 1 Appl TP BID
23. Fluticasone Propionate 110mcg 2 PUFF IH BID
24. glimepiride *NF* 2 mg Oral QAM
25. MetFORMIN (Glucophage) 1000 mg PO BID
26. Victoza 2-Pak *NF* (liraglutide) 1.2 mg Subcutaneous QPM
27. Nebulizer
Please provide patient with 1 nebulizer.
28. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
Only use if albuterol nebulizer is not working.
RX *albuterol 2 puffs IH every six (6) hours Disp #*1 Inhaler
Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: COPD exacerbation
Secondary: 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 pleasure taking care of you while you were a patient at
___. You came in because of
shortness of breath and cough. We performed a CT scan of your
lungs to make sure there was no pneumonia or blood clot. We
didn't find anything concerning on the CT scan. This suggests
that your symptoms were due to temporary worsening of your COPD.
We treated you with steroids, antibiotics, and breathing
treatments which significantly improved your symptoms.
At home, please remember to take your fluticasone inhaler twice
a day. You are being discharged with a prescription for more
albuterol which you should use when you are short of breath.
In terms of follow-up, please be sure to keep your appointment
with Dr. ___ on ___. We are working on getting
you an appointment in the Pulmonary Clinic. It is very important
that you follow-up with Dr. ___ in the next few weeks
about your breathing.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q8H
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN
indigestion
3. Artificial Tears 1 DROP BOTH EYES QAM
4. Aspirin 162 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Guaifenesin 15 mL PO Q4H:PRN cough
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Loratadine 10 mg PO DAILY:PRN itch
11. Magnesium Oxide 400 mg PO DAILY
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Mirtazapine 37.5 mg PO HS
14. OLANZapine 2.5 mg PO DAILY:PRN agitation
15. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Oxcarbazepine 300 mg PO BID
18. Senna 17.2 mg PO HS
19. Vitamin D 400 UNIT PO DAILY
20. Nitroglycerin SL 0.3 mg SL PRN PAIN Q5MIN chest pain
21. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Doses
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Urinary tract infection
Secondary: Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were transferred to ___ from ___ Hospital
after you fell at your nursing facility. There was concern that
you had bleeding inside your brain, for which you were worked up
with a CT scan. The scan showed no acute bleeding. You were
however found to have a urinary tract infection for which you
were treated with antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you.
You were admitted to the ___
for shortness of breath. You were treated for fluid overload
and underwent a cardiac catheterization which you tolerated
well. You were also seen by the lung doctors who ___
and ___ continue to follow you as an outpatient. You will be
visited at home by nurses who will come to draw blood to monitor
your comadin levels, and they will ensure that you received your
lovenox injections as prescribed until the shots are no longer
needed. Weigh yourself every morning, call your primary care
doctor if your 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 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch daily Disp #*30 Patch
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours
Disp #*30 Capsule Refills:*0
5. Alendronate Sodium 70 mg PO QMON
6. ARIPiprazole 15 mg PO QHS
7. Atorvastatin 20 mg PO QPM
8. Furosemide 20 mg PO DAILY:PRN swelling
9. HumaLOG (insulin lispro) 100 unit/mL SC 20 units TID
10. insulin glargine 100 unit/mL subcutaneous 15 units BID
11. LamoTRIgine 100 mg PO BID
12. Levothyroxine Sodium 137 mcg PO DAILY
13. Lisinopril 2.5 mg PO DAILY
14. LORazepam 0.5 mg PO BID
15. TraZODone 100 mg PO QHS
16. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
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 Acute Care Surgery Service on ___
with a small bowel obstruction. You had an exploratory
laparotomy with lysis of adhesions. You are have recovered in
the hospital, are now tolerating a regular diet, and ready to
be discharged with the following 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. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Epoetin Alfa 10,000 UNIT IV 3X/WEEK (___)
6. Gabapentin 300 mg PO Q48H
7. Fluoxetine 10 mg PO DAILY
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO BID
11. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
12. Benzonatate 100 mg PO TID cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
13. Guaifenesin ___ mL PO Q6H:PRN cough
14. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN shortness of breath
15. Acetaminophen 325-650 mg PO Q6H:PRN pain
16. DiphenhydrAMINE 25 mg PO BID:PRN itch
Discharge Disposition:
Home
Discharge Diagnosis:
Cough
Viral bronchitis
End stage renal disease
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital with cough, muscle pains and
low grade fevers. We gave you cough medications and your
symptoms improved. These symptoms are likely due to a virus and
should continue to improve. You do not need antibiotics at this
time.
At home, you can use the following medications to manage your
cough:
-Tessalon pearls three times daily
-Guaifenesin cough syrup as needed
-You can also use your Combivent inhaler (previously prescribed
by your primary care doctor) if you feel short of breath or
wheezy
It was a pleasure taking care of you during your hospitalization
and we wish you a speedy recovery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days.
Disp:*48 Capsule(s)* Refills:*0*
4. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8
hours).
Disp:*90 Capsule(s)* Refills:*0*
5. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Clostridium difficile colitis
Rectal bleeding
Hemorrhoids
Acute on chronic renal failure
Anemia
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 with bleeding from your rectum. During your
hospitalization, we checked your blood counts multiple times
found them to be low, so we gave you a blood transfusion. A GI
consultation felt the bleeding was related to hemorrhoids.
Furthermore, we found that you were suffering from an infection
in your intestines called C. Diff. We are treating you with oral
antibiotics for this infection. It is very important that you
complete the course of antibiotics in order to eliminate the
infection. Additionally, the ulcers on your finger tips were
evaluated by our rheumatology department, and it was felt that
the cause of the painful ulcers was related to a chemotherapy
drug you have been receiving called gemcitabine. One of your
blood tests, the anti-nuclear antibody, was positive and may
provide additional information as to the cause of these ulcers.
We have set you up with a rheumatology appointment for
follow-up, and we have started you on a medication which may
diminish these effects, nifedipine. Finally, we noted that your
kidney function was abnormal. A renal ultrasound was done, which
only showed two simple cysts, which do not explain the cause of
the kidney dysfunction. We recommend that you see a
nephrologist as an outpatient and have made an appointment for
you with Dr. ___ below). We also recommend you see a
rheumatologist and have made this appointment as well.
Please note the following changes to your medications:
Start baby aspirin (for your finger ulcers)
Start Nifedipine (for your finger ulcers)
Start Vancomycin (for your C diff infection) - for 12 more days
Start Zofran for Nausea (as needed)</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
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB/Wheeze
3. amLODIPine 10 mg PO DAILY
4. Calcitriol 0.25 mcg PO 3X/WEEK (___)
5. Calcium Carbonate 750 mg PO TID
6. Furosemide 20 mg PO EVERY OTHER DAY
7. imiglucerase 3200 units injection EVERY 2 WEEKS
8. Labetalol 200 mg PO TID
9. Losartan Potassium 100 mg PO DAILY
10. Mycophenolate Mofetil 250 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. raloxifene 60 mg oral DAILY
13. Sertraline 125 mg PO DAILY
14. Simvastatin 40 mg PO QPM
15. Sodium Bicarbonate 650 mg PO BID
16. Tacrolimus 1 mg PO Q12H
17. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*12 Capsule Refills:*0
18. Vitamin D 1000 UNIT PO 4X/WEEK (___)
19. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Issues:
#Diarrhea
Chronic Issues:
#History of recurrent C. diff
#Hypertension
#Normocytic anemia
#S/P LLRT ___
#Depression
#Insomnia
#Mineral metabolism
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. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you were fatigued and had abdominal
pain as well as diarrhea
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- We ran tests which showed you did not have an infection.
WHAT DO I NEED TO DO AFTER DISCHARGE?
- Please have close follow-up with your transplant doctors
- Please stop taking any form of laxatives, and discuss this
with your PCP.
Thank you for choosing ___ for your care. We wish you luck for
the future.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 50 mcg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. RISperidone 1 mg PO QHS
9. Simvastatin 40 mg PO QPM
10. Thiamine 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
13. Lorazepam 0.5 mg PO BID:PRN anxiety
14. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Depression, Confusion/Altered Mental Status, s/p
mechanical fall
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital because of your fall and
because of confusion. We evaluated you with a CT scan of your
head and xrays of your chest and spine which showed no acute
changes. We also evaluated your electrolytes and your blood
counts which were normal. We also checked your B12 level and
your thyroid function. The results of these tests are still
pending. We also evaluated you with urine culture. These results
are still pending as well. We believe your fall and your
confusion may have happened because of the medications you are
taking. We stopped your mirtazapine and your busiprone and we
decreased your duloxetine.
After discharge, you should follow up with your primary care
physician for further management of your medical conditions. You
should follow up with your psychiatrist for further management
of your psychiatric medications and for further management of
your confusion.
We wish you the best!
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Simethicone 40-80 mg PO QID:PRN gas pan
2. Vitamin D 1000 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Escitalopram Oxalate 20 mg PO DAILY
6. Famotidine 20 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye)
Q12H:PRN itchy eyes
10. Loratadine 10 mg PO DAILY
11. LORazepam 0.5 mg PO QHS:PRN insomnia
12. MethylPHENIDATE (Ritalin) 5 mg PO BID
13. Montelukast 10 mg PO DAILY
14. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
15. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
17. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
18. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Partial SBO, loculated ascites
Secondary: Metastatic mixed carcinosarcoma/serous endometrial
cancer
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 ___ because you were having abdominal
pain, adn you were found to have a partial blockage and
increasing fluid. You had a procedure known as a paracentesis to
remove the excess fluid in your abdomen. You initially needed an
tube in your nose to help relieve the blockage in your bowels.
This was removed and you tolerated eating solid food and then
had bowel movements. If you develop this issue in the future,
you should discuss with your palliative care doctors having
something called a venting g-tube placed to help relieve the
pressure.
Please follow up with all appointments and take all medications
as prescribed. If you develop any of the danger symptoms below,
please seek medical evaluation immediately.
We wish you 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. Azithromycin 250 mg PO Q24H
continue until you ___ with your pulmonologist
2. GuaiFENesin ER 600 mg PO Q12H
3. ___ Neb 1 NEB NEB Q6H:PRN wheezing
take PRN for wheezing or shortness of breath
4. Nicotine Patch 14 mg TD DAILY
5. PNEUMOcoccal ___ polysaccharide vaccine 0.5 ml IM NOW
X1
6. PredniSONE 10 mg PO DAILY Duration: 3 Days
7. Torsemide 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Benztropine Mesylate 0.5 mg PO DAILY
10. ClonazePAM 1 mg PO QHS
11. ClonazePAM 0.25 mg PO DAILY 2PM
12. ClonazePAM 0.5 mg PO DAILY
13. Docusate Sodium 100 mg PO DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Levothyroxine Sodium 50 mcg PO DAILY 8pm
16. Linzess (linaclotide) 290 mcg oral daily
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP for up to 3 doses
18. Omeprazole 20 mg PO BID WIHT LUNCH AND DINNER
19. Oxybutynin 5 mg PO BID
20. RisperiDONE 1 mg PO DAILY
21. Senna 8.6 mg PO QHS:PRN constipation
22. Sertraline 150 mg PO DAILY
23. Simvastatin 20 mg PO QPM
24. Symbicort ___ mcg/actuation
inhalation BID
25. Systane Gel (artificial tears(hypromellose);<br>peg
___ glycol) ___ % ophthalmic TID
26. TraMADol 50 mg PO TID
27. Warfarin 3 mg PO DAILY16
28. HELD- Loxapine Succinate 30 mg PO DAILY This medication was
held. Do not restart Loxapine Succinate until you discuss with
PCP
29. HELD- Nitroglycerin Patch 0.1 mg/hr TD Q24H This medication
was held. Do not restart Nitroglycerin Patch until discuss with
PCP - soft BPs on discharge
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
COPD exacerbation
Right heart failure, RV Strain
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>Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with shortness of breath
which was likely due to a combination of pneumonia, COPD
exacerbation and fluid in your lungs. You were treated with
Antibiotics, steroids and diuretics and you improved. You were
started on an oral diuretic which you should continue on
discharge. It is important that you follow up with your
cardiologist and pulmonologist after discharge
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. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not exceed 4000 mg daily.
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
Do not drink alcohol while taking this medication.
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute 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 ___ with acute appendicitis. You were
managed non-operatively with IV antibiotics and bowel rest. You
have recovered well and are now ready for discharge home. Please
follow the instructions below to ensure a speedy recovery.
ACTIVITY:
-no restrictions
-resume your normal activity as tolerated
DIET:
-no restrictions
-resume your normal diet as tolerated
MEDICATIONS:
-you may continue to take Tylenol as needed for abdominal pain
(do not take more than 4000 mg daily)
-You are being discharged with a prescription for antibiotics
(Ciprofloxacin and Flagyl). You should take these for 10 days.
It is important that you finish taking these as prescribed.
FOLLOW-UP:
-Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
-At follow-up appointment, can discuss scheduling of
laparoscopic appendectomy 6 weeks from date of diagnosis.
Contact your surgeon or present to the ED if you experience any
of the following:
- 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
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Surgery 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
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 600 mg PO HS
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Amiodarone 200 mg PO BID
6. Digoxin 0.125 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO TID
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Acetaminophen 325 mg PO Q8H:PRN pain
10. acidophilus-B.bifidum-B.longum (L.acidoph &
___ acidophilus) 150 mg (3
billion cell) oral BID
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
13. Enoxaparin Sodium 40 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
14. Guaifenesin ER 600 mg PO Q12H
15. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN cough
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. Mesalamine (Rectal) ___ID
18. Multivitamins 1 TAB PO DAILY
19. Omeprazole 20 mg PO BID
20. saccharomyces boulardii 250 mg oral BID
21. Tolterodine 4 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 5 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cholecystitis
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 to ___ with cholecystitis.
You underwent percutaneous cholecystostomy tube placement.
Please, follow up these instructions
-the drain will stain ___ weeks. Please, follow these drain care
instruction
General 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.
Please, follow these general 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.
*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 1000 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
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 for what was likely early appendicitis. You
infection has cleared and you are cleared to be discharged home
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 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: [/INST] </s><s>You were admitted to the hospital with a flare of your
ulcerative colitis. This improved with use of two doses of
infliximab. you are also on steroids at discharge with
prednisone.
If you have new GI symptoms you can contact the GI on call ___ such as new abdominal pain, fever, chills, bloody
stools, worse diarrhea.
We wish you the best in your recovery,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*7
Capsule Refills:*0
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. dimethyl fumarate 120 mg (14)- 240 mg (46) oral BID
4. Ketoconazole 2% 1 Appl TP BID
5. Metoclopramide 5 mg PO BID:PRN with tecfidara
6. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-25 mcg
oral DAILY
7. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Relapsing Remitting Multiple sclerosis
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 came into the hospital because you were having double
vision, dizziness, and sensory changes. You are admitted to the
hospital to have a lumbar puncture and additional imaging. You
received 2 doses of steroids.
When you leave the hospital you should:
- Take all of your medications as prescribed. You should
complete your steroid course as an outpatient.
- Attend all scheduled clinic appointments.
It was a pleasure taking care of you,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for evaluation of shortness of breath and had a
catheterization - you were found to have a blockage in of the
arteries in your heart. You had a stent placed to open the
blockage. You were started on plavix. It is VERY important that
you DO NOT stop this medication unless you are told do so by
your cardiologist. Please be sure to consult your cardiologist
before stopping plavix.
This helped your breathing. You were also given lasix to get
extra fluid off of you and help your breathing. Your oxygen
levels improved.
You were also found to have a urinary tract infection and you
were given antibiotics.
You worked with physical therapy who felt that you would benefit
from rehab to improve your strength.
Your kidney function worsened a little bit while you were in the
hospital. Please try to drink fluids at home to keep hydrated
(no more than 1.5 liters)
Please 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. Atorvastatin 80 mg PO QPM
2. GlipiZIDE XL 5 mg PO QAM
3. GlipiZIDE XL 10 mg PO QHS
4. Metoprolol Tartrate 50 mg PO BID
5. Acetaminophen 1000 mg PO Q8H
6. Docusate Sodium 100 mg PO BID
please hold for loose stool
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Heparin 5000 UNIT SC BID
10. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3H Disp #*30
Tablet Refills:*0
11. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using HUM Insulin
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
13. Senna 8.6 mg PO BID
please hold for loose stool
14. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
15. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L rib fx ___, sternal fx, T8 vertebral body fracture, R lateral
malleolus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital after suffering a motor
vehicle accident. You were found to have multiple left rib
fractures, a sternal fracture, T8 vertebral body (spine)
fracture and a right lateral malleolus (ankle) fracture. You
were admitted to the Trauma/Acute Care Surgery service and
transferred to the Intensive Care Unit (ICU) to help manage your
pain and monitor your breathing.
When medically stable, you were transferred to the surgical
floor. You worked with the Physical Therapy team who
recommended your discharge to a rehabilitation center to
continue your recovery. You are now medically cleared for
discharge. Please note the following discharge instructions:
Rib Fractures:
* Your injury caused left-sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain (ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Spine Injury Instructions:
Please wear your TLSO brace while out of bed
Instructions for your Right Ankle Fracture:
Please wear air cast boot on right foot when out of bed.</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. Docusate Sodium 100 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600-800
mg-IU oral DAILY
6. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Alzheimer's dementia
- Delirium and lethargy due to acute UTI
- Urinary tract infection
Secondary:
- Carotid artery stenosis NOS
- Vertebral compression Fractures
- Glaucoma
- Vaginal Prolapse
Discharge Condition:
Somnolent, minimally responsive. Withdraws and says 'ouch' to
pain.
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure participating in your care during your recent
stay at ___. You were hospitalized for lethargy after a fall.
CT and MRI scans of your ___ were taken to look at the
structure of your ___ and showed ___ atrophy with enlarged
ventricles but no acute abnormalities. EEG
(electroencephalogram) testing was performed to look for
evidence of seizures and showed diffuse encephalopathy; your
clinical picture is not consistent with seizures, and you will
not be on anti-seizure medication. You had a lumbar puncture to
evaluate for normal pressure hydrocephalus, and the procedure
was not consistent with that diagnosis. Your final diagnosis is
Alzheimer's Disease, and your increased lethargy is due to UTI,
which has been treated with antibiotics. It will take time to
recover your mental status from this infection, and you may only
experience a partial recovery.
You were also evaluated by physical therapy who felt that it
would be best if you were to go to rehabilitation to help build
up your strength again.
Once again, thank you for the opportunity to participate in your
care. 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. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
8. Amoxicillin 500 mg PO Q8H Duration: 10 Days
RX *amoxicillin 500 mg 1 tablet(s) by mouth three times daily
Disp #*29 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Acute complicated cystitis
- Sepsis
Secondary diagnoses:
- Atrial fibrillation with rapid ventricular response
- Metastatic bladder carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
___ was a a privilege to care for you here at ___. You were
admitted to ___ due to fevers. Your evaluation revealed
concern for a bladder infection. You were treated with IV
antibiotics (vancomycin) for an enterococcal UTI and then were
transitioned to oral amoxicillin to complete for 10-days. Your
fevers resolved at discharge.
Please keep all your doctors' appointments.
We wish you all the best!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aripiprazole (ARIPiprazole) 30 mg ORAL QHS
2. Aspirin 81 mg PO DAILY
3. Glargine 46 Units Breakfast
Glargine 6 Units Bedtime
Humalog 12 Units Breakfast
Humalog 10 Units Lunch
Humalog 15 Units Dinner
4. LaMOTrigine (lamoTRIgine) 300 mg ORAL DAILY
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D 800 UNIT PO DAILY
7. Acetaminophen 1000 mg PO Q8H
Maximum 6 of the 500 mg tablets daily
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*24 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*40 Capsule Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
No driving if taking this medication. Taper as tolerated
RX *oxycodone 5 mg 1 capsule(s) by mouth every ___ hours Disp
#*35 Tablet Refills:*0
10. Senna 8.6 mg PO DAILY
RX *sennosides [___] 8.6 mg 1 tablet by mouth daily Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
8 cm hepatic adenoma in the right lobe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Please call Dr ___ office at ___ for fever > 101,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, pain not controlled by your pain medication,
swelling of the abdomen or ankles, yellowing of the skin or
eyes, inability to tolerate food, fluids or medications,
incisional redness, drainage or bleeding, or any other
concerning symptoms.
You may shower. Allow water to run over the incision. Pat the
area dry, do not apply lotions or powders to the incision area.
No lifting more than 10 pounds
No driving if taking narcotic pain medication</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
2. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Collision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>* You are advised to stay home from work for at least 2 weeks.
* You are advised to avoid any contact sports or any activity
that may involve impact to your abdomen, for at least ___ weeks.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus).</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 10 mg PO QPM
3. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation X2 PRN
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lisinopril 10 mg PO BID
6. Metoprolol Tartrate 100 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 108 mcg inhalation X2 PRN
9. Tiotropium Bromide 1 CAP IH 2 INHALATIONS DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gastrointestinal Bleed
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 ___ for
evaluation of rectal bleeding and were found to have a
gastrointestinal bleed which required many blood transfusions.
You were evaluated by the interventional radiology and
gastroenterology teams and were closely monitored in the
intensive care unit. Your blood counts (hematocrit and
hemoglobin) have been stable and you are recovering well. You
are now ready for discharge. Please follow the instructions
below to continue your recovery:
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.
*You are dizzy, overly fatigued or weak.
*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.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day
Disp #*30 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. BusPIRone 5 mg PO DAILY
9. BusPIRone 10 mg PO QHS
10. Calcium Carbonate 500 mg PO TID
11. Ferrous Sulfate 325 mg PO DAILY
12. Venlafaxine XR 300 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right femoral fracture
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>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:
-Right lower extremity 50% partial weightbearing
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.
TREATMENT/FREQUENCY:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be left
open to air unless actively draining after POD3. If draining,
you may apply a gauze dressing secured with paper tape. You may
shower and allow water to run over the wound, but please refrain
from bathing for at least 4 weeks postoperatively.
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 greater than 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</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
You were admitted to the Acute Care Surgery Service with right
upper quadrant pain. You had a CT scan and ultrasound of your
abdomen that showed acute cholecystitis and a gallstones causing
an obstruction. You had an ERCP procedure and had three stones
removed. You were given antibiotics and taken to Interventional
radiology for placement of a tube to help drain the infection
from your gallbladder. You tolerated the procedure well and are
now ready to be discharged to home 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.
*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: 1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. NPH insulin sc 10 units daily
4. humalog sliding scale: ___ units morning, 4 units sc at
lunch, ___ units at dinner
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain for 5 days: please do not drive while taking
this medication.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right flank abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You wee admitted to the hospital with an abscess on your right
flank. You were started on intravenous antibiotics. You
underwent a cat scan of the pelvis and the abscess was found to
have a localized collection which was drained. Your vital signs
have been stable and your white blood cell count normal. You
are being discharged home on 7 days of antibiotics. So your last
day of antibiotics will be on ___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day. Narcotic
medication can make you constipated so take over the counter
colace as instructed on the bottle if you do take the narcotic
pain medication.
The packing in your wound will need to be changed once a day.
You will be set up with a visiting nurse to help with this.</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 taking care of you during your hospitalization
at ___. Briefly, you were hospitalized with fever. You were
started on antibiotics. Blood and urine cultures did not show
any bacteria. A chest x ray and ultrasound of your liver/gall
bladder were also negative for signs of infection. Antibiotics
were discontinued and you will follow up with Dr. ___ as an
outpatient in the liver clinic.
Sincerely,
Your ___ Treatment Team</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. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1250 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Sertraline 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
13. Simvastatin 20 mg PO DAILY
14. Cyanocobalamin 1000 mcg IM/SC MONTHLY
15. Myrbetriq (mirabegron) 25 mg oral daily
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN arm
rash
RX *triamcinolone acetonide 0.1 % apply 4 times per day
Refills:*0
18. Morphine Sulfate (Oral Soln.) 5 mg PO Q4H:PRN dyspnea
RX *morphine 10 mg/5 mL 0.5 (One half) teaspoon by mouth every 4
hours Refills:*0
19. Levothyroxine Sodium 175 mcg PO DAILY
20. Rivaroxaban 20 mg PO DAILY
21. Docusate Sodium 100 mg PO DAILY:PRN constipation
22. Sarna Lotion 1 Appl TP QID:PRN itchy skin
23. Estrogens Conjugated 0.625 gm VG DAILY
24. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Atypical healthcare associated pneumonia
Hypoxia
acute diastolic CHF exacerbation
Contact dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking part in your care at ___. You were
admitted because you had difficulty breathing and low oxygen. We
treated you with IV antibiotics for several days and gave you
water pills to help you urinate. After several discussions, you
stated to us that you would not want to be re-hospitalized under
any circumstances, would not want to return to the hospital for
antibiotics, IV lines, or diuretics, and that you would rather
stay at home and focus on being made comfortable. We are sending
you home to continue this transition towards being comfortable.
Your ___ and case manage will continue to work with you to make
sure your care is within your goals.
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. Ciprofloxacin HCl 250 mg PO Q12H
2. Clotrimazole 1 TROC PO QID:PRN Thrush
3. Dexamethasone 0.5 mg PO EVERY OTHER DAY
4. Docusate Sodium 100 mg PO BID:PRN Constipation
5. Glargine 20 Units Bedtime
6. LevETIRAcetam 250 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tolterodine 4 mg PO BID
10. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Mirtazapine 15 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral ___ DVTs, Bilateral PE's
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. ___,
You were admitted for low blood pressure and found to have blood
clots in your legs and in your lungs. You were started on a
medication to treat these blood clots, called lovenox. You
should continue taking these injections until your outpatient
doctor tells you to stop. You are now safe for discharge with
close follow up. For your blood pressure we are decreasing your
home metoprolol.
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. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Clindamycin 300 mg PO Q6H Duration: 10 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
3. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using NOVOLOG Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] check blood
glucose four times a day Disp #*100 Strip Refills:*2
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) AS DIR 10 Units before BKFT; Disp #*1 Syringe
Refills:*2
RX *lancets [FreeStyle Lancets] 28 gauge check blood glucose
four times a day Disp #*100 Each Refills:*2
RX *insulin lispro [Admelog SoloStar U-100 Insulin] 100 unit/mL
AS DIR Up to 10 Units QID per sliding scale Disp #*1 Syringe
Refills:*2
4. Linezolid ___ mg PO Q12H Duration: 10 Days
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
5. Zolpidem Tartrate 5 mg PO QHS insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Right breast cellulitis and abscess
2) Type II diabetes (initiated on insulin this admission)
Discharge Condition:
x
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Please follow these discharge instructions:
-Continue to monitor your right breast area for continued
improvement. If the redness and swelling increase, please call
the doctor's office to report this.
-Should you have fevers and chills, please call the doctor's
office immediately to report.
-Continue your antibiotics until they are finished.
-You may consider eating a probiotic yogurt daily to replace the
'good' bacteria in your intestinal tract. If you cannot
tolerate yogurt then you may buy 'acidophilus' over the counter
as a supplement choice. Acidophilus is a 'friendly' bacteria
for your gut.
-If you start to experience excessive diarrhea, please call the
doctor's office to report this.
-Do not overexert yourself and no strenuous exercise for now.
-You may take either tylenol or advil (ibuprofen) for your
discomfort. Take as directed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: To be taken for 10 additional days
until ___.
Disp:*20 Tablet(s)* Refills:*0*
2. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
3. Calcium-Vitamin D 600 mg calcium- 400 unit Tablet Sig: One
(1) Tablet PO twice a day.
4. omega-3 fatty acids-vitamin E Oral
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puff Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Elevated liver function tests
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 burning on urination,
fevers, and feeling unwell. You were found to have a kidney and
urinary tract infection, called pyelonephritis. An ultrasound
of your kidneys showed no evidence of a complicated infection,
and antibiotics were started with improvement of your symptoms.
You also had a low blood count and concern for blood in your
stool, and underwent an endoscopy which showed no abnormalities
in the upper gastrointestinal tract. However, you will need to
have a colonoscopy as an outpatient to assess your lower
gastrointestinal tract. Please also follow up with your primary
care physician regarding your low blood counts.
Your liver function tests were abnormal, and you had pain in the
right upper abdomen on exam, which you did not experience when
you were not being examined. An ultrasound of your gallbladder
showed no evidence of gallstones, and your liver function tests
were trending back towards the normal range. Please follow up
with your primary care physician regarding these findings.
The following changes were made to your home medications:
- Ciprofloxacin was STARTED, to be taken for 10 additional days
until ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
Do not take if loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Hold if loose stools
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*3
3. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*240 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
Do not take if sedated
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn pain Disp #*30
Tablet Refills:*0
6. ammonium lactate 12 % topical apply to legs BID PRN dryness
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
8. LORazepam 0.5 mg PO BID
RX *lorazepam 0.5 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
9. magnesium hydroxide unknown oral DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ruptured abdominal aortic aneurysm
Right lower leg critical limb ischemia status post ruptured
abdominal aortic aneurysm
Type II Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
Hypertension
Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent, intermittently anxious.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ for a
ruptured abdominal aortic aneurysm. You underwent an
endovascular repair to fix this major blood vessel in your
abdomen.
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate, do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less
irritating to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
Take all the medications you were taking before surgery,
unless otherwise directed
Take one aspirin daily, unless otherwise directed
ACTIVITIES:
No driving until postop
visit and you are no longer taking pain medications
You should get up every day, get dressed and walk, gradually
increasing your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate, do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over 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
over the area
CALL THE OFFICE FOR : ___
Redness that extends away from your incision
Purulent or foul smelling drainage from your incision
We wish you the best in your health,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 60 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. PredniSONE 3 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tamoxifen Citrate 20 mg PO DAILY
10. Atenolol 6.25 mg PO DAILY
11. cilostazol 50 mg oral BID
12. Citracal Regular (calcium citrate-vitamin D3) 315/250 mg
oral daily
13. Furosemide 20 mg PO QHS:PRN edema
please take this daily at least until your renal appointment
next week
14. Lubiprostone 8 mcg PO BID
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Vitamin D ___ UNIT PO DAILY
17. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
18. Phosphorus 250 mg PO BID
RX *sod phos,di & mono-K phos mono [K-Phos-Neutral] 250 mg 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
19. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
20. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 0.1 units/hr
Basal rate maximum: 0.3 units/hr
Target glucose: ___
Fingersticks: QAC and HS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
#Gastroenteritis
#Pyelonephritis
#Acute kidney injury
#Hypophosphatemia
Secondary diagnoses:
# S/p renal transplant
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 ___. You were admitted
with nausea, vomiting, and diarrhea likely from gastroenteritis.
You also developed a urinary tract infection. We treated you
with fluids and antibiotics and your symptoms improved. You will
need to continue ciprofloxacin for a two week course (starts
___. We also treated you for low phosphorous in your blood
and decreased your cyclosporine level. Your electrolytes and
phosphorus will need to be checked in the next week or so, at
your appointment with Dr. ___.
If you have questions about your blood sugars, you can call the
___ Nurse on Call at ___.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Lactulose 30 mL PO TID
2. Methadone 65 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
5. U500 insulin as advised by your outpatient endocrinologist
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hepatic Encephalopathy
Secondary: Uncontrolled diabetes
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 at the ___
___. You were admitted after you went to
the Emergency Department with shakiness and confusion (due to
your liver) and were also found to have high blood sugar. Your
shakiness and confusion improved with extra doses of lactulose
and does not appear to be due to infection. To prevent this in
the future, we have added a medication called Rifaximin to be
taken twice daily in addition to your Lactulose. Also, if you
feel that your hands are jerking in a similar fashion and you
feel confused, you should take an extra dose of lactulose to
help with this and then call the liver doctors if not improving.
Your high blood sugars were have been a chronic issue and it is
important to follow the new regimen that your outpatient
diabetes doctor prescribed for you.
You also mentioned you have shoulder pain in both shoulders. You
should follow up with your orthopaedist that you have seen
previously because it seems to have gotten worse.
Also, it is important that you follow up with your PCP about the
fall you experienced 10 days prior. Your CAT scan didn't show
any blood in your head but it is important that we try to
prevent this from happening again. If you get dizzy in the
future, try to sit down as quickly and safely as possible.
It has been a pleasure taking care of you and 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. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 2.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Oxybutynin 5 mg PO Q8H:PRN bladder spasms
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
6. Phenazopyridine 200 mg PO Q8H:PRN bladder discomfort
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral ureteral stones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Calcium Carbonate 500 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Mirtazapine 15 mg PO HS
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H
Continue until ___ to complete a two week antibiotic course.
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Twice
daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Klebsiella Bacteremia
Secondary: Cirrhosis
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 true pleasure caring for you at ___!
You were admitted due to bacteria in your bloodstream that
caused a severe illness. In the intensive care unit you were
stabilized and given strong antibiotics which cleared your
infection. We did an MRI and an ERCP procedure to look for the
source of these bloodstream bacteria but found none. You are now
ready for discharge with close outpatient follow-up.
Please continue Cipro (oral antibiotic) for another week.
Please call the Liver clinic to set up an appointment next week
for follow-up as noted below.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO BID:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Hydroxychloroquine Sulfate 200 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Simethicone 120 mg PO QID:PRN gas
6. Ursodiol 600 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*5 Tablet Refills:*0
9. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral TID
10. Ferrous Sulfate 325 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Bethanechol 10 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Complicated urinary tract infection
GAVE s/p thermal therapy
Secondary:
Autoimmune cirrhosis
Rheumatoid arthritis
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 came to the hospital with burning with urination and were
found to have a urinary tract infection. We treated you with
intravenous antibiotics and transitioned you to the pill form of
antibiotics to complete a full 7 day course of antibiotics. You
also had lower blood counts so we had a procedure called an
endoscopy and procedure to stop bleeding. We also gave you blood
transfusion with stabilization of your blood counts.
You developed some diarrhea before leaving the hospital so we
sent of a stool test to check you for an infection called c.
difficile colitis that was negative and showed no infection
which is great news.
Your antibiotic will be delivered to your home later today.
Please follow up with your appointments below.
It was a pleasure being involved in your care.
Your,
___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Labetalol 200 mg PO TID
2. Lisinopril 40 mg PO DAILY
3. Phenazopyridine 100 mg PO TID Duration: 3 Days
you should take it for 3 days
4. amLODIPine 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal hemorrhage
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 dizziness, nausea and
emesis resulting from an ACUTE HEMORRHAGIC STROKE. We think this
happened due to high blood pressure. In order to prevent another
hemorrhagic stroke we encourage you to take your medication as
prescribed.
We are changing your medications as follows:
-Start Lisinopril 40mg daily
-Start Amlodipine 10mg daily
-Start Labetalol 200mg three times daily
-STOP Aspirin
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. BuPROPion (Sustained Release) 300 mg PO QAM
2. Lorazepam 0.5-1 mg PO BID:PRN anxiety, insomnia
3. MethylPHENIDATE (Ritalin) 5 mg PO BID
4. Sertraline 200 mg PO DAILY
5. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*120 Tablet Refills:*0
6. Cetirizine *NF* 10 mg Oral daily
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
spinal tumor with concern for cord compression
metastatic renal cell carcinoma
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 participating in your care at ___. You were
admitted with back pain, weakness, and numbness, and were found
to have a tumor in your spinal canal. You have received two
days of radiation and should return on ___ for the
remainder of your radiation therapy, and for MRIs of your head
and the rest of your spine. You should also continue taking
oral steroids to relieve the swelling around your tumor.</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. LORazepam 0.5 mg PO Q6H:PRN nausea/anxiety
3. Mirtazapine 15 mg PO QHS
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Rectal Cancer
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 with shortness of breath and worsening liver
function tests. This was thought to be due to your metastatic
rectal cancer. You were given chemotherapy which you will
continue as an outpatient tomorrow.</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 100 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
one spray each nostril
4. Lisinopril 2.5 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Mirtazapine 15 mg PO HS
7. Quetiapine Fumarate 12.5 mg PO BID
8. Senna 2 TAB PO HS
9. Simvastatin 20 mg PO DAILY
10. Megestrol Acetate 200 mg PO DAILY
liquid form; plan for 2 week course per ___ home records
11. MetFORMIN (Glucophage) 250 mg PO DAILY
12. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Outpatient Lab Work
Please draw chem 7, Ca, Mg, Phos on ___ and fax to Dr.
___ at ___.
14. Outpatient Lab Work
Please draw chem 7, Ca, Mg, Phos on ___ and fax to Dr.
___ at ___.
15. Aspirin EC 325 mg PO DAILY
16. Levothyroxine Sodium 150 mcg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure exacerbation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for
difficulty breathing. We treated you for a heart failure
exacerbation with diuretics (medicines to increase your
urination). We also monitored your heart rate and blood oxygen
levels in the hospital and they have been stable.
We also noticed that your thyroid function continues to be
decreased despite treatment. Please make sure the thyroid
replacement medicine Levothyroxine is taken on an empty stomach,
as food can impair its absorption.
Going forward, the nursing home should weigh you every morning.
If you gain more than 3lbs in a day, your cardiologist Dr.
___ be notified.
Please START Furosemide 40mg Daily
Please CONTINUE Megase
Please STOP Torsemide</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
2. NovoLIN ___ FlexPen U-100 (insulin NPH and regular human)
12 units subcutaneous DAILY
RX *insulin NPH and regular human [Novolin ___ FlexPen U-100]
100 unit/mL (70-30) 12 units SC once a day Disp #*15 Syringe
Refills:*0
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
4. Ascorbic Acid ___ mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. CARVedilol 12.5 mg PO BID
8. Diltiazem Extended-Release 180 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU BID
12. Fosfomycin Tromethamine 3 g PO 1X/WEEK (___)
13. HydrALAZINE 10 mg PO TID
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze/sob
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. LevETIRAcetam 500 mg PO BID
17. Loratadine 10 mg PO EVERY OTHER DAY
18. Mycophenolate Mofetil 250 mg PO BID
19. Omeprazole 20 mg PO DAILY
20. PredniSONE 5 mg PO DAILY
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
22. Repaglinide 1 mg PO TIDAC
23. Sodium Bicarbonate 650 mg PO BID
24. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
25. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID:PRN sob
26. Tiotropium Bromide 1 CAP IH DAILY
27. TraZODone 25 mg PO QHS:PRN insomnia
28. ValACYclovir 500 mg PO Q24H
29. Vitamin D ___ UNIT PO 1X/WEEK (WE)
30.Equipment
Please provide portable home nebulizer
ICD code: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute Kidney Injury ___ hypovolemia
CHRONIC DIAGNOSES
=================
ESRD ___ HTN and DM s/p DDRT c/b CKD of renal allograft
Heart Failure with Preserved Ejection Fraction
Type II diabetes
Chronic Obstructive Pulmonary 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. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were feeling dizzy and weak at home
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have a kidney injury, likely because you
were not drinking enough fluids at home.
- You received intravenous fluids.
- You had imaging of your kidney and lungs.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
- Please weight yourself every day, if your weight increases by
3 pounds or more, please call your healthcare provider.
- Your dose of diuretic medication called Furosemide was
decreased from twice daily to once daily.
- Weigh yourself daily and call your doctor if your weight
increases by more than 3 lbs in 2 days or 5 lbs in 1 week.
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. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 gm IV q8hr
Disp #*125 Intravenous Bag Refills:*0
2. Aspirin 81 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Zomig (ZOLMitriptan) 2.5 mg oral PRN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MSSA bacteremia with cavitary penumonia
Elevated ALT
HTN
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 with MSSA bacteremia and found to have a
cavitary pneumonia. You improved on IV Antibiotics and these
were tapered per sensitivity testing. You were seen by
infectious disease consult service and will followed by them
over the next ___ months. You underwent transthoracic and
transesophageal echocardiography without evidence of heart valve
infection. The ID team will establish and contact you with
follow appointment information. You will need weekly labs with
results faxed to ID team ___ clinic) as per paperwork. You
are may not drive yourself home tonight.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 40 mg PO DAILY
2. bromfenac 0.07 % ophthalmic Qhs
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Guaifenesin 10 mL PO Q6H:PRN cough
6. Lidocaine 5% Patch 1 PTCH TD QAM right knee
7. Metoprolol Succinate XL 25 mg PO HS
Hold for systolic blood pressure < 100 or HR < 60
8. Multivitamins 1 TAB PO DAILY
9. Nystatin Cream 1 Appl TP BID breasts
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO DAILY:PRN constipation
13. Torsemide 40 mg PO DAILY
Hold for systolic blood pressure < 100 or HR < 60.
14. Vitamin D 1000 UNIT PO DAILY
15. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN cough or sore
throat
RX *phenol [Cepastat] 14.5 mg Take 1 lozenge Up to every 2 hours
Disp #*90 Lozenge Refills:*0
16. Ciprofloxacin HCl 500 mg PO Q12H
Last dose is on ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Every 12 hours
Disp #*5 Tablet Refills:*0
17. ___ (cranberry extract) 500 mg oral BID
18. Nitroglycerin SL 0.3 mg SL ASDIR
19. Amoxicillin 500 mg PO Q8H
last day = ___
RX *amoxicillin 500 mg 1 capsule(s) by mouth Every 8 hours Disp
#*30 Capsule Refills:*0
20. NPH 14 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
------------------
PRIMARY DIAGNOSES
------------------
Urinary tract infection
Sepsis
Hypotension
Shock liver
------------------
SECONDARY DIAGNOSES
------------------
Chronic systolic congestive heart failure
Coronary artery disease
Acute renal failure
Chronic kidney disease, stage III
Diabetes mellitus type II, insulin dependent
Anemia
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 to take care of you during your hospital stay.
You were admitted to the hospital because you had fever, rigors,
and pain upon urination. You were found to have a urinary tract
infection. At first this was treated with IV antibiotics. After
a few days, you no longer had fevers, your blood pressures
became stable, and you no longer had nighttime sweats or chills.
At this point, your blood cultures were negative, so we felt it
was safe to switch you from IV to PO antibiotics. You will be
discharged with 2 antibiotics: ciprofloxacin and amoxicillin.
Your last day of ciprofloxacin will be ___ for 10 total days,
and your last day of amoxicillin will be ___ for 14 total days.
You were restarted on your blood pressure and heart medications
(lisinopril and metoprolol) before discharge and your blood
pressure was stable. When you are at home, you can continue to
check your blood pressure. If your systolic blood pressure is
less than 100 (the top number) or your heart rate is less than
60, please call your primary care physician to ask if you should
continue taking lisinopril and/or metoprolol.
We also stopped Tylenol while your were in the hospital because
your liver enzymes were high. You should discuss with your PCP
___ you can restart Tylenol.
Please continue to follow up with your primary care physician.
You are now being discharged to home with ___ and ___ services.
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cinacalcet 30 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Omeprazole 40 mg PO BID
5. Simvastatin 20 mg PO QPM
6. Vitamin E 400 UNIT PO DAILY
7. Warfarin 6 mg PO DAILY16
8. Oxybutynin 5 mg PO Q8H:PRN Bladder pain
9. saw ___ Dose is Unknown ORAL Frequency is Unknown
10. Calcitriol 1 mcg PO 3X/WEEK (___)
11. Placebo #00 (cellulose (bulk)) unknown ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Atypical chest pain
Hematuria
SECONDARY DIAGNOSES:
End-stage renal disease
Gastritis
Anemia
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. ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because you were
experiencing chest pain. Tests did not show any evidence of
heart attack. Your chest pain seemed to be related to change in
position and could be musculoskeletal in nature.
You were also found to have blood in the urine, which is related
to your recent bladder procedure. You also experienced some
injury from the urinary catheter, which was also contributing to
the blood in the urine. We removed the catheter before your
discharge and treated your bladder spasm with pain medications.
Please remember that you might continue having blood in the
urine because you are on the blood thinner warfarin.
Please make sure to follow up with your doctors as ___ and
take all your medications on time.
Best regards,
___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Mrs. ___, you were admitted for anastomotic leak. However,
this is a contained leak, and you appeared very well throughout
this hospital admission. We attempted at interventional
radiology drainage, but there is no drainable collection. Thus
you will be discharged with follow-up with Dr. ___.
Warning signs: If you experience fever, chills, nausea/vomiting,
inability to tolerate oral intake, please call the office or
come to the emergency room.
Diet: No restrictions
Medications: You may resume all your home medications. We will
continue oral antibiotics for the next ___ days. Lastly, we will
send you home on Lovenox (therapeutic lovenox) and you can
follow-up with your PCP for bridging to Coumadin. It is
extremely important, for you to follow-up with your PCP for
___ bridging, as you are at high risk for clotting, and
other thromboembolic events.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
RX *brimonidine 0.15 % 1 drop optho twice a day Refills:*0
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
RX *dorzolamide 2 % 1 drop eye three times a day Refills:*0
5. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
RX *timolol [Betimol] 0.5 % 1 drop eye twice a day Refills:*0
7. bimatoprost 0.01 % ophthalmic QHS
RX *bimatoprost [Lumigan] 0.01 % 1 drop eye at night Refills:*0
8. glipiZIDE-metformin 2.5-500 mg oral BID
RX *glipizide-metformin 2.5 mg-500 mg 1 tablet(s) by mouth twice
a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
left hand weakness
SECONDARY DIAGNOSIS:
hypertension
type 2 diabetes
glaucoma
hyperlipidemia
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 at the ___.
You were admitted in the hospital because of weakness in your
left arm and leg which improved on their own. You underwent a
CAT scan and MRI of the head which did not showed a new stroke.
We were concerned that you had not been taking your home
medications and we restarted these during your stay. It is
important to take these medications even while you feel well as
we think these medications will KEEP you feeling well. Please
make sure to take your medications regularly and keep you follow
up appointments with your PCP and neurologist.
It was a pleasure taking care of you at the ___.
We wish you all the best,
Your ___ team.</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 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Metoprolol Tartrate 75 mg PO BID
6. Mirtazapine 30 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 1 mg PO DAILY16
Do not give on ___. Give 2mg instead
11. azelastine *NF* 0.05 % ___ BID PRN
1 drop to affected eye
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Hydroxyurea 500 mg PO 2X/WEEK (___)
___
14. Loratadine *NF* 10 mg Oral daily
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
1 tab under tongue every 5 min as needed for chest pain, up to 3
doses
16. Proctosol HC *NF* (hydrocorTISone) 2.5 % Rectal BID
17. tetrahydrozoline *NF* 0.05 % ___ prn conjunctivitis
18. Warfarin 2 mg PO ___
2mg on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Orthostasis secondary Afib and volume depletion
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 stay at ___.
You came in due to lightheadedness and dizziness. A CT scan of
your head showed no bleeding or strokes. An EKG showed that you
were in atrial fibrillation, which is a heart arrhythmia you
have a history of. Your blood pressure dropped significantly
when you stood up which is most likely why you felt dizzy. We
also gave you intravenous fluids because we felt you were
dehydrated. Your atrial fibrillation stopped and you now feel
less dizzy and lightheaded.
Please continue to take all of your home medications as
directed.
We also met with you and your family about your care for the
future. Please follow-up with your outpatient providers with
any questions that may come up later regarding medications and
further care.
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. Oxybutynin 5 mg PO TID:PRN bladder spasms
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times
daily as needed for bladder spasms Disp #*20 Tablet Refills:*0
2. Phenazopyridine 100 mg PO TID PRN dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times
daily as needed for urinary pain Disp #*20 Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID urinary tract
infection Duration: 14 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth every 12 hours Disp #*28 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS Pain related to stent
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*30
Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Obstructing ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Senna 17.2 mg PO BID:PRN constipation
4. Diltiazem 30 mg PO Q6H
RX *diltiazem HCl [Cardizem] 30 mg 1 tablet(s) by mouth every
six (6) hours Disp #*120 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
6. Ibuprofen 600 mg PO Q8H:PRN pain
7. Metoprolol Tartrate 37.5 mg PO Q6H
RX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. QUEtiapine Fumarate 50 mg PO QHS Insomnia
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
10. Warfarin 2.5 mg PO ONCE Duration: 1 Dose
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
11. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg/5 mL 10 mL by mouth every six (6) hours
Refills:*2
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough/wheezing
13. amLODIPine 5 mg PO DAILY
14. fluticasone 50 mcg/actuation inhalation BID:PRN allergy
symptoms
15. Hydrochlorothiazide 25 mg PO DAILY
16. Lisinopril 40 mg PO DAILY
17. Lotrimin AF Powder (miconazole nitrate) 2 % topical TID:PRN
itching/rash
18. Ondansetron ___ mg PO Q8H:PRN nausea
19. OxycoDONE Liquid ___ mg PO Q4H:PRN moderate to severe pain
RX *oxycodone 5 mg/5 mL 5 mL by mouth every six (6) hours
Refills:*0
20. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mrs. ___,
___ were admitted to the hospital with confusion and mental
status changes following a recent surgery. ___ were treated for
alcohol withdrawal syndrome and are now ready to be discharged
home to complete your recovery there.
Please make sure to follow these instructions after your
discharge to assure timely recovery.
DIET:
___ may continue a FULL LIQUID DIET until ___ are seen by Dr.
___ in clinic and are instructed to advance your diet. All
medications and pills must be crushed in apple sauce, yogurt or
other soft creamy foods. There is a risk they will get stuck in
your esophagus if taken whole. The only pill ___ may take whole
is your levothyroxine (synthroid).
ACTIVITY:
___ may resume regular activity without restrictions.
FOLLOW-UP:
___ should follow up with Dr. ___ as instructed. ___ have an
appointment set up for ___.
MEDICATIONS:
___ are being discharged on your home medications plus several
new ones. ___ no longer need to take acid reflux medications
like omeprazole or nexxium. Because ___ had atrial fibrillation
or afib in the hospital, and ___ cannot take pradaxa for now (it
cannot be crushed and ___ are not allowed to take pills for the
next two weeks), ___ are leaving with a prescription for
Coumadin. This is a blood thinner similar to pradaxa, but
requires monitoring, which your primary care physician ___
provide. It is imperative that ___ call and set up an
appointment with your primary care doctor within 2 days of your
discharge from the hospital.
ALCOHOL:
___ should refrain from alcohol at all costs. A medication ___
were given to treat alcohol withdrawal (phenobarbital) will
remain in your system for a week after ___ stop taking it. When
mixed with alcohol, it causes a high risk of respiratory
suppression which can be life-threatening. Make sure ___ report
any urge to drink to a physician or relative who can help ___.
We recommend social work and withdrawal counseling services.
Thank ___ for letting us participate in your care!
Good luck!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheeze
2. Aspirin 325 mg PO DAILY
3. Disopyramide CR 300 mg PO Q12H
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. fluticasone *NF* 220 mcg/actuation Inhalation DAILY:PRN
allergy season
8. Montelukast Sodium 10 mg PO DAILY:PRN during allergy season
Discharge Disposition:
Home
Discharge Diagnosis:
Acid reflux
Esophageal spasm
Secondary:
Hypertrophic cardiomyopathy
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 for a positive stress test. After discussion
with your cardiologist, we determined that the stress test
result was probably a false-positive. You had cardiac
catheterization in ___ that demonstrated no angiographically
apparent coronary artery disease, and it is unlikely that you
developed coronary disease that needs intervention in the
meantime.
Your pain was likely either A) acid reflux from possible
recurrence of H.pylori or B) esophageal spasm. We are
recommending you see a gastroenterologist for further
evaluation. You can call our GI department ___
and make an appointment.
In addition, please call Dr ___ office at ___ and
make an appointment to be seen this week for follow-up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
You were admitted to ___ due to recurrent chest pain. Your
EKG was reassuring and your cardiac enzymes were normal. This
reassured us that the pain was unlikely to be related to cardiac
ischemia. You underwent a CT scan of your chest that showed
evidence of a small blood clot in the lungs. This may be
contributing to your pain. You were started on anticoagulation
(blood thinner) for the clot and will need to continue on this
for the next few months at least, and follow up with the clinic
in ___. We do suspect that there may be another source for
your pain, so it is important that you ___ with the
gastroenterologists for an upper endoscopy. We have started you
on the medication sucralfate to help with your abdominal pain.
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. Ondansetron 4 mg PO TID
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*24 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Disposition:
Home
Discharge Diagnosis:
Peutz-Jehgers syndrome, nausea and vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
Please call ___ to schedule an appointment with dr.
___ ___. I know you still don't feel at best and anxious
that those symptoms will be back, but I trust Dr. ___ will
take care of you and come up with plan to address your disease
in the best way available.
Warmest wishes from ___ Medicine 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. Gabapentin 600 mg PO QHS:PRN fibromyalgia
3. Losartan Potassium 100 mg PO DAILY
4. Topiramate (Topamax) 30 mg PO QHS:PRN migraine
5. Xopenex Neb ___ puffs inhalation every ___ hours
Discharge Disposition:
Home
Discharge Diagnosis:
Polycythemia ___
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Hello Ms. ___,
It was a pleasure taking care of you here at ___.
You presented to us ___ night with a one-day history of
throbbing right-sided headache, blurry vision, and left hand
weakness. Your hematocrit count was 57.6 - consistent with your
diagnosis of polycythemia ___. An extensive MRI of the
tissue/arteries/veins in head and neck was normal.
To relieve your symptoms, you were given a therapeutic
phlebotomy, which relieved your right-sided headache, and
brought your hematocrit down to 50.9.
We wish you all the best!
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
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QHS Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 at bedtime Disp #*14 Syringe
Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. RISperidone 0.25 mg PO HS
8. Lorazepam 0.5 mg PO HS:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left 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>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:
- Non weight-bearing, left lower extremity</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Warfarin 10 mg PO DAILY16
2. Atorvastatin 10 mg PO DAILY
3. Digoxin 0.375 mg PO 4X/WEEK (___)
4. Digoxin 0.5 mg PO 3X/WEEK (___)
5. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 5 mg PO DAILY
HOLD FOR BP<100
7. CefePIME 2 g IV Q12H
RX *cefepime 2 gram 1 infusion every 12 hours Disp #*17 Unit
Refills:*0
8. Miconazole 2% Cream 1 Appl TP BID
RX *miconazole nitrate 2 % apply to both tops and bottoms of
feet and to toe webspaces twice a day Disp #*1 Tube Refills:*1
9. Vancomycin 1250 mg IV Q 8H
RX *vancomycin 500 mg 1500mg dose every 8 hours Disp #*25 Unit
Refills:*0
10. Outpatient Lab Work
Please check CBC, CHEM 10, INR and vancomycin trough (1 hour
prior to next dose of vancomycin) on ___ and fax results to
Dr ___ platelet monitoring, Creatinine monitoring,
vancomycin dose adjustment, goal vancomycin level ___ and
coumadin dose adjustment, goal INR ___
Dr ___: ___
Fax: ___
11. Metoprolol Succinate XL 100 mg PO DAILY
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight hours
Disp #*25 Tablet Refills:*0
13. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking urge
RX *nicotine (polacrilex) [Nicorette] 2 mg 1 gum every hour as
needed to curb the urge to smoke Disp #*100 Gum Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Osteomyelitis
Secondary
Diabetes
Atrial Fibrillation
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 to the hospital because you had a left foot
infection. You were found to have osteomyelitis of the left ___
toe, and underwent surgical ray resection. You were also treated
with the intravenous antibiotics. You will continue to take
antibiotics for another 8 days. Please note that you CANNOT
drink alcohol while taking the antibiotics as you can have a
very severe reaction.
Weight bearing instructions left foot: Weight bearing to heel
___ a surgical shoe</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Azithromycin 250 mg PO Q24H
3. Gabapentin 800 mg PO TID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. Lorazepam 0.5 mg PO BID:PRN nausea
6. Metoprolol Tartrate 25 mg PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. PredniSONE 40 mg PO DAILY Duration: 4 Weeks
40 mg daily and decrease as per taper
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*50
Tablet Refills:*0
12. Sertraline 100 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. TraZODone 50 mg PO QHS
15. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
RX *alum-mag hydroxide-simeth [Antacid M] 200 mg-200 mg-20 mg/5
mL ___ ml by mouth qid prn Refills:*3
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
shortness of breath/wheezing
17. budesonide-formoterol 160-4.5 INHALATION BID
18. Diphedryl (diphenhydrAMINE HCl) 12.5 mg/5 mL ORAL QID
19. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
20. Mag-Al Plus (alum-mag hydroxide-simeth) 200 mg/5 mL ORAL QID
21. Prochlorperazine 5 mg PO Q6H:PRN nausea
22. Ertapenem Sodium 1 g IV DAILY Duration: 13 Doses
last day ___
RX *ertapenem [Invanz] 1 gram 1 gram IV Q24H Disp #*13 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Enterobacter bacteremia
COPD exacerbation
SECONDARY DIAGNOSES:
___
CAD
GERD
Depression
Insomnia
Neuropathy
___
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 Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted for shortness of breath initially to the ICU. You were
found to have a bacterial infection of your bloodstream, which
you will need to complete a course of antibiotics for at home
through a special catheter in your arm, and your port was
removed. You also underwent your radiation treatments while you
were here, and we decided that chemotherapy at this point would
probably do more harm than good. We treated your COPD while you
were here, and you should complete a tapered course of steroids
as instructed. Please follow-up with your outpatient providers
as listed below.
We wish you all the best!
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
2. Docusate Sodium 100 mg PO BID
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 Tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p MVC with +LOC
Left distal clavicle 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 the hospital after a motor vehicle
accident. You lossed consciousness at the scene but your injury
is a broken collar bone (clavicle). You were evaluated by
orthopedics for this who determined your injury to be
nonoperative. You should remain in a sling and not bear weight
on your left arm for 2 weeks until you follow up in ___
clinic. You remove your arm from the sling from time to time and
perform range of motion exercises.
You will receive a prescription for pain medication to take by
mouth. Take the medication as prescribed as needed. Narcotic
pain medication can cause constipation so it is generally
recommended that you take an over-the-counter stool softener
such as colace or milk of magnesia to prevent this. Narcotics
also cause sedation so do not drink alcohol or drive/operate
heavy machinery while taking narcotic pain medications.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
Do not take more than 8 extra strength tablets per day
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally Daily Disp #*30
Suppository Refills:*0
3. Fentanyl Patch 75 mcg/h TD Q72H
RX *fentanyl 75 mcg/hour Apply as directed Q72Hr Disp #*10 Patch
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. LORazepam 0.5 mg PO Q8H:PRN anxiety
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Leg Pain
Metastatic Colon 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 to the hospital with leg pain. You were
evaluated for a cause for the pain but unfortunately we could
not find one despite many different images including MRIs and CT
scans. You were treated with pain medication and your pain was
better controlled. Please take your medications as directed and
follow up as directed below.</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. Acyclovir 400 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. CefTRIAXone 1 gm IV Q24H
7. Cyanocobalamin 100 mcg PO DAILY
8. Docusate Sodium 100 mg PO DAILY
9. Enoxaparin Sodium 40 mg SC DAILY
10. Fleet Enema (Saline) ___AILY:PRN constipaton
11. HydrALAZINE 10 mg PO Q6H:PRN SBP >160
12. LamoTRIgine 125 mg PO QHS
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
15. Mirtazapine 15 mg PO QHS
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN rib
discomfort
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
20. Pravastatin 40 mg PO QPM
21. Prochlorperazine 10 mg PO BID:PRN for nausea before the car
ride to ___
22. Ranitidine 150 mg PO BID
23. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
24. Sodium Chloride 2 gm PO QID
25. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Discharge Diagnosis:
# Hyponatremia
# Urinary Tract Infection
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>Ms. ___,
It was a pleasure to participate in your care. You were admitted
for low sodium. You received IV fluids and your condition
improved. You were also treated for a urinary tract infection.
Best Regards,
Your ___ Medicine Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amitriptyline 100 mg PO QHS
2. ARIPiprazole 5 mg PO DAILY
3. ClonazePAM 0.5 mg PO TID
4. Gabapentin 400 mg PO BID
5. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis: Community acquired pneumonia
Secondary Diagnosis: Chronic pain
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 to ___ due to symptoms of fever and
confusion in the context of a several day history of productive
cough. Based on these symptoms and clinical findings, you were
diagnosed with pneumonia. We treated your pneumonia with
levofloxacin for 5 days. You completed this treatment on ___.
You tolerated this treatment well and your symptoms improved.
You will be discharged to a rehab facility to continue your
recovery.
During your hospitalization your blood pressure was often high.
To address this we restarted the medication
(hydrochlorothiazide) that you had been taking last year. You
tolerated this medication well and it helped control your blood
pressure. You should follow up with your primary care physician
about your high blood pressure, and the best possible treatment.
It was a pleasure caring for you during this hospitalization and
we wish you the best of health.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: Dilaudid ___ PO q6 hours prn pain
Discharge Disposition:
Home
Discharge Diagnosis:
symptomatic cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were treated at the hospital for symptomatic cholelithiasis
with a laparascopic cholecystectomy.
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, changes location, or moves 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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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. Docusate Sodium 100 mg PO BID:PRN constipation
2. Lactulose 15 mL PO TID:PRN constipation
3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
6. Senna 8.6 mg PO BID:PRN constipation
7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
-Superficial thrombophlebitis
Secondary Diagnosis
-Gallbladder cancer
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 care for you at ___. You came to our
hospital for right arm redness and pain. We evaluated your arm
for a blood clot and it did show a superficial vein blood clot,
but no deep vein clots. This is likely the cause for the pain
and redness and it is likely related to your recent chemotherapy
treatments.
There is no need to treat the blood clot with blood thinners at
this time. Please make sure to call your doctors ___ present to
the emergency room if you have worsening pain, swelling, or
redness, of if you have fevers, chills, or sweats.
Please continue to use hot compresses to your arm, and you can
use Motrin/ibuprofen 600mg up to every 8 hours as needed for
pain. Always take this with food.</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
2. Phenytoin Sodium Extended 200 mg PO BID
RX *phenytoin sodium extended 100 mg 2 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*2
3. Zonisamide 200 mg PO BID
RX *zonisamide 100 mg 2 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*2
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing
5. Gabapentin 300 mg PO QHS
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. LevETIRAcetam 1000 mg PO QAM
8. LevETIRAcetam ___ mg PO QPM
9. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent. Mildly inattentive
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were hospitalized at ___ after being found confused
with slurred speech. Your doctors think that this was most
likely due to a seizure. You were admitted to the Neurology
Service and monitored for seizures.
While in the hospital, an MRI was done. Your AVM was stable
(no new change or bleed) compared to prior imaging. You were
monitored on EEG. Though no convulsive or clinical seizures
were detected, multiple seizures without clinical correlate
(non-convulsive electrographic seizures) were detected. You had
no symptoms from these. While your anti-seizure medications
were optimized, new agents were not started because these events
were not interfering with your life.
After talking with your daughter, you were felt to be your
normal self and were safe for discharge. Given the change in
your phenytoin dosing however, your doctors request that ___ get
a phenytoin level drawn on an outpatient basis. This should be
a "trough" level, drawn roughly ___ minutes prior to your
morning dose. This was ordered for you and may be done at any
___ lab in ___ weeks.
If you have any questions following discharge, please feel
free to contact ___ 11 or Dr. ___ office.
It was a pleasure taking care of you,
Your ___ Care Team.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12
Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 200 mg 2 tablet(s) by mouth q8 Disp #*90 Tablet
Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch daily Disp #*30 Patch
Refills:*0
6. Morphine SR (MS ___ 15 mg PO Q8H
RX *morphine 15 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*25 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17gram
powder(s) by mouth ___ times daily Refills:*0
9. Polyethylene Glycol 17 g PO QID:PRN Constipation - Third
Line
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
11. Vitamin D ___ UNIT PO 1X/WEEK (FR) Duration: 8 Weeks
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth weekly (every ___ Disp #*8 Capsule
Refills:*0
12.Outpatient Physical Therapy
evaluate and treat as needed
metastatic breast cancer to spine
Discharge Disposition:
Home
Discharge Diagnosis:
pathologic L3 vertebral fracture
metastatic malignancy to bone
breast cancer
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. ___,
You were admitted to ___ with severe back pain. Unfortunately
you were found to have a fracture in your back as well as
lesions that were concerning for cancer. You underwent further
workup and testing for these lesions while you were in the
hospital. You were also started on pain medications to help with
your pain. Please do not drink alcohol or drive while taking
oxycodone or MS ___. Please take your medication as
prescribed involved with doctors as recommended below.
We found breast cancer on biopsy that we think has spread to the
spine bone. You will see cancer specialists in follow up.
It has been a pleasure taking care of you and we wish you the
best.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q6H:PRN Disp #*21
Tablet Refills:*0
2. Diphenoxylate-Atropine 2 TAB PO Q8H:PRN lose stool
3. Gabapentin 300 mg PO TID
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. Opium Tincture (morphine 10 mg/mL) 6 mg PO Q6H:PRN lose stool
RX *opium tincture 10 mg/mL (morphine) 6 mg by mouth every six
(6) hours Disp ___ Milliliter Milliliter Refills:*0
7. Rifaximin 550 mg PO TID
8. Simvastatin 20 mg PO QPM
9. Acetaminophen 1000 mg PO Q6H:PRN pain
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Choledocholithiasis
SECONDARY DIAGNOSIS:
- Afib (not on anticoagulation),
- Perforated infectious colitis requiring emergent subtotal
colectomy with ileostomy
- GERD
- HLD
- Open subtotal colectomy with ileostomy (___)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ came to ___ for abdominal pain and were found to have a
stone obstructing one of your bile ducts. ___ had a procedure to
remove the stone, along with symptomatic treatment for pain.
Your liver enzymes were elevated, which is expected when ___
have an obstruction of your bile ducts. Thankfully these liver
enzymes have slowly decreased.
Please follow up with your primary care doctor and also with
your gastrointestinal doctor once ___ have been discharged. ___
and your GI doctor can consider a cholecystectomy to prevent
future episodes of stone pain after discussing the benefits and
risks of each option. Continue ciprofloxacin antibiotic for five
days.
We wish ___ a speedy recovery. It was a pleasure taking care of
___!
Sincerely,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. DASatinib 70 mg PO Q12H )
( )
RX *dasatinib [Sprycel] 70 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*60 Tablet Refills:*2
4. PredniSONE 10 mg PO DAILY Duration: 11 Doses
Take 30 mg (3 pills) ___.
Take 20 mg (2 pills) ___.
Take 10 mg (1 pill) ___.
RX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*11 Tablet
Refills:*0
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*0
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Sertraline 100 mg PO QAM
8. Sertraline 50 mg PO QPM
9. HELD- Aspirin 81 mg PO BID This medication was held. Do not
restart Aspirin until you have discussed with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Ph+ ALL
Pancytopenia
Secondary diagnoses:
Anxiety
Depression
Hypertension
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you during your admission to ___.
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you had Acute Lymphoblastic
Leukemia.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a bone marrow biopsy that showed acute lymphoid
leukemia.
- You were treated with Prednisone and Dasatinib.
- You had a lumbar puncture and received methotrexate.
WHAT SHOULD I DO WHEN I GO HOME?
-Take your medications as prescribed
-Keep your follow up appointments with your team of doctors
Thank ___ for letting us be a part of your care!
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. OLANZapine (Disintegrating Tablet) 2.5 mg PO QID: PRN
anxiety, agitation
RX *olanzapine 2.5 mg 1 tablet(s) by mouth QID:PRN Disp #*20
Tablet Refills:*0
3. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*63 Vial Refills:*0
4. PredniSONE 30 mg PO DAILY
See instructions on discharge worksheet, taper by 5mg weekly
with plan to maintain on 10mg daily
Tapered dose - DOWN
RX *prednisone 5 mg 6 tablet(s) by mouth once a day Disp #*80
Tablet Refills:*1
5. Pyridostigmine Bromide 15 mg PO Q8H:PRN myasthenic sx
6. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Myasthenic crisis
#Diverticulitis
#Pelvic abscess s/p ___ drain replacement ___
#R gluteal abscess
#Leukocytosis
#Diarrhea
#Hypokalemia
#Hypomagnesemia
#Hypophosphatemia
#Hypernatremia
#Anxiety
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 ___,
You presented to ___ with abdominal pain,
somnolence, emesis, and respiratory distress.
You were found to have an infection and myasthenia crisis. You
were treated with plasmapheresis, IVIG, and antibiotics. Your
potassium and magnesium were found to be low. You were seen by
the surgery, interventional radiology, neurology, medicine,
nephrology, and infectious disease specialists.
You received a CT scan which showed a new abscess.
Interventional radiology performed a procedure and you expressed
strong wishes to go home the next day.
We set up ___ services for you after leaving the hospital.
Additionally, you should follow up with your primary care doctor
and your neurologist as an outpatient. We also recommend follow
up with surgery and a gastroenterologist. You will need regular
lab checks after leaving the hospital to monitor your potassium,
magnesium, and other electrolytes as well as your blood count.
We wish you the best,
Your ___ team
Instructions for Drain Care:
You will be going home with your surgical drain. 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). Maintain suction of the bulb. Please flush drainage
catheter with 10 cc of sterile saline twice daily. 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 as needed and record output. You may shower; 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: 1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Every 5
minutes Disp #*10 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
6. CARVedilol 6.25 mg PO BID
7. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Torsemide 20 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- amLODIPine 2.5 mg PO DAILY This medication was held.
Do not restart amLODIPine until you are told to do so by your
primary care doctor
14. HELD- HydrALAZINE 100 mg PO TID This medication was held.
Do not restart HydrALAZINE until you are told to do so by your
primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
NSTEMI
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 ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to have a heart attack.
- You had a procedure to assess the arteries around the heart.
There were two blockages found that were stented. You were
started on medications to prevent further blockages in your
heart.
- You were found to have fluid in your lungs after the procedure
and were given medications to help remove the fluid.
- An ultrasound of your heart showed mildly reduced heart
function.
- A physical therapist evaluated you and found that you were
safe to go home independently.
- When your chest pain improved, you were discharged home.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- If you experience severe chest pain, worsening shortness of
breath, or loss of consciousness, please return to the Emergency
Department.
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. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Senna 17.2 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. dutasteride 0.5 mg oral QPM
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Rosuvastatin Calcium 20 mg PO QPM
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Warfarin 10 mg PO 2X/WEEK (___)
12. Warfarin 7.5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding and clot retention after TURP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>-drink plenty of water
-minimize constipation
-no heavy lifting
These steps can help you recover after your procedure.
DO drink plenty of water to flush out the bladder.
DO avoid straining during a bowel movement. Eat
fiber-containing foods and avoid foods that can cause
constipation. Ask your doctor if you should take a laxative if
you do become constipated.
Don't take blood-thinning medications until your doctor says
it's OK.
Don't do any strenuous activity, such as heavy lifting, for
four to six weeks or until your doctor says it's OK.
Don't have sex. You'll likely be able to resume sexual
activity in about four to six weeks.
Don't drive until your doctor says it's OK. ___, you can
drive once your catheter is removed and you're no longer taking
prescription pain medications.
You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve. You may
have clear or yellow urine that periodically turns pink/red
throughout the healing process. Generally, the discoloration of
the urine is OK unless it transitions from ___,
___ Aid to a very dark, thick or like tomato juice
color
Resume your pre-admission/home medications EXCEPT as noted.
You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care team.
Unless otherwise advised, blood thinning medications like
ASPIRIN should be held until the urine has been clear/yellow for
at least three days. Your medication reconciliation will note
if you may resume aspirin or prescription blood thinners (like
Coumadin (warfarin), Xarelto, Lovenox, etc.)
If needed, you will be prescribed an antibiotic to continue
after discharge or save until your Foley catheter is removed
(called a trial of void or void trial).
You may be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and it is available
over-the-counter
AVOID STRAINING for bowel movements as this may stir up
bleeding. Avoid constipating foods for ___ weeks, and drink
plenty of fluids to keep hydrated
No vigorous physical activity or sports for 4 weeks or until
otherwise advised
Do not lift anything heavier than a phone book (10 pounds) or
participate in high intensity physical activity (which includes
intercourse) for a minimum of four weeks or until you are
cleared by your Urologist in follow-up
Acetaminophen (Tylenol) should be your first-line pain
medication. A narcotic pain medication may also be prescribed
for breakthrough or moderate pain.
The maximum daily Tylenol/Acetaminophen dose is 3 grams from
ALL sources.
Do not drive or drink alcohol while taking narcotics and do
not operate dangerous machinery.</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
2. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
4. Docusate Sodium 100 mg PO BID
5. Donepezil 5 mg PO QHS
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. guaiFENesin 200 mg oral DAILY
8. lactulose 20 gram oral DAILY
9. Meladox (melatonin) 3 mg oral DAILY
10. PARoxetine 30 mg PO DAILY
11. Senna 17.2 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Aspiration Pneumonia
Acute Hypoxemic Respiratory Failure
Hypotension
Secondary:
Alzheimer's
Downs syndrome
Constipation
Osteoporosis
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 Mr ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came in for fevers
What did you receive in the hospital?
- You were found to have pneumonia
What should you do once you leave the hospital?
- Continue to take the medications we prescribe you
- Follow up with all your doctors ___ as below
- Be sure to have someone help you eat, and follow a careful
puree'd and thickened diet (see diet section)
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. glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day.
2. metformin 500 mg Tablet Sig: 0.5 Tablet PO twice a day.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levemir 100 unit/mL Solution Sig: ___ (55) units
Subcutaneous once a day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
Disp:*30 packet* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: Do not exceed 4gm a day.
Disp:*100 Tablet(s)* Refills:*0*
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
12. ceftriaxone ___ dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours): Continue until
the Infectious Disease specialists tell you to stop.
Disp:*84 grams* Refills:*0*
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*20 syringes* Refills:*1*
14. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 2 weeks.
Disp:*28 syringes* Refills:*0*
15. Outpatient Lab Work
Weekly labs while on Ceftriaxone: Please draw CBC with
differential, Basic Metabolic Panel, Liver Function Tests, ESR,
CRP and fax results to Infectious Disease at ___.
16. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Septic knee
Secondary Diagnosis: Type II diabetes, hypertension, high
cholesterol, obesity, mild renal insufficiency, and a previous
history of asthma.
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. ___,
It was a pleasure taking care of you at ___
___. You were admitted for an infection ___ your knee
which required a surgical procedure to remove the infected
material. The plastic liner ___ your knee was replaced during
the procedure. You were treated with antibiotics and are doing
better, although you will need to continue intravenous
antibiotics as an outpatient to fully treat the infection and
you will need to go to a rehabilitation facility to get your
mobility back. You should follow up with the infectious disease
specialists (see appointment below) and with your original
orthopedic surgeon at ___.
The following medications were ADDED:
CONTINUE Ceftriaxone 2gm intravenously one time daily - course
will be decided by Infectious disease physicians.
TAKE tylenol ___ every 4 hours as needed for pain. Do not
exceed 4gms per day.
TAKE oxycodone 5mg by mouth every 6hours as needed for pain.
CONTINUE lovenox 30mg 1 syringe twice daily, continue for 2
weeks
TAKE Lisinopril 10mg (you used to take 20mg) by mouth daily.
While on all these pain medications you are at risk risk for
constipation. Please take the following medications regularly
to keep your bowel movements soft.
TAKE senna 1 tablet by mouth twice daily.
TAKE docusate sodium 1 tablet twice a day by mouth.
TAKE Miralax 1 packet by mouth daily.
Please continue your other medications as prescribed. No other
changes have been made.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
2. Bisacodyl 10 mg PO DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
5. Meclizine 25 mg PO TID
6. Senna 17.2 mg PO BID:PRN Constipation
7. Diazepam 10 mg PO Q8H:PRN muscle spasm
8. LevETIRAcetam 1000 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN local back pain
10. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN BREAKTHROUGH
PAIN
11. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
12. Topiramate (Topamax) 25 mg PO BID
13. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
14.Walker with attachment and with wheels
Walker with attachment and with wheels
Customer ID # ___
15.Wheelchair standard with no attachment
Wheelchair standard with no attachment
Customer ID # ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non-epileptic seizures
Pseudoseizure
Chronic progressive distal myopathy
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>You were admitted to ___ for evaluation of lower extremity
weakness and spells of altered consciousness; you were evaluated
by neurology and psychiatry, who determined that these spells
are likely non-epileptic in nature.
Activity:
- You should take safety precautions because of these spells.
Use caution when swimming and bathing. You may drown or become
seriously injured if you have a spell while in water.
- Avoid climbing ladders or performing activities involving
heights unattended.
- Take all medications as directed
- Do not drive. You are not allowed to drive by law if you
experience an episode of altered consciousness.
- Please use your wheelchair at all times for mobility.
- Physical therapy will work with you to help you regain your
strength. They will advise you when you may return to using your
cane/walker, and will further advise you on your activity level.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once daily at night
Disp #*30 Tablet Refills:*0
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Prasugrel 10 mg PO DAILY
RX *prasugrel 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
NSTEMI
HLD
HTN
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 at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you had a heart
attack, which happens when the blood supply to your heart gets
blocked
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You underwent a procedure that showed that one of your
arteries that supplies blood to your heart was almost closed
off. We opened it during the procedure with a metal tube called
a stent, which stays in the artery.
- We started you on a lot of medicines to help prevent a heart
attack from happening in the future and prevent your stent from
clotting and giving you another heart attack
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- It is very important to take your aspirin and prasugrel every
day.
- These two medicines keep the stent in the artery open and help
reduce your risk of having a future heart attack.
- If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents and having another
heart attack
- Please do not stop taking either medication without taking to
your heart doctor.
- You are also on other new medications to help your heart,
including metoprolol and lisinopril. These medicines help to
reduce your blood pressure and keep your heart healthier after
the heart attack. Please take these as directed.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team</s> |