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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. FoLIC Acid 1 mg PO DAILY
4. Glargine 8 Units Breakfast
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Sodium Bicarbonate 1300 mg PO TID
9. Furosemide 20 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Allopurinol ___ mg PO DAILY
12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
13. Ascorbic Acid ___ mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 20 mg PO QPM
16. Calcitriol 0.25 mcg PO DAILY
17. Calcium Carbonate 500 mg PO BID
18. Cilostazol 50 mg PO QPM
19. Cilostazol 100 mg PO QAM
20. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
21. Esomeprazole 40 mg Other BID
22. Ferrous Sulfate 325 mg PO DAILY
23. HydrALAZINE 50 mg PO QHS
24. Levothyroxine Sodium 125 mcg PO DAILY
25. Lidocaine 5% Patch 1 PTCH TD QAM
26. melatonin 10 mg oral QHS
27. Mycophenolate Mofetil 500 mg PO BID
28. naftifine 2 % topical BID To soles of feet and between toe
webs
29. PredniSONE 6 mg PO DAILY
30. Promethazine 25 mg PO DAILY PRN nausea
31. Ranolazine ER 500 mg PO BID
32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
34. Trimethobenzamide 300 mg oral BID
35. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Subarachnoid Hemorrhage
Nonketotic hyperosmolar hyperglycemic state
Type 1 Diabetes Mellitus
Hypertension
Orthostatic Hypotension
Neurogenic Bladder
ESRD status post living donor transplant
Anemia
Secondary diagnoses:
Gastroparesis
Pancreatic mass
CAD s/p ___ Failure with reduced ejection fraction
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 ___,
___ were admitted to the hospital after ___ suffered from a head
injury when ___ fell. ___ were initially admitted to the
neurosurgery ICU because ___ suffered from a small amount of
blood in your brain (subarachnoid hemorrhage), which occurred
when ___ hit your head.
On admission to the hospital, we found that your blood sugar
levels were high. We think that changes in your blood sugar
levels may have contributed to your fall. We adjusted your
insulin and were able to keep your blood sugars in a normal
range.
We initially held your aspirin and brilanta but restarted it on
___. We imaged your brain arteries to obtain a more
comprehensive picture of the blood in your head. Your MRA showed
that the bleeding had stopped and that your brain arteries were
not clogged. We recommend that ___ try to keep your blood
pressure below 160 to protect your brain from having another
bleed.
While ___ were at ___ ___ had a picture taken of
your belly which showed a pancreatic mass. We cannot tell what
this mass is because the quality of the picture was limited.
Unfortunately, we cannot improve the quality of the picture
because it may cause damage to your kidney transplant.
Therefore, we have scheduled ___ for an outpatient esophageal
ultrasound- another type of picture that will not hurt your
kidneys- to try to get a better look at your pancreas. We were
not able to do this in the hospital because we were worried that
if ___ vomited while getting the anesthesia needed for the
ultrasound, it might make your brain bleed worse. It will be
safer to get this ultrasound done in a week or so when ___ have
healed more.
What ___ should do when ___ get home:
-Work on getting stronger at rehab.
-Continue to monitor your blood pressure and take your blood
pressure medications. Try to keep your blood pressure in the
120-150's to protect your brain from re-bleeding.
-Continue to monitor your blood glucose closely, and take your
insulin. ___ will need a new continuous glucose monitor. Please
call the phone number on the back of your current CGM to order a
new one.
-Follow up in the dysautonomia, hematology, GI, traumatic brain
injury clinics to make sure that ___ are healing well.
-Take great care when ___ get up from lying down or sitting to
prevent yourself from falling again.
Medication changes on this admission:
-We changed your metoprolol succinate to 100 mg Metoprolol XL.
XL is the longer acting form of the medication and will help
control your blood pressure.
-We changed your insulin to 8U Lantus in the morning and 2U
Humalog before meals
Thank ___ for allowing us to participate in your care.
Take Care,
Your SIRS General ___ ___ 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. Cepacol (Menthol) 1 LOZ PO Q4H:PRN sore throat
4. Docusate Sodium 100 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Guaifenesin ER 1200 mg PO BID
7. Lorazepam 0.5 mg PO BID nausea
8. Mirtazapine 15 mg PO HS
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 1 TAB PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO DAILY
12. Vancomycin 750 mg IV Q 12H
Continue until ___.
13. Omeprazole 20 mg PO DAILY
14. Ranitidine 150 mg PO DAILY:PRN reflux
15. ondansetron *NF* 8 mg Oral q8hr chemo related nausea
16. Halobetasol Propionate *NF* 0.05 % Topical TID pruritis
17. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4hr
cough/wheeze
18. Piperacillin-Tazobactam 4.5 g IV Q8H
Continue until ___.
19. Ketorolac 15 mg IV Q6H:PRN pain Duration: 2 Days
You will takle this for two more days.
20. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis secondary to pneumonia
Lung adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
It was a pleasure participating in your care at ___
___.
You were admitted because you had a serious pneumonia that
required you to be treated in the Intensive Care Unit. With
strong antibiotics, you improved and no longer needed
supplemental oxygen. You will need to continue these antibiotics
until ___.
You also had a jejunostomy tube placed to help you obtain
nutrition. You should continue tube feeds in the evening to
supplement your oral nutrition. Speech and Swallow experts
determined that you should consume a diet of regular liquids but
moist ground solids to prevent any problems with eating.
Medications:
Continue VANCOMYCIN and ZOSYN until ___ for pneumonia.
Continue KETOROLAC for two more days for chest pain.
You will follow up with Dr. ___ next week on
___ at 2:30pm.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen [Children's Acetaminophen] 325 mg/10.15 mL 650
mg by mouth every six (6) hours Disp #*1000 Milliliter
Refills:*0
2. Cephalexin 500 mg PO Q8H Duration: 5 Days
RX *cephalexin 250 mg/5 mL 10 mL by mouth every eight (8) hours
Disp ___ Milliliter Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % swish and spit twice a day
Disp #*420 Milliliter Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
please hold for loose stool
RX *docusate sodium 50 mg/5 mL 10 mL by mouth twice a day Disp
___ Milliliter Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. 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:
Left Mandiubular body to root of left molar fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the Acute Care Trauma surgery service after
an assault. You were found to have a fracture of your left jaw.
You were taken to the operating room with the ___ (oral
maxillofacial-surgery) team and had your jaw repaired with one
tooth extracted. You are now doing better, tolerating a full
liquid diet, and ready to be discharged home to continue your
recovery. You will be sent home with a prescription for
antibiotics, please complete the full course.
You were also seen by Orthopedics for right ankle pain due to an
old medial malleolus facture. An xray was taken which was
negative, and the Orthopedic team recommended continuing the air
boot and weight bearing as tolerated.
Please note the following discharge instructions:
Regarding your Oral Surgery:
-Please remain on a full liquid diet for the next ___ weeks
until your follow-up appointment with ___
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO HS
4. Furosemide 40 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral Daily
8. Carvedilol 12.5 mg PO BID
9. Digoxin 0.125 mg PO EVERY OTHER DAY
10. Docusate Sodium 100 mg PO BID:PRN constipation
this will prevent constipation while ___ are on iron
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth
BID:PRN Disp #*40 Capsule Refills:*0
11. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
12. GlipiZIDE XL 5 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Sertraline 50 mg PO DAILY
15. Valsartan 40 mg PO BID
16. Warfarin 2.5 mg PO 3X/WEEK (___)
17. Warfarin 3.75 mg PO 4X/WEEK (MO,WE,TH,FR)
18. Bengay Cream 1 Appl TP PRN pain
RX *menthol [BenGay] 5 % Apply to affected area as needed twice
a day Refills:*0
19. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*12 Tablet Refills:*0
20. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate [iron] 325 mg (65 mg iron) 1 capsule(s) by
mouth twice a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
GI bleed
elevated INR
atrial flutter
Secondary Diagnosis:
Coronary Artery Disease
paroxismal Afib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital after you had shortness of
breath and were found to have low blood counts because of a
bleed in your gastrointestinal tract. You were given blood
cells to correct your anemia. You had an endoscopy to find the
source of your bleeding. Although the endoscopy did reveal some
irritation of the esophagus this was not thought to account for
such a dramatic drop in your blood count. The
gastroenterologists recommended a follow up colonoscopy to find
the site of bleeding. You declined this colonoscopy despite the
risk of a recurrent serious bleed at home. You can follow up
with the gastroenterology doctors as ___ outpatient to arrange
further follow up.
You were also found to have a high INR putting you at increased
risk for a bleed. Your INR was reversed with plasma products to
which you unfortunately had an allergic reaction. When the
bleeding stopped you were restarted on your coumadin and had
heparin to thin your blood until the coumadin was at the right
levels.
You were also found to have a hard to control heart rate. While
hospitalized you had an ablation procedure and your heart rate
was subsequently well controlled.
Please take all you medications at home as you did before coming
to the hospital including your coumadin. Please follow up with
your primary care doctor to make sure your INR is at target as
the coumadin was stopped while you were inpatient. Please
follow up with your primary care doctor and have your INR
checked within one week of leaving the hospital. PLEASE SEEK
URGENT MEDICAL ATTENTION IF YOU DEVELOP SHORTNESS OF BREATH,
LIGHTHEADEDNESS, OR SEE BLOOD IN YOUR VOMIT OR YOUR STOOL.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of 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 500 mg PO Q6H:PRN Pain - Mild
2. Baclofen 5 mg PO TID
hold for sedation or rr<12
RX *baclofen 5 mg 1 tablet(s) by mouth 3 times daily Disp #*12
Tablet Refills:*0
3. CefTRIAXone 2 gm IV Q24H Duration: 35 Days
4. Cyclobenzaprine 10 mg PO HS
hold for sedation or rr<12
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth nightly Disp #*4
Tablet Refills:*0
5. Diazepam 5 mg PO TID:PRN muscle spasm, ___ line
hold for sedation or rr<12
RX *diazepam 5 mg 1 tablet(s) by mouth 3 times daily Disp #*12
Tablet Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN BREAKTHROUGH PAIN
RX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6)
hours Disp #*16 Tablet Refills:*0
7. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation ___ spray nasal as needed
Disp #*2 Spray Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO BID
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
12. Vancomycin 1500 mg IV Q 12H Duration: 35 Days
13. Gabapentin 300 mg PO QHS
14. Amphetamine-Dextroamphetamine XR 30 mg PO BID
15. Escitalopram Oxalate 20 mg PO DAILY
16. Gabapentin 600 mg PO BID
17. Methadone 50 mg PO DAILY
Consider prescribing naloxone at discharge
18.Outpatient Lab Work
CBC with differential, BUN, Cr, AST, ALT, total bilirubin,
alkaline phosphatase, CRP, and vancomycin trough (1 hour before
vancomycin administration), starting on ___ until ___.
Please fax all results to ___ CLINIC - FAX: ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
L2-L3 discitis/osteomyelitis
Hip, back, groin pain secondary to psoas/paraspinal muscle
inflammation and muscle strain
Acute renal injury
Secondary diagnoses:
Polysubstance use disorder
Low back pain
ADHD
Depression/anxiety
Seizure disorder
Hepatitis C, untreated
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 privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
============================================
You had a spine infection which was causing you a lot of pain.
You also had a lot of hip and back pain that we think is related
to the infection.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
============================================
You had a biopsy of your backbone and then were started on
antibiotics to treat your bone infection, and medicine to treat
the pain.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
Please continue to take all your medications and follow up with
your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Wear your cervical collar at all times
You must shower with the cervical collar on. You have been
given a second collar to use after showering while allowing the
other to dry.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. baclofen 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
2. cyclobenzaprine 5 mg Tablet Sig: One (1) Tablet PO ___ times
per day as needed for muscle spasm.
3. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
4. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
9. nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
10. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
11. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
12. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
16. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*2 inhalers* Refills:*4*
17. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
18. guaifenesin 100 mg/5 mL Syrup Sig: ___ mL PO four times a
day as needed for cough.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
# COPD exacerbation
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 taking care of you during your recent
admission.
You were admitted with an exacerbation of your chronic
obstructive pulmonary disease (COPD). You were treated with
antibiotics, steroids and inhalers, which improved your
breathing. With time, we were able to wean you off of
supplemental oxygen and you were stable for discharge.
The following changes were made to your medication regimen:
- start azithromycin once a day, through ___, this is an
antibiotic to treat any infection that may have provoked your
flare
- start prednisone once a day through ___, this is a steroid
to decrease inflammation
- start spiriva inhaler once a day
- continue advair twice a day
- continue albuterol inhaler as needed for shortness of breath
- for allergies, we recommend you try fexofenadine (allegra)
daily</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Hydrocortisone 20 mg PO QAM
4. Hydrocortisone 10 mg PO QPM
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Prasugrel 10 mg PO DAILY
RX *prasugrel [Effient] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Pravastatin 80 mg PO QPM
8. fenofibrate 145 mg oral Daily
9. Leuprolide Acetate 22.5 mg IM MONTHLY
10. Potassium Chloride 20 mEq PO DAILY
11. Ketoconazole 400 mg PO BID
12. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*8 Tablet Refills:*0
13. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Hypoxia
Coronary Artery Disease
Secondary Diagnoses:
Metastatic Prostate Cancer
Chronic Kidney Disease
Hypernatremia
Chronic Obstructive Pulmonary Disease
Type II 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 ___,
You were admitted to the hospital because you were short of
breath. You were found to have worsening of your heart failure.
You required oxygen to help you breathe. You were treated with
medications to remove the extra fluid from your body adn your
condition markedly improved. You will be discharged on a higher
dose of lasix to help prevent these episodes from happening
again. However, you must also adhere to a low salt diet and lose
some weight or we expect you will return to the hospital within
several weeks with the same problem.
Please take all medications as prescribed and keep all scheduled
appointments. Should you have a recurrence of the same symptoms
that brought you to the hospital, experience any of the warning
signs listed below, or have any other symptoms that concern you,
please seek medical attention. Additionally, weigh yourself
everyday and call your doctor if your weight increases by more
than 3 pounds in 1 day, or if it increases by more than 5 pounds
in 5 days.
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 caring for you here at ___. You were
admitted for worsening abdominal pain, and vomiting blood after
your banding procedure done yesterday. We took a picture of your
abdomen to rule out any serious problems such as perforations in
your gastrointestinal tract. The images came back normal. We
also checked labs to rule out infection, pancreatitis or any
instability of your blood levels. Everything looks reassuring.
We discussed with Dr. ___ also believes your symptoms are
post procedural. Please follow up with your primary care doctor
as well as your hepatology doctor for follow up.
___, be sure to follow up on your difficulty swallowing with
Dr. ___.
We are wishing you the best.
Sincerely,
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. Align (Bifidobacterium infantis) 4 mg oral DAILY
3. amLODIPine 2.5 mg PO BID
4. Ascorbic Acid ___ mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Cranberry Juice Powder (cranberry extract) 425 mg oral Daily
7. Ferrous Sulfate 18 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Chest pain (non-cardiac)
SECONDARY DIAGNOSIS
CKD
Hyponatremia
Severe AS
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 ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had an episode
of chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- Your blood tests showed you did not have a heart attack
- We did a stress test of your heart function which was normal
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor at ___
if your weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 169 lb. You should use this as your
baseline after you leave the hospital.
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. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO HS
3. Clonazepam 0.5 mg PO DAILY
HOLD for sedation, RR < 12
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H wheezing, shortness of
breath
5. Azithromycin 250 mg PO Q24H Duration: 5 Days
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing,
shortness of breath
8. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing, shortness of
breath
9. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN wheezing, shortness
of breath
10. PredniSONE 40 mg PO DAILY Duration: 5 Days
Start date ___
11. Ranitidine 300 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Mirtazapine 7.5 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
COPD exacerbation
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 taking care of you during your hospitalization
at ___.
Your were hospitalized with acute shortness of breath and
increased sputum production. Your symptoms were attributed to a
COPD exacerbation. You were treated with steroids and an
antibiotic called Azithromycin, and will be discharged to the
rehab facility to continue these medications. You should also
continue to take your Advair inhaler to help with your
breathing. Use the albuterol and ipratropium nebulizers as
needed to help with shortness of breath.
During this admission, a swallowing study was done that showed
that you were aspirating on thin liquids. Diet modifications
have been made to help prevent this from happening.
A medication called Mirtazipine was also started to help with
your mood symptoms.
Keep all up-coming appointments. Upon discharge from rehab, make
an appointment with your primary care physician.</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
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*240 Tablet Refills:*0
2. AcetaZOLamide 125 mg PO BID
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q8H
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE TID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
6. MedroxyPROGESTERone Acetate 20 mg PO Q12H Duration: 7 Days
RX *medroxyprogesterone 10 mg 2 tablet(s) by mouth twice a day
Disp #*66 Tablet Refills:*0
7. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Atorvastatin 10 mg PO QPM
9. Calcium Carbonate 500 mg PO QID:PRN indigestion
10. Cetirizine 10 mg PO DAILY:PRN allergies
11. darbepoetin alfa in polysorbat 200 mcg/mL injection 1X/WEEK
___
12. Lantus U-100 Insulin (insulin glargine) 10 units
subcutaneous Q24H
13. Lidocaine-Prilocaine 1 Appl TP PRN and prior to dialysis
14. LOPERamide 2 mg PO PRN diarrhea
15. LORazepam 1 mg PO 3X/WEEK (___) before HD
16. Nephrocaps 1 CAP PO DAILY
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. Sertraline 100 mg PO DAILY
19. sevelamer CARBONATE 1600 mg PO TID W/MEALS
20. Torsemide 100 mg PO 4X/WEEK (___)
21. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until instructed by your primary care doctor
___ held due to vaginal bleeding)
Discharge Disposition:
Home
Discharge Diagnosis:
Neovascular glaumoma
Menorrhagia
Anemia
Dizziness
ESRD
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 due to glaucoma of your right
eye and vaginal bleeding. While in the hospital you were started
on medications by the ophthalmology team to help with your eye
pain and pressure. These medications were effective in improving
your symptoms and the pressure in your eye. You continued to
have some vaginal bleeding, although fortunately your blood
levels remained relatively steady. The gynecology team
recommended provera, which is a form of the hormone
progresterone. They have recommended taking this for several
weeks and then following up with them in clinic. Your dizziness
seemed to be related to your eye pain and glaucoma, and also
worsened while at dialysis. We recommend continuing to take
tylenol as needed and picking up your new glasses. If you at any
point feel unsteady or if your symptoms worsen you should seek
further care.
FYI the ophthamologists sent the prescriptions for your eye
drops and your acetazolamide (for the eye pressure/neurovascular
glaucoma) to your pharmacy already. If you have any trouble
getting those medications, please call us at ___.
Because your new medication acetazolamide (diamox) can cause
symptoms like confusion, dizziness, or weakness if it builds up
too much in your body, it will be important to watch out for any
of these symptoms while you are taking it. If those occur you
should stop taking it and seek further care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth Q6 Disp #*60 Tablet Refills:*1
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
RX *alprazolam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*1
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
5. Nicotine Patch 7 mg TD DAILY
RX *nicotine 7 mg/24 hour 1 once a day Disp #*30 Patch
Refills:*1
6. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
7. Sertraline 100 mg PO DAILY
RX *sertraline 100 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
8. Metoclopramide 5 mg PO QIDACHS PRN gastroparesis
RX *metoclopramide HCl 5 mg 1 tab by mouth four times a day Disp
#*120 Tablet Refills:*0
9. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
10. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % (700 mg/patch) apply to right leg in evening
hs Disp #*30 Patch Refills:*0
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply to left leg
morning Disp #*30 Patch Refills:*0
11. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
q5min Disp #*30 Tablet Refills:*0
13. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth Q6 Disp #*60
Tablet Refills:*0
14. Pregabalin 50 mg PO DAILY
RX *pregabalin [Lyrica] 50 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
15. Glargine 4 Units Breakfast
Glargine 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 4 Units before
BKFT; 3 Units before BED; Disp #*1 Vial Refills:*3
RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 6 Units
QID per sliding scale Disp #*1 Vial Refills:*3
16. Lidocaine Jelly 2% 1 Appl TP ASDIR for wound care
RX *lidocaine [Topicaine] 4 % To wounds prior to dressing
changes PRN Refills:*1
17. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8 Disp #*30 Tablet
Refills:*1
18. Albuterol Inhaler 2 PUFF IH Q6H PRN SOB
RX *albuterol sulfate 90 mcg 2 puff IH Q6 Disp #*1 Inhaler
Refills:*1
19. Vancomycin 1000 mg IV HD PROTOCOL
Last dose to be given at HD on ___
20. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth after HD Disp #*30 Capsule Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Acute on chronic diastolic CHF
- Acute on chronic renal failure with initation of HD
- Probable LLE cellulitis
- LLE post-vein graft non-healing ulcers: 3x1 cm
proximal-medial, 1x1cm mid calf-medial.
- RLE foot superficial blister: heel, dorsum of foot
- Post-operative sternal pain
- Hypothyroidism vs sick-euthyroid; synthroid initiated.
- Mixed anemia iron deficiency and CKD
Secondary:
- CAD/MI s/p ___ (___), CABG x 3 (___)
- CKD stage IV
- Diabetes mellitus type I
- Peripheral neuropathy
- Celiac disease
- Severe gastroparesis
- Nonalcoholic steatohepatitis
- Gastroesophageal reflux disease
- Hypertension
- Depression/anxiety
- ETOH and drug abuse in remission
- Functional hypothalamic amenorrhea
- H/O retinal vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with chest pain which was
determined to be from your surgical wound. You were evaluated
for a pulmonary embolus and while this was not ruled out, it was
determined to be a less likely cause of your symptoms. You were
also noted to have a congestive heart failure exacerbation which
was managed with diuretics. You started dialysis ___,
___ and were treated for a cellulitis (skin infection of
your leg)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Alendronate Sodium 70 mg PO QSUN
2. Atorvastatin 80 mg PO QPM
3. benazepril 10 mg oral DAILY
4. Clopidogrel 75 mg PO DAILY
5. LORazepam 1 mg PO BID:PRN anxiety
6. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chorea
Falls
Subarachnoid hemorrhage
Acute on chronic kidney disease
Uncomplicated UTI
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 ___
___.
You were in the hospital because of spells that caused you to
fall. One of the falls caused you to have a small bleed in your
brain, but this did not require surgery.
In the hospital, we did several tests to figure out why you were
having spells. An EEG (brain wave ___, did not show any
seizures, although this not definitively mean you were not
having seizures. We did several blood tests and an MRI, but
these were normal.
When you leave the hospital, you should follow up with the
movement disorders specialists to continue work-up of your
spells. They may discuss genetic testing with you.
We also ordered an EEG for you to complete as an outpatient. You
will be called to schedule this. You should sleep less than
usual on the day prior to this ___.
We also ordered a heart monitor called ___ of Hearts to look
for abnormal heart rhythm. This will be mailed to you.
You should also undergo a colonoscopy to screen for colon
cancer, and continue to follow up with your cancer doctor.
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 Q4H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*90 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM to L side
RX *lidocaine 5 % put 1 patch on every day once a day Disp #*7
Patch Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
4. Simethicone 40-80 mg PO QID gas pain
RX *simethicone 80 mg 1 tab by mouth every eight (8) hours Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
sickle cell disease
acute chest syndrome
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
##############
DISCHARGE EXAM:
GENERAL: Young AA man sleeping but easily arousable, alert and
in
no apparent distress
EYES: Anicteric, pupils equally round; no conjunctival pallor.
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart RRR, no murmurs/rubs/gallops.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, still distended, non-tender to palpation.
Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
EXT: WWP, 2+ distal pulses, no ___ edema
SKIN: No rashes or ulcerations noted
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
GENERAL: Young AA man sleeping but easily arousable, alert and
in
no apparent distress
EYES: Anicteric, pupils equally round; no conjunctival pallor.
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart RRR, no murmurs/rubs/gallops.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, still distended, non-tender to palpation.
Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
EXT: WWP, 2+ distal pulses, no ___ edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to ___ for severe pain and difficulty
breathing that is related to your sickle cell disease. You were
in the ICU and received treatment for acute chest syndrome and a
pneumonia. You got better and were discharged from the floor off
oxygen.
Please go to your appointment with hematology.
Please continue using the incentive spirometer 2x/day (10
inspirations each time).
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. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Atorvastatin 40 mg PO QPM
3. BusPIRone 15 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous 55U qam
7. Levothyroxine Sodium 100 mcg PO DAILY
8. LORazepam 1 mg PO DAILY:PRN anxiety
9. LORazepam 1 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY:PRN SBP>120/130
11. Ondansetron ODT 4 mg PO Q6H:PRN Nausea/Vomiting - First
Line
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
13. Pantoprazole 40 mg PO Q12H
14. Rivaroxaban 20 mg PO DINNER
15. Tiotropium Bromide 1 CAP IH DAILY
16. Tizanidine 4 mg PO TAKE 1 TAB IN AM AND 1 TAB MIDDAY AND 3
TABLETS AT BEDTIME AS NEEDED FOR MUSCLE SPASM
17. Torsemide 10 mg PO 5X/WEEK (___)
18. Torsemide 20 mg PO 2X/WEEK (MO,TH)
19. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
20. TraZODone 200 mg PO QHS
21. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-------------------
Atypical, non-cardiac chest pain
SECONDARY:
-------------------
Coronary artery disease
Heart failure with preserved EF
Diabetes mellitus, II
Transaminitis
History of PE and RLE DVT w/ IVC filter
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 admitted to the hospital because you were having
chest pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a cardiac catheterization which was normal and did not
show a blockage in the arteries of your heart.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please bring this discharge paperwork with you to your
appointments.
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. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours).
Disp:*22 syringes* Refills:*0*
2. methimazole 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
5. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Right iliac DVT
Klebsiella UTI
Secondary diagnosis:
Hyperthyroid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking part in your care. You came to the
hospital because you had right leg swelling and side pain. You
were found to have a blood clot in your leg vein. You were
started on blood thinners (injections called Lovenox) to treat
this and will need to continue this for several months. You
were seen by our vascular surgeons and they recommended you
continue to wrap your leg and keep it elevated to improve
swelling. You had a CT scan that also showed some enlargement
of the lymph nodes around the clot. This may have been from the
clot itself. But because you have a history of transitional
cell carcinoma in the same location we had our urologists come
see you and they would like you to see an oncologist to do
further testing and make sure this is not recurrence of your
cancer.
You were also found to have a urinary tract infection and were
started on antibiotics to treat this. You will need to take
this for 6 more days for a total of 7 days.
Please note the following changes to your medications:
***START lovenox injections twice a day (you will need to talk
with your primary care doctor and the oncologist to determine
how long you will need to take this)
***START Bactrim DS tab twice a day for urinary tract infection
(to end ___
***continue all of your other medications as prescribed
Please follow up with your urologist, Dr. ___ at your regularly
scheduled appointment (see below). You should also follow up
with your primary care doctor and the oncologist (we have made
the primary care appointment for you and someone will call you
to schedule the oncology appointment).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ValACYclovir 1000 mg PO TID
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times daily
Disp #*18 Tablet Refills:*1
2. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Varicella zoster rash
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 a rash. It appears to be caused
by the virus varicella zoster. This could therefore be a repeat
case of chicken pox (uncommon but possible) or a reactivation of
the virus from your original chicken pox infection. Until the
rash crusts over, you could spread the virus to anyone who is
not immune (not vaccinated or never had chicken pox)
Instructions:
- Take Valtrex ___ mg three times daily for at least 6 more
days or until the rash has crusted over
- Please follow up with your primary care provider before going
back to work
- If you notice any worsening of the rash, please call your
primary care provider or go to the emergency department</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth every day Disp #*60
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 30 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
Please take until INR is therapeutic
RX *enoxaparin [Lovenox] 30 mg/0.3 mL 1 syringe SC every evening
Disp #*14 Syringe Refills:*0
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four to six hours
Disp #*40 Tablet Refills:*0
7. Senna 8.6 mg PO BID
8. Donepezil 10 mg PO QHS
9. Enablex (darifenacin) 15 mg oral DAILY
10. Warfarin Titrated mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated left lower extremity
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 until Coumadin becomes therapeutic. Then
ok to stop lovenox.
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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
- weight bearing as tolerated left lower extremity
- ROMAT left lower extremity
Treatments Frequency:
- dressing to come off on POD5 ___
- may leave wound open to air
- if wound oozing, then may place ABDs+tape</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. Acetylcysteine 20% ___ mL NEB Q4H:PRN cough
3. Acyclovir 800 mg PO Q8H
4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of
breath
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Dexamethasone 2 mg PO Q12H
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. GuaiFENesin 10 mL PO Q4H:PRN cough
9. Heparin 5000 UNIT SC BID
Stop when patient ambulating regularly
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze
12. Labetalol 300 mg PO BID
13. LevETIRAcetam 1000 mg PO Q12H
14. Lidocaine 5% Patch 1 PTCH TD DAILY PRN Pain
15. Nystatin Oral Suspension 5 mL PO QID Duration: 14 Days
16. Omeprazole 40 mg PO DAILY
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. QUEtiapine Fumarate 12.5 mg PO DAILY agitation
19. Senna 17.2 mg PO QHS:PRN constipation
20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
21. Gabapentin 400 mg PO TID
22. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
hold for sedation or RR<12
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4 hours prn
Disp #*30 Tablet Refills:*0
23. Verapamil 120 mg PO Q12H
24. Hydrochlorothiazide 50 mg PO DAILY
25. Multivitamins 1 TAB PO DAILY
26. HELD- Aspirin EC 81 mg PO DAILY This medication was held.
Do not restart Aspirin EC until your neurology team tells you to
restart
27.Prescription
Hair or scalp prosthesis
ICD___ code: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
============
___ frontal brain lesion
Cerebral edema and compression
Small cell lung cancer
Aspiration pneumonia
Secondary Diagnosis
=============
Hypertension
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 came to the hospital because you were having headaches and
were found to have a tumor in your brain that came from the
spread of your lung cancer.
While you were here, you had surgery to take the tumor out. You
also were started on chemotherapy for your cancer. You did have
some trouble breathing, so you were given antibiotics to treat a
pneumonia. We also found that sometimes you have trouble
swallowing correctly and food can get into your lungs, so we
recommended changes to your diet to help prevent that from
happening.
When you leave the hospital, it is important you follow-up with
the neurosurgery team, you oncologists, and you primary care
doctor. It is also very important you take all your medications
as prescribed.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason
It has been a pleasure to care for you, and we wish you the
best!
Your ___ Care Team
Below are further recommendations from your surgeons:
Activity:
=========
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at - your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications:
============
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
========================
- You may experience headaches and incisional pain.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
===============================================
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Gabapentin 800 mg PO QID
2. LeVETiracetam 1000 mg PO BID
3. Methadone 90 mg PO DAILY
4. Prazosin 5 mg PO QHS
5. Venlafaxine XR 150 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
7. Levofloxacin 500 mg PO DAILY
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
8. ClonazePAM 1 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
1. Suicide attempt via ingestion of unknown medications
2. Alcohol withdrawal
3. Depression/Anxiety
4. Community Acquired Pneumonia
Secondary
1. Seizure Disorder
2. Hx of IVDU
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to the hospital after
overdosing on unknown pills. Because you reported heavy
drinking, you were started on a medication for alcohol
withdrawal called phenobarbital. Your psychiatric medications
were initially held in the setting of recent overdose and
gradually restarted when it was determined to be safe.
On your second day, you had a very high fever. We performed many
studies and ultimately found that you had a pneumonia. You were
given antibiotics to treat this infection.
Due to concerns for your safety, you were evaluated by our
psychiatrists who determined that although you engage in high
risk behavior you did not appear to be an immediate danger to
yourself.
Please follow up with all scheduled appointments and continue
taking all medications as prescribed. If you develop any of the
danger signs below, please contact your health care providers or
go to the emergency room immediately.
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. Raltegravir 400 mg PO BID
2. Pyridoxine 100 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
hold for sbp < 100 or map <60
RX *lisinopril 10 mg 1 Tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
4. Isoniazid ___ mg PO HS
5. Etravirine 200 mg PO BID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Morphine SR (MS ___ 100 mg PO Q12H
hold for sedation or rr < 10
8. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough/wheeze
9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
10. Labetalol 300 mg PO BID
hold for SBP < 120
RX *labetalol 300 mg 1 Tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Hypercarbic respiratory failure
Acute renal failure
SECONDARY:
HIV
Hypertension
COPD
HIV neuropathy
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 presented because of some jerking movements that you have
had in the past. You were admitted to the ICU with respiratory
and renal failure. You were intubated, stabilized, and then
extubated from the breathing machine. After you were given IV
fluids, your kidney fuction improved back to your baseline.
The cause of your jerking movements is not entirely clear; it is
possible that due to the kidney injury there was a buildup of
medications in your blood causing these symptoms. Currently,
this has resolved.
It is very important that you refrain from using unprescribed
medications and illicit drugs, as these can lead to serious
medical issues.
Note that while you were here you had very elevated blood
pressures; your blood pressure regimen was increased.
The following changes were made to your medications:
STOP LYRICA (pregabalin)
STOP CYCLOBENZAPRINE (flexeril)
INCREASE Labetalol to 300 mg twice daily for blood pressure
RESTART Lisinopril 10 mg once daily for blood pressure</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
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 (One)
tablet(s) by mouth every six (6) hours Disp #*30 Tablet
Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Liver laceration.
Left hallux (big toe) fracture.
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 a liver
laceration and underwent surgical intervention for your
injuries. The following instructions are extremely important for
your recovery:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Continue to use your crutches until you are able to tolerate
weight-bearing. You will be re-evaluated at your next visit.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever, pain.
8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritus.
9. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. miconazole nitrate 2 % Powder Sig: One (1) application
Topical three times a day as needed for skin redness/iritation:
Apply to affected area.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Urinary tract infection
Sepsis
Altered mental status
Secondary diagnoses:
Alzheimer's dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ for altered mental status, UTI and sepsis. You were
treated with a course of IV antibiotics for your UTI and your
mental status improved. You had difficulty swallowing food and
were seen by the speech/swallow team this admission. After a
discussion with your family, you were allowed to eat food
knowning the risk of aspirating some of the food and risk for
lung infection.
The following changes were made to your medications:
CHANGE labetalol to 200mg twice daily
START hydroxyzine 25mg q6h as needed for itching
START miconazole powder three times daily to affected area as
needed</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
3. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*10 Capsule Refills:*0
4. 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
5. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left 6th rib fracture
Left pneumothorax
Pulmonary contusion
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 dirt bike accident.
You broke one of your ribs on the left side and had a small
pneumothorax, or leak of air into the lung cavity, on the left.
You were given oxygen and observed until you were safe to go
home. Your vital signs have been stable and your are preparing
for discharge home with the following instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
Please do not fly on an airplane for 2 weeks.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following a broken
rib. Your pain should get better day by day. You may receive a
prescription for pain medicine to take by mouth. It is important
to take this medicine as directed. Do not take it more
frequently than prescribed. Do not take more medicine at one
time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe. 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.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
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.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. 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.</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 Q4H:PRN wheeze, SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb INH every four
(4) hours Disp #*24 Vial Refills:*0
2. Fentanyl Patch 100 mcg/h TD Q72H
RX *fentanyl 100 mcg/hour Apply to skin q72h Disp #*1 Patch
Refills:*0
3. Fluocinonide 0.05% Ointment 1 Appl TP BID
RX *fluocinonide 0.05 % Apply to chest wall twice a day
Refills:*2
4. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth qAM, noon Disp #*6
Capsule Refills:*0
5. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*3
Capsule Refills:*0
6. Ibuprofen 600 mg PO Q6H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL
INH every six (6) hours Disp #*12 Ampule Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % Apply to chest wall qAM Disp #*15 Patch
Refills:*0
9. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Severe
RX *oxycodone 10 mg ___ tablet(s) by mouth q3h Disp #*72 Tablet
Refills:*0
11. amLODIPine 10 mg PO HS
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. LORazepam 1 mg PO QID:PRN anxiety
RX *lorazepam 1 mg 1 mg by mouth four times a day Disp #*12
Tablet Refills:*0
14. Senna 8.6 mg PO BID:PRN constipation
15. Sertraline 25 mg PO QHS
RX *sertraline 25 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
16. TraZODone 50-100 mg PO QHS:PRN insomnia
RX *trazodone 50 mg ___ tablet(s) by mouth at bedtime Disp #*6
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Pleural effusion
Severe pain
SECONDARY
Small cell lung carcinoma
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 caring for you at the ___
___.
===================================
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted because you had severe pain and worsening
shortness of breath
========================================
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
========================================
-We found that the fluid has re-collected in your lungs, making
it harder for you to breathe
-You were seen by the Palliative Care team
-We changed your pain medications to help control your pain
-We met with you and your sons, and we made a plan together to
help keep you comfortable at home on hospice
=========================
WHAT SHOULD I DO AT HOME?
=========================
-You will work with the hospice team to monitor and treat your
pain and help your breathing
-Do not smoke with your oxygen on. This can cause a fire or
explosion. Remove your oxygen and turn it off if you are going
to smoke.
-Please keep your follow up appointments with your doctors
___ for letting us be a part of your care!
Your ___ Oncology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You came to the ___ ED after you were told
that you had anemia (low red blood cell level) and were
admitted to the hospital. During your hospitalization you
received 3 units of blood which improved your red blood cell
level (hematocrit). We believe that your anemia was caused
primarily by your chronic kidney disease but we also recommend
that you see the hemotology/oncology specialists.
Please follow up with your appointments below.
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 650 mg PO Q8H:PRN pain
2. Acyclovir 500 mg IV Q12H
continue until ___
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE TID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
5. Gabapentin 100 mg PO HS
6. Gabapentin 100 mg PO QAM
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Amlodipine 5 mg PO DAILY
9. HydrALAzine 10 mg PO Q6H SBP>180
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
VZV polyradiculopathy or plexopathy
shingles
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 ___, you were hospitalized because of continuos
pain and weakness of you right shoulder and arm, that started
shortly after you had developed shingles. You were found to have
symptoms consistent with a varicella (which is the virus that
causes chickenpox and shingles) infection of your cervical nerve
roots. Your MRI did not show involvement of your spinal cord.
You were started on an antiviral medication called acyclovir,
which will be continued for a total of 14 days.
Because of the acyclovir you developed an acute kidney injury,
which fortunately improved with a lower dose of acyclovir and a
lot of iv fluids.
In addition we started gabapentin for your pain, which helped.
Your medications are now as follows:
START gabapentin 100mg BID
START acyclovir 500mg iv daily, continue until ___
It was a pleasure taking care of you during this
hospitalization.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Caphosol 30 mL ORAL QID:PRN dry mouth
2. CeFAZolin 2 g IV POST HD (MO,WE)
3. CeFAZolin 3 g IV POST HD (FR)
4. DiphenhydrAMINE 25 mg PO QHS:PRN itching or sleep
5. Ferrous Sulfate 325 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO Q6H
7. Sarna Lotion 1 Appl TP DAILY:PRN dry skin
8. Vitamin D ___ UNIT PO 1X/WEEK (FR)
9. Acetaminophen 325-650 mg PO Q6H
10. Acyclovir 200 mg PO Q12H
11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*20 Tablet Refills:*0
12. Amiodarone 200 mg PO DAILY
13. ammonium lactate 12 % topical rub into skin all over body
BID - pt now uses PRN
14. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eye
15. Aspirin 81 mg PO DAILY
16. Atorvastatin 40 mg PO QPM
17. Benzonatate 100 mg PO TID:PRN cough
18. Calcitriol 0.25 mcg PO 3X/WEEK (___)
19. Clindamycin 1% Solution 1 Appl TP BID:PRN rash
20. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
21. Hydroxychloroquine Sulfate 200 mg PO DAILY
22. LOPERamide 2 mg PO QID:PRN watery stool
23. LORazepam 0.5 mg PO Q8H:PRN anxiety
24. Nephrocaps 1 CAP PO DAILY
25. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
26. Pantoprazole 40 mg PO Q12H
27. PredniSONE 5 mg PO DAILY
28. sevelamer CARBONATE 800 mg PO TID W/MEALS
29. Simethicone 40-80 mg PO QID:PRN gas pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Septic arthritis (Staphylococcus lug___) of left shoulder
and left knee
- Anemia from a GI bleed
SECONDARY DIAGNOSIS:
- Lupus
- End stage renal disease on hemodialysis
- Common variable immunodeficiency
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. ___-
___ was a pleasure taking care of you at ___. You originally
came to the emergency room because of increasing pain and
swelling in your left knee and shoulder.
While you were here, the radiologists took samples of fluid from
both joints and they grew a bacteria called Staphylococcus
Lugdunesis. The orthopedic surgeons took you to the operating
room on ___ and ___ to clean out your knee and shoulder
respectively. The bacteria was found to be sensitive to an
antibiotic called cefazolin and you will be treated with it for
six weeks.
Over the course of your time in the hospital, but in particular
after returning to the main part, you had continued bleeding
from two blood vessels in your stomach. It could not be
adequately controlled despite endoscopic procedures. The final
plan formulated from multiple multidisciplinary discussions was
to discontinue your Plavix to control the bleeding.
Things to keep in mind when you leave:
- Call your primary doctor if you have more swelling and pain in
your joints.
- Call your doctor if you cough up blood or notice blood in your
stool or dark, tarry stool
- Continue your scheduled follow-up with your infectious disease
doctor to determine additional steps in your antibiotic
treatment
Thank you for letting us participate in your care.
-Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
2. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*2
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Donepezil 5 mg PO QHS
5. Esomeprazole 40 mg Other BID
6. Gabapentin 800 mg PO DAILY
7. Gabapentin 400 mg PO QHS
8. Aspart 10 Units Dinner
Glargine 30 Units Bedtime
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Januvia (SITagliptin) 50 mg oral DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Ranitidine 300 mg PO BID
13. Sucralfate 1 gm PO TID
14. Tizanidine 2 mg PO TID:PRN muscle spasm
15. TraMADol 50 mg oral DAILY
16. Venlafaxine 75 mg PO DAILY
Discharge Disposition:
Home
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>It was a pleasure to take care of you while you were at ___!
Why was I admitted to the hospital?
- You were admitted to the hospital because your primary care
doctor sent you to the emergency department because you looked
unwell and had a slow heart rate. In the Emergency Department
you were found to have elevated heart enzymes, indicated you had
a heart attack.
What was done while I was in the hospital?
- While you were in the hospital, your medications were adjusted
to help your heart function better.
- Your Midodrine was stopped because your blood pressures were
high
- Your diuretic medication was stopped
What should I do when I go home?
- Please call Dr. ___ on ___ and see him in clinic in one
week
- Please make sure to take all of your medications EXACTLY as
prescribed
- Please make sure to go to all of your follow up doctor's
appointments, including with your primary care doctor and your
primary cardiologist (Dr. ___.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
MEDICATIONS:
STOPPED Medications
- Aspirin 81 mg PO DAILY This medication was stopped because no
longer needed per Dr. ___ due to bleeding risk.
- Furosemide 40 mg PO 3X/WEEK (___) This medication was
stopped because no longer needed, speak with Dr. ___ you
feel your weight is gaining.
- Furosemide 20 mg PO 4X/WEEK (___) This medication was
stopped because no longer needed, speak with Dr. ___ you
feel your weight is gaining.
- Metoprolol Tartrate 50 mg PO BID This medication was stopped
because it is no longer needed and it is being replaced with
metoprolol succinate
- Midodrine 5 mg PO TIDThis medication was stopped because it
is no longer needed.
NEW Medications
- Metoprolol Succinate XL 50 mg PO DAILY
CHANGED Medications
- Apixaban 2.5 mg PO BID decreased from 5mg BID
- Atorvastatin 40 mg PO QPM decreased in dose from 80mg</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amiodarone 200 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Febuxostat 40 mg PO DAILY
4. LeVETiracetam 1000 mg PO BID
5. Pravastatin 40 mg PO QPM
6. Tamsulosin 0.8 mg PO QHS
7. Valsartan 40 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. glimepiride 1 mg oral daily
10. Omeprazole 20 mg PO DAILY
11. Furosemide 20 mg PO DAILY:PRN LEG SWELLING
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Warfarin 2 mg PO DAILY16 to be adjusted by PCP
___:
Home
Discharge Diagnosis:
Microcytic anemia, suspected occult GI loss, Aspiration
Pneumonia, Lower GI bleeding
Discharge Condition:
Mental Status: Confused - sometimes.
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 were
hospitalized for coughing up a small amount of blood due to
frequent coughing. You were found to have a pneumonia which was
treated with antibiotics and your symptoms resolved. You were
also incidentally found to have a low blood count, or anemia,
which was concerning for slow blood loss in your GI tract. You
received upper and lower endoscopies which did not reveal any
sources of bleeding. The GI doctors have recommended that you
follow up with their clinic as an outpatient to receive a
capsule endoscopy study. After your endoscopies, you experienced
some small amounts of bleeding into the toilet, likely as a
result of having had a polyp removed while being on blood
thinners. Your bleeding steadily decreased and stopped. Your
blood counts and vital signs remained stable. You were given a
blood transfusion to elevate your blood counts prior to
discharge. You were restarted on your coumadin and your INR was
in therapeutic range on the day of discharge. You will follow up
with your primary care doctor to continue monitoring of your
INR.</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 BID
2. Amikacin Inhalation 500 mg IH BID
3. budesonide 0.25 mg/2 mL inhalation BID
4. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN shortness of breath
5. Loratadine 10 mg PO DAILY
6. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*0
7. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL ___ mL by mouth every four (4) hours
Disp ___ Milliliter Refills:*0
8. Ranitidine 150 mg PO HS
9. Cepastat (Phenol) Lozenge 1 LOZ PO Q4H:PRN throat pain
RX *phenol [Cepastat] 14.5 mg Take 1 lozenge every four (4)
hours Disp #*60 Lozenge Refills:*0
10. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ mL by mouth every six (6)
hours Disp #*1 Bottle Refills:*1
11. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
- Tracheobronchial malacia
SECONDARY DIAGNOSES
- bronchopulmonary dysplasia
- chronic bronchitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure to take care of you during your hospital stay.
You were admitted to the hospital because you were having
increased cough and some shortness of breath. You were seen by
ENT and the infectious disease teams. Your symptoms were most
likely not related to an infection or tracheitis (inflammation
of your trachea). Your symptoms may be related to frequent
suctioning and you should not suction yourself as often as you
have been doing.
Please keep your follow-up appointments as below. Please call
___ to schedule an appointment with speech and
swallowing for a video swallow in the next few days. Please
return to the emergency room if you experience fevers, chills,
chest pain, cough, shortness of breath or worsening cough.
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. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
3. Aspirin 325 mg PO DAILY
4. Baclofen 5 mg PO TID
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Docusate Sodium 100 mg PO BID
8. Famotidine 20 mg PO Q12H
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Glucose Gel 15 g PO PRN hypoglycemia protocol
11. Heparin 5000 UNIT SC BID
12. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using REG Insulin
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze/SOB
14. Metoprolol Tartrate 25 mg PO BID
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 17.2 mg PO QHS
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
19. Cyanocobalamin 1000 mcg PO DAILY
20. Levothyroxine Sodium 100 mcg PO DAILY
21. Multivitamins 1 TAB PO DAILY
22. Thiamine 100 mg PO DAILY
23. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aneurysmal Subarachnoid Hemorrhage
Hydrocephalus
Small bowel obstruction
C-diff infection
Respiratory failure
PNA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions
Aneurysmal Subarachnoid Hemorrhage
Surgery/ Procedures:
*** You had a cerebral angiogram to coil the aneurysm. You may
experience some mild tenderness and bruising at the puncture
site (groin).
*** You had a VP shunt placed for hydrocephalus. Your incision
should be kept dry until sutures or staples are removed.
*** Your shunt is a ___ Strata Valve which is
programmable. This will need to be readjusted after all MRIs or
exposure to large magnets. Your shunt is programmed to 0.5.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
***You may be instructed by your doctor to take one ___ a
day and/or Plavix. If so, do not take any other products that
have aspirin in them. If you are unsure of what products contain
Aspirin, as your pharmacist or call our office.
***Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. alfuzosin 10 mg oral DAILY
2. Amoxicillin ___ mg PO PREOP dental procedures
3. Atorvastatin 10 mg PO QPM
4. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
5. DULoxetine ___ 20 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Magnesium Oxide 500 mg PO DAILY
8. melatonin 5 mg oral QHS
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Propranolol 40 mg PO BID
11. Sildenafil 20 mg PO QHS:PRN ED
12. Testosterone Cypionate 200 mg IM EVERY 2 WEEKS (MO)
13. TraZODone 100 mg PO QHS:PRN Insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vestibulopathy
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 acute onset dizziness
resulting from PERIPHERAL VESTIBULOPATHY, a condition where your
inner ear temporarily makes you feel like you are moving when
you are sitting or standing still. An MRI scan of your brain
showed that your symptoms were not due to a stroke.
We are not changing any of your medications. Please take your
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. Fluticasone Propionate NASAL 2 SPRY NU BID
RX *fluticasone 50 mcg 2 sprays each nostil twice a day Disp #*1
Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Tachycardia
Secondary:
Rhinorrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization at ___. You
were admitted for observation of your fast heart rate. This
resolved on its own and may have been related to some anxiety.
All of your lab studies and imaging were normal and no serious
cause of this fast heart rate was found. We feel it is safe for
you to be discharged home.
We wish you the best in the future!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
Take until restarting eliquis ___. Lisinopril 20 mg PO DAILY
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Sertraline 200 mg PO DAILY
9. Simethicone 40-80 mg PO QID:PRN gas pain
10. Gabapentin 200 mg PO TID
11. Allopurinol ___ mg PO DAILY
12. Atorvastatin 20 mg PO QPM
13. CARVedilol 25 mg PO TID
14. Digoxin 0.125 mg PO DAILY
15. Furosemide 40 mg PO DAILY
16. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur 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>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:
-Touchdown weightbearing in the left lower extremity
MEDICATIONS:
1) Take Tylenol ___ mg 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 ___ 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.
Call your surgeon's office with any questions.
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
THIS PATIENT IS EXPECTED TO REQUIRE LESS THAN 30 DAYS OF REHAB</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
2. Azathioprine 200 mg PO DAILY
3. Benztropine Mesylate 1 mg PO BID
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Calcium Carbonate 500 mg PO QID:PRN reflux
6. Divalproex (EXTended Release) 500 mg PO QAM
7. Divalproex (EXTended Release) 1000 mg PO QHS
8. Docusate Sodium 100 mg PO BID
9. Fluphenazine 5 mg PO QHS
10. Gabapentin 300 mg PO TID
11. 70/30 95 Units Breakfast
70/30 75 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: continuing home medication
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Losartan Potassium 25 mg PO DAILY
hold for SBP<100
14. Omeprazole 20 mg PO DAILY
15. PredniSONE 10 mg PO DAILY
You were unsure of your dose. Please continue to take as
directed by your prescribing physician.
16. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
17. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
18. Ferrous Sulfate 325 mg PO BID
19. Loperamide 2 mg PO QID:PRN diarrhea
20. Miconazole 2% Cream 1 Appl TP BID
21. Symbicort *NF* ___ mcg/actuation
Inhalation daily
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: obstructive sleep apnea
secondary diagnoses: type 1 diabetes, asthma, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were short of breath and
found to have a low oxygen level. This was likely related to
your lungs not fully expanding and your obstructive sleep apnea.
It is important that you continue to use your CPAP machine while
sleeping.
There were no changes made to your medication regimen. Please
take your medications as prescribed and follow up with your
doctors as ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nabumetone 500 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
8. HELD- Donepezil 5 mg PO QHS This medication was held. Do not
restart Donepezil until ___ see your neurologist
9. HELD- LevETIRAcetam 500 mg PO ONCE This medication was held.
Do not restart LevETIRAcetam until ___ see your neurologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
TIA vs seizure
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 ___ were hospitalized due to symptoms of left sided weakness of
unknown etiology. It is possible that ___ experienced
recrudescence of your prior stroke. However, we did not find a
clear etiology that could explain recrudescence. It could also
be possible that ___ experienced a transient ischemic attack
from a clot in your brain that has resolved. Another possibility
is that your symptoms are caused by seizures. ___ were
previously on keppra for that but told us that ___ stopped it.
We recommend to follow up with your neurologist to decide if ___
should continue this medication. In addition, ___ your Donepezil
was also recently stopped. Again we recommend follow up with Dr.
___ on further decision regarding this medication.
Please followup with Neurology as listed below.
If ___ 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
___
- 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: [/INST] </s><s>It was a pleasure caring for you at the ___ ___
___.
You were hospitalized with a exacerbation of COPD and a possible
aspiration pneumonia. You continue to have some need for oxygen
and you should continue to use your inhalers and stay out of bed
as much as you can to improve your breathing.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Allopurinol ___ mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
6. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
ih inh twice a day Disp #*1 Disk Refills:*0
8. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Metoprolol Succinate XL 37.5 mg PO DAILY
RX *metoprolol succinate 25 mg 1.5 tablet(s) by mouth daily Disp
#*45 Tablet Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Rolling walker
Diagnosis: Acute coronary syndrome 411.1
Prognosis: Good
Length of need: 13 months
13. Warfarin 5 mg PO 5X/WEEK (___)
14. Warfarin 2.5 mg PO 2X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Coronary Artery Disease
Secondary Diagnosis:
Antiphospholipid syndrome
COPD
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 ___
___. You presented to the hospital with chest pain
and were found to have a heart attack (NSTEMI). You had a
catherization (test to look at the blood vessels of your heart)
that showed several severe blockages. During the
hospitalization, you needed 2 different devices to help your
heart supply blood to those vessels. It was too high risk for
you to have surgery (coronary bypass) so you had a second
catheterization with 5 stents placed (to open the blood
vessels). We started you on aspirin and plavix to help keep the
stents from clotting. You should NOT stop these medications
unless your cardiologist tells you to.
While here, you had the hematologist see you who ordered some
labs tests to confirm the anti-phospholipid syndrome. You will
follow up with the hematologist as an outpatient.
Please follow up at the appointments below. Attached is your new
medication list.
~Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 40 mg PO QPM
2. Finasteride 5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute urinary retention secondary to prostate enlargement
SECONDARY DIAGNOSIS
===================
Post-obstructive acute kidney injury
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 had urinary retention that required a catheter insertion.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had a Foley catheter inserted and watched for recovery of
your kidney function due to the 2-day urinary obstruction.
- You were seen by the general medicine service along nephrology
service and the urology service for your condition.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Multivitamins 1 TAB PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium 500 + D (calcium carbonate-vitamin D3) 1 tab ORAL BID
4. beta carotene 1 tab ORAL QID
5. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 1X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Transient ischemic attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were hospitalized due to symptoms of speech difficulty
resulting from an TRANSIENT ISCHEMIC ATTACK, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
We are changing your medications as follows:
Aspirin 81 mg for stroke prevention
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Calcium Carbonate 500 mg PO QID:PRN indigestion
2. Colchicine 0.6 mg PO BID
take for 3 months
RX *colchicine 0.6 mg 1 capsule(s) by mouth twice a day Disp
#*90 Capsule Refills:*0
3. GuaiFENesin ER 600 mg PO Q12H
4. LOPERamide 2 mg PO QID:PRN diarrhea
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Torsemide 20 mg PO DAILY
RX *torsemide 10 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
7. Metoprolol Succinate XL 50 mg PO QHS
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth every night
Disp #*30 Tablet Refills:*2
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
9. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*2
10. Atorvastatin 20 mg PO QPM
11. DICYCLOMine 10 mg PO BID
12. esomeprazole magnesium 40 mg oral DAILY
13. fluticasone-salmeterol 500 mcg/100 mcg inh INHALATION BID
14. Metoprolol Succinate XL 150 mg PO DAILY
15. Montelukast 10 mg PO DAILY
16. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
New Onset Diastolic Heart Failure
SECONDARY
==========
Atrial ___ pneumonia
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 because you had new
onset heart failure.
It is very important to take all of your heart healthy
medications. This includes torsemide, to prevent your lungs from
becoming overloaded with fluid, colchicine, to control
inflammation of your heart lining, metoprolol, to control your
heart rate, and apixaban, to prevent blood clots.
At discharge, you weighed 143 lbs. Please weigh yourself every
day in the morning after you go to the bathroom and before you
get dressed. If your weight goes up by more than 3 lbs in 1 day
or more than 5 lbs in 3 days, please call your heart doctor or
your primary care doctor and alert them to this change.
We wish you the best with your health,
Your ___ Cardiac Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl ___AILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. Docusate Sodium 100 mg PO BID
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Metoprolol Tartrate 37.5 mg PO BID
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 17.2 mg PO QHS
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D ___ UNIT PO DAILY
18. darbepoetin alfa in polysorbat 25 mcg/mL injection every 8
weeks
19. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 0.08-1.80
gram-kcal/mL oral BID
20. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
21. CefTAZidime 1 g IV POST HD (___)
IF ON HD, administer dose on after patient returns from each
hemodialysis session.
22. CefTAZidime 2 g IV POST HD (SA)
IF ON HD, administer dose on after patient returns from each
hemodialysis session.
23. Clopidogrel 75 mg PO DAILY
24. Lisinopril 5 mg PO DAILY
25. Sodium Bicarbonate 1300 mg PO TID
26. ___ MD to order daily dose IV HD PROTOCOL
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Group G Strep bacteremia
Secondary:
Type 1 diabetes mellitus
Peripheral vascular disease s/p angioplasty of right and left
lower extremity
Coronary artery disease s/p CABG
End Stage Renal Disease 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 Mr. ___,
You were seen at ___ due to
fever and confusion. You were found to have bacteria in your
blood, and you were placed on antibiotics. The bacteria in your
blood most likely came from your dialysis catheter line, as
external lines always have a risk of infection. Yours appeared
red and infected, and it had to be removed. A new line was
placed for you to get dialysis. Your peritoneal dialysis
catheter was removed as you did not need that line anymore.
In addition, you were seen by our foot doctors ___ to the wounds
on your feet. They recommended to continue IV antibiotics for 6
weeks. You should not bear weight on your feet due to the
infections and skin damage on your heels.
You were seen by our kidney doctors and were continued on
dialysis.
Please take all medications as prescribed and please follow up
with the appointments we have arranged. It was a pleasure taking
care of you at ___.
Sincerely,
Your ___ care team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you at ___
___.
You were admitted with worsening heart failure. While you were
here, we gave you diuretics, which are medications to help you
urinate. First, we did this through your IV, and you improved.
We wanted to continue treating you with IV medications, but you
elected to leave against medical advice. We switched you to an
oral regimen prior to leaving. We wanted to take more fluid
weight off, but you wanted to leave against medical advice
despite knowing the risks of doing so.
At discharge, you weighed 140.3kg (309lb). It is very important
that you weigh yourself every morning before getting dressed and
after going to the bathroom. Call your doctors if your ___
goes up by more than 3 lbs in 1 day or more than 5 lbs in 3
days.
You were started on a new insulin, U-500. You will not need to
give yourself large doses of Humalog standing with each meal or
any insulin Glargine (Lantus). Please check your blood sugars 4
times per day while you are on this insulin. We have arranged
for you to see ___ doctor in the next 2 days.
We wish you all the best,
Your ___ Cardiology team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Calcium Carbonate 500 mg PO DAILY
2. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*1
3. Vitamin D 400 UNIT PO DAILY
4. Torsemide 100 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*1
5. amLODIPine 10 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Atovaquone Suspension 1500 mg PO DAILY
8. Buprenorphine-Naloxone (8mg-2mg) 0.25 TAB SL TID
9. LORazepam 0.5 mg PO BID
10. Ondansetron ODT 4 mg PO BID:PRN nausea
11. PredniSONE 80 mg PO DAILY
12. tadalafil 20 mg oral WEEKLY:PRN
13.Outpatient Lab Work
Please check chemistry panel (sodium, potassium, chloride,
bicarbonate, BUN, Creatinine) on ___
If at ___, Dr. ___ follow up results on OMR. If
outside lab, please fax results to ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Minimal change disease
Acute Renal Failure
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 worsening kidney function and
volume overload on your outpatient diuretic regimen.
What happened while I was in the hospital?
- You were given IV diuretics and high doses of steroids to
treat your minimal change disease. We monitored your urine
output, your kidney function and electrolytes. Your kidney
function improved over your hospital course.
What should I do after leaving the hospital?
- Please weigh yourself every morning after you urinate and call
Dr. ___ your weight increases by more than 3 lbs. Your
discharge weight is 226 lbs.
- Please also contact Dr. ___ you lose more than 5
pounds in a day as this may warrant a decrease in diuretic dose.
- You will need your ___ drawn by the end of this week, we are
giving you a prescription and Dr. ___ follow it up
- 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!
Your ___ Healthcare Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___. Cyclobenzaprine 10 mg PO TID:PRN neck pain
3. DiphenhydrAMINE 25 mg PO Q6H:PRN insomnia
4. Heparin 5000 UNIT SC TID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
6. Ibuprofen 800 mg PO Q8H:PRN Pain
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Docusate Sodium 100 mg PO BID
hold for diarrhea
9. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
grade 4 splenic laceration
grade 1 liver laceration
Left kidney laceration
Left adrenal hemorrhage
Left rib fracture ___, w/ pulmonary contusion
small Left pneumothorax
right trapezius muscle 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>You were admitted to the hospital after sustaining multiple
injuries from a motor vehicle accident. You injured your spleen,
liver, kidney, lung, neck muscles, and fractured several ribs on
the left side. You have done well and you are ready to go to a
rehab to continue your recovery. Please note the following
discharge instructions:
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Rib Fractures:
* Your injury caused 4 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).</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 EC 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Carbonate ___ mg PO BID
6. Darunavir 800 mg PO DAILY
7. Enalapril Maleate 2.5 mg PO DAILY
8. Lorazepam 1 mg PO DAILY:PRN anxiety, insomnia
9. RiTONAvir 200 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. sitaGLIPtin 100 mg oral daily
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus Suspension 0.375 mg PO 1X/WEEK (TH)
14. Ciclodan (ciclopirox) 8 % topical daily
15. econazole 1 % topical BID
16. Epzicom (abacavir-lamivudine) 600-300 mg oral daily
17. Sildenafil 50 mg PO PRN intercourse
18. Testosterone Cypionate 200 mg IM Q2 WEEKS
19. Fish Oil (Omega 3) 1000 mg PO DAILY
20. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
21. Outpatient Lab Work
Please draw INR on ___ and fax to Dr. ___:
___ Fax: ___. ICD-9 Code: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: DVT
Secondary: HIV on ART
Secondary: LURT
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 participating in your care at ___. You were
admitted after you developed some left lower extremity pain and
swelling. Ultrasound showed a blood clot in your vein called a
deep vein thrombosis. Because of your kidney function, you were
admitted for initiation of anticoagulation therapy with Heparin
and Coumadin. After your Coumadin levels were therapeutic, the
Heparin was discontinued. You will need to be on the Coumadin
for several months after discharge. Dr. ___ will follow the
levels of your Coumadin and adjust the dosing as needed. Please
follow up with the appointments listed below. We wish you the
best.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 15 mL PO DAILY:PRN constipation
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*20 Tablet Refills:*0
7. Furosemide 40 mg PO BID
hold for sbp<90
RX *furosemide 40 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*2
8. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K >5
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Critical Aortic stenosis
Acute systolic heart failure
S/p fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of ___ here at ___.
___ were admitted to the hospital with too much fluid in your
lungs due to an acute change in your heart failure likely
because of your tight heart valve. ___ were given extra fluid
pills and given it IV as well and had improvement in your
breathing and ___ are now ready for discharge. ___ were seen by
physical therapy after your fall and they felt that ___ were
stable to go home with physical therapy. We found that ___ had a
UTI and are treating ___ with antibiotics for 10 days.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q6H
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. FLUoxetine 20 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
7. Gabapentin 300 mg PO TID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Ibrance (palbociclib) 100 mg oral DAILY
10. LORazepam 1 mg PO TID
11. Nystatin Oral Suspension 5 mL PO QID:PRN Thrush
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
We are giving you a limited supply of 20 more tabs.
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H PRN Disp #*20 Tablet
Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO QHS:PRN constipation
15. Simvastatin 20 mg PO QPM
16. Tiotropium Bromide 2 puffs IH DAILY
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
R leg pain
Anxiety
COPD
Secondary Diagnoses:
====================
Osteoarthritis
Hyperlipidemia
Congestive heart failure
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 initially came in because of R leg pain along your femur,
headache, and cough. Your headache and cough spontaneously
resolved, and all infectious studies, including viral ones, were
completely normal.
For your R leg pain, we did a series of X rays that did not
demonstrate fracture or cancer involvement of your leg. We had
initially planned on getting an MRI, however, your pain had
resolved and you were able to walk around with a cane without
any difficulty. Therefore, we thought that you were sufficiently
well to go home.
For pain control, we recommend scheduled Tylenol (maximum is
total of 4 grams daily), and we will also give you a script for
oxycodone. If your pain worsens or you are unable to bear
weight, please let your oncology doctor know!
Thank you for giving us the opportunity to participate in your
care.
Please take care; 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. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
4. RABEprazole 20 mg oral daily
5. Tiotropium Bromide 1 CAP IH DAILY
6. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
7. Aspirin 325 mg PO DAILY
8. Citalopram 10 mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Pravastatin 20 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute left medial pontine ischemic stroke
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 gait instability and an
episode of difficulty finding the right words to say, resulting
from an ACUTE ISCHEMIC STROKE, a condition in which a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Left vertebral artery stenosis
Peripheral vascular disease
Smoking history
We are changing your medications as follows:
Start pravastatin, aspirin, fish oil, multivitamin and celexa.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO 5X/DAY
2. Enoxaparin Sodium 40 mg SC QHS
3. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
4. atenolol
5. sorbitol
6. lorazepam
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric femur fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated on the right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
___, WBAT RLE
Treatments Frequency:
Please follow up in 2wk for postop visit and wound check
Staples will be removed at that time</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
Thank you for choosing ___ as your site of care!
Why was I admitted to the hospital?
-You were admitted to the hospital because you were having
trouble breathing at home.
What was done for me while I was in the hospital?
-An image of your lungs showed lots of fluid on your lungs
making it hard for you to breathe.
-We were also concerned that you might have an infection in your
lungs.
-We gave you medication through an IV initially to help you
urinate out the extra fluid.
-We completed an image of your heart called an echocardiogram
which demonstrated your heart does not pump blood forward well.
-You also had a procedure called a coronary angiogram to look at
the vessels of your heart. We did not see any blocked vessels.
What should I do when I leave the hospital?
-You should follow up with your doctors as listed below.
-Our cardiology office will contact you with an appointment. If
you do not hear from our office within 2 days of discharge
please call ___.
-Please limit your fluid to 2L per day.
-Please weigh yourself daily. If you notice you gain more than
3lbs please contact your doctor.
-___ weight at time of discharge is 137lb.
It was a pleasure taking care of you!
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 - Mild/Fever
2. amLODIPine 10 mg PO DAILY
3. Furosemide 20 mg PO BID
4. Trelegy Ellipta (fluticasone-umeclidin-vilanter) 100-62.5-25
mcg inhalation DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Minimally displaced sternal fracture
Complete atrioventricular block
HFpEF
Hypertension
COPD
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 transferred for evaluation after your car accident.
You had a CT scan which showed a very small fracture to your
sternum. You were seen by the trauma team and they recommend
treating pain with Tylenol. Consider taking this 'around the
clock' in the first few days after your injury to keep the pain
under control so that you can take full deep breaths. Continue
to use the incentive spirometer 10 x's an hour while you are
awake and sitting up in a chair and walking frequently to
prevent pneumonia.
You were also found to have complete heart block, which is a
slow and abnormal/ineffective heart rhythm. A permanent
pacemaker was placed to help the heart beat more effectively.
Activity restrictions and information regarding care of the
procedure site on your chest are included in your discharge
instructions.
An appointment was made for you to return in 1 week to the
device clinic to check the wound.
If you have any urgent questions that are related to your
recovery from your procedure or are experiencing any symptoms
that are concerning to you and you think you may need to return
to the hospital, you may call the ___ Heart Line at
___ to speak to a cardiologist or cardiac nurse
practitioner.
It has been a pleasure to have participated in your care and we
wish you the best with your health.
Your ___ Cardiac Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Citalopram 30 mg PO QAM
2. BuPROPion (Sustained Release) 100 mg PO QAM
Discharge Disposition:
Home
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>Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cyanocobalamin 50 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO BID
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Heparin IV per Weight-Based Dosing Guidelines
Initial Bolus: 3900 units IVP
Initial Infusion Rate: 850 units/hr
Start: Today - ___, First Dose: 1600
Target PTT: 60 - 100 seconds
7. Nephrocaps 1 CAP PO DAILY
8. Warfarin 5 mg PO DAILY16
first dose ___
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Sarna Lotion 1 Appl TP PRN itching
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: acute oliguric renal failure, deep vein thrombosis,
anemia, thrombocytopenia, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were hospitalized with low blood pressure
and low blood counts. You were treated with blood transfusions,
kidney replacement therapy, and antibiotics. You were found to
have a blood clot in your leg and are being treated with blood
thinning medications. Your platelets were low but these
recovered. Your kidney function has not recovered prior to
leaving the hospital and you will be discharged with a
hemodialysis line. You were evaluated for GI bleeds, and these
studies were reassuring. If you continue to bleed, you may
benefit from a capsule study as an outpatient.
Best wishes,
Your ___ Care 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. Calcitriol 0.25 mcg PO DAILY
3. Cinacalcet 60 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ezetimibe 10 mg PO DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 5 mg PO DAILY
10. Ropinirole 1 mg PO QPM
11. Rosuvastatin Calcium 40 mg PO DAILY
12. sevelamer CARBONATE 2400 mg PO TID W/MEALS
13. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
14. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
15. Nephrocaps 1 CAP PO DAILY
16. darbepoetin alfa in polysorbat *NF* 40 mcg/0.4 mL Injection
every other week
17. Lactulose 30 mL PO DAILY
18. Lanthanum 1000 mg PO TID W/MEALS
19. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
20. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*1
21. Metoprolol Tartrate 12.5 mg PO TID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*1
22. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Expectorant Cough Syrup] 100 mg/5 mL 5 ml by
mouth every six (6) hours Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Incisional pain, palpitations
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics.
Wounds CDI
ext: lower extremity edema +1
Followup Instructions:
___ [/INST] </s><s>Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CeFAZolin 2 g IV POST HD (___)
Dose 1g for 24 hrs between HD sessions, 2g for 48 hrs, 3g for 72
hrs. End date ___.
2. CeFAZolin 3 g IV POST HD (SA)
Dose 1g for 24 hrs between HD sessions, 2g for 48 hrs, 3g for 72
hrs. End date ___.
3. CeFAZolin 1 g IV POST HD (FR)
Dose 1g for 24 hrs between HD sessions, 2g for 48 hrs, 3g for 72
hrs. End date ___.
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Dialyvite 800 (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
6. Docusate Sodium 100 mg PO BID
7. paricalcitol 1 mcg oral DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Senna 8.6 mg PO DAILY
10. sevelamer CARBONATE 1600 mg PO TID W/MEALS
11. HELD- Pindolol 5 mg PO ASDIR heart rate above 110 This
medication was held. Do not restart Pindolol until you follow-up
with your PCP or ___.
12. HELD- Torsemide 10 mg PO DAILY:PRN SBP > 140 This
medication was held. Do not restart Torsemide until you
follow-up with your PCP or ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Bacteremia
Large volume ascites
Secondary
Polycystic kidney and liver disease
ESRD on HD
HTN
HLD
Diarrhea
Cdiff colonization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a blood stream infection and workup for
the fluid build up in your abdomen.
What was done for me while I was in the hospital?
-We treated you with antibiotics and removed your dialysis line.
-We then placed a new dialysis line after a few days of healing.
-You continued to receive dialysis in the hospital.
-We found that many liver cysts are compressing the blood
vessels in your liver causing fluid buildup in your abdomen.
-You are being evaluated for liver and kidney transplant and
should continue to follow-up with the transplant team as an
outpatient.
What should I do when I leave the hospital?
-Please follow-up with the transplant team to treat your liver
and kidney disease.
-Please continue to take all of your medications as prescribed
and keep all of your appointments.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Glargine 14 Units Bedtime
Humalog 14 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Lisinopril 2.5 mg PO DAILY
3. Torsemide 10 mg PO DAILY
4. Amiodarone 200 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation with RVR
Troponinemia
Heart Failure with Reduced Ejection Fraction
Acute Kidney Injury
Venous stasis
Hypothyroidism
Type II Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of ___ at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
Your heart rhythm was very fast and irregular (atrial
fibrillation) and ___ were in acute heart failure with excess
fluid in your body. Your kidney function was also impaired.
WHAT HAPPENED IN THE HOSPITAL?
==============================
Your home heart mediations were restarted and adjusted slightly.
___ had imaging of your heart (echocardiogram) and ___ were
given medications (Lasix) to remove excess fluid from your body.
WHAT SHOULD I DO WHEN I GO HOME?
================================
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. ___ should continue to take all of your medications
as directed by your doctors. ___ should follow up with your
primary care doctor and your cardiologist.
Thank ___ for allowing us to be involved in your care, we wish
___ all the best!
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation Q4H:PRN shortness of breath or wheezing
RX *DuoNeb 0.5 mg-3 mg (2.5 mg base)/3 mL 1 nebulizer IH every
four (4) hours Disp #*60 Vial Refills:*0
2. fluticasone *NF* 220 mcg/actuation Inhalation BID
6 puffs twice a day
RX *Flovent HFA 220 mcg 6 puffs IH twice a day Disp #*1 Inhaler
Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Montelukast Sodium 10 mg PO DAILY
RX *Singulair 10 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Loratadine *NF* 10 mg Oral Daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
RX *Serevent Diskus 50 mcg 1 discus IH every twelve (12) hours
Disp #*1 Inhaler Refills:*0
7. Omeprazole 20 mg PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
RX *Spiriva with HandiHaler 18 mcg 1 cap IH daily Disp #*1
Inhaler Refills:*0
9. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H:PRN shortness of breath or wheezing
RX *albuterol sulfate 90 mcg 2 puffs IH every four (4) hours
Disp #*1 Inhaler Refills:*0
10. Nicotine Lozenge 4 mg PO Q1H:PRN craving
RX *nicotine (polacrilex) 4 mg 1 lozenge by mouth every hour
Disp #*120 Lozenge Refills:*0
11. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*91
Tablet Refills:*0
RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*100
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Asthma/COPD exacerbation
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 difficulty breathing.
This was likely due to an exacerbation of your asthma. You may
also have COPD, another chronic lung disease. It is important
you take all of your breathing medications every day. You should
stop smoking to avoid having more of these episodes.
.
Some of your medications were changed during this admission:
START prednisone taper, take 60mg daily for one week, then 40mg
daily for one week, then 20mg daily for one week, then 10mg
daily for one week.
.
You should continue to take all of your other medications as
prescribed.</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 once a day.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
3. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice
a day as needed for constipation.
6. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
every six (6) hours as needed for constipation.
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for pain.
11. acyclovir 400 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
12. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop
Ophthalmic once a day.
13. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: ___
drops Ophthalmic PRN as needed for dry eyes.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
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 abdominal pain after having your CT scan
as an outpatient. You were given IV fluids for hydration and
placed on bowel rest. Your CT scan showed some stool in your
colon. Be sure to take over-the-counter stool softners/gentle
laxatives if needed while taking narcotic pain medication as
narcotics can cause constipation. Examples of these medications
include colace, dulcolax, senna, milk of magnesia.
Do not drink alcohol or drive/operate heavy machinery while
taking narcotics as it may cause sedation and impair your
reflexes.
You may resume all other medications you were taking prior to
coming to the hospital.
Please follow up at the appointment scheduled below in ___
clinic. If you have any problems before then feel free to call
the clinic.
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.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Gabapentin 300 mg PO DAILY
2. Minocycline 100 mg PO Q12H
3. Omeprazole 20 mg PO DAILY
4. Warfarin 2 mg PO QHS
5. Acetaminophen ___ mg PO Q6H:PRN pain
6. Linezolid ___ mg PO Q12H
7. AmLactin (ammonium lactate;<br>ammonium,pot.and sodium
lactat) 12 % topical BID
RX *ammonium,pot.and sodium lactat [AmLactin] twice a day
Refills:*0
8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
Please apply to left legon red/scaly rash x14 days on, 14 days
off; never use on face/groin/axillae
RX *triamcinolone acetonide 0.1 % twice a day Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4 Disp #*40 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Stasis Dermatitis
Lymphedema
Melanoma
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 rash thought to be due to swelling in
your legs resulting in a condition called stasis dermatitis
which is treated with steroid creams and relief of leg swelling.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 325 mg PO DAILY
2. Donepezil 5 mg PO HS
3. Furosemide 40 mg PO DAILY
4. GlipiZIDE XL 10 mg PO DAILY
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Succinate XL 300 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID:PRN constipation
14. Spironolactone 25 mg PO DAILY
15. ___ MD to order daily dose PO DAILY16
16. Warfarin 5 mg PO ONCE Duration: 1 Dose
17. Zytiga (abiraterone) 1000 mg oral daily
18. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
19. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*28 Capsule Refills:*0
20. Acetaminophen 650 mg PO Q6H:PRN pain
21. Leuprolide Acetate 7.5 mg IM Q12 WEEKS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Wound infection
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
a urinary tract infection and a wound infection along the
incision of your previous fem to DP bypass site. You were
started on IV antibiotics for this. Your urine and wound
cultures grew bacteria that require continued antibiotics.
- you should continue your prescribed antibiotics (ciprofloxicin
and doxycycline) for 14 days.
- Please keep your wound dry until it is healed. You may sponge
bathe, but keep your leg dry.
- Your wound dressings should consist of adaptic over the wound
itself, dry Kerlix gauze, and an ACE wrap. This should be
changed daily and should be kept clean. Please ensure that ACE
wrap is on at all times.
- Keep your leg elevated at all times while sitting or laying ___
bed
- ___ the event of large bleeding from your leg wound, apply
pressure and return to the emergency department immediately
- Resume all of your home medications unless advised otherwise.
- Do not drive or drink alcohol if taking narcotic pain
medication.
- Please go to your scheduled follow up appointment with your
surgeon.
-Call your surgeon if you have any questions.
-Call your surgeon or go to the nearest emergency room if you
have fevers > ___ F, if your wound appears red, hot, painful or
swollen, if your wound opens, or for anything else that is
troubling you.
While ___ the hospital, you were seen by urology for blood ___
your urine. They recommend:
- Please remember or have someone remind you to urinate every
three hours while awake to prevent another urinary tract
infection.
- The urology service would like you to follow up with them as
an outpatient. They recommend that you get an endorectal coil
MRI and cystocopy. This can be scheduled at your office visit
with them.
You were also found to have a trace amount of blood ___ your
stool. Please call ___ to make an appointment with
the GI specialists.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO BID
2. Acyclovir 400 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. Cyclobenzaprine 5 mg PO TID:PRN pain
7. Diclofenac Sodium ___ 75 mg PO TWICE WEEKLY
8. Docusate Sodium 100 mg PO DAILY:PRN constipation
9. estradiol 1 g vaginal TWICE A WEEK
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Furosemide 20 mg PO DAILY
12. Lenalidomide 10 mg po DAILY
13. Levothyroxine Sodium 137 mcg PO DAILY
14. Loratadine 10 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Polyethylene Glycol 34 g PO DAILY
17. ___ 1 drop both eyes bid
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
19. Vitamin D 1000 UNIT PO DAILY
20. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until you see Dr. ___
21. HELD- Losartan Potassium 100 mg PO DAILY This medication
was held. Do not restart Losartan Potassium until you see Dr.
___
___ Disposition:
Home
Discharge Diagnosis:
Neurologic symptoms of numbness and subjective weakness likely
triggered by anxiety
Multiple myeloma on Revlimid
HTN
CAD
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital for evaluation of episodes of
blurred vision, facial weakness, and dysarthria (trouble
speaking clearly). You were evaluated by the neurologist and had
head imaging that did not reveal any concerns for stroke or
seizure activity.
Your blood pressure was in the lower range of normal on your
home medications, so they have been stopped for now until you
see Dr. ___. Please continue to take your blood pressure
every morning and record it for your next appointment. Blood
pressure in the 130s/80s is ok, but please call Dr. ___
___ if it is rising.
Your thyroid level was checked and was low, and this should be
rechecked in ___.
It is possible that your symptoms may be triggered by anxiety or
stress, as we discussed.
Please do not take your Revlimid until you see Dr. ___. Please
keep your appointments as listed below.
Best wishes,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 150 mg 2 capsule(s) by mouth every 6 hours
Disp #*96 Capsule Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
3. Mesalamine ___ 800 mg PO TID
RX *mesalamine [Delzicol] 400 mg 2 capsule(s) by mouth three
times a day Disp #*180 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN severe pain
please taper this medication down daily with the goal to taper
off. Take only as directed
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
if needed for constipation while taking pain medication. Can
purchase over the counter
6. Acetaminophen ___ mg PO Q6H:PRN pain
take first. Max daily dose 4grms. Take as directed. You may
purchase over the counter
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Myositis
Crohns disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms ___,
You were admitted for cellulitis of the hand and infection in
the underlying muscle. To treat this, we started IV
antibiotics which you continued for 7 days. We then started you
on oral antibiotics (clindamycin), which you should continue for
an additional 2 weeks (see prescriptions). It is very
important that you follow up with a hand surgeon within 1 week
of discharge. Please see the number below to arrange for follow
up should you be staying in the ___ area. Also, you had some
nausea and vomiting during admission. Your xray was unrevealing.
However, it will be very important that you establish care with
and arrange for gastroenterology follow up to ensure appropriate
care for your Crohn's disease. Please see the number to the ___
clinic below if you will remain in the ___ area for some
time. These follow up appointments are very important.
You were given a small supply of pain medication to take upon
discharge. The goal is to taper this medication down daily to
stop taking this medication. Please take only as directed.
Please try Tylenol first as directed and take this with the pain
medication. Do not drive when taking this medication. Take with
a stool softener that you can purchase over the counter if
needed for constipation. This medication can become addicted so
be sure only to take sparingly and as needed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atenolol 50 mg PO DAILY
2. Desipramine 25 mg PO QHS
3. LOPERamide ___ mg PO QID:PRN diarrhea
4. Ranitidine 300 mg PO BID
5. Vitamin B Complex 1 CAP PO DAILY
6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
7. Cetirizine 10 mg PO DAILY:PRN Allergy symptoms
8. Glucosamine-Chondroitin Max St (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral DAILY
9. Slow-Mag (magnesium chloride) 71.5 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Acute pancreatitis.
Secondary diagnosis: functional diarrhea.
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 because of vomitting and abdominal pain. You
initial lab tests show that you blood markers of injury to the
pancrease was elevated. In the emergency department you had
imaging studies done which where normal. On the same day we did
a special imaging test (MRCP) that looks at your liver and bile
drainage system. We kept you overnight to monitor to give you
fluids and make sure that your vomitting is improved and that
you can eat solid food and not vomit it. You tolerated food very
well and your diarrhea improved as well.
Again it was a pleasure taking care of you.
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. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
2. Albuterol Sulfate (Extended Release) 4 mg PO Q4H:PRN
wheezing, dyspnea
3. Cetirizine 10 mg PO QD:PRN allergies
4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Topiramate (Topamax) 50 mg PO BID:PRN headache
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma Exacerbation
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 in the hospital because of shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
In the hospital you were examined and determined to have an
asthma exacerbation. You were treated with medications
(prednisone, nebulizers) with improvement in your symptoms.
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.
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. Acyclovir 400 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
5. Lotemax (loteprednol etabonate) 0.5 % ophthalmic PUT ONE DROP
IN LEFT EYE ONLY EVERY NIGHT
6. Rosuvastatin Calcium 40 mg PO QPM
7. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
8. alfuzosin 10 mg oral DAILY
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Doc-Q-Lace] 100 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
10. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
11. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
12. Travatan Z (travoprost) 0.004 % ophthalmic PUT 1 DROP INTO
RIGHT EYE EVERY EVENING
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ mg by mouth every four (4) hours Disp
#*60 Tablet Refills:*0
14. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [___] 8.6 mg 1 tablet by mouth twice a day
Disp #*60 Tablet Refills:*0
15. Lactulose 30 mL PO BID:PRN constipation
RX *lactulose 10 gram/15 mL 30 ml by mouth twice a day Disp
#*600 Milliliter Refills:*0
16. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 capful by
mouth daily Refills:*0
17. Morphine SR (MS ___ 45 mg PO Q12H
RX *morphine 15 mg 3 tablet(s) by mouth every twelve (12) hours
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Compression fractures of L1-L3
#Multiple myeloma
#hyperglycemia
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 were admitted to the hospital after you experienced severe
back pain and were found to have new fractures in your vertebrae
(spinal bones). You were seen by our orthopedic surgeons, who
put you in a "TLSO" brace to help your spine heal. We increased
your oral pain medications to help control your pain, and will
have you follow up with the orthopedic doctors ___ month after
discharge. You will need to wear this brace for at least 6
weeks.
***Please call ___ to schedule an appointment with Dr.
___ or Dr. ___ orthopedics in one month from
discharge.
Because you were due for your chemotherapy, we gave you your
second cycle while you were hospitalized. After your discharge,
you will need to follow up with your oncologist as listed below.
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. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every 12 hours Disp
#*30 Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 2 by mouth daily Refills:*0
3. Potassium Chloride 40 mEq PO BID
RX *potassium chloride 10 mEq 4 capsule(s) by mouth daily Disp
#*120 Capsule Refills:*0
4. Torsemide 80 mg PO BID
RX *torsemide [Demadex] 20 mg 4 tablet(s) by mouth twice a day
Disp #*120 Tablet Refills:*0
5. ALPRAZolam 0.5 mg PO QHS:PRN anxiety
6. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
8. Levothyroxine Sodium 125 mcg PO DAILY
9. pomalidomide 3 mg oral DAILY
10. Pravastatin 40 mg PO QPM
11. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
acute on chronic heart failure exacerbation
SECONDARY DIAGNOSES
pulmonary hypertension
deep venous thrombosis
atrial fibrillation s/p pacemaker placement
multiple myeloma
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
___ were admitted for your heart failure and ___ underwent
aggressive diuresis and urinated well to the medicine we gave
___ were first on intravenous diuretics and then
transitioned to an oral pill. ___ are to continue the oral
torsemide 80mg twice a day. Also supplement with potassium 40 mg
daily. Please weigh yourself daily to check your volume status.
We also switched ___ to a long-acting diltiazem for your
abnormal heart rhythm, ___ will take 180mg daily.
For your pulmonary hypertension, we discussed the possibility of
a right heart catheter but ___ declined this option inpatient.
For your myeloma, we have been continuing ___ on atovaquone and
acyclovir, two medicines to prevent infection. We have been
holding the pomalidomide while ___ were hospitalized. ___ will
continue outpatient with the oncology team to discuss restarting
this medicine.
If your weight increases > 3lbs in the next few days, please
return for evaluation. ___ will follow up with oncology and
cardiology (nurse practitioner) both next week.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic BID (2 times a day).
5. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for con stipation.
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
12. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO
once a day.
13. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: ___
Tablet, Delayed Release (E.C.)s PO at bedtime as needed for
constipation.
14. Lupron Depot (4 Month) 30 mg Syringe Kit Intramuscular
15. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Last day ___. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Urinary Tract Infection
Chronic hematuria
Hypernatremia
Acute kidney injury
Secondary Diagnosis:
Prostate Cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
Thank you for coming to the ___
___. You were admitted to the hospital because you had a
urinary tract infection. We treated you with broad spectrum IV
antibiotics at first and then switched to oral medcations when
the urine culture returned. You also had some bleeding in your
urine so we gave you a blood transfusion. You were also a little
dehydrated so we gave you IV fluids. We stopped the
levetiracetam (keppra) because you no longer need this
medication. We did not make any other changes to your
medications.
Medication Recommendations:
Please START cefpodoxime 100 mg daily for 3 more days
Please STOP levetiracetam</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
___.
9. Glucosamine 750 mg Tablet Sig: Two (2) Tablet PO daily ().
10. potassium chloride 20 mEq Packet Sig: One (1) PO once a
day: Please get your potassium levels checked regularly on this
medication.
Disp:*30 packets* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Altered Mental Status
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
NEURO EXAM: mild memory dysfunction, L big toe extensor
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were seen in the hospital because you had an episode of
confusion. We did a CTA that showed no evidence of stroke. We
did an EEG which showed no evidence of seizure. Therefore, we
are not sure what caused your transient confusion.
We made the following changes to your medications:
1) We STOPPED your ATORVASTATIN. You were already on
Lovastatin, and you only need one of these types of medications.
2) We STARTED you on POTASSIUM REPLETION 20mEQ once a day (which
your son reported you had been on previously). You will need to
call your PCP on ___ to have your labs checked to ensure that
your potassium does not get too high.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Allopurinol ___ mg PO DAILY
2. Metoprolol Tartrate 37.5 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Aspirin EC 81 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*6
8. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour apply 1 patch daily Disp #*1 Box
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Transient Ischemic attack
2. Severe atherosclerosis with ~ 70% stenosis of the right
internal carotid artery.
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 here at the ___
___. You were admitted on ___ after
experiencing two minutes of difficulty speaking in route to
getting your back steroid injections. Imaging revealed that air
had entered a part of your brain, which we think was related to
the steroid injections. Given that your speech difficulties
preceeded the injections, we are not concerned about the air,
which should be reabsorbed over time naturally.
Imaging also revealed significant fat deposits along your blood
vessels, which may have contributed to your symptoms. We are
switching your cholesterol medication from simvastatin 40 mg to
atorvastatin 80 mg.
For the next 3 months, take BOTH aspirin and plavix to prevent
stroke. After 3 months, STOP taking the aspirin and CONTINUE the
plavix, which you should continue for the rest of your life
unless otherwise directed by your doctor. The motivation behind
this change is that your symptoms developed despite being on
aspirin, so we want to switch to a different agent. It is very
important that you take these medications as directed.
You are also scheduled for a follow-up appointment with Dr.
___ it is very important that you make this appointment.
Please take all medications as prescribed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Apixaban 10 mg PO BID Duration: 7 Days
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*0
3. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
4. Donepezil 5 mg PO DAILY
5. LORazepam 0.25 mg PO QHS:PRN sleep
6. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
___ DVT
Meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
-You came to the hospital for further evaluation after an
ultrasound revealed a blood clot in your left leg.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on a blood thinner through the IV,
transitioned to a pill afterwards called Apixaban (Eliquis). It
is VERY important that you take this medication everyday as
prescribed.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- If you notice any of the danger signs listed below, please
call your PCP or go to an emergency room immediately
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. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every ___ hours as needed for pain for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute, uncomplicated appendicitis
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 ___ surgery service for acute
appendicitis.
A laparascopic appendectomy was performed and you tolerated the
procedure well. You were discharege to home with plans to
follow up in Dr. ___ in 2 weeks.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
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.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*You may take the gauze off your incision in 48 hours.
Steri-strips will remain on your incision and will fall off on
their own or 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. Lidocaine 5% Patch 2 PTCH TD QAM
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
4. Ascorbic Acid ___ mg PO DAILY
5. Atovaquone Suspension 1500 mg PO DAILY
6. Azithromycin 250 mg PO Q24H
7. calcium carb-mag oxide-zinc ox 334-134-5 mg oral DAILY
8. CARVedilol 6.25 mg PO BID
9. Cyanocobalamin 25 mcg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. GuaiFENesin ER 600 mg PO DAILY
13. Lisinopril 2.5 mg PO DAILY
14. Omeprazole 40 mg PO DAILY
15. PredniSONE 30 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. ValACYclovir 500 mg PO Q24H
18. Vitamin D 1000 UNIT PO DAILY
19. Vitamin E 400 UNIT PO DAILY
20. HELD- lactobacill.acidophilus (bulk) 1 billion unit/gram PO
DAILY This medication was held. Do not restart
lactobacill.acidophilus (bulk) until you speak to your primary
care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
- Colitis, likely infectious
SECONDARY DIAGNOSES:
====================
- Chronic Obstructive Pulmonary Disease
- Asthma
- Heart failure with reduced ejection fraction
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you had abdominal pain and bright
red bloody diarrhea.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had imaging that showed inflammation in your colon.
- Your abdominal pain and appetite improved with symptomatic
treatment.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Continue to take all your medicines and keep your
appointments.
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. Azithromycin 250 mg PO DAILY To end ___
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*1
Tablet Refills:*0
2. PredniSONE 60 mg PO DAILY To end ___
This is dose # 1 of 3 tapered doses
3. PredniSONE 40 mg PO DAILY Duration: 4 Doses from ___
This is dose # 2 of 3 tapered doses
4. PredniSONE 20 mg PO DAILY Duration: 4 Doses from ___
This is dose # 3 of 3 tapered doses
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN COPD
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
7. Allopurinol ___ mg PO DAILY gout
8. Aspirin 81 mg PO DAILY
9. CARVedilol 12.5 mg PO BID
10. Gabapentin 200 mg PO BID
11. GuaiFENesin ___ mL PO Q6H
12. HydrALAZINE 50 mg PO Q8H
13. Multivitamins 1 TAB PO DAILY
14. Rosuvastatin Calcium 20 mg PO QPM
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
16. Tiotropium Bromide 1 CAP IH DAILY
17. Torsemide 60 mg PO BID
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypercarbic respiratory failure
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you at ___.
What happened to you during your hospitalization?
- You were admitted because of worsening shortness of breath and
for a COPD exacerbation
- Because of your worsening oxygenation, you required a
breathing tube with a ventilator
- You were given steroids, antibiotics, and nebulizer breathing
treatments to treat your COPD
What should you do when you leave the hospital?
- Continue to take all of your medications as prescribed
- Follow-up with your PCP ___ 1 week
- Please keep all of your other scheduled health care
appointments as listed below
- We discussed ongoing methadone usage. You mentioned you were
going to stop using the methadone, which is very important as
ongoing use can cause problems with your heart. It can lead to
heart rhythm abnormalities and, in the worst case, sudden death.
We highly recommend that you stop the methadone. However, we
also understand that sometimes it can be difficult to stop
methadone, especially since you can have withdrawal symptoms.
While we still recommend stopping methadone, if you do choose to
take methadone, please consider taking less methadone than
normal and slowly try to taper down (for example, cut down by
10mg every ___ days) and make sure you are around others when
taking to avoid sedating effects.
- It is important for you to not smoke and to also avoid
secondhand exposure to smoking. We have spoken with your
daughter about not having smoke in your home. It is important to
do so, as we do not want your lungs to get worse and have you
end up back in the hospital.
Sincerely,
Your ___ Care Team</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 1 capsule(s) by mouth every six (6) hours
Disp #*10 Capsule Refills:*0
2. ClonazePAM 1 mg PO BID
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Montelukast 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. Zolpidem Tartrate 10 mg PO HS
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*10 Capsule Refills:*0
9. Docusate Sodium 100 mg PO BID
please do not take if you have loose stools.
RX *docusate sodium [Colace] 50 mg 1 capsule(s) by mouth twice a
day Disp #*10 Capsule Refills:*0
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q4H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chronic Abdominal Pain
Secondary Diagnosis:
asthma
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
abdominal pain related to your chronic colitis. In the hospital
we treated you with pain medication and the antibiotics that you
were prescribed in the emergency room. At discharge your
abdominal pain had resolved and you were no longer nauseous.
In addition it is very important that you attend you
gastroenterology appointment with Dr. ___ on ___ at 1:30
___. We are discharging you with some pain medication you can
take as needed for your abdominal pain and some medication for
constipation.
Wishing you a complete recovery. It was a pleasure getting to
know 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. ClonazePAM 0.5 mg PO BID:PRN anxiety
2. Gabapentin 800 mg PO TID
3. Naproxen 500 mg PO Q12H:PRN migraine
Please take when a migraine starts.
RX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
4. Sumatriptan Succinate 50 mg PO BID:PRN migraine
RX *sumatriptan succinate 50 mg 1 tablet(s) by mouth twice daily
Disp #*8 Tablet Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*12 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Migraines
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 ___
___. You were admitted for headaches. We did a CT scan on
your head which did not show any abnormality. We gave you
medications for pain and nausea which seemed to help you feel
better. You should follow up with your PCP ___ 1 week to
reevaluate your migraines. Please ask if it would be appropriate
to start a medication that would be preventitive for migraines.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Warfarin 2.5 mg PO 5X/WEEK (___)
8. Warfarin 5 mg PO 2X/WEEK (___)
9. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice daily Disp #*120
Tablet Refills:*0
10. PredniSONE 60 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 5 mg as directed tablet(s) by mouth daily Disp
#*216 Tablet Refills:*0
11. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Melanoma with enteritis seconday to ipilimumab
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 participating in your care at ___
___.
You were admitted with abdominal pain that was caused by a
reaction to your chemotherapy. You improved with steroids and it
is important that you continue taking the steroid as directed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. deferasirox 750 mg oral DAILY
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*14
Capsule Refills:*0
3. FoLIC Acid 5 mg PO DAILY
RX *folic acid 1 mg 5 tablet(s) by mouth once a day Disp #*70
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- Beta-thalassemia intermedia
- Acute Anemia due to viral infection
- Nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms ___,
It was a pleasure taking care of you. You were admitted with
low blood counts. You were seen by hematology experts, who
thought your blood counts were low because of a recent viral
infection. They recommended increasing your folic acid to 5mg
daily. You were treated with a blood transfusion, and your
blood counts improved.
It will be important for you to see your hematologist Dr.
___. His office will be in touch within ___ days regarding
setting up a follow-up visit. If you do not hear from them,
please call
___.
You were also found to have kidney stone and were started on a
new medication ("Flomax"). Please schedule an appointment with
a urologist within ___ weeks by calling ___.
Please see your primary care doctor within the next 2 weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
Restart ___. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H
Last day ___.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
Disp #*8 Tablet Refills:*0
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Choledocholithiasis, rapid atrial
fibrillation
Secondary diagnosis: hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
sent to the ER because of rapid heart rates from your atrial
fibrillation. You have also recently had a bout of abdominal
pain and Left shoulder pain. EKGs and blood tests were done and
there was ___ evidence of a heart attack. Your heart rates
improved. You had a CAT scan which showed a abnormality in the
tube that drains the liver (called the common bile duct) that
was concerning for a gallstone in the tube. Thus, the GI doctors
took ___ for a procedure called an ERCP. This showed a gallstone
in your common bile duct. A stent was placed but they could not
get the gallstone out. You will need to have a repeat ERCP in
___ weeks to remove the stent and take care of the gallstone.
Please follow-up at the appointments listed below. Please see
the attached list for updates to your home medications. Please
note the following key changes:
- START Ciprofloxacin 500mg Twice daily until ___
- STOP your Aspirin and RESTART on ___
- START Metoprolol succinate 25mg once daily</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY CAD
2. Amiodarone 200 mg PO TID Duration: 1 Month
Start date: ___
RX *amiodarone 200 mg 1 tablet(s) by mouth three times daily
Disp #*90 Tablet Refills:*0
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Isosorbide Dinitrate 20 mg PO TID
RX *isosorbide dinitrate 20 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
5. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Furosemide 40 mg PO DAILY CHF
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Glargine 70 Units Lunch
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL 70 units sc lunch Disp
#*3 Vial Refills:*1
RX *insulin lispro [Humalog] 100 unit/mL As directed units sc
QID per sliding scale Disp #*3 Vial Refills:*1
10. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply to affected area daily
Disp #*30 Patch Refills:*0
11. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Cardiac arrest
Hypoxemic respiratory failure
Hyperkalemia
Hyperglycemic hyperosmolar sydrome/hyperglycemia
Acute kidney injury
Ileus
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure treating ___ at ___
were admitted because of your concerning heart issues. ___ had
respiratory failure and then ___ had a cardiac arrest, likely
due to your potassium levels being too high. ___ also had some
kidney injury from your heart not working well, which improved,
and also a blood clot in your right arm which we are treating.
___ recovered remarkably well from your cardiac arrest, and
after staying in the Intensive Care Unit, ___ were able to be
transferred to the Internal Medicine Service, and then
discharged to home.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. Also, please follow-up with your doctors as
___ below, and take all of your medications as prescribed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Fluconazole 100 mg PO Q24H
RX *fluconazole 100 mg 1 tablet(s) by mouth Daily Disp #*12
Tablet Refills:*0
2. GuaiFENesin ER 1200 mg PO Q12H
3. HYDROmorphone 0.5 - 12 mg oral Q3H:PRN pain
RX *hydromorphone 1 mg/mL 0.5 - 12 mg by mouth q3h Refills:*1
4. Lidocaine 5% Patch 1 PTCH TD QAM Pain
5. LORazepam 0.5 - 2 mg oral Q4H:PRN anxiety
RX *lorazepam [Lorazepam Intensol] 2 mg/mL 0.5 - 2 mg by mouth
every four (4) hours Refills:*0
6. Miconazole Powder 2% 1 Appl TP TID:PRN groin rash
7. ondansetron HCl ___ mg oral Q8H:PRN nausea
RX *ondansetron HCl 4 mg/5 mL ___ mg by mouth every eight (8)
hours Refills:*0
8. OxyCODONE SR (OxyconTIN) 10 mg PO BID
RX *oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 20 mg PO QHS
RX *oxycodone 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
10. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
RX *albuterol sulfate 0.63 mg/3 mL 1 neb IH every four (4) hours
Disp #*1 Vial Refills:*0
12. Docusate Sodium 100 mg PO BID
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff IH twice a day Disp #*1 Disk Refills:*0
14. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
15. LevETIRAcetam 500 mg PO BID
16. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Metastatic adenocarcinoma
SECONDARY DIAGNOSES:
-Post-obstructive pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you at ___.
Unfortunately, there is no further treatment we can offer you
for your cancer. You are being discharged to a hospice house,
where they will focus on managing your symptoms.
Please do not hesitate to contact us with any questions or
concerns that may come up. Our number is ___.
Sincerely,
Your ___ Oncology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
2. amLODIPine 10 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
CSF leak following endoscopic sinus surgery now s/p repair of
right nasal CSF leak (ethmoid region) with free mucosal graft.
Discharge Condition:
Mental status at baseline, able to ambulate without assistance.
Followup Instructions:
___ [/INST] </s><s>Patient discharge instructions:
Sinus surgery / CSF leak precautions:
- Do not lie flat until cleared by your surgeon
- No blowing nose
- Sneeze with mouth open
- Do not do any exercise other than walking for 1 week.
- DO NOT strain or lift anything heavier than a phone book until
your follow-up appointment.
- Avoid bending at the waist; bend at the knees for 1 week.
- Avoid traveling by air until you see your doctor at your
follow-up visit.
- Do not swim or dive for 2 months.
- You may return to work when your doctor says it is ok.
Diet
- Regular diet
Pain control
- Oxycodone/acetaminophen as needed</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 20 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Vasovagal syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital at ___
___ from ___ to ___ after two episodes of
syncope (fainting). Labwork and monitoring during your admission
were normal, so we think these were most likely vasovagal
episodes.
Given your family history of sudden cardiac death, it is
important that you follow up with your primary care doctor for
further evaluation.
It has been a pleasure caring for you during your stay at ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Colchicine 0.6 mg PO BID
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Indomethacin 25 mg PO TID
Take 3x/day x 2 weeks, then 2x/day x 2 weeks, then 1x/day for 2
weeks, then stop
RX *indomethacin 25 mg 1 capsule(s) by mouth three times per day
Disp #*84 Capsule Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth daily Disp #*30 Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis
Elevated liver function tests
High cholesterol
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 in the hospital. You came
in because you were having chest pain. We did a number of tests
on you, including CAT scans to make sure you did not have clots
in your lungs and no broken blood vessels near your heart. Your
blood tests and your symptoms were consistent with pericarditis
so we started you on appropriate treatment with non-steroidal
anti-inflammatory drugs (NSAIDS) and colchicine. You will need
to continue taking these medications as prescribed to help
prevent a recurrence of this problem. It is important for you to
follow up with your new primary care provider to help make sure
that you continue to improve and that your heart is well
protected.
Sincerely,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with fevers and night sweats.
You were evaluated with imaging and with biopsy of your pancreas
which showed B cell lymphoma. We treated you with chemotherapy
and your symptoms improved.
While in the hospital you were found to have a pleural effusion,
which is a fluid collection around your lungs. We believe this
was caused by your lymphoma. You had a pigtail catheter placed
by interventional pulmonology to help continue draining this
fluid. After discharge your should follow up with the
interventional pulmonologists as scheduled.
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. clobazam 10 mg Tablet Sig: One (1) Tablet PO twice a day for
2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. clobazam 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Evoxac 30 mg Capsule Sig: One (1) Capsule PO tid ().
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
6. Anusol-HC 25 mg Suppository Sig: One (1) Rectal twice a day
as needed for pain.
7. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
9. indomethacin 25 mg Capsule Sig: One (1) Capsule PO three
times a day.
10. Ativan 1 mg Tablet Sig: ___ Tablets PO once a day for 6
days: Please take 5mg on ___, 4mg on ___, 3mg on ___, 2mg on
___, 1mg on ___ then 1mg on ___ then stop taking ativan.
11. medroxyprogesterone 150 mg/mL Syringe Sig: One (1)
Intramuscular Q3 Months.
12. mupirocin 2 % Ointment Sig: One (1) application Topical
twice a day as needed for nasal concern.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Trileptal 300 mg Tablet Sig: Three (3) Tablet PO twice a
day.
Disp:*180 Tablet(s)* Refills:*2*
15. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO once a day.
16. pregabalin 75 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
17. Fiber Choice plus Calcium ___ gram-unit-mg Tablet,
Chewable Sig: One (1) Tablet, Chewable PO twice a day.
18. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Shaking Episodes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Dr. ___ were seen in the hospital for shaking episodes. ___ were
started on an anti-seizure medication that helped with the
shaking.
We made the following changes to your medications:
1) We STARTED ___ on CLOBAZAM 10mg twice a day.
2) We INCREASED your TRILEPTAL to 900mg twice a day.
3) We STOPPED your KEPPRA.
4) We are TAPERING your ATIVAN. ___ will take 5mg on ___, 4mg
on ___, 3mg on ___, 2mg on ___, 1mg on ___ and 1mg on ___ then
STOP.
Please continue to take your other medications as previously
prescribed.
If ___ experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of ___ on this hospitalization.
Please follow these seizure safety guidelines:
SEIZURE SAFETY
________________________________________________________________
The following tips will help ___ to make your home and
surroundings as safe as possible during or following a seizure.
Some people with epilepsy will not need to make any of these
changes. Use this list to balance your safety with the way ___
want to live your life.
Make sure that everyone in your family and in your home knows:
- what to expect when ___ have a seizure
- correct seizure first aid
- first aid for choking
- when it is (and isn't) necessary to call for emergency help
Avoid things that are known to increase the risk of a seizure:
- forgetting to take medications
- not getting enough sleep
- drinking a lot of alcohol
- using illegal drugs
In the kitchen:
- As much as possible, cook and use electrical appliances only
when someone else is in the house.
- Use a microwave if possible.
- Use the back burners of the stove. Turn handles of pans toward
the back of the stove.
- Avoid carrying hot pans; serve hot food and liquids directly
from the stove onto plates.
- Use pre-cut foods or use a blender or food processor to limit
the need for sharp knives.
- Wear rubber gloves when handling knives or washing dishes or
glasses in the sink.
- Use plastic cups, dishes, and containers rather than breakable
glass.
In the living room:
- Avoid open fires.
- Avoid trailing wires and clutter on the floor.
- Lay a soft, easy-to-clean carpet.
- Put safety glass in windows and doors.
- Pad sharp corners of tables and other furniture, and buy
furniture with rounded corners.
- Avoid smoking or lighting fires when ___ by yourself.
- Try to avoid climbing up on chairs or ladders, especially when
alone.
- If ___ wander during seizures, make sure that outside doors
are
securely locked and put safety gates at the top of steep stairs.
In the bedroom:
- Choose a wide, low bed.
- Avoid top bunks.
- Place a soft carpet on the floor.
In the bathroom:
- Unless ___ live on your own, tell a family member ___
before ___ take a bath or shower.
- Hang the bathroom door so it opens outward, so it can be
opened
if ___ have a seizure and fall against it.
- Don't lock the bathroom door. Hang an "Occupied" sign on the
outside handle instead.
- Set the water temperature low so ___ won't be hurt if ___ have
a seizure while the water is running.
- Showers are generally safer than baths. Consider using a
hand-
held shower nozzle.
- If taking a bath, keep the water shallow and make sure ___
turn
off the tap before getting in.
- Put non-skid strips in the tub.
- Avoid using electrical appliances in the bathroom or near
water.
- Use shatterproof glass for mirrors.
At work:
___
Out and about:
- Carry only as many medications with ___ as ___ will need, and
2
spare doses.
- Wear a medical alert bracelet to let emergency workers and
others know that ___ have epilepsy.
- Stand well back from the road when waiting for the bus and
away
from the platform edge when taking the subway.
- If ___ wander during a seizure, take a friend along.
- Don't let fear of a seizure keep ___ at home.
Sports:
- Use common sense to decide which sports are reasonable.
- Exercise on soft surfaces.
- Wear a life vest when ___ are close to water.
- Avoid swimming alone. Make sure someone with ___ can swim
well
enough to help ___ if ___ need it.
- Wear head protection when playing contact sports or when there
is a risk of falling.
- When riding a bicycle or rollerblading, wear a helmet, knee
pads, and elbow pads. Avoid high traffic areas; ride or skate
on
side roads or bike paths.
Driving:
- ___ may not drive in ___ unless ___ have been
seizure- free for at least 6 months.
- Always wear a seatbelt.
Parenting:
- Childproof your home as much as possible.
- If ___ are nursing a baby, sit on the floor or bed with your
back supported so the baby will not fall far if ___ should lose
consciousness.
- Feed the baby while he or she is seated in an infant seat.
- Dress, change, and sponge bathe the baby on the floor.
- Move the baby around in a stroller or small crib.
- Keep a young baby in a playpen when ___ are alone, and a
toddler in an indoor play yard, or childproof one room and use
safety gates at the doors.
- When out of the house, use a bungee-type cord or restraint
harness so your child cannot wander away if ___ have a seizure
that affects your awareness.
- Explain your seizures to your child when he or she is old
enough to understand.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Levofloxacin 750 mg PO Q48H Duration: 1 Dose
1 more dose on ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*1 Tablet Refills:*0
2. Glargine 15 Units Bedtime
NPH 10 Units Breakfast
RX *insulin NPH human recomb [Humulin N] 100 unit/mL 10 units SC
10 Units before breakfast Disp #*1 Vial Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 3 Days
___
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. CloNIDine 0.1 mg PO BID
8. Diltiazem Extended-Release 180 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Furosemide 40 mg PO DAILY
11. GlipiZIDE 10 mg PO BID
12. HydrALAZINE 50 mg PO Q8H
13. Metoprolol Succinate XL 25 mg PO BID
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
Community acquired pneumonia
Chronic obstructive pulmonary disease exacerbation
Hypertensive urgency
SECONDARY DIAGNOSES
====================
Chronic kidney disease stage 4
Diabetes mellitus type 2
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You came to the hospital because you were experiencing worsening
shortness of breath. You were diagnosed with an exacerbation of
your COPD and a pneumonia. You were treated with antibiotics and
a course of higher dose steroids. You will need to continue
taking the steroids and antibiotics for a few more days.
Your blood pressure was also elevated while in the hospital and
you should continue to monitor your pressures at home and
discuss your blood pressure regimen with your primary care
doctor.
Because of your diabetes, you were also temporarily started on
another type of insulin in the morning called NPH. You should
continue to take the NPH insulin until you go back to your
normal dose of steroids. You should continue to check your blood
sugars and call your doctor if your blood sugar is over 300 for
one day.
Please continue to weigh yourself daily and call your doctor if
your weight goes up by more than 3 pounds in one day or 5 pounds
in one week.
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. Acyclovir 400 mg PO Q8H
2. Calcium Carbonate 1250 mg PO DAILY
3. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. PredniSONE 7.5 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. testosterone propionate 1% transdermal daily
9. Vitamin D 1000 UNIT PO DAILY
10. Enoxaparin Sodium 80 mg SC Q12H
Start: ___ - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 1 each SC twice a day Disp #*10
Syringe Refills:*0
11. Warfarin 5 mg PO DAILY16
12. Sildenafil 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
dyspnea
fatigue
myeloma
anticoagulation ___ PE/DVT hx
PE/DVT hx
panhypopituitarism
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 fatigue and shortness of breath from the
___ clinic. We did a work-up, including chest xray,
chest CT scan, lung perfusion scan. We were looking for any
evidence of clot in your lungs, and did not find any. Your
chest CT shows changes suggestive of a resolving pneumonia.
You will need to continue taking your coumadin, but at the 5mg
dose. You should have your INR checked at ___ on ___
in their ___ clinic. You will need to continue the lovenox
until you are told to stop by our office. HOWEVER: you are
taking an antibiotic (Levaquin), which can increase your IRN,
therefore, if you are unable to have your INR drawn at ___
___ on ___, please call us ASAP, as you will need to come
in here for an INR check. Once the antibiotic finishes on ___,
your INR will come back down and need to be checked again.
You will take an antibiotic to help resolve your prior
pneumonia, you will continue this for 5 more doses once you are
home.
Start taking 7.5mg po prednisone until you see ___.
Please call us if you have any questions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
Please do not continue scheduled Tylenol for more than 5 days
2. Atenolol 12.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 200 mg PO TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*0
7. Senna 8.6 mg PO QHS
8. Sodium Chloride 2 gm PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right parieto-occipital intraparenchymal hemorrhage with
intraventricular extension
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 hospitalized due to symptoms of confusion resulting
from an ACUTE HEMORRHAGIC STROKE. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
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 325 mg PO Q4H:PRN Pain - Mild
2. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
4. Atorvastatin 80 mg PO QPM
5. Citalopram 40 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. RisperiDONE 0.5 mg PO TID
11. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until after your procedure
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ for cholecystitis, which is an
infection in your gallbladder which is caused by a stone that is
obstructing the flow of bile out of your gallbladder. Throughout
the admission your labs improved and so did your symptoms. An
MRCP was done to better visualize your gallbladder and bile duct
which showed that you did not have a stone in your bile duct,
but you did have some stones in your gallbladder remnant.
Because there was no stone in your bile duct, an ERCP was not
done because the purpose of the ERCP would have been to remove
any obstructing stones. It is likely that you had a stone in
your bile duct at one point but passed it on your own. Because
you have had multiple episodes of pain in the past month, GI
felt that a sphincterotomy would be a good option for you. The
sphincterotomy will cut the sphincter at the end of your bile
duct so that stones will be less likely to get stuck. The ERCP
team will call you to set this up as an outpatient.
Ultimately you were discharged home with a plan to follow-up
with ___ as an outpatient to get your procedure done.
The following changes were made to your medications:
- Stop taking Plavix until instructed to resume 5 days after
your procedure
Please attend your follow-up appointments as listed below.
Thank you for choosing ___ for your health care needs. It was
a pleasure taking care of you.
Sincerely,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO/NG Q6H:PRN fever ___ pain
Do not exceed 3000mg in 24 hours.
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours as
needed for pain Disp #*240 Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO/NG DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth once daily Disp #*420
Milliliter Milliliter Refills:*0
3. Baclofen 10 mg PO/NG TID
RX *baclofen 10 mg 1 tablet(s) by mouth three times daily Disp
#*90 Tablet Refills:*0
4. Dolutegravir 50 mg PO DAILY
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*0
5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
RX *emtricitabine-tenofovir alafen [Descovy] 200 mg-25 mg 1
tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0
6. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 0.4 mL SC once daily Disp #*30
Syringe Refills:*0
7. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice
daily Disp #*60 Tablet Refills:*0
8. LORazepam 0.5-2 mg PO ONCE:PRN Anxiety while traveling
Duration: 1 Dose
RX *lorazepam 0.5 mg ___ tablet(s) by mouth once Disp #*4 Tablet
Refills:*0
9. Metoprolol Tartrate 25 mg PO Q8H
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth every 8 hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- Traumatic brain injury
Discharge Condition:
Mental Status: Confused, always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of bed with assistance to chair ___
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Surgery:
- You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You must
wear a helmet at all times when up in a chair ___ out of bed.
- It is best to keep your surgical incision open to air, but it
is okay to cover it when outside.
- Please call doctor ___ neurosurgeon if there are any signs of
infection like fever, redness, ___ drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
___ other strenuous exercise.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- You may take a shower.
- No driving.
- No contact sports.
Medications:
- Resume your normal medications, and begin new medications as
directed.
- Please do not take any blood thinning medication (aspirin,
Coumadin, ibuprofen, Plavix, etc.) until cleared by
neurosurgeon.
- You have been discharged on levetiracetam (Keppra). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions. It is
important that you take this medication consistently and on
time.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- Please do not smoke.
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet.
Headaches:
- Headache is one of the most common symptoms after a traumatic
brain injury.
- Most headaches are not dangerous, but you should call
neurosurgeon if the headache gets worse, if you have increased
sleepiness, if you have nausea ___ vomiting, ___ if you develop
arm ___ leg weakness.
- Mild pain medications may be helpful with these headaches, but
avoid taking pain medications on a daily basis unless
prescribed.
- There are other things that can be done to help with your
headaches, including daily exercise, getting enough sleep,
avoiding caffeine, ice ___ heat packs, relaxation, meditation,
massage, and acupuncture.
When To Call A Doctor ___:
- Severe pain, redness, swelling, ___ drainage from the surgical
incision site
- Fever greater than 101.5 degrees Fahrenheit
- Nausea ___ vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain medications
- Seizures
- Any new problems with your vision ___ ability to speak
- Weakness ___ changes in sensation in your face, arms, ___ legs
Call An Ambulance And Go To The Nearest Emergency Department If
You Experience Any Of The Following:
- Sudden numbness ___ weakness in the face, arms, ___ legs
- Sudden confusion ___ trouble speaking ___ understanding
- Sudden trouble walking, dizziness, ___ loss of balance ___
coordination
- Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Entecavir 1 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Glargine 10 Units Bedtime
4. Sucralfate 1 gm PO QID
5. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. abdominal pain
2. decompensated hepatitis B and alcoholic cirrhosis
3. acute tubular necrosis, acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You were admitted with abdominal pain. You were
placed on a lactose-free diet and your lactulose was stopped.
We kept you in the hospital because your bilirubin, one of your
liver function tests, was rising. However, this started to come
back down. You will need to check your liver studies on ___ and have the results sent to Dr. ___. You have an
active order and can go to the lab anytime to get your bloodwork
done.
Also while you were here, you were listed for liver
transplantation and were seen by a dentist who cleared you for
transplant surgery.
If you develop any nausea, vomiting, diarrhea, fevers, chills,
or abdominal pain (or any other symptom that concerns you),
please call the clinic or come to the Emergency Department for
further evaluation.
We wish you all the best in your health,
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 40 mg PO QPM
3. Carvedilol 25 mg PO BID
4. Famotidine 20 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CHEST PAIN
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN PAIN
9. Spironolactone 25 mg PO DAILY
10. Benzonatate 100 mg PO TID:PRN COUGH
RX *benzonatate 100 mg 1 capsule(s) by mouth TID PRN Disp #*21
Capsule Refills:*0
11. Levofloxacin 500 mg PO Q48H
Last dose ___
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth Every 48
hours Disp #*3 Tablet Refills:*0
12. Outpatient Lab Work
R74.0 Please check on ___, LFTs (AST, ALT, LDH, T. bili, Alk
phos)
Fax results to: ___ MD Fax: ___
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml INH q6h:prn
Disp #*20 Vial Refills:*0
14. Lorazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth BID:prn Disp
#*10 Tablet Refills:*0
15. Lanthanum 1000 mg PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
Atypical Pneumonia
Influenza like illness
SECONDARY DIAGNOSES
===================
End stage renal disease
Systolic Congestive Heart Failure
Transaminitis
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 to us after you
developed cough and fatigue. Upon work-up here, we think that
your illness was mostly cause a viral infection. We also started
treating you for a possible pneumonia with an antibiotic. Your
symptoms should get better within the next one to two weeks.
Please call your doctor if they do not.
You also underwent dialysis while here.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
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. Lisinopril 20 mg PO DAILY
2. Lorazepam 0.25 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg one-half tablet by mouth twice daily Disp
#*30 Tablet Refills:*0
3. Vitamin D 1000 UNIT PO DAILY
4. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral daily
5. Zenpep *NF* (lipase-protease-amylase) 20,000-68,000 -109,000
unit Oral TID
6. OLANZapine 2.5 mg PO BID
RX *olanzapine 2.5 mg 1 (One) tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
7. OLANZapine 2.5 mg PO DAILY:PRN anxiety/agitation
RX *olanzapine 2.5 mg 1 (One) tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
UTI
Delirium
Worsening dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It has been a pleasure taking care of you here at ___. You
were admitted with worsening confusion and anxiety. A urine test
showed that you had a urinary tract infection for which you
received antibiotics. Since your anxiety and agitation did not
completely improve with treatment of this infection, the
geriatric doctors and psychiatry ___ were consulted to help
you. It is likely that your confusion and occasional agitation
is due to dementia. Your medications have been adjusted to treat
your anxiety and agitation. Please take all medications as
directed. Below is a list of your follow up appointments. Please
keep all appointments.</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 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. LevETIRAcetam 250 mg PO BID
RX *levetiracetam 250 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
6. Fluticasone Propionate NASAL 2 SPRY NU BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Tamsulosin 0.8 mg PO QHS
9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Home
Discharge Diagnosis:
stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
WHY WAS I IN THE HOSPITAL?
-You had an episode of unresponsiveness
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- You had an MRI and an EEG
- You were started on a seizure medicine
- You were started on aspirin
- You had a heart ultrasound
- You were found to have small strokes
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should wear your Zio patch for 30 days
- You should see your neurologist
Be well!
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
every twelve (12) hours Disp #*10 Tablet Refills:*0
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
RX *betamethasone dipropionate 0.05 % Apply a small amount to
affected areas twice a day Refills:*0
3. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. calcium carbonate-vitamin D3 500 mg calcium- 400 unit/5 mL
oral daily
8. Colchicine 0.6 mg PO BID
9. NPH 28 Units Breakfast
10. Multivitamins 1 TAB PO DAILY
11. Sertraline 100 mg PO DAILY
12. triamcinolone acetonide 0.5 % topical daily
vaginal application
13. Vesicare (solifenacin) 5 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right ___ toe abscess/cellulitis
Sweet's syndrome
Seronegative inflammatory arthritis
Diabetes mellitus
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 the hospital with an abscess on your right
___ toe. The abscess was drained by the podiatry team and you
were treated with antibiotics. An MRI of your foot showed no
evidence of bone infection. You are being discharged on an
antibiotic called Augmentin, which you should continue through
___ (10 days total).
While here, you were noted to have a flare of your Sweet's
syndrome and your arthritis. You were seen by the dermatology
and rheumatology teams, and your prednisone dose was increased.
Please continue prednisone 20mg PO daily until you see your
rheumatology team on ___.
Please take your medications as prescribed and follow-up with
your outpatient doctors as below.
With best wishes,
___ Medicine</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*20 Tablet Refills:*0
6. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Polytrauma:
[] Right posterior sternoclavicular joint dislocation
[] Vertical fracture through the right scapular spine and blade
[] C7 and T1 and T2 transverse process fractures
[] Right non displaced orbital fracture
[] Nondisplaced fractures of the right ___ and probably ___
ribs posteriorly. Displaced fractures of the right ___ ribs
laterally.
[] Right pleural effusion consistent with hemothorax
[] Right lung contusion
[] Grade II laceration of the lateral right hepatic lobe
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 you fell out of a motor
vehicle. You sustained multiple injuries: right clavicle joint
dislocation, right rib fractures, cervical and thoracic
fractures, lung injury and liver injury.
You were taken to the operating room with the Orthopedic
Surgeons and underwent ORIF of the clavicle. They recommend
non-weight bearing to the right upper extremity, no range of
motion, and sling for 6 weeks. You will need to call the ___
clinic to arrange follow-up in 2 weeks.
Your blood levels and vitals have been monitored and there is no
concern for bleeding from the liver laceration. Your respiratory
status has been stable, your rib fractures and lung injury will
heal with time. Continue to use the incentive spirometer, take
deep breaths, and ambulate several times a day.
___ and OT have been working with you, and you are now cleared
for discharge home.
Liver lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Rib Fractures:
* Your injury caused multiple right 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).</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
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tab-cap
by mouth every 6 hours as needed Disp #*55 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right supraclinoid ICA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Activity
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
You may be instructed by your doctor to take one ___ a day
and/or Plavix. If so, do not take any other products that have
aspirin in them. If you are unsure of what products contain
Aspirin, as your pharmacist or call our office.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few
weeks.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg</s> |