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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Vitamin D 1000 UNIT PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Gabapentin 300 mg PO QHS
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
6. LamoTRIgine 200 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. LORazepam 1 mg PO Q4H:PRN seizure
9. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to ___ for increased seizures. You underwent
an EEG which initially showed some slowing but quickly improved.
No changes to your medications were made. We believe the trigger
for your seizure was due to seasonal allergies.
Please take your medications as prescribed. Please follow up
with your PCP as below.
It was a pleasure taking care of you,
Best,
Your ___ care team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. DULoxetine 60 mg PO DAILY
2. Enoxaparin Sodium 70 mg SC Q12H
3. Gabapentin 600 mg PO QAM
4. Gabapentin 1200 mg PO QHS
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Nortriptyline 50 mg PO QHS
7. Octreotide Acetate 100 mcg SC Q8H
8. Omeprazole 20 mg PO DAILY
9. Ramelteon 8 mg PO QHS:PRN sleep
10. Vitamin C
11. Ferrous Sulfate
12. Multivitamin
Discharge Disposition:
Home
Discharge Diagnosis:
prolapsed fistula s/p reduction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left frontal SDH, hemorrhagic contusions, and SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Artificial Tears ___ DROP BOTH EYES TID
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
3. Clobazam 20 mg PO TAKE 1 TAB IN THE MORNING, ___ TAB AT
LUNCH, ___ TAB AT DINNER AND 1 TAB AT BEDTIME
4. Divalproex (EXTended Release) 250 mg PO QID
5. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Haloperidol 1 mg PO DAILY
8. Keppra XR (levETIRAcetam) 750 mg oral 1 tablet(s) by mouth
in the am; 1 tab at lunch; 1 tab at dinner; and 2 tabs before
bed
9. LACOSamide 50 mg PO TAKE 1 TABLET AT 8AM, 2 TABLETS AT 12PM,
1 TABLET AT 5PM, AND 2 TABLETS AT BEDTIME
Discharge Disposition:
Home
Discharge Diagnosis:
Lightheadedness, ?medication side effect
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 due to episodes of lightheadedness concerning
for ongoing seizures. You were monitored on EEG which did not
show seizures. Routine studies for infection were negative. Your
medications were not switched.
On discharge, please avoid driving or operating heavy machinery
for at least 6 months following your last seizure. Take all of
your medications as directed and do not miss doses. Please
follow up with your neurologist as scheduled.
It was a pleasure taking care of you.
Sincerely,
___ Neurology</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Vancomycin 1000 mg IV Q48H
RX *vancomycin 1 gram 1 gram IV every 48 hours Disp #*8 Vial
Refills:*0
2. Ferrous Sulfate 325 mg PO BID
3. Zolpidem Tartrate ___ mg PO HS:PRN insomnia
4. Levofloxacin 500 mg PO Q48H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every 48
hours (2 days) Disp #*2 Tablet Refills:*0
5. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Locally invasive bladder cancer
urinary tract infection
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 during your hospitalization
at ___. You were admitted with fever and found to have a
urinary infection as well as a pneumonia. You were treated with
antibiotics but developed a rash. You continued to have fevers
and you were seen by infectious disease. Your antibiotics were
changed. You had a CT scan which showed an infection of your
kidney. You were discharged on oral antibiotics as well as
intravenous antibiotics to follow up with your PCP and
oncologist.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks
last dose ___. Aspirin EC 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Heparin 5000 UNIT SC TID
8. Lisinopril 10 mg PO DAILY
Hold if SBP <110
9. Metoprolol Tartrate 25 mg PO BID
Hold if SBP <110, HR <60
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Potassium Chloride 10 mEq PO DAILY
Hold for K > 5.2
12. Senna 1 TAB PO BID:PRN constipation
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
urinary tract infection
troponin leak
acute cholecystitis
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 with upper abdominal pain. You
underwent an ultrasound of your abdomen and you were found to
have multiple gallstones and sludge. You were started on
intravenous antibiotics. As part of the work-up you were found
to have special enzymes in the blood which appear when you have
any damage to the heart. Because of this, you underwent cardiac
testing and you were seen by the Cardiologist who made
recommendations about your management. You were also found to
have a urinary tract infection. Your blood work is normalizing
and your abdominal pain has diminshed. You are now preparing
for discharge to a rehabilitation facililty where you can
further regain your strenght. You will need further work-up on
your heart and follow-up with a Cardiologist when you are
discharged.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
4. Ferrous Sulfate 325 mg PO DAILY
5. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until you are told to do so by your
healthcare provider
6. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until you are told to do so
by your healthcare provider
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
Acute on chronic microcytic anemia
Decompensated cirrhosis
___
SECONDARY DIAGNOSES
====================
Hyponatremia
Severe Malnutrition
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 admitted to the hospital because you had low blood
counts.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We gave you blood transfusions
- We gave you IV iron transfusion
- You had a colonoscopy which showed a polyp in your colon
which was not taken out.
- We removed fluid from your abdomen. You did not have an
infection of that fluid but you did find blood in that fluid.
- You improved and were ready to leave the hospital.
- Nutrition saw you and recommended nutritional
supplementation.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*21 Tablet Refills:*0
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Complicated diverticultitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ with sigmoid diverticulitis. While
you were hospitalized, you were treated with IV Antibiotics and
stayed on strict bowel rest. At the time of your discharge, your
pain had improved and you were tolerating a regular diet. You
will be discharged home with a 2 week course of antibiotics
along with followup appointments listed below.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
Last day: ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*8 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ because you had high fevers and body
aches.
You were given IV antibiotics. We looked for an infection. We
found bacteria in your urine, and think that you had an
infection in your kidney called pyelonephritis.
When you leave the hospital:
- Please follow up with your doctors ___
- ___ finish your antibiotics as directed
It was a pleasure taking care of you!
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*100 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
hold for loose stools
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp
#*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
hold for loose stools
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily while taking narcotics Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 1 syringe subc daily at night Disp
#*28 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
don't drink/drive/operate heavy machinery while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
hold for loose stools
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily
while taking narcotics Disp #*60 Tablet Refills:*0
7. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
(WE)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right superior pubic rami, Right comminuted ilium fx, right
clavicle 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:
- You were in the hospital for your orthopaedic injury.
- 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 on bilateral lower extremities
- weight bearing as tolerated on right upper 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 daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
weight bearing as tolerated on b/l lower extremities
<br><br>RUE: weight bearing as tolerated. can range fingers,
elbow, wrist as tolerated. sling for comfort only
Treatments Frequency:
none</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acyclovir 400 mg PO Q8H
2. Docusate Sodium 100 mg PO BID constipation
3. Entecavir 1 mg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN nausea or anxiety
5. Omeprazole 20 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Ranitidine 75 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Sulfameth/Trimethoprim DS 1 TAB PO MON, WED, FRI
11. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Chest pain; High Grade, diffuse large B-Cell Lymphoma
SECONDARY: Hepatitis B, Anemia, Thrombocytopenia
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 to take part in your care during your stay in
the hospital. You came into the hospital with left sided
chest/rib pain. You had multiple imaging studies which showed
that your did NOT have a heart attack nor clot in the lungs.
Your pain was likely from inflammation around your rib cage or
from your spleen.
You were seen by your oncology team while in the hospital and
they discussed with you and your family that your lymphoma had
returned dispite the chemotherapy. You were started on a new
chemotherapy while in the hospital and completed your first
cycle without complication. You were also given your injection
of Neulasta prior to leaving the hospital. You will follow up
with Dr. ___ on ___ in clinic. You will
receive another chemotherapy medication in clinic, but you will
be able to return home after the administration. If you
experience fevers, chills, shortness of breath or any other
concerning symptom, please call the clinic number.
Thank you for allowing us to participate in your care during
your stay.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 Units SC Every evening Disp #*28
Syringe Refills:*0
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left patella fracture
Left clavicle fracture
Right fifth metacarpal 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:
- Left lower extremity: Weight-bearing as tolerated with ___
locked in extension.
- Left upper extremity: Non-weight-bearing in sling.
- Right upper extremity: Non-weight-bearing in splint.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 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.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Weight-bearing as tolerated left lower extremity with brace
locked in extension.
Non-weight-bearing left upper extremity in sling.
Non-weight-bearing right upper extremity in splint.
Treatments Frequency:
Wound monitoring
Dry sterile dressing as needed</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>You were admitted to the hospital with abdominal pain and found
to have disruption of your staple line. You were placed on
bowel rest, given intravenous anti-acid medication, antibiotics
and and nutrition. You have elected to leave the hospital at
this time due to issues with insurance coverage. However, you
must seek ___ medical attention should you develop a fever
greater than 100, chest pain, shortness of breath, recurrence of
abdominal pain, nausea or vomiting, vomiting blood or dark
material, blood in your stool, severe abdominal bloating,
inability to eat or drink, or any other symptoms which are
concerning to you.
Stay on Stage III diet until your follow up appointment. Do not
self advance diet, do not drink out of a straw or chew gum.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Disp #*210
Milliliter Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by
mouth once a day Disp #*60 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. GlipiZIDE 5 mg PO BID
RX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
7. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*2
9. GuaiFENesin ___ mL PO Q6H:PRN cough
10. Methotrexate 20 mg PO QWED
11. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
13. Aspirin 81 mg PO DAILY
14. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
15. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
16. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection prn
anaphylaxis
17. HydrOXYzine 25 mg PO Q6H:PRN itching
18. Senna 8.6 mg PO BID:PRN Constipation - First Line
19. Simvastatin 20 mg PO QPM
20. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
21. Tiotropium Bromide 1 CAP IH DAILY
22. HELD- Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY This medication was held. Do not restart
Victoza 3-Pak until you see your endocrinologist
23.Equipment
Suction machine w/ Yankours & suction tubing and canisters
CODE:___
DX:___.9
___: ___
24.Equipment
Air compressor/humidified
CODE:___
DX:C32.9
___
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===================
- Glottic squamous cell carcinoma
- Acute necrotizing cutaneous vasculitis
- Post-radiation laryngeal edema
SECONDARY DIAGNOSES:
====================
- Type 2 Diabetes
- Asthma
- Chronic Obstructive Pulmonary Disease
- Hypertension
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 had difficulty breathing and throat tightness and were
transferred to ___ from ___.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a tracheostomy placed to help you breathe
- You received a PEG tube in your stomach for tube feeds
- You had a vocal cord biopsy showing cancer and plans were
arranged for further care
- You were treated for your lower leg rash which was consistent
with vasculitis
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- 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. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
Q8hr Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4hr
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: gunshot wound
Left hemothorax
GSW Left arm
Left 8th rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital after you sustained a gunshot
wound to the left arm and chest. You had a tube placed into
your chest to drain the collection of fluid. The tube was
removed and your vital signs have been stable. You are now
preparing for discharge home with the following instructions:</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 fever or pain
2. Calcium Carbonate 1000-1500 mg PO QID:PRN dyspepsia
"TUMS"
3. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*22 Tablet Refills:*0
4. Omeprazole 40 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 17.2 mg PO QHS
7. Simethicone 40-80 mg PO QID:PRN gas
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cerebellar Hemorrhage
Right verterbral dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
You also underwent a cerebral angiogram to look at the vessels
of your brain. There was some injury to your vessels to your
brain.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 10 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO DAILY constipation
5. Polyethylene Glycol 17 g PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours as
needed for pain Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Choledocholithiaisis
Cholecystolithiasis
Atelectasis
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 infection due to bile stone impaction in
your bile passages. You underwent endoscopic procedure for
removal of the stones followed by surgery for removal of your
gallbladder. Your infection was treated with antibiotics. You
should follow-up as outlined below with your PCP and with out
patient surgery clinic.
- please complete your antibiotic treatment as prescribed.
- You should get your blood tested for liver functions in two
weeks to make sure these have normalized.
- Please present to the emergency department or call your PCP
without delay for any fever, chills, worsening abdominal pain,
vomiting or any other symptom that concerns you.
-You do not need to take any antibiotics</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Lisinopril 40 mg PO DAILY
Hold for sBP <90
8. Metoprolol Tartrate 25 mg PO BID
Hold for HR <50
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Senna 1 TAB PO HS
11. Simvastatin 10 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. Doxycycline Hyclate 100 mg PO Q12H Duration: 8 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth q12hrs Disp
#*5 Tablet Refills:*0
14. Calcium Citrate + *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
with meals
15. FiberCon *NF* (calcium polycarbophil) 625 mg Oral Daily
16. Glucosamine Chondroitin MaxStr *NF*
(glucosamine-chondroit-vit C-Mn) 500-400 mg Oral daily
17. vitamin C-vitamin E *NF* 0 ORAL DAILY
18. oxygen
2L via NC continuous pulse dose for portability. RA sat 85%, dx
CHF
19. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
20. Miconazole Powder 2% 1 Appl TP QID
21. Cyanocobalamin 1000 mcg PO DAILY
22. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
23. Gabapentin 300 mg PO Q12H
24. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- acute diastolic congestive heart failure exacerbation
SECONDARY:
- bronchitis/bronchiolitis
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 for choosing ___ for your medical care. You were
admitted after developing shortness of breath caused by a rapid
buildup of fluid into your lungs. You required a medication
called furosemide, or Lasix, to help remove extra fluid and
improve your breathing ability. You stated that you had bad
reactions to Lasix in the past, including GI distress and
diarrhea, but you tolerated it well on this admission. You were
then started on torsemide which you also tolerated well. You
were also started on antibiotics to treat a skin infection at
the site where you injured your right leg. You should continue
these antibiotics for 2 more days with end date ___.
It is very important you weigh yourself daily. Call your doctor
if your weight goes up by more than 3 lbs.
Upon discharge, please continue to take all medications as your
doctors have ___. Please continue to keep your
appointments with your doctors, and bring a copy of your
medication list to these visits.
Please inform the staff members at your living facility if you
develop any of the following: chest pain, trouble breathing,
increasing weight gain, loss of conciousness, abdominal
swelling, swelling of your legs, spreading redness around the
site of your leg wounds, fever, chills, night sweats, or any
other symptoms that concern you.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Citalopram 20 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q4H:PRN pain
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>You were admitted to ___ on
___ with abdominal pain. On further evaluation using CT
scanning, you were found to have a small bowel obstruction. You
were given bowel rest (nothing by mouth), given IV fluids and a
___ tube was inserted for gastric (stomach)
decompression. As your obstruction resolved, your diet was
slowly advanced. Your obstruction has now resolved and you are
being discharged home with the following instructions.
- Please resume all regular home medications, unless
specifically advised not to take a particular medication.
- It may be beneficial for you to avoid raw, uncooked vegetables
and nuts in the future. These food items may contribute to
obstructive symptoms, e.g. abdominal pain, no passing of
flatus/gas, nausea, vomiting.
At your request, a CD of your abdominal CT scan has been
provided.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. DICYCLOMine 10 mg PO BID
RX *dicyclomine 10 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO QHS
4. Calcium Carbonate 1500 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. IBgard (peppermint oil) 90 mg oral TID W/MEALS
9. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
10. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Magnesium Oxide 400 mg PO BID
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Potassium Chloride 10 mEq PO BID
15. Pravastatin 40 mg PO QPM
16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
17. Vitamin D 5000 UNIT PO DAILY
18. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000
unit oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
viral gastroenteritis
SECONDARY DIAGNOSIS:
====================
hepatocellular carcinoma s/p TACE in ___ and on ___ for
recurrence
NASH/HCV cirrhosis
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 had abdominal pain
and diarrhea and you were found to have lower than normal white
blood cell count.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We tested you for infections and did not find any source of
infection to cause your diarrhea. It is likely you had a viral
infection causing diarrhea and had irritable bowel syndrome type
symptoms after this.
- We got an ultrasound and CT scan of your abdomen which was
overall normal and we did not find anything that would cause
your pain and diarrhea.
- You improved with a new medication called dicyclomine and were
ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- Seek medical attention if you have new or concerning symptoms
It was a pleasure participating in your care. 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. Amlodipine 2.5 mg PO DAILY
2. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN cough
3. Vitamin D 1000 UNIT PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
5. Sodium Chloride Nasal 2 SPRY NU QID:PRN nasal dryness
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Viral upper respiratory infection
Acute kidney injury
Dehydration
Discharge Condition:
Tolerating diet, ambulating, not short of breath.
Followup Instructions:
___ [/INST] </s><s>You were admitted with a cough, and were found to have a lung
virus. Even though you still feel sick, you feel like you will
recover better at home.
We are sending you home with a visiting nurse to check on you.
Do not take your hydrochlorthiazide until you see the doctor
next week. Do not take your valsartan until you see the doctor
next week.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Heparin 5000 UNIT SC BID
4. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN
hemorrhoidal pain
5. Ibuprofen 800 mg PO Q8H Duration: 10 Days
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q3H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4hrs as needed
Disp #*20 Capsule Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
8. Ranitidine 150 mg PO BID
9. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic breast cancer
Bony and liver metastatic lesions
Abnormal liver function tests
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 with severe back pain and
underwent extensive imaging. The CT and MRI scans showed
multiple lesions concerning for cancer including a collapsed
vertebrae at T-10 and a large liver lesion. We found a large
lesion in your left breast, and a biopsy from your liver
confirmed breast cancer. You will be following up with Atrius
oncology for your treatment plan and I have recommended that
they have you meet with palliative care to assist with symptom
management while pursuing treatment.
You had very high calcium, and received a drug called
pamidronate to bring the levels back down to normal. You also
received a course of radiation therapy to your back to reduce
your pain.
It has been a pleasure taking care of you. We wish you the best
of luck with this journey.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
2. Apixaban 2.5 mg PO BID
3. Metoprolol Tartrate 12.5 mg PO Q12H
4. Miconazole Powder 2% 1 Appl TP BID Duration: 7 Days
5. econazole 1 % topical BID
6. LORazepam 0.5 mg PO QHS:PRN anxiety
7. Losartan Potassium 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Rosuvastatin Calcium 10 mg PO QPM
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Ischemic Stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were hospitalized due to symptoms of right sided weakness
and difficulty speaking resulting from an ACUTE ISCHEMIC STROKE,
a condition where a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. Atrial Fibrillation
We are changing your medications as follows:
1. Start apixaban 2.5mg BID
2. Stop taking aspirin
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
Sincerely,
Your ___ Neurology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Phenazopyridine 100 mg PO TID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN c
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. oxyCODONE-acetaminophen ___ mg oral Q8H:PRN pain
16. Oxybutynin 2.5 mg PO BID
RX *oxybutynin chloride 5 mg 0.5 (One half) tablet(s) by mouth
Once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
UTI
Secondary:
- papillary RCC, incidentally discovered on left
nephroureterectomy for bladder TCC, 9 mm in size, early stage
- bladder TCC s/p multiple resections - most recently TUR
___
- COPD, s/p left lobectomy per ___ and ___ records
- Perioperative Afib
- ___ DVT
- DM
- Hypertension
- BPH
- CKD - Cr baseline 1.2
- Urinary retention (straight caths)
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 ___ due to
pain on urination and suprapubic pain. You were found to have a
urinary tract infection, however cultures we were unable to
identify any organisms. Given your history of recurrent UTIs,
you were given a 7 day course of antibiotics and started on
oxybutynin, a medication to help with bladder urgency. You
stayed in the hospital until the antibiotics were completed.
It was a pleasure taking care of you at ___. If you have any
questions in the care you received, please do not hesitate to
ask.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen IV 1000 mg IV TID:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Glycopyrrolate 0.2 mg IV Q8H:PRN Secrretions
4. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting
5. HYDROmorphone (Dilaudid) 0.5-1.0 mg IV Q30 MIN:PRN
Breakthrough Pain, or Respiratory distress
RX *hydromorphone 1 mg/mL ___ every 30 minutes Disp #*12
Syringe Refills:*0
6. HYDROmorphone (Dilaudid) 0.5 mg IV Q4H
RX *hydromorphone 0.5 mg/0.5 mL 0.5 (One half) mg SQ every 4
hours Disp #*24 Syringe Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cardiomyopathy likely secondary to cardiac amyloidosis;
depressed ejection fraction
Congestive heart failure, ___ Class
II-III Permanent pacemaker placement for presumably due to heart
block ___)
Chronic atrial fibrillation
Aortic stenosis (valve area: *0.6 cm2)
OTHER PAST MEDICAL HISTORY:
Hyperlipidemia
CKD (baseline Cr ___
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to fix your hip after a fall. Unfortunately
your heart failure is very severe and you required medical
support after surgery to support your hearts function. The
decision was made to treat your pain and support your needs
making you as comfortbale as possible as you come to the end of
your life.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amiodarone 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. Colchicine 0.6 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Furosemide 120 mg PO BID
7. HumaLOG KwikPen (insulin lispro) 16 U subcutaneous TID
W/MEALS
8. Lactulose 30 mL PO TID
9. Lantus Solostar (insulin glargine) 25 U subcutaneous QHS
10. Metoprolol Succinate XL 6.25 mg PO DAILY
11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
12. Pravastatin 40 mg PO QPM
13. Spironolactone 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Abdominal Pain
2. Choledocholithiasis without cholangitis or cholecystitis
3. Chronic systolic heart failure - ICM EF 20%
4. Paroxysmal atrial fibrillation ___ ABJ on anticoagulation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with concern for an issue
with your gallbladder. However, when you arrived to BID your
pain had resolved and you did not show signs of infection. Your
liver function and gallbladder function tests were normalized.
We do think you possibly had a gallbladder stone that was lodged
in your draining system, but this has since passed. An ERCP
(endoscopy) was considered but due to your heart risks it was
not needed unless emergent/urgent.
There is a chance you could develop symptoms again. If you
develop sudden pain again that lasts for >4 hours, is
accompanied by nausea/vomiting, fever, or yellowing of the skin
or eyes, please call return to the ED.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please continue your salt restriction and current
cardiac medications.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Aspirin EC 325 mg PO DAILY Duration: 2 Weeks
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*65 Tablet Refills:*0
6. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
right Shatzker VI tibial plateau fracture s/p ORIF with anterior
compartment release
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:
- TDWB RLE in unlocked ___, ROMAT
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 aspirin daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*10 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth q8hours Disp #*15
Tablet Refills:*0
3. Humalog ___ 11 Units Breakfast
Humalog ___ 11 Units Dinner
4. Aspirin 81 mg PO DAILY
5. Creon ___ CAP PO TID W/MEALS
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. lactobacillus combination ___ billion cell oral DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 40 mg PO DAILY
10. LORazepam 0.5-1 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
11. Multivitamins 1 TAB PO DAILY
12. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
13. Pantoprazole 40 mg PO Q24H
14. Pyridoxine 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Presumed cholangitis, in the setting of biliary stent and
elevated liver function tests. Does not meet sepsis criteria.
# Leukopenia, mild, may be secondary to oncology therapy.
# Metastatic Pancreatic Cancer, mets to liver and lungs.
# Recurrent Cholangitis
# Transaminitis, with associated elevated alkaline phosphatase.
# Mild coagulopathy (elevated INR)
# Diabetes, adequate control.
# Hypertension, controlled. Holding home lisinopril for now,
plan to resume this at discharge.
# Anxiety
# Normocytic anemia, appears to be chronic and and baseline.
Discharge Condition:
Going home.
Patient ambulating, tolerating regular diet.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It was a pleasure taking care of you this hospitalization. You
were treated for cholangitis, and you underwent ERCP and you had
a stent placed in the common bile duct. This will allow the
common bile duct to drain both from the gallbladder and the
liver better.
Your liver tests were elevated but are trending down. I have
started you on ciprofloxacin and flagyl which you should take
for a total of 7 days for treatment of cholangitis.
Please be advised, I recommend close follow-up with your
outpatient PCP you have an appointment next week with your
oncologist for follow-up of the pancreatic and biliary changes.
Thank you,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina: may
repeat 1 tablet every 5 minutes for up to 3 tablets.
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn as
needed for pain: Back pain. Do not exceed 4grams per day.
6. cholecalciferol (vitamin D3) Oral
7. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. omega-3 fatty acids Oral
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Unstable Angina,CAD
Secondary Diagnosis:
Lung mass
MDS
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for pain in your neck and
chest, and given your changes on electrocardiogram, we were
concerned for a problem with blood flow to your heart. A cardiac
catheterization was performed which showed 2 blockages in your
arteries. These were stented with 2 bare metal stents. Your
symptoms resolved and you were monitored after the procedure.
Additionally, you received 3 units of PRBCs during this
admission for a low blood count.
Please make the following changes to your medications:
START Aspirin 325mg daily
START Plavix 75mg daily
STOP Omeprazole as this can interfere with Plavix, an important
medication to prevent blood clots forming around the new drug
eluting stent.
START Ranitidine 150mg daily. This medication works similarly as
omeprazole and so has been substituted for it.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Ten (10) Subcutaneous qam: Please take 10 U in the
morning; take 6 U on mornings of dialysis.
13. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous before meals as needed: please see insulin sliding
scale.
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
15. glycerin (adult) Suppository Sig: One (1) Suppository
Rectal PRN (as needed) as needed for constipation.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. ceftazidime 1 gram Recon Soln Sig: One (1) Intravenous per
HD for 5 days: please administer after HD, last day ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Nephrotic syndrome/acute kidney injury
Urinary tract infection
Bacteremia
Anemia
.
Secondary:
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
.
It was a pleasure taking part in your medical care. You were in
the hospital because your kidneys were not working well. We
tried IV steroids to help your kidneys but unfortunately you
still required dialysis. You will continue to have dialysis in
rehab and then as an outpatient. You should call your
nephrologist, Dr. ___, to schedule an appointment after
discharge.
.
You also had a urinary tract infection and an infection in your
blood. We treated you with IV antibiotics. You should continue
the antibiotics to complete a 2 week course on days that you get
dialysis.
.
You were also noted to be anemic. You had a small amount of
blood in your stool so you underwent an EGD to rule out bleeding
from you upper GI tract. This showed gastritis (irritation of
the stomach) but no bleeding. You should follow up with Dr.
___ gastroenterologist, as scheduled below to discuss
repeating a colonoscopy.
.
We have made multiple changes to your medications. Please see
the updated list below.
.
Please attend the follow up doctor's appointments as scheduled
below.
.
We wish you all the best!</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 DAILY
3. Ciprofloxacin HCl 250 mg PO Q24H
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Spironolactone 25 mg PO DAILY
7. Outpatient Physical Therapy
Vestibular therapy for BPPV
8. glimepiride 2 mg ORAL QD
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. saxagliptin 5 mg oral qd
11. Vitamin D 50,000 UNIT PO 1X PER MONTH
12. Meclizine 12.5 mg PO TID
RX *meclizine 12.5 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
13. Compression stockings
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Benign Paroxysmal Posistional Vertigo
SECONDARY DIAGNOSES
1. Hyponatremia
2. Chronic urinary tract infections
3. Hypertension
4. Diabetes Mellitus
5. Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for dizziness and lightheadedness which we
believe was caused by Benign Paroxysmal Positional Vertigo. You
were evluated by Neurology and Physical Therapy. You symptoms
improved somewhat during your stay, and it was felt that you
could be discharged home safely. Please use a walker for the
time being until your symptoms fully resolve.
Please follow up with your primary care doctor and vestibular
physical therapy.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Simvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe at bedtime Disp #*14
Syringe Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth q3-5hrs Disp #*80
Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L distal radius and L 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>MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Short arm cast should remain on until follow up. Please keep
cast dry
ACTIVITY AND WEIGHT BEARING:
- NWB in LUE and WBAT LLE
Follow Up:
Please follow up with ___ in the orthopedic trauma
clinic ___ days post-operation for evaluation. Call
___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission and any new medications/refills.
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</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: Amlodipine 10mg PO QD
Atorvastatin 40mg PO QD
Plavix 75mg PO QD
HCTZ 25mg PO QD
Tripletal 600mg PO QAM, 1200mg PO QPM
Aspirin 81mg PO QD
Vitamin D3
Multivitamin
PreserVision AREDS 2 2 tabs daily
Fish oil
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Ischemic Stroke
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 right-sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
Your risk factors for stroke are:
Hypertension
Hyperlipidemia
In order to prevent future strokes, we would like you to use a
heart monitor for 30 days to assess for any rhythm problems,
specifically atrial fibrillation.
Please continue taking 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. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
2. Carvedilol 12.5 mg PO BID
3. DiCYCLOmine 40 mg PO QID
4. Gabapentin 200 mg PO TID
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
6. Niacin SR 1000 mg PO BID
7. Rosuvastatin Calcium 2.5 mg PO DAILY
8. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
9. Byetta (exenatide) 10 mcg/0.04 mL subcutaneous BID
10. exemestane 25 mg oral daily
11. losartan-hydrochlorothiazide 50-12.5 mg oral daily
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. PredniSONE 20 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
14. PredniSONE 10 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
15. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
16. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg 1 tablet(s) by
mouth q6 Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Inflammatory arthritis and rash
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 worsening rash and arthritis. We feel
that the rash and arthritis are probably inflammatory (not
infectious or contagious in origin) and likely are related to an
autoimmune process. For this reason, we started you on
steroids, with significant improvement in your joint swelling.
You will need to be on prednisone 30 mg X 3 days, 20 mg X 3
days, 10 mg X 3 days, 5 mg X 3 days, then can stop. Rheumatology
will contact you regarding a follow up appointment next week.</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
Take as instructed by your Neurologist.
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
Take as instructed by your Neurologist.
3. Aspirin 325 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*1
6. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
7. Famotidine 20 mg PO BID
8. Methylprednisolone 10 mg PO BID Duration: 2 Doses
See package insert for tapering the dose.
This is dose # 2 of 6 tapered doses
RX *methylprednisolone 4 mg Taper tablets(s) by mouth as
directed Disp #*1 Dose Pack Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Headaches
Left ICA aneurysm s/p pipeline embolization
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 ___ Neurosurgery service for further
evaluation of your headache. Your non-contrast head CT was
stable and showed no new signs of bleeding. You were kept
overnight for observation. As you remained neurologically
stable, you are being discharged home with the following
instructions.
- As instructed by your Neurologist, do not take more than one
dose of either Fioricet or Tylenol three times during the week.
If you do, you are risk for rebound headaches.
- You are being discharged on a Medrol dosepack which could help
in diminishing your headache symptoms.
- You are also being started on Gabapentin at the recommendation
of Neurology. This is used to help treat your left facial
tingling and headaches.
- If you have any questions or concerns, you may call the
Neurosurgery office or your Neurologist.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
5. Senna 8.6 mg PO BID
6. Albuterol Inhaler 4 PUFF IH Q6H:PRN sob/wheezing
7. ClonazePAM 0.5 mg PO BID
8. CloNIDine 0.1 mg PO BID
9. FLUoxetine 40 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Loratadine 10 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. Omeprazole 20 mg PO BID
15. Tiotropium Bromide 1 CAP IH DAILY
16.Rolling Walker
Diagnosis: Right femur fx
Prognosis: good
length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
regular
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 right 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 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- 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:
- weight bearing as tolerated right lower extremity
Treatments 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. 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.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 1 Day
4. Metoprolol Tartrate 37.5 mg PO Q6H
5. Vitamin D ___ UNIT PO 1X/WEEK (___)
6. Warfarin 2.5 mg PO DAILY16
7. Atorvastatin 10 mg PO QPM
8. Clobetasol Propionate 0.05% Soln 1 Appl TP BID scalp soln
9. Losartan Potassium 50 mg PO DAILY
10. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Encephalopathy
Urinary tract infection
Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital with confusion because of a
urinary infection. This improved with antibiotics. You were also
found to have an abnormal heartbeat when you came to the ER
called "A fib." You had an echo that showed an EF of 75% with
moderately thickened mitral valve leaflets. We started you on a
blood thinner called Coumadin to prevent strokes which will be
titrated at the rehab facility.
It was a pleasure to take care of you,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Tacrolimus 1.5 mg PO Q12H
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth Twice a day Disp
#*30 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.5 mcg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Febuxostat 120 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Pantoprazole 40 mg PO Q24H
16. Sirolimus 1 mg PO DAILY
17. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
-Atypical chest pain
Secondary diagnosis
- Acute kidney injury
- End stage renal disease status point kidney transplant
- 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 Ms. ___,
You were admitted to the hospital because you were having chest
pain and shortness of breath. Our tests for blood clots and
heart attacks were all normal. Your pain improved, and we felt
it was safe to be discharged and follow up with your
cardiologists for a possible echocardiogram or stress test.
Please call your cardiologist and make an appointment in the
next few weeks for an echocardiogram or stress test. Please also
get your standing kidney labs checked on ___ or ___ at
your usual site; they will be forwarded to your kidney doctor.
Your dose of Prograf was decreased from 2mg twice a day to 1.5
mg twice a day based on your blood levels.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Methimazole 2.5 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Psyllium 1 PKT PO DAILY
6. tolterodine 4 mg oral daily
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve hours
Disp #*8 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 10 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
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. ___,
You came to ___ for abdominal pain, and you were treated with
antibiotics for a urine infection (which we think was the cause
of your pain). We will discharge you home with a course of
cefpodoxime (antibiotics) for your urine infection. You also
talked to a member of a home hospice team but declined their
program at this time.
Please see below for your medications and antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking opiate pain medications.
4. insulin lispro 100 unit/mL Solution Sig: As directed
Subcutaneous QIDACHS: glucose 151-200, 2U
201-250, 4U
251-300, 6U
301-350, 8U
351-400, 10U
Higher than 400, call your PCP.
Disp:*2 pens* Refills:*2*
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
ONCE (Once): constipation. Suppository(s)
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
syncopal episode secondary to dehydration and medication
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___ [/INST] </s><s>Continue to take the Flomax as directed and do not take the
terazosin until you see your PCP. Continue to drink and eat
adequately. It is important to stay hydrated.
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. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
standing dose
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days
RX *enoxaparin 40 mg/0.4 mL once a day Disp #*28 Syringe
Refills:*0
4. Gabapentin 800 mg PO Q8H pain
RX *gabapentin 800 mg every eight (8) hours Disp #*60 Tablet
Refills:*0
5. Multivitamins 1 CAP PO DAILY
6. Senna 1 TAB PO BID
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg every four (4) hours Disp #*100 Tablet
Refills:*0
8. hospital bed
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right distal femur fracture
Discharge Condition:
stable
alert and oriented
ambulatory with assistance
Followup Instructions:
___ [/INST] </s><s>******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Partial weight bearing right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with Dr ___ in 14 days post-operation
for evaluation. Call ___ to schedule appointment upon
discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
partial weight bearing RLE
Treatments Frequency:
physical therapy</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once daily at
bedtime Disp #*30 Tablet Refills:*5
2. Cyanocobalamin 500 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth
once daily Disp #*30 Tablet Refills:*5
3. Apixaban 2.5 mg PO BID
4. Atenolol 50 mg PO DAILY
5. LevoFLOXacin 500 mg PO Q24H
6. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
transient dysarthria not secondary to TIA or stroke
Mild Vitamin B12 deficiency
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 slurred speech due to
concern for an ACUTE ISCHEMIC STROKE, a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms. However, the MRI of your brain did not show
evidence of stroke or TIA. Your symptoms could have been related
to blood pressure, dehydration, alcohol use, or a combination of
these factors.
We are changing your medications as follows:
Increase apixaban to 2.5mg twice daily
Start Vitamin B12 daily supplement
Please take your other medications as prescribed.
Please follow up with your primary care physician as listed
below. You should also follow up with your cardiologist as you
were noted to have occasional pauses on cardiac monitoring.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, please pay attention to
the sudden onset and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. BuPROPion 75 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Furosemide 80 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Simvastatin 20 mg PO QPM
8. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0
9. Doxazosin 4 mg PO BID
RX *doxazosin 4 mg 1 tablet(s) by mouth BID (twice daily) Disp
#*60 Tablet Refills:*0
10. NovoLOG (insulin aspart) 0 units SUBCUTANEOUS QAC
Please take per home dosing
11. Lantus (insulin glargine) 15 units SUBCUTANEOUS QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. End Stage Renal Disease
2. Hypocalcemia
3. Hypertension
Secondary Diagnosis:
1. Diabetes, Type I
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you!
You were admitted with poor kidney function and started on
hemodialysis through your left brachiocephalic fistula placed in
___. You tolerated 3 sessions of HD well and will
continue HD as an outpatient at ___ Dialysis ___
beginning ___ at 3pm.
You were also noted to have very low calcium which is likely due
to poor vitamin D absorption because of your kidney disease. You
were given IV calcium with improvement in your calcium level.
You calcium will continue to be corrected at dialysis.
You also had elevated blood pressure during this admission,
likely due to excess fluid prior to hemodialysis. Your doxazosin
was increased during this admission. Your blood pressure
improved with increased doxazosin and hemodialysis. Your HCTZ
(hydrochlorathiazide) was stopped as this is not effective given
your kidney function.
While here, you were noted to lack immunity to hepatitis B. You
were given the first of three vaccines here. You will need to
follow-up with your primary doctor for the second vaccine in 1
month and the third vaccine in 6 months.
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Nizoral 2 % Shampoo Sig: One (1) use Topical twice weekly.
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
6. lisinopril-hydrochlorothiazide ___ mg Tablet Sig: One (1)
Tablet PO once a day: Do not re-start until ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic hypotension secondary to medication error at home
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 feeling dizzy. Because you took an extra
dose of your blood pressure medication, this made your blood
pressure low. When you were straining to have a bowel movement,
your blood pressure was low enough to cause your symptoms.
Please make sure to get a pill-box from your pharmacy as we
discussed. Taking incorrect medication can be very dangerous,
and a pill-box can help keep track of which medications you
should take and when. One thing to consider is to have two
pillboxes, one for the morning, and one for the evening to help
prevent getting confused.
Please note the following medication changes:
-Please DO NOT TAKE your lisinopril-hydrochlorothiazide (blood
pressure medicine) today. You can restart this medicine
tomorrow, ___.
-We have not changed any of your other medications</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ondansetron ODT 4 mg PO Q8H:PRN nausea/vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*2
2. Minocycline 50 mg PO BID
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. Bisacodyl ___VERY 3 DAYS IF NO BOWEL MOVEMENT DURING
THE OTHER TWO DAYS
5. Diazepam 5 mg PO Q12H:PRN agitation
6. Docusate Sodium 100 mg PO BID
7. Dronabinol 5 mg PO QID
8. Omeprazole 80 mg PO DAILY
9. Pseudoephedrine 30 mg PO Q6H:PRN congestion
10. Senna 8.6 mg PO BID
11. Sertraline 200 mg PO DAILY
12. Simethicone 40 mg PO TID
13. Tazorac (tazarotene) 0.1 % topical DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
[] Intussusception of sigmoid colon at the stoma site
[] Postoperative fascial dehiscence with evisceration
[] Bacteremia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent (Hx of CP)
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ with abdominal pain and bowel
prolapsing out of your colostomy. You were taken urgently to the
operating room for repair of the bowel. Five days after your
operation, you developed a fascial dehiscence and had bowels
protruding from your incision. This required you be taken back
urgently to the operating room for repair. You have tolerated
these procedures well.
Your blood and urine cultures were positive for bacterial
growth, and you have completed a course of antibiotics to treat
this.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
**You will go home with the Foley Catheter in place. Your
urologist should remove this in clinic in ___ days time.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 325 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Valsartan 80 mg PO DAILY
4. PrimiDONE 50 mg PO HS
5. Pravastatin 20 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Colchicine 0.6 mg PO DAILY
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily, as
needed Disp #*30 Tablet Refills:*0
8. Labetalol 200 mg PO QAM
Please take your 200mg dose of Labetolol at 6:00am every
morning.
RX *labetalol 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Labetalol 300 mg PO QPM blood pressure
Please take your 300mg dose of Labetolol at 6:00pm every night.
RX *labetalol 300 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
10. Labetalol 300 mg PO QPM
please take 3rd dose of the day of 300mg at 10pm
11. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every ___
hours as needed for pain Disp #*30 Tablet Refills:*0
12. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
intramural hematoma
Discharge Condition:
stable, AAOx3, clear and coherent
Followup Instructions:
___ [/INST] </s><s>CALL THE OFFICE FOR: ___
- Sudden onset of chest pain, abdominal pain, back pain,
neck pain, jaw pain or left or right arm pain.
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move, use or feel your arm
or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cyanocobalamin ___ mcg PO DAILY
2. 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 #*6 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. Senna 17.2 mg PO QHS:PRN Constipation - First Line
5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
7. Calcium Carbonate 500 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
13. Vitamin D ___ UNIT PO DAILY
14. HELD- Alendronate Sodium 10 mg PO DAILY This medication was
held. Do not restart Alendronate Sodium until ___, then
you can start it
15. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until the rehab doctors think ___ need it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute blood loss anemia
left hip hematoma
___ on CKD
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You came to the hospital because your blood count was low. It
improved after getting blood. You had bleeding into your hip
after your surgery. This can happen sometimes. It was likely
made worse by the lovenox given to you to help prevent blood
clots. You are no longer taking that medicine, so it is very
important to keep intermittent compression on your legs and move
as much as you can at rehab.
It was a pleasure caring for you and 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 650 mg PO TID
please change to every 6 hours PRN as needed for pain after
___
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezes
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
continue until patient becomes ambulatory
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Omeprazole 20 mg PO DAILY
8. amLODIPine 5 mg PO DAILY
9. FLUoxetine 20 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Levothyroxine Sodium 50 mcg PO DAILY
14. LORazepam 1 mg PO Q8H:PRN anxiety
15. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: mechanical fall
right sided rib fractures, ___
small right apical pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital after a fall in which you
sustained right sided rib fractures and a small collapse of your
right lung. Your vital signs have been stable and you are
preparing for discharge to a rehabilitation center to help
further regain your strength and mobility. You are being
discharged with the following instructions:
Your injury caused right sided_rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
In addition to the rib fracture recommendations, I have included
the following instructions:
You experience new chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*9 Tablet Refills:*0
2. Acetaminophen ___ mg PO Q8H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Meclizine 12.5 mg PO TID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Montelukast Sodium 10 mg PO HS
7. Myfortic (mycophenolate sodium) 360 mg oral BID
8. NIFEdipine CR 90 mg PO DAILY
9. Ranitidine 300 mg PO DAILY
10. Outpatient Lab Work
Labs: Chem-7 and tacrolimus trough level
Please fax results to ___.
ICD-9 code: ___
11. Tacrolimus 3 mg PO QAM
RX *tacrolimus 1 mg 3 capsule(s) by mouth every morning Disp
#*90 Capsule Refills:*0
12. Tacrolimus 4 mg PO QPM
RX *tacrolimus 1 mg 4 capsule(s) by mouth every evening Disp
#*120 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
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 to care for you here at ___
___. You were admitted on ___ for abdominal
pain and found to have a urinary tract infection. You were
treated with antibiotics. You will need to continue to take this
medication until it is finished (last day is ___.
Additionally, your tacrolimus dose was changed. It is very
important that you have your tacrolimus level checked at a lab
in 1-week (have the lab fax these results to ___.
It is also very important you be seen by the ___
here at ___. Please see below for scheduled appointment.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice daily Disp #*60 Tablet Refills:*0
3. Nystatin Oral Suspension 5 mL PO QID Duration: 14 Days
RX *nystatin 100,000 unit/mL 5 mL by mouth four times daily
Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six hours Disp
#*20 Tablet Refills:*0
7. Mycophenolate Mofetil 1500 mg PO BID
RX *mycophenolate mofetil 500 mg 3 tablet(s) by mouth every 12
hours Disp #*30 Tablet Refills:*0
RX *mycophenolate mofetil 500 mg 3 tablet(s) by mouth every 12
hours Disp #*180 Tablet Refills:*0
8. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
9. Alendronate Sodium 70 mg PO QWED
10. ALPRAZolam 0.25 mg PO TID:PRN anxiety
11. Amitriptyline 10 mg PO QHS
12. FLUoxetine 40 mg PO DAILY
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=============================
# MIXED CONNECTIVE TISSUE DISORDER FLARE / MYOSITIS
SECONDARY DIAGNOSES
=============================
# ELEVATED TROPONIN
# ELEVATED TRANSAMINASES
# VOLUME OVERLOAD
# DIAPHORETIC EPISODES
# ORAL CANDIDIASIS
# MACROCYTIC ANEMIA
# BORDERLINE QTc
# LIKELY MILD SCLERODERMA ASSOCIATED LUNG DISSEASE
# DYSPHAGIA
# LEFT HIP BURSITIS
# STEROID INDUCED HYPERGLYCEMIA
# FIBROMYALGIA
# BONE HEALTH
# HYPOTHYROIDISM
# ANXIETY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- weakness
- worsening symptoms of your connective tissue disorder
What was done for you in the hospital:
- We gave you high dose steroids and IVIG to help treat your
connective tissue disorder.
- We performed a stress test to test your heart function - this
showed it was in good condition
- We gave you a medication (Lasix) to help remove extra fluid
from your body received from the IVIG. With this your breathing
improved.
- You were evaluated by the rheumatology team who will continue
to see you as an outpatient.
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
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. Hydration
Dx: Hypercalcemia, metastatic renal cell carcinoma.
IV normal saline 2L/d at 150mL/hr.
Dispense: 14L.
Refills: 4.
2. axitinib *NF* 5 mg Oral BID
3. Lactulose 30 mL PO BID
please titrate to 2 BMs
RX *lactulose 10 gram/15 mL 30 mL by mouth twice a day Disp
#*1800 Milliliter Refills:*1
4. Ondansetron 8 mg PO Q8H:PRN Nausea
5. denosumab *NF* 120 mg/1.7 mL (70 mg/mL) Subcutaneous ONCE
Next due on ___
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 1 TAB PO BID:PRN cpnstipation
8. Dronabinol 2.5 mg PO BID
Take before lunch and dinner.
9. Ranitidine 150 mg PO BID
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth q6HR
Disp #*20 Tablet Refills:*1
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q4HR Disp #*50 Tablet
Refills:*0
12. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*1
13. Calcitonin Salmon 200 UNIT NAS DAILY:PRN High calcium
Do not take for more than one week.
RX *calcitonin (salmon) 200 unit/dose 1 spray NAS Daily Disp #*1
Bottle Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypercalcemia (elevated calcium level).
Weakness/fatigue.
Altered mental status (confusion).
Metastatic kidney cancer.
Hyponatremia (low sodium level).
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>You were hospitalized for fatigue, altered mental status
(confusion), and hypercalcemia (elevated calcium levels). The
high calcium is likely the cause of the fatigue and confusion.
Also, your blood sodium level was low. You were treated with
intravenous fluids and your symptoms and calcium improved.
Additionally, CT of the head and abdomen were unrevealing other
than progressing cancer in the liver. MRI of the brain was
normal. Because the current chemotherapy is not working, you
will be changed to a new chemotherapy medication called
everolimus (Afinitor), which has been ordered and should arrive
in approximately one week. In the meantime, you should continue
the previous chemotherapy axitinib. You have also been set up
for home IV fluids to maintain a low calcium level. You were
started on calcitonin a nasal spray to help bring your calcium
levels down. This should be used sparingly as it does not
continue to work long-term (>1 week). You can use it when you
suspect the calcium levels are elevated (worsening
fatigue/weakness, confusion, or confirmed high calcium on blood
work). You will need to continue monthly denosumab (Xgeva)
injections in the clinic.
While you were hospitalized, you were evaluated by a
nutritionist. The following recommendations were made by the
nutritionist:
1. Please start drinking Ensure Plus three times per day.
2. Please continue eating and drinking as much as possible.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24h Disp
#*21 Intravenous Bag Refills:*0
2. Fentanyl Patch 100 mcg/h TD Q72H
3. Pregabalin 300 mg PO TID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Docusate Sodium 100 mg PO BID
6. Celecoxib 200 mg ORAL DAILY
7. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Liver abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because your liver
abscess grew out bacteria. You were started on IV antibiotics
and had a "PICC" (a semi-permanent IV) placed. You will be
discharged on IV antibiotics to be continued for at least 3
weeks. You will need a repeat Ultrasound in 3 weeks to evaluate
the abscess. You should keep the drain in place until then (care
instructions below).
Please follow up at your appointments as scheduled.
We wish you the best!
~your ___ team
___ Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
-If you drain stops putting out any fluid, please have the ___
call Interventional Radiology at ___ at ___ and page
___. This is the Radiology fellow on call who can assist you.
-A ultrasound should be scheduled for you in 3 weeks. We will
review the ultrasound and determine if the collection has
resolved, if so we will pull the drain at this time.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Duloxetine 30 mg PO DAILY
6. Gabapentin 1800 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Omeprazole 40 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. Quinapril 40 mg PO DAILY
12. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*40 Tablet Refills:*0
13. TraZODone 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*7 Tablet Refills:*0
14. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*63 Tablet Refills:*1
15. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram 1000 mg ___ 24 hours Disp #*42 Vial
Refills:*0
16. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*84 Tablet Refills:*0
17. Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
LABS:
VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough
QUINOLONES: 7 DAYS POST DISCHARGE: AST, ALT, Total Bili, ALK
PHOS
18. Collagenase Ointment 1 Appl TP DAILY
Apply to R foot wound bed
RX *collagenase clostridium histo. [Santyl] 250 unit/gram Apply
Daily Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Foot Infection
Osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for treatment of your Right
foot Infection. You had samples of your bone obtained for
pathology evaluation. The results revealed an infection in your
bone for which you will need to receive at least 6 weeks of IV
antibiotics. You were given IV antibiotics and your ulceration
was treated while in the hospital. You are being discharged home
with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.</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
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
3. ClonazePAM 0.25 mg PO BID PRN anxiety
4. Escitalopram Oxalate 2.5 mg PO BID
5. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left cerebellar infarct
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 nausea and gait
instability resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Elevated cholesterol (Chol 239, LDL 166)
We are changing your medications as follows:
Begin Atorvastatin
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. Ezetimibe 10 mg PO DAILY
2. Furosemide 40 mg PO ONCE Duration: 1 Dose
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Tartrate 50 mg PO BID
4. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
# Shortness of breath
# Alcoholic cirrhosis complicated by ascites and edema
Secondary diagnoses:
# Hypertension
# Dyslipidemia
# Diabetes mellitus, type 2
# Pancreatic adenocarcinoma
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 ___. You were admitted
after you had some shortness of breath after your EGD procedure.
You received a paracentesis in the Emergency Department to
remove fluid from your belly. We also gave you a diuretic during
your stay in the hospital. Your symptoms improved and we
discharged you home.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q4H
2. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
3. Gabapentin 1200 mg PO Q8H
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
L hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT
Physical Therapy:
WBAT
Treatment Frequency:
daily DSD</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen-Caff-Butalbital 2 TAB PO Q8H:PRN Pain -
Moderate
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 2 tablet(s)
by mouth three times a day Disp #*180 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 4 mg ___ tablet(s) by mouth every 3 hours as
needed Disp #*180 Tablet Refills:*0
3. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H:PRN
pain
RX *hydromorphone 1 mg/mL ___ mg by mouth every 3 hours as
needed for pain Disp ___ Milliliter Milliliter Refills:*0
4. Ondansetron ODT ___ mg PO DAILY:PRN severe nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth once a day as needed
Disp #*8 Tablet Refills:*0
5. Senna 17.2 mg PO TID constipation
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO BID
8. Gabapentin 1500 mg PO QHS
9. Letrozole 2.5 mg PO DAILY
10. LORazepam 0.5 mg PO Q4H:PRN anxiety/nausea
RX *lorazepam 0.5 mg 1 tablet by mouth every 4 hours as needed
Disp #*80 Tablet Refills:*0
11. Methadone 2.5 mg PO QAM
12. Methadone 10 mg PO QHS
13. Metoclopramide 10 mg PO QID:PRN nausea
14. Omeprazole 20 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic Breast Cancer
Headaches
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 headache. Your lumbar puncture did not
show evidence of cancer cells in the fluid surrounding the
brain. It is not clear what is causing the headaches at this
point, but we do not think there are cancer cells around the
brain causing them and therefore we would not recommend
radiation treatment to the brain at this time. You do have some
cancer in the skull, which could be pressing on the brain or
blood vessels in some areas of the head and causing the
headaches.
For pain, we decided on the following regimen:
Take the following meds NO MATTER WHAT:
Gabapentin and methadone
ADDITIONAL MEDS TO TAKE WHEN YOUR PAIN GETS WORSE:
If you have more pain during the day, take ___ (can take up
to 2 tabs, three times a day - so total of 6 tabs) or dilaudid.
Dilaudid you can take ___ mg (recommend taking at least 6) every
___ hours as needed for additional pain.
We STOPPED your morphine. Use dilaudid now when you would have
taken the morphine before.
Because you are taking the ___ use Tylenol because
the ___ has Tylenol in it too.
FOR NAUSEA:
For your nausea, take metoclopramide up to 4 times a day as
needed if you need it for nausea, and if you are having a lot of
nausea just take the metoclopramide three times a day no matter
what to prevent it. and if needed low doses of Ativan can make
you sleepy but would be fine to use.
IN CASE OF EMERGENCIES WHEN YOU ARE TOO NAUSEATED TO TAKE PILLS:
** in emergency when you are too nauseated to take a pill, we
have sent you with a prescription for ondansetron (also called
Zofran) which can be dissolved under the tongue</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO EVERY OTHER DAY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Vitamin D ___ UNIT PO DAILY
8. bifidobacterium infantis 4 mg oral daily
9. Cyanocobalamin 1000 mcg IM/SC QMONTH
10. Docusate Sodium 100 mg PO BID
11. Estrogens Conjugated 0.625 mg PO EVERY OTHER DAY
12. Estrogens Conjugated 1.25 mg PO EVERY OTHER DAY
13. Famotidine 10 mg PO BID
14. Losartan Potassium 25 mg PO DAILY
15. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
16. Outpatient Lab Work
Please have your creatinine checked on ___. Results should
be faxed to Dr. ___ office at ___.
Diagnosis: urinary tract infection
Discharge Disposition:
Home
Discharge Diagnosis:
Proteus bacteremia
Occlusive nephrolithiasis
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 left groin pain which most likely occurred
from a kidney stone which passed quickly while you were in the
hospital. You were found to have a blood stream infection most
likely from acute urinary obstruction causing bacteria to move
from your urinary system into the blood. You were treated with
an antibiotic and will continue for a total 2 week course.</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 priviliege to care for you at the ___
___. You were admitted with back and leg pain and
found to have muscle inflammation that is likely a side effect
of your statin medication. We held this medication and you
received IV fluid hydration to improve your kidney injury. You
were seen by our physical therapist, who recommended that you go
to rehab to get stronger.
You ate quite a few bananas and your potassium was a little
high, so we held your blood pressure medication at discharge,
this can be restarted as an outpatient.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed 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. ClonazePAM 0.5 mg PO Q8H PRN anxiety
2. QUEtiapine Fumarate 200 mg PO QHS
3. Simvastatin 20 mg PO DAILY
4. Valproic Acid ___ mg PO QHS
5. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by
mouth every 6 hours Disp #*90 Capsule Refills:*0
6. PredniSONE 60 mg PO DAILY
Please take until instructed otherwise by your oncologist
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*50 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Ipilimumab-associated colitis
Secondary diagnosis: Malignant Melanoma, Hypovolemic
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you! You were admitted to the
inpatient oncology service at ___
___ diarrhea. We think your diarrhea is related to your
ipilimumab and started you on steroids for this. You had a
procedure to look at your colon called a sigmoidoscopy. Biopsies
for this were taken which showed colitis (inflammation of your
colon). Please continue to take steroids as prescribed until you
see your oncologist. Thank you for allowing us to participate in
your care!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. BD Ultra-Fine Mini Pen Needle (pen needle, diabetic) 31
gauge x ___ miscellaneous QID
RX *pen needle, diabetic [BD Ultra-Fine Mini Pen Needle] 31
gauge X ___ four times a day Disp #*90 Each Refills:*0
2. Cephalexin 500 mg PO QID Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth q6hr Disp #*28
Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO BID Duration: 7 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
4. FreeStyle Lancets (lancets) 28 gauge miscellaneous QID
RX *lancets [FreeStyle Lancets] 28 gauge four times a day Disp
#*360 Each Refills:*0
5. FreeStyle Lite Meter (blood-glucose meter) miscellaneous
QID
RX *blood-glucose meter [FreeStyle Lite Meter] four times a
day Disp #*1 Kit Refills:*0
6. FreeStyle Lite Strips (blood sugar diagnostic)
miscellaneous QID
RX *blood sugar diagnostic [FreeStyle Lite Strips] four times
a day Disp #*360 Strip Refills:*0
7. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
subcutaneous sliding scale (beginning at 8u for fingerstick
>200)
8. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous DAILY, 35u qAM if fingerstick >200
9. Losartan Potassium 25 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 500 mg PO BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Omeprazole 20 mg PO DAILY GERD
14. Oxybutynin XL (*NF*) 10 mg Other DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
CELLULITIS
DIABETIC KETOACIDOSIS
THROMBOCYTOPENIA
SECONDARY
=========
BACTEREMIA - Coagulase negative staph
OBESITY
HYPERLIPIDEMIA
HYPERTENSION
HEART FAILURE WITH REDUCED EJECTION FRACTION
BREAST CANCER
TYPE 2 DIABETES MELLITUS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were not feeling well and
had an infection on your arm.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were also given insulin for your high blood sugar levels.
You met with the ___ diabetes experts, who came up with a
plan for managing your diabetes. You were given IV antibiotics
for your infection that had spread to your blood and discharged
on PO antibiotics.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please measure your blood sugars at home while on metformin.
If your sugars are > 200, please administer insulin as
recommended (lantus 35U in the morning as well as Humalog per
the sliding scale provided to you)
- Please go to your ___ appointment at ___
- Please see your PCP to ___ on your medical conditions
- 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. Budesonide 9 mg PO DAILY
RX *budesonide 9 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral
DAILY
4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks
5. Vitamin D ___ UNIT PO DAILY
1. Budesonide 9 mg PO DAILY
RX *budesonide 9 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral
DAILY
4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's disease
Acute abdominal pain
Chronic asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ with abdominal pain after some
alcohol consumption and fast food consumption. Your acute pain
went away with bowel rest and time.
You were seen by the GI doctors who ___ that your underlying
Crohn's disease was not adequately treated with your present
regimen of medication and they advised that we start you on
budesonide daily.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Dexamethasone 4 mg PO Q6H
2. HYDROmorphone (Dilaudid) 0.125-0.25 mg IV Q4H:PRN Moderate
Pain
RX *hydromorphone [Dilaudid] 0.5 mg/0.5 mL 0.125-0.25 mg IV q3h
PRN Disp #*15 Syringe Refills:*0
3. LevETIRAcetam 500 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Meningioma
Cerebral Edema with Midline Shift
Secondary:
HTN
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
You were not eating well and you had lost a lot of weight.
WHAT HAPPENED WHILE YOU WERE HERE?
You had imaging of your head that showed a brain tumor and
swelling. We gave you medication to help reduce the swelling and
prevent seizures.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- You are being discharged to a ___ facility where the
doctors and ___ continue to make sure you are
comfortable.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*9 Tablet Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. FLUoxetine 60 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
9. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth once Disp
#*1 Tablet Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY:PRN heart burn
12. OXcarbazepine 450 mg PO BID
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
====================
Ureterovesicular Stone
Urinary Tract Infection
Seizure Disorder
Secondary Diagnosis:
=====================
History of Roux en y procedure
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/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 of back pain and
because you had a stone that was in your urinary system.
What was done for me while I was in the hospital?
You had a renal ultrasound and a CT scan which showed a stone.
Your kidney showed some dilation, but this is mild.
You received IV fluids and IV antibiotics and your pain
resolved.
We discussed the imaging with our Urology team who felt that the
stone will likely pass on its own.
What should I do when I go home?
Please continue to take your antibiotics for the next 5 days.
You will be contacted by the Urology office to be seen in
clinic.
It is very important you take your seizure medication every day.
If you notice worsening abdominal pain or fever, please return
to the emergency department.
You should drink 2.5L of water every day.
Please call your primary care provider to be seen within the
next 7 days.
We wish you the best!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic BID (2 times a day).
2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: One (1)
Capsule, Delayed & Ext.Release PO DAILY (Daily).
Disp:*30 Capsule, Delayed & Ext.Release(s)* Refills:*0*
7. Outpatient Lab Work
Please have your electrolytes checked (including sodium,
potassium, bicarbonate, chloride, BUN, creatinine, glucose,
calcium, magnesium and phosphorus) prior to your
Nephrology-Renal appointment or PCP ___.
FAX RESULTS TO: ___, MD ___
8. pamidronate 90 mg/10 mL (9 mg/mL) Solution Sig: Ninety (90)
mg Intravenous once a month for 3 months: last dose ___ -
next dosing in a ___ months.
Disp:*3 doses* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Severe hypercalcemia
2. Unintentional weight loss
3. Generalized malaise and fatigue
4. Chronic, persistent diarrhea with microscopic colitis
5. Right-sided upper lobe lung nodule concerning for early
bronchogenic carcinoma
.
Secondary Diagnoses:
1. Temporal arteritis
2. Osteopenia
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Hyperparathyroidism (per report)
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>Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your fatigue, weakness, and unintential weight loss and
persistent, chronic diarrhea. Laboratory evaluation revealed you
had life-threatening hypercalcemia and acute kidney injury
(acute renal failure) which was treated aggressively with IV
hydration. You were treated with medications to lower your
calcium and further laboratory studies and imaging were obtained
to determine the source of your elevated calcium. You had an
upper and lower endocscopy performed which showed no evidence of
malignancy, just some microscopic colitis. You had an extensive
work-up started to rule out malignancy, and your chest imaging
showed a right-sided lung nodule. All of your other laboratory
work was reassuring. Your nutrition remains a concern, and you
should consider follow-up with a Nutritionist regarding these
issues. You will follow-up with your primary care physician, an
___, your Renal and GI physicians.
.
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
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Budesonide 3 grams by mouth daily
START: Pamidronate 90 mg IV every 7-days at the Pheresis IV
infusion clinic for hypercalcemia treatment. Your primary care
physician ___ help coordinate this.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Calcium supplement
DISCONTINUE: Vitamin D supplement
DISCONTINUE: Triamterene-Hydrochlorothiazide
DISCONTINUE: Gabapentin
DISCONTINUE: Citalopram
DISCONTINUE: Cholestyramine-Aspartame
DISCONTINUE: Prochlorperazine
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ibuprofen 400 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Spinal cord compression from metastatic disease
Secondary diagnoses:
Metastatic melanoma
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 stay at ___. You were
admitted for lower extremity weakness with falls. You received
an MRI which showed that your cancer has probably spread to your
spine; however, the imaging did not show definite signs of
spinal cord compression. The spine surgeons examined you and
reviewed your records, and did not feel you would benefit from
surgery at this time. You were seen by physical therapy, who
felt you could benefit from rehabilitation services as an
outpatient. You were sent home in good condition. Your
follow-up appointments are listed below.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
2. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*28 Tablet Refills:*0
3. Ascorbic Acid ___ mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium Carbonate 500 mg PO BID
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. GlipiZIDE 10 mg PO DAILY
12. Lisinopril 5 mg PO DAILY
13. LORazepam 0.5 mg PO Q12H:PRN anxiety
14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
Reason for PRN duplicate override: changing frequency of drug
18. Pantoprazole 40 mg PO Q24H
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
20. Sarna Lotion 1 Appl TP BID:PRN pruritis over back
21. Senna 8.6 mg PO BID:PRN constipation
22. Sertraline 100 mg PO DAILY
23. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
24. Zinc Sulfate 220 mg PO DAILY
25. HELD- Gemfibrozil 600 mg PO BID This medication was held.
Do not restart Gemfibrozil until told to do so by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non-ST elevation myocardial infarction requiring stent placement
Severe sepsis secondary to cellulitis
Secondary:
Coronary artery disease
Peripheral vascular disease
Diabetes mellitus
Hypertension
Hyperlipidemia
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were seen at ___ for fevers
and for chest pain. Your fevers were ultimately felt to be due
to an infection of your skin/fat tissue (called "cellulitis").
You were initially treated with broad IV antibiotics but these
were adjusted to oral antibiotics with the input of infectious
disease. You will continue these antibiotics (cephalexin) for 7
days after you are discharged (end ___.
For your chest pain, you underwent a cardiac catheterization
early in your admission to determine if there was a blockage in
the arteries to your heart.
What should you do when you leave the hospital?
- Please follow up with the appointments we have arranged.
- Please continue cephalexin (an antibiotic) until ___.
- Please discontinue your gemfibrozil due to the
drug-interaction with atorvastatin.
- There were no other major medication changes. Please continue
taking your Plavix.
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: xxxxxxxx
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right femur fracture
left hip dislocation, s/p closed reduction in ED
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Followup Instructions:
___ [/INST] </s><s>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:
- RLE WBAT
- LLE WBAT w/ posterior hip precautions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- 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.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
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</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4G/day
2. LevETIRAcetam 500 mg PO BID Duration: 7 Days
Take for a total of 7 days, End date ___
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*9 Tablet Refills:*0
3. Amiodarone 200 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Gabapentin 600 mg PO QID
8. Glucosamine (glucosamine sulfate) 1000 mg oral DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Januvia (SITagliptin) 100 mg PO DAILY
11. Jardiance (empagliflozin) 10 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Metoprolol Tartrate 75 mg PO BID
14. Pantoprazole 20 mg PO Q24H
15. Polyethylene Glycol 17 g PO DAILY
16. Ranitidine 150 mg PO BID
17. Senna 17.2 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Mild traumatic brain injury
Traumatic acute subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions:
Traumatic Brain Injury
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.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
**Please DO NOT take your ___ for at least one month
following your injury. Please follow-up with your PCP/Prescriber
regarding this important medication change. At your follow up
appointment with Dr. ___ your ___ will be
discussed.
You have been discharged on Keppra (Levetiracetam). 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.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 80 mg PO QPM
2. Eplerenone ___ mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. LamoTRIgine 100 mg PO BID
5. Modafinil 200 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Aspirin 81 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. ammonium lactate 12 % topical BID
11. HydrALAZINE 37.5 mg PO Q8H
RX *hydralazine 25 mg 1.5 tablet(s) by mouth every eight (8)
hours Disp #*120 Tablet Refills:*6
12. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
13. Pantoprazole 40 mg PO Q12H
14. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
decompensated heart failure
NSTEMI
anemia likely secondary to bleed
HepC cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
You were admitted for your chest pain and management of bleeding
of vessels in your stomach due to your liver disease. You were
initially managed in the ICU for difficulty breathing and found
to have worsening heart failure and need for blood transfusions.
After you were stabilized and transferred to the medicine
floors, you had your procedure to stop the vessels in the
stomach from bleeding.
You are to continue your medications as shown below and
follow-up with your appointments listed. If you have pain,
swelling, purulence at the incision site or in your abdomen, you
should return to the hospital immediately. If you have recurring
chest pain, shortness of breath, severe fatigue/weakness, you
should return to the hospital immediately.
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. Sarna Lotion 1 Appl TP TID:PRN itch
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply
liberally over affected areas three times daily as needed
Refills:*0
2. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1 tab by mouth up to four times a day as
needed Disp #*60 Tablet Refills:*0
3. Cholestyramine 4 gm PO TID
4. Lactulose 45 mL PO BID
5. Levemir U-100 Insulin (insulin detemir U-100) 100 unit/mL
subcutaneous BID
6. Rifaximin 550 mg PO BID
7. HELD- Furosemide 80 mg PO BID This medication was held. Do
not restart Furosemide until you have further discussion with
your hospice providers
8. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until you have further
discussion with your hospice provider
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Alcoholic cirrhosis
Acute kidney injury
Macrocytic anemia
Thrombocytopenia
Hyponatremia
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 presented to ___ because your doctor
referred you here to discuss the possibility of liver
transplant.
While in the hospital, you were found to have severe liver and
kidney disease.
-You were treated with albumin.
-You had a number of labs drawn to make sure you don't have an
infection.
-You were seen by the nutrition specialist to help you decide
what kind of food is best for you.
-You were informed that a liver transplant would require blood
transfusions; however, you declined transfusions given your
beliefs.
-You have decided to pursue hospice care at this point.
After you leave the hospital, it is important that you continue
taking your medications as prescribed. Make sure you follow up
with your doctors in ___.
We wish you the best,
Your ___ medicine team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin EC 325 mg PO DAILY
2. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Atorvastatin 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Vasovagal presyncope
Secondary: CAD, HLD
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 having you here at the ___ ___
___. You were admitted here after you were having
chest pain and an episode of feeling lightheaded. A stress test
done here was equivocal. We feel your lightheadedness was an
adverse reaction after your exercise stress test. We
discontinued your plavix and started you on a medication for
blood pressure called labetalol. Please keep your follow up
appointments below.
We wish you the very best
Your ___ medical team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Fenofibrate 160 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Mesalamine ___ 1600 mg PO Q12H
4. Rosuvastatin Calcium 40 mg PO QPM
5. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ONCE Duration: 1
Dose
Take on the morning of you appointment for stent removal
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
once Disp #*1 Capsule Refills:*0
8. Docusate Sodium 100 mg PO BID
While taking narcotic pain medications to avoid constipation.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
moderate to severe pain.
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right sided kidney stone
Left sided bladder tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Docusate Sodium 200 mg PO BID
3. Cyclobenzaprine 10 mg PO TID:PRN back spasms
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
4. Gabapentin 300 mg PO 0800 DAILY
RX *gabapentin 300 mg 1 capsule(s) by mouth Daily every morning
at 8 AM Disp #*14 Capsule Refills:*0
5. Ranitidine 150 mg PO DAILY
6. Gabapentin 600 mg PO 2PM DAILY
RX *gabapentin 300 mg 2 capsule(s) by mouth every day at 2 ___
Disp #*56 Capsule Refills:*0
7. Gabapentin 600 mg PO HS
RX *gabapentin 300 mg 2 capsule(s) by mouth prior to bedtime
daily Disp #*56 Capsule Refills:*0
8. Morphine SR (MS ___ 15 mg PO Q12H
HOLD for sedation, RR < 12
RX *morphine 15 mg 1 tablet(s) by mouth every 12 hours Disp #*28
Tablet Refills:*0
9. TraMADOL (Ultram) 50 mg PO Q6H
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*56
Tablet Refills:*0
10. Senna 1 TAB PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Constipation ___ narcotic use for pain control
Secondary diagnosis:
s/p thoracolumbar fusion ___
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 ___.
You were hospitalized with constipation secondary to opioid use
for pain control. You were given an agressive bowel regimen
during this admission and had bowel movements. Upon discharge,
take a daily bowel regimen, including senna, colace, and
FiberCon. If you do not have a bowel movement after 2 days,
please use medications like bisacodyl, magnesium citrate. If you
do not have a bowel movement after 3 days, try a fleets enema
(can be purchased over the counter. If you still do not have a
bowel movement after these attempts, please see medical
attention.
Keep all hospital follow-up appointments. They are listed below.
We have made adjustments to your pain medication regimen. STOP
taking dilaudid for pain control. Instead use tramadol every ___s increased doses of gabapentin. Continue taking
MS ___ morphine) you were doing previously.
Continue taking cyclobenzaprine as needed for back muscle
spasms.</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 / fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Amlodipine 5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Aztreonam 1000 mg IV Q8H proteus UTI
6. Calcium Carbonate 500 mg PO TID
7. Digoxin 0.125 mg PO DAILY
8. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
9. Labetalol 200 mg PO Q6H:PRN SBP > 180
10. Metoprolol Tartrate 25 mg PO BID
11. Niacin 500 mg PO DAILY
12. Ranitidine 150 mg PO DAILY
13. Rosuvastatin Calcium 2.5 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infections
Recent acute ischemic stroke
Discharge Condition:
Mental Status: ___ make some eye contact at times, variably
interacts with caregivers ___ only family)
Level of Consciousness: Lethargic.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Ms. ___ was admitted to the ___ Neurology Wards for new onset
fever and breathing difficulties. She received some gentle
suctioning which relieved her tachypnea in the ED. We found a
urinary tract infection, and she received one dose of treatment
with ceftriaxone. She sustained an allergic reaction to this
medication, with stridor, facial and tongue swelling, and she
was switched to other agents. Ultimately, she was transitioned
to AZTREONAM, based on the pattern of sensitivies. Blood
cultures grew out skin contaminants. She needs to remain on
AZTREONAM until ___. A PICC line was placed.
A NCHCT done in the ED showed no new hemorrhage, but a
combination of old strokes of various ages. While in the
hospital, she was maintained on the remainder of her
medications. Her son, ___, was updated on the day of
discharge.</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
Take before using oxycodone
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheezing
9. Lisinopril 30 mg PO DAILY
10. Metoprolol Tartrate 6.25 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Senna 8.6 mg PO HS
14. Simvastatin 40 mg PO QPM
15. Thiamine 100 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Torsemide 40 mg PO DAILY
18. Bisacodyl 10 mg PO DAILY:PRN constipation
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY
20. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Encephalopathy
Hypoxemic respiratory failure
Acute kidney injury
Secondary:
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Diastolic 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 has been a pleasure taking care of you at ___. You were
admitted to the hospital because your nursing home was concerned
for a change in your mental status. In the Emergency Department,
you were found to have low oxygen levels, which required placing
a breathing tube. We also found that you kidney was injured. You
were treated in the Medical Intensive Care Unit briefly and then
on the general medicine unit. Your breathing improved and we
were able to remove the breathing tube. Your kidney injury also
resolved with fluids through an IV. We were also initially
concerned that you might have another urinary tract infection.
Because of this, you were briefly started on antibiotics.
However, your mental status improved and you had no signs of
infection and we were able to stop the antibiotics and remove
the larger IV (PICC) in your arm. Your mental status and
confusion improved during your hospital stay. We think that your
low oxygen levels and confusion occured from a little
dehydration that caused kidney injury. This kidney injury may
have then caused some build-up of your pain medications in your
body. This can cause both low oxygen levels and confusion.
Please take all of your medications as directed and follow up
with your doctor. Weigh yourself every morning, call MD if
weight goes up more than 3 lbs.
It has been a pleasure taking care of you and we wish you all
the best.
Best,
Your ___ care team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. TraMADOL (___) 25 mg PO Q6H:PRN pain
RX *tramadol [___] 50 mg 0.5 (One half) tablet(s) by mouth
every 6 hours as needed Disp #*30 Tablet Refills:*0
2. Propranolol LA 160 mg PO DAILY
3. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl LEFT EYE BID
4. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
6. Acetaminophen 1000 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
globe laceration s/p repair
Discharge Condition:
awake alert and oriented
ambulatory
vision in L eye impaired
Followup Instructions:
___ [/INST] </s><s>Dear Ms ___,
You were admitted to the hospital due to a globe laceration of
your left eye due to a fall. The laceration was surgically
repaired and you are ready for discharge home. Please follow up
with the ophthalmologist as scheduled tomorrow. Please also
schedule a follow up with Dr ___ a week. For pain
control, please use tylenol as needed but do not exceed 3 grams
per day. I have also prescribed you another pain medication
named ___ which is a non-narcotic. It is sometimes sedating
so, be mindful. If you have any questions or concerns after
discharge please call me.
Best,
___, MD</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were diagnosed with a heart rhythm called "atrial
fibrillation"
- You had fluid in your lungs that was giving you shortness of
breath, likely a result of high blood pressure and the atrial
fibrillation.
What was done while I was in the hospital?
- We gave you medications to help remove extra fluid off your
body, which helped your breathing
- You were started on a medication to slow your heart rate
called "diltiazem"
- You had a "cardioversion" which was a procedure under
anesthesia to shock your heart back into a normal rhythm.
- You were started on a blood thinner called "pradaxa" (the
generic name is ___.
- You were seen by neurologists who believed it was safe for
you to take the pradaxa even with your history of a bleed in
your brain
What should I do when I go home?
- It is very important that you take your pradaxa and
diltiazem.
- Please go to your scheduled appointment with your
cardiologist, Dr. ___. You will be called with an appointment
for follow up.
- If you have chest pain or shortness of breath, please tell
your primary doctor or go to the emergency room.
Best wishes,
Your ___ 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 day will be ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*21 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Alendronate Sodium 70 mg PO QFRI
4. Calcium Carbonate 500 mg PO BID
5. Fexofenadine 180 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Gabapentin 300 mg PO QHS
8. Montelukast 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
-Bilateral pyelonephritis, E. coli pansensitive
-Bacteremia, Gram negative rods, pansensitive
-Diabetes Mellitus Type 2
SECONDARY DIAGNOSES:
====================
-None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
-You were concerned about your back pain and fevers
What did you receive in the hospital?
-We tested your blood and urine, and you were found to have a
kidney and blood infection. We began antibiotic therapy, and you
responded appropriately.
-You were constipated which may have contributed to your pain.
We gave you laxatives which resolved your constipation and some
of your pain.
-You had high sugars (glucose) in your blood, and we discovered
you have diabetes. Fortunately, your sugar levels are only
mildly elevated and may be managed initially with behavioral
changes.
What should you do once you leave the hospital?
-You should continue taking your antibiotic, ciprofloxacin,
everyday until ___ (last two doses will be taken on
___.
-You should follow up with your primary care physician as
scheduled below. Please speak with your primary care physician
regarding your new diagnosis of diabetes.
-Make sure you continue to hydrate well, roughly 1.5L of water
everyday. Please drink more water if you happen to exercise.
-We did not make any other changes to your home medication
regimen.
NEW MEDICATIONS:
================
-Ciprofloxacin 500mg 1 tab by mouth twice a day (last doses on
___
STOPPED MEDICATIONS:
====================
NONE
CHANGED MEDICATION DOSING TO:
=============================
NONE</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Citalopram 40 mg PO DAILY
3. DiCYCLOmine 20 mg PO QID:PRN IBS symptoms
4. Donnatal ___ PO QID PRN IBS symptoms
5. Famotidine 40 mg PO DAILY
6. Gabapentin 300 mg PO HS
7. LeVETiracetam 1000 mg PO BID
8. Propranolol LA 80 mg PO DAILY
9. Sumatriptan Succinate 100 mg PO DAILY:PRN migraine
10. Topiramate (Topamax) 100 mg PO BID
11. Zolpidem Tartrate 10 mg PO HS
12. Oxcarbazepine 150 mg PO BID
RX *oxcarbazepine 150 mg 1 tablet(s) by mouth TWICE DAILY Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Post traumatic Epilepsy
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 ___. You were
hospitalized in the neurology wards to investigate further the
cause for your recent increase in seizure events. During your >
24 hour stay here, you did not have any typical events. We
continued your home medications, and we obtained an EEG and MRI
of your brain. Your EEG did not identify any seizures or obvious
epileptiform discharges. The brain MRI also did not identify any
significant abnormalities.
We discussed the various options. At this time you have an
appointment to see Drs ___ in the Department
of Neurology at ___. We tried to increase your KEPPRA from
1000mg twice daily to 1500mg twice daily, but this caused
problems with somnolence/drowsiness. Instead, we will add
another anti-seizure medication, with the goal of ultimately
discontinuing the keppra in the long term. There were no other
medication changes made today.
Do keep your follow up appointment with our neurology
department and your primary care doctor here at . We would also
like to obtain an AMBULATORY EEG (one where EEG leads are placed
and you are able to go home). To arrange this, please call ___ (the order for this test has already been placed).
Do not hesitate to contact us with questions or comments ___, ask for Dr. ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atenolol 50 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q3H Disp
#*50 Tablet Refills:*0
5. Losartan Potassium 50 mg PO DAILY
6. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 by mouth QACHS Disp #*56 Tablet
Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron [ZOFRAN ODT] 4 mg 1 tablet,disintegrating(s) by
mouth every eight (8) hours Disp #*30 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth once a day Disp #*30 Tablet Refills:*5
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Acetaminophen 1000 mg PO Q6H
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
13. Simvastatin 10 mg PO DAILY
14. Pancrelipase 5000 1 CAP PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic ductal adenocarcinoma
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 at ___ for surgical
resection of your pancreatic mass. You have done well in the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have 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. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*32 Tablet
Refills:*0
2. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*32
Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*32
Tablet Refills:*0
5. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP
INH daily Disp #*32 Capsule Refills:*0
6. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*32 Tablet
Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*32 Tablet Refills:*0
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs INH
Q4-6H:PRN Disp #*1 Inhaler Refills:*0
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q8H:PRN wheeze
11. Premarin (conjugated estrogens) 0.625 mg/gram vaginal PRN
12. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*32
Tablet Refills:*0
13. Furosemide 20 mg PO DAILY:PRN heart failure
weigh yourself daily, notify MD if weight up more than 3 lbs. Do
not take unless instructed by MD.
RX *furosemide 20 mg 1 tablet(s) by mouth daily:PRN Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Dyspnea NOS
- Chronic systolic heart failure (EF 40-50%)
Secondary:
- COPD (50 pack/year tobacco)
- Pulmonary nodules
- Iron deficiency anemia
- Left sided pleural effusion
- Hiatal hernia
- Obesity
- Hypothyroidism
- Hypertension
- Hyperlipidemia
- Carotid Stenosis
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure participating in your care here at ___
___. You came to us with shortness of
breath and chest pain. You got a CXR which showed a small
reaccumulation of your left sided pleural effusion and
pneumothorax. You were evaluated by interventional pulmonology
who recommended treatment with nebulizers but no repeat drainage
of your effusion. You were provided copies of your cytology
results from your previous pleural drainages which were negative
for cancer cells.
You also had a cardiac ECHO done which showed reduced heart
function and some wall motion abnormality. You had a subsequent
nuclear stress test which showed normal perfusion of your heart.
We started you on metoprolol succinate XL 25 daily and
Lisinopril 5mg daily to help control your blood pressure,
hypertension and heart disease. We stopped your triamterene/HCTZ
pill and your potassium supplement because they are no longer
needed. We also reduced your aspirin dose to 81 mg to prevent
increased risk of bleeding.
We also stopped your simvastatin and started you on atorvastatin
40mg daily to help further reduce your risk of cholesterol build
up in your arteries.
We understand that you will be leaving for vacation and you
should take a scale with you and weigh yourself daily. If your
weight increases by more than 3 lbs and/or you become increasing
short of breath please notify an MD immediately. Please fill
Lasix prescription prior to your departure. ___ MD assessment
he or she can decide if you will need to take your Lasix
medication.
Please continue taking your medications as prescribed and attend
all of your follow up appointment as scheduled below.
Thank you for choosing ___ for your healthcare needs.
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. Diltiazem 90 mg PO BID
3. Levothyroxine Sodium 25 mcg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO QAM
5. MetFORMIN XR (Glucophage XR) 1000 mg PO QPM
Do Not Crush
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatitis
biliary colic
abnormal LFTs
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were evaluated for evidence of biliary blockage causing
fevers, pancreatitis and abdominal pain. Your symptoms and lab
abnormalities have improved. There was no evidence of a
gallstone causing these symptoms, though it may be that a
gallstone was present and passed on its own. Unfortunately this
is impossible now to prove at this point. Less likely
possibilities that are related to dysfunction of the sphincter
allowing passage from the bile duct or stricture of the biliary
duct. The situation will require monitoring for symptoms return
and follow up with Dr. ___ in ___ weeks.
Please pick up your radiology CD on the ___ floor of the
___ building when you leave the hospital.
Please see below for medicines and followup.
It was a pleasure caring for you and 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. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 by mouth Three times a day with
meals PRN Disp #*90 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Cyanocobalamin unk mcg PO DAILY
4. Furosemide 20 mg PO BID
5. Apixaban 2.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Lumigan (bimatoprost) 0.01 % ophthalmic qHS
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Mirtazapine 15 mg PO QHS
14. Pantoprazole 40 mg PO Q24H
15. Polyethylene Glycol 17 g PO DAILY
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN wheezing
17. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Nausea
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 hospital stay
at ___. You were hospitalized
for nausea.
You did not spike any fevers and your white blood cell count,
which can be a marker of infection, was normal, so it is very
unlikely that your nausea is caused by an infection that needs
to be treated. You got an abdominal cat-scan, which did not show
an acute process that might be causing your nausea. There was a
small mass seen in your pancreas which was too small to be
causing your nausea and does not need to be monitor as per the
gastroenterologists.
You were treated with anti-nausea medications and your symptoms
improved.
We recommend that you follow up with a gastrointestinal
specialist to further investigate the cause of your nausea. They
may decide to do an upper endoscopy.
Take Care,
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
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO EVERY OTHER DAY
3. Hydroxyurea 1000 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Calcet Creamy Bites (calcium citrate-vitamin D3) 500 mg
calcium -400 unit oral BID
7. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. 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
SICKLE CELL ANEMIA
chronic dilated cardiomyopathy
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 had chest pain. There was
concern that this chest pain may have been due to you not having
adequate blood flow to your heart. At the hospital, you
underwent a stress test that showed that your heart had mild
ischemia (a condition where the heart has pain because of
inadequate blood flow). It is important for you to take
medicines to protect your heart, lower your blood pressure, and
decrease cholesterol, but at this time you do not need any
stents placed in your heart. As a result we are sending you
home, with follow up with your primary care provider. We ask
that you call and cancel your appointment for your
echocardiogram as listed below as you had one in the hospital.
We wish you all the best!
-Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Colchicine 0.6 mg PO Q12H Duration: 3 Months
RX *colchicine 0.6 mg 1 tablet(s) by mouth every 12 hours Disp
#*30 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q8H Duration: 14 Days
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Perimyocarditis
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 ___ on ___ for chest discomfort. You
were subsequently diagnosed with a condition called
'perimyocarditis', which refers to inflammation in the heart and
the sac that surrounds the heart. This is usually a benign
condition that resolves spontaneously, although you should avoid
strenuous activity (including sports such as basketball) at
least until you are seen in follow up by Dr. ___.
We have prescribed ibuprofen which you should take as directed
for the next ___ days for your chest discomfort. Additionally,
you should take another medication called 'colchicine' for the
next 3 months. You should continue to take this medication for
this duration even in the absence of chest pain as it reduces
your risk of recurrence of this condition.
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Amlodipine 10 mg PO DAILY
Please hold for SBP <100
3. Ascorbic Acid ___ mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Calcitriol 0.25 mcg PO DAILY
6. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED hypertension
7. Docusate Sodium 100 mg PO BID
8. Febuxostat 40 mg PO DAILY
9. NPH 11 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Labetalol 200 mg PO BID
Please hold for SBP <100 or HR <55
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN consitipation
13. PredniSONE 10 mg PO DAILY
14. Senna 1 TAB PO BID:PRN constipation
15. Simvastatin 20 mg PO DAILY
16. Venlafaxine 37.5 mg PO DAILY
17. Warfarin 2 mg PO DAILY16
18. Vancomycin Oral Liquid ___ mg PO Q 8H
19. Torsemide 30 mg PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
Please take with food
21. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Influenza
Acute on chronic diastolic congestive heart failure
Secondary Diangoses:
Type 2 Diabetes ___
Recurrent C.difficile
Chronic kidney disease
Atrial fibrillation
Normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for shortness of breath, low
blood sugar and confusion. You were diagnosed with the flu.
You were found to have too much fluid in your lungs, so you were
given medications to reduce the fluid in your body. Your
symptoms improved and you will be discharged to a rehab
facility.
We wish you a quick recovery.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Azathioprine 100 mg PO DAILY
2. Flecainide Acetate 100 mg PO Q12H
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Ranitidine 150 mg PO BID:PRN Indigestion
6. Rivaroxaban 20 mg PO DAILY
7. TraZODone 50-100 mg PO QHS:PRN Insomnia
8. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
10. Losartan Potassium 50 mg PO DAILY
11. Calcium 600 + Minerals (calcium carbonate-vit D3-min) 600 mg
calcium- 400 unit oral DAILY
12. melatonin 20 mg oral DAILY:PRN insomnia
13. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
-Cardiac tamponade
-Toxic metabolic encephalopathy
Secondary diagnoses:
-Hyponatremia
-Anemia
-Lung nodule
-Atrial fibrillation
-Granulomatous polyangitis
-Sick sinus syndrome s/p pacemaker placement
-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. ___,
You were admitted to ___ due to fluid that accumulated around
your heart and made it difficult for your heart to function
well. The fluid was removed with a needle and a drain was
briefly placed in your chest. You became confused in the
intensive care unit and needed to be intubated to perform a
lumbar puncture. Fortunately, there was no infection in your
brain. Your heart rhythm converted to atrial fibrillation
during your hospitalization likely due to the stress of being
sick and the inflammation around your heart. We scheduled you
for cardioversion on ___ to try and convert you back to a
regular rhythm. We started you on a new medication for the
inflammation around your heart called colchicine. You will need
to follow up with your primary care doctor, ___,
and your rheumatologist. You will also need to see a neurologist
for cognitive testing.
We enjoyed providing your care at ___,
-Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Gabapentin 600 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *Cipro 500 mg 1 tablet(s) by mouth Twice a day Disp #*20
Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 10 Days
RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
4. Budesonide 9 mg PO DAILY Duration: 10 Days
RX *budesonide 3 mg 3 capsule by mouth Once a Day Disp #*30
Capsule Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 6hrs Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's Flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you at ___. You came to the
hosptial becuase of a Crohn's Flare. A cat scan done in the
emergency department showed inflammation in your small
intestine. We drew blood cultures and took stool samples to rule
out infectious causes of your bowel inflammation - these were
still pending at the time of discharge. You were treated with
steroids and antibiotics through your veins, which improved your
symptoms. You were discharged on steroids and antibiotics by
mouth.
Please call your gastroenterologist to make an outpatient
appointment with him as soon as possible. We were unable to
make an appointment for you over the weekend.
MEDICATION CHANGES:
START budesonide 9mg daily x 10 days
START ciprofloxacin 500 mg by mouth twice a day for 10 days
START flagyl 500 mg by mouth three times a day for x 10 days</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Escitalopram Oxalate 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lidocaine Viscous 2% 15 mL PO TID:PRN Pain
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Nortriptyline 20 mg PO QHS
6. Ondansetron ___ mg PO Q8H:PRN Nausea
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
RX *oxycodone 20 mg 1 tablet(s) by mouth every 8 hours Disp #*60
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
9. Pregabalin 75 mg PO BID
10. Aquaphor Ointment 1 Appl TP TID:PRN XRT Burn
11. Benzonatate 100 mg PO TID cough
12. Bisacodyl ___ mg PO DAILY:PRN constipation
13. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 mL by mouth twice a day
Refills:*6
14. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
15. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every
6 hours as needed Refills:*0
16. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
17. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
18. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL ___ mg by mouth every 4 hours as needed
Refills:*0
19. Senna 8.6 mg PO BID:PRN Constipation
20. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
21. Simvastatin 40 mg PO QPM
you can restart this after the fluconzaole finishes so on ___. CefePIME 2 g IV Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Esophagitis/mucositis
Thrush
Anemia
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 pleasure caring for you during your stay at
___. You were admitted with mouth and throat pain related to
side effects of chemotherapy and radiation treatment. You were
treated with supportive measures including pain medications and
IV hydration. You were also treated with antifungal for yeast
infection of mouth and esophagus. You developed fever and were
found to have a pneumonia which was treated with antibiotics.
You should continue the levofloxacin for pneumonia through ___.
Please also continue the fluconazole through ___ then stop both
of these medications.
if you ahve worsening cough or sputum please call Dr. ___
___.
You ___ eating a lot so we haven't been having you take the
metformin. When your appetite/ability to eat returns please
check your blood sugars and if they are elevated you will need
to rsetart this
Hold your aspirin for now your blood platelets were low. When
you see Dr. ___ ask him when it is ok to restart that.
Increasing your lisinopril to 20mg daily. Started a new med for
appetite and depression called mirtazapine.
Don't restart your simvastatin until ___, it can interact with
fluconazole. Fluconazole finishes ___ so you can start the
simvastatin again on ___.
Please follow up with your PCP in the next ___ weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
You were admitted for a pneumonia. You were placed on IV
antibiotics initially, did well, and were transitioned to an
oral antibiotic on which you are still doing well and will stop
tomorrow.
Continue all your medications with the following changes:
-Continue aspirin 121.5mg daily until ___ (plastic surgery)
-start verapamil 240mg SR daily
-Continue Coumadin at normal dose and have ___ check INR in the
next day or two
-continue levaquin until tomorrow
-try Tylenol ___ every 8 hours first
-tramadol ___ every 8 hours as needed for pain
-stop morphine
-stop Chlorthalidone until seen by your cardiologist
You were transferred to the cardiology service for a pacemaker
for symptomatic pauses. The pacemaker was placed and you
converted to sinus rhythm shortly before your procedure. Follow
up with Device Clinic in one week.
Because you have intermittent shortness of breath with exertion,
you can discuss with your cardiologist if perhaps this is due to
episodes of atrial fibrillation, or if you need a repeat stress
test eventually.
You also appear to have iron deficiency anemia; you should
consider starting iron supplementation with your primary care
physician, as well as undergo a colonoscopy to look for a source
of GI bleeding.
Please follow up with your plastic surgeons as directed and your
PCP in one month.
Finally, please have your ___ draw your blood on ___ or
___ for an INR check, sending the results to the ___
___ clinic as they usually do. ***have the ___ get
your SODIUM drawn as well.
We wish you all the best,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Calcium Carbonate 500 mg PO TID
2. Docusate Sodium 100 mg PO BID
Please take while on prescription pain medication
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe
Refills:*0
4. Multivitamins 1 CAP PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
6. Vitamin D 400 UNIT PO DAILY
7. Acetaminophen 1000 mg PO Q8H pain
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left open tibia/fibula fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___ [/INST] </s><s>MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Air cast boot must be worn until follow up appointment unless
otherwise instructed
- TLSO brace to be worn at all times when out of bed
ACTIVITY AND WEIGHT BEARING:
Left lower extremit: weight bearing as tolerated in air cast
boot</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 500 mg PO Q6H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lactulose 30 mL PO QID
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H pain
8. Rifaximin 550 mg PO BID
9. Tacrolimus 0.5 mg PO DAILY
10. Outpatient Lab Work
Please check CBC, Tacrolimus trough, Chem7, ALT, AST, Alkaline
Phosphatase, T.bili and fax results to: Liver Transplant Office
___ Attn: Dr. ___. ICD-9 code ___.54.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute Kidney Injury
Anemia
Secondary: S/p OLT for HCV Cirrhosis
HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted because of lab work
showing that your blood counts were low and your kidneys were
not functioning as well as they normally do. The blood work
here suggested that you might have been a little dehydrated
before coming in to the hospital and the kidneys were working at
their baseline after you drank plenty of fluids. You will be
given a prescription to have your labs checked tomorrow
(___) at ___. Your transplant coordinator will
receive these results and inform you if there is anything
concerning.
Your appointment with Dr. ___ has been rescheduled for
___. If you have any conflicts with this appointment please
call to reschedule.
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. Ibuprofen Suspension 600 mg PO Q6H:PRN Pain
2. Lidocaine 5% Patch 1 PTCH TD DAILY Pain
On 12 hours, off 12 hours.
3. Methimazole 5 mg PO BID Hyperthyroidism
4. Montelukast Sodium 10 mg PO QHS
5. Verapamil 40 mg PO Q8H Hypertension
6. Multi-Delyn *NF* (multivitamin) 5 ml Oral Daily
7. NexIUM *NF* (esomeprazole magnesium) 40 mg PO/NG BID
8. Ondansetron 4 mg PO Q8H:PRN Nausea
9. Vesicare *NF* (solifenacin) 5 mg Oral Daily:PRN Urinary
retention
10. Vitamin D 50,000 UNIT PO 2X/WEEK (___)
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
Day 1 of therapy = ___
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth two times per
day Disp #*13 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: abdominal pain, urinary tract infection, hypernatremia
Secondary: gastroesophageal reflux disease, Grave's disease,
neurogenic bladder, gastroparesis
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 during your hospitalization
at ___. You presented with abdominal pain and dehydration,
which we treated with IV fluids. You were seen by the Thoracic
surgery team, who felt your G-J tube was in the correction
position. A CT scan of your abdomen did not show any
abnormalities to explain your pain. We changed your tube feeds
while you were here. Your pain improved, and we felt you were
stable for discharge. You were also found to have a urinary
tract infection and were treated with antibiotics.
You were also found to have a urinary tract infection, which we
treated with antibiotics.</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 pain
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth ___ times daily Disp #*50 Tablet Refills:*2
2. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*50
Tablet Refills:*0
3. DiphenhydrAMINE 25 mg PO Q6H:PRN Itching/rash
RX *diphenhydramine HCl ___ Plus Allergy] 25 mg 1
tablet by mouth every 6 hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
epigastric pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the gynecology service for monitoring of
your abdominal pain. You have recovered well and the team
believes you are ready to be discharged home. Please call
___ with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your follow-up appointment.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* light-headedness or dizziness
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*3 Tablet Refills:*0
2. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose
RX *magnesium citrate 300 mL by mouth once a day, may repeate
once Refills:*0
3. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*100 Packet Refills:*0
4. BuPROPion (Sustained Release) 100 mg PO QAM
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. CloNIDine 0.3 mg PO TID
7. Methadone 10 mg PO TID
Consider prescribing naloxone at discharge
8. MethylPHENIDATE (Ritalin) 10 mg PO QAM
9. Prazosin 1 mg PO QPM
10. QUEtiapine Fumarate 300 mg PO QHS
11. Topiramate (Topamax) 100 mg PO QHS
12. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
#Radiation induced Ischemic Colitis
#Constipation
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 Dr. ___,
___ was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were constipated.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given antibiotics for a possible gastrointestinal
infection.
- You were given medication to help move your bowels.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with your primary care doctor.
- Follow up with your gastroenterologist.
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 (Immediate Release) ___ mg PO Q4H:PRN pain
do not drink alcohol or drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr Disp #*85 Tablet
Refills:*0
2. Enoxaparin Sodium 40 mg SC DAILY Duration: 7 Days
Start: ___, First Dose: Next Routine Administration Time
complete 28 course following post-op discharge (continue through
___
RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*7 Syringe
Refills:*0
3. Alendronate Sodium 70 mg PO QMON
4. Atorvastatin 20 mg PO QPM
5. Calcipotriene 0.005% Cream 1 Appl TP BID
6. Diazepam ___ mg PO QHS:PRN insomnia
7. Lisinopril 20 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Restasis 0.05% Other BID
10. Sertraline 50 mg PO DAILY
11. Trifluoperazine HCl 2 mg PO TID
12. Acetaminophen 1000 mg PO Q8H:PRN pain
13. Senna 17.2 mg PO BID:PRN constipation
14. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*69 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left total hip arthroplasty dislocation
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>1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
8. ___ (once at home): Home ___.
9. ACTIVITY: Weight bearing as tolerated on the operative
extremity; KNEE IMMOBILIZER at all times for 4 weeks - may come
out of knee immobilizer only for showering and for range of
motion with physical therapy. STRICT Posterior precautions. No
strenuous exercise or heavy lifting. Mobilize frequently
Physical Therapy:
WBAT LLE in knee immobilizer at all times, except for shower or
for ROM with Physical Therapy, x4 WEEKS
Treatment Frequency:
none</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, shortness of
breath
2. Lorazepam ___ mg PO Q8H:PRN anxiety
3. Tiotropium Bromide 1 CAP IH DAILY
4. Cetirizine 10 mg PO DAILY
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*12 Tablet Refills:*0
8. Metoprolol Succinate XL 300 mg PO DAILY
RX *metoprolol succinate 100 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You are were admitted to ___ after you had a stent replaced.
You had a fast heart rate and due to low blood pressures, you
were watched and treated in the intensive care unit.
Your heart rate was fast due to a condition called atrial
fibrillation, which is not a new diagnosis for you. Your heart
rates were fast and blood pressure low, likely due to an
infection. We gave you IV fluids and antibiotics. You improved.
We started a new heart medication called diltiazem to slow your
heart rate and increased your home dose of metoprolol.
You will need to continue to take the antibiotics through
___.
Please make sure to follow-up with your oncologist (cancer
doctor) as well as the GI doctors.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN migraine
3. Acyclovir 400 mg PO Q12H
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Laxative] 5 mg 2 tablet(s) by mouth Daily as
needed for constipation Disp #*28 Tablet Refills:*0
5. Calcium Carbonate 500 mg PO TID W/MEALS
6. Citalopram 30 mg PO DAILY
7. Desonide 0.05% Cream 1 Appl TP BID
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily as needed for constipation Disp #*28 Capsule Refills:*0
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Gabapentin 400 mg PO TID
RX *gabapentin 400 mg 1 capsule(s) by mouth Three times daily
for pain control Disp #*45 Capsule Refills:*0
11. Iron Polysaccharides Complex ___ mg PO BID
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Every 4 to 6 hours
as needed for pain control Disp #*90 Tablet Refills:*0
13. Milk of Magnesia 30 ml PO BID:PRN Constipation
14. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
RX *oxycodone 10 mg 1 tablet(s) by mouth Daily each evening for
pain control Disp #*20 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 2 TAB PO HS
RX *sennosides [senna] 8.6 mg 2 tabs by mouth Daily as needed
for constipation Disp #*28 Capsule Refills:*0
17. Tizanidine ___ mg PO TID:PRN spasms
RX *tizanidine 2 mg ___ capsule(s) by mouth Up to three times
daily as needed for spasms Disp #*40 Tablet Refills:*0
18. Doxycycline Hyclate 100 mg PO Q12H Duration: 10 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth Twice daily
for ___isp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pelvic ex-fix pin site infection
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___ [/INST] </s><s>discharge instructions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Daily dressing changes and ex pin site wound care by ___
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated right lower extremity, Touch down
weight bearing left lower extremity
Physical Therapy:
Weight bearing as tolerated right lower extremity
Touch down weight bearing left lower extremity
Treatments Frequency:
Daily ex pin site wound drssing changes and cleaning</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. BuPROPion 150 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Lisinopril 5 mg PO BID
8. Lorazepam 0.5 mg PO BID
9. Metoprolol Tartrate 25 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30
Tablet Refills:*0
11. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Shortness of breath, COPD, AAA s/p repair
Secondary: Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms ___,
It was a pleasure taking care of you during your stay at ___
___. You were transferred her for
concern regarding the integrity of you AAA repair site based on
images obtained from the outside hospital. Review of your
imaging by the vascular team did not show any evidence of leak
and you were clinically stable without signs or symptoms of
bleeding. In addition, while in the emergency department, you
were experiencing some shortness of breath. You were given
inhalers which improved your symptoms and you were transferred
to the medical floor to be observed overnight. In the morning
your breathing continued to improve and you had no fevers,
chills or cough. Please continue your home medications for your
COPD and return to the hospital if you have any shortness of
breath, dizziness, fainting, blood in your stool, nausea,
vomiting, or chest pain.
Best Wishes,
Your ___ Team</s> |