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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female history of depression, anxiety, dementia
who presents today from her nursing home after an unwitnessed
fall. She was unable to bear weight or ambulate following the
incident. She complained of immediate pain. She denied any
other injuries. Unclear if she sustained head strike or loss of
consciousness. She is confused at baseline and a poor
historian.
Per her ___ she does not walk with assistance of a walker or
cane
and suffers frequent falls. On arrival her trauma evaluation
was
negative for any other injuries. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process.
Remainder as above. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute fracture.
2. Degenerative changes cervical spine, as above.
3. Thyroid nodules, largest 3.3 cm, ultrasound recommended, see below.
RECOMMENDATION(S):
Thyroid nodule. Ultrasound recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150. CT CHEST/ABD/PELVIS W/ CONTRAST showed 1. Intertrochanteric right femoral neck fracture with varus angulation.
2. No acute intrathoracic or intra-abdominal process.
3. Endometrial thickening measuring up to 14 mm. Recommend further evaluation
with pelvic ultrasound on a nonemergent basis, as endometrial carcinoma cannot
be excluded.
4. Enhancing 3.4 cm left thyroid mass. Recommend further evaluation with
thyroid ultrasound on a nonemergent basis.
5. Subcentimeter liver lesions are indeterminate and too small to
characterize, but may represent hemangiomas
RECOMMENDATION(S):
1. Pelvic ultrasound.
2. Thyroid ultrasound. HIP NAILING IN OR W/FILMS AND FLUORO RIGHT showed Intraoperative images were obtained during surgical fixation of the comminuted
intertrochanteric fracture. Please refer to the operative note for details of
the procedure. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___.
Atelectasis is still severe in the left lower lobe, moderate on the right.
Upper lobes are clear. Lungs elsewhere are clear. Heart is moderately
enlarged, distorted by severe thoracic scoliosis. THYROID U.S. showed Limited ultrasound evaluation due to limited cooperation. Partially seen is a
left thyroid nodule better characterized on recent CT. CHEST (PORTABLE AP) showed Severe kyphoscoliosis limiting evaluation of the chest x-ray. Within this
limitation no acute pulmonary abnormality beyond small amount of pleural
effusion on the left. CHEST (SINGLE VIEW) showed Patchy bibasilar opacities likely reflect atelectasis, though underlying
pneumonia is difficult exclude.. DX PELVIS AND FEMUR showed Intertrochanteric right femoral neck fracture with varus angulation. The patient was diagnosed with Pain in right hip. The patient was treated with Right TFN. At the time of discharge, the patient had Right intertrochanteric hip fracture
Acute toxic metabolic encephalopathy
community acquired UTI
___
Hypoxemic respiratory failure
Leukocytosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMHx recurrent severe depression who came to the hospital
after a fall at her nursing home, found to have a R
intertrochanteric hip fracture. She underwent repair with
Orthopedic Surgery on ___. Hospital course was complicated
by encephalopathy (hyper/hypo active delirium), hypoxia, ___ and
Klebsiella UTI. She improved and was discharged to rehab near
her mental status baseline.
Of note, she had a markedly elevated LDH and a leukocytosis that
was of unclear etiology. She also had uterine thickening and an
exophytic uterine mass (possibly fibroid) that warrants follow
up as an outpatient (PCP and ___ were made aware).
TRANSITIONAL ISSUES
===================
[] Patient will require heparin ppx through ___ per
orthopedic surgery recs (4wks)
[] Patient will require orthopedics follow-up 2wks after
discharge with ___, NP
[ ]Staples to be removed at follow-up appointment in 2 weeks
[] Patient was started on levothyroxine 50mcg qDay. Repeat TFTs
in ___
[] Patient will require repeat thyroid US as an outpatient to
evaluate L thyroid mass
[] Should consider nonemergent pelvic US vs. MRI to evaluate
incidental endometrial thickness measuring up to 14mm
(endometrial carcinoma cannot be excluded)
[] ECG was notable for inferior Q-waves, patient should have
HbA1C/lipids evaluated, consider initiation of ASA/statin
[ ] Repeat CBC and LDH 1 week after discharge and send result to
PCP. Discharge WBC 16.9, discharge LDH 500.
[ ] Ibuprofen and lansoprazole should be stopped on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ 4 day history of right sided groin pain. He is s/p left
inguinal hernia repair in ___. He has noted an increasing bulge
over the last several days in his right groin which has become
increasingly tender to palpation. He denies any nausea,
vomiting, fevers, chills, diarrhea, constipation or changes in
his bowel habbits. Radiology showed 1. No evidence of small bowel obstruction.
2. Patient is status post ileocolic and gastrojejunal anastomosis with mild
focal dilation of bowel loop proximal to ileocolic anastomsis with evidence of
fecalization/ stagnation.
Findings discussed with ___ by ___ via telephone on
___ at 15:25, time of discovery. The patient was diagnosed with UNILAT INGUINAL HERNIA. The patient was treated with Laparoscopic appendectomy. At the time of discharge, the patient had Non-incarcerated symptomatic right inguinal hernia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the ___ service with HPI as stated
above. A CT scan demonstrated a small fat-containing right
inguinal hernia with no evidence of bowel loops within it as
well as evidence of previous abdominal surgery. He was taken to
the operating room for a right inguinal hernia repair which went
without complication. The patient was extubated and went to the
PACU and then to the floor in stable condition.
Pain was well-controlled on an appropriate regimen of pain
medicines and the patient remained afebrile in the postoperative
period. He tolerated an advanced diet without nausea or
vomiting. He was discharged to home on ___ with
appropriate prescriptions and instructions to follow up in ___
weeks in ___ clinic as well as what signs and symptoms of which
to be vigilant. He expressed appropriate understanding of all
instructions and was discharged to home in good condition. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with history of pan-ulcerative
colitis on balsalazide, IBS, and bipolar disorder, who presents
with bright red blood per rectum and diarrhea for 1 month. Radiology showed Unremarkable exam. The patient was diagnosed with Ulcerative colitis, unspecified, without complications. The patient was treated with Flex sigmoidoscopy (___). At the time of discharge, the patient had #Primary:
Ulcerative colitis flare
C.diff infection
#Secondary:
Bipolar disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a history of pan-ulcerative colitis on balsalazide,
IBS, and bipolar disorder, who presented with BRBPR and diarrhea
x1 month found to have C diff infection and ulcerative colitis
flare, treated with PO Vancomycin and steroids.
# Ulcerative colitis
Patient with h/o UC, presented with bloody diarrhea and
abdominal pain, consistent with UC flare. This was likely
exacerbated by or triggered by C diff infection. Patient
evaluated by GI with flex sig on ___ which showed diffuse
erythema, edema and friability of the mucosa, pathology
consistent with ulcerative colitis. Stool studies as above
notable for C diff infection, remaining stool studies pending at
the time of discharge. She was started on IV methylprednisone
and transitioned to oral prednisone after ~48 hours. CRP
initially elevated to 72.2, peaked at 96, and improved to 55 at
the time of discharge. Patient also with marked improvement in
symptoms following treatment with steroids/vanc. Patient
declined DVT ppx during admission despite understanding of risks
and benefits - that she is particularly high risk for DVT given
h/o UC. Patient discharged on PO prednisone taper (40 mg x 10
days, then 30 mg x 10 days, then 20 mg x 10 days, then 10 mg x
10 days). She was given a prescription for omeprazole
(prescribed previously by outpatient providers) given prednisone
taper. Home balsalazide held during admission per GI, restarted
at discharge.
# C diff infection:
Found to be C diff positive on admission, likely community
acquired. Treated with PO vancomycin 125mg q6hrs, ___, which
she will continue for 14d course through ___.
# Bipolar Disorder:
Continued home dextroamphetamine-amphetamine, divalproex, and
mirtazapine
TRANSITIONAL ISSUES:
====================
[ ] Patient discharged on PO prednisone 40 mg x 10 days, then 30
mg x 10 days, then 20 mg x 10 days, then 10 mg x 10 days.
[ ] Continue PO Vancomycin 125mg q6hrs through ___.
[ ] Provided Rx for omeprazole, previously prescribed by
outpatient providers but patient unable to fill. F/U with
outpatient providers, including PCP and GI, to determine
requisite course.
[ ] Stool Cx pending at discharge. F/U with outpatient providers
for these results.
[ ] F/U pending pathology, CMV staining. F/U with GI for these
results. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year old woman with T2DM (on insulin), HTN,
HLD, newly diagnosed AF (not on anticoagulation), who presented
from ___ (assisted living ___) at 6am with 2
hours of chest pressure, EMS EKG with ST elevations in
precordial leads and associated ST depressions in inferior
leads, urgently taken to cath lab. CHEST (PORTABLE AP) showed New opacities in the left lower lobe worrisome for pneumonia. The patient was diagnosed with Chest pain, unspecified. The patient was treated with ___: cardiac angiography with DES x2 to LAD. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
===================
S-T segment elevation myocardial infarction
LV apical aneurysm
Ischemic cardiomyopathy with reduced ejection fraction
Coronary artery disease
SECONDARY DIAGNOSES:
=====================
Atrial fibrillation
Depression
Anxiety
Type 2 diabetes mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ year old woman with T2DM (on insulin), HTN,
HLD, newly diagnosed AF (not on anticoagulation), who presented
from ___ (assisted living facility) with 2 hours
of chest pressure, EMS EKG with ST elevations in precordial
leads and associated ST depressions in inferior leads, urgently
taken to cath lab, now s/p 2 DES to LAD.
#STEMI:
#CAD:
#LV apical aneurysm:
Patient without prior history of CAD. Presented with chest pain,
found in EMS EKG to have ST elevations in precordial leads and
associated ST depressions in inferior leads, and urgently taken
to cath lab. On cardiac angiography, found to have 3 vessel
disease with 2 DES to LAD. Given heparin bolus and loaded with
cangrelor. She was started on ASA 81mg daily and metoprolol
12.5mg q6h. Her pravastatin was changed to atorvastatin 80mg
daily. She then underwent TTE which showed reduced EF 35%,
severe apical hypokinesis with focal akinesis, and LV apical
aneurysm. She was started on coumadin for LV thrombus ppx. Given
need for anticoagulation for apical aneurysm, patient's
antiplatelet agent was switched from ticagrelor to clopidogrel.
During ___, she was noted to be bradycardic to the ___ and
her metoprolol was decreased to 12.5mg BID. She was then
transitioned to metoprolol succinate 25mg daily. When her
creatinine recovered, she was started on lisinopril 5mg daily
and her amlodipine was discontinued.
#Acute ischemic cardiomyopathy with reduced EF:
As above, patient's post-MI TTE with new reduced EF 35%, severe
apical hypokinesis with focal akinesis, and LV apical aneurysm.
As above, she was started on metoprolol and high-dose statin.
She was also started on anticoagulation with Coumadin.
Lisinopril 2.5mg daily was started, but discontinued after 1
dose due to post-cath ___. She was started on lisinopril 5mg
daily once her post-cath ___ improved. She had minimal ectopy on
telemetry and therefore did not receive a lifevest. Plan for
repeat TTE in 8 weeks to reassess LVEF.
#Atrial fibrillation:
Newly diagnosed during admission in ___. Rate controlled with
diltiazem ER 120mg. Not placed on anticoagulation at that time
despite CHADS-Vasc score 5 due to concern for age and fall risk.
Her diltiazem was d/c'd post-MI and she was started on
metoprolol (as above). She was also started on Coumadin for LV
apical aneurysm.
___:
Patient with increase in creatinine from baseline 1.0 to 1.3
after catheterization. Initially had been started on lisinopril,
which was d/c'd after bump in creatinine. When her creatinine
improved, she was started on lisinopril 5mg daily.
#Depression
#Anxiety:
Patient with noted anxiety during admission. Her outpatient
psychiatrist recommended discontinuing fluoxetine and starting
duloxetine 30mg daily instead.
TRANSITIONAL ISSUES:
=====================
#Medication changes:
- stopped diltiazem
- started metoprolol succinate 25mg daily
- stopped pravastatin
- started atorvastatin 80mg qPM
- started aspirin 81mg daily
- started clopidogrel 75mg daily
- started warfarin 2.5mg daily (to be adjusted per
___ clinic)
- started lisinopril 5mg daily
- stopped amlodipine
- stopped fluoxetine
- started duloxetine 30mg daily
[] post-STEMI TTE with newly reduced EF 35%. Not given LifeVest
as she had very minimal ectopy on telemetry. Please obtain TTE
in 8 weeks (___) to check for recovery of LVEF. If
continues to be depressed, consider ICD placement.
[] Patient with episodes of bradycardia to ___ with ___.
Metoprolol decreased from 12.5mg q6 to 12.5mg q8. She was then
transitioned to metoprolol succinate 25mg daily. Please continue
to monitor HR and adjust metoprolol dosage as clinically
indicated.
[] Patient started on Coumadin, ASA, and Plavix for LV apical
aneurysm s/p PCI for STEMI. Please monitor for bleeding.
[] Check Chem 7 on ___ to check creatinine and
lytes while on lisinopril.
[] Check INR on ___ and adjust warfarin dose as
needed.
[] Consider starting spironolactone as outpatient given low EF
and insulin-dependent diabetes.
# CODE: Full (confirmed)
# CONTACT: HCP: daughter ___ ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ central sleep apnea who is presenting here to the ED
for a <1 day hx of epigastric pain that has not improved. He
says he was in his usual state of health when he developed
epigastric pain around 7:30 pm last night. He notes having eaten
clam chowder for lunch around 1:30pm. He has also had several
episodes of n/v, and denies any other sx; ROS is otherwise
negative except as noted before. He says he has never had
similar sx before. Labs show WBC 11.0, LFTs wnl, and a CT A/P
was obtained which showed distended gallbladder w/
hyperenhancing wall, some pericholecystic fluid, and 3 cm
gallstone at the GB neck. We were consulted for further
management. RUQ U/S was requested and pending. Of note he is
visiting from ___. CT ABD AND PELVIS WITH CONTRAST showed Findings suggest acute calculous cholecystitis. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Findings suggest acute calculus cholecystitis. The patient was diagnosed with Acute cholecystitis, Dyspnea, unspecified, Right upper quadrant pain, Epigastric pain. The patient was treated with Laparoscopic cholecystectomy. At the time of discharge, the patient had Acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was evaluated by the Acute Care Surgery team in the ED
on ___ as described in the HPI. Admission CT abdomen/pelvis
and RUQ ultrasound both demonstrated acute calculous
cholecystitis. He was admitted on ___ under the Acute Care
Surgery service for management of his acute cholecystitis. He
was taken to the operating room and underwent a laparoscopic
cholecystectomy on HD 1. Please see operative report for details
of this procedure. He tolerated the procedure well and was
extubated upon completion. Of note, he voided prior to his
surgery, but when a Foley catheter was placed for the procedure,
he had a post-void residual of greater than 400 CC. He was
subsequently taken to the PACU for recovery.
After a brief, uneventful stay in the PACU, the patient arrived
on the floor tolerating a clear liquid diet, on IV fluids, and
with scheduled acetaminophen/toradol and PRN oxycodone for pain
control. He was hemodynamically stable. His vital signs were
routinely monitored and he remained afebrile and hemodynamically
stable. Post-operative labs were notable for elevated lactate to
4.0, which was attributably to likely dehydration. He was
initially given IV fluids postoperatively, as well as a 1000 CC
fluid bolus with improvement in his lactate to 1.0. His
maintenance IV fluids were discontinued when he was tolerating
PO intake. His diet was advanced during the afternoon of POD 0
from clear liquids to regular, which he tolerated without
abdominal pain, nausea, or vomiting. He was voiding adequate
amounts of urine without difficulty. Given his high post-void
residual in the OR, we sent a UA, which was unremarkable.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. His pain level was routinely assessed and
well controlled at discharge with an oral regimen as needed.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. He was voiding appropriately, and on questioning
reported urinary frequency prior to this hospitalization. He was
instructed to mention this to his PCP at follow up for further
work up and possible intervention. The patient was discharged
home without services. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. He was instructed to follow
up with his PCP in ___ in ___ weeks. If necessary, his PCP
may refer his to Urology or General Surgery as needed. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ man with a history of prior stroke
who presents to the ED as a transfer from an outside hospital
after a motor vehicle crash and possible seizure. CR - CHEST PORTABLE AP showed There has been interval replacement of the nasogastric tube which terminates
in the body of the stomach. The endotracheal tube is been removed. Otherwise,
no significant interval change compared to study from earlier today. CTA CHEST showed 1. No evidence of main or segmental pulmonary arterial embolus. Evaluation of
sub segmental pulmonary artery sub limited by severe motion artifact.
2. Small left and small to moderate right-sided pleural effusion with adjacent
atelectasis. These are more pronounced compared to most recent outside
hospital imaging.
3. Mild opacification of the right lower lobe bronchi may represent retained
secretions or aspiration. No convincing evidence of pneumonia at this stage. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Previous mild pulmonary edema has improved. Small bilateral pleural effusions
moderate cardiomegaly remain. No pneumothorax.
Left PIC line ends in the right atrium, as before. Nasogastric drainage tube
ends in the midportion of a nondistended stomach. Radiology showed 1. Left PICC terminating at the cavoatrial junction.
2. Central pulmonary vascular congestion with mild interstitial edema. Small
bilateral pleural effusions.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:28 am, 2 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed 1. Minimally worsened mild pulmonary edema.
2. Interval resolution of right pleural effusion. Small left pleural
effusion is unchanged. CHEST (PORTABLE AP) showed Progressive now mild-to-moderate pulmonary edema. Recurrence of small right
pleural effusion. Small left effusion is unchanged. CHEST (PORTABLE AP) showed Left PICC line tip is at the proximal right atrium and should be pulled back
at least 2 cm. Heart size is enlarged. Vascular congestion has progressed
now with interstitial pulmonary edema associated with bilateral pleural
effusions. No pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, the patient has taken a slightly
better inspiration. In cardiomediastinal silhouette and mild elevation of
pulmonary venous pressure are stable. Small bilateral pleural effusions with
underlying compressive atelectasis are again seen. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. No acute infarct or intracranial hemorrhage. No abnormal enhancement or
masses.
2. Right PCA territory infarct with encephalomalacia of the right occipital
lobe extending to the right posteromedial temporal lobe and hippocampus.
Hemosiderin staining of the right occipital lobe noted.
3. No evidence of focal cortical dysplasia or gray matter heterotopia.
4. Chronic microvascular angiopathy changes and additional findings as
described above. Radiology showed ET tube tip 2.5 cm from the carina. CTA HEAD AND CTA NECK Q16 CT NECK. showed 1. No acute intracranial abnormality.
2. Occlusion of the left vertebral artery from its origin to the V2 segment
where it is reconstituted. Occlusion of the right vertebral artery at C2-3,
with reconstitution distally at C1. Both vertebral arteries receive
collateral supply from paraspinal arteries, and patent to the basilar origin.
Findings are age-indeterminate, although appearance and collateral vessels
suggest chronic findings, acute occlusion not excluded.
3. Patent bilateral cervical carotid arteries. Calcified plaque at the
carotid bulbs and extracranial ICAs causes 30% left extracranial ICA luminal
narrowing by NASCET criteria. No significant right ICA luminal narrowing by
NASCET criteria.
4. 1-2 mm right intracranial ICA infundibulum. Mild luminal narrowing,
cavernous and paraclinoid intracranial ICAs, due to calcified plaque.
Remainder of the circle of ___ is widely patent. No aneurysm, additional
stenosis, or occlusion.
5. Medial right occipital encephalomalacia, likely sequela of remote right PCA
territory infarction.
6. Small chronic lacunar infarcts, bilateral thalami, right basal ganglia.
7. Mild changes of chronic white matter microangiopathy.
8. Moderate sinus disease, involving ethmoid air cells, maxillary sinuses,
with air-fluid levels.
9. Incidental findings include bilateral layering small nonhemorrhagic pleural
effusions; prominent and numerous cervical and upper mediastinal lymph nodes,
nonspecific, possibly reactive; moderate biapical paraseptal and centrilobular
emphysema. Other incidental findings, as above. Radiology showed Support lines and tubes are unchanged in position. Heart size is upper limits
of normal. There is a left retrocardiac opacity, stable. There is again seen
mild pulmonary edema. There are lower lung volumes than previous. There are
no pneumothoraces The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus, Car driver injured in collision w car in traf, init. The patient was treated with ___ Intubation (at outside hospital). At the time of discharge, the patient had Seizure
History of stroke
Heart failure with preserved EF
Left atrial thrombus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o male with a past medical history of stroke in ___,
aortic regurg s/p bioprosthetic valve replacement ___, HFpEF,
found seizing in parked car with preceding erratic driving,
presented with slight hypothermia (95 degrees at OSH), intubated
on arrival to outside hospital. Transferred to ___ for cvEEG,
which was negative for seizure. Course complicated by tenuous
respiratory status ___ COPD, aspiration PNA), and paroxysmal
atrial fibrillation with RVR.
#Seizure
#Altered Mental Status
At OSH, received a total of 6 mg of lorazepam, 2L normal saline,
1 g of Keppra, and started on a propofol drip. By report, he may
have received a dose of phenytoin at OSH, not clearly
documented, though phenytoin level on arrival to ___ was 18.7.
Unclear trigger for seizure. Meningitis was considered so
empiric coverage with vancomycin, ampicillin, acyclovir was
initiated, though was discontinued after he rapidly improved on
arrival to ___. LP therefore deferred. Continuous EEG showed
diffuse background slowing and disorganization, no seizures or
epileptiform discharges. Initiated keppra 750 mg BID, which he
tolerated well.
#Acute respiratory insufficiency
#Aspiration PNA
#COPD exacerbation
#Pleural effusions:
Intubated as above for airway protection in setting of concern
for seizure. Extubated ___ with continued respiratory distress
(wheezing, accessory muscle use, shortness of breath). Etiology
likely multifactorial due to pleural effusions (including fluid
collection above hemithorax- nonsurgical, aspiration PNA, and
reactive airway disease (h/o smoking). CTA negative for PE. He
was diuresed with Lasix, as high as 40mg IV, with modest
benefit. Respiratory status improved with initiation of high
dose IV steroids x5 days (___) and unasyn x7 days
(___) for COPD/aspiration pneumonia.
#Paroxysmal atrial fibrillation with RVR:
Placed on dilt gtt initially, which was weaned with uptitration
of home metoprolol with good effect. However, despite high doses
of Metoprolol, heart rate remained elevated to the 130s. He was
therefore given a bolus + 48 hour infusion of Amiodarone, with
some improvement in his heart rate. Switched home rivaroxaban to
apixaban per discussion with outpatient cardiologist to reduce
bleeding risk. On the floor, cardiology consulted for additional
recs, recommended TEE and potential cardioversion. On TEE,
however, patient found to have a left atrial thrombus, so
cardioversion was aborted. Plan for 4 weeks of uninterrupted
anticoagulation, followed by cardioversion. This was
communicated with his outpatient cardiologist Dr. ___.
#Heart failure
Diuresed with 40mg IV BID to good effect, discharge dry weight
was 52.4kg. Discharge diuretic dose will be 40mg PO BID.
#ETOH use disorder:
Per wife, he does not drink, though records from the outside
hospital indicate 3 or more alcoholic beverages per night. He
was given a phenobarb load x1 on admission. Initiated thiamine,
folic acid repletion.
#History of stroke:
Transitioned to apixaban as above. Continued home atorvastatin.
#Thrombocytopenia:
Likely due to splenic sequestration in setting of chronic ETOH
use.
#HTN:
Held home lisinopril.
#History of aortic valve replacement:
TTE with well seated and normally functioning valve.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Primary Care Physician: ___ (___)
CHIEF COMPLAINT: Headache, Delirium, Ataxia
HISTORY OF PRESENT ILLNESS:
___, a ___ yo M PMHx AIDS (PCP ___ ___, didnt
complete treatment, recently started on ART, CD4 39 ___,
active crystal meth use, and history of syphilis, who left AMA
on ___ after an admission for headache, presents to ED
with headache/ataxia. The patient reportedly followed up with
___ Health after discharge where he started HAART. He cannot
recall the name, but believes that there are 3 different
medications. He reports that his headaches that caused his
admission previously had improved, but a few days prior to
admission, he started developing ___ frontal headaches that was
made worse with sounds. He also reports that he sometimes has
difficulty finding the right words. He denies taking any
medications for his headaches. He reports that he last snort
crystal meth 1 week ago and has not injected it for >6 months.
As per report, he was having difficulty walking as well which
prompted his family to bring him in. He denies any fevers,
chills, nausea, vomiting, abdominal pain, diarrhea, cough,
shortness or breath, DOE, chest pain.
On the previous admission for headache, he was found to have
fever/tachycardia, epididymitis/orchitis (G/C negative),
negative headache workup, and a cavitary lung lesion (AFB
negative x3, PCP negative, prior positive Quantiferon Gold®).
Per ___ documentation, he had a headache to 1.5 weeks prior
to presentation but presented to clinic without delirium/ataxia
on ___.
In the ED initial vitals were: 98.9 ___ 18 97% RA. Labs
were notable for CBC 6.8. Chem 7 notable for hyponatremia to
128. LFTs unremrkable. Serum tox negative, but urine tox
positive for ampehtamines. lactate 2.7. Patient underwent CT
head that showed new scattered hypodensities in the bilateral
basal ganglia, thalami, left temporal lobe, and cerbellum. It
also showed diffuse atrophy. CTA did not show dissection.
Neurology was consulted in the ED and believed that because of
his significant involvement of the cerebellum with some
indication of increased pressure in the posterior fossa, a
lumbar puncture could not be safely performed and LP was
deferred. ID was consulted and recommended broad spectrum
coverage with acyclovir, vancomycin, ceftriaxone, PCP ___
(atovaquone ppx). Patient was given acyclovir 750mg, 2L NS,
Ceftriaxone 2gm. Vital signs on transfer: 99 84 128/71 16 RA.
On CC7, patient is intermittently somnolent but oriented,
somnolent and confused with difficulty following even simple
commands, and agitated pull lines out. CHEST (PA AND LAT) showed Minimal bibasilar patchy opacities, likely atelectasis. CT HEAD W/O CONTRAST showed 1. New scattered hypodensities in the bilateral basal ganglia, thalami, left
temporal lobe, and cerebellum. The etiology is unknown, though these could
represent posterior reversible encephalopathy syndrome, HIV associated
encephalitis, vasculitis, embolic phenomenon, or potentially infection such as
toxoplasmosis. Further evaluation with a contrast enhanced MRI is recommended.
2. Diffuse atrophy, which is out of proportion for a patient of this age, and
may relate to HIV. CTA HEAD AND CTA NECK showed 1. No stenosis, occlusion, or aneurysm of the major intracranial and
extracranial arterial circulation.
2. Parenchymal hypodensities described on CT head from earlier the same day
are not well visualized on this study optimized for evaluation of the
vasculature. No definite parenchymal enhancement is identified,however, this
study is optimized for evaluation of the vasculature rather than the brain
parenchyma.
3. Maxillary periodontal disease and mild maxillary sinus mucosal thickening.
Other details as above. MRI head without and with intravenous contrast showed Only limited MR ___ and sagittal T1 images were obtained only as the patient
could not remain still within the scanner.
1. Foci of abnormal signal in the left temporal lobe, bilateral basal ganglia,
and bilateral cerebellar hemispheres. Complete MRI of the brain without and
with intravenous contrast is recommended for further evaluation when the
patient is clinically suitable.
2. Hypointense marrow signal in particular in the cervical spine, occipital
bones and in the clivus.
Inadequately assessed on the present incomplete MRI study.
Correlate clinically and with hematology labs for anemia, systemic disease,
myeloproliferative or infiltrative disorders, etc. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is obliquity of the patient at
somewhat obscures detail. There is been placement of an endotracheal tube
with its tip approximately 6 cm above the carina. Nasogastric tube extends at
least to the mid stomach were crosses the lower margin of the image.
There has been development of increased opacification at the left base with
poor definition of the hemidiaphragm, this is consistent with volume loss in
the left lower lobe and pleural effusion.
No evidence of vascular congestion. MR HEAD W AND W/O CONTRAST showed Multiple ring and solid enhancing lesions in the supratentorial and
infratentorial white matter and within the bilateral basal ganglia and bowel
MRI. Differential diagnosis for these findings is broad and includes
opportunistic infections such as toxoplasmosis, fungal disease, bacterial
abscess, CNS lymphoma, and less likely metastatic disease. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the tip of the nasogastric
tube is in the lower portion of the stomach. Endotracheal tube is unchanged.
Continued opacification at the left base consistent with volume loss in the
left lower lobe and pleural effusion. Indistinctness of pulmonary vessels is
consistent with elevated pulmonary venous pressure. CHEST (PORTABLE AP) showed Cardiomegaly and widening mediastinum are stable. Mild vascular congestion,
bibasilar atelectasis larger on the left side and a small left effusion are
grossly unchanged. Lines and tubes are in standard position. CHEST (PORTABLE AP) showed Right supraclavicular catheter tip is in the proximal right atrium. Can be
withdrawn couple of cm for more standard position. There is no pneumothorax.
No other interval change from prior study. CHEST (PORTABLE AP) showed In comparison with the earlier study of this day, there has been placement of
a Dobbhoff tube that extends just beyond the level of the esophagogastric
junction. Little change in the appearance of the heart and lungs. CHEST (PORTABLE AP) showed In comparison with the study of ___, the right IJ catheter has been pulled
out by the patient. Dobbhoff tube is no longer present. Continued enlargement
of the cardiac silhouette with pulmonary edema. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is again some enlargement of
the cardiac silhouette with mild indistinctness of pulmonary vessels raising
the possibility of some elevated pulmonary venous pressure. No evidence of
acute focal pneumonia. MR HEAD W AND W/O CONTRAST showed Decrease in size of the enhancing lesion seen previously in the supra and
infratentorial brain. Surrounding edema has also decreased. Multiple
enhancing lesions are still identified. Followup as clinically indicated. CT CHEST W/CONTRAST showed 1. Effectively treated right upper lobe cavitary lesion and scattered
opacities described on CT ___.
2. Bibasilar ground-glass opacities in the setting of cardiomegaly suggest
pulmonary edema which may be followed with conventional chest radiographs.
3. Small adrenal nodule is likely an adenoma, but this needs to confirmed with
non-contrast CT imaging on any subsequent Chest or Abd CT.
RECOMMENDATION(S): Small adrenal nodule is likely an adenoma, but this needs
to confirmed with non-contrast CT imaging on any subsequent Chest or Abd CT. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was treated with IJ Central Venous Catheter Placement - ___
Dobhoff Placement - ___
Endotracheal Intubation and Mechanical Ventilation ___
Bronchoscopy ___. At the time of discharge, the patient had PRIMARY:
Central Nervous System Toxoplasmosis complicated by delirium and
ataxia
SECONDARY:
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
HIV/AIDS
Cavitary Lung Lesion (resolved)
Acute Kidney Injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___, a ___ yo M PMHx AIDS (only known OI PCP ___ ___
and did not complete tx, recently started on HAART, most recent
CD4 39 on ___ ___, actively smoking crystal
meth, syphilis, and who left AMA on ___ after an admission
for headache and represented to the ___ ED on ___ with
headache and AMS. He is now s/p intubation for MRI showing
multiple ring enhancing lesions concerning for toxo vs. CNS
lymphoma, and 6d MICU stay c/b SIADH and agitation, during which
he was transitioned to empiric treatment for toxo. LP was not
performed initially due to concern of cerebral edema with high
risk of herniation. He self-extubated in MICU and was
transferred to floor for continued treatment. He continued to
improve (and therefore did not require lumbar puncture or brain
biopsy), his mental status returned to baseline, his ataxia
resolved, ___ cleared patient to go home, his lung lesions noted
previously resolved.
# Central Nervous System Toxoplasmosis (presumed): Patient with
history of HIV/AIDS presented with ___ days of headache, ___
days of ataxia, and 1 day of delirium and CT-Head showing
multiple hypodensities in bilateral basal ganglia, thalami, left
temporal lobe, and cerebellum. Initial differential included
drug intoxication (positive amphetamines but wouldn't explain
ataxia), toxic-metabolic disease (Na 128 but otherwise normal),
cryptococcal disease (negative serum antigen), toxoplasmosis,
meningitis (HSV, TB), neurosyphilis, PML, CNS fungal disease,
septic emboli, CNS ___, PRES (by imaging, no significant
hypertension or relevant drug exposures), vasculitis, and
HIV-associated encephalitis (possibly superimposed on
HIV-associated neurocognitive dysfunction/atrophy). Neurology
Consult wanted MRI Brain but did not want lumbar puncture due to
concern of posterior fossa edema and thus increased risk of
herniation. Infectious Disease Consult wanted cryptococcal
antigen and initially wanted many CSF labs (also started
initially on vancomycin/ceftriaxone/ampicillin/acyclovir at
meningitic dosing). Patient initially had poor
concentration/judgement but this worsened to disorientation and
severe agitated delirium requiring 4-point restraints (patient
still managed to slip out, jump out of bed, and immediately
strike head against wall). Team attempted twice to obtain MRI
on main hospital floor (once within hours of arrival without
sedation which failed, a second time shortly before ICU transfer
with 4mg of lorazepam also failed). Due to need for MRI Brain
to determine clinical course, continued worsening of patient's
encephalopathy, and by Neurology/ID recommendation, patient was
transferred to MICU for MRI, Bronchoscopy, and potentially LP
and Brain Biopsy. MRI Brain showed multiple ring and solid
enhancing lesions in basal ganglia and
supratentorial/infratentorial white matter most concerning for
toxoplasmosis, CNS lymphoma, and less likely
fungal/bacterial/metastatic disease. Given concerns regarding
herniation from LP and invasiveness of brain biopsy (as well as
known Toxoplasmosis IgG), patient was started on empiric course
of pyrimethamine/sulfadiazine/leucovorin starting ___ along with
a single day of dexamethasone and levetiracetam for seizure
prophylaxis. Patient had history of sulfonamide allergy and so
underwent desensitization (without incident). Neurosurgery was
consulted for possibility of brain biopsy. After patient
self-extubated in ICU and was stable, he was transferred back to
the hospital floor. Due to overall stability and dramatic
improvement in focal neurological deficits by ___, patient did
not receive LP or brain biopsy (improvement at that time no
longer felt to be dexamethasone-related). His regimen was
subsequently changed to TMP-SMZ 2tabs BID on ___ with continued
improvement (total 6 week course, improved compliance). His
ataxia resolved completely (with mild residual upper extremity
dysmetria), his confusion cleared completely, and ___ cleared
patient to go home. HCP noted that patient had repeated
exposures to an outdoor cat and cleaned after the cat despite
being repeatedly warn by doctors and family not to. Repeat MRI
on ___ demonstrated dramatic improvement in the CNS lesions and
patient was discharged (taxi'd to ___ to receive
prepackaged TMP-SMZ and levetiracetam).
# Delirium/Agitation: Noted on admission, likely secondary to
CNS Toxoplasmosis versus contributions from amphetamine usage
versus possibly bipolar syndrome. Made admission MRI Brain
impossible without intubation/sedation. In ICU, patient
self-D/Cd central line, endotracheal tube, and innumerable
peripheral IVs. Currently somnolent with antipsychotics and
tolerating PO. Then Code Purpled on ___ in early morning
wanting to leave AMA but was redirected without force and with
quetiapine/lorazepam. Of note, last hospitalization at ___
ended with AMA discharge. On 5:00 on ___, Code Purple was
called since patient was bored and wanted to go home; received
25mg PO Quetiapine. At 6:30 again Code Purpled. Nightfloat
attempted to redirect but patient went out of room into hallway,
was unable to state consequences of leaving, and received
lorazepam 1mg, and was peacefully brought back to his room. At
8:00, he Code Purpled a ___ time, made it to the ___ elevator,
assaulted the PGY2, and had to be escorted back to room by
security. Later in the day he was less agitated with sister/HCP
present. Quetiapine was replaced with olazapine due to concern
of effect on ART. Late ___, he Code Purpled for a ___ time
but was easily redirected back into his room; given lorazepam
1mg PO x1. His quetiapine was changed to olanzapine due to
concern of ART interaction. His QTc was in low 400s and so
daily EKG monitoring was stopped due to stability. As of
___, he demonstrated some impulsivity but understood the
consequences of leaving and was fully oriented. Physical
Therapy consult felt that the patient had no acute ___ needs.
Since ___, patient was calm and no attempted to leave AMA.
Speech and Swallow recommended aspiration diet but liberalized
over the course of his hospital stay. for the remainder of his
inpatient stay, he was stable on olanzapine 5mg and trazodone
50mg. He was oriented and was able to understand the nature of
his condition and treatments and consequences of noncompliance
and was discharged to home without any psychiatric medication.
# SIADH / Hyponatremia: Noted to have Na 120s on admission with
Urine Na 100s that worsened with IV normal saline in ED. Likely
in setting of active CNS process, though lung process is also
possible given recent chest findings. Na has since returned to
140+, from 128 on admission, with hypertonic saline. ___ have
been a component of hypovolemia (since patient was not eating in
final days prior to hospitalization) and SIADH may improve with
improvement in brain lesions. Down to low 130s on ___ and
beyond despite fluid restriction but patient overall
asymptomatic.
# HIV/AIDS: Patient with a long history of HIV/AIDS (unclear if
acquired from MSM or IVDU) for as well as thrush and PCP ___
(did not complete treatment) recently started on ART ___,
not previously did to concerns of noncompliance) On ___, his
CD4 count was 39 and his viral load was ~250,000. On a visit on
___, his VL was 984 (notions of medication noncompliance but
VL would suggest otherwise). His outpatient regimen of
Emtricitabine-Tenofovir 200-300mg PO Daily, Ritonavir 100mg PO
Daily, Darunivir 800mg PO Daily,
Azithromycin/Atovaquone/Nystatin was continued as inpatient
aside from atovaquone (replaced with toxoplasmosis treatment).
Of note, patient did not receive TMP-SMZ due to recorded
sulfonamide allergy (no issues with desensitization during ICU
stay) which may have resulted in poor coverage of toxoplasmosis.
# Leukopenia: Patient with HIV/AIDS with previously normal WBC
noted to be leukopenic on ___ having recently been started on
Toxoplasmosis treatment. No neutropenia on ___ and WBC normal
on ___ and beyond.
# History of Crystal Meth Use and IVDU: Patient had allegedly
stopped IVDU 6 months prior to presentation and crystal
methaphetamine several days prior to presentation (positive
urine toxicology). After the acute phase of his
hospitalization, patient was noted to be somewhat somnolent
possibly secondary to methamphetamine withdrawal. Patient was
counseled to abstain from recreational drug use.
# Right Upper Lobe Cavitary Lesion and Ground Glass Opacities:
Lung findings (6mm cavitary lesion) noted on prior imaging with
patient no-showing numerous outpatient bronchoscopies. Overall
unclear etiology given lack of fever/chills/cough, positive IGRA
but negative AFBx3 in ___. Bronchoscopy with bronchoalveolar
lavage on ___ (while intubated in ICU) by Interventional
Pulmonology grew late CMV Early Antigen Positive and later
pansensitive Staphylococcus aureus but Infectious Disease was
not concerned given lack of CXR findings and change in symptoms.
Patient was initially on Contact/Airborne precautions but these
were discontinued once patient was in ICU. Repeat CT-Chest on
___ showed interval resolution of all lung pathology.
Differential on discharge includes viral pneumonia versus
incidentally treated PCP ___ (with evidence on BAL) versus
unclear etiology.
# ___: Most likely pre-renal or contrast-induced, given contrast
for CT angiography on ___ oliguria during MICU stay. Cr has
since returned to baseline. Nephrology was consulted in ICU for
assistance with ___ and SIADH but signed off in ICU given
normalization of renal function.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o HCV cirrhosis s/p OLT ___ who presents with chest
discomfort and ___. Patient states that yesterday (___) he
developed sharp pleuritic type chest pain that was worse with
deep inspiration. He has never had pain like this before. Pain
did not travel. It persisted for at least one day and prompted
him to present to outside hospital. There an EKG was negative
for acute ischemia and initial troponin was reported as
indeterminate near his baseline. Due to elevated creatinine,
patient was unable to undergo CTA and was transferred here.
Patient with history of liver transplant ___ years ago and
infected hardware in the left knee that has been removed several
months ago while he waits for a new knee repair. Currently
anticoagulated with Coumadin for history of PE and atrial
fibrillation. Patient states he does not remember what his prior
PE felt like. In the ED his CP resolved. On arrival to the floor
he complained only of right Knee pain for which he receives high
doses of narcotics at his rehab. He reports pain is ___
currently compared to ___ yesterday, but he will not beable to
sleep with this level of pain. RENAL U.S WITH DOPPLERS. showed 1. No evidence of hydronephrosis.
2. Extremely limited Doppler evaluation due to technically limited study,
demonstrating both kidneys to be vascularized. No further Dopp;er analysis
could be obtained. Radiology showed Right-sided PICC line terminating in the mid SVC. The patient was diagnosed with CHEST PAIN NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
===================
Acute on chronic kidney disease
SECONDARY DIAGNOSES:
=====================
Hypertension
Catheter-associated urinary tract infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman with HCV cirrhosis ___ years
s/p OLD and h/o DVT and PE (on Coumadin) who was transferred
from an OSH with chest pain, which resolved on admission, but
found to have supratherapeutic INR and ___.
# Acute on chronic kidney disease: Cr up to 2.2 on admission
from baseline of 1.4-1.5. Cr rose to 2.7 after albumin/IVF
boluses. Muddy brown casts were seen on urine sediment. Per
renal, multiple hypotensive episodes and bradycardia likely
resulted in ATN. Patient's creatinine slowly improved after
starting diuretics. Cr on discharge was 2.1. Kidney function
is expected to recover with time.
# Anasarca: Patient was grossly anasarcic after being volume
resuscitated with albumin for hypotension. TTE was largely
unchanged. Patient was diuresed with 40-80 mg IV Lasix/day and
his edema improved. He was discharged on torsemide 40 mg po
daily.
# Hepatitis C cirrhosis s/p OLT: Transplanted in ___, on
cyclosporine 75 mg q12h. MMF was stopped in clinic in
___ and LFTs remained normal. HCV VL 342,000 IU/mL on
___. Last biopsy was performed at previous admission
revealed Grade ___ inflammation, no acute cellular rejection, no
steatosis or ballooning, and stage ___ fibrosis. Atovaquone
was continued for prophylaxis. Cyclosporine was decreased to 50
mg q12h and levels were monitored.
# Supratherapeutic INR: Patient's Coumadin was held on
admission for supratherapeutic INR. He received vitamin K for
INR 5.2 and INR then became subtherapeutic. Warfarin was
restarted with a heparin gtt until INR became therapeutic. INR
became supratherapeutic again and Coumadin dose was adjusted.
INR on discharge was 3.6. He was discharged on Coumadin 1 mg
daily.
# Hypertension: Patient was initially hypotensive and losartan
and diuretics were held. He received an albumin bolus with
improvement in his blood pressure. He then became hypertensive
during the latter part of his hospitalization (SBP up to
170/180s). Losartan continued to be held given ___. Patient
was started on amlodipine 5 mg daily, which can be uptitrated as
needed.
# Prior left knee infection s/p hardware removal in ___:
Patient has chronic pain related to his previous knee
infection/hardware removal. He also has shallow venous stasis
ulcers on bilateral lower extremities. Patient's orthopedic
surgeon plans to replace his knee hardware once his ulcers have
healed and his leg swelling has resolved. Patient's pain was
well-controlled on home Oxycontin and po Dilaudid. He became
confused after receiving IV Dilaudid, so this was avoided.
# Catheter-associated UTI: Initial urine culture was negative.
Repeat urine culture after catheter was placed grew >100,000
Klebsiella sensitive to ceftriaxone. Foley was exchanged and
patient completed a 7 day course of ceftriaxone. Foley was
removed prior to discharge.
# Chest Pain: Patient had chest pain at OSH, which resolved on
admission here. No ischemic changes on EKG and three sets of
cardiac enzymes were negative. Considered PE, especially given
h/o prior PE, but patient had been therapeutic on Coumadin. CTA
was deferred given ___.
# Atrial fibrillation/pauses: Not on agents for rate or rhythm
control. During last admission (___), patient was
bradycardic at night with ___ second pauses seen on telemetry.
Patient continued to have pauses with HR ___, though rates
improved to ___ without intervention. It is unclear if these
pauses are contributing to hypotensive episodes. Patient is
followed by Dr. ___ have further outpatient EP
evaluation if warranted.
# Hyponatremia: Na persistently low (as low as 130s), which is
chronic per review of prior discharge summaries. Hyponatremia
neither responded to nor worsened with albumin or diuretics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with history of unprovoked left
carotid dissection, left MCA stroke with hemicraniectomy and
bilateral pulmonary emboli in ___,
residual right sided weakness and aphasia, and right hip
fracture in ___ who presented with 5 days of increased RLE
weakness. He had been at ___ and ___
following his right hip fracture hospitalization and was
improving and had been discharged home. Shortly after returning
home, he began having increased right leg weakness. He had been
on warfarin from ___ until ___ for prior stroke and
immobility (risk factor), then was stopped by hematology. He was
on prophylactic Lovenox when he was discharged in ___ after
his hip fracture, which was discontinued when he left rehab in
late ___. BILAT LOWER EXT VEINS showed 1. Occlusive deep venous thrombosis of the right common femoral, femoral,
popliteal, gastrocnemius, posterior tibial, and peroneal veins, extending down
to at least the level of the ankle.
2. No deep venous thrombosis of the left lower extremity. The patient was diagnosed with Weakness. At the time of discharge, the patient had Right lower extremity deep vein thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of unprovoked left
carotid dissection, left MCA stroke with hemicraniectomy and
bilateral pulmonary emboli in ___, residual right sided
weakness and aphasia, and right hip fracture in ___ who
presented with 5 days of increased RLE weakness and was found to
have extensive right leg DVT. He had been on warfarin from ___
until ___ for prior stroke and immobility, then was stopped
by hematology. He was on prophylactic Lovenox when he was
discharged in ___ after his hip fracture, which was
discontinued when he left rehab in late ___.
Ultrasound on ___ showed "1. Occlusive deep venous thrombosis
of the right common femoral, femoral, popliteal, gastrocnemius,
posterior tibial, and peroneal veins, extending down to at least
the level of the ankle. 2. No deep venous thrombosis of the left
lower extremity." He was started on a heparin drip and then
transitioned to Lovenox 1 mg/kg BID. He was started on warfarin
5mg QHS on ___. He had mild RLE pain. His INR was 2.4 on
___, the day of discharge.
Hematology was consulted and recommended having 2 therapeutic
INR values 24 hours apart before discontinuing Lovenox. He will
need at least 3 months of therapeutic anticoagulation.
When he was admitted he also had a non-contrast CT head that
showed no acute intracranial findings and stable chronic
infarcts. Neurology was consulted and will arrange outpatient
follow-up. He had no new neurologic changes on exam.
He also had frequent headaches that he described as unilateral
and associated with lacrimation and rhinorrhea, lasting minutes
to hours. He felt these were like cluster headaches he had in
the past. He has not had success with finding pain relief
previously, but he and his wife wanted to try increasing the
nortriptyline, as they felt this had partially helpful in the
past. This was increased to 150mg QHS.
He was evaluated by ___ and OT, who both recommended rehab. He
was discharged to ___ on ___.
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was greater
than 30 minutes.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of CAD, peripheral vascular disease s/p recent
RLE angiogram, SFA stenting and peroneal angioplasty for a cool,
painful RLE now presenting with similar symptoms. The patient
had been discharged after a course noted only for
pseuodoaneurysm development of the left groin after his right
SFA stenting and angioplasty. This was treated with manual
compression, with resolution. The patient was continued on his
aspirin and ticagrelor therapy and discharged home in good
condition with strong dopplerable distal signals. Radiology showed Occlusion of the distal right SFA stent. No evidence of left
groin pseudoaneurysm or AV fistula. The patient was diagnosed with CIRCULATORY DISEASE NEC. The patient was treated with ___: Right lower extremity angiogram, angiojet w/ 60mg tPA,
Right SFA stent, R SFA stent PTA. At the time of discharge, the patient had Peripheral arterial disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the Vascualar Surgery service with
HPI as stated above. including recent placement of 2 left SFA
stents and peroneal angioplasty. He underwent duplex which
noted no flow through the distal stent.
He went back to the OR on ___ for occluded right distal
superficial
femoral artery stent and underwent Right lower extremity
imaging, AngioJet thrombectomy, stenting of distal SFA, and
balloon angioplasty of proximal superficial femoral artery
stent; for full details please see the dictated operative
report.
He tolerated the procedure well and went to the PACU and then to
the floor on good condition. He was maintained on a heparin
drip as well as his home aspirin and ticagrelor overnight, and
his activity and diet were advanced on POD#1. He was normalized
on his home meds and the heparin drip was discontinued; he
voided without catheter.
On the afternoon of POD#1 that patient was felt to be
progressing well and appropriate for discharge. He will
continue his home anticoagulation and resume all other home meds
upon discharge. He is discharged to home on the afternoon of
POD#1, ___, in good condition and with appropriate
instructions, information, and plans to follow up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o woman with PMHx EtOH cirrhosis c/b esophageal varicies
(last EGD ___ and ascites, HTN, HLD and AS s/p bioprosthetic
AVR in ___ (last TTE ___, mean AV gradient 24) presenting
with SOB. She states that she last felt in her USOH in ___.
At that time she was able to walk her dogs ___ mile, 8 times per
day. Since then, she has noted progressive DOE; currently she is
only able to walk 20 feet before needing to stop and rest. She
denies any recent CP or pedal edema. For the past 36 hours she
has noted orthopnea, which is new for her and some PND. She is
not sure if she has gained weight recently. She denies personal
history of CAD, CHF or MI, though she has a very strong family
history of early CAD. She denies syncope and states she has
never had exertional CP before.
.
Initial VS in the ED:
T 96.9 HR 61 BP 125/41 RR 18 O2 Sat 95% RA
Labs were notable for BNP 5230, trop <0.01, normal CBC, normal
lytes. CXR showed moderate pulmonary edema, b/l pleural
effusions L>R, and cardiomegaly, which is new compared to study
dated ___. She was given Lasix 80mg IV x1 and admitted to
medicine. She received Lasix 80mg IV in the ED at 01:15, to
which she had put out 400cc of urine on arrival to the floor at
02:45.
.
On the floor, initial VS were:
T 98 BP 115/57 HR 65 RR 18 O2 Sat 95% 2L (88% RA) Radiology showed 1. Nodular hepatic contour with a coarsened echotexture consistent with
history of cirrhosis.
2. 8 mm hypoechoic nodule in segment ___ as well as poorly defined larger
isoechoic lesion in segment 4A which are suspicious for ___. Recommend
further evaluation with MRI or multiphasic liver CT.
3. Cholelithiasis.
These findings were discussed with Dr. ___ by Dr. ___ telephone
at 4:45 pm on ___. Radiology showed 1. Background cirrhosis without imaging features of portal hypertension.
2. No suspicious lesions within the liver, in particular no lesions to
correlate with the suspicious areas seen on the recent ultrasound. A
follow-up ultrasound is advised in 3 months to ensure stability/ resolution of
these findings.
3. Fatty deposition within the liver.
4. Cholelithiasis.
5. Bilateral pleural effusions with associated bibasilar atelectasis The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS. At the time of discharge, the patient had Critical Aortic Stenosis
Acute Congestive Heart Failure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o woman with PMHx EtOH cirrhosis c/b esophageal varicies
and ascites, HTN, HLD and AS s/p bioprosthetic AVR in ___
(previous TTE ___, mean AV gradient 24) presenting with CHF
___ aortic stenosis.
.
Active Problems:
# Decompensated aortic stenosis with acute CHF: Pt s/p AVR in
___ for AS with bioprosthetic valve and has had good functional
capacity. Orthopnea, cardiomegaly, hypoxia and pulmonary edema
in the setting of progressive decline in functional capacity and
elevated BNP is consistent with acute decompensated CHF. TTE
showed normal EF with concern for increased gradient in aortic
valve, concerning for symptomatic AS with TEE confirming
non-working AVR. She denies CP or syncope. She was seen by
cardiology who recommended cardiac surgery eval for redo AVR.
Patient currently at or near dry weight. Functional capacity
increased from walking 10ft on presentation to 5 laps around the
nursing station on d/c. Low Na diet. Switched to PO Lasix 120mg
with strict instructions for patient to weight herself every
morning as critical AS is pre-load dependent and do not want to
dry her out too much. Patient will return to AS clinic on ___.
Hepatology deemed her low risk for surgery.
# EtOH Cirrhosis: Due to longstanding EtOH use. Currently well
compensated. ___ Class A. MELD 7. RUQ showed mass
suspicious for HCC, AFP 2.6. MRI read did not pick up any mass
and after speaking to radiologist confirmed that sometimes there
can be a "fake out" with U/s. Did recommend f/u ultrasound in 3
months. Continued home Spironolactone, Nadolol. EGD without any
significant changes from previous.
Chronic Problems:
# GERD: Patient reports heart burn for 2-days that lasts about
30min. Had not mentioned this previously because didn't think a
big deal. Not worse with exercising. Pt on Pantoprazole at home
for GERD. Likely non-cardiac. EKG no acute changes. Encourage
sitting upright after meals. Continue Protonix
.
# Anxiety: Continue home Alprazolam </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ w/ HTN, DL, T2DM, CAD s/p
CABG ___ admitted ___ for nausea and found to have
new AML who p/w orthopnea. No F/C, no cough, no N/V, no chest
pain. She is a poor historian and unable to provide more
history.
She went to OSH where CT and CXR revealed pleural effusions,
moderately sized. She was transferred to ___ for continuity of
care. She was seen in the ED by IP who noted sig dyspnea and
placed b/l chest tubes, fluid studies c/w CHF. She felt sig
improved. On arrival to ___, she noted no dyspnea. CHEST (PORTABLE AP) showed Status post placement of bibasilar chest tubes with near complete resolution
of previously demonstrated bilateral pleural effusions. Minimal residual
atelectasis in the lung bases. No pneumothorax. Radiology showed Mediastinal wires and bilateral pleural pigtail catheters are again seen.
Cardiomediastinal silhouette is within normal limits. There are no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___.
Small right pleural effusion and mild bibasilar atelectasis are new. No
pneumothorax. Upper lungs clear. Heart size normal. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence acute intracranial abnormality. Chest radiograph, portable AP upright. showed Suspected small pleural effusions, otherwise unchanged. The patient was diagnosed with Pleural effusion, not elsewhere classified. The patient was treated with Bilateral chest tubes by Interventional Pulmonology ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PATIENT SUMMARY
=================
Ms. ___ is a ___ year-old woman with AML (now in
ongoing Complete Response following Decitabine/Venetoclax x 3
cycles), who was admitted on ___ with recurrent pleural
effusions secondary to acute on chronic Congestive Heart Failure
exacerbation (resolved following bilateral chest tubes), Acute
Kidney Injury (Cr improved to 1.3 on discharge, peak 2.0), and
failure to thrive.
TRANSITIONAL ISSUES
===================
[] Please refer patient to establish Primary Care and Cardiology
(any provider) follow up at ___ as she wishes to receive
all her care there
[] Metformin was held given labile renal function, consider
restarting if patient improves and PO tolerance is improved
[] Home olanzapine was also held given lethargy during
admission, can restart PRN
[] f/u Cr and diuretic dosing within the next 2 weeks: pt has a
history of nephrotic syndrome, with significant variability in
the serum creatinine over the past several months from
0.9-2.4mg/dL.
[] f/u dyspnea and pulmonary exam: pt may need titration of home
diuretic and hypertension medications to prevent reaccumulation
of pleural effusions.
[] f/u BP, medication adherence: pt with labile BPs, can have
SBPs up to 180s when refusing PO amlodipine and metoprolol.
ACUTE ISSUES
==============
# Bilateral pleural effusions
# Dyspnea
Presented from home with recurrent bilateral pleural effusions
and dyspnea x3-4 days. Labs consistent with transudative pleural
effusion, most likely ___ acute on chronic CHF. S/p bilateral
chest tube placement by IP on ___ with resolution of dyspnea,
removed ___. Diuresis held intermittently in setting of ___, as
below. Discharged on torsemide 20mg PO QD per nephrology
recommendations to help prevent reaccumulation of pleural
effusions.
# Acute on Chronic HFmrEF
Presented with elevated BNP, b/l pleural effusions, ___,
elevated JVD, consistent with acute heart failure. Dyspnea
improved after chest tube placement. No clear precipitant of her
CHF though her home medications did not previously include a
daily diuretic. EKG w/o acute ischemic changes and she denied
chest pain so less likely ACS. ___ TTE without significant
change from prior. She has a history of nephrotic syndrome for
which she required on the last admission 80-160mg IV Lasix
boluses. S/p IV diuresis, appeared euvolemic at time of
discharge. Continued home metoprolol.
# Failure to thrive
# Malnutrition
# Lethargy
Pt noted to have 40 pound weight loss on admission (~120lb)
compared to last documented weight 1 month prior (~160lb). Bed
weight accuracy limited and possible contribution of weight from
edema during last admission, however pt likely has lost
significant weight related to insufficient PO. Very poor PO
intake during this admission. Diet liberalized and supplements
provided per Nutrition. Pt was also noted to be often somnolent,
although arousable. ___ be related to generalized weakness and
failure to thrive. NCHCT negative for intracranial bleed. Per
discussion with social work, patient, and family, patient tends
to do much better when at home where she has an extensive
support network and home services.
# AML
Diagnosed during last admission, now in ongoing Complete
Response following Decitabine/Venetoclax x 3 cycles. Continued
home acyclovir. Per discussion with Dr. ___ on ___, pt will
follow up with Dr. ___ in ___ for further AML care.
# ___
# Nephrotic syndrome
Pt has a history of nephrotic syndrome, Cr bumped 1.5 to 2.0 on
___, likely ___ IV Lasix. Diuresis was held and ___ resolved.
Renal spun urine, no casts, many calcium phosphate crystals
including triple phosphate. Discharge Cr 1.3.
# Leukocytosis
# P. acnes in pleural fluid
WBC 9.2 -> 19.6 on ___ with left shift (86% PMNs), downtrended
to normal without antibiotic treatment. Flu negative in the ED.
CXR without evidence of consolidation. Pt endorsed cough and
transient sore throat, no abd pain or diarrhea, dysuria. BCx,
UCx neg. Reassuringly she remained afebrile and HDS. ___
anaerobic pleural fluid with P. acnes, likely contaminant. BCx
were negative throughout admission.
# HTN
Per chart review, during her last admission SBPs often up to
180s, home losartan 25mg QD was changed to amlodipine 10mg QD
due to labile renal function. On amlodipine 10mg QD she had SBPs
130s-160s, regimen not uptitrated further because of labile SBPs
sometimes dipping to ___. Continued home amlodipine and
metoprolol, in addition to PO hydralazine 25mg q6h prn for
SBP>160. Pt often refusing PO medications.
CHRONIC ISSUES
==============
# Delirium
Patient has a history of hypoactive delirium inpatient.
Continued delirium precautions during this admission.
Discontinued home olanzapine given occasional lethargy.
# Stage II Pressure ulcers
Pt noted to have two stage 2 pressure injuries on admission.
Continued wound care with mepilexes.
# CAD: cont metoprlol
# T2DM: held home metformin, discontinued ISS as has not been
requiring insulin
# DL: not on statin
# GERD: cont famotidine, protonix
# OA: cont lidocaine patch
CORE MEASURES
=============
#CODE: full code, presumed
#CONTACT: Name of health care proxy: ___
___: Daughter
Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History of Present Illness: ___ y.o woman with history of
dementia, hypertension who presents from her nursing home with
acutely altered mental status. Per corollary history from EMS,
the patient was last seen normal the evening before, but this
morning was acutely altered with at one point 3 minutes of
decorticate posturing with no incontinence. She also was
tachycardiac as well to 160 with hypertension to 210/100. There
was also an unconfirmed report that the patient had a urinary
tract infection. Fingerstick glucose was normal at 132, and
there was no report of a fall or trauma to the head.
.
In the ED, initial VS were: 97.2 ___ 2L
Patient was given 2L NS, ativan and zyprexa for agitation.
Vitals on transfer were hr 109 160/98 20 100% on RA
.
Review of systems:
Unable to obtain
. Radiology showed No acute intracranial process. Radiology showed No acute cardiopulmonary process. Apparent mild elevation of the
left hemidiaphragm may relate to patient positioning. The patient was diagnosed with ALTERED MENTAL STATUS , SCHIZOPHRENIA NOS-UNSPEC, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE. At the time of discharge, the patient had Acute delerium, unclear cause
Dementia
HTN
Blindness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with history of dementia, hypertension who
presents to the hospital with with an acute encephalopathy which
spontaneously resolved.
.
# Acute encephalopathy (toxic-metabolic) - During this
admission, there was no clear predisposing etiology for her
change in mental status. Per history there was a
supraventricular tachycardia during her acute event, however we
have no ECG record of this. During this admission, she underwent
an EEG that showed no evidence of seizures. Her bloodwork was
unremarkable and did not reveal any metabolic derangement. An
infectious workup including chest Xray and urinalysis were
unremarkable; blood and urine cultures had not growth, but were
still pending at the time of discharge. A CT head was also
unremarkable and the patient had no significant focal findings
on neurologic exam to support a stroke. She was monitored on
telemetry and ruled out for an ischemic cardiac event with 2
sets of negative cardiac enzymes. She did have a slightly
elevated lactate on admission, which resolved with
administration of IVF, suggesting the patient may have been
dehydrated. In the emergency room she received ativan and
zyprexa for agitation and was sleepy overnight. In the morning,
she appeared to have returned to her baseline mental status; she
was oriented and cooperative and requested to return home to her
nursing home.
.
# Tachycardia - The patient had an EKG showing normal sinus
rhythm on admission. She was monitored on telemetry and had
several episodes of non-sustained sinus tachycardia, which were
asymptomatic.
.
# Hypertension - The patient was significantly hypertensive
during this admission. Her amlodipine was increased to 10mg
daily, and she was started on metoprolol 12.5 mg twice daily.
.
# Glaucoma - continued home meds.
. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o metastatic pancreatic cancer receiving palliative FOLFOX
who presents with dyspnea on exertion. She reports two weeks of
worsening dyspnea on exertion. This became significant worse on
___ and ___. She states that she now cannot walk from
one room to another without feeling very short of breath. She
felt some chest pain last week, which is now resolved. She also
notes intermittent nausea and vomiting. She is overall very
fatigued. She has had diarrhea recently which is not black or
bloody and was C. diff negative. She was recently set up for
home IVF. CTA CHEST showed 1. No evidence of pulmonary embolism or acute aortic abnormality.
2. New ___ opacification in the superior segment of the left lower
lobe, likely small airways infection, with slightly increased airway wall
thickening.
3. Persistent small left pleural effusion and slightly increased left lower
lobe perifissural atelectasis.
4. Multiple bilateral perifissural nodules are similar to the prior exam, and
metastases are not excluded.
5. Multiple osseous sclerotic metastases again noted. The patient was diagnosed with Acute bronchitis, unspecified, Dyspnea, unspecified. The patient was treated with Blood transfusion ___. At the time of discharge, the patient had Symptomatic anemia
Pneumonia
Pancreatic cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ h/o metastatic pancreatic cancer receiving palliative FOLFOX
who presents with dyspnea on exertion and weakness found to have
anemia and pneumonia.
1. Acute on chronic normocytic anemia and thrombocytopenia
-s/p chemotherapy ___ with subsequent nadir as likely cause
of anemia. She essentially has pancytopenia with
thrombocytopenia and a relative leukopenia (drop in WBC from
30.8 ___ s/p Neulasta to 7.8 today). Transfused 1Unit PRBC ___
with improvement in hemoglobin to 7.4 to 7.6. Fecal occult
testing was negative. She noted improvement of her SOB even
prior to transfusion and felt better and requested to be
discharged home for further management as an outpatient
2. Community Acquired Pneumonia
-Potential small airway infection noted on CT. She has been
afebrile this admission. Was treated with a 5 day course of
levofloxacin that will continue through ___.
3. DOE and weakness
-Likely in setting of symptomatic anemia although potentially
mulficatorial in setting of pneumonia and poor PO intake. No PE
on CTA chest. She reported improvement in her SOB and symptoms
even prior to transfusion.
CHRONIC MEDICAL PROBLEMS
1. Metastatic pancreatitic cancer: Most recent treatment ___
with FOLFOX w/ Neulasta support. Continue oxycodone and
pancreatic supplementation.
2. Nausea/vomiting: Seems to be a side effect of chemotherapy on
antiemetics not currently an issue.
3. GERD: continue omeprazole
4. Opioid-induced constipation: continue bowel regimen
5. Hypophosphatemia: replete and monitor
>30 minutes spent on discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with Hx SBR and AAA s/p repair x 2 (___) c/b graft
infection on chronic suppressive antibiotics, presenting with
recurrent GI bleed and concern for aorto-enteric fistula. CTA abdomen/pelvis showed 1. No active extravasation of contrast to suggest a source of bleed within the
small bowel or colon on this examination. Colonic diverticulosis. Colonic
anastomosis as described above.
2. Aorto bi-iliac graft. Dilated portion of the left common iliac artery
consistent with arterial anastomosis. Narrowing of the right common iliac
artery, however it remains patent.
3. 11 mm left renal hyperdense enhancing lesion which is concerning for an
underlying renal neoplasm and could be assessed by MRI.
4. 1.8 cm cystic lesion within the body of the pancreas may represent
intraductal papillary mucinous neoplasm (IPMN), which may be re-assessed at
the time of MRI for left kidney.
NOTIFICATION: Findings discussed with Dr. ___ at 11AM on ___, 30 minutes after discovery of the findings. Radiology showed NG tube extends below the diaphragm with the tip out of view of the stomach. Radiology showed 1. Right internal jugular introducer remains in place with its tip in the
proximal SVC. The endotracheal tube continues to have its tip approximately
4.5 cm above the carina. A nasogastric tube is seen coursing below the
diaphragm with the tip not identified. Lungs appear well inflated without
evidence of focal airspace consolidation, pulmonary edema, or pneumothorax.
Overall cardiac and mediastinal contours are unchanged with calcification of
the aortic knob consistent with atherosclerosis. There is no evidence of free
intraperitoneal air or pleural effusions. No pneumothorax. CHEST PORT. LINE PLACEMENT showed Left-sided PICC seen terminating in the lower SVC .
Bibasilar linear atelectasis. The patient was diagnosed with GASTROINTEST HEMORR NOS, OTHER MALAISE AND FATIGUE, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with ___
aortogram, b/l limb religning, perclose. At the time of discharge, the patient had Aorto-enteric fistula. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospital course prior to Vascular Surgery involvement:
___ y/o F with PMH of of AAA s/p repair x 2 (___) c/b
aortic graft infection on chronic suppressive antibiotics and
diverticulosis who presented with GI bleeding.
ACTIVE ISSUES
# Bleeding per rectum: Source localized to duodenum, which
could represent ulcer or vascular lesion within the GI tract.
Also, there was high concern by Surgery for the possibility of
aorto-enteric fistula given h/o AAA s/p repair with aortic graft
infection. There was no bleeding GI lesion evident on recent
endoscopy ___. Colonoscopy on ___ showed internal
hemorrhoids, a polyp in the ascending colon, and no evidence of
recent or current bleeding. Push enteroscopy on ___ showed a
___ tear with no bleeding in the gastroesophageal
junction. She was transferred to the medical ICU for
hematochezia and presyncopal symptoms on ___ as per HPI. Urgent
CTA abd/pelvis was negative for extravasation of blood. She
underwent capsule endoscopy. A trauma line was placed in the
RIJ. She became hypotensive in the afternoon to SBP ___ and
received 1L LR. Tagged RBC was positive for blood in the ___
portion of the duodenum. Hct dropped from 30 to 21. She received
3U pRBC, ___, and calcium repletion overnight for Hct down to
21. She had multiple episodes of hematochezia overnight and
remained hemodynamically stable. Hct responded well to three
units pRBCs which suggested that bleeding had at least
temporarily stopped. GI anticipated repeat endoscopy in the
morning to look at duodenum more closely, but per Surg it would
not change their management due to strong concern for fistula.
She was transferred to the ___ to be under the
management of Vascular Surgery.
CHRONIC ISSUES
# Aortic graft infection: The patient is on chronic antibiotics
since ___. As cefixime is non-formulary, antibiotic was
chanaged to cefpodoxime 400 mg PO QD at time of admission.
# GERD: Continued home omeprazole.
# Anxiety: She was continued on home citalopram and lorazepam.
She was written for IV lorazepam on ___ due to escalating
anxiety due to medical problems and NPO status.
TRANSITIONAL ISSUES
#CTA revealed small renal neoplasm and pancreatic cyst which
need MRI evaluation.
#F/u capsule endoscopy results.
Hospital course after time of initialy Vascular Surgery
involvement:
Ms. ___ was admitted to the Vascular Surgery service with
HPI as stated above and went to the OR emergently for the
above-listed procedure. During the procedure, she required 7
units of PRBCs and 4 units of FFP. Post-operatively her crit
was found to be 38.9; she had a brief episode of hypotension to
the ___ post-op but recovered and repeat crit was found to be
36.
Overnight into POD#1 she had three bloody maroon bowel movements
and persistent melena. Her hematocrits, measured serially,
drifted to 33, but she remained stable and was transferred to
the VICU the following day. There, repeat crits were stable in
the low ___, and it was decided to advance her diet. The
following day, POD#3, she was considered safe to bear weight and
got up with physical therapy; she became briefly orthostatic to
the ___ but was entirely asymptomatic and recovered. PO intake
was encouraged and she got up again later and did well.
Also on POD#3, ID was consulted and recommended not less than 6
weeks of PO metronidazole and IV ceftriaxone. These were
initiated in the inpatient setting. The patient received a
left-sided PICC line to continue receiving IV antibiotics in the
outpatient setting. On the same day, her foley came out and she
voided.
She tolerated a regular diet and her pain was well controlled on
POD#4, she ambulated well with minimal assistance, and she was
determined to be safe for discharge to home with services. She
will continue to receive daily ceftriaxone infusion through her
PICC. She will take daily aspirin for anticoagulation and oral
metronidazole for infection prophylaxis. She has follow-up
arranged with ID and with vascular surgery. She is discharged
to home on POD#4 with all appropriate information, warnings,
prescriptions, and follow-up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ woman w/newly diagnosed cirrhosis who
presents with jaundice, right upper quadrant pain, and right leg
swelling. Patient was referred to the ED by her provider for
deterioration in performance status and concern for increased
abdominal swelling. Patient states that she feels weak, and
complains of sharp intermittent right upper quadrant pain.
Pertinent negatives include: chest pain, shortness of breath,
lower extremity pain/rash, dizziness, lightheadedness, fainting
episodes, injury, trauma, fall, coughing, hemoptysis, or bloody
stool. CHEST (AP AND LAT) showed Small to moderate left pleural effusion with mild pulmonary vascular
congestion. Bibasilar airspace opacities, more pronounced on the left, could
reflect atelectasis, though infection or aspiration is not excluded in the
correct clinical setting. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. No cholelithiasis or sonographic evidence of cholecystitis.
2. Cirrhotic liver with large volume ascites.
3. Patent portal vein. No intrahepatic biliary dilation. UNILAT LOWER EXT VEINS RIGHT showed 1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. Subcutaneous edema without drainable fluid collection identified. The patient was diagnosed with Acute and subacute hepatic failure without coma, Hyperkalemia, Unspecified jaundice, Chest pain, unspecified. The patient was treated with Therapeutic Paracentesis ___
Diagnostic Paracentesis ___. At the time of discharge, the patient had PRIMARY
==========
Cirrosis
Anemia
Hypertension
Hypoxia
Enterococcus bacteriuria
SECONDARY
==========
Alcohol use disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman w/newly diagnosed cirrhosis who
presented with jaundice, right upper quadrant pain, and right
leg swelling in the setting of hypotension and large volume
ascites. She was found to have hypoxia with evidence of pleural
effusions on CXR in the ED. She was transferred to the MICU for
hypotension and suspected shock. However, she was negative for
SBP based on diagnostic paracentesis and never required pressors
in the ICU. She was initially hypoxic to 91% on room air; CXR
notable for RLE atelectasis, likely compression from large
volume ascites. Oxygen requirement resolved after therapeutic
paracentesis as below
# Cirrhosis
# Ascite.
# Alcoholic Hepatits.
Newly diagnosed cirrhosis in the outpatient setting, presumed
___ alcohol use, though final workup is still pending.
Decompensated by ascites this hospital stay. Elevated
ferritin:TIBC ratio (1:1), possibly suggestive of iron
overload/hemochromatosis as a contributor, though important to
note that with alcoholic hepatitis, ferritin is expectedly
elevated. Pt endorses a moderate history of EtOH use in the past
(3 drinks per day per her report)., though brother thinks she is
drinking significantly more than this. No evidence of PVT on
RUQUS ___. Underwent paracentesis with removal of 6 L fluid on
___ resultant improvement in subjective dyspnea as well as
hypoxia as below. TTE echocardiogram (___) showed Mitral and
tricuspid valve prolapse with late systolic mitral and tricuspid
regurgitation but normal biventricular systolic function.
Patient was resumed on ___ spironolactone 50 mg daily as well
as furosemide 20 mg daily. Though ascites did slowly increase
over the course of her hospital stay, she did not require repeat
therapeutic paracentesis during her stay here. Patient was
followed by nutrition consul. Due to downtrending MDF and GIB on
___, steroids were not used in treatment of patient's alcoholic
hepatitis. Dobhoff tube placement was attempted on ___ via EGD
that was complicated by laceration as below. Due to downtrending
discriminative function, Dobbhoff tube placement and tube feeds
were ultimately not started though risks and benefits
conversation with patient was had regarding concern for
malnutrition and need for at least ___ kcal/day intake.
#Hypotension
# Asymptomatic Bateruria.
In the ED the patient's BP went from 146/75 to 94/53 suggesting
shock. Differential diagnosis included infection (SBP), systemic
vasodilation ___ liver disease, medication effect or other
infectious source. No evidence evidence of infection on
diagnostic or therapeutic paracentesis on ___ and ___
respectively. Blood cultures with no growth. Chest x-ray with no
evidence of pneumonia. Urine with growth of enterococcus species
___. This was deemed an asymptomatic bacteriuria as patient had
no signs or symptoms of urinary tract. It was not treated. She
notea that
she and her family have always had low blood pressure
# Esophageal Laceration. Patient underwent EGD on ___ for
scheduled Dobhoff tube placement and suffered an esophageal
laceration. She was initially treated for an upper GI bleed with
IV pantoprazole 40 mg Q12H, IV ceftriaxone and octreotide. She
had no signs of repeat bleed and remained hemodynamically stable
with stable hemoglobin. Diet was advanced to a regular diet over
the course of a 24 hour period. She was discharged on oral
pantoprazole 40 mg Q12H and 7 days of oral antibiotic
prophylaxis as below.
# Anemia
# Thrombocytopenia. Likely a chronic issue secondary to her
cirrhosis. No acute management.
# Hypoxia (resolved). Patient initially required up to 2 L O2
via NC. CXR revealed pulmonary vascular congestion and L sided
effusion, likely related to cirrhosis and volume overload as
below. Resolved with therapeutic paracentesis as above.
Transitional Issues
===============
- Code status: Patient states that she would not want
interventions done "if
there were no point." However, she does feel frustrated that she
continues to get asked about code status questions in the
hospital. This conversation should be continued in the
outpatient setting.
- She should have follow up iron studies in ___ months given
elevated ferritin and TIBC
- Antibiotics: She should remain on antibiotics for a total of 7
days after her GI bleed on ___ (start date ___ | projected end
date ___
- Consider increase of diuretics as an outpatient
- Patient suffered an esophageal laceration during EGD. She was
intially managed on IV PPI, octreotide and IV ceftriaxone and
de-escalated to p.o. pantoprazole every 12 hours and
ciprofloxacin p.o. for prophylaxis as above. Please reassess the
need for PPI in the outpatient setting.
- Diuretic: Spironolcatone 50 mg/Lasix 20 mg. ___ uptitrate in
outpatient setting as tolerated
- Please repeat chem10 one week after discharge to monitor for
electrolyte stability on current diuretic regimen
- Continue sucralfate for 9 days after discharge </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old M presenting with jaundice. Pt with very complex
past medical history, best outlined in recent visit with Dr
___ in ___. Pt with UC/chrons diagnosed at age ___ which
has been quiescent and has not needed medications. Also with
history of autoimmune disorders including thyroiditis s/p
thyroidectomy, type 1DM, ITP, and likely autoimmune leukopenia.
Pt also with achalasia s/p myotomy. In addition he has
hemoptysis from lung granulomas of uncertain etiology. Resected
specimens negative for mycobacteria. CHEST (PA AND LAT) showed The left hemidiaphragm remains elevated. The patient is status post left
upper lung surgery with stable postsurgical changes in the left hemithorax.
Patchy opacities seen at the medial right lung base which may reflect an area
of atelectasis, although pneumonia should also be considered. Clinical
correlation is advised. No pneumothorax. No pulmonary edema. Relatively low
lung volumes. No large effusions. Radiology showed 1. Stenting of left hepatic duct to duodenum with adequate contrast flow.
2. Placement of 3 left hepatic fiducials.
3. Drainage of an incidentally found new 6 cm biloma anterior to left hepatic
lobe. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Hepatic architectural distortion and biliary dilatation consistent with
history of PSC. No focal liver lesions.
2. Patent hepatic vasculature with conventional hepatic arterial anatomy.
3. Sequela of portal hypertension including ascites and splenomegaly. CT CHEST W/CONTRAST showed 1. No evidence of intrathoracic malignancy.
2. Postsurgical changes seen in the left lung. Mild bibasilar atelectasis.
3. Dilated esophagus with diffuse esophageal wall thickening and fluid
extending to the level of the thoracic esophagus, in keeping with known
history of achalasia. Radiology showed 1. Successful placement of the left ___ internal-external biliary drain.
2. Uncomplicated biopsy of common hepatic and left main biliary duct stenoses.
Results pending. The patient was diagnosed with JAUNDICE NOS, DIABETES UNCOMPL JUVEN, LONG-TERM (CURRENT) USE OF INSULIN, HYPOTHYROIDISM NOS. The patient was treated with ___ ERCP. At the time of discharge, the patient had Cholangiocarcinoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT/PLAN: ___ with PSC Child's B MELD 16, UC/Crohn's,
autoimmune thyroiditis, achalasia, ITP, DMI who presented for
evaluation of jaundice, found to have stricture of common
hepatic duct now confirmed to be cholangioCA after 2 biopsies
and FISH studies. Patient developed VRE and Dapto resistent SIRS
after stent placement through the stricutre caused by the
cholangiocarinoma. Last positive blood cultures was ___. After
biopsy results, pt was not longer a candidate for tranplant at
this institution; however, ___ in ___ will
perform. Pt was given that option, however, declined and wanted
to move forward with chem and radiation here. In prepartion for
treatment, a metal biliary stent replaced the plastic one and
three fiducial markers were placed for raditation treatment. Pt
started and discharged on 2 week course of Linezolid ___ BID
since first negative Bcx--with stop date ___. He is to follow
up with rad onc, heme one, liver clinic, and ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is an ___ M with h/o tobacco abuse, COPD who presents
to the ___ ED with vertigo starting very early this morning.
Last evening the patient was in his usual state prior to going
to bed for the evening. He had gotten up to use the bathroom and
did so without difficulty. When he laid back down, he had the
sudden onset of room spinning dizziness. It improved somewhat
with sitting up right on the edge of the bed, but continued for
about 30 minutes before abating. He was then able to stand and,
though cautious, walk steadily. He went back to bed at about
4am. This morning, the patient got up to use the restroom and
was feeling ok. While in the bathroom he leaned forward and
again felt very dizzy. He fell, but did not strike his head or
lose consciousness. He laid there for a bit and continued to
feel dizzy. EMS was called and he was brought to the ED. Now in
the ED, he states that he is asymptomatic when sitting with his
head up, but symptoms return every time he tilts his head
downward. He has never had vertigo before. CHEST (AP AND LAT) showed Streaky opacity in the lingula concerning for pneumonia. CT HEAD W/O CONTRAST showed 1. Study is mildly degraded by motion.
2. No acute intracranial process.
3. Possible atypical arachnoid granulation pit in the right frontal bone which
can be further characterized by nonemergent MRI.
RECOMMENDATION(S): Consider nonemergent bone scan or MRI to further assess. CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. No evidence of aneurysm greater than 3 mm, dissection, vascular
malformation, or significant luminal narrowing.
2. Less than 50% stenosis at the origin of the left internal common carotid
artery.
3. Lytic right frontal calvarial lesion for which a bone scan can be acquired
further evaluation.
RECOMMENDATION(S): Bone scan to evaluate the calvarial lesion. MR HEAD W/O CONTRAST showed No acute infarcts identified. Moderate cortical brain atrophy seen. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, VERTIGO/DIZZINESS. At the time of discharge, the patient had peripheral vertigo
Pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is an ___ M with h/o tobacco abuse, COPD who presents
to the ___ ED with vertigo starting very early this morning.
Symptoms have been somewhat fluctuating in intensity, but
relatively continuous and brought on more severely with bending
the head downward. His exam is notable only for gait
instability. There are no other clear signs of cerebellar
dysfunction. HIT is inconclusive. Given gait instability and
continuing vertigo, admitted for and MRI of his head. MRI
negative for stroke, evaluated by ___ who recommended outpatient
___ rehab.
Also found a pneumonia on CXR in the ED, given levaquin once,
started on Z-pak for a 5 day course to be finished as
outpatient. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with history of
recurrent parastomal hernia related SBO, CKD stage V, CAD s/p
MI,
atrial fibrillation, chronic diastolic heart failure, severe AS
s/p TAVR, complete heart block s/p PPM, bladder cancer s/p
cystectomy and ileal conduit with urostomy, prostate cancer s/p
radical prostatectomy who presents as transfer from ___ for SBO on ___. Radiology showed Gas distention of multiple loops of small and large bowel, with air and stool
in the rectum.
Clinical correlation for ileus is recommended. The patient was diagnosed with Other partial intestinal obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of recurrent
parastomal hernia related SBO, CKD stage V, CAD s/p MI, atrial
fibrillation, chronic diastolic heart failure, severe AS s/p
TAVR, complete heart block s/p PPM, bladder cancer
s/p cystectomy and ileal conduit with urostomy, prostate cancer
s/p radical prostatectomy who presents as transfer from
___ for SBO on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: History obtained from son and ___ note, as pt has been
having worsening mental status per son. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral peribronchovascular opacification, concentrated in the right
upper and lower lobes, is consistent with multifocal pneumonia.
3. Main pulmonary artery dilatation up to 3.5 cm is suggestive but not
diagnostic of pulmonary arterial hypertension. Chest radiograph showed Right PICC should be retracted by 5 cm. Multifocal pulmonary opacities as
seen on the same-day CT examination consistent with multifocal pneumonia.
NOTIFICATION: The findings were discussed with ___, by ___
___, M.D. on the telephone on ___ at 4:55 pm, 2 minutes after discovery
of the findings. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. Chest radiograph showed There is little changed compared the prior examination. Right PICC is
unchanged. Lung volumes remain low. There remains mild cardiomegaly and
unfolding of the thoracic aorta. The areas of increased opacity in the
bilateral lung fields correspond to the consolidations as seen on the prior
CT, consistent with multifocal pneumonia, though these findings do not appear
worsened. There may be some superimposed pulmonary vascular congestion and
mild edema. There is no large effusion or pneumothorax. Chest radiograph showed Right PICC terminates in the right atrium, and could be retracted by 2-3 cm
for more ideal positioning. Otherwise no change. Lung volumes remain low.
Cardiomediastinal silhouette is unchanged. There is no gross consolidation.
There is no large effusion or pneumothorax. CT HEAD W/O CONTRAST Q111 CT HEAD. showed 1. Three areas of hemorrhage, with a subdural hematoma involving the left
frontoparietal lobe and measuring 1.7 x 1.2 cm, associated with sulci
effacement and significant edema without frank uncal herniation. 5 mm left to
right shift of normally midline structures.
2. Subdural hematoma in the left frontal lobe measuring 5 x 2 mm.
3. Hemorrhage along the left tentorium.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:16 pm, 5 minutes after
discovery of the findings. CT of the abdomen and pelvis: showed 1. Small bilateral pleural effusions. 2. No lymphadenopathy in the abdomen
or pelvis. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Left hemisphere subdural hematoma without evidence of new hemorrhage.
2. Overall unchanged effacement of sulci without increase in mass effect. UNILAT UP EXT VEINS US LEFT showed No evidence of deep vein thrombosis in the left upper extremity. CHEST (PA AND LAT) showed Compared to chest radiographs ___ through ___.
Mild cardiomegaly and vascular congestion of the mediastinum and right hilus
are chronic. Previous right upper lobe pneumonia has resolved. Lungs are
essentially clear. No appreciable pleural abnormality.
Right PIC line ends in the upper right atrium, as before. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Evolution of left hemispheric subdural hematoma without evidence of new
hemorrhage.
2. Slight improvement in mass effect when compared to the study from ___. CT HEAD W/O CONTRAST Q111 CT HEAD showed Mixed density subacute on chronic left hemispheric subdural hematoma, with
small volume of interval hemorrhage since ___. The patient was diagnosed with Pneumonia, unspecified organism, Non-Hodgkin lymphoma, unspecified, unspecified site, Dyspnea, unspecified. The patient was treated with bone marrow biopsy ___. At the time of discharge, the patient had lymphoma
atrial tachycardia
subdural hemorrhage
indolent TB
hep B. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is an ___ originally presenting with 3 weeks of back pain,
forgetfulness and hemoptysis found to have high grade B cell
lymphoma now s/p 1C of mini CHOP.
#High grade B cell lymphoma: with peripheral/bone marrow
involvement at diagnosis. initiated C1 mini CHOP per primary
attending recommendations (multiple comorbities/age limited use
of EPOCH)
CycloPHOSPHAMIDE 720 mg IV Day 1. (___)
(750 mg/m2 - dose reduced by 47% to 400 mg/m2)
Reason for dose reduction: mini-CHOP, elderly
DOXOrubicin 45 mg IV Day 1. (___)
(50 mg/m2 - dose reduced by 50% to 25 mg/m2)
Reason for dose reduction: mini-CHOP, elderly
VinCRIStine (Oncovin) 1 mg * IV Day 1. (___)
(1.4 mg/m2 [cap at 2 mg] - dose reduced by 50% to 1 mg)
Reason for dose reduction: mini-CHOP, elderly
PredniSONE 100 mg PO Q24H Duration: 5 Doses
Give on Days, 2, 3, 4 and 5.
Filgrastim-sndz 480 mcg SC DAILY until ___ recovery, plan to
d/c once ___ >1000, D/C ___ prior to discharge
- Transfuse for Hgb < 7 and plt < 50 fibrinogen < 150 in
setting
of SDH--less frequent due to count recovery
- give low dose Rituxan 100mg IV once only on ___ (high risk of
reaction due to circulating disease, age, comorbities) pre-med
appropriately and do not escalate per primary attending
recs--tolerated well
-plan for POC placement prior to next cycle of mini CHOP--need
to schedule outpatient
-will f/u in clinic every other day for possible plt transfusion
and will see Dr. ___ on ___
# Subdural Hematoma
Discovered on ___ ___omplained of headache.
Neurosurgery
as immediately consulted, who recommended rescanning the next AM
and ppx Keppra 500 mg BID. Will follow with interval scans.
- last repeated ___ and reviewed with Dr ___
25mg BID to prevent seizures and plt threshold >50K
- repeat NCHCT for any new neurologic symptoms
- Transfuse for plts < 50
- SBP < 160
- see neuro surg notes for further recommendations
# Sinus tachycardia - evaluated by cardiology--will f/u
outpatient as well
- tapered off short acting meto (patient has been responding to
IV diltiazem over meto )
- Change short acting diltiazem 30 mg q6h to 120mg daily long
acting starting ___, increased to 180mg in setting of low grade
tachycardia over weekend of ___
-monitor rate/symptoms, last EKG NSR ___
# Fever
# Multifocal PNA
resolution.
- Continue cefepime until count recovery (___), d/c
with ANC >900 on ___
# AMS: waxes/wanes
Differential diagnosis includes delirium, toxic metabolic
encepholopathy, dementia, EtOH withdrawal, leukostasis. Will
continue to monitor closely. Psychiatry has evaluated, suspect a
combination cultural factors, educational factors, baseline
argumentative personality, with overlying significant delirium.
-continues Seroquel @hs, rec while receiving steroids and could
consider peeling off when off, will continue for now while
inhouse for long period of time and re-introducing high dose
steroids every ___ weeks with chemo regimen.
# Unclear ___
Records from PCP office suggest pt was in good health with only
___ knee replacement and glaucoma surgery prior to this
hospitalization.
# EtOH use disorder
Son reports daily EtOH use, concerning for alcohol use disorder.
Unknown history of seizures. s/p CIWA protocol. Pt has not
required diazepam.
# Hep B core Ab positivity: Will continue lamivudine
# latent TB : +quant gold, to treat per ID. on INH/B6
# FEN: Gentle IVF/ Replete PRN/ Regular low-bacteria diet
# ACCESS: ___--line care outpatient due to frequent
transfusions
# PROPHYLAXIS:
-Bowel: senna, colace
-DVT: none indicated, thrombocytopenic
-viral: acyclovir
-fungal: fluc while neutropenic, d/c on discharge
-PCP: bactrim
# CODE: Presumed Full
# DISPO: home with 24hr supervision confirmed with son and
grand-daughter with multiple services in place--see case
management note</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male who presents with approximately one week
history of malaise, and abdominal pain. He describes the pain as
sharp, non-radiating and constant ___. Located periumblical and
epigastric area mainly. Started about one week ago and is not
associated with food or drinking. Not associated with long
periods of fasting either. No nausea/vomiting. He has had no
previous episodes of this. He has a hx of a perforated gastric
ulcer and underwent a subtotal gastrectomy in ___ complicated
by peritonitis and CVA with right hemiparesis. He has had
chronic diarrhea since the surgery with no recent change in
bowel habits. Does not know if he has been given NSAIDs at ___
___ where he resides.
In the ED, initial vital signs were: T98.3 102 179/91 16 97% RA Radiology showed 1. Extensive inflammatory changes and complex fluid in the right upper
quadrant just lateral to the proximal duodenum, with areas appearing confluent
with the duodenal wall, is most consistent with severe duodenitis. No free
air or extraluminal oral contrast to suggest frank perforation. No organized
fluid collections are present. Etiologies for these findings include infected
ulcer, a postoperative injury, or an inflammatory neoplasm. Correlate with
surgical history. Endoscopy is recommended following resolution of acute
condition as underlying mass cannot be excluded.
2. The gallbladder lies adjacent to this process, but appears intact and
non-distended, and is not felt to be the source.
3. Nonspecific mild bile duct prominence which may be age-related.
4. Colonic diverticulosis. The patient was diagnosed with ABDOMINAL PAIN EPIGASTRIC. At the time of discharge, the patient had Primary Diagnosis: Duodenitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o gentleman with PMH of HTN and gastric ulcer presenting
with abdominal pain found to have duodenitis.
#Abdominal pain/duodenitis: The patient presented to the
hospital with abdominal pain, malaise, nausea, and vomiting for
one week. CT Abdomen/Pelvis in the ED shows finding consistent
with severe duodenitis. No obvious free air but small underlying
rupture cannot be excluded; reassured by no evidence of perf on
imaging though. Given the acute inflammation, there was no role
for endoscopy on this admission. The patient was initially
started on IV cipro/flagyl, IV pantoprazole, and was made NPO.
His pain significantly improved overnight. According to the
___ stewardship team, there is no definitive role
for antibiotics in the treatment of duodenitis and thus his
antibiotics were discontinued on his second hospital day (___)
without clinical deterioration. His abdominal exam remained
benign without evidence of peritonitis. The patient's diet was
advanced without issue. He did have some mild abdominal pain on
his ___ hospital day for which he was started on sucralfate with
good response (total course 14 days ending ___. He was
discharged home with resumption of home services. The patient
should have an endoscopy after resolution of acute inflammation
(> approximately 6 weeks).
#HTN: Stable while admitted. Home metoprolol was continued.
#Hypothyroidism: Stable while admitted. Home levothyroxine was
continued.
Transitional Issues:
- DNR, ok to intubate
- The patient should have an upper endoscopy in > 6 weeks or
when acute inflammation resolves
- The patient should follow up with his PCP upon discharge
- Stool h. pylori and h. pylori antibody test pending at
discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old-man with past medical history of
stage D HFrEF on dobutmaine s/p elective single chamber ICD
placement ___, coronary artery disease status post stent to
RCA, OSA and T2DM who was admitted after episode of dizziness
and hypotension. Radiology showed Cardiomegaly without superimposed acute cardiopulmonary process. CHEST (PORTABLE AP) showed Comparison to ___. The patient now carries an intra-aortic balloon
pump, an external pacemaker and the Swan-Ganz catheter. All devices are in
correct position. The tip of the intra-aortic balloon pump is 1 mm be low the
upper most part of the aortic arch. Low lung volumes. Moderate cardiomegaly
without pulmonary edema. No pleural effusions. No pneumothorax. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is noted. The position of
the intra-aortic balloon pump is stable, with the tip of the pump projecting
over the aortic knob. The position of the pacemaker lead and of the Swan-Ganz
catheter as well as of the right PICC line are stable. Mild pulmonary edema
is present. No pleural effusions. No pneumonia. CHEST (PORTABLE AP) showed Comparison to ___. All monitoring and support devices are in
stable position. In particular, the intra-aortic balloon pump is unchanged.
The tip continues to project over the aortic knob. Stable position of the
Swan-Ganz catheter and of the pacemaker leads. Moderate cardiomegaly persists
in unchanged manner. No pulmonary edema. No pneumothorax. No pleural
effusions. CHEST (PORTABLE AP) showed Comparison to ___. The tip of the intra-aortic balloon pump
continues to project over the aortic knob. Moderate cardiomegaly persists.
No pulmonary edema. Radiology showed Lungs are low volume with mild interstitial edema. Moderate cardiomegaly is
again seen. Left-sided pacemaker is also unchanged. Intra-aortic balloon
pump remains in place. No pneumothorax is seen. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Mild cardiomegaly has improved, interstitial edema has resolved. Lungs are
clear and there is no pleural effusion.
Intra-aortic balloon pump in standard placement. Transvenous right
ventricular pacer defibrillator lead tip projects over the right ventricular
apex. Chest radiograph showed New ET tube and LVAD since ___, both appropriately placed. No evidence
of complications.
Unchanged appearance of remaining cardiopulmonary support devices.
No significant interval change of lung and cardiac appearances. CHEST RADIOGRAPH showed 1. Endotracheal tube tip terminates approximately 7 cm above the carina, for
which advancement of 2 cm may be considered.
2. Low lung volumes and persistent mild pulmonary vascular congestion.
3. No new focal consolidations or pleural abnormality. Radiology showed Tip of the Swan-Ganz pattern has been pulled back approximately 3 cm and now
projects over the midline of the spine. Endotracheal tube has been removed.
There is a persistent left-sided pacemaker. There is mild prominence of the
left heart. There is no focal consolidation, pulmonary edema, or large
pleural effusions. There are no pneumothoraces BILAT UP EXT VEINS US showed The study is technically limited as discussed above. There is a peripheral
nonocclusive thrombus within the right internal jugular vein that is likely
subacute or chronic.
Otherwise, there is no evidence of deep vein thrombosis in the other deep
veins of the bilateral upper extremities.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:19 pm, 5 minutes after
discovery of the findings. Radiology showed Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is within normal limits. There are no focal consolidations,
pleural effusion, or pulmonary edema. There are no pneumothoraces. Radiology showed Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette
is stable. Left-sided pacemaker is unchanged. And Impella device is in
place. No pneumothorax is seen CHEST (PORTABLE AP) showed Impella devise is in place. Swan-Ganz catheter is in place. Pacemaker
defibrillator lead is in place. Overall the position of the devices is
stable.
NG tube has been discontinued.
There is interval improvement in pulmonary edema with no vascular congestion
or pulmonary edema currently seen. No appreciable pleural effusion. No
pneumothorax. CHEST U.S. showed 4.9 x 3.4 x 2.5 cm collection in the subcutaneous tissue of the right chest
wall overlying Impella. No internal vascular flow seen. Differential
diagnosis includes hematoma, seroma, superinfection is not excluded. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices
are unchanged. Continued enlargement of the cardiac silhouette without
appreciable vascular congestion, pleural effusion, or acute focal pneumonia. Radiology showed The left-sided pacemaker and the heart meet devices are unchanged in position.
The Swan-Ganz catheter is also unchanged. Lungs continue to be low volume.
Moderate cardiomegaly is unchanged. There is no pleural effusion. No
pneumothorax is seen CHEST (PORTABLE AP) showed Swan-Ganz catheter tip is at the level of the right ventricular outflow tract.
Impella devise and pacemaker leads are in unchanged position. Cardiomegaly is
unchanged. There is no pulmonary edema. There is no appreciable pleural
effusion or pneumothorax. Radiology showed Support lines and tubes are unchanged. Left-sided pacemaker is stable. There
is moderate cardiomegaly. There is mild interstitial edema. There are no
pleural effusions. No pneumothorax is seen Radiology showed Lungs are low volume with mild interstitial prominence. Moderate cardiomegaly
is unchanged. Left-sided pacemaker and ventricular assist device are in
place. There are no pleural effusions. No pneumothorax is seen
cardiomediastinal silhouette is stable CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is noted. Stable position
of the ventricular assist device and of the pacemaker. Moderate cardiomegaly
persists. No pulmonary edema. No pleural effusions. No pneumonia. UNILAT UP EXT VEINS US RIGHT showed A small amount of nonocclusive deep vein thrombus is re-demonstrated within
the right internal jugular vein, and is decreased compared to prior
ultrasound. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Moderate to severe cardiomegaly is stable. Right trans subclavian Impella
device unchanged in position, extending to the floor of the left ventricle.
Transvenous right ventricular pacer defibrillator lead also stable. Pulmonary
vasculature is mildly engorged, but there is no frank pulmonary edema. No
pneumothorax or pleural effusion. Radiology showed Left-sided pacemaker is unchanged. Left IJ sheath has been removed.
Cardiomediastinal silhouette is stable. A right sided Impella device is seen
projected over the heart. Lungs are low volume with mild pulmonary vascular
congestion. There is no pleural effusion. No pneumothorax is seen Chest radiograph showed Stable postoperative appearance with expected mild mediastinal bleeding and a
small pneumomediastinum.
Newly placed monitoring devices.
Lung volumes are low but otherwise clear. Radiology showed Support lines and tubes including left-sided pacemaker and ventricular assist
device are unchanged. There is new parenchymal opacity in the right upper
lobe which could represent edema or pneumonia. Cardiomediastinal silhouette
is stable. There are small bilateral effusions left greater than right. No
pneumothorax is seen Radiology showed Increased aeration of the right upper lobe. Otherwise no significant interval
change since prior Radiology showed Support lines and tubes unchanged. Cardiomediastinal silhouette is stable.
There is no pleural effusion. No pneumothorax is seen. Pulmonary edema is
stable. Radiology showed The tip of a right transjugular Swan-Ganz catheter projects over the right
pulmonary artery. The endotracheal and gastric tubes have been removed. A
left chest tube and mediastinal drain are noted. Skin staples project over the
right axilla.
Retrocardiac opacities likely reflect atelectasis and small volume pleural
fluid. There is mild pulmonary edema. No pneumothorax or right
consolidation. The size of the cardiac silhouette is enlarged but unchanged. Radiology showed Cardiomediastinal silhouette is stable. Pulmonary edema has worsened.
Left-sided pacemaker and ventricular assist device are unchanged. CHEST (PORTABLE AP) showed In comparison with the study of ___, there are slightly improved lung
volumes. Cardiac silhouette remains substantially enlarged, though there is
minimal if any vascular congestion. Retrocardiac opacification is consistent
with volume loss in the left lower lobe and pleural fluid. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is further improvement in
lung volumes. Monitoring and support devices are essentially unchanged. The
any vascular congestion is minimal. Retrocardiac opacification is again
consistent with volume loss in left lower lobe and probable small pleural
effusion. CHEST (PORTABLE AP) showed In comparison with the study of earlier in this date, the chest tubes have
been removed and there is no evidence of pneumothorax. A lower lung volumes
with stable enlargement of the cardiac silhouette. Increasing opacification
is seen in the left hemithorax. Some of this could represent asymmetric
pulmonary edema with pleural fluid and basilar atelectasis. However, in the
appropriate clinical setting the, superimposed aspiration/pneumonia would have
to be considered. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support
devices are stable, as is the overall appearance of the heart and lungs. CR - CHEST PORTABLE AP showed 1. Interval placement of a right upper extremity PICC which terminates in the
right atrium. Retraction by 2 cm is recommended for optimal positioning at
the cavoatrial junction.
2. Interval removal of the Swan-Ganz catheter.
3. Otherwise, no significant interval change from earlier today. Radiology showed Left-sided pacemaker and ventricular assist device are unchanged. Right-sided
PICC line projects to the cavoatrial junction. Right IJ sheath has been
removed. Cardiomediastinal silhouette is stable. Small bilateral effusions
left greater than right are stable. Pulmonary edema has minimally improved.
No pneumothorax is seen AP portable chest radiograph showed Interval improvement in now mild pulmonary edema on the left and a small left
pleural effusion. There is no pneumothorax. CHEST (PA AND LAT) showed Compared to chest radiographs ___ through ___.
Moderate left pleural effusion is enlarging, with equivalent enlargement of
left lower lobe atelectasis maintaining the mediastinum in the midline.
Moderate enlargement of cardiac silhouette has not changed. Right lung shows
a mild increase in pulmonary vascular congestion but no edema as yet and no
right pleural effusion. No pneumothorax.
Right PIC line ends in the mid to low SVC. Transvenous right ventricular
pacer lead unchanged in standard position. LVAD also grossly unchanged. Radiology showed Moderate cardiomegaly is unchanged. Pulmonary edema has improved. Small left
pleural effusion is stable. Ventricular assist device and left-sided
pacemaker are also unchanged. Right-sided PICC line projects to the
cavoatrial junction. No pneumothorax is seen. Cardiomediastinal silhouette
is stable. CHEST (PORTABLE AP) showed Right PICC line tip is at the level of lower SVC. LVAD is in place. No
pneumothorax. No pleural effusion increase. No pulmonary edema. UNILAT UP EXT VEINS US showed No evidence of deep vein thrombosis in the right upper extremity. CHEST (PORTABLE AP) showed In comparison with study of ___, a the monitoring support devices are
unchanged. There is increasing opacification at the left base, consistent
with a combination of reaccumulating pleural effusion and volume loss in the
retrocardiac region. Continued enlargement of the cardiac silhouette with
moderate pulmonary vascular congestion. Chest CTA showed Filling defects consistent with thrombi/emboli seen in the right subclavian
and in the right internal jugular vein.
LVAD in appropriate positioning.
Large left pleural effusion, not hemorrhagic, causing compressive atelectasis
in the left lower lobe and lingula and mild pulmonary edema in the left upper
lobe.
NOTIFICATION: The findings were discussed with Dr ___, M.D.
by ___, M.D. on the telephone on ___ at 8:17 pm, 5 minutes
after discovery of the findings. Chest radiograph showed New left-sided chest tube with tip obscured by part of the LVAD but apparently
in the left costophrenic angle. Radiology showed Left-sided pacemaker ventricular assist device are unchanged. Right-sided
PICC line projects to the cavoatrial junction. Moderate cardiomegaly is
unchanged. Small left pleural effusion stable. There is mild pulmonary
vascular congestion. No pneumothorax is seen CT CHEST W/O CONTRAST showed Status post left-sided chest tube placement.
Decrease in volume of the left pleural effusion which is now small volume and
partially loculated.
Trace right pleural effusion is unchanged.
No interval change in the cardiomegaly and small mediastinal lymph nodes. An
LVAD and left-sided pacemaker are unchanged.
Lack of intravenous contrast limits evaluation. No pneumothorax CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Elevated left hemidiaphragm, left lower lobe collapse, small to moderate left
pleural effusion all long-standing. Right lung clear. Stable large
cardiomediastinal silhouette.
LVAD device unchanged in position.
Transvenous pace maker defibrillator lead projects over the right ventricular
apex. The right PIC line ends in the low SVC as before. CHEST (PA AND LAT) showed In comparison with the study of ___, the there is no evidence of
appreciable pneumothorax following chest tube removal. Little change in the
appearance of the heart and lungs and the monitoring and support devices. The patient was diagnosed with Heart failure, unspecified, Hypotension, unspecified, Syncope and collapse, Dizziness and giddiness. The patient was treated with ___ - Implant of Heartmate III LVAD, removal of Right
axillary impella 5.0.
___ - Re-exploration of Right axillary incision,
evacuation of small hematoma, repositioning of Impella.
___ - Right axillary cutdown, Impella 5.0 placement.. At the time of discharge, the patient had Primary Diagnosis:
Congestive Heart Failure, chronic systolic
Coronary Artery Disease
Anemia
Blood stream infection
Leukocytosis
Epistaxis
Hyponatremia
Delirium
Secondary Diagnosis:
Asthma
Atrial Fibrillation
Diabetes Mellitus Type II
Diverticulosis
Gastroesophageal Reflux Disease
Obstructive Sleep Apnea on BiPAP
Small Bowel Obstruction with diverting ostomy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old-man with PMHx of mixed
ischemic/non-ischemic cardiomyopathy (LVEF 25%) s/p elective
single chamber ICD placement ___, CAD s/p DES to RCA
___, OSA and T2DM who was admitted after episode of dizziness
and hypotension thought to be secondary to over diuresis. While
admitted the patient was transitioned from dobutamine to
milrinone because of eosinophilia. A RHC was completed that
showed poor CI and high PVR. The patient did not improve on
inotropes, and it was felt he needed mechanical support. He was
transferred to the CCU and a balloon pump was inserted while
awaiting LVAD placement. On ___ his IABP was removed and
replaced with impella 5.0 to bridge to LVAD, which was placed on
___. His course was complicated for a CoNS blood stream
infection, for which he received 4 weeks of IV antibiotics,
anemia, for which he received multiple pRBC transfusions, and a
challenging anticoagulation course.
# CORONARIES: R-dominant; LMCA, LAD, LCx without flow limiting
disease, DES to RCA ___
# PUMP: EF 25%
# RHYTHM: Sinus
ACTIVE ISSUES
=============
# Mixed ischemic/non-ischemic HFrEF (Stage D, EF 25%) Patient
admitted for hypotension/presyncope, but found to have
eosinophilia thought to be secondary to dobutamine. Patient was
transitioned to milrinone, then to digoxin and sildenafil.
Patient worsened to the point that he needed mechanical support
in the CCU w/ a balloon pump while awaiting LVAD, which was
placed on ___. The IABP was removed and replaced with
impella to bridge to LVAD, which was placed on ___ (of note,
impella graft was left in). He was then transferred to the floor
where he stabilized on a PO Torsemide regimen. He was initially
on milrinone for right ventricular support, but was able to
transition to sildenafil and digoxin. Physical therapy worked
with him extensively to improve his strength and he and his
family members received LVAD training. He had some challenges
with anticoagulation, which are detailed below. His course was
also complicated by persistently low hemoglobin, continued fluid
reaccumulation, a blood clot in his arm, and a major life event.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with decompensated NASH cirrhosis (ascites, jaundice), AAA
with planned repair this week, had pre-op labs drawn showing Na
117. Surgery was cancelled and pt advised to go to ED.
.
First diagnosis with ascites/cirrhosis in ___. Patient
noted to have hyponatremia in the past with adjustment of
diuretics. On ___ had Na 124.
.
In the ED, initial vs were: 97.2 81 ___ 100%ra. Pt was
give 1L NS and started on ___ L while in ED. While there, he
denied symptoms, pain, CP, SOB, n/v, any changes to BM or
urinary outpt. Abdomen noted to be distended and firm to
palpation, lungs clear.
Vitals before transfer: 97.9, 110/71, 82, 16, 99% RA.
.
On the floor, complains of hunger, but otherwise feels well.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias. Evaluation of the patient with abdominal aortic
aneurysm before repair.
PA and lateral upright chest radiographs were reviewed in comparison to CT of
the abdomen from ___.
Heart size is normal. Mediastinum is normal. Lungs are essentially clear.
Old rib fracture on the right is noted involving eighth right rib. There is
no pleural effusion or pneumothorax. was done. Radiology showed 1. Cirrhotic liver without concerning focal liver lesion. No bile duct
dilation.
2. Main portal vein patent with a normal waveform. The patient was diagnosed with HYPOSMOLALITY/HYPONATREMIA, DIABETES UNCOMPL ADULT. The patient was treated with Paracentesis. At the time of discharge, the patient had Primary:
Decompensated Cirrhosis
Hyponatremia
AAA
.
Secondary:
Diabetes, type 2. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Summary: ___ M with decompensated cirrhosis with ascites and
varices, admitted for hyponatremia noted prior to planned AAA
repair, with SBP diagnosed on ___.
.
# Hyponatremia - No symptoms. Initially managed with fluid
restriction and holding of lasix/spironolactone. Tolvaptan was
later initiated, and the patient demonstrated a good response,
with peak Na of 132 (levels were trended carefully to ensure
sodium did not correct too rapidly). Lasix/spironolactone were
restarted. After tolvaptan was stopped, the patient's sodium
decreased to 126. Subsequently, this was restarted prior to
discharge. The patient was instructed to follow-up with his
primary care doctor, and to obtain basic labwork shortly after
discharge to monitor sodium levels closely.
.
# SBP: Initial diagnostic paracentesis was negative. however,
the cultures grew coagulase negative staph in very low numbers,
raising suspician for contamination. The patient had a repeat
paracentesis (with 3L of fluid removed), which was positive for
SBP. This infection may have been the precipitant of his
hyponatremia, however it was suspected that the coag negative
staph was likely an unrelated contaminant. He completed a 5 day
course of Ceftriaxone 2g on ___, with Albumin given on D1 and
D3. Ciprofloxacin was initated for prophylaxis upon discharge.
.
# Pancytopenia, low fibrinogen, and coagulopathy: Likely
related to low-grade DIC from infection or liver failure, or a
combination of the two. He had no evidence of bleeding, with
the exception of during peripheral lab draws. Aspirin was held,
and the patient was instructed to follow-up with his primary
doctor regarding whether to restart this medicine. His CBC,
Fibrinogen, and coags were stable or improving at the time of
discharge.
.
# Decompensated cirrhosis - Likely secondary to NASH. history of
grade 1 varices, ascites, and SBP; no history of encephalopathy.
Diuretics were restarted after initially being held. Nadolol
was added with resting HR in ___ (atenolol was stopped).
.
# T2DM: Treated with metformin at home. His blood sugars were
elevated this admission, and the patient was instructed to
follow-up closely with his primary doctor regarding additional
treatment options.
.
# HTN: Started nadolol in lieu of atenolol as above.
.
# Vitamins: Continued Vitamin B12, Vitamin C. Vitamin D weekly
at home.
.
# Primary prophylaxis: Holding aspirin for now, to follow-up
with PCP.
.
==========</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yoF with h/o HTN, asthma, and recent rotator cuff surgery on
___ who presents with severe headache and dizziness.
Reports waking up yesterday morning with a severe frontal
headache. Accompanied by dizziness, worse with standing/walking.
+ photosensitivity. Also had onset of left sided non-pleuritic
chest pain that was sharp and did not radiate. CP not
positional. Had nausea but no vomiting. Had recent rotator cuff
surgery and shoulder pain was also worse. Took a Percocet with
mild improvement in her HA. Recently started lisinopril 10mg po
daily (3 days ago) for poorly controlled blood pressure. Denies
any weakness, numbness, shortness of breath. Dizziness is a
lightheaded sensation, not vertigo. When symptoms began, seen by
outpatient physical therapist who took BP which was reportedly
SBP 180. Also endorsed some palpitations during this time. Does
have a neighbor with acute viral gastroenteritis symptoms.
In the ED, initial vitals were 98.2 94 137/80 16 100%RA. ECG
showed sinus rhythm with LAD, nonspecific ST changes.
Orthostatics were negative. Guaiac negative. Head CT without
acute process. CTA showed no evidence of PE. LP was attempted by
4 people (including ED attending) and could not be performed.
Currently, she reports feeling mildly improved but still with
headache. Was able to ambulate to the bathroom without
substantial dizziness. Radiology showed No acute intracranial process. Radiology showed No acute process in the chest. Specifically, no evidence of
pulmonary embolism. The patient was diagnosed with HEADACHE, CHEST PAIN NOS. The patient was treated with LP attempted, unsuccessful. At the time of discharge, the patient had Migraine
Secondary diagnoses:
hypertension
asthma
anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yoF with h/o HTN, asthma, and recent rotator cuff surgery on
___ who presents with severe headache and dizziness.
#Headache: Thought to be due to ___ initially based on
presentation. Multiple failed attempts at LP. No signs of acute
bleed on head CT or brain MR. ___ the following morning.
Seen by neuro, who felt this to be most consistent with
migraine. Pt educated on migraine triggers and recommended HA
log.
# Dizziness: Resolved following AM. Likely component of
headache.
# Chest pain: CTA negative for PE. Troponins negative x2, no EKG
changes. Resolved the following AM. Likely anxiety or GERD.
Unlikely ACS.
# HTN: continued home HCTZ and lisinopril
# Anemia: At recent baseline. no signs of bleeding. Did not
receive transfusions.
# Depression: continued ome meds.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with hepatitis C
cirrhosis s/p orthotopic liver transplantation ___. His
post-transplant course has been complicated by recurrent HCV,
acute cellular rejection, and stage I fibrosis. He was admitted
from liver clinic today with hyperkalemia, acute-on-chronic
renal insufficiency (Cr 1.9 from recent discharge Cr of 1.5),
and transaminitis, which was concerning for acute rejection vs.
recurrent HCV.
Of note, Mr. ___ has had several biopsies positive for mild
acute cellular rejection this fall. He was recently admitted for
mild acute cellular rejection from ___ to ___. During
this stay, he his immunosuppression regimen was changed from
sirolimus to tacrolimus and he was dosed with IV steroids. He
had a repeat biopsy on ___ which showed mild acute cellular
rejection and recurrent HCV. He also developed acute kidney
injury, which was attributed to tacrolimus, though he continued
to make urine normally and had no electrolyte abnormalities. Radiology showed Ultrasound-guided 18 G non-targeted core liver biopsy. One core was taken.
Pathology pending. Radiology showed 1. Little change in comparison to the prior study with patent hepatic
vasculature, stable resistive indices and no ductal dilatation,
2. Splenomegaly, no ascites. The patient was diagnosed with HYPERKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED. The patient was treated with Liver biopsy
ERCP. At the time of discharge, the patient had Primary Diagnosis:
- Transaminitis
- Acute on chronic renal failure
Secondary Diagnosis:
- Orthotopic Liver transplant recipient
- Hepatitis C. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>REASON FOR ADMISSION
Mr. ___ is a ___ gentleman with a history of
hepatitis C cirrhosis who received an orthotopic liver
transplant on ___. His post-transplant course has been
complicated by recurrent hepatitis C (HCV), acute cellular
rejection, and stage I fibrosis. He was admitted from clinic
with hyperkalemia, acute-on-chronic renal insufficiency, and
transaminitis.
ACTIVE ISSUES
1. Transaminitis: As noted in the HPI, Mr. ___ was recently
admitted for acute cellular rejection, which was treated with a
dose of IV methylprednisolone and an increase in his
immunosuppression from sirolimus to tacrolimus. Biopsy during
his prior admission also showed evidence of recurrent HCV. Mr.
___ now presents with elevation of his AST/ALT/Tbili to
183/85/5.6 from his prior discharge values of 98/76/2.3 on
___. Liver biopsy this admission was negative for acute
cellular rejection but did show recurrent HCV vs. biliary
obstruction. A repeat ERCP showed a tortuous duct but no
evidence of obstruction. He has had recent negative CMV viral
load in ___ and ___. HCV viral load has increased
steadily and is now 21,737,817. Patient's LFT's improved
slightly during hospital stay. His tacrolimus was
supratherapeutic at 14. Given recent evidence of rejection,
tacrolimus goal is 10. His dose was reduced to 1 mg BID. He was
continued on home dose of mycofenalate mofetil 1000 mg BID. He
will be discharged with close outpatient follow-up and
consideration of outpatient treatement for his recurrent HCV.
2. Acute-on-Chronic Renal Failure: During his previous
admission, Mr. ___ immunosuppression was changed from
sirolimus to tacrolimus to better treat acute cellular rejection
of his liver graft. He was noted to have elevation of his
creatinine from a baseline of 1.0 to 1.5 at the time of
discharge, which was attributed to tacrolimus toxicity given his
history of tacrolimus-induced kidney failure and the fact that
it did not respond to fluids or to reductions in diuretic dose.
His providers agreed to tolerate the elevation in creatinine
given the importance of treating his rejection. Upon admission,
creatinine had increased to 1.9 in the setting of a
supratherapeutic tacrolimus level. Fractional excretion of Urea
was 24% and fractional excretion of sodium, 0.5%, both of which
supported a pre-renal etiology such as tacrolimus toxicity.
Patient's tacrolimus dose was decreased from 3 mg BID to 1 mg
BID with a goal trough of ___. His valganciclovir was
decreased to 450 mg daily given CrCl < 50. Patient's creatinine
improved to 1.5 on day of discharge. He will need close
monitoring of renal function as an outpatient.
3. Hematocrit Drop: Mr. ___ had a drop in his hematocrit
from 38 to the low 30's during admission. There was no obvious
source of bleeding, and he remained hemodynamically stable. It
is possible this drop was due to dilution and frequent
phlebotomy. Hematocrit remained stable after liver biopsy.
Please continue to monitor hematocrit as an outpatient.
4. Hepatitis C Cirrhosis, s/p Liver Transplant: As discussed
above, patient's tacrolimus dosing was decreased to 1 mg BID
with a goal trough of ___. He was continued on MMF 1000 mg
BID. For prophylaxis, he was continued on Bactrim SS 1 tab
daily. His Valgancyclovir was decreased from 900 mg to 450 mg
daily due to renal failure. He continued Ursodiol 300mg BID and
Femotidine 20mg q12h.
CHRONIC ISSUES
1. Hypertension: Patient's furosemide was initially held in the
setting of acute renal failure. It was then restarted. He was
continued on home metoprolol.
2. Diabetes Mellitus: Patient continued his home regimen of
glargine 30 units QHS. In addition, he received a Humalog
sliding scale.
3. Back pain: Patient continued home oxycodone and oxycontin.
4. HLD: Patient's home fenofibrate was held given LFT
abnormalities.
TRANSITIONAL ISSUES
1. Follow-up pending tacrolimus level from ___
2. Patient will walk in for a repeat chemistry, liver panel, and
tacrolimus level on ___
3. Adjust Valgancyclovir dose as creatinine improves
4. Consider treatment of HCV as outpatient once appropriate
5. On discharge medication reconciliation, I inadvertently
checked that patietn should restart fenofibrate. This is
incorrect; he should continue to hold his fenofibrate given his
transaminitis. I will call him to clarify the instructions.
6. Goal tacrolimus level ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of migraines, prior admission for L sided
facial pain with negative work up for temporal arteritis,
presenting with bilateral episodes of facial pain and spasms,
associated with tearing that started last night. Patient first
noticed pain around her eyes. Per son, patient's speech is
slightly more slurred than normal. No muscle weakness of facial
droop. Pain is sharp and stabbing, intermittent. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed No acute intracranial process.
Fibromuscular dysplasia of the extracranial cervical internal carotid arteries
bilateral, and probably mild involvement of the extracranial right vertebral
artery. No evidence of dissection, aneurysm formation, thrombosis or
significant atherosclerotic stenosis.
Incidental finding of a peripheral filling defect in the right superior lobar
pulmonary artery suggesting a pulmonary embolus. This has the appearance of
being late subacute to chronic. Dedicated chest imaging advised.
19 mm hypodense nodule in the left lobe of thyroid for which correlation with
thyroid ultrasound is advised.
RECOMMENDATION(S): Thyroid ultrasound.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 4:03 pm, 5 minutes after discovery of the
findings. CTA CHEST WITH CONTRAST showed 1. Bilateral pulmonary emboli involving up to lobar pulmonary arteries of
indeterminate age, but may be chronic given areas of strand-like appearance.
2. There is evidence of pulmonary hypertension with dilation of the left and
right pulmonary arteries.
3. Cholelithiasis without evidence of cholecystitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:15pm, 5 minutes after discovery
of the findings. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Jaw pain. At the time of discharge, the patient had Primary diagnosis:
Pulmonary embolism
Secondary diagnosis:
Trigeminal neuralgia
Facial spasms
Hypertension
Pulmonary Hypertension
Thyroid nodule. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>===========================
Patient summary statement for admission
===========================
Ms. ___ is a ___ with history of migraines, prior admission
for L sided facial pain with negative work up for temporal
arteritis, presenting with bilateral episodes of facial pain and
spasms, associated with tearing that started night prior to
admission. Patient had CTA head and neck for stroke workup, and
bilateral filling defects in upper lobes of lungs were found
incidentally.
============================
Acute medical/surgical issues addressed
============================
#Bilateral lobar pulmonary embolism
Patient with incidental finding of bilateral pulmonary embolisms
found on CTA head and neck, confirmed later by CTA chest. Due to
stranding appearance, PEs thought to be chronic. Not a candidate
for thrombolytics. Upon further questioning, patient stated she
did have shortness of breath with exertion, new in the last 2
weeks. Did have a long trip several months ago but unclear if
related. Lower extremity ultrasound were negative for DVTs.
While admitted, patient was hemodynamically stable with good O2
sat on RA. Started on heparin drip initially but transitioned to
Apixiban 5mg BID ___. Moderate Pulmonary hypertension as a
result of PE was demonstrated on TTE, this will need pulmonary
follow up.
#Bilateral facial pain and spasms
#History of trigeminal neuralgia
Patient presented after worsening facial pain/headache and
facial spasms that started the evening prior to admission.
Neurology was consulted in the ED. Patient was found to have
intact temporal pulses and normal visual acuity. CK/CRP were
WNL. CTA head and neck showed no arterial dissection or
structural abnormalities. Since patient with no focal deficits,
Neurology recommended deferring further stroke workup. Per
neurology facial pain and twitching could be due to autonomic
neuralgia in setting of her underlying trigeminal neuralgia vs
autonomic dysfunction due to SUNCT. Headache improved with
Tylenol and increased Gabapentin dose. Facial twitching subsided
the following day. Patient to follow-up with outpatient
Neurologist, Dr. ___.
=========================
Chronic issues pertinent to admission
=========================
#Hypertension
Started losartan 25mg and continued hydrochlorothiazide with SBP
in 130s to 150s. Will transition to home irbesartan at discharge
#Thyroid nodule
1.9 cm hypodense nodule within the left lower thyroid lobe,
should be further evaluated with dedicated nonemergent
outpatient thyroid ultrasound.
# h/o depression
continued duloxetine
#insomnia
continued zolpidem in lower dose (ER nonformulary). Continued
Seroquel
================
Transitional issues
================
- Gabapentin dose increased from 300 mg PO QHS to TID
(___)
- Patient started on Apixaban 5mg BID for PE
- 1.9 cm hypodense nodule within the left lower thyroid lobe,
should be further evaluated with dedicated nonemergent
outpatient thyroid ultrasound.
- Patient with evidence of pulmonary hypertension on CTA chest
not noted in previous ECHO (___) and on Echo trom ___-
Moderate Pulmonary HTN.
- Given PEs diagnosed on this admission, please ensure patient
has age-appropriate cancer screening
- Please consider hypercoagulability work-up in 6 months, when
patient has completed appropriate course of apixiban</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: UNILAT LOWER EXT VEINS LEFT showed Nonocclusive deep venous thrombosis within proximal left popliteal vein. Radiology showed No acute fracture or dislocation. Mild prepatellar soft tissue swelling. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Findings concerning for a likely chronic subdural hematoma with hypo and
hyperdense components, over the left frontal convexity. The hyperdense
components are age-indeterminate but cannot exclude an acute or subacute
process.
2. There is a focal hypodensity at the inferior left frontal lobe near the
gyrus rectus which is concerning for a prior contusion injury.
NOTIFICATION: The findings were discussed with ___, M.D. by ___.
___, M.D. on the telephone on ___ at 8:18 pm, 18 minutes after
discovery of the findings. US NECK, SOFT TISSUE showed No abnormality detected in the imaged portion of the soft tissues of the right
neck. CT HEAD W/O CONTRAST Q111 CT HEAD showed Stable small subdural hematoma along the left frontal cerebral convexity. No
new sites of intracranial hemorrhage. CT ABD AND PELVIS WITH CONTRAST showed 1. Interval enlargement of the spleen with development of multiple
hypoenhancing lesions measuring up to 2.5 cm concerning for infiltrative
process such as lymphoma or in the spectrum of extramedullary hematopoiesis.
Differential diagnosis includes abscesses
RECOMMENDATION(S): MRI could be considered for further evaluation of splenic
lesions CT CHEST W/CONTRAST showed 1. No evidence of intrathoracic malignancy.
2. Small bilateral pleural effusions with associated compressive atelectasis.
3. Please refer to separate report of CT abdomen and pelvis performed on the
same day for description of the subdiaphragmatic findings. SPLEEN ULTRASOUND showed Multiple hypoechoic variable-sized rounded splenic lesions. These lesions are
amenable to ultrasound-guided biopsy. Ultrasound-guided targeted splenic biopsy showed 1. Technically successful ultrasound-guided core biopsy of splenic lesion.
Immediate bleeding within the lesion at time of close approximation of the
biopsy needle is suggestive of cystic rather than solid content.
2. Mild periprocedural intraparenchymal hemorrhage. Otherwise no immediate
postprocedural complications. The patient was diagnosed with Anemia, unspecified. The patient was treated with ___ Colonoscopy
___ ultrasound-guided biopsy of the sp. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES
===================
[ ] Discharge Hgb 8.2
[ ] Discharge Cr 1.1
[ ] Discharged on warfarin, though displayed poor understanding
of dosing of medication. Please closely follow his INR. Next INR
should be drawn on ___. He will require 3 months of
anticoagulation as provoked DVT (___). INR on discharge
2.0.
[ ] He has a history of medication noncompliance with his
diabetes regimen. ___ was consulted to try to simplify his
diabetes regimen, as detailed below. IF ___ follow up is
preferred, please contact ___ Central Appointment at (___) or email ___.
[ ] Please obtain repeat INR and FSBG on ___. We
discharged him on 7.5mg warfarin daily (for one week, please
adjust as indicated by INR), and added Repaglinide at dinnertime
to compensate for removal of dinnertime insulin.
[ ] Hep B nonimmune, so will need Hep B vaccine series
[ ] His spleen biopsy was nondiagnostic, and hematology oncology
recommended outpatient PET/CT scan. They have set up an
appointment and imaging time.
[ ] Can consider discontinuing PPI after 1 month (___)
if symptoms have resolved.
[ ] Need for tooth extraction, but is on warfarin now. Patient
has private dentist that he wants to see upon discharge.
Recommend at least 1 month of uninterrupted anticoagulation
(AC), though preferably should complete 3 month of AC and then
get dental procedure done. Patient should see outpatient dentist
post discharge and see how urgent this procedure is and what his
dentist recommends regarding timing off AC.
BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ man with a history of type 2
diabetes, hypertension, large bowel obstruction s/p colostomy,
poor social support at home, deficiencies in cognitive
functioning, and recent traumatic subarachnoid hemorrhage who
presented with hyperglycemia, anemia with concern for
gastrointestinal bleed, and left lower extremity deep venous
thrombosis (DVT). For his DVT, he was started on a heparin drip
which was bridged to warfarin. He underwent colonoscopy with
biopsy, which showed pouchitis and colitis. He had a CT
abdomen/pelvis which showed multiple splenic lesions, which were
biopsied and nondiagnostic, prompting recommendation for further
outpatient work-up with hematology oncology. His diabetes
medication regimen was also optimized to maximize non-injectable
medications.
=============
ACUTE ISSUES
=============
#Provoked DVT
#Non-occlusive popliteal vein clot
Patient was found to have a non-occlusive popliteal vein clot,
considered provoked given recent hospitalization and prolonged
immobility. No evidence of pulmonary embolus. Given concern for
acute anemia, GIB with oozing colitis, risk of falls, and head
bleed, discussed anticoagulation with neurosurgery and GI teams
with plan to start heparin drip with subsequent coumadin bridge,
given easy reversibility of the latter. He was successfully
bridged to warfarin with 48 hour overlap period. Given history
of medication noncompliance with diabetes regimen, had
considered DOAC or Lovenox; however, neurosurgery, in the
context of head bleed, recommended against those agents, with
preference for warfarin, given easy reversibility. Will plan for
3 months of anticoagulation as provoked DVT.
#Iron Deficiency Anemia
#Gastrointestinal bleed
Patient admitted with Hgb 7.6, from 12.6 on ___, and
hematochezia. Patient was transfused as needed and remained
hemodynamically stable. Colonoscopy ___ showed pouchitis and
colitis up to cecum with terminal ileum sparing, with very
friable and oozing mucosa, concerning for IBD, and biopsy was
taken. Given cachexia/weight loss/lymphadenopathy and bright red
blood per rectum, there was also concern for malignancy;
however, no findings of mass seen on colonoscopy. CRP was
elevated at 75.2. Biopsy showed severely active chronic colitis,
without evidence of inflammatory bowel disease or malignancy. He
was placed on a proton pump inhibitor for a 1 month course, plan
to end ___.
#Severe Malnutrition
#Cervical Lymphadenopathy
#Splenic lesions
Patient was noted to have right-sided cervical lymphadenopathy
on exam. He has also had weight loss, which raises concern for
malignancy. He does also have poor dentition and supposed to get
teeth extracted so palpated LN could be reactive LAD. Neck U/s
on ___ showing normal-appearing LNs with no abnormality.
Colonoscopy did not show mass; it did show mucosal friability
and inflammation. CT A/P showed multiple hypoenhancing splenic
lesions measuring up to 2.5 cm concerning for infiltrative
process such as lymphoma or in spectrum of extramedullary
hematopoiesis. CT chest negative. LDH negative. Beta 2
macroglobulin mildly elevated. Splenic biopsy was inconclusive,
and hematology/oncology recommended outpatient PET/CT scan.
#Hyperglycemia
#Type 2 diabetes mellitus
Patient was admitted with significant hyperglycemia but no
evidence of DKA/HHS. He showed initial improvement with addition
of long acting insulin. Discharged home on Glargine 22u in the
morning and Repaglinide at breakfast and dinner.
#Tooth Pain
Patient reported significant left-sided dental pain. Poor
dentition on exam with gum tenderness, erythema, no clear
collection. Soft tissue swelling overlying. Patient needs teeth
extraction, but will defer to the outpatient. He completed a 5
day course of amoxicillin.
#H/o traumatic SAH
Patient has a small frontal SAH. Repeat imaging on admission and
upon reaching therapeutic heparin PTT was stable. No neurologic
deficits. Neurosurgery following, with discussion re:
anticoagulation as above. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with a PMH of IBS who presents
with 1 day of RLQ abdominal pain, N/V, and diarrhea. She states
that the pain started at 7AM yesterday in the RLQ. She initial
believed the pain was related to 'food poisoning', since a
friend
initially had similar symptoms following a shared meal. When her
symptoms did not improve, she presented to the ___ ED. A CT
A/P
showed appendicitis without evidence of abscess, phlegmon or
perforation. ACS was consulted for further management. CT abdomen and pelvis with contrast showed 1. Enlarged fluid filled appendix, measuring up to 10 mm, with associated fat
stranding and hyper enhancement, compatible with acute appendicitis. No
evidence of perforation or abscess formation. The patient was diagnosed with Unspecified acute appendicitis. The patient was treated with ___: laparoscopic appendectomy. At the time of discharge, the patient had acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to ___ ED on ___ with abdominal pain.
CT scan showed acute appendicitis. She was given IV antibiotics
and taken to the Operating Room where she underwent a
laparoscopic appendectomy. For full details of the procedure,
please refer to the separately dictated Operative Report. She
was extubated and returned to the PACU in stable condition.
Following satisfactory recovery from anesthesia, she was
transferred to the surgical floor for further monitoring.
Diet was advanced to regular post-operatively which she
tolerated well. IV fluids were discontinued when oral intake was
adequate. Pain was well controlled with oral medication. She had
no issues voiding spontaneously and ambulating independently.
She was discharged home on ___ with instructions to follow up
in ___ clinic in 2 weeks. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female hx of hypothyroidism, active smoker who
sustained a right hip injury after a mechanical fall earlier
today while walking. She states she experienced immediate pain
however was able to stand up and partially weight-bear albeit
with severe pain. She was initially brought to an outside
hospital by a friend where x-rays reportedly revealed a right
femoral neck fracture. Given patient's desire to be treated
elsewhere she was transferred to ___ for
further evaluation and management. Currently she states that
her
pain is well controlled at rest however she has severe pain with
movement of the hip. She denies any numbness tingling or
weakness in the foot. She is a community ambulator without
assistance. She lives alone. CHEST (AP) showed No acute cardiopulmonary abnormality. Radiology showed Minimally displaced and impacted right subcapital femoral neck fracture. HIP NAILING IN OR W/FILMS AND FLUORO RIGHT showed Fluoroscopic assistance was provided to the surgeon without the radiologist
present. These demonstrate 2 partially threaded screws transfixing the right
femoral neck.. The total intra-service fluoroscopic time was 70 seconds .
Please refer to the procedure note for additional details. The patient was diagnosed with Unsp intracapsular fracture of right femur, init for clos fx, Other fall on same level, initial encounter. The patient was treated with Surgical fixation of right femoral neck fracture. At the time of discharge, the patient had Right valgus impacted femoral neck fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for surgical fixation
of right femoral neck fracture, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated] in the right lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: She was at a ___ when she stepped over the
pelvic rope, and tripped. She felt immediate pain and presented
to ___ where ___ was placed and she was
attempted to transfer out last night but was unable to due to
the weather for her femoral neck fracture diagnosed on plain
films. She has been stable since then. She otherwise feels
well without fever chills sweats nausea vomiting or diarrhea. Radiology showed Intraoperative images demonstrate placement of three cannulated screws
fixating a femoral neck fracture. No hardware related complications are seen.
Total intra service fluoroscopic time is 89.9 seconds. Please refer to the
operative note for additional details. The patient was diagnosed with Unsp fracture of right femur, init for clos fx, Fall on same level, unspecified, initial encounter. The patient was treated with CRPP of right valgus impacted femoral neck fracture. At the time of discharge, the patient had right valgus impacted femoral neck fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for CRPP, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on Lovenox 40mg daily for DVT prophylaxis.
The patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo M with a PMHx of stage IV adenocarcinoma of the
lung s/p ___ with progression now with brain
met's who s/p multiple cycles of brain XRT who p/w unsteady gait
and mild confusion.
.
The patient had a prior admission ___ to ___ with
similar complaints of AMS and confusion. At that time the
patient was found to have a Na of 119 and without intervention,
AMS resolved without intervention. Na was 130 on d/c.
.
Several days prior to admission, the patient wife reports mild
confusion and the patient to have a "temper" which isn't typical
for the patient. She also reports an unsteady gait, without
falls or head trauma. This gait is improved from prior
admissions but has never returned to normal. Over the last few
days the patient has devloped coughing (without blood) and
wheezing. The patient last dose of XRT was ___ and last dose
of chemo was ___. The patient currently endorses a frontal
h/a, ___ in nature without changes in vision. The patient also
reported bilateral rib pain last ___ which resolved with po pain
medications. The patients last BM was yesterday and was
non-bloody.
.
The patient reported to his Oncologists office today and was
found to have a Na of 118 and came to the ED. In the Ed they
gave the patient IVF's and sent him to the floor.
.
12 point ros is otherwise negative. Radiology showed New patchy left infrahilar opacity concerning for possible
pneumonia. Followup radiographs may be helpful in this regard. The patient was diagnosed with HYPOSMOLALITY/HYPONATREMIA, SEC MAL NEO BRAIN/SPINE, HX-BRONCHOGENIC MALIGNAN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Primary Diagnosis: toxic metabolic encephalopathy due to
hyponatremia, syndrome of inappropriate anti-diuretic hormone
Secondary Diagnosis: metastatic lung cancer with brain
metastases, hypertension, hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES:
[ ] Chem 7 check on ___ with Dr. ___. Patient
instructed to call Dr. ___ office on ___ morning to
make an appt.
==================================
Mr. ___ is a ___ M w h/o metastatic lung ca s/p ___
sessions total brain irradiation presenting with acute
confusion/MS changes, found to have hyponatremia. His
hyponatremia was thought to be due to SIADH and treated with
volume restriction and salt tabs without much improvement.
Demeclocycline was tried without effect. Patient responded well
to tolvaptan, however, given the cost, there was no feasible way
that the patient could be on it as an outpatient. He was started
on lasix and fluid restriction and his sodium remained stable.
# Hyponatremia: Most likely due to SIADH ___ lung cancer and
brain metastasis (similar presentation as last admission, and
improved with fluid restriction and salt tabs at that time).
Given FeNA of <1% during this admission, he was fluid challenged
without improvement. Other causes of hyponatremia was checked
and his TFT panel was wnl except for slightly low T3, and AM
cortisol was slightly low, but thought to be due to
dexamethasone he is on. As his Na did not improve on 1L fluid
restriction daily and salt tabs, he was started on
democlocycline without effect. Renal was consulted and
recommended trial of tolvaptan, which increased his Na to 136
(from 122). However, patient could not afford the medication as
outpatient, so he was changed to lasix with ___ L fluid
restriction and his Na remained stable in low 130s. His mental
status remained clear throughout.
# Toxic metabolic encephalopathy from hyponatremia: Confused on
initial presentation, most likely related to hyponatremia. As
his sodium improved and remained in 120s, he felt well with
resolution of confusion, and remained AOX3.
# Brain metastases: Had recently completed his outpt course of
whole brain radiation for brain mets. He was continued on
dexamethasone 2 mg daily per outpt taper, with pulse dosing for
his pemetrexate. He was tapered down to dexamethasone 1 mg daily
prior to discharge and will follow further instruction from Dr.
___ his taper.
# Metastatic lung adenocarcinoma: Diagnosed in ___ with
metastatic disease to vertebrae. Brain mets found in ___ and
treated with a course of whole brain radiation, and started on
Pemetrexed (last dose ___. Further treatment per outpatient
oncologist (Dr. ___
# Reported unsteady gait without falls: patient was evaluated by
physical therapy and was cleared to go home with home physical
therapy.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ who sustained a fall while climbing down a
ladder earlier today. Patient states his ladder slipped, and
while he was sliding down, his L foot was caught inbetween the
ladder rungs. He denies any headstrike, LOC or other injuries.
He
had immediate pain and obvious deformity in his L ankle and was
unable to ambulate. He was taken urgently to the ___ ED where
clinical exam and imaging demonstrated a closed fracture
dislocation of the L ankle. He was NV intact on arrival.
Orthopedics was consulted for further management. Radiology showed Status post ORIF medial malleolar and distal fibular fractures,
in overall anatomic alignment. The patient was diagnosed with FX BIMALLEOLAR-CLOSED, FALL-1 LEVEL TO OTH NEC. The patient was treated with ORIF left ankle fx. At the time of discharge, the patient had L bimalleolar ankle fracture-dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left bimalleolar ankle
fracture-dislocation and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for ORIF left ankle fx, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with ___ as decided after ortho follow up was appropriate. The
patient was kept until ___ to evaluate his soft tissues.
Silvadine cream was applied to the blisters and soft tissues on
___ before redressing and applying the bivalve cast. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the left
lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with history of ileocolonic Crohn's disease s/p
laparoscopic left hemicolectomy, proctectomy, end colostomy and
subsequent completion colectomy with end ileostomy on ___
currently on tofacitinib 5mg bid since ___ with last
steroid use in ___ presenting with recurrent abdominal pain.
She has also had multiple ileostomy revisions, two in the past
year, and the last of which was in ___, with a revision of
the ileostomy and debridement/drainage of abscess/fistula. She
had a hospital admision in ___ for partial small bowel
obstruction, and following a normal ileoscopy on ___, was
discharged on home tofacitinib after bowel rest, antiemetics and
pain control. She was readmitted in early ___ for similar
symptoms. Ileoscopy at that time noted that the stoma appeared
narrow but was easily palpated on exam. She has been scoped
through these episodes without evidence of recurrent disease or
fixed obstruction of her ileostomy (and does feel better
thereafter), however there may be some mechanical kinking in
conjunction with her delayed small bowel emptying due to
narcotics. She was seen by Dr. ___ her second admission
and discharge on ___. MR ___ showed Predominantly chronic inflammatory bowel disease involving the distal 9 cm of
ileum from the level of the ileostomy. These findings appear unchanged from
the prior CT from ___. No evidence of abscess, fistula formation,
or obstruction. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, REGIONAL ENTERITIS NOS. At the time of discharge, the patient had Abdominal pain, possibly due to partial small bowel obstruction
Crohn's disease
Anemia
Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with history of ileocolonic Crohn's disease s/p
laparoscopic left hemicolectomy, proctectomy, end colostomy and
subsequent completion colectomy with end ileostomy on ___ and
revisions in ___ and ___ currently on tofacitinib 5mg bid
since ___ presenting with recurrent abdominal pain.
#Abdominal pain, possible small bowel obstruction:
She has had three episodes of abdominal pain over the past 6
weeks. She has been scoped through these episodes without
evidence of recurrent disease or fixed obstruction of her
ileostomy, however there may be some mechanical kinking in
conjunction with her delayed small bowel emptying due to
narcotics. Recurrent Crohn's proximal to the points evaluated
by ileoscopy is also possible especially in the setting of
microcytosis, thrombocytosis, and elevated CRP. She was followed
by gastroenterology while hospitalized. The patient underwent
MRE without evidence of active inflammation. She was treated
with bowel rest, IVF and pain medications with improvement in
her symptoms. Her CRP trended down to 2.9 without intervention.
LFTs were rechecked and trended down. It is possible that her
symptoms were due to intermittent partial SBO which resolved
during the course the patient's hospitalization. Pain control
was challenging but was ultimatley achieved with liquid
oxycodone. She was tolerating a regular diet prior to discharge.
# Chronic LLQ pain at site of prior stoma. Differential
includes fibrous tissue with nerve involvement versus fistulous
disease, the latter of which would necessitate switch to another
medication for Crohn's disease.
-ultrasound of the abdominal wall to evaluate for fistulous
disease (may be done as outpatient)
# Ileocolonic Crohn's disease on tofacitinib
Continued tofacitinib
# Transaminitis.
Resolved without intervention
#Microcytosis without anemia.
___ be due to chronic inflammmation. Consider further w/o if
persists.
# Depression
Patient was intermittently tearful, and labile. She was seen by
social work for coping support and encouraged to follow up with
her outpatient therapist. Citalopram and lorazepam were
continued</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx A Fib, diastolic CHF, radiation-cystitis, and
recent admission for trochanteric bursitis who presents with
fever to 101.8 from Rehab. Patient was recently discharged for
trochanteric bursitis here at ___. He was evaluated by an MD
at rehab and found to be febrile with increased confusion. He
continues to have hip pain, but denies any subjective fevers,
chills, cough, chest pain, abdominal pain, dysuria, nausea,
vomiting or diarrhea. Radiology showed Patchy opacities within the left mid and lower lung fields may reflect
atelectasis or infection. Chronic opacities within the right upper and mid
lung fields peripherally. Radiology showed Penetration with thin consistency barium. The patient was diagnosed with URIN TRACT INFECTION NOS, PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Primary
healthcare associated pneumonia
hematuria
acute kidney injury
Secondary
right hip pain
diastolic CHF
hypertension
atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with atrial fibrillation, HTN, diastolic heart
failure and prostate CA s/p distant XRT presents with fevers and
malaise.
# Pneumonia: patient presented with fever, elevated white count,
and new infiltrates on CXR, concerning for pneumonia. The
patient was started on vancomycin and cefepime on the evening of
___. The patient is to complete an eight day course so he
should receive his final dose on the morning of ___. The
patient clinically improved and was asymptomatic and off oxygen
at the time of discharge.
# Hypotension: The patient had an episode of hypotension ___ the
ED with SBPs ___ ___, which resolved after 2L of IVF. Likely
related to hypovolemia due to poor PO intake and dysphagia for
past two days. BUN/Cr c/w pre-renal azotemia and hypovolemia.
The patient's blood pressures remained stable for the remainder
of his admission.
# Dysphagia: The patient complained of new onset dysphagia for
the 2 days prior to admission. Says to both solids and liquids.
He tolerated a normal diet well. Speech and swallow consuled and
recommended normal diet. Video swallow was done and was normal.
# ___: Patient with elevated BUN and creatinine from baseline on
admission. Creatinine 1.2 from baseline of 0.9. Likely from
hypovolemia. The patient's creatinine on discharge was 0.9.
# AMS: On admission had a report of AMS per report of rehab
attending and daughter ___ law. On admission to MICU no evidence
of AMS, no focal neuro deficits. Most likely was related
toinfection.
# Hyperkalemia: Increased K on admission to 5.5, likely ___ home
potassium supplements ___ setting of ___. Resolved.
# Hyponatremia: patient with sodium of 131 on admission,
appeared dry on exam, likely hypovolemic hyponatremia.
# Right lateral hip pain: Likely trochanteric bursitis. Previous
admission no fracture on CT with MRI showed evidence of greater
trochanteric bursitis versus gluteus medius tendinosis with a
small labral tear. Pt treated with oxydocone.
.
# Radiation cystitis: The patient did have evidence of hematuria
on exam. Urology was consulted and recommended conservative
management: they recommended not starting bladder irrigation and
monitoring the patient. His hematocrit was stable throughout the
hospitalization. His last hematocrit was 34 on ___. Explicit
instructions from urology for managing hematuria are attached to
this discharge summary.
.
# Chronic diastolic CHF: No increased evidence of worsening
heart failure. Lasix was initially held due to hypotension ___
ED.
.
# Atrial fibrillation: currently with good rate control.
Continued ASA, digoxin.
.
# HTN: Pt normotensive on admission. His lisinopril was held ___
setting ___ but then restarted.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with PMH CAD, lung CA s/p VATS and wedge resection of
spicukated LUL nodule on ___ presenting with dyspnea and jaw
pain. Pt states he awoke from sleep around ___ in the morning
with severe pain in tghe ___ his jaw of a sudden onset.
Also felt SOB at the time. No CP or arm pain but does have
recurrent epigastric pain. Took maalox overnight with some
relief. Has had a small cough since VATS procedure but only
minimally productive of sputum and hemoptysis once. Has had
increased DOE after the surgery as well. Denies fevers or
diaphoresis but "feels cold constantly." Denies orthopnea or
PND. No N/V/D/C, abd pain. Feels he has gained about 4lbs over
the course of the past few days. Radiology showed Small bilateral effusions are unchanged from prior. Left basilar streaky
opacity potentially atelectasis noting that infection is not completely
excluded. Radiology showed 1. No evidence of pulmonary embolism.
2. Patient is status post left upper lobe wedge resection with post-surgical
changes in the medial aspect of the left upper lobe, small left pneumothorax,
and small bilateral pleural effusions.
3. Minimally increased size of infrarenal abdominal aortic aneurysm since
___, measuring 3.5 cm in maximum diameter.
4. Small locules of gas within the bladder could relate to recent
instrumentaion; however, cystitis is also possible and correlation with UA is
suggested.
COMMENT:
Above findings were discussed with Dr. ___ by Dr. ___ at 5:10 pm
on ___ via telephone. The patient was diagnosed with RESPIRATORY ABNORM NEC. At the time of discharge, the patient had Primary
Hypoxia
Atypical chest pain
Secondary
Lung adenocarcinoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with PMH of CAD, lung CA s/p VATS and wedge resection of
spicukated LUL nodule on ___ presenting with dyspnea and jaw
pain found to have new TWI on EKG in ED during ___.
.
ACUTE ISSUES
# Jaw pain, EKG changes: New TWI on V2-V3 along with jaw
pain/dyspnea initially concerning for cardiac ischemia. However,
finding in V3 is non-specific, patient had no recurrence of
symptoms and his trops were negative x 4. Also, pt had normal
Stress MIBI last month so likelihood of new obstructive CAD is
unlikely. Patient was discharged on his home regimen of aspirin,
beta-blocker, and statin.
.
# Dyspnea on exertion: CTA Chest negative for acute
intrathoracic process. Patient was found to be mildly hypoxic
with ambulation so he was started on supplemental oxygen with
exertion for symptom relief.
.
# Adenocarcinoma pT2a w/o lymph node involvement s/p recent
VATS. CTA Chest on admission showed no acute post-surgical
changes that could account for symptoms.
.
# Anxiety: Likely a large contributor to patient's symptoms.
Continued ativan
.
CHRONIC ISSUES
# Hpothyroidism: continued levothyroxine
# Gout: continued allopurinol
# GERD: continued omeprazole
# COPD: continued tiotropium; fluticasone causes nose burning so
was held
.
TRANSITIONAL ISSUES
#CODE: Full
#Patient would benefit from further treatment of his anxiety</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ sudden onset of left testicular pain approximately one hour
prior to presentation to ED, that radiated into his left flank
associated with one episode of vomiting and some hematuria. He
denies prior episodes. Pain resolved in ED without meds. Pt
refused further medications, was able to ambulate in ED. He
denies family history of cancer. He also denies fever, night
sweats, weight loss, adenopathy, dysuria. He denies pain
currently and feels well. Radiology showed 1. No definite evidence for intrathoracic malignancy.
2. A 4 mm nodule in right middle lobe shows features most consistent with an
intrapulmonary lymph node, a benign finding. If the patient is proven to have
a malignancy, then follow up imaging in 3 months would be recommended. Radiology showed 1. 9.4 x 6.5 x 5.5 cm mass involving the interpolar region and lower pole of
the left kidney with extension to the renal sinus and collecting system. The
imaging features of this lesion, including T2 hypointensity and avid
enhancement, homogenous restriction of diffusion at DWI, as well as
hyperdensity on non-contrast portion of prior CT, are most suggestive of
angiomyolipoma with minimal fat. Papillary renal cell carcinoma is less
likely given the enhancement and signal intensity characteristic pattern.
2. Two left renal arteries, each of which supplies portions of the left
kidney that are uninvolved by tumor, with the tumor and involved portions of
the left kidney also supplied by branches from the main left renal artery. No
evidence of renal vein tumor thrombus.
3. No findings worrisome for metastatic disease in the abdomen or pelvis.
Two right renal arteries. Replaced common hepatic artery arising from the
superior mesenteric artery, possibly resulting in mild dilatation of the
adjacent duct of Santorini of doubtful significance.
4. Further evaluation of the left renal lesion could be obtained through
percutaneous biopsy if a nonoperative course of therapy is contemplated.
The results were discussed via telephone with ___ by Dr. ___
___ 15 minutes following discovery on ___ at 4:30 p.m. The patient was diagnosed with RENAL & URETERAL DIS NOS, ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had hematuria
renal mass. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y.o male with h.o asthma who presented with hematuria and
flank pain.
#RENAL MASS/HEMATURIA: Pt presented with one day of gross
hematuria and transient episode of flank/testicular pain and was
found to have 5.7 x 6.9 x 8.9 cm homogeneously hypoenhancing
mass arising from the left renal collecting system. Initial
different considered included TCC, RCC vs. lymphoma. MRI
abdomen was obtained for further characterization which
preliminary revealed concern for angiomyolipoma with former
bleeding vs. less likely papillary carcinoma. Differential is
still unclear at this time. Urine cytology was ordered twice and
does not appear to have been logged at the time of discharge.
The urology service was consulted (Dr. ___ who recommended
that pt could be discharged and the urology service will follow
up with the patient to schedule a follow up appointment to
discuss his options diagnosis and treatment of the underlying
mass. Pt is aware of this plan and was also provided with the
contact information to Dr. ___. Pt was given a small
supply of oxycodone and a bowel regimen to help with any flank
pain. Hematuria had resolved by the time of discharge and pain
was much improved.
.
#pulmonary nodule-Surveillence type of this lesion will depend
on if renal mass is malignant.
.
Transitional care
___ MRI abdomen and CT chest results
2.urine cytology
3.pulmonary nodule
4.pt will need urology f/u </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH depression, anxiety, chronic back pain, renal mass
suspicious for possible cell carcinoma, seen in ED on ___ for
low back pain and given 1 unit RBC for HCT of 22, now p/w
unwitnessed fall and possible seizure this morning. Patient
states she had an episode of diarrhea in the bed then again in
the bathroom this morning. She states she was walking back from
the bathroom when she had a "seizure." She woke up in her bed
and was told she had a seizure. Per family, patient reported
having a fall in kitchen this morning. Was found in her bed
incontinence of loose stools. Had not had diarrhea until today.
Stopped her ativan "cold ___ as ran out of her ativan and
endocet ___ days ago. Per her family she went through her 90mg
of Ativan and her entire bottle of endocet in roughly 2 weeks. Radiology showed No acute findings. If there is strong clinical concern for rib
fracture, recommend dedicated rib series to further assess. Radiology showed No acute intracranial process. Radiology showed No acute fracture or vertebral malalignment. Radiology showed 1. No convincing radiographic evidence of myeloma.
2. Degenerative changes in the lower lumbar spine.
3. Degenerative changes in the mid cervical spine, better assessed on the
recent CT.
4. Diffuse osteopenia in the spine. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY. The patient was treated with bone marrow biopsy. At the time of discharge, the patient had Primary:
prescription opiate and benzodiazepine addiction and abuse
benzodiazepine withdrawal seizure
normocytic anemia
thrombocytopenia
Secondary:
chronic degenerative changes of lower lumbar spine. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH depression, anxiety, chronic back pain, ?renal cell
carcinoma, seen in ED on ___ for low back pain and anemia now
presenting s/p fall and seizures likely due to benzo and opiate
withdrawal and worsening anemia and thrombocytopenia.
# withdrawal seizure: reports only 1 seizure in a past about ___
years ago, back when she was "partying too much" which she had
attributed to drugs and alcohol (which she denies currently).
Pt's recent seizure was most likely due withdrawal from
lorazepam and percocets. Pt was restarted on her home regimen of
lorazepam 1mg TID in the MICU with no further signs of seizures.
Per Pt's daughter, Pt started overusing lorazepam when her
percocets were controlled by her daughters. Other possible
etiologies include hyperviscosity syndrome given her previously
known IgM MGUS (see below), but serum viscosity was checked and
normal. Social work was consulted and met with patient for
prescription medication abuse, but she perseverated on obtaining
more benzos and opiates. Pt did not scoring significantly on the
___ and never needed another dose of diazepam. ___ was
discontinued on ___. Pt's condition was discussed in detail
with PCP and new anxiety and pain control plan instituted (see
below). Pt was tapered completely off her lorazepam and
percocets by ___.
# prescription opiate and benzodiazepine abuse: Pt's behavior is
highly concerning for prescription opiate and benzodiazepine
addiction and abuse. Pt's daughters feel that she is addicted
and report that she became extremely belligerent when they
attempted to control her medications. Situation was discussed in
detail with Pt's PCP ___, who agrees that she cannot be
prescribed strong opiates or benzos. Pt was transitioned
completely off lorazepam and percocets during her admission. For
her reported pain, she was started on acetaminophen 650mg po q6h
prn and tramadol 25mg po q6h prn. A pain clinic appointment at
the ___ was arranged for 3 days after discharge. She
was encouraged to try acetaminophen first and only use tramadol
if needed. She was also started on mirtazapine for anxiety and
insomnia per her daughter ___ suggestion (see below). Her
pharmacy was called to cancel the remaining refills on her
lorazepam. Her daughters and family members were also informed
to secure their own supplies of these medications (her son, who
lives with her also uses lorazepam). Pt remained highly
insistent that she be prescribed her old regimen of percocets
and lorazepam on discharge, which was not provided.
# normocytic anemia, thrombocytopenia: possibly due to
underlying MGUS, however Pt's daughter reports that she has now
with small dark guaiac positive stool raising possibility of
some acute GI bleeding. Plts were previously elevated and Pt is
positive for JAK2 V617F mutation, but Plts have been dropping
for the past few months, suggesting possible progression of MGUS
to MDS. ___ is also possible that Pt has a GI malignancy given
her heavy smoking history, two guaiac positive stools in MICU,
lack of any screening colonoscopy, and reported weightloss.
Hematology was consulted and concerned for possible progression
with hyperviscosity syndrome as a potential etiology of her
seizures, and recommended workup with repeat SPEP showing
monoclonal IgM Kappa now representing 6% of total serum, serum
viscosity normal, UPEP not collected, B2 microglobulin 4.3,
quantitative Ig's with elevated IgM, peripheral smear with
evidence of possible infiltrating or fibrotic marrow, iron
studies normal, retic index low, and skeletal survey that showed
no evidence of lytic lesions. Bone marrow biopsy was performed
on ___ with results pending. Pt was transfused 1 x pRBCs with
appropriate increase in serum hemoglobin. Pt has follow-up with
heme-onc in three weeks. Pt has never had a colonoscopy and
given anemia and guaiac positive stools, should have a
colonoscopy as an outpatient.
# weightloss: daughter reports that Pt has lost a significant
amount of weight over the last six months unintentionally.
States that she was generally 170 lbs, though per OMR PCP
records, she ___ been this that weight since ___. She was
in the 130lb range in ___, and ~120 lbs [54.4 kg] for the
later half of ___. Given Pt's long smoking history and absence
of screening colonoscopy, together with now guaiac positive
stools, concern for possible colonic malignancy. Pt also reports
reduced appetite, which could also be due to rx medication
abuse. Pt's weight is 51.2kg, which indicates ~ 7 lb weight loss
over 6 months. Albumin is normal. Pt's weight should be closely
monitored.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with a history of atrial
fibrillation, anxiety/depression, and breast cancer (T1N0M0
invasive lobular adenocarcinoma s/p RTX/implant/tamoxifen for ___
years) s/p bilateral mastectomy,
bilateral tissue expander placement and implant removal from the
left breast in ___ secondary to infection who presents
with right knee pain. Of note she was recently discharged from
the plastic surgery service for SSI c/b MSSA bacteremia for
which she was on a nafcillin pump.
She noticed today that her RLE became acutely swollen and
painful. She presented to an urgent care ___ which suggested
she may have "bone on bone pain." She presented to the ED as she
was unable to walk. She denied fever, chills, nausea, vomiting,
diarrhea, rash.
In the ED initial vitals were: Pain ___ Temp 98.1 HR 83 BP
167/80 RR 16 98%. Exam was notable for warm swollen asymmetric
right knee, unable to range with a large effusion. Xray revealed
native knee with effusion. She was seen by ortho who tapped >50
cc of cloudy yellow fluid removal, sent for culture/gram stain. RIGHT KNEE RADIOGRAPHS showed Moderate to large joint effusion. Mild degenerative changes. CHEST RADIOGRAPH showed PICC line terminating in the right upper superior vena cava. No evidence of
acute cardiopulmonary disease. The patient was diagnosed with ACUTE GOUTY ARTHROPATHY. The patient was treated with Right Knee Arthrocentesis ___
Right Knee Arthrocentesis and Steroid Injection ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with a history of atrial
fibrillation, anxiety/depression, and breast cancer s/p
bilateral mastectomy, bilateral tissue expander placement and
implant removal from the left breast in ___ secondary to
infection who presents with right knee pain, with joint aspirate
consistent with calcium pyrophosphate crystal deposition. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ h/o paranoid schizophrenia
referred from ___ with fever and hypoxemia. Initially
patient was noted to be shaking with O2 88% on room air and T
101.1. Patient given 650mg tylenol.
.
Patient denies any cough/ dyspnea/ neck stiffness/ dysuria,
although is a limited historian. She does endorse fevers and
denies diarrhea. Denies melena and hematochezia. Patient had a
mechanical fall ___ and was seen in the ED. Flu vaccine given
___.
.
In the ED, initial VS: 101.6 80 118/72 24 99%. Recieved
Azithromycin 250 and ceftriaxone 1g, 1000mg tylenol.1 liter of
NS given.
.
Currently, the patient denies pain but feels cold and tired. She
denies confusion, abdominal pain,headache,orthopnea, neck
stiffness, diarrhea,nausea,back pain, vomiting, dysuria.
.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. New PICC line placement.
AP radiograph of the chest was reviewed in comparison to ___.
Right PICC line tip terminates at the cavoatrial junction. Heart size and
mediastinum are stable. Lungs are essentially clear. was done. The patient was diagnosed with FEVER, UNSPECIFIED, HX OF BREAST MALIGNANCY. The patient was treated with ___ line placement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ h/o L-LCIS s/p lumpectomy ___ and paranoid schizophrenia
referred from ___ with fever, hypoxemia, and
leukocytosis.
# PNA
Pt presented with fever of 101, chills, O2 sat 88%,
leukocytosis. CXR showed LLL opacity most concerning for
pneumonia. UA was negative for infection. Legionella Ag was
negative. She had no neck pain or HA. Patient was treated for
healthcare-associated pneumonia given residence at a care
facility and recent ED stay. She was started on vancomycin
(start: ___, azithro (___), and ceftriaxone (___). Patient's
respiratory improved rapidly. She came off O2 and was satting
mid-90s on RA by the time of discharge. She had transient chills
but remained aftebrile and HD stable. She had a PICC line placed
for the total 8d course of abx. Azithromycin will continue for
1 more day (5 days total- last day ___, vancomycin for 5 more
days (8 days total- last day ___, and ceftriaxone for 4
more days (8 days total- last day ___. BCx is pending at
the time of discharge.
.
# ASPIRATION
Patient's history of cough after meals (esp. solids), no
dentures, and CXR notable for chronic bibasilar findings raised
a concern for aspiration. Speech and swallow found no acute
process with good muscle strength but silent aspiration could
not be ruled out. Patient was maintained on ground foods and
thick nectar as well as on general aspiration precautions. This
should be followed up outpatient along with proper denture
fitting.
.
# PLEAURAL EFFUSION
There was L-small pleural effusion increased from prior imaging
on ___. There was no clinical signs or symptoms of heart
failure. Differentials included parapneumonic effusion vs.
recurrent malignancy given her recent history of breast cancer
on the same side. Repeat CXR on ___ showed stable or decreased
effusion although comparison was limited due to portal CXR. We
recommended outpatient follow up.
.
# HISTORY OF BREAST CANCER
Patient has history of L-DCIS and LCIS. Her last mammogram and
follow up was in ___ per OMR. Her providers were contacted
regarding any recent followup. We recommend that patient gets
reconnected with outpatient followup especially given the new
pleural effusion on the same side.
.
# CHRONIC ANEMIA
Patient's Hct was 40 upon admission, which dropped to 35, which
was her baseline from ___, after IV fluid. This stayed stable
throughout. There was no overt active bleeding. MCV was wnl.
Iron studies 32, TIBC 209, Ferritin 166, TRF 161.
.
#Paranoid Schizophrenia
Remained stable with no auditory or visual hallucination or
suicidal or homocidal intentions. She remained alert and
oriented to time, place, and person. Her attention remained
intact with fluent days of week forward and backward. She was
continued on home resperidone, clonazepam, and trazodone.
.
#Chronic constipation
This remained stable on home regimen.
.
#Bradycardia
Patient has baseline bradycardia in 40-50s. This remained stable
on sinus bradycardia throughout.
.
# TRANSITIONAL ISSUES:
- Follow-up final read blood culture
- Proper denture fitting
- Follow up of possible silent aspiration given bibasilar
findings on CXR and h/o cough with meals
- Follow-up of breast cancer and if she desires consideration of
future treatment
- Follow-up of resolution of the non-tender L palpable cord
extending from the L popliteal fossa to the mid calf (chronic
thrombophlebitis)
- CODE: DNR/DNI (confirmed with patient)
- CONTACT: Sister, ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ polysubstance abuse (including alcohol, opioids, on
suboxone), anxiety, depression, PTTSD, chronic SI with multiple
suicide attempts presenting after suicide attempt with injection
of bleach and cocaine. UNILAT UP EXT VEINS US showed No evidence of deep vein thrombosis in the right upper extremity. The patient was diagnosed with Suicidal ideations, Other psychoactive substance abuse, uncomplicated. At the time of discharge, the patient had Primary diagnosis
Suicide attempt
Phlebitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ polysubstance abuse (including alcohol, opioids, on
suboxone), anxiety, depression, PTSD, chronic SI with multiple
suicide attempts presenting after suicide attempt with injection
of bleach and cocaine which he has done before. He has been
medically stable since admission.
# Suicide attempt
Pt presenting after suicide attempt with injection of bleach and
cocaine. There is limited literature regarding parental
injection of sodium hypochlorite (bleach). Patient initially
appeared somnolent with induration at the injection site but no
evidence of bradycardia or cardiac arrhythmia. Likely secondary
to benzodiazepine use. On reassessment was placed on ___.
Restarted home psychiatric medications which were well
tolerated. Was kept with one to one sitter.
#Phlebitis
From injection of irritant bleach. ___ possibly contain
superficial thrombus. Pain localized and improved during stay
with hot packs as only treatment.
# Polysubstance abuse
Monitored on ___ without withdrawal. Restarted home suboxone.
# Anemia
Baseline Hemoglobin ___. Was stable in this range</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with hx of HLD, fibromyalgia, and osteoprosis
previously on Fosamax for ___ years up until ___, presenting
with fracture of her hip and left gamma nail from a fall today.
Patient had been leaning over to spit when she slipped on the
ice and fell into her left hip. There was no head strike no
LOC, this was a closed isolated injury. She did have left hip
pain in ___nd suffered a left
subtrochanteric fracture, and underwent left gamma nail
fixation. This was a 11 by 300mm nail with 17mm proximal
diameter, and 90mm lag screw, without distal interlocking
performed by Dr. ___ at ___. In ___ she had a
similar subtrochanteric fracture now on the right side and
underwent gamma nailing of the right side. Since that time she
has had persistant pain in the left hip, but she figured this
was normal, and was placed on vicodin for it. She has been
ambulating well until the fall. Radiology showed No acute cardiopulmonary process. Radiology showed Minimally displaced left periprosthetic fracture involving the intramedullary
rod within the proximal femoral diaphysis. There is also a fracture of the
proximal aspect of the intramedullary rod at the level of gamma nail. No
dislocation. Radiology showed 1. Fracture of the intramedullary rod at the level of proximal nail with
varus angulation of the fixation construct.
2. Spiral periprosthetic fracture of the proximal femur without significant
displacement. The patient was diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL. The patient was treated with ___ - Left hip removal of hardware and open reduction
internal fixation. At the time of discharge, the patient had Left hip periprosthetic fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femur periprosthetic fracture with hardware
failure and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for a
removal of hardware and open reduction/internal fixation, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch down weight bearing in the
left lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female presents with RIGHT trimalleolar fx. Was walking
across the street when she slipped on ice and suffered inversion
ankle injury. Immediate pop. Unable to bear weight. Denies
paresthesias. Endorsing diffuse ___ pain dull aching along
medial, lateral, and posterior mall. ANKLE (AP, MORTISE AND LAT) RIGHT showed Trimalleolar fracture with widening of the ankle mortise. CHEST (PA AND LAT) showed No acute intrathoracic process. Radiology showed Post reduction views of the right ankle demonstrate near anatomic alignment of
trimalleolar fractures. CT LOW EXT W/O C RIGHT Q61R showed 1. Comminuted, mildly displaced trimalleolar ankle fracture, likely a
supination external rotation, likely ___ supination-external rotation
grade 4. ANKLE (AP, MORTISE AND LAT) RIGHT showed Right ankle fracture during ORIF. Please refer to operative report for
details. The patient was diagnosed with Displaced trimalleolar fracture of left lower leg, init, Fall on same level due to ice and snow, initial encounter. The patient was treated with Open reduction internal fixation of the right ankle. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation
of the right ankle, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ with a PMHx of CKD (baseline cr 1.3), HTN,
HLD, osteoporosis, atrial fibrillation (no anticoagulation) who
is presenting with abdominal and right flank pain 2 days after a
fall and a feeling that she was unable to empty her bladder.
She relates that she has been falling with some frequency over
the past several months. She also noted that she has fallen
more frequently over the last several days than she typically
does. She notes that on a recent fall 2 nights ago she hit her
right flank and has had rib pain ever since. She also notes two
episodes of "shaking" over the last ___ days. Additionally,
over the last several weeks she has had to awaken several times
during the night ___ times) to urinate. She endorses low urine
volumes but denies any change in urine appearance, odor,
sensation. Her son notes that he believes she has been
incontinent of urine over night over the last several weeks. CT ABD AND PELVIS W/O CONTRAST showed 1. No sequela of trauma within the abdomen or pelvis. No free fluid.
2. Severe right hydroureteronephrosis with unusual configuration of the right
lateral bladder wall near the UVJ appears chronic and could reflect
postoperative change from prior ureteral reimplantation. However, mural
thickening of the bladder wall is present and neoplasm cannot be excluded if
correlative history does not exist. This could be further evaluated with
cystoscopy.
3. Colonic diverticulosis, without evidence of acute diverticulitis.
NOTIFICATION: Updated findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 9:59 AM, 60 minutes after discovery of
the findings. CT CHEST W/O CONTRAST showed 1. Old bilateral healing rib fractures with an additional right lateral ___
rib fracture that is age indeterminate.
2. T4 compression deformity with 2-3 mm retropulsion, age indeterminate.
3. Dilated main pulmonary artery measuring 3.2 cm, which can be seen in the
setting of pulmonary arterial hypertension.
4. Mosaic areas of ground-glass attenuation most likely due to expiratory air
trapping or small airways disease. No pleural effusion.
5. Nonspecific flattening of the distal trachea, which can be seen in setting
of tracheobronchomalacia. If there is clinical concern for this entity,
non-urgent follow-up CT with dynamic maneuvers could be obtained.
6. CT abdomen/pelvis dictated separately.
RECOMMENDATION(S): Consider non-urgent follow-up CT with dynamic maneuvers if
there is clinical concern for tracheobronchomalacia.
NOTIFICATION: Updated findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 9:59 AM, 60 minutes after discovery of
the findings. KNEE (AP, LAT AND OBLIQUE) BILATERAL showed On the right there is tricompartmental hypertrophic spurring with narrowing
predominantly involving the medial compartment. Suggestion of meniscal
calcification. On the left, there is tricompartmental spurring with
substantial narrowing in the medial compartment.
No evidence of joint effusion, though there is extensive vascular
calcification on both sides. RENAL U.S. showed Persistent moderate to severe right hydronephrosis. Foley catheter present
within a decompressed bladder. CHEST (PA AND LAT) showed 1. Moderate cardiomegaly with mild pulmonary edema.
2. Known right 8th rib fracture is better visualized on the subsequent CT. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process on noncontrast head CT.
2. Atrophy and probable chronic small vessel disease. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute fracture in the cervical spine.
2. Age indeterminate T4 vertebral body compression deformity with 2 mm
retropulsion.
3. 2 mm anterolisthesis of C4 on C5 is almost certainly degenerative in
nature, although should be correlated clinically if there is concern for
ligamentous injury at this level. The patient was diagnosed with Unsp fracture of fourth thoracic vertebra, init for clos fx, Fall on same level, unspecified, initial encounter, Unspecified hydronephrosis, Unspecified atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented with abdominal pain and urinary retention.
She also had flank pain after a traumatic fall. She was found to
have hydronephrosis on imaging and had a foley catheter placed.
She was started on antibiotics for and UTI and pyelonephritis.
She will be discharged on augmentin and will continue this until
___. She was also seen by the spine service for her vertebral
fracture and will follow up with them on an outpatient basis.
# Acute Kidney Injury: Pt presented with acute kidney injury
from obstructive uropathy. This was evidenced by the
pyelonephritis on imaging. Her Cr on admission was 4.3 and her
Cr on discharge was 1.5. Her baseline Cr is approximately 1.3.
She had a foley catheter placed and will be discharged with the
foley catheter and will have follow up with urology on ___.
# UTI, pyelonephritis: The pt had a positive UA and met severe
sepsis criteria on admission. She reported rigors at home
before admission, had a leukocytosis with a left shift, had an
elevated lactate, and had a suspected source (urine).
Obstructive uropathy leading to urinary stasis put Ms. ___ at
increased risk of urinary infection. A foley catheter was
placed to relieve the obstruction and she was treated with
antibiotics. She was initially started on ceftriaxone in the ED
and was broadened to ampicillin/sulbactam on the floor. When
the urine cultures came back, she was transitioned to
amoxicillin/clavulanic acid. She will be discharged on
amoxicillin/clavulanic acid to complete a 14 day course to end
on ___. She will also be discharged with the foley
catheter in place for source control.
# Obstructive Uropathy: The cause of the obstructive uropathy
was not clear. On imaging, bladder wall thickening was seen and
UV junction blockage was suggested. This raises concern for
possible bladder mass. Urology was consulted and recommended
maintaining the foley catheter after discharge for urinary
drainage. She will follow up with urology in clinic on ___.
# Fall: The pt had multiple falls in the time period prior to
presentation. She had a fractured ___ right rib from a fall.
Her pain was managed and she was seen by both physical and
occupational therapy. They recommended that she have continued
outpatient services and that she be observed at all times.
# L4 Fracture: Pt had L4 compression fracture on admission. She
was seen by the orthopedic spine service on the ED. She was
given a TLSO brace for comfort but found it uncomfortable and
did not use it. She will follow up with the orthopedic spine
service in clinic.
# Hypertension
- Continued amlodipine
# Hyperlipidemia
- Continued simvastatin
# Hypothyroid
- Levothyroxine 75 mcg PO daily
# Depression
- Continued fluoxetine</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CT ABD AND PELVIS WITH CONTRAST showed 1. Procto-pancolitis likely reflective of an acute flare of ulcerative
colitis. There is free fluid in the pelvis, however no discrete, drainable
organized fluid collection or extraluminal air is identified. Radiology showed No free intraperitoneal air. Redemonstration of ahaustral appearance of the
colon with thickening of the folds compatible with active inflammatory bowel
disease. CHEST (PA AND LAT) showed No pneumonia or acute cardiopulmonary process. Radiology showed Interval decrease in the dilated loops of large bowel, now measuring up to 5.5
cm. No evidence of pneumatosis or free intraperitoneal air. Radiology showed Interval improvement in colonic distention, now only measuring up to 4.7 cm.
No evidence of pneumatosis or free intraperitoneal air. CHEST (PORTABLE AP) showed No evidence of pneumoperitoneum. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality.
The tip of the right PICC projects over the right atrium, approximately 3 cm
beyond the cavoatrial junction. Radiology showed Nonspecific, nonobstructive bowel gas pattern. CHEST (PORTABLE AP) showed NG tube tip is in the stomach. Heart size and mediastinum are stable. Lungs
overall clear. There is no appreciable pleural effusion or pneumothorax.
Right PICC line tip is at the cavoatrial junction. Radiology showed Nonspecific, nonobstructive bowel gas pattern. No intraperitoneal free air. Radiology showed Nonspecific, nonobstructive bowel gas pattern. No evidence of free
intraperitoneal air. The patient was diagnosed with Nausea. The patient was treated with ___: Single site laparoscopic total abdominal colectomy
with end ileostomy. At the time of discharge, the patient had Ulcerative colitis flare
Acute blood loss anemia
Severe malnutrition
Post-op ileus
Urinary retention. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was initially admitted to the medicine service on
___ with an acute ulcerative colitis flare. The GI service and
colorectal surgery were consulted in the emergency department
for steroid or biologic recommendations and possible colectomy
given concern for fulminant colitis.
#Severe UC Flare
#Acute blood loss anemia
Initially he was treated with Zosyn but per GI recommendations
was switched Rocephin/flagyl. He was also given ganciclovir
empirically for CMV (which later came back negative so
ganciclovir was stopped). On admission he was started on
methylpred 20mg IV q8hrs. Stool samples were sent to rule out
cyclospora, microsporidium, giardia, EHEC, shigella,
campylobacter, salmonella, and c.diff all of which were
negative. He got a daily KUB to monitor for perforation. On
___ overnight he went from little to no blood in bowel
movements to several bloody BMs, heart rate went from ___ to
140s, and his Hgb dropped from 9.9 to 5.9. CRS was called,
abdominal exam is slightly worse but felt no acute surgical
indication. He was transfused 2 units, blood cultures were
drawn, and his antibiotics were broadened back to zosyn. He
reports significant abdominal pain only improved with morphine,
with any motion setting of ___ sharp pain throughout his
abdomen. On ___ the patient had a pre-syncopal episode and
became hemodynamically unstable in the setting of acute blood
loss anemia. His labs were sent and his Hgb/Hct was notable for
___. He was transfused with 3 units of PRBCs and 3 units of
FFP. He was urgently taken to the operating room on ___ for a
laparoscopic total abdominal colectomy with end ileostomy. He
tolerated the procedure well without complications (Please see
operative note for further details). After a brief and
uneventful stay in the PACU, the patient was transferred to the
floor for further post-operative management.
Neuro: Pain was well initially well controlled on IV Tylenol and
a dilaudid PCA for breakthrough pain. Once tolerating oral
intake, the patient was transitioned to oral Tylenol and
tramadol for breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored and the patient
was placed on continuous cardiac monitoring. The patient was
noted to be slightly tachycardic to the low 100's and up to the
150's with ambulation in the immediate post-op period, EKG
obtained and revealed sinus tachycardia. As the patient became
more mobile and active, his tachycardia improved.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
ID: The patient was given an additional 4 days of Zosyn. He was
closely monitored for signs and symptoms of infection and fever,
of which there was none.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. He was encouraged to get up and ambulate
as early as possible. The patient is being discharged on
prophylactic Lovenox.
#Post-op ileus
The patient was initially kept NPO after the procedure. The
patient was later advanced to a regular diet. On ___, the
patient had an episode of emesis. A KUB was obtained which
showed dilated loops of bowel. A nasogastric tube was placed and
the patient was given IV fluids and IV pain medication the NGT
was removed on ___ due to severe discomfort causing ongoing
tachycardia for the patient. His stoma was thus intubated with a
red rubber catheter. The patient began to have output from his
stoma (both stool and gas) and on ___, he was advanced to a
regular diet which was well tolerated at time of discharge.
Patient's intake and output were closely monitored.
#Acute urinary retention requiring foley replacement:
The patient had a foley catheter in the operating room that was
removed in the PACU. At the time the patient was DTV, he was
bladder scanned for >1L. The foley catheter was replaced on
___ and the patient continued to have good urine output. It
was discontinued on ___ once again and at the time the patient
was DTV, he was bladder scanned for 800cc of urine. A foley was
once again placed on ___ and ultimately removed on ___. The
patient was able to void on his own without difficulty for the
remainder of the hospitalization. Urine output was monitored as
indicated.
#Severe protein calorie Malnutrition
Due to significant weight loss, a nutrition consult was placed.
Initially, due to concern for bacteremia, TPN was held and PPN
was given. Once blood cultures came back negative, a PICC line
was placed on ___ and the patient was started on TPN. The
patient continued on TPN until he was fully tolerating a diet
and TPN was discontinued on ___. The patient will be
discharged home on a multivitamin recommended by nutrition.
#Hyponatremia:
Likely hypovolemic hyponatremia in setting of poor po intake.
TPN adjusted accordingly.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in ___
weeks. This information was communicated to the patient directly
prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of DM, HTN, and HLD p/w CP x 1 day. He was in his
usual state ___ until this morning. He lives an active life
style with frequent exercise. He states that his CP started
around 2AM, described as a sudden-onset of pressure sensation
radiating to L arm. Denies SOB, N/V, diaphoresis, PND, or
orthopnea. At OSH, ECG reported to have hyperacute T waves
anteriorly and biphasic T waves inferiorly. He was placed on
heparin gtt and transferred to ___ for further management. CTA CHEST WITH CONTRAST showed No evidence of pulmonary embolism or aortic abnormality.
Calcified pleural plaques are noted, possibly from prior asbestos exposure. The patient was diagnosed with Cardiomyopathy, unspecified. The patient was treated with Cardiac catherization on ___. At the time of discharge, the patient had Primary diagnosis:
Non-cardiac chest pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of DM, HTN, and HLD p/w CP x 1 day.
# Chest pain: He reports a sudden-onset of pressure sensation
radiating to L arm. Denies SOB, N/V, diaphoresis, PND, or
orthopnea. At OSH, ECG reported to have hyperacute T waves
anteriorly and biphasic T waves inferiorly. He was placed on
heparin gtt and transferred to ___ for further management.
Patient was given atorvastatin 80, heparin gtt, nitro gtt,
methylpred 125 mg IV and sent directly to the cath lab. Cath was
notable for ___ lesion 50-60% occluded with no intervention.
After cath, patient continued to complain of pleuritic chest
pain for which he was admitted. He underwent a CTPA which did
not show any evidence of PE. His pain resolved with rest and
nitro drip. The nitro drip was weaned and his home medications
were restarted without any recurrence of his pain. Pain thought
to be non-cardiopulmonary in nature. He is being discharged on
81mg daily aspirin with PCP follow up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old M w/ no significant PMH who
presented to ___ with SOB and was found to have a
submassive PE with evidence of right heart strain, transferred
to ___ for further management of submassive PE. BILAT LOWER EXT VEINS showed 1. Deep venous thrombosis extending from the proximal right femoral vein,
throughout the right popliteal vein, and into 1 of the right peroneal veins.
2. No evidence of DVT on the left.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:37 pm, 2 minutes
after discovery of the findings. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale. At the time of discharge, the patient had Primary Diagnosis:
Submassive pulmonary embolism
Right ventricle strain
Right lower extremity DVT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old M w/ no significant PMH who
presented to ___ with SOB and was found to have a
submassive PE with evidence of right heart strain, transferred
to ___ for further management of submassive PE.
#Submassive PE: Patient presented with acute onset SOB and was
found to have significant clot burden in bilateral pulmonary
arteries with positive troponin and signs of right heart strain
on CTA. Started on heparin gtt and transferred to ___. In the
ED, cardiology was consulted and felt that patient did not have
current indication for thrombectomy or more invasive treatment.
Patient s/p ortho knee surgery ___ with intermittent RLE
swelling. Patient up to date on colonoscopy (next scheduled
___. ___ with DVT extending from proximal right femoral
vein, throughout the right popliteal vein, and into 1 of the
right peroneal veins. TTE with evidence of right heart strain
and elevated pulmonary pressures. He was treated with heparin
gtt and transitioned to Lovenox as bridge to Coumadin. He could
not be on NOAC due to interaction with primidone.
#Gout: patient had new left toe tenderness and edema; per
patient felt similar to prior gout flare. Started colchicine 1.2
mg loading dose with 0.6 mg daily after that.
#Splenomegaly: Seen on CT-A for PE study. Unclear etiology.
Could consider work up if concerned for occult malignancy as
cause of PE.
#Essential tremor: Continued primidone 100 mg qAM and 150 mg qPM
during admission. Discussed with outpatient neurologist Dr.
___ we would like to wean off primidone if possible due
to wanting to put the patient on a NOAC as ultimate
anticoagulation. She agreed with weaning off primidone with 50
mg decrease in dose every 3 days until off the medication.
Started 40 mg propranolol to treat essential tremor with plan to
f/u with neurology.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of HIV/AIDS (non-adherent to
ARVs, last CD4 147 ___K ___, HTN, HLD, DM2 who
presents with fevers, nausea, vomiting, diarrhea and abdominal
pain. He reports three days of symptoms one week ago that
self-resolved. He then had recurrence of symptoms on the day
prior to admission. He has had ___ non-bloody loose BMs per day
as well as ___ episodes of NBNB emesis. His abdominal pain is
primarily ___ in location. Radiology showed Mild pulmonary vascular congestion. No focal consolidation. Radiology showed 1. Wall edema, mucosal hyperenhancement, and minimal fat stranding
surrounding the terminal ileum extending into the cecum and very proximal
ascending colon compatible with mostly ileocecitis. Although the etiology is
likely infectious and there are no chronic findings to suggest ___
disease, inflammatory etiology cannot be excluded.
2. Splenomegaly.
3. Hepatic steatosis and mildly enlarged common hepatic and periportal lymph
nodes. Work-up for steatohepatitis or other hepatitides is recommended if not
previously performed.
NOTIFICATION: Updated findings discussed with ___ by Dr. ___
telephone at 9:55am on ___ following attending review. PORTABLE ABDOMEN showed No bowel distention. No obstruction. CHEST (PORTABLE AP) showed Pulmonary and mediastinal vascular congestion have improved and yesterday's
cardiomegaly has resolved. Lungs are grossly clear. The patient was diagnosed with NONINF GASTROENTERIT NEC, DIABETES UNCOMPL ADULT, ASYMPTOMATIC HIV INFECTION. At the time of discharge, the patient had Primary:
Clostridium difficile colitis
Shigella enterocolitis
Abdominal pain
Diarrhea
Secondary:
Hypertension
HIV
Diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with history of HIV/AIDS (non-adherent to
ARVs, last CD4 147 ___K ___, HTN, HLD, DM2 who
presented with fevers, nausea, vomiting, diarrhea, and abdominal
pain who was found to have C. diff colitis and Shigella.
# Severe sepsis secondary to C. diff: Patient presented with
___ SIRS criteria (fever, leukocytosis) and evidence of
end-organ damage (lactate 2.8). He was aggressively fluid
resuscitated. CT A/P revealed ileocecitis and patient stool
studies returned positive for C. diff. Patient was initially
started on broad coverage with IV vancomycin, cefepime, high
dose PO vancomycin, and metronidazole. Once C. diff returned
positive, IV vancomycin and cefepime were discontinued. Patient
remained clinically stable so metronidazole was discontinued and
PO vancomycin dose was decreased to 125 mg q6h (from 500 mg
q6h). Patient's pain was controlled with morphine. His
abdominal pain resolved and his diarrhea improved. He was able
to tolerate a regular diet.
# C. diff: Patient met criteria for severe C. diff (based on
admission ___ of stools/day). Given severe sepsis,
worsening leukocytosis, and rising lactate, he was treated as
severe-complicated initially with high dose vancomycin and IV
metronidazole. Once he clinically improved, metronidazole was
discontinued and vancomycin dose was decreased to 125 mg q6h.
He was discharged on a 14 day course of PO vancomycin.
# Shigella: In addition to C. diff, patient's stool studies
returned positive for Shigella. He was started on ciprofloxacin
and will complete at 7 day course.
# HIV: Last CD4 147 ___K ___. He has not been
adherent to ARVs for several months, possibly years. ARVs were
held and decision to restart should be addressed by his PCP.
Patient was continued on Bactrim for PCP prophylaxis as he has
intermittently been taking this at home.
# Drug abuse: Patient reports using daily methamphetamine. His
withdrawal symptoms were controlled with ___ scale (using
diazepam). He was seen by social work and offered resources for
substance abuse.
# Transaminitis: LFTs on admission notable for ALT/AST 43/42.
CT A/P notable for hepatic steatosis. Review of ___ records
reveals a ?history of (and treatment of) hepatitis C. LFTs
normalized.
# Hypertension: Home amlodipine-benazepril was held initially
in the setting of sepsis. Once he clinically improved, he was
restarted on amlodipine and lisinopril in equivalent doses
(amlodipine-benazepril is not on formulary).
# Diabetes: A1c 8.3. Patient has not been compliant with
metformin. His blood sugar was controlled on a Humalog sliding
scale. He was encouraged to continue metformin on discharge.
# HLD: Patient was restarted on atorvastatin and ASA.
# Depression: Patient's Effexor was held as he has not been
taking it.
# GERD: Held home PPI given C. diff, but restarted on
discharge.
Transitional Issues
- Lung nodule on prior CT in ___, may require follow-up CT
- Please continue to address substance use and medication
non-adherence
- Please discuss re-initiation of HAART with patient when he is
ready to re-start medications
- Please note, patient developed dark scotomata in L eye. Neuro
exam otherwise intact. Urgent Ophthalmology appointment
scheduled.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with history of dementia, htn, hld, h/o c diff s/p
colostomy who is admitted s/p mechanical fall, found to have a
humerus fracture for which ortho recommended non operative
management, who is now admitted due to delirium. HUMERUS (AP AND LAT) RIGHT showed Re- demonstrated spiral fracture of the right humerus with increased posterior
displacement of the distal fracture fragment.
Mild posterior angulation of distal fracture component.
Likely chronic superior subluxation of the humeral head related to rotator
cuff tear. Radiology showed 1. Posterior height loss, subtle cortical step off (best seen on sagittal
view) and sclerosis at the S1 vertebral body worrisome for sacral
insufficiency fracture/nondisplaced fracture. No hip fracture.
2. Wide diastases of the rectus abdominus and a wide-mouth ventral hernia
containing multiple loops of nonobstructed small bowel similar to the study of
___. The patient was diagnosed with Displaced spiral fx shaft of humerus, right arm, init, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Right humeral fracture
advanced dementia
SECONDARY DIAGNOSES:
hypertension
colostomy
history of atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with history of dementia, htn, hld, h/o c diff s/p
colostomy who is admitted s/p mechanical fall, found to have a
humerus fracture for which ortho recommended non operative
management, who was admitted due to delirium.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year-old right handed woman with a
history of relapsing-remitting MS on ___, migraine
headaches with aura, bipolar depression who presents to the ED
with bilateral vision changes. Neurology is consulted in the
ED. Radiology showed No acute intrathoracic abnormality. Radiology showed Multiple FLAIR hyperintense and hypointense lesions, in the cerebral white
matter, in the cerebellar peduncles as well as in the pons felt to represent
demyelinating lesions, without significant change compared to the prior study
of ___.
No abnormal enhancement; no obvious new lesions.
Limited assessment of the optic nerves is not targeted.
Other details as above. The patient was diagnosed with MULTIPLE SCLEROSIS. The patient was treated with IV steroids. At the time of discharge, the patient had MS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ year-old right handed woman with a history
of relapsing-remitting MS on ___, migraine headaches with
aura, bipolar depression who presents to the ED with bilateral
vision changes. Her neurological exam was notable for visual
acuity corrected ___, left RAPD, bilateral INO (L worse than
right) and subtle left NLFF. It appears that the patient is
having worsening visual symptoms likley representing an MS
___. She underwent MRI and one dose of IV steroids prior to
___ with plans to continue IV steroids as an out patient. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with stage III cT3N2M0 rectal cancer s/p neoadjuvant
chemradiation w/ ___ ___ and and radiation c/b proctocolitis, afib
( not on coumadin) and recent admission 1 month prior for BRBPR
coming in with BRBPR. The patient was at home when he had 3
bloodly BMs estimated at 50cc blood per BMs. he called his
outpatient oncologist and presented to the ED for evaluation. LIVER OR GALLBLADDER US (with Doppler. showed 1. Nodular heterogeneous liver compatible with known history of cirrhosis.
Small amount of ascites.
2. The posterior right portal vein is not visualized and likely occluded. In
review prior imaging including an MRI from ___ and a CT from ___ the right posterior portal vein branch appears attenuated and suggesting
this is a chronic finding. If further characterization is necessary recommend
CT. Likely slow flow in the main portal vein at the junction of the right
anterior portal vein.
3. Gallbladder sludge.
NOTIFICATION: These findings were discussed with ___ by Dr. ___
___ telephone at 17:00 on ___. Radiology showed 1. New right PICC ends in the mid to lower SVC
2. New bibasilar opacities
3. New left pleural effusion DUPLEX DOPP ABD/PEL showed 1. Continued nonvisualization of the posterior right portal vein which is
likely occluded.
2. Continued lack of visualized flow in the intrahepatic main portal vein,
unchanged since the prior exam from ___. This likely represents slow
flow; however, thrombus is also possible. If further evaluation is required
recommend CT.
3. Gallbladder sludge
4. Cirrhosis and a small amount of ascites.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
telephone at 19:25 on ___. CTV ABDOMEN showed 1. Patent portal vasculature with no evidence of thrombosis. Some of the
smaller vessels supplying the left medial segment are not fully opacified,
however no focal thrombosis seen.
2. Small amount of intraabdominal free air, in keeping with recent surgery.
3. Cirrhosis and small volume ascites.
4. Small left sided pleural effusion. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed No pneumothorax or appreciable pleural effusion. Mild left basal atelectasis
atelectasis is the only focal pulmonary abnormality. Normal cardiomediastinal
silhouette. No pneumothorax.
Right PIC line extends as far as the origin of the SVC where it is obscured by
the left subclavian line ends in the low SVC semi call on ___ a right
PIC line ended in the mid SVC. CHEST (PORTABLE AP) showed No appreciable interval change in focal right middle lobe airspace opacity
which may be due to atelectasis, but infection or aspiration would be
difficult to exclude in the appropriate clinical setting.
Right PICC line in satisfactory position in the mid SVC.
Stable cardiomegaly with left atrial enlargement. Ultrasound-guided paracentesis. showed Uneventful diagnostic and therapeutic paracentesis yielding 2 L of
yellow-colored ascitic fluid. The patient was diagnosed with GASTROINTEST HEMORR NOS. The patient was treated with ___ Sigmoidoscopy
___ Low anterior resection converted to abdominoperineal
resection and colostomy
___ paracentesis with 2L removed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ M with ETOH cirrhosis (c/b gastric and
rectal varices), afib (not on coumadin since ___, stage
IIIcT3N2M0 rectal cancer s/p neoadjuvant chemoradiation w/ ___ ___
(last ___ C2D1) and radiation therapy stopped prematurely due
to development of severe proctitis c/b GI bleed ultimately
requiring abdominoperineal resection and colostomy with course
complicated by afib with RVR and decompensation of cirrhosis
with ascites and secondary bacterial peritonitis.
# GI bleed: Patient recently had hospital admission for which he
had severe GI bleeding ___ rectosigmoid colitis ___ likely
radiation colitis, erythematous tissue around ca site, and
possible superimposed ischemic colitis during period of GI
bleeding. On admission to hospital and subsequent immediate
transfer to MICU from ED, it was noted that patient likely had
bleeding from prior rectosigmoid site. Patient was transferred
from ED to MICU on ___, and had 8 units of pRBCs, 2 units of
FFP and 1 unit of platelts transfused. Patient had bedside
sigmoidoscopy in MICU on ___ which showed few ulcerations was
noted in the rectosigmoid consistent with prior findings, and a
single oozing clot overlying a presumed ulcer was found in the
above the anal verge, which was subsequently injected with
epinephrine and clipped. After procedure, patient did not have
episodes of further bleeding. His home nadolol was held during
hospitalization, and metoprolol was used for rate control of
Afib with RVR. In the setting of a recent GIB his Coumadin was
held. He was transferred to the floor on ___ in stable
condition, with stable H/H s/p transfusions. However on ___ he
had more BRBPR and received 1u RBCs. He was taken back to GI
suite for flex sig and the clip had fallen out but there was no
intervention able to be undertaken. He had more significant
bleeding the early morning of ___ and required 2u RBCs, 1u
FFP, and had SBP in the ___. He was volume resuscitated also
with 1.5L IVF at that time. HR was controlled also with rate
control see below. He was taken to the OR on ___ (see below)
and had an abdominal perineal resection with end colostomy. His
H/H remained stable and he did not need any transfusions after
the immediate postop period.
# Afib/RVR: Pt with longstanding history of Afib, not currently
on anticoagulation given GI bleed as above. Rate was difficult
to control preoperatively in the setting of large volume active
bleeding. Pt required ongoing transfusions prior to the OR and
was clearly volume depleted. In that setting, combined with
lower BPs on ___, rate control was pursued cautiously, however
on ___ pt finally achieved good control with HRs down to the
___ 100s. This was with 50mg metop q6 po and continued on
dig with 1x extra dose given of 0.125 mg on ___ (for dig level
slightly low at 0.5). His bleeding improved a bit which also
contributed to improvement in volemic status and improved heart
rates. Echo was done that showed very dilated atria and combined
with his interesting but not fully explained history of liver
dysfunction/cirrhosis, cardiology raised the possibility of
amyloidosis. Accordingly, SPEP/UPEP were sent which were
negative. TSH/T4 was normal. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man with PMH DM, HTN, HLD
presenting with BRBPR and weakness x 1 day. CHEST (PORTABLE AP) showed Bibasilar atelectasis without definite focal consolidation. Dedicated PA and
lateral views may be helpful for further assessment if/when patient able. CHEST (PORTABLE AP) showed Heart size is enlarged. Mediastinum is stable. Lungs are overall clear but
there is new left suprahilar opacity that might potentially represent
infectious process.
RECOMMENDATION(S): Followup of the patient in 4 weeks after completion of
antibiotic therapy is recommended for documentation of resolution. The patient was diagnosed with Melena. At the time of discharge, the patient had Duodenal ulcer
Community acquired pneumonia
Acute blood loss anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY
___ man with PMH DM, HTN, HLD presenting with hematochezia and
weakness x 1 day, s/p ___ which found duodenal ulcer.
Patient received blood transfusions as needed with cauterization
of ulcer, with H. pylori stool antigen pending on discharge. He
was also found to have pneumonia as well as ___ proteus
mirabilis on urine culture and treated with ceftriaxone,
transitioned to cefpodoxime on discharge for total 7 day course,
to end ___, for combined coverage of community acquired
pneumonia/UTI. Azithromycin was discontinued given prolonged QTc
(530)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with past medical history of drug abuse, EtOH
abuse currently sober, bipolar disorder, aortic aneurysm, DVT,
PE, shingles, anxiety, depression, chronic left hip and back
pain
transferred from ___ for evaluation for
concern
of right third digit tenosynovitis. HAND (PA,LAT AND OBLIQUE) RIGHT showed No fracture or dislocation. Osteoarthritis, most pronounced at the basal
joint. The patient was diagnosed with Cellulitis of right upper limb. At the time of discharge, the patient had Cellulitis of R ___ digit. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Information for Outpatient Providers: ___ M R___
p/w ulcer, erythema, and swelling of the ___ digit of his R hand
admitted for management of uncomplicated cellulitis. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI:
___ h/o hyperlipidemia, depression, presents for eval of
epigastric abdominal pain. Patient states that her pain began
about 2 days prior to presentation, describes it as a sharp
stabbing abdominal pain with radiation to the back constant not
affected by what she ate. No clear trigger for pain. Prior to
this she was in a general state of good health. She endorses
associated nausea and vomiting. She denies any fevers, chills,
dysuria, urinary frequency. He denies any history of prior
abdominal surgery. Denies history of gallstones. Denies
diarrhea. States the pain is constant in nature and unrelenting.
___ pain -> ___ pain worse than labor pain. Seen at outside
hospital where ultrasound shows 6.7 mm dilation of the CBD as
well as 4 mm dilation of the pancreatic duct along with early
intrahepatic ductal dilatation. Discussed with ERCP here,
recommend transfer for MRCP.
===========
In ER: (Triage ___ 45 ___ 97% )
Meds Given: Dilaudid 1 mg x 4, zofran,
Fluids given: NS
Radiology Studies: none
consults called: d/w ERCP who recommended MRCP
======================
.
Currently in ___ pain in the epigastrum which radiates around
to her back.
No weight loss/no sudden visual changes. No change in her bowel
habits.
Her synthyroid was recently increased.
No URI sx
No chest pain or shortness of breath.
No edema
No new MSK sx.
Chronic headaches are well controlled currently,
No easy bruising/bleeding.
No current SI/HI.
PSYCH: [] All Normal
[+/? ] Mood change [-]Suicidal Ideation [ ] Other:
ALLERGY:
[+ ]Several medication allergies
[X]all other systems negative except as noted above Radiology showed 1. Active duodenitis involving the first and second portion of duodenum,
associated with acute interstitial pancreatitis predominant in the head/neck,
as well as in a focal lobulation insinuating between the first and second
portion of duodenum, which likely represents a normal lobulation and less
likely incomplete annular pancreas. Distended gallbladder with mild
pericholecystic fluid, likely relates to the extensive duodenal/pancreatic
inflammation.
2. Mild intrahepatic/extra-hepatic bile duct dilation, pancreatic ductal
dilation associated with a mildly prominent ampulla, likely relate to
duodenitis.
The above findings were discussed with ___ on ___ at 6:30 P.M. The patient was diagnosed with ABDOMINAL PAIN EPIGASTRIC, OBSTRUCTION OF BILE DUCT. At the time of discharge, the patient had Pancreatitis
Duodenitis
Hypertension
Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>\The patient is a ___ year old female with h/o depression,
migraines, HLD, smoking history who presents with acute
pancreatitis found to have intrahepatic dilatation, CBD
dilatation and pancreatic ductal dilation concerning for
possible obstruction.
.
Abdominal Pain: Patient with evidence of active pancreatitis
and duodenitis seen on MRCP with clear evidence of ductal
dilation. LFTs normal, but elevated lipase. This clinical
picture may be secondary to a gallstone. No gallstone clearly
seen on MRCP. There was mention of slight ampullary dilation on
MRCP. As such, she needs outpatient f/u with our ERCP staff to
consider ERCP given mention of ampullary dilation. Would
proceed with this workup prior to consideration of
cholecystectomy.
** Patient was discharged with a prescription for oxycodone 5 mg
(15 tabs) but then called the medical floor the day after
discharge to request a new prescription; we told her that we
have strict policies against replacing narcotic prescriptions so
she was not given an additional one.
HTN: Continued on clonidine only given her bradycardia.
Bradycardia: Metoprolol held, and EKG showed sinus arrhythmia.
QTC also prolonged at 480. Needs outpatient recheck and patient
notified not to take any medicines that prolong the qtc. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with a history of poorly controlled diabetes, severe
systolic heart failure (EF ___ in ___ secondary to
ischemic cardiomyopathy, history of DVT/PE and LV thrombus on
warfarin and severe peripheral vascular disease s/p right ___
toe amputation with recent bypass procedure due to poor wound
healing who was brought in by ambulance from rehab for BRBPR and
clots. He has been on ASA, Lovenox bridge to Coumadin after his
bypass procedure. After dinner this evening around 6:30pm he
experienced abdominal cramping and massive amounts of bloody
stool with dime sized clots. Rehab called EMS who noted that on
arrival he had SBPs in the ___ but dropped to mid ___ systolic
by the time he arrived in ED. Per EMS over the ten minutes
prior to arrival in the ED he had become much more lethargic and
somnolent. Radiology showed Left IJ catheter projects over the thoracic inlet. No pneumothorax visualized
on this supine film. CTA ABD AND PELVIS showed 1. No active hemorrhage detected.
2. Right-sided diverticulitis at the hepatic flexure (3b:246). No fluid
collection.
3. Dilated common hepatic duct measuring up to 1.4 cm with dilation of the
cystic duct and mild intrahepatic biliary ductal dilatation with a transition
at the level of a calcification in the pancreatic head, possibly a stone at
the duodenal ampulla (3b:249, 601b:55) but difficult to distinguish from an
adjacent calcification. This could be further evaluated by MRCP if clinically
indicated.
4. Wall thickening of the bladder suggests cystitis, correlate clinically.
5. Mild wall thickening of the distal sigmoid colon without adjacent fat
stranding may reflect mild colitis. No associated fluid collection.
6. Left adrenal mass likely represents an adrenal adenoma but is indeterminate
on the noncontrast study. Adrenal protocol CT or MRI could be performed on an
outpatient basis for further characterization if clinically indicated.
7. Nephrolithiasis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 4:50 ___, 40 minutes after the
discovery of the findings. CHEST (SINGLE VIEW) showed Left IJ catheter has two kinks. The tip projects in the junction of the left
IJ and left subclavian veins. The upper lungs are clear. The patient was diagnosed with GASTROINTEST HEMORR NOS, LONG TERM USE ANTIGOAGULANT. The patient was treated with EGDx2, colonoscopy. At the time of discharge, the patient had Lower GI bleed, ___, DM2, hx of LV thrombus, diverticulosis,
diverticulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with complicated history of maximally-medically managed
systolic heart failure, severe peripheral vascular disease and
poorly-controlled diabetes who presented from rehabilitation
with BRBPR while on lovenox and coumadin for anticoagulation.
# GI BLEED: Thought to be lower in etiology given history but
could not rule out upper GI bleed on admission. He was
hemodynamically unstable in ED and massive transfusion protocol
was activated. Patient continued to have bleeding in the ICU
requiring additional 3u pRBCs and fluid. He underwent NGT
placement for gastric lavage which was negative. Given his
ongoing bleeding and hemodynamic instability he underwent CTA in
attempt to localize the bleed. This was unfortunately
unrevealing as to source but did show evidence of diverticulitis
in the hepatic flexure. There was also concern for CBD
dilation. Patient underwent EGD per GI which showed evidence of
gastritis but no obvious source of bleeding. A biopsy was not
taken at the time. Had continued slow downtrend in Hct. Became
hypotensive requiring low dose norepinephrine, with marked
improvment by the end of ___ s/p 3U pRBCs and 2L NS. His H/H
then normalized with no further melena or hematechezia. A repeat
EGD and colonoscopy was performed on ___ which showed
intestinal metaplasia in the esopagus and diffuse diverticular
and adenomatous disease in the colon. However, no source of
bleed was clearly located. It was thought that this event likely
represented a brisk diverticular bleed, which spontaneously
resolved. He will need to follow up with gastroenterology as an
outpatient in order to discuss management of adenomatous disease
of colon. GI differed excision during this admission because of
need to anticoaulate given other comorbidities (see below). The
risks and benefits should be discussed with PCP and GI.
# H/O DVT/PE and LV THROMBUS: Anticoagulated with coumadin and
being bridged with lovenox since late ___. INR noted to be
highly variable, from 1.04 to >10 on ___. Was on 7mg warfarin,
last dose ___. In the setting of bleed his anticoagulation was
held. Becuase of his LGIB and ___ it was thought that restarting
lovenox would carry too much risk for further adverse events. He
was therefore started on a heparin drip as a bridge to coumadin.
On day of discharge he is taking 7.5 mg PO daily of coumadin and
his INR is at goal at 2.0 (___). He will need close follow up as
he recently discontinued antibiotics, which could cause
fluctuations in INR.
# ACUTE KIDNEY INJURY: On admission creatinine elevated to 2.5,
baseline appears to be 1.5-2.0, although the patient has
suffered fluctuations over his multiple hospitalizations.
Etiology is likely pre-renal given history of blood loss, and
likely concurrent diuretic use. No evidence of heart failure
exacerbation to suggest cardiorenal etiology. With volume
resuscitation, renal function improved to baseline Cr of
1.2-1.5. Of note, his lisinopril was held for hypotension and
was not restarted in the setting of ___. His BPs have been at
goal but should consider restarting it for renal/cardiac
protective effects.
#Bradyarrhythmia/Hyperkalemia: Patient with single episode of
unclear bradyarrhythmia to ___ caught on monitor late on ___.
Likely wenckebach AV block with intermittent ventricular escape
beats. K that morning had been 5.7. Pt refused lab draws. Pt
treated empirically with 2g IV calcium gluconate. 12 lead EKG
did not capture rhythm or show evidence of acute ischemia. No
further episodes were appreciated during the course, and his
potassium normalized.
#Diverticulitis: CTA on ___ with incidental finding of
uncomplicated diverticulitis. He was treated with intial bowel
rest and a 10 day course of ciprofloxacin and flagyl.
# PERIPHERAL VASCULAR DISEASE: s/p right toe amputation c/b
poor healing and polymicrobial wound infection with recent
bypass surgery from femoral to dorsalis pedis. Vascular surgery
was notified of admission given blood filled bullae at incision
site. His anticoagulation was initially held on admission given
bleed as above (see above). He had a vascular surgery
appointment scheduled during this admission and will therefore
have to reschedule. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality.
2. Mild sinus disease.
3. Nonspecific fullness of the adenoids may be reactive in the context of
sinus disease. Please correlate for recent upper respiratory infection. CTA CHEST WITH CONTRAST showed Study is moderately limited in the setting of motion artifact and extensive
streak artifact emanating from spinal fixation hardware. Within these
limitations, no evidence of pulmonary embolism or acute aortic abnormality
identified. ABDOMEN US (COMPLETE STUDY) showed Normal abdominal ultrasound. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Study is degraded by motion.
2. No acute intracranial abnormality, with no definite evidence of acute
infarct.
3. Within limits of study, no definite evidence of lesion or enhancing
intracranial mass. Please note that this examination is not a dedicated
seizure protocol, and if continued concern for seizure foci, consider seizure
MRI for further evaluation.
4. Paranasal sinus disease , as described.
5. Nonspecific prominent nasopharyngeal/adenoid tissues, which may be
reactive. The patient was diagnosed with Tachycardia, unspecified. At the time of discharge, the patient had Primary:
Bipolar disorder with psychotic features
Volume depletion
Tachycardia
Drug induced liver injury
Rhabdomyolysis
Mild anticholinergic toxicity. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient Summary:
===================
___ female with a history of bipolar disorder with
psychotic features. Prior to admission she was admitted to
___. At the facility she was not
reliably taking her prescribed aripiprazole 2 mg/day. She been
complaining of auditory and visual hallucinations and became
increasingly paranoid/agitated. She ended up requiring chemical
sedation at ___ consisting of 200 mg of Thorazine, 100 mg
of Benadryl, and 2 mg of Ativan. She subsequently became
lethargic, hypotensive, and tachycardic so EMS was called. She
was transferred to our emergency department. She was evaluated
by our toxicology department and was found to have minor
anticholinergic toxicity which did not require physostigmine. We
held anticholinergic meds briefly with improvement in her
symptoms. However, she remained significantly tachycardic with
heart rates in the 120s to 140s with activity. We conducted
further work-up to exclude underlying medical disorders which
could be causing tachycardia. Lower extremity Dopplers, and a
CTA chest were negative for DVT/PE. Basic infectious work-up was
negative. While inpatient, the patient continued to struggle
with psychosis. She required as needed Haldol in order to
control her agitation, after receiving Haldol her LFTs were
mildly elevated. She did not complain of any abdominal pain. We
have performed a right upper quadrant ultrasound which was
unrevealing. We performed a hepatitis panel which was
unrevealing. We attributed the patient's transaminitis to
drug-induced liver injury from Haldol. During this time the
patient's CK was also significantly elevated. We reconsulted
toxicology to rule out NMS, and the toxicology department agreed
that she did not have any concerning signs for NMS. We
attributed the CK elevation to rhabdomyolysis from restraints.
She was seen by our neurology department who will work-up
outpatient for possible myositis as well to exclude this as a
cause of her CK elevation.
The patient was sent here on a ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old lady with history of prior left
frontal stroke, as well as HTN, CHF, CAD who presents with a
sensation of spinning that started yesterday and is persistent
today. Radiology showed Low lung volumes with atelectasis. Cardiomegaly, no pulmonary edema. Radiology showed No acute intracranial process, or significant change since the prior head CT
dated ___. MRI AND MRA BRAIN showed 1. No acute intracranial process. No infarct or mass effect.
2. White matter changes described above compatible small-vessel ischemic
disease.
3. Allowing for common anatomic variations, essentially unremarkable MRA of
the head. The patient was diagnosed with VERTIGO/DIZZINESS. The patient was treated with na. At the time of discharge, the patient had Benign paroxysmal positional vertigo
HTN
CHF
CAD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a delightful and fiercely independent ___ year
old lady with history of prior left frontal stroke, as well as
HTN, CHF, and CAD who presented with vertigo. Her exam was
notable for positive HIT to the left. MRI was negative for acute
infarct. The patient was admitted due to trouble with ambulation
___ her peripheral vertigo. She improved during her stay after
working with ___ she will go home with home ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI
___ hx CAD s/p PCI, CMP of uncertain etiology (EF 35% on ___ OSH TTE). She developed chest and back pain, was brought to
___ by EMS, and was transferred to ___ ED.
Here, she was found by a circuitous path to have acute
cholecystitis, and is admitted to medicine after a perc biliary
drain. CHEST (PA AND LAT) showed Heart size at the upper limits of normal or minimally enlarged. No
significant change in the cardiac silhouette is appreciated compared with the
outside scanned-in chest x-ray from ___ dated ___ at 04:40.
Stent noted, best correlated with the specifics of the procedure.
No acute pulmonary process identified. No CHF or focal infiltrate. Possible
minimal bibasilar atelectasis. CT CHEST WITH CONTRAST showed 1. No acute abnormality within the chest. No evidence of pneumomediastinum.
2. Multiple gallstones within a fluid-filled and distended gallbladder. Rim
of enhancement within the surrounding liver parenchyma (rim sign), which may
be perfusional, but raises suspicion for acute cholecystitis. Right upper
quadrant ultrasound is recommended.
RECOMMENDATION(S): Right upper quadrant ultrasound is recommended. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Gallstones within a distended gallbladder and mild gallbladder wall edema,
likely reflecting early or mild acute cholecystitis. No intra or extrahepatic
biliary dilatation. Ultrasound-guided percutaneous cholecystostomy tube placement showed Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
RECOMMENDATION(S): Q6 hr H&H overnight to evaluate for any signs of
hemorrhage. The patient was diagnosed with Chest pain, unspecified. The patient was treated with Percutaneous cholecystostomy. At the time of discharge, the patient had Primary Diagnosis
- Acute Cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with recent mLAD stent (___) on DAPT and
new diagnosis of cardiomyopathy who presented with chest pain
and was found to have acute cholecystitis, had a percutaneous
c-tube placed, and improved.
# Acute cholecystitis: Initially concerned for ACS or other
cardiac cause given recent diagnosis of cardiomypathy and LAD
stent, however workup was negative. Ultimately found to have
acute cholecystitis on ultrasound with white count of 20K. Not
deemed to be a good surgical candidate because of recent cardiac
issues and current anticoagulation. Percutaneous cholecystostomy
successfully performed though did drain some blood which
continued until discharge in small quanities likely due to dual
anti platelet therapy and HGB dropped from 11.9 on admission and
was 11. 3 on discharge. Started on ceftriaxone. Patient's pain
was much improved, and antibiotics switched to oral amox/clav
for a total of a 5 day course. Will follow up with surgery for
definitive surgical management.
# Cardiomyopathy and heart failure: Patient with new
cardiomyopathy and reported outside EF of ~35% per primary
cardiologist. All troponins negative and no other concerning
findings in cardiac workup. Echo performed and current EF at
55%. Following percutaneous cholecystotmy, chest pain improved.
Patient discussed with outpatient cardiologist and recommended
no additional workup in hospital.
#Pain control - Tylenol and oxycodone 5mg
#GERD- Pantoprazole 40mg daily continued from home medications
Transitional Issues
====================
- Patient is on dual antiplatelet therapy and should remain
until approved by cardiologist to stop treatment.
- Amox/Clav started for 5 day total course of antibiotics to be
completed ___
-Follow up with ___ surgery in 6 weeks for planning ongoing
surgery.
- Follow up with interventional radiology in 6 weeks for
evaluation of cholecysostomy tube.
- Patient's EF on echo in hosptital is >55% which is improved
from prior. Recommend continued workup for cause of heart
failure symptoms and dose adjustment/need for beta-blocker and
ace inhibitor</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of uterine cancer s/p radiation presenting with
F/C, and acute onset LLE pain x3 days. MR PELVIS WANDW/O CONTRAST showed 1. Unusual appearances at the left hip with a large joint effusion with
surrounding soft tissue edema but with relative preservation of the normal
bone marrow signal in both the femoral head and the acetabulum. There is bony
destruction involving the medial acetabular wall as seen on the prior CT study
and extension of the fluid into the iliacus muscle but with the peripheral
calcified rim. The appearances suggest a chronic destructive process of the
left hip. Potentially a very indolent infection could have such an appearance
but alternative etiologies such as inflammatory arthropathy, rheumatoid
arthritis and psoriatic arthritis should also be considered.
2. Multiple insufficiency fractures and apparent bone infarcts in the sacral
ala. MR ___ SPINE WITH CONTRAST showed 1. Multilevel, multifactorial degenerative changes throughout the lumbar
spine, with irregular contour at the endplates, more significant at the
superior endplate of L2 consistent with Schmorl's nodes.
2. The signal intensity in the bone marrow is heterogeneous with areas of
high-signal intensity on the STIR sequence at the endplates of L1-L2, L2-L3
and L4-5 levels, suggesting bone edema, probably degenerative in nature, there
is no evidence of abnormal enhancement to indicate discitis osteomyelitis. INJ/ASP MAJOR JT W/FLUORO was done. DX CHEST PORTABLE PICC LINE PLACEMENT showed The tip of the right PICC line projects over the distal SVC. No pneumothorax. The patient was diagnosed with Pain in left hip. The patient was treated with 1. Left hip joint aspiration ___. Irrigation and debridement with arthrotomy of the left hip
on ___. Girdlestone procedure for femoral head avascular necrosis
and osteomyelitis on ___. At the time of discharge, the patient had # L hip septic arthritis
# Acute L hip osteomyelitis
# Orthostatic hypotension
# Constipation
# Hypothyroidism
# Hyperlipidemia
# History of thromboembolic disease
# Peripheral neuropathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old female with past medical history of
uterine cancer admitted with L hip septic arthritis and acute L
hip osteomyelitis now status post L hip incision and drainage
and L hip girdlestone procedure, course complicated by
constipation, orthostatic hypotension, subsequently improving on
antibiotics and able to be discharged to a rehab facility on
prolonged course of IV antibiotics.
# L hip septic arthritis
# Acute L hip osteomyelitis
Patient was admitted with L hip pain, fever and joint swelling.
Imaging showed a large left hip effusion as well as bony
destruction. ___ guided fluid aspiration revealed joint fluid
with WBC > 50K. Patient was started on empiric antibiotics.
Fluid culture grew coag neg staph and group C strep. She was
seen by orthopedic surgery consult service and infectious
disease consult service, and underwent left hip I&D, girdlestone
procedure on ___. TTE did not reveal signs of endocarditis.
Patient was recommended to complete ___ weeks of IV ceftriaxone,
to be determined by ___ ID OPAT follow-up. Patient had a PICC
line placed, and was able to be discharged to a rehabilitation
facility. At time of discharge, she was using oxycodone prn for
pain.
# ___ course complicated by orthostatic hypotension in
setting of poor PO intake from recent surgical procedure. This
resolved with IV fluid resuscitation and improved PO intake, and
did not recur for the remainder of the admission
# Constipation
Post-operatively patient developed constipation. Resolved with
augmentation of bowel regimen.
# Peripheral neuropathy
Continued home gabapentin
# History of Venous Thromboembolic disease:
The patient has a history of a uterine vein clot ___ ago. She
is on lifelong anticoagulation with lovenox ___ mg daily.
Lovenox was briefly held for her surgical procedure and then
restarted once surgically safe to do so.
# Abnormal MRI Pelvis - Admission MRI read as "Multiple
insufficiency fractures and
apparent bone infarcts in the sacral ala". Discussed this
finding with orthopedics who believe most likely result of her
prior radiation and not concerned re: embolic process--no
additional workup or management was recommended.
# Hypothyroidism:
Continued home levothyroxine
# Hyperlipidemia
Continued statin
Transitional Issues
- Discharged to rehab
- Discharged with PICC in place; would remove PICC on completion
of antibiotic course;
- Planned for ___ week course of IV ceftriaxone to be determined
by ___ ID OPAT follow-up appointment (see below)
- TTE incidentally showed "Mild to moderate tricuspid
regurgitation."; "Possible small asd vs stretched pfo."; Defer
to outpatient regarding potential need for additional workup or
referral.
- MRI incidentally showed "Multilevel, multifactorial
degenerative changes throughout the lumbar spine, with irregular
contour at the endplates, more significant at the superior
endplate of L2 consistent with Schmorl's nodes."; </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a history of HTN, HLD,
DM2, Afib on Coumadin, ADPKD c/b ESRD s/p LRRT (___) c/b graft
failure ___ tacro on HD, and recent admission for PD
catheter infection and colon perforation requiring transverse
colectomy and end colostomy, peritonitis (end date of cipro,
flagyl, dapto, fluconazole ___, new dx afib on warfarin, who
now presents with two days of lower abdominal pain, flank pain,
n/v, hematuria, dysuria, and fevers to 104. Radiology showed 1. No evidence of abscess in the abdomen pelvis. No obstruction.
2. Transplant kidney is grossly normal without hydronephrosis. There are
multiple subcentimeter hypoattenuating lesions in the transplant kidney which
are too small to characterize but unchanged from ___.
3. Small amount of perihepatic and pelvic free fluid of unclear etiology.
NOTIFICATION: Free fluid CT ABDOMEN AND PELVIS WITHOUT CONTRAST showed 1. Several cysts are seen in the right kidney which have enlarged since ___ with hyperattenuating internal contents, suggestive of interval
development of hemorrhagic cysts. Additionally, the right proximal ureter
appears dilated and hyperattenuating, concerning for clots.
2. Interval increase in bilateral pleural effusions and basilar atelectasis
since ___.
3. Small pockets of gas are seen within the calices of the right transplant
kidney. Although this can be explained by recent Foley catheter insertion and
reflux, emphysematous pyelitis should be considered, correlation with
urinalysis is recommended. No CT evidence of pyelonephritis or air within
renal parenchyma.
4. Persistent mild perihepatic and pelvic free fluid without evidence of
organized fluid collections.
5. Diffuse anasarca.
RECOMMENDATION(S): Correlation with urinalysis and urine culture is
recommended to rule out a urinary tract infection.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:17 pm, 20 minutes after discovery
of the findings. Radiology showed 1. No evidence for bowel obstruction.
2. Right double-J ureteral stent with partial uncoiling of the proximal
pigtail loop. Radiology showed Technically successful coil embolization of three areas of bleeding seen on
right renal arteriogram. NON-INVASIVE PERIPHERAL ARTERIAL STUDY showed No evidence of pseudoaneurysm, fistula or hematoma. The patient was diagnosed with Urinary tract infection, site not specified. The patient was treated with ___ Cystoscopy
___ Renal angiogram with coiling 2 non bleeding pseudo
aneurysms and 1 bleeding. At the time of discharge, the patient had Primary diagnosis
=================
Cyst rupture
Pyelonephritis
Pseudo aneurysm
Secondary diagnosis
====================
Autosomal dominant polycystic kidney disease
Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a history of hypertension,
hyperlipidemia, diabetes, recently diagnosed paroxysmal atrial
fibrillation on Coumadin, autosomal dominant polycystic kidney
disease (ADPKD) complicated by end stage renal disease status
post left renal transplant in ___, complicated by graft failure
in ___ on tacrolimus, now on dialysis and with recent admission
for peritoneal dialysis catheter infection and colon perforation
requiring transverse colectomy and end colostomy, peritonitis
(end date of cipro, flagyl, dapto, fluconazole ___, who
presented on ___ with 2 days of fevers, abdominal pain, and
hematuria despite broad spectrum antibiotics.
#Pyelonephritis: Presented with fevers, chills, rigors.
Infectious work up notable for positive UA, negative cultures to
date, otherwise negative CT abdomen for intraabdominal abscess.
Hematuria and pain consistent with patients presentation of cyst
rupture. Diagnosed with cyst rupture complicated by likely
pyelonephritis, treated with meropenem (___) and micafungin
(___) and then transitioned to daptomycin (___),
ceftazidime (___), and fluconazole (___) with ID
consulted. On ___, patient was febrile to 101.8 and
asymptomatic with negative work up, cultures pending. Decision
was made to monitor closely for 24 hours. No recurrent fevers,
and patient continues to look well so was discharged with close
follow up.
#Ruptured Cyst: Presented with hematuria and abdominal pain. INR
peaked at 4.0, given no afib (likely brought on during last
hospitalization in the setting of infection) and significant
hematuria, warfarin was discontinued. Hematuria and pain
consistent with patients presentation of cyst rupture. Her
course was complicated by recurrent cyst rupture causing
significant hematuria and pain, needing continuous bladder
irrigation and pain management with dilaudid. Patient had a
cystoscopy done which showed old blood in right ureter,
procedure was complicated by a perforation of right ureter
status post stent placement. Given recurrent hematuria with 3
units of RBC transfusion, ___ got involved to find the source of
the bleed through renal angiogram. ___ performed renal
arteriorgram and identified 3 potential sources of bleeding
(pseudoaneurysms) including 1 actively bleeding vessel. All 3
were coiled. Hematuria on discharge still persistent, but
urinating well so CBI discontinued. Patient advised to monitor
for frank blood on urination, and tolerate dark colored urine.
CBC should be monitored at her HD sessions to ensure stability
and not requiring additional pRBC transfusion. On discharge,
pain from PKD cyst rupture and recent ___ procedure was well
controlled on the oral regimen, which should be able to be
tapered down over the course of the next days to weeks.
#Ostomy prolapse: Course complicated by ostomy prolapse,
transplant surgery and ostomy nurse visited often with
instructions to hold cold compress with improvement.
# Nutrition: ___ removed secondary to great PO intake.
Nutrition recs:ensure clear TID, CIB w/ whole milk TID,
nephrocaps, monitor weight post-HD ___.
#Hypocalcemia / Vit D deficiency: Continued Vit D.
#Thrombocytosis: In the setting of sepsis, resolved. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI:
Ms. ___ is a ___ year old female in good health who presents
to the ED because of left arm numbness over the last few days
and
visual distortion noted this morning that has associated nausea
and lightheadedness. She also has noticed worsening of the
tingling to involve her head, face and rim of her tongue. Radiology showed 1. No CT evidence for acute intracranial process.
2. Punctate calcifications along the anterior frontal lobes, left basal
ganglia, and right temporal lobe. The frontal calcifications may be
extra-axial, but could be parenchymal. Punctate parenchymal calcifications are
nonspecific and could be seen in neurocysticercosis or prior infection such as
TB or TORCH infections. Given patient's geographic background, correlation
with serology is recommended.
Discussed with ___ Brown by ___ by phone at 7:15 p.m. on
___. Radiology showed No significant abnormalities on MRI of the brain with and without
gadolinium. Radiology showed Mild posterior disc protrusions at C5/6 and C6/7. Otherwise,
unremarkable cervical spine MR.
___ wet read was entered into the system by Dr. ___ on ___ at 9:55 AM. The patient was diagnosed with SKIN SENSATION DISTURB. At the time of discharge, the patient had Cervical radiculopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with no
significant stroke risk factors who presents with a subacute
presentation of left arm numbness (tingling) that progressed to
involve the back of her head, her face and tongue. She also had
a
sense of oscillopsia and lightheadedness.
The patient was admitted to the Neurology service. She had a CT
of the head which shows likely old neurocysticercosis infection.
She had an MRI of the brain and cervical cord which showed no
stroke and mild degenerative change. The patient's numbness and
weakness are most likely due to cervical radiculopathy. She was
discharged with outpatient ___ and to follow up in neurology
clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old female with history of intermittent upper
abdominal pain and known gallstones. She presents after 1 day of
upper abdominal pain and nausea. She states that she had pain
most of the day prior to arrival, worst at 11pm, better at time
of evaluation. She does complain of some nausea that is
described more as stomach upset than feeling as though she will
have emesis. Denies fevers, chills, diarrhea, constipation. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Cholelithiasis without sonographic evidence of cholecystitis.
3. Patulous CBD measuring 7 mm though no gallstone is noted within the
visualized common bile duct.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 9:09 AM, following wet-read change. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with ___: Laparoscopic cholecystectomy, liver biopsy. At the time of discharge, the patient had Symptomatic cholelithiasis
Transaminitis
Steatosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed an echogenic liver
consistent with steatosis, cholelithiasis without sonographic
evidence of cholecystitis and a 7 mm with no gallstone
visualized. Her labwork was significant for transaminitis, which
was also seen ___ years ago.
The patient underwent laparoscopic cholecystectomy and liver
biopsy, which went well without complication (reader referred to
the Operative Note for details). After a brief, uneventful stay
in the PACU, the patient arrived on the floor tolerating a
regular diet, on IV fluids, and oral oxycodone for pain control.
The patient was hemodynamically stable.
Pain was well controlled. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old female who complains of ABD PAIN.
___ past medical history of hypertension presents with right
lower quadrant pain. Patient reports lack of energy and appetite
for several days. Yesterday, she began to develop crampy lower
abdominal pain and nausea. The pain is most severe in her right
lower quadrant. Today, pain improved the patient did develop
fever at home to 101. The patient has not vomited. She has no
chest pain or shortness of breath. Patient came in at ears fever
husband was concerned that she may have appendicitis. She has
not had diarrhea, black stools, bloody stools. Radiology showed Findings consistent with acute appendicitis with significant
phlegmonous change in the right lower quadrant potentially concerning for
early perforation. No drainable collection at this time. The patient was diagnosed with ACUTE APPENDICITIS NOS. At the time of discharge, the patient had acute perforated appendicitis
atrial fibrillation with rapid ventricular response. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is an otherwise healthy ___ year old woman who was found in
the emergency department to have acute perforated appendicitis.
She was admited to observation where she was monitored and
treated medically for her abdominal infection. No surgery was
required. She was clinically stable and responded apporpriately
to antibiotics. She was found in the hospital to have no onset
Afib with RVR. The majority of her hospital stay was spent
managing this condition. The patient had low blood pressures at
baseline. We attempted to control her Afib with metroprolol but
it caused asymptomatic hypotension in the patient and it was
held. She was started on diltizem which was able to control her
Afib. Cardiology was consulted who said warfarin was not
required for ___ CHADS of 1. She was started on daily aspirin.
She tolerated diet well and was fully ambulatory and was
clinically able to meet all of her ADLs. She was discharged on
HD7 to home to finish out a 2 week course of antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old lady with HTN, MVP s/p repair ___ years
ago, OA s/p R THA admitted with L tibial and ___ metatarsal
fracture after mechanical fall s/p successful ORIF on
___, now with new onset asymptomatic afib with RVR (HR
100-120s). CHEST (PA AND LAT) showed As above. CT left lower extremity without contrast showed 1. Spiral comminuted fracture of the distal tibial diaphysis, subsequent
internal fixation has been performed.
2. Vertically-oriented fracture through the medial malleolus
3. Transverse fracture through the base of fifth metatarsal
NOTIFICATION: Review of the electronic medical record indicates that the
orthopedic surgery service were where these findings at the time of CT. Radiology showed No acute cardiopulmonary process. CHEST (PORTABLE AP) showed In comparison to ___ chest radiograph, cardiomegaly is
accompanied by mild pulmonary vascular congestion and a persistent small left
pleural effusion. No new or worsening pulmonary opacities to suggest the
presence of pneumonia. The patient was diagnosed with Displaced comminuted fracture of shaft of left tibia, init, Nondisp fx of fifth metatarsal bone, left foot, init, Fall (on) (from) unspecified stairs and steps, init encntr. The patient was treated with ___: L Tibia IMN, ORIF L medial malleolus. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Left tibia fracture
___ metatarsal fracture
Atrial Fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ HTN, MVP s/p repair, OA s/p R THA admitted for mechanical
fall with L tibial and ___ metatarsal fracture:
#s/p mechanical fall
#left tibia fracture
#left ___ metatarsal fracture
The patient was found to have a left tibia fracture and was
taken to the operating room on ___ for left tibia IMN and ORIF
L medial malleolus which the patient tolerated well. She was
evaluated by ___ during hospital course and was discharged as
non-weight bearing LLE until re-eval as outpatient with boot
placement. At the time of discharge the patient's pain was well
controlled with oral medications (Tylenol only), incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate ___ care. The patient expressed readiness
for discharge.
#Atrial fibrillation:
On POD 2 patient developed new onset atrial fibrillation with
RVR noted incidentally on telemetry and EKG. She remained
hemodynamically stable without symptoms. Potential causes for
her include volume overload/CHF, which is not unlikely given
cardiomegaly and vascular congestion on imaging, and elevated
proBNP. No current or recent ischemic event (Q waves noted in
the inferior leads in EKG are unchanged from many years prior).
TTE was done which showed biatrial enlargement with normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. TTE also demonstrated mild
mitral regurgitation, pulmonary artery diastolic hypertension,
and right ventricular free wall hypokinesis. Other risk factors
for afib include obesity w/ likely OSA, hx of MVR, and
catecholamine surge post operatively. TSH normal. She has an
CHADS2-Vasc2 score of ___ (HFpEF, HTN, female, age ___,
making her high risk (4% annual risk of stroke) requiring
anticoagulation. Given her history of GI bleed and recent
surgery, warfarin was initiated for reversibility compared to
NOACs. Patient discharged on warfarin 2.5 mg daily with lovenox
bridge (goal INR ___. Patient will have long term ___ for
INR w/ cardiologist (Dr. ___. Rate control was achieved with
metoprolol mg q6hr and patient was ultimately discharged on
metoprolol XL 100 mg BID.
#Pleural Effusion:
Patient was noted to have left lower lobe pleural effusion on
CXR. This was thought to be ___ volume overload iso HFpEF vs.
___ post-surgical atelectasis. Patient was given 20 mg IV lasix
w/ -2L fluid off. The patient was noted to have normal oxygen
saturation prior to discharge.
#Orthostatic Hypotension: Patient diuresed for c/f for volume
overload iso of cough/desaturation not responsive to
bronchodilators. CXR c/f vascular congestion. Patient given 20
mg IV lasix with -2 L net negative. Upon working with ___ the
following day, she was orthostastic. It was recommended that she
stay in the hospital until this resolved because of the risk of
falls and injuries. She expressed understanding of the risk of
falls and injuries, but still insisted on leaving against
medical advise. Patient agreed to fluids prior to discharge.
Orthostatics vital signs improved, but patient still refused
further monitoring and further fluids. She continued to express
understanding of risks of leaving AMA. Patient was instructed to
avoid stairs, but to have help if she needed to use stairs. She
was also educated regarding using a walker/table to stabilize
herself when going from seated/laying to standing position.
---------------
CHRONIC ISSUES:
---------------
# HTN: Stabilized on metoprolol 100 mg XL by outpatient
cardiologist. Uptitrated to 100 mg XL BID for better rate
control.
#Depression/Anxiety: Patient had anxiety during hospital stay
requiring a dose of Ativan. She has a history of depression
treated with Paroxetine at home; however, this was not restarted
on admission initially. Withdrawal effect from Paroxetine may
have contributed to anxiety. Patient's anxiety was also
exacerbated by a patient sharing the room with her who was
suffering from delirium and agitation. Patient's home Paroxetine
was resumed.
# HLD: Continued Atorvastatin 40 mg PO/NG QPM
--------------------</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ year old woman with a history of prior
unruptured brain aneurysm clipping in ___ with subsequent
CSF leak that was repaired, h/o migraine with aura, p/w
transient
visual symptoms. She was at a medical office setting up some
referral appointments and chatting with the receptionist when
she
suddenly had onset of a very abnormal feeling in her L eye. She
describes it as feeling as if she is dizzy or lightheaded INSIDE
her L eye. She also describes that she had flickering of her L
eye vision with light/dark alternation, "like sunshine
flickering
through leaves". This affected her whole vision at once and did
not seem to move from one part of her visual field to another.
This went on for 45 minutes to an hour and then resolved. She
tried covering one eye and then the other, and she said that the
phemonon was only in her L eye, but her R eye vision seemed a
bit
blurry or cloudy. MR HEAD W AND W/O CONTRAST showed No acute changes. Sequela of prior presumed aneurysm surgery. The patient was diagnosed with VISUAL DISTURBANCES NEC. At the time of discharge, the patient had Retinal Migraine. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Upon further interviewing during the hospitalization, the
following information was obtained by Dr. ___. "She was at a
medical office when she
noticed a dark shade come down over her left eye's field of
vision from the top to the bottom. This shade descended over
seconds and stayed for several seconds. She is not clear on the
pattern with which the shade went away. She did close one eye at
a time and confirmed that it was the left eye that was affeted.
Once her vision returned, she also had a sensation of a black
area closing in on her left eye's field of vision. There was a
pressure and "lightheadedness" behind her left eye.
The temporary loss of vision of the left eye due to a shade
descending occurred eight to ten times. It happened ___ times
while she was walking down the hallway of the office, and then
again several times while she was sitting down. These episodes
occurred over one hour."
She was not considered to be at risk for temporal arteritis. ESR
and CRP were within normal limits. She had intact temporal
artery pulses bilaterally. Optho was consulted and she was found
to have a normal exam without evidence of intraocular pathology.
Her vision disturbances were not thought to be related to the
right paraclinoid ICA aneurysm. Neurosurgery was also consulted
regarding this right paraclinoid ICA aneurysm but no
intervention was needed. MRI brain did not show evidence of a
stroke. Echo did not show evidence of PFO or cause for emboli to
cause a TIA. A limited hypercoagulable panel and sent and was
still pending at the time of hospital discharge. Overall it was
felt that the transient loss of vision of the left eye could be
a retinal migraine. Transient monocular vision loss due to
thrombosis was thought to be less likely.
She was recommended to continue aspirin 81mg daily for now for
protection against the possibility of thrombosis and TMVL. She
was encouraged to cease smoking cigarettes. She was given a
nicotine patch.
She had right sided severe neck pain that was non radiating.
This neck pain may possibly due to degenerative cervical disc
disease and muscle spasm. She was given tramadol, flexeril, and
a lidocaine patch which were helpful. She did not feel that a
soft cervical collar was helpful. She should follow up with her
outpatient provider for continued evaluation and management of
the right sided neck pain and to obtain rescheduling of her MRI
cervical spine. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female recently diagnosed with infectious mononucleosis
presenting with fevers, abdominal pain and weakness. SPLEEN ULTRASOUND showed Spleen is mildly enlarged. The patient was diagnosed with Infectious mononucleosis, unspecified without complication. At the time of discharge, the patient had # acute EBV Mononucleosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with acute EBV presenting with fever and abdominal pain,
admitted for ongoing supportive care.
# Acute EBV "Mononucleosis"
Presented with fever, Abdominal Pain Sore throat and fatigue
with positive monospot and contact with roommate who recently
had mono. No concern for major complications such as splenic
rupture or airway compromise from tonsilitis. Noted to have
cholestatic hepatitis . Treated with supportive care including
IVF and antipyretics. Patients able to tolerate PO prior to
discharge.
# Abnormal LFTs:
Cholestatic hepatitis due to acute EBV infection. RUQ-US without
stones or biliary obstruction. No concern for acute liver
failure. LFTs elevated but stable at time of discharge.
> 30 mins spent in discharge planning. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with quadriplegia, DM2, non-healing R decubital ulcer
found to have osteomyelitis on CT ___ in context of rising
ESR/CRP, admitted for further workup. Nursing home contacted ID
here who recommended deep culture from pelvic bone, possible
debridement, flap closure by plastic surgery, prolonged
antibiotic(s). Patient reports that this ulcer has been an issue
for the past ___ years. Radiology showed Erosive changes centered at the right ischial tuberosity similar
to CT scan from one week prior concerning for osteomyelitis. The patient was diagnosed with AC OSTEOMYELITIS-PELVIS. The patient was treated with Bone Biopsy ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M with quadriplegia, cirrhosis, DM2, history of
osteomyelitis admitted with recent CT imaging indicating
possible acute on chronic osteomyelitis for planned bone biopsy
with further management to be coordinated with ID and plastic
surgery as an outpatient. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo F with history of DM2, hypothyroidism,
HTN, DVT LLE ___, IBD s/p distant colectomy, abscess ___
___ s/p repeat colectomy and small bowel resection at ___
___ bleed, PICC-associated DVT's and PE's who presented
for hypotension and hypoglycemia. CHEST (PORTABLE AP) showed Right lower lobe pneumonia. CT abdomen and pelvis without contrast showed 1. Right lower and middle lobe pneumonia.
2. Interval decompression of an abscess in the subcutaneous tissues of the
lower anterior abdominal wall, with no significant residual fluid.
3. Cholelithiasis, with no evidence of acute cholecystitis.
4. Trace pericardial effusion is slightly increased from prior.
5. Hypoattenuation of the blood pool relative to the myocardium is suggestive
of anemia. HIP 1 VIEW showed No fractures seen on this single AP view Radiology showed 1. No evidence of acute intra-abdominal or intrapelvic process.
2. No evidence of fluid collections, abscess or alternative source of
infection within the abdomen or pelvis.
3. Post partial colectomy with end colostomy and ___ pouch.
4. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings. CT CHEST W/CONTRAST showed -Pericardial effusion with enhancing pericardium. Possible pericarditis. No
evidence of cardiac tamponade. Further evaluation with echocardiogram is
recommended.
-Bibasilar atelectasis and pleural effusions, decreased from prior.
Persistent lymphovascular congestion of the right lower lobe.
-Right thyroid hypodensity measuring up to 2.5 cm. Dedicated ultrasound is
recommended on nonurgent basis.
-Left upper arm nodule. Clinical exam of this area is recommended.
RECOMMENDATION(S): Echocardiogram for pericardial effusion.
Right thyroid hypodensity measuring up to 2.5 cm. Dedicated ultrasound is
recommended on nonurgent basis.
Left upper arm nodule. Clinical exam of this area is recommended.
NOTIFICATION: The findings were discussed with BROWN, ___, M.D.
by ___, M.D. on the telephone on ___ at 4:08 pm, 20 minutes
after discovery of the findings. MRI of the Pelvis showed Exam is very limited and was terminated early. Only motion degraded T2
weighted images were obtained. Of note the bowel wall of the ___ pouch
is not appear to be grossly thickened or edematous The patient was diagnosed with Sepsis, unspecified organism, Non-ST elevation (NSTEMI) myocardial infarction, Acute kidney failure, unspecified. At the time of discharge, the patient had Primary
=======
Sepsis
Severe clostridium difficile colitis
Persistent leukocytosis
Sinus tachycardia
Sacral wound herpes simplex 2 infection
Diversion Colitis
Chronic malnutrition
Hypoglycemia
Demand ischemia
Acute kidney injury
Anemia
Secondary
=========
History of pulmonary embolism
Inflammatory bowel disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a very pleasant ___ yo woman with history of NIDDM,
DVT/PEs (on Coumadin), HTN, IBD (s/p distant colectomy c/b
abscess then repeat colectomy and small bowel resection
(___) w/ recent admission for purulent drainage from midline
incision c/b MSSA bacteremia who was admitted to ___ with
sepsis physiology, was initially treated for HAP and then
developed c diff and persistent leukocytosis. Over the course of
her hospital stay, the following issues were addressed:
# Goals of Care. Patient's healthcare proxy and nephew ___
___ expressed
concern that she Ms. ___ has been chronically ill for a long
time and had
reached a point where he was more concerned about her overall
well-being. Ms. ___ expressed being tired of hospitalizations
and invasive diagnostic testing/intervention multiple times
throughout hospital stay. Patient was followed by our palliative
care team and several goals of care discussions were initiated
___. ___ was connected with home hospice liaisons.
Eventually plan was decided to start Hospice at home, and
patient had MOLST filled out stating she was DNR/DNI.
# Sepsis. Hypotensive ___ ED to systolic ___, but fluid
responsive and never required pressor. CXR showed RLL pneumonia.
UA with pyuria, hematuria, and many bacteria though culture
showed polymicrobial growth. Denied respiratory symptoms and was
not hypoxic. Difficult to determine other symptomatology as she
said "I hurt all over." MRSA swab negative. Treated with
Vanc/zosyn and rapidly narrowed to vanc/cefepime (day ___.
Due to lack of symptoms and no improvement ___ leukocytosis with
initiation of abx and the fact that patient was discovered to be
C. Diff positive, the source of her leukocytosis was more
consistent with C. Diff colitis and vancomycin and cefepime were
stopped on ___ after 6 days of antibiotics. Transferred from
MICU to floor on ___.
#C. Diff Colitis. Stool tested positive for C. Diff. Stool
output was variable throughout stay and patient remained
afebrile and hemodynamically stable. However, significant
leukocytosis >15 and serum albumin <3 indicative of severe
disease. She was maintained on PO Vancomycin 125 mg Q6h (start
date ___ IV flagyl was added from ___ due to transient
decrease ___ stool output (with concern for developing ileus) and
persistent leukocytosis as below. Ceftriaxone was administered
___ to ___ and Vancomycin was extended until ___ to cover 7
days after all other antibiotics (start date ___ | projected
end date ___.
# Leukocytosis & intermittent monocytosis. Patient was noted to
have a persistent leukocytosis from ___ for entire length of
hospital stay as well as intermittent monocytosis (15% ___ and
16% ___. No improvement on treatment of c diff as above. UA
with 33 RBC's, 22 WBC's, yeast, but negative for bacteria and
nitrates. No coughing, SOB, fever, and CT does not not show
evidence of pulmonary infiltrate suggestive of pneumonia. No
change ___ collapsed abscess or new abscess formation on repeat
CT. Patient had purulent, beefy red sacral ulcers over back
entire hospital stay which eventually tested positive for HSV 2.
Leukocytosis began downtrending on administration of acyclovir
and rectal hydrocortisone below.
# Sacral Ulcers
# HSV 2. Patient presented with areas of macerated skin over
thighs and sacrum and developed further desquamation with areas
of ulceration on gluteals and posterior thights with exudate.
She was treated with ceftriaxone from ___ to ___ with some
improvement ___ leukocytosis. Eventually grew HSV 2 from wound
swab culture (confirmed with DFA). No discrete ulcers noted on
vaginal exam or vesicles noted over sacrum but certainly
possible that this is contributing to patient's leukocytosis and
even to her urinary retention (rare extravaginal complication).
Started acyclovir 200 mg five times per day for 10 days (start
___ | projected end date ___. She also grew pseudomonas from
these wounds but these were felt to be colonizers.
# Diversion Colitis. Patient with persistent leukocytosis and
oozing blood per rectum noted ___ concerning for diversion
colitis of ___ pouch vs IBD flare ___ rectal stumpy.
Flexible sigmoidoscopy of rectal remnant was attempted but
patient refused. Due to patient's underlying IBD, Hydrocortisone
Acetate 10% Foam ___ID was initiated (start ___. She
will need to be on this medication BID for 2 weeks, and then
every other day for 1 week and then twice a week for 2 weeks and
then stop.
# Bacterial PNA: Patient initially presented with tachycardia,
leukocytosis and hypotension. Found to have right lower and
middle lobe infiltrates on imaging and started empirically on
vancomycin and zosyn for suspected pneumonia, then transitioned
to vancomycin and cefepime(D1= ___. Patient had no respiratory
symptoms and no improvement ___ leukocytosis with initiation of
abx. GPC's ___ clusters on blood culture from ___ were likely
contaminants. MRSA swab negative. ___ light of this, and the fact
that patient was discovered to be C. Diff positive, the source
of her leukocytosis was more consistent with C. Diff colitis and
vancomycin and cefepime were stopped on ___.
# Bilateral knee pain and back pain. Chronic, secondary to
osteoarthritis. Significant cause of pain. Pain regimen was
titrated with aid of pain and palliative consult service. Final
regimen: Lidocaine 5% Patch 2 PTCH TD QAM Please apply 1 patch
to each knee, OxyCODONE (Immediate Release) 2.5 mg PO/NG TID,
Gabapentin 200 mg PO/NG BID, acetaminophen 1 g Q8H, OxyCODONE
(Immediate Release) 2.5 mg PO/NG Q4H:PRN BREAKTHROUGH PAIN.
# History of DVT/PE. Patient had initial LLE DVT at ___
___, placed on lovenox to warfarin bridge with goal INR of
___. Patient represented to ___ ___ with GIB during which
time warfarin and heparin were held. She subsequently developed
right UE PICC-associated DVT and later ___ that hospital stay had
CT angiogram of the chest performed and was found to have
multiple subsegmental PEs. She has thus been on coumadin for 4
continuous months, with all INRs ___ our system ___ the
therapeutic to supratherpeutic range. INR was reversed ___
but was labile and increased above ___ several times during
hospital stay despite administration of both PO and IV vitamin
K. She was first maintained on a heparin drip and then
transitioned to apixaban 2.5 mg BID (originally on 5 mg BID but
dose-reduced to 2.5 mg BID due to patient's weight and concern
for bleeding).
# Severe Malnutrition. Ms. ___ had poor PO intake throughout
hospital stay, with ongoing coagulopathy and poor wound healing.
She was given multivitamin with minerals and nutritional
supplements. Nutrition recommended supplementation with tube
feeds but patient refused placement of Dobhof tube. Zinc and
copper levels were within normal limits.
# Hypoglycemia. Per collateral from ___, FSBS ___ on
metformin and glipizide. Likely due to sepsis and glipizide.
Treated with IV D5W on day 1 and quickly dc'd with stable BS
throughout hospital course.
# ___. Creatinine 2.4 on admission from baseline 0.7. Likely
pre-renal/ATN from sepsis. Improved to baseline with IVF and
antibiotics.
# Type II NSTEMI. Troponin T elevated to 0.07 on admission, and
subsequently downtrended. No chest pain or ischemic EKG changes.
# Anemia: Hypoproliferative, normocytic anemia. Pattern of
down-trending Hgb following pRBC transfusions. Low Fe, low TIBC,
normal haptoglobin, increased ferritin, and decreased
transferrin portray anemia of chronic disease. Consistent with
hx of IBD and multiple bowel resections. Elevated D-dimer and
fibrinogen reassuring that patient was not ___ DIC. Has a hx of
UGI bleed ___ setting of previous supratherapeutic INR and
anastomosis. Less suspicious for current GI bleed given that she
has not had any episodes of hemoptysis, melena from ostomy site,
and is remaining normotensive. Hb was labile and patient
received a total of 4 units pRBCs ___ due to downdrifting
Hb below 7. Only clinical sign of bleeding was scant rectal
bleeding from rectal pouch as described above.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of alcohol use disorder and recent left knee
(meniscal) and hand injury who presents with several weeks of
black stools and blood spotting after bowel movements without
blood in the stool itself. She has had worsening abdominal
distention for about 2 months. She endorses some abdominal pain
after eating. She denies fevers, shortness of breath, chest
pain,
dizziness, headaches, changes to urinary function. She has
20-pack-year history and currently still smokes half pack per
day. She previously drank 30 alcoholic drink per week, her last
drink was 2 weeks ago. She denies any illicit drug use. Radiology showed No acute cardiopulmonary process. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. CT ABD AND PELVIS W/O CONTRAST ___ showed 1. Moderate to large ascites.
2. Fatty liver with features suggesting cirrhosis; overall findings are most
consistent with acute on chronic liver disease.
3. Nonspecific moderate gastric distension.
4. Cholelithiasis.
5. Findings consistent with chronic pancreatitis.
6. No hydronephrosis. Neither renal cortex appears thinned. RENAL U.S. showed No hydronephrosis or obstructing stones demonstrated.
Free-fluid in the pelvis as seen on recent abdominal ultrasound. CT CHEST W/O CONTRAST Q411 showed 1. Small right-sided pleural effusion with the basilar opacities that may be
due to atelectasis in conjunction with mild asymmetric pulmonary edema.
Presence of pneumonia is possible, however.
2. Asymmetric calcification along the vocal cord, possibly post inflammatory.
Correlation with direct inspection is recommended in followup.
3. Small right middle lobe nodule measuring 5 mm. If there are risk factors
such as smoking, occupational exposure or family history of pulmonary
malignancy, then followup chest CT might be considered in one year.
Abdomen is reported separately. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with moderate volume ascites.
2. Patent portal vein with to and fro flow.
3. Unremarkable gall bladder. CHEST (PA AND LAT) showed No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia. The patient was diagnosed with Alcoholic cirrhosis of liver with ascites. The patient was treated with ___ - EGD
___ - Diagnostic/therapeutic paracentesis, 2L
___ - Diagnostic/therapeutic paracentesis, 2L
___ - Diagnostic paracentesis
___ - Diagnostic/therapeutic paracentesis, 3L. At the time of discharge, the patient had Primary diagnosis:
-Alcoholic cirrhosis decompensated with ascites and esophageal
varices
-Acute kidney injury
Secondary diagnosis: alcohol use disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of alcohol use disorder p/w abdominal
distension and dark stools, found to have cirrhosis and moderate
volume ascites, with diagnostic/therapeutic paracentesis on
___, and ___ negative for SBP. Her hospital course
c/b initially worsening ___ c/f HRS vs sepsis vs volume
overload, and fever of unknown source s/p Zosyn (___).
Her Cr and urine output began to improve after a week of albumin
challenge, octreotide, and maximum dose midodrine.
TRANSITIONAL ISSUES
===================
[] Noted to have low grade temperatures during week of
discharge, most recently 100.2, no source of infection found
after multiple paracentesis and asymptomatic. Would continue to
monitor for true fever and evaluate if concern for infection
[] Evaluate abdominal ascites at next appt- may need
paracentesis
[] She is being discharged off diuretics due to recent profound
kidney injury, concerning for HRS now improved.
[] Will need outpatient GI ___ w/ hepatology after D/C within
one month
[] Will need PCP ___ after D/C in ___ wks
[] Has iron deficiency anemia, will need iron supplementation
[] Had duodenal polyp removed, will need follow-up upper
endoscopy in 6 months (___) for eval of adenoma removal and
foveolar metaplasia eval
[] Discharge creatinine 1.2
[] Discharge weight 141.8 lbs
[] Patient has not had routine healthcare screening and has had
limited access to healthcare prior to this hospitalization. It
will be very important for this patient to have all
age-appropriate routine screening (mammography, colonoscopy, pap
smear) so that she can be further considered for a liver
transplant in the future.
[] Patient needs hepatitis B immunization</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman w/ PMHx of SLE on
hydroxychloroquine, depression, hypothyroidism, who presents
with increased pain on the internal side of her right hip. MRI MSK PELVIS WANDW/O CONTRAST showed 1. Increased signal and size of the rectus femoris tendon at the attachment on
the anterior inferior iliac spine, consistent with tendinosis, with
surrounding soft tissue edema . When correlated to radiograph there is
suggestion of small soft tissue calcification in this area. Findings may
represent calcific tendinitis versus partial tear of the recurrent head
tendon. The straight head of the tendon appears intact, without tear.
2. Mild degenerative changes of the right hip joint. No evidence of fracture
or AVN.
3. Right iliac lymph nodes, that are borderline enlarged, of uncertain
etiology or significance. Clinical correlation is required. The patient was diagnosed with Pain in right hip. At the time of discharge, the patient had Hip Pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo woman w/ PMHx of SLE on
hydroxychloroquine, depression, hypothyroidism, who presents
with increased pain on the internal side of her right hip.
# Right hip pain: patient is on hydroxychloroquine and given her
SLE would question whether avascular necrosis or a septic
arthritis is possible. Patient has not had fever, CRP is wnl
making septic arthritis less likely. MRI showed ___ acute
abnormality and patient's pain was resolved. Recommend she
follow up with her PCP for further work up.
-cont colchicine for pseudogout in shoulder per rheumatologist
# SLE
- Continue hydroxychloroquine.
# Hypothyroidism
- Continue levothyroxine.
# Asthma
-patient reports taking advair only as needed, which seems
incorrect. On albuterol as well.
#GERD: cont home medications
[] Code: Full.
[] Dispo: pending results of MRI
[x] Discharge documentation reviewed, pt is stable for
discharge
[ ] >30 minutes was spent on day of discharge on coordination
of care and counseling
Electronically signed by ___, MD, pager ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx chronic pancreatitis, ESRD on HD, CAD, PVD, and diabetes
who presents with acute epigastric pain radiating to the back.
States that she went to dialysis yesterday and did fine,
afterwards ate a meatball sub and developed acute epigastric
pain afterwards. Characterizes this pain as exactly like her
previous abdominal pain admissions. The pain was associated with
nausea, vomiting and diarrhea, exactly like her previous episode
1 week prior. She has had multiple hospitalizations for
epigastric pain of unclear etiology.
.
RECENT COURSE:
___
Patient has had several admissions for abd pain. Presented on
___ with "normal" abdominal pain. She was treated with IV
dilaudid for pain and IV zofran for nausea and patient's pain
and nausea resolved following a brief stay with supportive care.
___
thrombosed LUE AV graft, s/p revision
___
LUE AV graft thrombectomy
___
AV graft occlusion s/p AV graft thrombectomy on ___
Abdominal pain after dialysis, treated symptomatically
.
In the ED, initial VS were 89 187/82 32 100%. She triggered for
RR 32 and her oxygen sat on room air was 88. Her pain was
typical of her pancreatitis flares and was reproducible on
palpation. She was given SL NTG x3, a full dose aspirin, zofran
and dilaudid.
.
Upon transfer to the floor, vitals were 98po 86 17 168/79 100%
3L nc Radiology showed No evidence of pneumonia. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, END STAGE RENAL DISEASE. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx ESRD on HD, CAD s/p MI, HIT, COPD and schizoaffective
disorder who presents approximately 1.5 weeks after discharge
with recurrent epigastric abdominal pain radiating to her back,
consistent with prior episodes of her chronic abdominal pain.
.
#Abd pain: pt states exactly like her previous episodes of
chronic abdominal pain thought to be chronic pancreatitis, which
were also a/w n/v/d like this episode. Lipase wnl. Has had
extensive w/u for this in the past including EGDs with biopsies.
EUS ___ showed some changes consistent with chronic
pancreatitis but not enough to declare a diagnosis. Treated per
her usual care for chronic pancreatitis with NPO, IVF and IV
pain medications. At the time of discharge, she was tolerating
PO well without pain or nausea/vomiting.
.
#hypoglycemia: unclear etiology for persistent hypoglycemia.
Per pt report, has had episodes of hypoglycemia at home over the
recent past as well. Not receiving insulin or other
hypoglycemic medications. Was found to have glucose of ~40 on
multiple occasions throughout her hospitalization while NPO.
Combination with new thrombocytopenia suggests possible liver
etiology, however this is unlikely in this woman who has minimal
risk factors for liver pathology with has normal LFTs. It is
possible that she has reduced glucagon secretion from her
chronic pancreatitis. Other etiologies include thyroid related
illness versus adrenal related versus insulinoma vs IGF-1
overproduction. During the admission, she also had some
hyponatremia that suggested possible adrenal cause but her
fasting AM cortisol was within normal limits. She had
c-peptide, insulin and beta-hydroxybutyrate levels drawn which
will be followed up as an outpatient. She has been scheduled to
see endocrinology as an outpatient for followup.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ F with h/o SLE, HTN, prior
cerebellar infarct and antiphospholipid syndrome with positive
anti-cardiolipin antibody on coumadin who presents with sudden
onset vertigo 3 days prior to presentation. The patient was at
home watching television when she suddenly felt dizzy. The
dizziness is described as feeling off balance and having a
sensation that she is spinning when she is not moving. The
dizziness has been persistent and unchanged since onset. She has
had some feelings of unsteadiness while walking, but has not
fallen and has not noticed that she falls to one side or the
other more frequently. Her INR is supratherapeutic today at 3.4.
She was noted to be orthostatic at an OSH and had worsening of
her symptoms with standing. Radiology showed No acute cardiopulmonary process. CTA HEAD AND CTA NECK showed 1. No acute intracranial process.
2. Allowing for anatomic variations, essentially unremarkable CTA of the head
and neck. MR HEAD W/O CONTRAST showed 1. No acute intracranial process. No acute infarct.
2. Single nonspecific FLAIR white matter hyperintensity of the right frontal
lobe, which may be seen the setting of chronic migraine or small vessel
ischemic disease. MR HEAD W AND W/O CONTRAST showed Ill-defined area of FLAIR signal abnormality in the right posterior
pontomedullary junction. The appearance is nonspecific but given the absence
of mass effect and the clinical history of lupus, it may be a vasculitic
lesion. It is not significantly changed in appearance from prior MRI four days
ago given differences in technique. Another small focus of FLAIR signal
abnormality in the right frontal subcortical white matter is also unchanged
and may be due to the same process. Follow-up imaging is suggested at an
interval to be determined based on the patient's clinical scenario. The patient was diagnosed with VERTIGO/DIZZINESS. At the time of discharge, the patient had Primary Diagnosis:
Secondary Diagnosis: lupus, +lupus anticoagulant antibodies,
+anti-cardiolipin antibodies. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F w PMHx SLE ___ years, +lupus anticoagulant and
+anti-cardiolipin antibody (on home coumadin), membranous GN
with vascular occlusion in ___ (seen on kidney biopsy), HTN,
and prior cerebellar infarct presents with sudden onset vertigo
beginning 3 days prior to presentation. Her exam is notable for
direction changing nystagmus evoked with lateral and superior
gaze. CTA preliminary read is without abnormality. MRI brain w/o
contrast: focus of FLAIR hyperintensity along the right medulla
extending to the facial colliculus, that could be compatible
with sequela of remote infarct. Pt discussed w outside
___, Dr. ___ recommended ___
Rheumatology consultation. ___ Rheumatology consult
recommended solumedrol 1g IV x3d. Pt reported signficant
improvement in subjective well being after steroid course. Her
neuro Repeat MRI Brain W/ and W/O contrast on ___ showed an
ill-defined area of FLAIR signal abnormality in the right
posterior pontomedullary junction. The appearance is nonspecific
but given the absence of mass effect and the clinical history of
lupus, it may be a vasculitic lesion. It is not significantly
changed in appearance from prior MRI four days ago given
differences in technique. It was considered less likely that
this lesion was a chronic ischemic infarct. Another small focus
of FLAIR signal abnormality in the right frontal subcortical
white matter is also unchanged and may be a
vasculitic/demyelinating lesion secondary to lupus. She should
follow up with her outpatient Rheumatolgist Dr. ___
determination of the appropriate long term therapy for her
lupus. As pt had significant clinical improvement in the inteval
between her MRI studies, decision was made to discharge with
suggested imaging follow up (MRI brain with and without
contrast) at one month, but will defer to her outpatient
neurologist Dr. ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ history of poorly controlled diabetes, HTN, and
HLD presents to the emergency room for evaluation of fever
chills
and general malaise. Patient states that he had periumbilical
abdominal pain for one day approximately one week ago that then
resolved without any treatment. Then over the course of the
week
he was unable to leave his house and could barely leave his bed
to go to the bathroom. Has not showered ___ over 1 wk. He was
feeling very lightheaded when he stood up and also c/o fever and
chills. He suspected food poisoning, but had not traveled
anywhere recently or eaten anything suspect. He was not having
any vomiting. He did have loose BMs, but only 1-2/day. They
were
not bloody or acholic. FSBS ___ 460s at the outside hospital
where
a CT showed e/o acute cholecystitis with possible underlying
mass. RUQ US was suspicious for a perforated gallbladder. He
also had an incidental finding of a lung nodule, and this had
been seen on a prior CXR. He was found to have transaminitis
and
elevated alk phos. The surgery team at the OSH felt he was too
complex and recommended transfer to a tertiary care center. wbc
16.9, creatine 2.1 at OSH. Known to have elevated cr/CKD at
baseline. MRCP showed 1. Hepatic abscess in direct continuity with a perforated gallbladder, as
described above. No definite mass is identified. Follow-up after treatment
is recommended to exclude a subtle underlying lesion which may be obscured by
the surrounding inflammatory changes.
2. Bland thrombus within the peripheral aspect of the middle hepatic vein
which courses through the inflamed region.
3. Choledocholithiasis with a 5 mm stone at the ampulla and several smaller
stones upstream. There is associated mild intra and extrahepatic biliary duct
dilation.
4. Borderline splenomegaly.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:59 AM, 25 minutes
after discovery of the findings. Ultrasound-guided hepatic collection drainage showed Successful US-guided placement of ___ pigtail catheter into the
collection. Samples was sent for microbiology evaluation.
RECOMMENDATION(S): Short-term follow-up ultrasound in 48-72 hr is recommended
to reassess the status of the gallbladder and the hepatic collection and to
ensure that both entities are being adequately drained. The patient was diagnosed with Perforation of gallbladder. The patient was treated with ___ ___ placement of 8 ___ drain into hepatic abscess. At the time of discharge, the patient had Hepatic abscess/perforated gallbladder
cholelithiasis
DM, uncontrolled
Lung Nodules. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ M with one month h/o RUQ pain, fevers, found to have right
lobe abscess adjacent to the gallbladder. He was pan-cultured
and started on IV antibiotics then underwent ___ drainage on
___. Ultrasound demonstrated an enlarged, distended gallbladder
with complex echogenic internal material, ___ addition to a 6.5 x
6.0 cm hepatic collection adjacent to the gallbladder fossa.
There was visible disruption ___ the gallbladder wall measuring
up to 2.2 cm. The findings were highly
suggestive of perforated cholecystitis with associated liver
abscess. An 8 ___ drain was placed into the collection that
appeared purulent and a sample sent to microbiology. Micro
isolated no pmns, 2+GPC, 2+GNR, 1+GPR and sparse growth GPC. IV
Unasyn continued pending finalization of abscess culture. An MRI
was done to assess whether abscess represented a perforated
cholecystitis or an underlying tumor. MRI was done on ___ that
demonstrated the following:
1. Hepatic abscess ___ direct continuity with a perforated
gallbladder, as
described above. No definite mass is identified. Follow-up
after treatment
is recommended to exclude a subtle underlying lesion which may
be obscured by
the surrounding inflammatory changes.
2. Bland thrombus within the peripheral aspect of the middle
hepatic vein
which courses through the inflamed region.
3. Choledocholithiasis with a 5 mm stone at the ampulla and
several smaller
stones upstream. There is associated mild intra and
extrahepatic biliary duct
dilation.
4. Borderline splenomegaly
Tumor markers were sent off. CEA was elevated at 5.0 and AFP was
0.6. CA ___ was 27.
Upon learing MRI findings, ERCP was consulted and on ___, he
underwent ERCP with the following note:
note of small filling defects ___ the lower bile duct suggestive
of sludge/stone. There was mild diffuse biliary dilation,
including mild saccular dilation of the lower CBD. The cystic
duct was filled with contrast, and the intrahepatics were
well-visualized and only mildly dilated. A sphincterotomy was
performed and a moderate amount of sludge was extracted.
Completion cholangiogram was normal. Otherwise normal ERCP to
___ portion of duodenum.
Post ERCP, he received IV fluid hydration. Labs were improved
and diet was resumed and tolerated.
He was hyperglycemic. Sliding scale insulin was used to control
his glucoses. HgA1c was elevated at 8.2. A ___ consult was
obtained and insulin was adjusted with improved control. At time
of discharge to home, home meds (actos/glipizide)were resumed.
He was instructed to hold his Januvia for a week and f/u with
his PCP for DM management. A Humalog sliding scale was
recommended for home. The ___ DM educator reviewed glucometer
teaching and injection with an insulin pen. He was provided with
scripts for Humalog pen with pen needles, strips, lancets.
A time of discharge, antibiotics were switched to Augmentin for
2 weeks from drain placement. Drain output was averaging 570cc.
___ was arranged to see him at home to assess management.
Of note, he will see Dr. ___ consult)for
evaluation of pulmonary nodules that were noted on OSH CT scan
uploaded on ___ imaging(1.3cm nodule ___ the right apex with
small peripheral calcification and adjacent scarlike opacity,
7.5mm supleural nodule ___ the right lung base, 5mm subpleural
nodule ___ the right middle lobe and 5mm subpleural nodule ___ the
left upper lobe posteriorly). </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ otherwise healthy presents from ___ for brain mass.
He began having a gradually worsening frontal, throbbing
headache
last night. This morning he began having nausea and vomiting. He
went to ___ where he was given Reglan and Morphine and MRI
showed a 1.4cm x 1.7cm sella mass. His headache and nausea are
currently improved. No vision changes, weakness, numbness. Radiology showed 1. No evidence of mass.
2. Mild cardiomegaly. MR ___ ___ CONTRAST showed A 1.7x2.4x1.7cm heterogeneous lesion in the sella with cystic/ necrotic and
solid components, extending into the suprasellar region as described above
with indentation on the optic chiasm and compression/ encasement of the
infundibulum and possible minimal extension into the cavernous sinuses.
DDx incudes macroadenoma, craniopharyngioma, etc.
Other details as above CTA HEAD WANDW/O C AND RECONS showed 1. Lesion in the pituitary gland, extending into the suprasellar location,
better assessed on the recent MRI pituitary study. Please see details on that
report.
2. Patent major intra cranial and upper cervical arteries as described above.
3. Cavernous carotid segments and the right ICA para clinoid segment in
proximity to the sellar lesion without encasement or narrowing.
4. Mild thinning of the dorsum sella. CT HEAD W/O CONTRAST showed Unchanged pituitary lesion extending into the suprasellar area, better
assessed on recent MRI pituitary. No acute intracranial process. The patient was diagnosed with BRAIN CONDITION NOS. At the time of discharge, the patient had Pituitary macroadenoma
Pituitary Appoplexy
Hypokalemia
Hyponatremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was seen and evalauted in the emergency department as a
transfer from an outside hospital on the evening of ___.
Iamging had revealed a sellar lesion. Workup was initiated to
assess if tumor was causing abnormal secretion of hormones and a
dedicated Pituitary MRI was obtained. On ___, the patient
remained neurologically stable and waiting for the MRI of the
brain. On ___, the patient's MRI of the brain was completed
confirmed a pituitary macroadenoma. The endocraine service was
consulted to follow along for the suprasellar mass. Prolactin
was normal. Dr ___ met with the patient and his wife on
___ to discuss surgical options. The plan was made for the
patient to return the following week for surgery. Pre-op testing
and mapping would be done during this admission and the patient
will dc home ___.
On ___, patient reported an episode of LOC while in the
bathroom and came to on the floor with a small laceration to his
left cheek. Patient was evaluated and was neurologically intact.
A STAT CT head was performed and showed more blood within the
lesion. Dr ___ was made aware, the patient was transferred
to the SDU. Given no deficits he will continue to be monitored
and DC was cancelled. An EKG showed no changes and labs were
sent. His K was mildly low and repleted. His NA is trending up
compared to 129. The midlevel spoke to his wife to update her.
___, the patient was discharged home in stable condition with
instructions to return for visual field testing and a planned
resection. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo male who presents w/ 1-day history of
abdominal pain severe enough to prevent sleeping. It began as a
periumbilical pain around ___ p.m. Pt denies migration of the
pain overnight. Claims it felt like stomach cramps different
from
the pain he associated w/ his previous cholecystitis and GERD.
Endorses intermittent vomiting throughout the night, along w/
loose stools. Pt denies recent fevers or chills, though
developed
sweats during the night. The pain is mild ___ ___ut
movement causes moderate pain and palpation severe pain. Pt has
only had scattered sips since ___ p.m. CT ABD AND PELVIS WITH CONTRAST showed Acute appendicitis, with the tip of the appendix dilated to 1.4-cm and
periappendiceal stranding. No evidence of an adjacent abscess or rupture. The patient was diagnosed with ACUTE APPENDICITIS NOS. The patient was treated with ___: laparoscopic appendectomy. At the time of discharge, the patient had laparoscopic appendectomy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the hospital with right lower
quadrant abdominal pain and an elevated white blood cell count.
He was made NPO, given intravenous fluids, and underwent
imaging. A cat scan of the abdomen showed acute appendicitis.
Based on these findings, the patient was taken to the operating
room on HD #1 where he underwent a laparoscopic appendectomy.
The operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room. His post-operative course was stable. He was
started on a regular diet. His incisional pain was controlled
with oral analgesia. He was voiding without difficulty. On the
operative day, the patient was discharged home in stable
condition. An appointment for follow-up was made with the acute
care service. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx diastolic CHF, dementia, who presents to the ED
after a unwitnessed fall. Pt is ___ speaking only. History
was obtained with help of her daughter.
Pt was found down at 2pm on ___ at home by her helper. Pt was
conscious when found. She stated that she felt dizzy prior to
the fall. It is unclear whether pt lost consciousness during the
event, and pt could not recall chest pain or any prodromal
symptoms.
Of note, this is the ___ fall in the past month for Ms.
___. She had a fall a couple weeks ago, and crawled on the
floor for an extended period of time, resulting in multiple
bruises over her legs. Pt received 10 days amoxicillin and
doxycycline, that were finished about one week ago. Per family,
pt denies F/C, CP, SOB, cough, appetite, N/V/D, dysuria. Pt has
good appetite, and her last BM was yesterday, unclear form or
color. family reported that pt gained 12 lbs in the past month.
At baseline, pt needs help with ADL. She lives along with helper
visiting daily.
In the ED, initial VS was 98 83 118/53 20 98%. Hip X-ray showed
small nondisplaced ramus fracture. CXR showed possible increased
opacity in RLL. CT head could not be completed as pt was not
cooperative. Labs were not available at the time of transfer
because of access issues. Pt was given 1 gram Vancomycin for
cellulitis.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed Possible nondisplaced fracture of the left superior pubic ramus. Radiology showed Moderate size right and small left pleural effusions. Worsening opacification
in the right lung base could reflect compressive atelectasis though infection
is difficult to exclude. Retrocardiac atelectasis. The patient was diagnosed with CELLULITIS OF LEG. At the time of discharge, the patient had s/p fall
anemia
___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMHx diastolic CHF, hemolytic anemia, who presents to
the ED after a unwitnessed fall, found to have hemolytic anemia.
# ___: Pt presented with Cr. 1.6 from baseline of 0.7-1. FeUrea
16%, peaked at 2.1, now 1.4. Initially thought ___ anemia and
hypovolemia from increased lasix, however pt appeared volume
overloaded and creatinine worsened with IVF and holding
diuretics. Renal spun urine and saw some yeast and acanthocytes,
wanted to consult, however repeat spin showed only one
acanthocyte, per renal no e/o vasculitis. The pt was restarted
on her home lasix 60mg PO BID and her cr downtrended. On day of
discharge cr was 1.4.
# Weakness: Likely multifactorial, due to deconditioning,
anemia, accidentally doubling her medications at home. Anemia
managed as stated below. ___ worked with pt and felt she would
benefit from rehab. Of note, TSH was elevated at 7 and free T4
0.91. PCP was notified and will follow-up as an outpt.
# Paroxysmal Afib: Pt with baseline sinus rhythm, found to have
afib with RVR for several hours. The pt was started on metop
12.5mg BID with good rate controle, however subsequent reverted
to sinus braycardia. Metoprolol was dced and the pt remained in
normal sinus. Given pt was asymptomatic with afib with rvr,
unclear if this was an isolated event or if she has ongoing
paroxysmal afib. Given the pt's CHADS2 score of 2,
anticoagulation was consider, but felt to be contraindicated in
the setting of her frequent falls. High dose aspirin was also
considered, however pt also with hx of esophageal ulcerations
and ongoing issues with anemia. Pt was continued on aspirin 81mg
daily.
# Anemia: The pt presented with a macrocytic anemia with HCT 23
from baseline of ___, down to 20. The pt has an extensive hx
of hemolytic anemia, and was found to have LDH elevated, hapto
<5, +DAT. GUAIAC negative. She was very difficult to crossmatch
but received 2u prbc with bump to 28. Hemonc was consulted, and
felt she should f/u as an outpatient given her hcts stabilized.
Vitamin B12 greater than assay, folate wnl, however folate 1g
daily started per hem recs.
# s/p fall: Per pt history, likely mechanical, and ___ weakness
from extra medication and anemia. Management of anemia as above.
___ recommended rehab.
# Possible nondisplaced fracture of the left superior pubic
ramus. Pt comfortable, able to ambulate, full ROM. ___ as above.
Should continue lovenox 30mg q24h for DVT ppx while in rehab.
# Funguria: Presented with significant pyuria. Ucx ___. Pt
treated with diflucan 150mg PO x1 per renal recs.
# Heel pain: On day of discharge pt complained of worsening R
heel pain, which, per grandson, has been ongoing for a few
months. Pt has spent a lot of time in bed, and heels appear
slightly cracked and tender, likely applying more pressure than
at baseline. Wound care recs below. Tramadol prn pain. If pain
worsens, can consider outpt eval by podiatry or xray foot.
# Diastolic heart failure: continued home meds. Losartan was
held due to decreased creatinine clearance. Should be restarted
as pt renal function improves, as tolerated by BPs.
# BLE traumatic ulcerations: chronic from crawling on the floor
after prior fall. Wound care evaluated, recs below.
# Asthma: continued home meds
# Hypothyroidism: continued home meds. Of note, TSH was elevated
at 7 and free T4 0.91. PCP was notified and will follow-up as an
outpt.
# HLD: continued home meds </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with h/o Etoh cirrhosis c/b esophageal
varices s/p banding and ascites who p/w abdominal pain c/w
previous flares of chronic pancreatitis, as well as hematemesis.
He was admitted most recently for acute-on-chronic pancreatitis
from ___, during which time he received IVF and pain
control and was tolerating POs by the time of discharge. He
reports that he was in his USOH until the day PTA, when he
developed constant, throbbing epigastric pain, ___ in
intensity, radiating to the back, and entirely c/w past acute
exacerbations of his chronic pancreatitis. Unlike in the setting
of prior exacerbations, however, he experienced hematemesis x1,
filling ___ cups, on the day of admission; it is not clear as to
whether he was coughing or retching prior to vomiting. He
emphasizes that he has had no recurrent hematemesis since the
time of his variceal bleeds in ___. He endorses heavy EtOH
use (1 pint ___ daily) since discharge, as well as
chills over the same period. He denies subjective fevers,
lightheadedness, CP, diarrhea/constipation, or melena/BRBPR,
though he does note that his stools were guiac-positive in the
ED. Radiology showed No acute findings, specifically no free air below the diaphragm. The patient was diagnosed with ALCOHOL ABUSE-UNSPEC, ABDOMINAL PAIN GENERALIZED, NAUSEA WITH VOMITING, ACUTE PANCREATITIS. The patient was treated with Esophagogastroduodenoscopy. At the time of discharge, the patient had Acute-on-chronic pancreatitis
Esophagitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with h/o Etoh cirrhosis c/b esophageal
varices s/p banding and ascites who p/w abdominal pain c/w
previous flares of chronic pancreatitis, as well as hematemesis.
#Hematemesis: Patient with known h/o esophageal varices s/p
banding p/w single episode of hematemesis without active signs
of bleeding or HD instability on admission. EGD ___ demonstrated
severe esophagitis, nonbleeding grade 1 varices, lesions c/w
___, and mild portal gastropathy, for which he was treated
with IV pantoprazole, transitioned to PO at discharge. He
remained HD stable throughout admission without recurrent
hematemesis. From 40.4 on admission, Hct remained stable at
34-35, with initial decline likely at least partially
dilutional.
#Abdominal pain: Patient with known h/o chronic EtOH
pancreatitis p/w epigastric pain radiating to the back, entirely
c/w past episodes of acute-on-chronic pancreatitis. Abdominal
exam was notable for epigastric TTP without peritoneal signs.
LFTs were at baseline, and lipase was within normal limits on
admission. There was no e/o free air on CXR. He was treated
initially with IV Dilaudid, with transition to PO Dilaudid once
tolerating clears. He was tolerating solids by the time of
discharge.
#EtOH dependence: Patient continues to drink heavily despite
explicit knowledge that his EtOH use leads to recurrent
admissions. He remained HD stable without signs of withdrawal or
benzodiazepine requirement throughout admission.
#EtOH cirrhosis: Patient with known h/o EtOH cirrhosis c/b
varices and ascites in the past. There was no e/o
encephalopathy, ascites, or asterixis on admission, and LFTS,
platelets, and INR were c/w baseline. Home nadolol was
continued.
#Bipolar disorder: Patient with known h/o bipolar disorder
without manic or depressive symptoms or SI/HI on admission. He
reported taking Seroquel, trazodone, and an antidepressant,
identity unknown to him, in the past, but also indicated that he
had not been seen by a psychiatrist for some time. Psychiatric
medications were held on the last admission concluding ___,
given reports that his psychiatrist had discontinued his
medications due to drug-seeking behavior, and continued to be
held on the current admission.
#Transitional issues:
- Patient will need GI follow-up for esophagitis, discharged on
pantoprazole, and EtOH cirrhosis, continued on nadolol. It was
unclear as to whether he had been seeing a GI provider at an
outside location, given his h/o visiting multiple providers and
hospitals with similar complaints.
- Patient readily acknowledged heavy EtOH use and received some
counseling from medical team, but was not amenable to further
discussion on this admission, noting that he had taken part
in/continues to take part in programs without success. He should
continue to be encouraged to seek counseling, detoxification,
and will be discharged to ___ House.
- Patient's current psychiatric medication regimen was not
clear, and he will need psychiatric follow-up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old female with metastatic rectal
adenocarcinoma on FOLFOX therapy C2D17 (last dose ___ c/b
bowel obstruction resulting in sigmoid diverting colostomy
___, Hx L tibia osteosarcoma (s/p ___
resection/reconstruction and ___ wide excision of recurrence),
and sickle cell disease (c/b splenic infarction, acute chest
syndrome, pulm infarction, AVN), who presented from ___
clinic on ___ with URI symptoms, course complicated by
unresponsiveness and possible cardiac arrest caused by Zosyn
infusion, now called out from ___ for further management of URI
and post-anyphylactoid reaction care. Chest: Frontal and lateral views showed Possible mild interstitial pulmonary edema; more confluent area in the right
mid lung may relate to vascular congestion, but a small focus of infection is
difficult to exclude. CHEST (PORTABLE AP) showed Mild pulmonary edema and central vascular congestion is grossly unchanged as
compared to most recent chest radiograph. CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormality.
2. There is opacification of multiple paranasal sinuses. Clinical correlation
for sinusitis is recommended. CHEST (PORTABLE AP) showed Right Port-A-Cath catheter tip is at the level of lower SVC. Heart size and
mediastinum are stable. Lungs overall clear. There is no appreciable pleural
effusion. There is no pneumothorax. The patient was diagnosed with Fever, unspecified, Tachycardia, unspecified. The patient was treated with Cardiopulmonary resuscitation. At the time of discharge, the patient had Primary Diagnoses:
Upper respiratory tract infection
Metastatic rectal carcinoma
Anemia
Thrombocytopenia
Secondary Diagnoses:
Sickle cell disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY
=========
___ is a ___ year-old female with metastatic rectal
adenocarcinoma on FOLFOX therapy C2D18 (last dose ___ c/b
bowel obstruction resulting in diverting colostomy, Hx L tibia
osteosarcoma (s/p ___ resection/reconstruction and ___ wide
excision of recurrence), and sickle cell disease (c/b splenic
infarction, acute chest syndrome, pulm infarction, AVN), who
presented from ___ clinic on ___ with URI symptoms,
course complicated by unresponsiveness and pulselessness caused
by Zosyn infusion, now called out from ___ for further
management of URI and post-anyphylactoid reaction care.
ACUTE ISSUES
============
# Unresponsiveness
# Cardiac arrest
She became unresponsive, apneic, and rigid and her pulse could
not be detected after brief administration of zosyn. ROSC was
obtained after 2 minutes CPR and epi 1 mg x1. Unknown rhythm
before/during this episode, reportedly sinus tach (140s-150s)
following ROSC. Ddx for this episode includes anaphylactoid
reaction to Zosyn causing hypotension/syncope, and vasovagal
reaction. Bedside TTE in ED without RHC to suggest PE or other
obvious abnormalities. Seizure was felt to be unlikely as she
had no post-ictal period. Formal TTE unremarkable except for
mild MR. ___ was monitored in the ICU following this episode and
lidocaine 5% patch was applied to chest for sternal pain. She
was subsequently called out to the floor for further monitoring.
She was monitored on telemetry and electrolytes were monitored
and repleted as needed. Pain was controlled with IV and PO
dilaudid and Tylenol.
# Anemia
# Thrombocytopenia - improving
Cell count derangements were noted in the setting of malignancy
(currently C2D19 on FOLFOX) and probable sequestration. The
patient's Hgb was noted to be 7.1, and she was given 1 u pRBCs
with appropriate response. Her platelets were noted to be 29
following cardiac arrest episode, an abrupt decrease from plts
404 noted 8 hours prior, raising concern for epinephrine
mediated thrombocytopenia. However her platelet count up trended
and she had no signs of bleeding during the hospitalization.
Concern for immune mediated destruction process given patient's
reaction to zosyn and marked acute thrombocytopenia and worsened
anemia. Hemolysis labs remarkable for low hapto, high LDH, high
indirect bili c/w hemolytic process. She was monitored with a
daily CBC and active T&S was maintained. When her platelets rose
above 50, she was anticoagulated with subcutaneous heparin for
DVT prophylaxis.
# URI
# Leukocytosis
Patient presented from ___ clinic with 2 weeks of fatigue,
pharyngitis, rhinorrhea, productive cough, and myalgias c/w
viral vs. bacterial URI, in setting of immunocompromised state.
CXR reassuring but cannot r/o small focus of consolidation. No
s/s acute chest syndrome. Flu negative. Blood and urine cultures
were drawn, and a respiratory viral screen was obtained.
Leukocytosis downtrended. Following admission to ICU, cefepime
and azithromycin were started, which was switched to
levofloxacin following transfer to medicine floor. She was given
IV fluids as needed during the hospitalization. Her symptoms
improved during the admission. She was instructed to complete a
7 day course of levofloxacin for community acquired URI
(___).
# Metastatic rectal carcinoma
Diagnosed in ___. Complicated by large bowel obstruction
resulting in sigmoid diverting colostomy. Currently undergoing
treatment with FOLFOX C1D1 ___. Last treatment ___.
# Hypophosphatemia
# Hypomagnesemia
Electrolytes were monitored with a daily CMP and electrolyte
sliding scales and phos repletion were used as needed.
# Sickle cell disease
Previously complicated by splenic infarction, acute chest
syndrome, pulmonary infarction, AVN. Not currently on
hydroxyurea secondary to thrombocytopenia expected from
chemotherapy. During this admission she had hip pain consistent
with her pain crises. Anemia and thrombocytopenia were treated
as above. Her home folic acid was continued. Her pain was
controlled with IV Dilaudid and Tylenol, which was converted to
a PO Dilaudid regimen prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ w/ stage IA breast cancer and
stage IIIB lung adenocarcinoma diagnosed in ___,
with CNS metastasis confirmed by biopsy, s/p WBRT now on
protocol
___ ___ w/ alectinib 600 mg BID, who p/w nausea, abdominal
pain, and increased weakness and dizziness on standing. Several
days ago while in the shower she felt faint and fell onto her
right shoulder but no head trauma nor LOC. CT CHEST W/CONTRAST showed Substantial decrease in size of pre-existing, previously enlarged mediastinal
lymph nodes.
Near complete resolution of a nodular component of scarring in the left lower
lobe.
No new or growing nodules or lymph nodes.
The pre-existing bilateral lower lobe emboli are no longer visible.
Unchanged areas of parenchymal scarring, notably in the right upper lobe. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, MAL NEO BRONCH/LUNG NOS. At the time of discharge, the patient had Primary diagnosis: orthostasis
Secondary diagnosis: nausea, vomiting, lung cancer,
constipation, dysuria/increased urinary frequency, vaginal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a pleasant ___ w/ stage IA breast cancer and
stage IIIB lung adenocarcinoma diagnosed in ___,
with CNS metastasis s/p resection and VP shunt placement, s/p
WBRT and crizotinib, now on protocol ___ ___ w/ alectinib
600 mg BID who presented with nausea, vomiting, and orthostasis.
# Orthostasis: likely ___ dehydration in the setting of
significant nausea and poor PO intake. TSH checked in ___ was
wnl and B12 was wnl. Adrenal insufficiency was on the
differential however cortisol/cosyntropin stimulation test was
wnl. Patient received IV hydration and her symptoms improved.
# Nausea/vomiting: etiology was unclear but was initially
attributed to her study drug. During her last admission she had
an extensive workup which consisted of an MRI brain and EGD.
Patient was recently on a steroid taper (which she completed at
home) however states that steroids made her symptoms worse and
therefore steroids were not continued during this
hospitalization. A CT abdomen/pelvis was performed and did not
show an acute process that would explain her symptoms. Her neuro
exam was non-focal and she did not complain of symptoms
suggestive of elevated ICP. Neurosurgery was contacted to
discuss her case and they felt a VP shunt series was not
necessary at this time. Neuro-Oncology was consulted and they
felt that patient may benefit from a LP as an out patient to
evaluate for leptomeningeal carcinomatosis as well as
paraneoplastic syndromes. Patient did not want LP in house as
she was feeling better upon day of discharge. Patient may follow
up with Neurology as an out patient to obtain LP if desired.
# Dysuria/increased frequency: UA negative for infection, Urine
culture ___ negative, chronic. ? interstitial cystitis vs.
autonomic dysregulation. Patient will follow up with uro-gyn as
an out patient.
# Vaginal pain, likely ___ pain as patient does not
have abnormal vaginal discharge or other symptoms/signs
suggestive of infection
-ibuprofen PRN
-phenazopyridine 100mg tid
-pelvic exam as out patient
# h/o PE: continued home lovenox ___ mg daily</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year-old with a PMH significant hypertension,
hyperlipidemia, depression and anxiety, GERD, degenerative joint
disease and congenital hip dislocation who was recently admitted
on ___ with altered sensorium found to have high grade MSSA
bacteremia with a left thigh abscess, right iliacus and SI joint
abscess, epidural abscess and aortic valve endocarditis who
underwent multiple joint washouts and drainage procedures and
discharged on a prolonged course of IV cefazolin who now
re-presents with persistent left hip pain.
The patient was discharged to a rehabilitation facility on
___ on longterm IV cefazolin given her recent high grade MSSA
bacteremia with seeded joints. While at rehab, she denies
participation in physical therapy secondary to pain. She has
been taking Oxycontin and Dilaudid for breakthrough without
significant relief. She denies recent fevers or chills.
She notes that over the last several days she has participated
in increasing occupational and physical therapy exercises with
worsening pain that is not relieved by her oral narcotics. The
pain has now exceeded her mobility limits and occurs at rest;
she reports a ___ pain on admission. She says that she has
only been able to transfer to the commode and get to the edge of
the bed and that causes significant pain. Even touching the
overlying skin is painful for her. She denies erythema, warmth
or overling skin changes around her incision. She denies fevers,
chills or nightsweats. Of note, she was recently seen in ___
clinic on ___ and was continued on Cefazolin with the
addition of Rifampin. Interestinlgy, her inflammatory markers
were recently checked and were markedly elevated.
In the ED initial VS, 98.8 91 158/92 18 100% RA. Labs notable
for WBC 4.4, HCT 25.6%, PLT 337. INR 2.7. Creatinine 0.5.
Potassium 3.1. She had a pelvic CT while in the ED. She received
IV Dilaudid and Lorazepam 2 mg IV while in the ED.
On arrival to the floor, she is complaining of left hip pain. Radiology showed Rim enhancing fluid collection within the left thigh and hip is
smaller than ___ and may represent postsurgical seroma, although an
underlying infection is not excluded. Collapsed residua of previous fluid
collection within the right iliacus muscle following drainage. Radiology showed 1. Successful ultrasound-guided aspiration of fluid collection within the
left hip joint pocket. 45 mL of serosanguineous/cloudy fluid was aspirated
and sent to the lab for microbiology and fluid analysis.
2. Moderate-to-large fluid collection within the left hip joint space may
represent postsurgical seroma and/or abscess. Followup with pathology is
recommended.
Dr. ___, the attending radiologist, was present and supervised
the entire procedure. The patient was diagnosed with JOINT PAIN-PELVIS. The patient was treated with Joint fluid aspiration. At the time of discharge, the patient had PRIMARY DIAGNOSIS
1. Hip pain
Secondary Diagnosis:
1. hx of MSSA bacteremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a PMH significant for hypertension, hyperlipidemia,
depression and anxiety, GERD, degenerative joint disease and
congenital hip dislocation who was recently admitted on ___
with altered sensorium found to have high grade MSSA bacteremia
with a left thigh abscess, right iliacus and SI joint abscess,
epidural abscess and aortic valve endocarditis who underwent
multiple joint washouts and drainage procedures and discharged
on a prolonged course of IV cefazolin who now re-presents with
persistent left hip pain. Her pain is much better controlled
today.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with a history of rectal and
prostate cancer, status post end ileostomy ___, who presented
with fever, bloody output from his ostomy, and gas. In the ED,
he
was initially febrile to 101.1 and tachycardic to 120 with BP
119/52 and nonfocal exam. He was subsequently found to be
hypotensive to 81/41, HR 110 temperature of 101.8. He received
2L
IVF fluid, cipro, flagyl, vanc. His blood pressures improved
though he was found to be anemic and thrombocytopenic. Heme was
consulted and he received 1 unit PRBCs and 2 units of platelets.
A CT abdomen/pelvis was obtained to evaluate for source of
sepsis
and found a 6mm obstructing stone in the mid distal ureter with
moderate to severe left hydroureteronephrosis. Urology, ___, and
colorectal surgery were consulted, ___ placed a perc nephrostomy
tube and urology will follow. CT ABD AND PELVIS W/O CONTRAST showed 1. 6 mm obstructing stone in the mid distal ureter with moderate-to-severe
left hydroureteronephrosis. A second 9 mm nonobstructing stone in lower pole
of the left kidney is also noted. Slightly higher density material layering
dependently in the lower pole renal calices and upper ureter suggesting
underlying complexity within the urine potentially due to infection, less
likely hemorrhage.
2. Known hepatic metastases are better evaluated on recent CT abdomen and
pelvis with contrast on ___.
3. Redemonstration of gastrohepatic lymphadenopathy, rectal mass, and
sclerotic metastases within the lumbar spine.
4. Cholelithiasis, without evidence of acute cholecystitis.
5. Splenomegaly. Radiology showed No definite acute cardiopulmonary process. Radiology showed Successful placement of left 10 ___ nephrostomy tube. VENOUS DUP EXT UNI (MAP/DVT) LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of acute territorial infarction, hemorrhage or mass. Chronic
lacunar infarct in the right caudate body. Additional hypodensity in the right
lentiform nucleus may represent a lacunar infarct of indeterminate chronicity
or a prominent perivascular space. If there is high clinical concern for an
infarct or intracranial metastases, further evaluation may be performed with
MRI brain. RENAL U.S. showed 1. Bilateral nephrolithiasis without hydronephrosis.
2. Partially imaged left percutaneous nephrostomy tube.
3. Ureteral jets demonstrated on the right, not demonstrated on the left. The patient was diagnosed with Sepsis, unspecified organism, Tachycardia, unspecified, Altered mental status, unspecified. The patient was treated with ___ Percutaneous Nephrostomy Tube placement. At the time of discharge, the patient had septic shock
nephrolithiasis
obstructive uropathy
acute kidney injury
anemia
thrombocytopenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male w/ rectal and prostate cancer,
status post end ileostomy ___, who initially presented with
septic shock ___ to genitourinary infection in s/o obstruction
requiring FICU admission, now s/p percutaneous nephrostomy w/
improvement in hemodynamics, transferred to medicine.
Subsequently had resolving ___, toxic metabolic encephalopathy,
as well as anemia/thrombocytopenia.
# UTI, pyelonephritis
# septic shock
# nephrolithiasis
# hydronephrosis
Presented in septic shock. Started on vanc/cefepime empirically
(___), narrowed to ampicillin after cultures returned
sensitive enterococcus. Underwent percutaneous nephrostomy by ___
with return of pus, also growing sensitive enterococcus. Urology
followed and recommended outpatient follow up with them for
definitive stone management and/or stent placement. Will
continue abx until definitive stone management or at least 14
days from PCN placement (ie until ___, whichever is later.
# ___
# obstructive nephropathy
# hydronephrosis
# nephrolithiasis
Initial cr 1.1 (baseline), quickly rose to 2.5 which was likely
a combination of obstructive nephropathy and ATN. Plateaued at
that level and eventually came down with resolution of
obstruction, IVF and time. Repeat u/s showed no more
hydronephrosis. Meds were renally dosed (including switching
morphine on transfer out of ICU to oxycodone). Plan per urology
for nephrostomy to remain in place on discharge until urology
follow up. Cr 1.4 on discharge.
#Toxic metabolic encephalopathy: likely ___ combination of
sepsis and medications in renal failure as well as renal failure
itself. Other than baseline LUE weakness, exam was non-focal. He
continued to improve with time and especially with renal
improvement and reductions in meds (switched morphine to
oxycodone/reduction in clonazepam on transfer from ICU to
floor). On discharge mental status had resolved back to
baseline.
# LUE weakness: pt reports baseline, but at risk for both mets
or bleeding. Unlikely acute. CT with old lacunar infarcts but
these would not explain the weakness. Will eventually need MRI.
# Serosanguinous drainage from nephrostomy in ba: in setting of
low platelets, had some thicker sanguinous drainage when
platelets were particularly low, never with clots. But with
platelets and time this improved, was having light red tinged
urine on discharge.
#LLE swelling: negative ___
#Thombocytopenia, anemia likely ___ chemotherapy. No
schistocytes seen on smear. Per outpatient oncologist, he may
take longer than normal to respond, particularly given the
infection. Was transfused several units of PRBCs (goal >7) and
plts (goal >50 given serosanguinous drainage in PCN bag. Ostomy
without any bleeding. Discussed with oncologist, will get labs
two days after discharge and decision on neulasta at that point.
#Rectal cancer, prostate cancer: recently received FOLFOX. Pain
was controlled with oxycodone in place of morphine given ___ as
above. Chemo on hold until renal issues are resolved.
#Anxiety: on long-standing clonazepam, would not want to stop
this abruptly for risk of withdrawal. Decreased home clonazepam
to 0.5mg po BID for now.
#Stoma prolapse: does not appear incarcerated but given prolapse
could be at risk of such. Was seen by colorectal surgery who
reduced the prolapse. No acute surgical plan given that he's a
poor surgical candidate with comorbidities. ___ RN saw him,
gave him and wife new appliances, taught how to use the
equipment. Ostomy nurse to come see him at home.
#Hyponatremia: On admission due to hypovolemia, resolved with
IVF.
TRANSITIONAL ISSUES
========================
- Will need to continue antibiotics until definitive stone
management or at least 14 days from PCN placement (ie until
___, whichever is later. Has follow-up for KUB on ___ and
urology on ___
- Patient currently does not have PCP because his is on medical
leave and then retiring. He has been instructed to set up with
new PCP, which he will find locally in ___
- PCP: MRI brain w/wo as o/p once creatinine is back to normal
- needs follow up with ___ in ___ weeks, which ___ is planning to
arrange
- nephrostomy to stay in place until definitive treatment of
kidney stones by urology
- repeat labs including creatinine and CBC w/ diff within one
week after discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hep b infection on tenofovir presenting with fatigue,
abd pain. Patient states he stopped taking tenofovir approx 9
months ago thinking that he no longer needed it (lfts normalized
and vl suppressed). 25 days ago his mother passed away and he
flew to ___ for the funeral. He began to feel fatigued while
there, and 15 days days ago developed progressively worsening
RUQ pain and nausea. Had labs checked ___ with worsenign
transaminitis. Resumed his tenofovir about a week ago. Has had
worsening poor PO intake progessively since his return from
___.
Denies f/c/sick contacts. No hematemesis/melena/hematochezia.
In the ED, initial vitals were: 97.2 65 114/65 14 99% RA
- Labs were significant for alt 1873, ast 118, T bili 19.2, plt
124, inr 1.6
- Imaging revealed no ascites on RUQ U/S, no abnormality on cxr
- The patient was given 1L NS, 5 mg IV morphine x 1, 4 mg IV
zofran x 1.
Vitals prior to transfer were: 60 101/62 16 97% RA
Upon arrival to the floor, patient recounts above history. Pain
somewhat improved. Radiology showed No definite acute cardiopulmonary process. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Unremarkable right upper quadrant ultrasound. CT scan of the abdomen and pelvis showed 1. Hepatic steatosis. No suspicious focal hepatic lesion identified.
2. Gallbladder wall thickening and mucosal hyper enhancement, likely reactive
to the overlying hepatitis.
3. Few ___ nodules seen in the left lingula, query underlying viral
bronchitis.
4. Incidental horseshoe kidneys.
5. Liver volumes will be dictated as an addendum when they are available. MR ___ showed 1. Increased stiffness of the liver, consistent with stage F4, or maybe F3
fibrosis with a nodular liver suggesting cirrhosis.
2. No hepatic steatosis or significant iron deposition.
3. No focal liver lesion.
4. Evidence of portal hypertension with mild splenomegaly, varices, and trace
ascites.
5. Gallbladder wall edema is nonspecific, though likely related to the
chronic liver disease.
6. Horseshoe kidney. NASOINTESTINAL TUBE PLACEMENT WITH FLUORO showed Successful placement of ___ feeding tube. The tube
is ready to use. CHEST (PORTABLE AP) showed Feeding tube with the wire stylet in place ends in the mid stomach. Lungs
clear. Heart size normal. No pleural abnormality. ABDOMEN (SUPINE ONLY) showed The Dobhoff tube extends to the lower part of the second portion of the
duodenum. Mild adynamic ileus with residual contrast presumably in the
hepatic flexure of the colon. Portable chest radiographs showed A Dobhoff tube terminates in the gastric fundus. NASOINTESTINAL TUBE PLACEMENT showed Successful placement of a Dobhoff post-pyloric feeding tube into the second
portion of the duodenum. The tube is ready to use. CHEST (PA AND LAT) showed Comparison to ___. Minimal atelectasis at the left lung bases.
No pneumonia. No pulmonary edema, no pleural effusion. The course of the
feeding tube is unremarkable. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Coarse liver without suspicious lesions. No evidence of portal vein
thrombosis.
2. Splenomegaly and mild ascites. ___ TUBE PLACEMENT (W/FLUORO) showed Successful placement of ___ feeding tube. The tube
is ready to use. CHEST (PORTABLE AP) showed The tip of the Dobhoff is in the distal esophagus and needs to be advanced at
least 15 cm. This was subsequently advanced under fluoroscopic guidance. ___ TUBE PLACEMENT (W/FLUORO) showed Successful advancement of Dobhoff post-pyloric feeding tube. The tube is
ready to use. CHEST (PORTABLE AP) showed Since a recent radiograph of ___, a feeding tube is been replaced,
with tip terminating in the proximal stomach. Cardiomediastinal contours are
stable in appearance. Minimal blunting of left costophrenic sulcus may
reflect small pleural effusion or pleural thickening. The patient was diagnosed with Unspecified viral hepatitis B without hepatic coma. The patient was treated with EGD ___
Colonoscopy ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with a history of chronic HBV who
presented with liver failure from reactivation HBV in the
setting of medication non-adherence. AST/ALT > 1000s and TBili
of 19 on presentation. The patient was restarted on tenofovir.
However, LFTs did not improve and TBili continued to uptrend, so
entecavir was added with subsequent decrease in HBV viral load.
He reported early satiety throughout admission. He was initiated
on tube feeds via Dobhoff to ensure adequate nutrition. He was
evaluated for liver transplant and listed on ___.
================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Note: Patient report of history limited by word-finding
deficits and cognition, key aspects of history confirmed with
wife via phone. Radiology showed No significant interval change compared to the prior CT. No new areas of
opacification within the lungs. Radiology showed Metastatic disease with extensive vasogenic edema within the left
cerebral hemisphere, unchanged in degree from prior MRI. If further
characterization of metastatic disease is needed, an MRI would be the study of
choice.
The above findings were communicated to Dr. ___ to reflect the change in
the wet reading at 1740 hours by telephone by Dr. ___. Radiology showed No fracture. Radiology showed 1. Multiple large metastatic hemorrhagic lesions, stable in size with stable.
No midline shift. No acute infarct.
2. Stable left cerebellar rim-enhancing and left cerebellar leptomeningeal
enhancing lesions. Radiology showed Similar large metastases with intralesional hemorrhage, in
keeping with the known melanoma metastases. No evidence of interval
hemorrhage since the last study on ___. Slightly improved
perilesional FLAIR signal abnormality. No acute infarction. No new lesions.
Dr. ___ has discussed the pertinent findings with the primary team, Dr.
___, at 8:00 a.m. on ___, shortly after the preliminary
interpretation of the study. The patient was diagnosed with ALTERED MENTAL STATUS , OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had PRIMARY
- metastatic cutaneous melanoma
- pulmonary embolism
SECONDARY:
- acute confusional state
- diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ man with known metastatic
melanoma here with weakness, falls, and report of worsening
mental status at home. Significant aspects of his hospital
course by problem are documented below.
(1) Altered Mental Status and Weakness: Patient's altered
mentation remained stable throughout his admission. He remained
oriented to self and person, was able to name year and season
but not specific month or date. As confirmed with wife, he had
pre-admission right-sided strenght deficits on neurologic
examination; throughout his stay his RUE and RLE were motor
strength ___ while the remainder of his examination was ___.
His cognitive difficulties were attributed to his underlying
cerebral metastases. It was presumed his pre-admission taper to
BID dosing of dexamethasone from TID may have contributed to his
new confusion. He was re-started on TID dosing upon admission,
though this was scaled back to dexamethasone 6mg PO daily during
his stay with planned continuation on this therapy for the
forseeable future. He underwent MRI scanning on ___ which
revealed the following: "1. Multiple large metastatic
hemorrhagic lesions, stable in size with stable. No midline
shift. No acute infarct. 2. Stable left cerebellar rim
enhancing and left cerebellar leptomeningeal enhancing lesions."
Given the continuing course of his melanoma, he was started on
bevacizumab (Avastin) on ___. Prior to starting this
therapy, the risks of hemorrhage and subsequent neurologic
deterioration were discussed with both the patient and his
family. All were in agreement to proceed with this course.
Unfortunately, Mr. ___ suffered a pulmonary embolism during
his hospitalization. It was felt this complicationh was
secondary to the hypercoagulable state of his melanoma and also
due to bevacizumab toxicity. He required anti-coagulation for
this PE, as discussed below. An MRI performed prior to
initiating anti-coagulation identified stable cerebral
metastases (no new hemorrhage) as above. His mental status was
unaffected by anti-coagulation; he did not demonstrate evidence
of new cerebral hemorrhage. Upon discharge, he was alert to
place and person, but disoriented to time. He continued to have
mild word finding difficulties, but was generally appropriate
with his communication.
(2) Pulmonary Embolism: As mentioned above, Mr. ___ suffered
the unfortunate complication of a pulmonary embolism. This was
discovered on CTA after the patient desaturated while ambulating
and was found to be tachycardic. This complication was
attributed to his melanoma and bevacizumab therapy. Given the
significant size of the emboli coupled with his stable cerebral
disease (on MRI shortly after CTA), it was felt anti-coagulation
was necessary. He was started on a heparin drip without initial
bolus dosing and at a decreased PTT goal of 50-70 (therapeutic
considered to be 60-100). After 24 hours of stable neurologic
examination and mentation, this anti-coagulation was
transitioned to subcutaneous enoxaparin. Based on his weight,
the recommended dose for anti-coagulation was 60mg BID. Mr.
___ was started on 50mg BID, roughly 80% of suggested dose, in
an effort to both treat the pulmonary emboli and prevent new
cerebral hemorrhage. He did not exhibit signs of new bleeding
with either heparin or enoxaparin. He was discharged on
enoxaparin SQ 50mg BID.
(3) Metastatic Melanoma: Melanoma initially presented at right
cheek and now known to be metastatic to brain, liver, and lung.
Levetiracetam was continued while hospitalized for seizure
prophylaxis given his cerebral involvement. He was started
bevacizumab ___ as above. His next scheduled dose was
___, however, this was delayed given the development of
pulmonary embolism. He was discharged on ___ with
scheduled appointment as an outpatient on ___ to receive
his next dose of bevacizumab.
(4) Diabetes Mellitus: Recent admission to ___ for diabetic
ketoacidosis. Management c/b current steroid use. His serum
glucose levels were well-controlled while hospitalized with his
home dose of insulin and sliding scale adjustment. He was
discharged with a ___ appointment with the endocrinology
service for further evaluation and management.
(5) Pneumocystis Pneumonoia: This was diagnosed on ___ by
___. He was prescribed 3 week course of Bactrim DS TID
(completed on ___. Now, he is on 1 tab Bactrim DS daily
for PCP ___. He will need to continue this regimen
until one month after stopping steroids (likely to be on
dexamethasone for extended period of time).
(6) Hypothyroidism: He continued home dose of levothyroxine.
(7) Oral Thrush: This was documented on ___ during visit
to Dr. ___. Outpatient nystatin was continued
while hospitalized.
(8) Physical Therapy: Mr. ___ performed well on his physical
therapy assessments during his stay, ambulating well with the
assistance of ___ staff members.
==========================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ complex past medical history including hypertension,
___ disease, history of PE (previously on warfarin but
discontinued due to ___), sclerosing cholangitis, kidney
disease,
presenting with productive cough and fevers x 1 week. The pt was
admitted on ___ when diagnosed with CAP. CTAP with no PE,
showed LLL PNA with small opacifications in RUL. Also showed
splenic infarct. Treated with CTX, azithro for two days,
discharged on Cefuroxime (for full 7 days course) and Azithro
(for full 5 day course.) She felt well for one week following
discharge, and went on a trip to ___ from which she returned
on ___. That day, she again deceloped cough, SOB and fevers for
which she presented to her PCP and was given a dose of
ceftriaxone on ___, doxycycline on ___ and ___, and CTX again
on
___ and ___. Despite these abx, she developed a fever to 103 on
___ and presented to the ED on ___. CHEST RADIOGRAPHS showed 1. Mild opacification of the left lung base likely reflects resolving
pneumonia.
2. No new focal consolidations. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis from the femoral to the popliteal veins.
Limited evaluation of the calf veins. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Minimal intrahepatic biliary ductal dilatation.
2. Multiple cysts throughout the pancreas, better evaluated on prior MRCP.
3. Multiple prominent and enlarged perihepatic and peripancreatic lymph
nodes.
4. Cholelithiasis without cholecystitis. MRCP showed Technically suboptimal study due to non breath hold technique and motion
artifact.
1. New multifocal areas of restricted diffusion within bilateral kidneys with
new retroperitoneal adenopathy raises the suspicion of lymphoma. The lymph
nodes would be amenable to CT guided biopsy.
2. 17 mm left lower lobe pulmonary lesion appears similar to previous and may
represent a true mass lesion versus an area of consolidation. Mild
superimposed bibasal airspace disease is seen, increased in the right lower
lobe from before but suboptimally evaluated.
3. Stable appearance of the liver with moderate intrahepatic biliary ductal
dilatation and cirrhotic morphology in keeping with known history of PSC. No
MRI findings to suggest cholangitis.
RECOMMENDATION(S): CT-guided biopsy retroperitoneal lymph node. Consider
chest CT if persistent thoracic symptoms.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:48 pm, 10 minutes after
discovery of the findings. Radiology showed Left lower lobe pneumonia. Radiology showed Right-sided PICC line projects to the cavoatrial junction. Small bilateral
effusions have slightly increased in volume. Patchy parenchymal opacity in
the right lower lobe is unchanged. Nodular opacity in the retrocardiac left
lower lobe is better seen on recent CT scan. No new consolidations. No
pneumothorax is seen. There is no pleural effusion. RENAL U.S. showed 1. Minimal symmetric fullness of the bilateral renal collecting systems
without frank hydronephrosis, likely secondary to prominent bladder
distension. Correlate for urinary outlet obstruction.
2. Echogenic debris within the left renal collecting system and trace debris
within the bladder. Infection cannot be excluded based on ultrasound in the
appropriate clinical context.
3. Several bilateral renal cysts. Chest radiograph showed Right-sided PICC is unchanged. Cardiomediastinal silhouette is unchanged.
Mild interstitial edema appears similar to mildly increased compared the prior
examination, though there remain hazy superimposed densities in the bilateral
lung bases. There are tiny bilateral pleural effusions, unchanged. There is
no pneumothorax. There is no upper lung consolidation. Chest radiograph showed There has been placement of a right IJ central venous catheter terminating in
the low SVC, satisfactory. Right PICC is unchanged. Cardiomediastinal
silhouette and hilar contours are stable. Patchy right greater than left lung
base opacities are unchanged along with small bilateral effusions. No new
consolidation is seen. There is no pneumothorax. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Redemonstration of cirrhotic liver with unchanged intrahepatic biliary
dilatation.
2. Peripancreatic and periportal adenopathy, as on prior.
3. Small perihepatic ascites. Chest radiograph showed Second image demonstrates Dobhoff tube in the mid gastric body, satisfactory.
Heart size is borderline. There remains mild unfolding of the thoracic aorta.
Hilar contours are stable. Hazy opacities in the right lung base have
improved compared the prior study. Small to moderate bilateral pleural
effusions have slightly increased in volume. There is adjacent compressive
atelectasis in the lung bases. The upper lung fields are clear. There is no
pneumothorax. Right PICC and right IJ central venous catheter are unchanged. Radiology showed The right-sided PICC line, right IJ line are unchanged. The NG tube has been
reposition and projects below the left hemidiaphragm and tip projects over the
stomach. Bilateral effusions have slightly increased in volume. There is
bibasilar atelectasis. No obvious pneumothorax is seen. Pulmonary edema has
mildly worsened Radiology showed Nonspecific, nonobstructive bowel gas pattern. Radiology showed Nonspecific, nonobstructive bowel gas pattern, as described above. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___.
Moderate bilateral pleural effusions have improved since ___. Left lower
lobe is still severely atelectatic. Skin folds obscure the right upper
lateral costal pleural margins, but if there were pneumothorax, I would expect
a fluid level given the substantial, right pleural effusion. Heart size
normal.
Right PIC line ends close to the superior cavoatrial junction. Right jugular
line ends in the upper SVC. Feeding tube ends in the upper stomach. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver morphology.
2. Partially imaged abdominal lymphadenopathy, better assessed on recent MRCP.
3. Persistent moderate intrahepatic biliary dilatation.
4. Small volume ascites. CT scan of the abdomen and pelvis with contrast showed 1. Cirrhotic liver, with stable intrahepatic biliary duct dilatation, in
keeping with known history of PSC.
2. Stable mesenteric and retroperitoneal adenopathy. Multiple hypoattenuating
foci in the bilateral kidneys. While some of these represent cysts, others
are too small to characterize.
3. Small volume ascites, increased since the previous MRI, with small
bilateral pleural effusions. Anasarca. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are
stable, as is the cardiomediastinal silhouette. The hazy opacification
bilaterally of less prominent. This could reflect improving pleural
effusions, though in some part could be a manifestation of a better
inspiration and more upright position of the patient. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. Superficial edema bilaterally. Chest radiograph showed The final image demonstrates the Dobhoff tube in the mid gastric body,
satisfactory. Right IJ central venous catheter is unchanged. There remains
mild cardiomegaly with central pulmonary vascular congestion and mild
interstitial edema, similar to the prior study. Tiny bilateral effusions
appear slightly decreased in volume with minimal residual bibasilar
atelectasis. Otherwise no new consolidation is seen. There is no
pneumothorax. Radiology showed 1. Successful placement of a 19 cm tip-to-cuff length tunneled dialysis
line. The tip of the catheter terminates in the right atrium. The catheter is
ready for use.
2. Removal of the pre-existing temporary HD line. The patient was diagnosed with Fever, unspecified. The patient was treated with ___ Left posterior cervical lymph node biopsy
___ Right Tunneled HD line placement. At the time of discharge, the patient had PRIMARY
=========
Diffuse large B cell lymphoma
Acute renal failure
Febrile neutropenia
SECONDARY
===========
Hyperbilirubinemia
Transaminitis
Malnutrition
Hyperglycemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ history of remote cutaneous lymphoma, eosinophilic
granulomatosis with polyangiitis, autoimmune hepatitis/PSC, FSGS
with CKD III and unprovoked PE who originally presented with
constitutional symptoms and concern for pneumonia but was
incidentally found to have aggressive DLBCL that was complicated
by secondary HLH. She was transferred to ___ for worsening
respiratory status and metabolic acidosis due to acute renal
failure requiring urgent renal replacement therapy. The patient
was stabilized in the FICU and was able to be transitioned to
HD. She was transferred back to the ___ service for continuation
of chemotherapy.
# DLBCL
# Secondary HLH
# Pancytopenia
Incidental finding of lymphadenopathy on ___ MRCP was
concerning for lymphoma. Subsequent PET scan showed widespread
disease. Excisional lymph node biopsy confirmed diagnosis of
diffuse large B cell lymphoma. The patient was initially started
on Cytoxan monotherapy however did not tolerate with the
development of renal failure and ongoing cytopenias. Course also
complicated by secondary HLH. She received one treatment of
rituxan, dose reduced etoposide and steroids. With improvement
in cell counts and liver function, the patient was started on
miniCHOP on ___. She was supported with G-CSF with improvement
in cell counts.
# Acute renal failure
# FSGS
Progressive renal failure with acidemia and volume overload
requiring transfer to the FICU for initiation of HD. Renal
failure most likely result of lymphoma invasion of kidneys. HD
sessions c/b A fib with RVR, hypotension, and SVT which resolved
with cessation of HD. Required CRRT for several days and
eventually was transitioned back to intermittent HD which she
then tolerated well. Began making some urine but continued with
HD. Tunneled line placed and continued on HD at discharge.
# Severe Malnutrition
Poor appetite, not meeting caloric needs so DHT placed ___.
Slowly advanced diet but unable to take sufficient nutrition.
Discussed moving towards PEG but decision made to remove DHT and
trial po intake for several days which resulted in some
improvement in appetite, meeting lower-end of calorie needs.
# CAP vs post obstructive pneumonia
Patient treated for PNA with 10 day course of cefepime/flagyl.
# HSV Infection
Developed fevers and had lesions on inner thigh c/f HSV
infection. No c/f MRSA. Treated with course of Valtrex then
transitioned back to acyclovir prophylaxis while neutropenic.
# Afib with RVR, resolved
Developed rapid rates to 170's during HD initiation and
subsequent HD sessions. Resolved outside of HD. Started on amio
during acute event, however this was discontinued.
# Steroid-Induced Hyperglycemia
Started on lantus and sliding scale Humalog to cover blood
sugars.
# ___ edema
# Elevated Pro-BNP
Likely ___ hypoalbuminemia iso lymphoma. No e/o heart failure.
TTE w LVEF 68% with Normal biventricular cavity sizes,
regional/global systolic function. No valvular pathology or
pathologic flow identified. High normal estimated pulmonary
artery systolic pressure. Mild-moderate tricuspid regurgitation.
# PSC
# Transaminitis
Pt with history of PSC. Developed worsening transaminitis during
admission with elevated TBili limiting chemotherapy options.
Unclear etiology for elevation, possibly ___ HLH given
improvement with etoposide. Continued Ursodiol.
# Eosinophilic Granulomatosis with Polyangiitis
Continued 10mg Prednisone (increased home dose in setting of
continued fatigue), additional steroids for lymphoma treatment
as above.
CHRONIC/STABLE ISSUES
=====================
# HTN
Holding home nifedipine given hypotension.
# COPD
Continued home Flovent.
# HLD
Held home statin given LFT abnormalities.
TRANSITIONAL ISSUES
===================
[ ] Monitor fingerstick BG daily, can use sliding-scale insulin
if needed. Not requiring Lantus at time of discharge.
[ ] Continued nutrition assessment to determine if meeting
caloric needs. ___ require PEG if not taking sufficient po.
[ ] Prednisone dose increased from 5mg daily to 10mg daily prior
to admission. Discharged on 10mg after finishing steroids for
chemotherapy.
[ ] Consider BRCA testing (father w h/o breast cancer)
[ ] Held nifedipine given intermittent hypotension here. If BPs
stable, can restart.
[ ] Held atorvastatin given LFT abnormalities. Check LFTs at
least weekly. Can restart as outpatient if LFTs
stable/improving.
[ ] Will need to come back to ___ clinic for cycle 2 of miniCHOP
on ___.
[ ] ___ need port in the future.
# Code: Full, confirmed
# Communication: Husband/HCP ___ (___) </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with mild static
encephalopathy and ___ syndrome who presents with an
increased frequency of her typical events.
Per group home staff, she had head-drops to evenings ago, then
yesterday she had two with Ativan given, then six events today.
These have interfered with her participation in group activity.
There have been no tonic-clonic seizure - the carers from the
home have actually never seen these, and do not know the last
time this happened. Per staff, she will suddenly drop her head,
the VNS is typically then swiped, she will then mumble and this
typically makes no sense, her lips will sometimes become blue.
If she is having a seizure and they lay her down to change her
(she is always double incontinent with seizure), she will kick
out and struggle a little whether the seizure has stopped or
not. Her eyes are typically open and her eyes are back. She
injured
her chin when having a head-drop event while cleaning her teeth.
Her head fell down and she hit her chin, resulting in a bite to
the tip of her tongue.
She has had frequent headaches and back pain, for which Tylenol
only was given. There has been malodorous urine recently, but
the patient denies 'burning with urination'. There has been no
cough, fever, aspiration, diarrhea or evidence of other
infection. ___ states that she had a very bad headache 'a
couple of months ago'. But staff suggest that this might have
been on ___.
She has recently had some rectal bleeding. She refused
colonoscopy - her mother apparently agreed. It was thought that
she likely had colitis, per hospital staff during a ___
admission for this complaint and upon a second bleed in ___
for which she was also taken to an ED, but not admitted. She
followed-up subsequently with her gastroenterologist. There has
been no bleeding since.
Summarizing from the ___ notes and after discussion with Dr.
___: Seizures appear to have begun in ___ with a likely
nocturnal seizure then a tonic-clonic seizure en route to an
emergency department. She aspirated during this event and
required intubation. These events appear to have been
generalized at onset. Complex partial events appeared in ___,
based on documentation that Dr. ___ had on her first review in
___, but semiology was not clear. Her first epilepsy monitoring
unit admission was in ___ at ___. "During
that admission, she had drop seizures and frontal spikes ...
interictal spikes were usually on the right side." Later, Dr.
___ the patient had had staring spells since
childhood. Given generalized seizures, head drop spells,
drop-attacks and absence-like events, a diagnosis of
___ syndrome was made. This appears to be cryptogenic
and medial temporal sclerosis is interpreted as a consequence of
her seizure disorder.
Review of systems negative except as above. Radiology showed No acute findings in the chest. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY. At the time of discharge, the patient had 1. ___ Gastaut epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ yo F with mild static encephalopathy and
___ syndrome who presented with increased frequency
of head drops (one of her typical seizure semiologies).
# NEURO: Patient was admitted to the Epilepsy service for
further workup and EEG long-term monitoring. She underwent
toxic-metabolic and infectious workup which was all negative.
Serum VPA level was therapeutic at 91. She was briefly placed on
a lorazepam "bridge" to treat her increased seizure frequency,
which was tapered and stopped after two days. She was monitored
on EEG LTM for 5 days which showed occasional bursts of
generalized spike and slow wave activity (usually during sleep)
which appeared baseline compared to her prior EEGs. Clinically,
she appeared well and at baseline throughout hospitalization,
with no clinical seizures observed. As she was clinically at her
baseline with no significant seizure activity on EEG, no
adjustments to Ms. ___ AED regimen were made during
hospitalization. She was discharged back to her group home on HD
#5, and will follow up as an outpatient with her epileptologist
Dr. ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with DM, HTN, HLD, smoker, presents with worsening
intermittent chest pain over the past several months. Patient
reports her chest pain is always left-sided, and has no
association with activity (occurs at rest and when active), has
been occurring for approx the past several months, and has been
worsening. Last night, she had sudden onset of severe substernal
CP at 0300, anxiety, diaphoresis, and dyspnea lasting
approximately ___ minutes, which woke her from sleep. The pain
then went away without intervention and she went back to sleep.
At 1100, the pain recurred and was similar in character and
lasted approximately 20 minutes. BP per ___ nurse during
witnessed episode this morning 150/90 with HR in ___ accompanied
by significant diaphoresis. Patient reports that she has a
cervical disk bulging resulting in parasthesias/pain in her arms
bilaterally, therefore it is hard to assess if the pain radiates
to her arms. Pain lasting several minutes with pain scale ___.
Pain was non exertional. Patient denies CP, N/V/D, chills,
fevers, cough. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with CHEST PAIN NOS. The patient was treated with right and left cardiac catheterization. At the time of discharge, the patient had Primary diagnosis: coronary artery disease, diastolic heart
failure
Secondary diagnosis: hypertension, hyperlipidemia, diabetes
type 2. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with DM, HTN, HLD, smoker, presents with sudden onset of
severe substernal CP overnight with diaphoresis and dyspnea
which woke her from sleep, then recurring several times since,
radiating to left arm, non-exertional, ST depressions. Cardiac
cath showed 1 vessel disease with elevated end diastolic
pressures in both biventricularly consistent with diastolic
heart failure. Patient has been medically optimized during
admission and has been getting IV diuresis for fluid overload. </s> |