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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Divalproex Sod. Sprinkles 125 mg PO BID
2. Heparin 5000 UNIT SC BID
Continue until ___
3. Ibuprofen Suspension 800 mg PO Q8H Duration: 5 Days
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Duration: 5 Days
5. Levothyroxine Sodium 50 mcg PO DAILY
6. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H:PRN
Disp #*17 Tablet Refills:*0
7. OxyCODONE (Immediate Release) 2.5 mg PO QHS
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*4 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Acetaminophen 1000 mg PO Q8H
11. LORazepam 1 mg PO QHS
12. LORazepam 0.5 mg PO QAM
13. Polyethylene Glycol 17 g PO DAILY
14. QUEtiapine Fumarate 25 mg PO QHS
15. QUEtiapine Fumarate 25 mg PO BID:PRN agitation
16. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
17. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
18. Escitalopram Oxalate 20 mg PO DAILY
19. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
20. Mirtazapine 15 mg PO QHS
21. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
22. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN dry
23. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric hip fracture
Acute toxic metabolic encephalopathy
community acquired UTI
___
Hypoxemic respiratory failure
Leukocytosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a fall at your nursing home and unfortunately broke
your right hip.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent a successful hip surgery with the orthopedic
surgeons.
- You were noted to be quite confused and so were transferred to
the general medicine service for ongoing treatment.
- You were treated for a urinary tract infection and started on
thyroid medication.
- You continued to have confusion and so had an MRI of your
brain which showed ####
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team
Surgical Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take SQH BID for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Non-incarcerated symptomatic right inguinal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You underwent a right inguinal hernia repair. Please follow
activity restrictions, take pain meds only as needed and to no
greater degree than as prescribed, and follow up in ___ clinic
as directed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than 15 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before then that is okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Continue your deep breathing exercises.
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
2. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth 4 times per day Disp
#*46 Capsule Refills:*0
3. PredniSONE 40 mg PO DAILY
40mg through ___ 30mg through ___, 20mg through ___, 10mg
through ___
RX *prednisone 10 mg 4 tablet(s) by mouth every day Disp #*100
Tablet Refills:*0
4. Amphetamine-Dextroamphetamine 30 mg PO DAILY
5. balsalazide 2250 mg oral TID
6. Divalproex (DELayed Release) ___ mg PO DAILY
7. erythromycin-benzoyl peroxide ___ % topical DAILY
8. Gabapentin 200 mg PO TID
9. Mirtazapine 60 mg PO QHS
10. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth every day Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary:
Ulcerative colitis flare
C.diff infection
#Secondary:
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why you were admitted to the hospital:
- You were having abdominal pain and bloody diarrhea
What happened while you were here:
- You were found to have an infection called c.diff, which
causes diarrhea
- A scope of your bowel showed that inflammation, consistent
with a flare of your ulcerative colitis
- You were treated with intravenous steroids and antibiotics and
your symptoms improved
What you should do once you return home:
- Continue taking your medications as prescribed
- You should taking oral vancomycin for two weeks (end date
___
- Continue taking prednisone 40mg through ___ 30mg through
___, 20mg through ___, 10mg through ___.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. DULoxetine 30 mg PO DAILY
RX *duloxetine 30 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Warfarin 2.5 mg PO DAILY16
Please take according to your ___ clinic
instructions.
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
9. Acidophilus (Lactobacillus acidophilus) oral DAILY
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
11. BusPIRone 11.25 mg PO BID
12. BusPIRone 7.5 mg PO QHS
13. Calcium Carbonate 500 mg PO BID
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. GlipiZIDE XL 10 mg PO QAM
16. GlipiZIDE XL 5 mg PO QPM:PRN if ___ is >200 at dinner
17. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous 30 units daily
18. Levothyroxine Sodium 50 mcg PO DAILY
19. LORazepam 0.5 mg PO TID:PRN anxiety
20. Ondansetron 8 mg PO Q8H:PRN nausea
21. Pantoprazole 40 mg PO Q24H
22. Senna 17.2 mg PO QHS:PRN constipation
23. Simethicone 125 mg PO QID:PRN gas
24. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
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
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were recently admitted to ___
___.
Why I was here?
- You were brought in with chest pain and found to have a heart
attack.
What happened while I was here?
- You underwent a cardiac catheterization and had the blockage
in your heart vessel opened.
- You were started on medications to help treat your heart
disease and prevent blood clots.
- You were seen by the physical therapists, who recommended
rehab.
What I should do when I go home?
- Continue to take all of your medications as directed.
- Follow up with your primary care doctor and the cardiologist.
- Follow up with the ___ clinic for management of your
Coumadin dosage.
Thank you for allowing us to care for you,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
3. Polyethylene Glycol 17 g PO DAILY
4. Gabapentin 1600 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in with your PCP ___ ___ weeks after
discharge.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Apixaban 5 mg PO/NG BID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 40 mg PO BID
4. LevETIRAcetam 750 mg PO BID
5. Metoprolol Tartrate 150 mg PO BID
6. Thiamine 100 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Cetirizine 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
History of stroke
Heart failure with preserved EF
Left atrial thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted for episodes concerning for seizures, which
was likely from your previous stroke. In addition, you were
found to have an abnormal heart rhythm, called atrial
fibrillation. In the course of working this up, you were found
to have a small clot in the heart, as well as heart failure. You
were seen by cardiology, who recommended several important
medication changes.
START apixaban 5mg twice daily
START levetiracetam 750mg twice daily
START furosemide 40mg twice daily
You will need to follow up with your cardiologist, as well as
cardiology at ___, for additional follow up imaging and
procedures.
Please weigh yourself daily and if you gain 3 or more pounds in
1 day, please call your cardiologist.
Sincerely,
___ Neurology</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 6 Weeks
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*72 Tablet Refills:*0
3. Azithromycin 1200 mg PO 1X/WEEK (SA)
4. Darunavir 800 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. RiTONAvir 100 mg PO DAILY
7. Nystatin 500,000 UNIT PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
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
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
had headaches, difficulty walking, and severe confusion. You
had a brain MRI that showed signs of toxoplasmosis (brain
infection because of your AIDS). You were started medication to
treat the infection and your neurological status improved. You
were evaluated by Physical Therapy who felt you were safe at
home and a repeat MRI showed that your brain infection was
getting much better. Best of luck to you in your future health.
Do not take methamphetamines or other illegal drugs or use
injection drugs. Please take all medications reliably and as
directed (including your antiretrovirals and your toxoplasmosis
treatment), followup with all providers as scheduled (or call
ahead of time to reschedule), and call a doctor if you have any
questions or concerns. You have been given a cab voucher to get
to ___ to pick up your pills.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atovaquone Suspension 1500 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluoxetine 20 mg PO DAILY
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth q6h prn Disp #*10
Tablet Refills:*0
8. Lactulose 30 mL PO QID
9. Omeprazole 40 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Polyethylene Glycol 17 g PO EVERY OTHER DAY
12. Ranitidine 75 mg PO BID:PRN heartburn
13. Senna 17.2 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
15. Warfarin 1 mg PO DAILY16
16. Amlodipine 5 mg PO DAILY
17. Torsemide 40 mg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
BID
20. OxyCONTIN (oxyCODONE) 10 mg oral Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Acute on chronic kidney disease
SECONDARY DIAGNOSES:
=====================
Hypertension
Catheter-associated urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted because your kidney function was abnormal. This
was likely due to damage to your kidneys from intermittently
having low blood pressure. Your kidney function slowly
recovered and will hopefully continue to improve. You were
given medications to remove fluid from your legs. After your
leg swelling resolves and your leg ulcers heal, the orthopedic
surgeons will replace your knee. Your blood pressure became
high, so you were started on a new medication to help with this.
It is very important that you continue to take your medications
as prescribed and keep your follow-up appointments.
We wish you good health!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Enoxaparin Sodium 80 mg SC Q12H
2. Warfarin 5 mg PO QPM
3. Nortriptyline 150 mg PO QHS
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Baclofen 30 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. FLUoxetine 60 mg PO DAILY
10. Gabapentin 100 mg PO TID
11. melatonin 3 mg oral QHS
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO DAILY
16. Tamsulosin 0.8 mg PO QHS
17. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
18. TraZODone ___ mg PO QHS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right lower extremity deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Mr. ___,
You were hospitalized for a right leg deep vein thrombosis
(blood clot). You were started on warfarin and your INR level
(that we monitor to make sure that your blood is adequately
thinned by the warfarin) is being monitored. You are also
getting another blood thinner called Lovenox injections twice
daily that will be stopped once your INR level is at a
therapeutic level. Your INR will still be checked at rehab.
You may still have some pain and discomfort in your right leg as
the clot heals. You will also be seeing the hematologist in
clinic in several weeks in follow up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO DAILY
3. TiCAGRELOR 90 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral arterial disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure taking care of you here at ___
___. You were re-admitted to our hospital
for management and care of your periheral arterial disease.
Unfortunately imaging showed your previous right lower extremity
SFA stents were no longer patent, causing your pain at rest. You
were placed on heparin drip to help perfuse your lower
extremity, and scheduled for surgery.
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily, and your home
ticagrelor as you previously took it
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ALPRAZolam 0.5 mg PO Q6H PRN anxiety
2. Cetirizine *NF* 10 mg Oral daily
3. Citalopram 20 mg PO DAILY
RX *citalopram 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Furosemide 120 mg PO DAILY
RX *furosemide 40 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
7. Nadolol 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Spironolactone 100 mg PO DAILY
10. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 5 Days
RX *mupirocin calcium [Bactroban Nasal] 2 % 1 application
topically twice a day Disp #*1 Unit Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Critical Aortic Stenosis
Acute Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to ___ with
shortness of breath due to your aortic valve replacement not
working. This caused fluid to build up in your lungs. We used a
water pill to remove this fluid, but you will require a aortic
valve replacement to prevent this in the future. You will meet
with cardiac surgeons on ___.
For your heart failure and fluid. You should weigh yourself
EVERY morning after going to the bathroom and before
eating/drinking. If this weight decreases or increases by more
then 2lbs, please call your doctor. You were started on a new
dose of Furosemide (Lasix) with a goal of keeping your weight
the same as currently. Your weight on discharge is 185.5lbs,
make sure to weigh yourself on your scale in case this differs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you were having
shortness of breath and were found to have fluid in your lungs
at ___.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Chest tubes were placed to drain the fluid from your lungs.
After your breathing improved, the chest tubes were removed.
- You received diuretic medications to help remove more fluid.
- You were more sleepy so tests were performed to make sure that
you do not have an infection or bleed in the brain. These tests
were negative.
- You preferred to return home rather than be evaluated for
rehab, you were felt to have capacity to make this decision
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Dr. ___ be the new Oncologist taking care of your
AML.
We wish you all the best!
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Exelon 4.6 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
once a day.
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
6. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day): to right eye.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Artificial Tears Drops Sig: ___ Ophthalmic once a day as
needed for dry eyes.
10. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
11. Fleet Enema ___ gram/118 mL Enema Sig: One (1) Rectal once
a day as needed for constipation.
12. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a
week.
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
16. diclofenac sodium 1 % Gel Sig: One (1) Topical once a day
as needed for pain: to use topically for arthritis pain.
Disp:*60 grams* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute delerium, unclear cause
Dementia
HTN
Blindness
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital out of concern that you were
not acting yourself. We did not find any signs of infection or
heart attack, or any other medical issues that might have caused
your confusion.
.
We made the following changes to your home medications:
INCREASE amlodipine to 10 mg daily
START metoprolol 12.5 mg twice daily
START diclofenac gel to painful arthritic joints</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Creon ___ CAP PO QIDWMHS
4. Dexamethasone 2 mg PO AS DIRECTED WITH CHEMOTHERAPY
5. Docusate Sodium 200 mg PO BID
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. LORazepam 1 mg PO QHS:PRN insomnia/anxiety/nausea
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Omeprazole 20 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
14. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic anemia
Pneumonia
Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
You were admitted with weakness and shortness of breath found to
have low blood counts (anemia) and received a blood transfusion
with improvement in your symptoms. You were also found to have
pneumonia treated with antibiotics.
Please continue to follow up with your oncology team.
It was a pleasure taking care of you.
-Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 grams IV once a day Disp #*42 Vial
Refills:*0
2. Citalopram 40 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Lorazepam 0.5 mg PO BID:PRN anxiety
6. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
7. Metoprolol Tartrate 12.5 mg PO TID
Follow up with your primary care doctor in the next week to
adjust this medicine as needed
RX *metoprolol tartrate 25 mg One-half tablet(s) by mouth every
eight (8) hours Disp #*40 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*126 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aorto-enteric fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take pain medications as prescribed for any post
procedure pain or discomfort; no not operate a vehicle nor any
other machinery while under the influence of narcotic medicine
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Take antibiotics as directed. You will be on two antibiotics,
Ceftriaxone and Metronidazole, delivered intravenously via your
PICC line and orally, respectively. Per the recommendation of
the Infectious Diseases service, you will likely be on these
antibiotics for at least 6 weeks. You also have follow up with
the infectious diseases doctors ___ below) in about 1.5 weeks.
You will follow up with Vascular Surgery clinic on ___ call
the office sooner for any questions or concerns.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO DAILY Duration: 2 Days
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidocare] 4 % QAM Disp #*30 Patch Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth Daily Disp #*30 Capsule
Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
5. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth four times
a day Disp #*1 Package Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily
Disp #*1 Tablet Refills:*0
7. Furosemide 20 mg PO DAILY
8. Spironolactone 50 mg PO DAILY
Discharge Disposition:
___ With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
==========
Cirrosis
Anemia
Hypertension
Hypoxia
Enterococcus bacteriuria
SECONDARY
==========
Alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital because your doctor ___.
___ was concerned for your abdominal swelling, right lower
leg swelling, abdominal pain, jaundice and your overall health
status.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were briefly in the medical intensive care unit due to low
blood pressures. This resolved without the need for an extended
course of antibiotics. You were not found to have any evidence
of infection.
- 6 L of fluid was removed from the abdomen on ___. You were
then restarted on your ___ medications to help continue to
remove fluid from your abdomen.
- Your laboratory results were followed closely during your
hospital stay. It was decided that you did not need steroids to
help with inflammation around your liver, though this was
discussed extensively with you.
You were followed by our nutritionists during your stay. The
importance of nutrition was stressed multiple times during this
hospital stay. You will need to take in at least ___ kcal per
day.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed (listed
below)
- Keep your follow up appointments with your doctors
- Please drink at least 3 Ensures per day and eat at least ___
kcal. Avoid food with salt/sodium and avoid alcohol at all
costs.
- Avoid the use of any NSAIDs (naproxen, ibuprofen, Alleve,
Motrin etc). You make take up to ___ mg acetaminophen (Tylenol)
per day.
- Please call your doctor or present to the emergency department
if you experience any of the danger signs listed below.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Atorvastatin 10 mg PO DAILY
2. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Levothyroxine Sodium 225 mcg PO DAILY
4. Lorazepam 1 mg PO Q6H:PRN anxiety
5. Ursodiol 500 mg PO BID
6. Lactulose 30 mL PO DAILY
RX *lactulose [Enulose] 10 gram/15 mL 30 ml by mouth three times
a day Refills:*5
7. Linezolid ___ mg PO Q12H
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
8. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth Q6H:PRN Disp #*90
Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Furosemide 20 mg PO DAILY
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze
14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation bid
15. TraZODone 100 mg PO HS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth QHS:PRN Disp #*30
Tablet Refills:*0
16. Outpatient Lab Work
LFTs, CBC, CHEM 10.
Forward results to Dr. ___ #: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you while you were here. You
came to us with jaundice and after extensive testing and workup
we found a cancer in your bile duct, called cholangiocarcinoma.
We placed a metal stent to open the occluded duct to allow bile
to drain. We also placed markers to help the radiation
oncologists give you directed radiation treatment. You will have
close follow up with interventional radiology for the bile
drain, with radiation oncology and medical oncology for chemo
and radiation, and with your liver doctor.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
2. Vitamin D 1000 UNIT PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
5. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
6. Outpatient Physical Therapy
___ rehab
Discharge Disposition:
Home
Discharge Diagnosis:
peripheral vertigo
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: no truncal ataxia, very unsteady on his feet and falls
backwards. CN exam benign, motor exam ___ throughout. No
nystagmus. Inconclusive HIT.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted for vertigo. This is likely due to a middle
ear problem. Your MRI of your brain did not show a stroke. Of
note, you were also found to have a community-acquired
pneumonia. We treated you with IV antibiotics while you were in
the hospital. You ___ continue azithromycin for an additional
three days at home.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
2. Ondansetron ODT 4 mg PO TID W/MEALS nausea
3. Senna 8.6 mg PO BID Constipation - First Line
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. Epogen (epoetin alfa) 20,000 unit/mL injection q14 days
8. Ferrous Sulfate 650 mg PO DAILY
9. HydrALAZINE 10 mg PO TID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Sodium Bicarbonate ___ mg PO TID
14. Torsemide 20 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Small bowel obstruction
Acute on chronic kidney disease
Klebsiella urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital for a bowel obstruction.
Typically we treat this with bowel decompression by an NG tube.
You asked that the NG tube be removed after it was initially
placed. Your bowel obstruction was not resolving spontaneously,
so surgery was consulted. They were willing to consider surgery
in you, but you declined. Your bowel obstruction gradually
resolved spontaneously. You abdominal pain resolved on ___ and
you started passing gas. On ___ you started passing stool. You
diet was advanced and you were able to tolerate a regular diet.
For the subsequent days in the hospital you continued to pass
normal bowel movements and continued to tolerate a regular diet
without abdominal pain or nausea. After your small bowel
obstruction resolved, you were evaluated by physical therapy.
They felt that you were physically deconditioned and would
benefit from acute rehab prior to returning to your assisted
living facility. Initially your kidneys were injured, but they
returned to your baseline as your small bowel obstruction
resolved. You were also treated for a urinary tract infection.
It will be important to take your medications as directed below
and follow up with your primary care doctor.
Best of luck with your continued healing.
Take care,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*3
2. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
4. Isoniazid ___ mg PO DAILY
RX *isoniazid ___ mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. LaMIVudine 100 mg PO DAILY
RX *lamivudine 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch every AM Disp #*30 Patch
Refills:*0
7. Ondansetron ODT 8 mg PO ASDIR
RX *ondansetron 8 mg 1 tablet(s) by mouth TID prn Disp #*30
Tablet Refills:*3
8. Pyridoxine 50 mg PO DAILY
RX *pyridoxine (vitamin B6) 50 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
9. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth @hs Disp #*30 Tablet
Refills:*0
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*3
11. Topiramate (Topamax) 25 mg PO BID
RX *topiramate [Topamax] 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
12. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth every 8 hours as
needed Disp #*30 Tablet Refills:*0
13. Artificial Tear Ointment 1 Appl BOTH EYES PRN ___ eyes
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
lymphoma
atrial tachycardia
subdural hemorrhage
indolent TB
hep B
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
You were admitted with back pain and found to have lymphoma. You
were started on chemotherapy for this and will continue this
outpatient with Dr. ___.
During your hospitalization, you were found to have an elevated
heart rate, this was treated with medications and you will
continue to follow up with the cardiology team outpatient to
manage this. You also were found to have a bleed in your brain
due to low blood counts associated with your lymphoma. This
resolved with time.
You will follow up in the clinic as stated below. It was a
pleasure taking care of you. Please call in the meantime with
any questions or concerns.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 1000 mg PO QHS:PRN dyspepsia
3. Gabapentin 100 mg PO BID
4. Guaifenesin 10 mL PO Q6H:PRN cough
5. Levothyroxine Sodium 12.5 mcg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Milk of Magnesia 30 mL PO Q6H:PRN dyspepsia
8. Mirtazapine 15 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. Acetaminophen 650 mg PO TID
11. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
12. Fleet Enema ___AILY:PRN constipation not relieved
by dulcolax
13. Furosemide 20 mg PO DAILY
14. Hydrocortisone Cream 1% 1 Appl TP BID:PRN inflammation
15. Omeprazole 20 mg PO BID
16. Sucralfate 1 gm PO QID Duration: 14 Days
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*52 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital because you were having
abdominal pain. You were found to have inflammation in your
abdomen around the first part of your small intestine called the
duodenum. There was evidence of inflammation but no signs of
infection. Your abdominal pain improved significantly while you
were in the hospital. It's important that you follow up with
your primary care doctor who will be able to refer you for an
upper endoscopy to further investigate the fluid collection once
the inflammation has resolved.
You are now ready to be discharged. Please continue taking your
medications as instructed.
It was a pleasure taking care of you,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth three times a day Disp #*180 Tablet
Refills:*0
2. Captopril 25 mg PO TID
RX *captopril 25 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. Digoxin 0.25 mg PO DAILY
RX *digoxin 250 mcg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
6. Glargine 12 Units Breakfast
Glargine 14 Units Bedtime
Humalog 19 Units Breakfast
Humalog 16 Units Lunch
Humalog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 12 Units before BKFT; 14 Units before BED; Disp
#*10 Syringe Refills:*1
RX *insulin lispro [Humalog KwikPen Insulin] 200 unit/mL (3 mL)
AS DIR 19U with breakfast, 16U with lunch, 14U with dinner Disp
#*10 Syringe Refills:*1
RX *insulin syringe-needle U-100 31 gauge X ___ Please use with
pens for insulin administration Disp #*5 Package Refills:*2
7. Ipratropium Bromide MDI 2 PUFF IH QID:PRN SOB
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 puffs
IH four times a day Disp #*1 Inhaler Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % Please apply one patch once daily
Disp #*30 Patch Refills:*0
9. LORazepam 0.5 mg PO Q8H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth every
eight (8) hours Disp #*15 Tablet Refills:*0
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
11. OxyCODONE SR (OxyconTIN) 10 mg PO DAILY
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Senna 8.6-17.2 mg PO QHS:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Sildenafil 20 mg PO TID
RX *sildenafil (antihypertensive) 20 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
15. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
16. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
17. Torsemide 20 mg PO DAILY
Total daily dose should be 120mg once daily.
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
18. Warfarin 8 mg PO DAILY16
RX *warfarin 4 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
19. Aspirin 162 mg PO DAILY
RX *aspirin 81 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
20. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
21. Torsemide 120 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
22. TraZODone 50 mg PO QHS:PRN Insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
23. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puff IH twice
a day Disp #*1 Inhaler Refills:*0
24. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
25. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
26. Sertraline 100 mg PO DAILY
RX *sertraline 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
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
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital because of dizziness. Please
see below for more information on your hospitalization. It was a
pleasure participating in your care!
What happened while you were in the hospital?
- Examination of your heart using a catheter showed that it
needed mechanical support.
- You had an intra-aortic balloon pump placed, then an impella,
and finally these were changed to a left ventricular assist
device to help your heart pump.
- A CT scan of your arm showed a blood clot.
- Our pulmonary team drained fluid from your left lung twice.
- A chest tube was placed in your lung to help drain additional
fluid.
- You received multiple blood transfusions to keep your blood
counts up.
- You received 4 weeks of antibiotics for a blood stream
infection.
What should you do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
For your LVAD,
- Please shower daily
- Wash incisions gently with mild soap, no baths or swimming,
look at your incisions daily
- NO lotion, cream, powder or ointment to incisions
- Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
- No driving for approximately one month and while taking
narcotics
- Clearance to drive will be discussed at follow up appointment
with surgeon
- No lifting more than 10 pounds for 10 weeks
- Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
We wish you the best!
- Your ___ Healthcare Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week: For 12 weeks.
2. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
3. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for Dry skin: Apply to
areas of bruised and/or dry skin.
Disp:*1 tub* Refills:*2*
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO 1X/WEEK
(___).
Disp:*15 Tablet(s)* Refills:*0*
10. tolvaptan 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please have AST, ALT, Alk Phos, Total bilirubin, a full
chemistry panel, and CBC with Differential on ___
and have the results called in to ___, MD
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Decompensated Cirrhosis
Hyponatremia
AAA
.
Secondary:
Diabetes, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted for low sodium, which is an electrolyte that
circulates in your blood. After changing some of your medicines
and starting a new one called tolvaptan, your number improved.
You also had evidence of an infection in your belly, which we
treated with 5 days of IV antibiotics. You should start an oral
antibiotic to prevent this type of infection from developing
again in the future. We also changed your atenolol to nadolol,
which is a better medication to lower your heart rate and helps
prevent bleeding related complications of your liver disease.
.
You should also follow-up with your primary doctor regarding
your diabetes and blood sugars, which were elevated during this
hospitalization. You should also have lab-work done on ___
when you see your PCP, and make sure Dr. ___ a copy
of the results.
.
You should follow-up with your doctors, as listed below.
.
Please note the following medication changes:
-Please STOP atenolol
-Please START nadolol
-Please START tolvaptan
-Please START ciprofloxacin
-Please STOP aspirin until you see your PCP on ___ and ___
whether it is safe to restart this medicine.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Mirtazapine 22.5 mg PO QAM
7. Mirtazapine 45 mg PO HS
8. Acetaminophen 650 mg PO Q6H:PRN pain, fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*40 Tablet Refills:*0
9. Clindamycin 1 Appl TP BID
10. Clotrimazole Cream 1 Appl TP BID
11. Differin *NF* (adapalene) 0.1 % Topical qhs
12. econazole *NF* 1 % Topical BID
13. Estradiol Transdermal Patch *NF* (estradiol) 0.25 mg/24hr
Transdermal weekly
14. Loratadine *NF* 10 mg Oral daily
15. Ibuprofen 400-600 mg PO DAILY:PRN shoulder pain
RX *ibuprofen 200 mg ___ tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine
Secondary diagnoses:
hypertension
asthma
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted for
a severe headache. Scans of your brain were performed which came
back normal. A lumbar puncture was attempted multiple times
without success in order to rule out dangerous causes of
headache. Your headache improved on its own. It was most likely
due to a migraine rather than something dangerous. We recommend
you keep a journal of your headaches to help identify any
triggers. For your shoulder pain, I would recommend speaking
with your primary care physician about an appropriate pain
regimen. In the meantime, use ibuprofen sparingly and ice packs
on the area.
We made the following changes to your medications:
START ibuprofen as needed
START tylenol as needed
If you experience another migraine, you can call ___ to
speak to the neurology urgent care line.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Docusate Sodium 100 mg PO BID
2. Famotidine 20 mg PO Q12H
3. Furosemide 20 mg PO DAILY
hold for SBP<100
4. Glargine 30 Units Bedtime
5. Metoprolol Tartrate 12.5 mg PO BID
hold for SBP<100, HR<60
6. Mycophenolate Mofetil 1000 mg PO BID
7. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
hold for oversedation, RR<12
8. Oxycodone SR (OxyconTIN) 80 mg PO Q6H
hold for oversedation, RR<12
9. Senna 2 TAB PO BID
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Ursodiol 300 mg PO BID
12. Tacrolimus 1 mg PO BID
13. ValGANCIclovir 450 mg PO DAILY
14. fenofibrate *NF* 54 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Transaminitis
- Acute on chronic renal failure
Secondary Diagnosis:
- Orthotopic Liver transplant recipient
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital from
clinic due to an increase in your liver enzymes (showing damage
to your liver). You underwent a liver biopsy which showed no
graft rejection but was concerning for Hepatitis C reactivity or
bile duct obstruction. You underwent an ERCP which showed no
bile duct obstruction, making recurrent Hepatitis C the most
likely cause of your elevated liver enzymes.
You also came in with injury to your kidneys. This was thought
to be due to your Prograf level being too high. Your dose was
decreased and your kidney function improved. This will continue
to be followed.
It is VERY important that you follow up with your GI
appointments listed below. It is also VERY important that you
have repeat laboratory testing tomorrow, ___, to
ensure your kidney function continues to improve and your
Prograf levels remain at goal.
Once again, it was a pleasure participating in your care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*41 Tablet Refills:*0
2. Gabapentin 100 mg PO QAM
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Gabapentin 100 mg PO Q12PM DAILY
4. Advair HFA (fluticasone-salmeterol) 115-21 mcg/actuation
inhalation 1 puff daily
RX *fluticasone-salmeterol [Advair HFA] 115 mcg-21 mcg/actuation
1 puff inhaled once a day Disp #*1 Inhaler Refills:*0
5. Ambien CR (zolpidem) 12.5 mg oral QHS
6. Aspirin 81 mg oral DAILY - ASPERDRINK FORMULATION
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Avapro (irbesartan) 75 mg oral daily
RX *irbesartan 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
9. DULoxetine 60 mg oral DAILY
RX *duloxetine 60 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 1 spray intranasal once a day
Disp #*30 Spray Refills:*0
11. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
12. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
13. Lactulose 30 mL PO BID:PRN constipation
RX *lactulose 10 gram/15 mL 30 ml by mouth twice a day
Refills:*0
14. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
___ puffs every ___ hours as needed for cough/wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every 4 to 6 hours Disp #*2 Inhaler Refills:*0
16. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
17.Rolling Walker
Please provide rolling walker
Diagnosis: Gait instability ICD 10: ___
Prognosis: Good
Length of Need: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pulmonary embolism
Secondary diagnosis:
Trigeminal neuralgia
Facial spasms
Hypertension
Pulmonary Hypertension
Thyroid nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
Thank you very much for allowing us to care for you during your
hospitalization at ___. During your hospitalization:
- We noticed you had facial pain and twitching and treated you
with pain medication. We also made sure you were not having a
stroke.
- We found that you had blood clots in your lungs and treated
you with blood thinning medications.
When you are discharged, it is important that you:
- Take all of your prescribed medications, especially a new
medication called apixaban.
- It is important that you follow up with your primary care
physician, ___. We will make you an appointment
- It is important that you follow up with your neurologist, Dr.
___ your facial pain and twitching. We will make
you an appointment.
It was a privilege to participate in your care.
Best wishes,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Lidocaine Viscous 2% 15 mL PO TID:PRN tooth pain
RX *lidocaine HCl [Lidocaine Viscous] 2 % take 15mL three times
a day as needed Disp ___ Milliliter Milliliter Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H Duration: 8 Days
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Repaglinide 0.5 mg PO BIDWM
take at breakfast and at dinner with food
RX *repaglinide 0.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Warfarin 7.5 mg PO DAILY16 leg clot
RX *warfarin 2.5 mg 3 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
7. Glargine 22 Units Breakfast
RX *blood sugar diagnostic ___ Aviva Plus test strp] use
with glucose meter Disp #*100 Strip Refills:*0
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 22 Units before BKFT; Disp #*2 Package Refills:*0
RX *blood-glucose meter ___ Aviva Plus Meter] use as
directed Disp #*1 Each Refills:*0
RX *lancets ___ Softclix Lancets] as directed once a day
Disp #*100 Each Refills:*0
8. Docusate Sodium 100 mg PO BID
9. Ferrous GLUCONATE 240 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Levothyroxine Sodium 12.5 mcg PO DAILY
12. Lisinopril 10 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Simethicone 120 mg PO QID:PRN constipation
15. Tamsulosin 0.4 mg PO QHS
16. HELD- CARVedilol 3.125 mg PO BID This medication was held.
Do not restart CARVedilol until you speak with your primary care
provider about why you were taking this medication.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
=================
Gastrointestinal bleed
Deep venous thrombosis
Splenic Lesions
SECONDARY DIAGNOSES
====================
Type II Diabetes
Hypertension
History of subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were noted to have high blood sugars and low blood counts
in clinic.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a colonoscopy to look into your gut which showed
inflammation. We also took a sample of the tissue in your
colon, which did not show cancer or inflammatory bowel disease
that would require further treatment.
- You were found to have a blood clot in your leg. You were
placed on blood-thinning medications to treat this.
- You also underwent full body imaging, given recent weight
loss. Based on this imaging, we took a sample of your spleen,
which was inconclusive. Because of this, we strongly recommend
that you continue to meet with our hematology/oncology team and
undergo imaging per their recommendation.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below. It is very important
that you take the warfarin and insulin every day as prescribed.
We wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
Do not exceed 4000 mg daily.
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Do not drink alcohol or drive while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ with acute appendicitis. You were
taken to the Operating Room where you underwent laparoscopic
appendectomy. You have recovered well and are now ready for
discharge. Please follow the instructions below to ensure a
speedy recovery:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Thank you for allowing us to participate in your care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
don't drink/drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*30
Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right valgus impacted femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 (One) syringe subcutaneous once a
day Disp #*30 Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*15 Capsule Refills:*0
5. Senna 8.6 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right valgus impacted femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
weight bearing as tolerated
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Call your surgeon's office with any questions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for insomnia.
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day) as needed for congestion.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for moderate to severe pain.
6. Combivent ___ mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation every ___ hours as needed for shortness of breath or
wheezing.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once a day
as needed.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Vitamin D3 2,000 unit Tablet Sig: Four (4) Tablet PO once a
day.
13. loratadine 5 mg Tablet, Chewable Sig: ___ Tablet, Chewables
PO every eight (8) hours as needed for allergy symptoms.
14. Fish Oil Oral
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
16. senna 8.6 mg Tablet Sig: ___ Tablets PO at bedtime as needed
for constipation.
17. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six
(6) hours as needed for pain.
18. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO once a
day.
19. Hospital Bed
Patient with metastatic non small cell lung carcinoma to brain
and spine, and also with history of falls, would require
hospital bed for safety.
20. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
21. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day: for total
of 10 mg per day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: toxic metabolic encephalopathy due to
hyponatremia, syndrome of inappropriate anti-diuretic hormone
Secondary Diagnosis: metastatic lung cancer with brain
metastases, hypertension, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was pleasure to take care of you at ___
___. You were admitted to the hospital with confusion
and unsteady steps and were found to have low sodium level. Your
sodium level was difficult to control, so couple of different
medications were tried in the hospital. Tolvaptan (Samsca)
worked very well but as it was too expensive and could not be
continued at home, it was discontinued. You were started instead
on furosemide (Lasix).
These CHANGES were made to your medications:
START furosemide (Lasix) 10 mg daily
DECREASE dexamethasone (Decadron) to 1 mg daily. Take this until
you are instructed by Dr. ___ to change the dosing.
STOP taking your salt tablets.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as
needed for pain control Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily as
needed for pain control Disp #*14 Capsule Refills:*0
5. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 capsule(s) by mouth Twice daily for 10
days Disp #*20 Capsule Refills:*0
6. Atorvastatin 40 mg PO DAILY
7. Clopidogrel 75 mg PO EVERY OTHER DAY
8. Enoxaparin Sodium 40 mg SC DAILY Duration: 10 Days Start:
___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sub-q Daily for 10 days Disp
#*10 Syringe Refills:*0
9. Lisinopril 20 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
L bimalleolar ankle fracture-dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>discharge instructions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing right lower extremity</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Citalopram 40 mg PO DAILY
2. Lorazepam 1 mg PO BID:PRN anxiety
3. Multivitamins 1 TAB PO DAILY
4. Sumatriptan Succinate 100 mg PO DAILY:PRN headache
5. Xeljanz (tofacitinib) 5 mg oral BID
6. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
7. cranberry 0 2 ORAL DAILY
8. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 0 1 ORAL DAILY
9. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
Do not take this medication and drive
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, possibly due to partial small bowel obstruction
Crohn's disease
Anemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>It was a pleasure taking care of you during your recent
admission to ___. You were admitted to ___ with abdominal
pain,nausea and vomiting.You were treated with bowel rest and
pain medications. You had an MRI of your abdomen which showed
evidence of chronic inflammatory bowel disease but no acute
changes. Your nausea and vomiting improved with time. It is
possible that your symptoms were due to a partial small bowel
obstruction.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Cyanocobalamin 1000 mcg PO DAILY
3. Digoxin 0.0625 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN leg pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 3 hours Disp #*60
Tablet Refills:*0
6. Pravastatin 80 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Senna 2 TAB PO BID constipation
9. Tamsulosin 0.4 mg PO DAILY
10. Docusate Sodium 200 mg PO BID
11. CefePIME 2 g IV Q12H
12. Vancomycin 750 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary
healthcare associated pneumonia
hematuria
acute kidney injury
Secondary
right hip pain
diastolic CHF
hypertension
atrial fibrillation
Discharge Condition:
The patient is clinically stable with a normal mental status. He
needs assistance with all ambulation due to chronic hip pain.
Followup Instructions:
___ [/INST] </s><s>You were admitted for pneumonia and were started on antibiotics.
You initially required oxygen but your pulmonary status improved
and you are now off oxygen. You will complete your antibiotics
course ___ rehab.
You had blood ___ your urine but the urology team feels this is
secondary to your chronic radiation cystitis and will be a
chronic problem. They have given instructions to your rehab for
how to manage blood ___ your urine if and when it comes.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. oxygen
Home Oxygen at 2 LPM via nasal cannula while ambulating
conserving device for portability
2. Acetaminophen 650 mg PO Q6H
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Atorvastatin 20 mg PO DAILY
7. DiCYCLOmine 10 mg PO BID:PRN IBS
8. Docusate Sodium 100 mg PO BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Lorazepam 1 mg PO BID:PRN anxiety
12. Omeprazole 20 mg PO BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY:PRN
itching
15. Simethicone 40-80 mg PO QID:PRN gas
16. Rehab
Outpatient pulmonary rehab
496.0 COPD
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Hypoxia
Atypical chest pain
Secondary
Lung adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted because you were feeling short of breath and
having jaw pain. Your cardiac enzymes were normal and initial
ECG findings were thought to be non-specific and did not warrant
further testing at this time. We felt your shortness of breath
was likely related to decreased oxygenation while you walk so we
started you on home oxygen to use when you are exerting
yourself.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*15 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
6. Senna 1 TAB PO BID:PRN c
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
hematuria
renal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted for evaluation of blood in the urine as well
as abdominal pain. You underwent imaging and you were found to
have a mass on/near your kidney. It is unclear at this time what
this mass represents. You were seen by the urology team who will
be following up with you to discuss options for ongoing
treatment of this mass. Please be sure to contact Dr. ___
___ office on ___ to ensure that follow up is arranged
if you have not heard from them.
.
Your MRI and CT scan reports are not finalized at this time and
will need to be followed up by the urology team as previously
planned.
.
You were given a small supply of pain medication to help with
any pain that may be associated with this mass. Please only take
this medication as prescribed, take with stool softeners and do
not drive while taking this medication. This medication can
cause sedation.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Multivitamins 1 TAB PO DAILY
2. Acetaminophen 500 mg PO Q4H:PRN pain, fever
do not take more than 6 pils in one day
RX *acetaminophen 500 mg 1 tablet(s) by mouth q4 hrs Disp #*120
Tablet Refills:*0
3. Mirtazapine 15 mg PO HS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN severe pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*60 Tablet Refills:*0
5. Cyanocobalamin 1000 mcg IM/SC EVERY 2 WEEKS
6. Ondansetron 4 mg PO Q8H:PRN nausea when taking mirtazapine
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
prescription opiate and benzodiazepine addiction and abuse
benzodiazepine withdrawal seizure
normocytic anemia
thrombocytopenia
Secondary:
chronic degenerative changes of lower lumbar spine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital because you had a seizure and
fall. This was most likely because you were withdrawing from
your lorazepam [Ativan] and possibly your Percocet. You received
treatment and did not have any evidence of additional seizures.
You did not have any additional concerning symptoms of
withdrawal. Your situation was discussed with Dr. ___
primary care physician. All of your care provider agree that you
showed behavior and symptoms highly concerning for prescription
drug addiction and abuse. Your daughters and other family
members agree with this assessment. You will no longer receive
prescriptions for benzodiazepines including lorazepam [Ativan]
from our healthcare institutions. You will also no longer
receive prescriptions for Percocets or similar strong opiate
pain medications from our healthcare institutions. You have been
given a prescription for acetaminophen [Tylenol] and tramadol to
use for pain as needed. We have also made an appointment for you
to see a pain specialist at the ___, who may perform
injections for your lower back and upper leg pain.
Your blood labs showed signs that were concerning for possible
atypical changes in your bone marrow. You were seen by our blood
and cancer specialists who performed a bone marrow biopsy. You
had several x-rays of the bones of your body, which did not show
any evidence of cancer. Many of your bone marrow test are still
in progress. Our blood specialists will be in touch with you
regarding your results. You also received a blood transfusion.
You may also need a colonoscopy as an outpatient, to be arranged
by Dr. ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 200 mg PO DAILY:PRN constipation
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Mirtazapine 15 mg PO HS
9. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 grams IV every
four (4) hours Disp #*72 Intravenous Bag Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. anastrozole 1 mg oral daily
12. Acetaminophen 325-650 mg PO Q6H:PRN Pain, fever, headache
13. Calcium Carbonate 1250 mg PO DAILY
14. Cyanocobalamin 1000 mcg IM/SC MONTHLY
15. Ferrous Sulfate 325 mg PO DAILY
16. nystatin 100,000 unit/gram topical daily
17. Vitamin D 400 UNIT PO BID
18. Indomethacin 50 mg PO TID
RX *indomethacin 50 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1. Pseugout
2. MSSA Bacteremia
3. Hypokalemia
4. Intraductal Carcinoma
5. Atrial Fibrillation
6. Hypertension
7. Anxiety/Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure to take care of you during your
hospitalization at ___. You were admitted to the hospital with
severe right knee pain which was limiting your ability to walk
and use your knee. You were found to have excess fluid in the
knee joint which was drained and showed a type of inflammatory
arthritis with crystal deposition called pseudogout. The
rheumatology (joint) specialists saw you for this problem and
removed some fluid and injected a steroid to help with the pain.
You were treated with a medication called indomethacin for pain
control which you should stop taking once your knee pain stops.
You were also treated with oxycodone for pain not controlled by
the indomethacin. We will give you a small supply of this
medication to only be taken for breakthrough pain at home.
In addition while you were in the hospital you were found to
have a very low iron level. We started you on iron supplements
which we would like for you to continue taking.
Finally, you were also continued on the Nafcillin which you were
started on at your last hospitalization for the blood stream
infection. You should continue to take this for a full 4 week
course. Please follow up with the infectious disease specialists
as scheduled from your previous admission.
Please continue to take the rest of your medications as
prescribed. ___ of luck to you in your future health.
Sincerely,
Your ___ Health Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
You were admitted to the ___ for pneumonia. Your breathing
improved and fever resolved once we started you on antibiotics.
You have a PICC line placed on your arm. You will be receiving
antibiotics through this for the total 8 day course. It is
important to complete all prescribed antibiotics.
You were also evaluated by the speech and swallow consult, who
recommended ground food and thick nectar fluids for your diet.
We found small amount of fluid in your left lung. This could be
related to pneumonia or something else. We would like you to
follow up with your PCP on this issue as well as your current
PNA after dischrage.
We have made the following changes to your medications:
- ADDED vancomycin- last day- ___
- ADDED azithromycin- last day ___
- ADDED ceftriaxone- last day ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. LORazepam 0.5 mg PO BID:PRN Anxiety
Taper as tolerated
2. Nicotine Patch 21 mg TD DAILY
You cannot smoke while taking this medication.
3. Baclofen 10 mg PO BID
4. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
5. CloNIDine 0.1 mg PO QHS
6. OLANZapine 7.5 mg PO QHS
7. Ondansetron 4 mg PO BID:PRN nausea
8. Prazosin 2 mg PO QHS
9. Pregabalin 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
Suicide attempt
Phlebitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Mr ___,
You were seen in the hospital for a suicide attempt with cocaine
and bleach. You were monitored and no issues were found. The
pain in your arm is likely a local irritation of the veins and
can be treated with warm packs. You have continued to endorse
suicidal ideation and are now being transferred to a psychiatric
unit for further care.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Simvastatin 20 mg PO EVERY OTHER DAY
2. Acetaminophen 650 mg PO Q6H
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
6. Senna 8.6 mg PO BID
7. Aspirin 81 mg PO EVERY OTHER DAY
8. Simvastatin 40 mg PO EVERY OTHER DAY
9. TraMADOL (Ultram) 50 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left hip periprosthetic fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Left lower extremity touch down weight bearing
- LLE ROM as tolerated
- Activity as tolerated
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Touchdown weight bearing, passive/active
range of motion as tolerated
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
Staples to be removed at 2-week follow-up visit.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with pain after a fall and you were found to have an obstruction
in your urinary tract. This resulted in kidney injury and an
infection in the kidney. You had a catheter placed in your
bladder to drain your urine. You were also treated with
antibiotics. With these interventions, your kidney function
improved. You also worked with physical therapy to improve your
strength and coordination. Please continue to take your
Augmentin antibiotics until XXX. You will also be discharged
with your urine catheter. Please leave this in place until you
see the urologist on ___. Thank you for allowing us to
participate in your care.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
2. Enoxaparin (Prophylaxis) 40 mg SC DAILY
Please take as prescribed
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*21
Syringe Refills:*0
3. Multivitamins W/minerals Chewable 1 TAB PO DAILY
4. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not drink or drive while taking
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
5. PredniSONE 15 mg PO DAILY Duration: 7 Doses
This is dose # 1 of 3 tapered doses
6. PredniSONE 5 mg PO DAILY Duration: 7 Doses
This is dose # 3 of 3 tapered doses
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
7. PredniSONE 20 mg PO DAILY
This is dose # 2 of 3 tapered doses
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
8. PredniSONE 10 mg PO DAILY
This is dose # 3 of 3 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ulcerative colitis flare
Acute blood loss anemia
Severe malnutrition
Post-op ileus
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted for abdominal pain and bloody diarrhea
concerning for an ulcerative colitis flare. You were treated
with antibiotics, steroids and received multiple blood
transfusions. You were evaluated by the gastroenterologists and
colorectal surgery team who both agreed surgery was the best
option. You underwent a laparoscopic total abdominal colectomy
with end ileostomy. You recovered from this procedure well and
are now ready to return home to continue your recovery.
You have a new ileostomy and stool no longer passes through the
colon (part of the body where water and electrolytes are
reabsorbed back into the body), so your output will be liquid.
The most common complication from an ileostomy is dehydration.
You must measure your ileostomy output for the next few weeks-
please bring your I&O sheet to your post-op appointment. The
output should be no less than 500cc or greater than 1200cc per
day. If you find that your output has become too much or too
little, please call the office. Please monitor for signs and
symptoms of dehydration. If you notice these symptoms, please
call the office or go to the emergency room. You will need to
keep yourself well hydrated, if you notice your ileostomy output
increasing, drink liquids with electrolytes such as Gatorade.
Please monitor the appearance of your stoma and care for it as
instructed by the ostomy nurses. ___ you notice that the stoma is
turning darker blue or purple please call the office or go to
the emergency room. The stoma may ooze small amounts of blood at
times when touched which will improve over time. Monitor the
skin around the stoma for any bulging or signs of infection. You
will follow up with the ostomy nurses in the clinic ___ weeks
after surgery. You will also have a visiting nurse at home for
the next few weeks to help to monitor your ostomy (until you are
comfortable caring for it on your own).
You have one laparoscopic surgical incision on your abdomen
which is closed with internal sutures. It is important that you
monitor this area for signs and symptoms of infection including:
increasing redness of the incision lines,
white/green/yellow/foul smelling drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. You may shower; pat the incisions dry with
a towel, do not rub. Please do not take a bath or swim until
cleared by the surgical team.
Pain is expected after surgery. This will gradually improve over
the first week or so you are home. You should continue to take
2 Extra Strength Tylenol (___) for pain every 8 hours around
the clock. Please do not take more than 3000mg of Tylenol in
24hours or any other medications that contain Tylenol such as
cold medication. Do not drink alcohol while taking Tylenol. You
may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days.
Please take Advil with food. If these medications are not
controlling your pain to a point where you can ambulate and
perform minor tasks, you should take a dose of the narcotic pain
medication tramadol. Please do not take sedating medications,
drink alcohol, or drive while taking the narcotic pain
medication.
You are being discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this medication for a
total of 30 days (including doses in hospital), please finish
the entire prescription. Please monitor for any signs of
bleeding: fast heart rate, bloody bowel movements, abdominal
pain, bruising, feeling faint or weak. If you have any of these
symptoms please call our office or seek medical attention
immediately. Please avoid any contact activity and take extra
caution to avoid falling while taking Lovenox.
Please follow the outlined steroid taper below:
Prednisone 20mg Daily ___
Prednisone 15mg Daily ___
Prednisone 10mg Daily ___
Prednisone 5mg Daily ___
Off
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs and
go outside and walk. Please avoid traveling long distances
until you speak with your surgical team at your post-op visit.
Thank you for allowing us to participate in your care, we wish
you all the best!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
2. Lisinopril 10 mg PO DAILY
3. Methylprednisolone 4 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
7. Vitamin D ___ UNIT PO DAILY
8. Simvastatin 20 mg PO QPM
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Quinine Sulfate 324 mg PO QHS
11. Terbinafine 1% Cream 1 Appl TP BID
12. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Non-cardiac chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital for chest pain. You underwent
tests to look at your heart and lungs, which fortunately did not
show any damage to either. We still do not have a good
explanation for your chest pain, so we encourage you to follow
up with your doctor to keep investigating it.
Though we do not think that your chest pain is due to your
heart, you were started on daily aspirin to protect your heart
in the future. All of your medications are detailed in your
discharge medication list. You should review this carefully and
take it with you to any follow up appointments.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Enoxaparin Sodium 90 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 0.9 mL SC twice a day Disp #*14 Syringe
Refills:*0
3. Propranolol 40 mg PO BID
RX *propranolol 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. PrimiDONE 100 mg PO QHS
RX *primidone 50 mg 2 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
5. PrimiDONE 50 mg PO QAM
RX *primidone 50 mg 1 tablet(s) by mouth QAM Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Submassive pulmonary embolism
Right ventricle strain
Right lower extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It has been a pleasure taking care of you at ___.
Why was I here?
- You were admitted to ___ for blood clots found in your lung.
What was done for me here?
- You were seen by the blood clot specialist team in the ER who
felt that you did not need any invasive procedure to remove the
clots.
- You were continued on IV heparin as a blood thinner.
- You had ultrasound of your legs which showed a large amount of
clot in the veins in your right leg.
- You had an ultrasound of your heart which showed some dilation
of the right side of your heart and some elevated pressures in
the right side of your heart.
- You were switched to Coumadin when you were feeling better.
What should I do when I go home?
- You should take your Lovenox shots twice a day.
- You should wean your Primidone medication as follows: Decrease
to 50 mg Primidone every morning and 100 mg Primidone every
evening x 3 days. On ___ decrease to no Primidone in the
morning and 50 mg Primidone in the evening x 3 days. On ___
stop taking all Primidone.
- You will start Propranolol 40 mg twice a day for your tremor.
- You have appointments with your primary care doctor,
___, urologist, and hematologist that you need to go to.
- You should discuss with your doctors before ___ to
exercise.
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*52 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Ciprofloxacin HCl 750 mg PO Q24H Duration: 3 Days
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
6. amlodipine-benazepril ___ mg ORAL DAILY
RX *amlodipine-benazepril 10 mg-40 mg 1 capsule(s) by mouth
daily Disp #*30 Capsule Refills:*0
7. ClonazePAM 1 mg PO BID:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
8. MetFORMIN (Glucophage) 1000 mg PO DAILY
RX *metformin 1,000 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Omeprazole 20 mg PO BID
10. Venlafaxine XR 150 mg PO DAILY
RX *venlafaxine 150 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Neutra-Phos 2 PKT PO DAILY Duration: 1 Dose
RX *potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250
mg 1 powder(s) by mouth daily Disp #*10 Packet Refills:*0
12. Atorvastatin 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Clostridium difficile colitis
Shigella enterocolitis
Abdominal pain
Diarrhea
Secondary:
Hypertension
HIV
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted for fever and gastrointestinal symptoms. You were found
to have two types of bacteria causing your infection (shigella
and clostridium difficile). You received medications for these.
We strongly recommend that you avoid use of any recreational
drugs in the future. Please talk to your doctor about
re-initiation of long-term treatment for your HIV. Treatment can
lower the risk of such infections drastically.
You also reported floaters in your left eye. You were schediled
for an urgent ophthalmology appointment.
We wish you well.
Your ___ Medicine Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 325 mg PO BID
2. Calcium Carbonate 500 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Acetaminophen 1000 mg PO Q8H
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO BID constipation
hold for loose stools
7. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Right humeral fracture
advanced dementia
SECONDARY DIAGNOSES:
hypertension
colostomy
history of atrial fibrillation
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - always.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___:
You were admitted to ___ because you had a broken bone in your
right arm as well as some confusion. Your confusion was most
likely due to getting some pain medications that cause confusion
as a side effect.
You were found to have a urinary tract infection for which you
were treated with an antibiotic which you will continue for 7
days (day ___.
It was a pleasure to care for you!
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. OLANZapine 5 mg PO QAM Duration: 10 Days
RX *olanzapine 5 mg 1 tablet(s) by mouth QAM Disp #*10 Tablet
Refills:*0
2. QUEtiapine Fumarate 25 mg PO QHS Duration: 10 Days
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
3. ClonazePAM ___ mg PO QHS anxiety
4. Gabapentin 400 mg PO DAILY
5. Ibuprofen 600 mg PO Q8H:PRN pain
6. LaMOTrigine 200 mg PO DAILY
7. Tecfidera (dimethyl fumarate) 240 mg oral BID
8. Vitamin D 4000 UNIT PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
10. Mirena (levonorgestrel) 20 mcg/24 hr ___ years) intrauterine
___
Discharge Disposition:
Home
Discharge Diagnosis:
MS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dr. ___,
You were admitted to the hospital for your vision changes. We
started you on IV steroids. The clinic is going to set up the
remaining treatments for the steroids. We are going to try to
coordinate this over the weekend however you will likely come
back for the next treatment on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Digoxin 0.125 mg PO DAILY
2. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lorazepam 0.5 mg PO BID:PRN anxiety, nausea
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Ranitidine 150 mg PO HS
7. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Outpatient Lab Work
Labs:
Glucose, BUN, Creat, Na, K, Cl, HCO3, Mg, Phos, Ca
ALT, AST, Alk phos, Tbili
PTT, ___, INR
Please fax results to ___
Attn: Dr. ___
10. Aspirin 81 mg PO DAILY
11. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. TraZODone 12.5 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.25-0.5 tablet(s) by mouth at bedtime as
needed for insomnia Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary: T3N2 rectal cancer complicated by lower GI bleed
secondary to radiation induced protocolitis requiring abdominal
perineal resection with end colostomy
Secondary: decompensated cirrhosis with ascites
A fib with RVR
Secondary bacterial peritonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure to take care of ___ at ___. ___ were
admitted with bleeding in your GI tract and required surgical
resection with colostomy. Your hospital course was complicated
by a fast heart rate requiring changes in your medications. ___
also had decompensation of your cirrhosis after surgery and
infection of the fluid in your abdomen for which ___ received
antibiotics. ___ had fluid removed from your abdomen and ___
were started on diuretic pills to continue to remove fluid. ___
may need another procedure to remove fluid from the abdomen in a
couple of weeks while will be determined by your outpatient
physicians. ___ were set up with follow up appointments with
your oncologist, new primary care physician, ___, and liver
specialist. It is very important that ___ continue to take your
medications as prescribed and attend your follow up
appointments. If ___ develop any fevers, abdominal pain,
confusion, bleeding, or increasing abdominal distention please
call your physicians or go to the emergency room.
Sincerely,
Your ___ medical team
Surgery notes:
Please monitor your bowel function closely. Some loose stool and
passing of small amounts of dark, old appearing blood are
expected. However, if ___ notice that ___ are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If ___ are taking narcotic pain
medications there is a risk that ___ will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If ___ have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
___ have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. ___ should have ___
bowel movements daily. If ___ notice that ___ have not had any
stool from your stoma in ___ days, please call the office. ___
may take an over the counter stool softener such as Colace if
___ find that ___ are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if ___ notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as ___
have been instructed by the wound/ostomy nurses. ___ will be
able to make an appointment with the ostomy nurse in the clinic
7 days after surgery. ___ will have a visiting nurse at home for
the next few weeks helping to monitor your ostomy until ___ are
comfortable caring for it on your own.
___ have an incision on your abdomen and the staples have been
removed. This incision can be left open to air or covered with a
dry sterile gauze dressing if it become irritated from clothing.
Please monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. ___ may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
There is an incision on your bottom where your rectum was
removed. This is healing well.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___ may
gradually increase your activity as tolerated but clear heavy
exercise with your surgical team.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck!</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*16 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheezing
5. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
6. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) TID
7. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. ginkgo biloba 60 mg oral DAILY
11. GlipiZIDE 5 mg PO DAILY
12. Lumigan 0.03% Ophth (*NF*) 1 drop Other QHS
13. Pravastatin 20 mg PO QHS
14. tacrolimus 0.1 % topical BID:PRN
15. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
16. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until instructe to
do so by a physician
___:
Home
Discharge Diagnosis:
Duodenal ulcer
Community acquired pneumonia
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for blood in your stool.
What was done for me while I was in the hospital?
- You were given a blood transfusion and fluids.
- You had an endoscopy which found ulcers in your small
intestine that were the likely source of bleeding. These ulcers
were treated to prevent future bleeding.
- You were treated with a medication to decrease stomach acid
production.
- You were found to have pneumonia and were treated with
antibiotics.
What should I do when I leave the hospital?
- Take your medications as prescribed.
- Keep all of your follow-up appointments.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Cephalexin 500 mg PO Q6H
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
4. ARIPiprazole 20 mg PO DAILY
5. Baclofen 10 mg PO TID
6. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line
7. ClonazePAM 0.5 mg PO TID:PRN anxiety
8. Docusate Sodium 100 mg PO TID
9. DULoxetine 120 mg PO DAILY
10. LamoTRIgine 100 mg PO BID
11. Mirtazapine 45 mg PO QHS
12. Pravastatin 40 mg PO QPM
13. QUEtiapine Fumarate 600 mg PO QHS
14. rOPINIRole 4 mg PO QPM
15. Tamsulosin 0.8 mg PO QHS
16. TraZODone 150 mg PO QHS:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis of R ___ digit
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a skin infection of your right middle
finger.
What was done for me while I was in the hospital?
- You were given intravenous (IV) antibiotics and switched to
pills as you continued to improve.
- Hand surgery specialists saw you and thought it was unlikely
that you had a more serious or deep tissue infection requiring
more intervention.
- An Xray was obtained of your right hand and showed no
fractures or anything more concerning than a superficial
infection.
What should I do when I leave the hospital?
- Please finish your course of antibiotics, even if you are
feeling better.
- Please follow up with your primary care physician.
Sincerely,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CloniDINE 0.3 mg PO BID
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN abdominal pain
RX *oxycodone [Oxecta] 5 mg 5 tablet, oral only(s) by mouth
every six hours as needed Disp #*15 Tablet Refills:*0
5. colesevelam 625 mg oral Daily
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Duodenitis
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to ___ for abdominal pain and were found to
have an inflammation of your pancreas and duodenum (first part
of your intestine). This may have been due to gallstones.
Over the next few days, please eat bland foods. AVOID alcohol
entirely.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
2. CarBAMazepine 100 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 3.125 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Glargine 22 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN moderate pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*18 Capsule Refills:*0
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Severe pain
RX *oxycodone 5 mg 2 capsule(s) by mouth every four (4) hours
Disp #*25 Capsule Refills:*0
10. Pancrelipase 5000 1 CAP PO QIDWMHS
11. Pantoprazole 40 mg PO Q12H
12. ammonium lactate 12 % topical BID
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Ascorbic Acid ___ mg PO BID
15. Docusate Sodium 100 mg PO BID
16. FoLIC Acid 1 mg PO DAILY
17. Guaifenesin 5 mL PO Q6H:PRN cough
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Multivitamins 1 TAB PO DAILY
20. Polyethylene Glycol 17 g PO DAILY
21. Senna 17.2 mg PO QHS
22. Gabapentin 600 mg PO QHS
23. Gabapentin 400 mg PO BID
24. Torsemide 10 mg PO DAILY
25. Warfarin 7.5 mg PO DAILY16
26. Juven (arginine-glutamine-calcium Hmb) ___ gram oral BID
27. solifenacin 10 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower GI bleed, ___, DM2, hx of LV thrombus, diverticulosis,
diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to ___ after you had a large bleed in your
gut. You required several units of blood and you had to spend a
few days in the ICU. We think the bleed came from your colon.
Over time the colon wall can become weak and develop pouches
(diverticula) that can bleed. The way to prevent this from
happening again is to eat a high fiber diet. Also, when we
looked inside your colon we found a lot of polyps. Polyps are
not cancer but they can develop into cancer and so it is
important that you follow up with your doctor and GI specialist
in order to discuss the best way to treat them.
Because of your bleed we had to stop your blood thining
medications. When we restarted them we put you on heparin
temporarily until your coumadin levels came up. It is important
for you to continue taking coumadin in order to prevent clots or
strokes. You will have your levels checked while you are at
rehab.
Your heart failure was pretty well controlled while you were
here. However, it is still very important that you weigh
yourself every morning and call your doctor if weight goes up
more than 3 lbs.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Sprintec (28) (norgestimate-ethinyl estradiol) 0.25-35
mg-mcg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Bipolar disorder with psychotic features
Volume depletion
Tachycardia
Drug induced liver injury
Rhabdomyolysis
Mild anticholinergic toxicity
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were in the hospital because you were having
hallucinations and became paranoid and agitated at your
psychiatric facility. Shortly after receiving sedating
medications at your facility, your heart rate went up and you
became lethargic. You were transferred here to make sure you did
not have any underlying medical problems causing these symptoms.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received CT scans and ultrasounds to make sure you did
not have any clots in your lungs that would cause you to have a
fast heart rate.
- You were seen by our toxicology team who made sure that you
did not have any major drug interactions or reactions from the
sedating medications you received at your facility.
- You were seen by our psychiatry team and neurology teams.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Amlodipine 2.5 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Valsartan 160 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
9. Rolling walker
Prognosis: Good
length of need: 13 Months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Benign paroxysmal positional vertigo
HTN
CHF
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms ___,
You were hospitalized due to symptoms of dizziness resulting
from Benign paroxysmal positional vertigo (BPPV). You underwent
an MRI which showed that you did not have a stroke.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
3. Sterile Water for Injection (water for injection, sterile)
10 ml tube flush DAILY
RX *water for injection, sterile [Sterile Water for Injection]
10 ml tube flush Daily Disp #*30 Ampule Refills:*0
4. Syringe without Needle (syringe (disposable)) 1 10cc syringe
miscellaneous DAILY
Please provide patient with 30 10CC syringes
RX *syringe (disposable) [BD Bulk ___ Non-Sterile] 10 mL
Instill 10ml sterile water into tube Daily Disp #*30 Syringe
Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nexplanon (etonogestrel) 68 mg Other subdermal implant
12. Pantoprazole 40 mg PO Q24H
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ were seen and evaluated for your chest pain and found to
have inflamation of your gallbladder (acute cholecystitis)
likely secondary to gallstones. ___ had a tube placed to help
relieve the pressure and your symptoms improved.
___ will still need follow up with surgery to evaluate ___ for
surgery and with interventional radiology to evaluate your tube
and set up a time to have your gallbladder removed.
Please continue to take your medications as prescribed.
PLEASE DO NOT STOP TAKING YOUR PLAVIX (CLOPIDEGREL) UNLESS
DIRECTED BY YOUR CARDIOLOGIST.
Please instill 10mL of sterile water into your tube daily as
instructed.
It was a pleasure taking care of ___!
Sincerely,
Your ___ Healthcare Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CefTRIAXone 2 gm IV Q24H
Plan for ___ weeks, to be determined by ___ ID OPAT Service
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*6 Tablet Refills:*0
3. Ascorbic Acid ___ mg PO BID
4. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
5. Enoxaparin Sodium 100 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Gabapentin 1200 mg PO TID
8. Levothyroxine Sodium 25 mcg PO 3X/WEEK (___)
9. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___)
10. Simvastatin 20 mg PO QPM
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# L hip septic arthritis
# Acute L hip osteomyelitis
# Orthostatic hypotension
# Constipation
# Hypothyroidism
# Hyperlipidemia
# History of thromboembolic disease
# Peripheral neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with L leg pain and were found to have an infection of your hip
joint. You were seen by infection doctors and ___
___. You underwent drainage of your hip infection, and an
operation on the infected bone ("girdlestone procedure"). You
were treated with antibiotics and improved. You are now ready
for discharge to rehab.
It will be important for you to complete your course of
antibiotics and follow-up with the ___ infection doctors.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every 8 hours Disp #*90 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
3. Heparin Flush (1000 units/mL) 4000-11,000 UNIT DWELL PRN
line flush
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3
hours as needed for Disp #*120 Tablet Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch every day everyday Disp
#*30 Patch Refills:*0
6. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Renal Caps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
7. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO BID:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth two times a day as needed Refills:*0
9. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth every day Disp #*30
Capsule Refills:*0
10. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally every day as
needed for constipation Disp #*60 Suppository Refills:*0
11. Calcium Carbonate 1000 mg PO QID:PRN heartburn
12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
13. Docusate Sodium 100 mg PO BID constipation
14. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day ___
minutes before food Disp #*60 Capsule Refills:*0
15. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [Senexon] 8.6 mg 1 tablet by mouth twice a day
Disp #*60 Tablet Refills:*0
16. Simethicone 40-80 mg PO QID:PRN gas pain
17. Sucralfate 1 gm PO QID
18. Tacrolimus 4 mg PO Q12H
19. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth every
night as needed for insomnia Disp #*30 Tablet Refills:*0
20. HELD- Cinacalcet 90 mg PO DAILY This medication was held.
Do not restart Cinacalcet until you speak to your nephrologist
21. HELD- Fenofibrate 48 mg PO DAILY This medication was held.
Do not restart Fenofibrate until you speak to your doctor
22. HELD- Metoprolol Tartrate 37.5 mg PO TID for afib This
medication was held. Do not restart Metoprolol Tartrate until
you speak with your primary care doctor
23. HELD- Zolpidem Tartrate 10 mg PO QHS for insomnia This
medication was held. Do not restart Zolpidem Tartrate until you
speak to your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
=================
Cyst rupture
Pyelonephritis
Pseudo aneurysm
Secondary diagnosis
====================
Autosomal dominant polycystic kidney disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you here at ___.
What happened while you were at the hospital?
- You were admitted for fever, worsening abdominal pain and
blood in your urine.
- Your physical exam was notable for significant right abdominal
tenderness and a fever.
- It was very concerning you were febrile despite being on such
serious antibiotics. We searched for an infectious source and
your work up showed your urine was concerning for an infection,
likely from your kidney. We had the infectious disease doctors
___ and they recommended an antibiotic/antifungal regimen
that you did very well on and completed on ___.
- Your course was complicated by cyst rupture which happened
over three times. These manifested as severe pain and blood in
your urine. We treated your pain with pain medication and the
blood in your urine with irrigation to ensure there was no
clotting. You required blood transfusions and we took you off
your blood thinner (warfarin). Urology did a cystoscopy on you
to investigate the source of the bleed, and there was a
complication during the procedure. Your ureter (the tube that
connects the kidney to your bladder) was nicked, a stent was put
in place to close the small cut. You will need to follow up with
urology to eventually remove the stent.
- Interventional radiology also did a renal angiogram to
investigate the bleed. They found one bleeding vessel and two
large vessels with high potential to bleed in your kidney. They
coiled off both of them. You tolerated the procedure well.
What to do on discharge?
- Please follow up with your primary care doctor for further
management of the following :
1. pain- right abdominal pain and suprapubic (lower central)
abdominal pain
2. Blood in your urine
3. Ostomy prolapse
4. Pain management
- Please follow up with urology to get the stent removed.
- Please follow up with nephrology during your next hemodialysis
session.
- If you start to experience any worsening right lower abdominal
pain or suprapubic pain, fevers, chills please seek immediate
medical help.
We are so happy to see you feeling better.
Sincerely,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: - Bupropion 300 mg daily
- Alendronate 70 mg once a week in AM
- Folic acid 1 mg daily
- Ferrous sulfate 325 mg daily
- Vitamin D 1000 units daily
- Vitamin D 50,000 units once weekly
- Calcium carbonate- vitamin D 600 mg (1500 mg) - 400 unit twice
daily
- MVI Daily
2. Outpatient Physical Therapy
DX: Cervical radiculopathy
please evaluate and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical radiculopathy
Discharge Condition:
cranial nerves intact.
Delt Bic Tri WrE FFl IO IP Quad Ham TA ___
L 5- 5- 4+ 5 4+ ___ 5 5 5 5 5
R 4+ 5- 4+ 5 3+ ___ 5 5 5 5 5
Followup Instructions:
___ [/INST] </s><s>You came to the hospital for numbness and tingling in the hands
and arms. You had a CT of the head that shows evidence of a
prior parasitic infection which is unrelated to your current
presentation. You had an MRI which showed no sign of stroke. We
feel your numbness and arm weakness are due to pinching of nerve
roots in your neck. We recommend physical therapy for this. You
should also follow up in neurology clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Doses
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*4 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 1 mg PO Q6H:PRN pain
RX *hydromorphone 2 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic cholelithiasis
Transaminitis
Steatosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ with
symptomatic cholelithiasis (stones in your gallbladder) and an
elevation in your liver enzyme levels. While you were here, we
took you to the operating room and removed your gallbladder
laparoscopically. We also took a biopsy of your liver. You
tolerated the procedure well and are now being discharged home
to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Also, your urine showed that you have a urinary tract infection,
which was present upon your arrival to this hospital. We are
treating this with oral ciprofloxacin, which you should continue
when you are discharged from the hospital for a total ___est wishes,
Your surgical team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Clotrimazole 1% Vaginal Cream 1 Appl VG HS
2. Restasis (cycloSPORINE) 0.05 % ___ BID
3. Tirosint (levothyroxine) 75-100 mcg Oral qd
4. Vivelle-Dot (estradiol) 0.1 mg/24 hr Transdermal EVERY OTHER
DAY
5. Vivelle-Dot (estradiol) 0.0375 mg/24 hr TRANSDERMAL EVERY
OTHER DAY
6. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*16 Tablet Refills:*0
8. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 180 mg 1 capsule,extended
release 24hr(s) by mouth once a day Disp #*30 Capsule Refills:*1
9. Docusate Sodium 100 mg PO BID
10. liothyronine (bulk) 1.2 mcg PO QAM
11. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*24 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 1 TAB PO BID:PRN constipation
14. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
Oral tid
Discharge Disposition:
Home
Discharge Diagnosis:
acute perforated appendicitis
atrial fibrillation with rapid ventricular response
Discharge Condition:
Medically stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were seen in the hospital for acute perforated
appendicitiis. You were treated nonoperatively. You were
started on antibiotics which you will complete a full course at
home. You were also found to have an abnormal heart rythm
called atrial fibrillation which we were able to control
medically. You were started on two medications (aspirin and
diltiazem) which you will continue to take until otherwise
directed by a cardiologist.
* Take your full course of Cipro (ciprofloxacin) and Flagyl
(metronidazole) as prescribed until the pill bottles are empty.
* Take one 325mg aspirin and one 180mg diltiazem extended
release pill daily.
* Follow up with your primary care provider within two days of
discharge.
* Follow up with cardiology (Dr. ___ within 2 days of
discharge. Call the office to make an appointment, or ask for a
referral from a cardiologist from your primary care physician.
We would ask that you make an appointment within ___ days of
discharge.
* Follow up with acute care surgery as directed below. We would
like to see you in ___ weeks. There you will discuss if further
surgery is indicated to remove your appendix.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* No strenuous activity until instructed by your surgeon.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Enoxaparin Sodium 30 mg SC Q12H atrial fibrillation bridge
to warfarin
Start: Today - ___, First Dose: Next Routine Administration
Time
d/c when INR ___
RX *enoxaparin 30 mg/0.3 mL ___very twelve (12) hours
Disp #*14 Syringe Refills:*0
3. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
6. PARoxetine 40 mg PO DAILY
7.Outpatient Lab Work
Atrial fibrillation
INR draw ___ through ___ services. Please fax INR results to
___ c/o Dr. ___ on ___. Please call
___ (Dr. ___ if any issues with the above
fax number.
8.Rolling Walker
Diagnosis: left tibia fracture, ___ metatarsal fracture
Prognosis: Good
Length of Need: 13 days
9.boot
ICD-10 Diagnoses: S82.202A UNSPECIFIED FRACTURE OF SHAFT OF
LEFT TIBIA, INITIAL ENCOUNTER FOR CLOSED FRACTURE
Services requested: Prefabricated: Aircast Boot (Tall)
Wear brace (duration): 3 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Left tibia fracture
___ metatarsal fracture
Atrial Fibrillation
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You came to the hospital after falling and fracturing your leg
bone. You underwent surgery for this with good result.
While you were in the hospital you developed a condition called
atrial fibrillation where you developed a rapid irregular heart
rate. This condition increases your risk of stroke. In
discussion with your outpatient Cardiologist Dr. ___ started
you on blood thinning medication called warfarin and lovenox. We
will have you continue the warfarin long term with monitoring of
your "INR." The use of the lovenox will be short term and Dr.
___ or your primary care physician ___ instruct you
on when to discontinue this medication once your INR is within
range.
While working with physical therapy, you had low blood pressures
while standing and walking. We recommended that you stay in the
hospital until these low blood pressures resolved. Low blood
pressures with standing can cause dangerous falls and injuries.
You indicated that you would like to go home despite these blood
pressures and voiced to us your understanding of the risk of
falling and bleeding.
You also expressed that you would have one-to-one help from your
husband. As a reminder, please be careful when standing up from
sitting or laying down. Always have something to brace yourself
(table, walker). If you feel dizzy, lightheaded or have vision
changes, please sit down immediately. Please call your doctor if
this continues to happen.
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Partial weight bearing left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
ANTICOAGULATION:
- You will be on warfarin and lovenox for atrial fibrillation.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Your appointments have been scheduled for you. See discharge
paperwork for details.
It was a pleasure being involved in your care.
-Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour Apply patch daily daily Disp #*14
Patch Refills:*0
4. Paroxetine 30 mg PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache/pain Duration: 10
Days
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hr Disp #*15
Tablet Refills:*0
6. Cyclobenzaprine 10 mg PO ONCE neck pain Duration: 1 Dose
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth every 6hr Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Retinal Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Ms. ___ you were admitted to ___ neurology service with new
vision changes. Opthalmology saw you in the ED and saw you had a
normal exam. An MRI brain was performed and you were not found
to have a stroke. An Echo of your heart was normal with no
evidence of blood clots. We have tried you on medication for
neck pain and suggest you ___ with your regular primary
care doctor regarding this problem. Also you may want to try a
pillow with neck support while sleeping. We have set you up with
outpatient opthalmology ___. We have drawn several labs to
evaluate if you are prone to blood clots, so far these are
normal but several are pending. Please have your primary care
doctor ___ on these results.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# acute EBV Mononucleosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a privilege to care for you at the ___. You were
admitted for further monitoring after presenting with abdominal
pain and fevers secondary to underlying mono. There are no
complications that warrant further hospitalization, but
unfortunately, it will take a few weeks for your symptoms to
fully resolve. We are prescribing some medications to take for
nausea. It is very important that you remain hydrated. If you
participate in any contact sports, then this should be avoided
for a total of eight weeks.
We expect that your fever will resolve over the next few days to
one week. Due to elevated liver enzymes from the mono, we
recommend that you do not take more than 2.5g of Tylenol total
in one day. It is safe to take ibuprofen as directed on the
packaging.
Lastly, we recommend arranging a follow up appointment with your
doctor once you arrive home. It is recommended that you have
repeat blood work including liver function tests and a CBC.
We wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO BID pain/fever
2. Ascorbic Acid ___ mg PO BID
3. Baclofen 10 mg PO QAM
4. Baclofen 20 mg PO Q6PM
5. Baclofen 30 mg PO HS
6. Baclofen 40 mg PO QNOON
7. Bisacodyl 10 mg PR HS
8. Diazepam 5 mg PO HS
9. Fluticasone Propionate NASAL 1 SPRY NU HS
10. Glargine 70 Units Bedtime
novolog 22 Units Breakfast
novolog 22 Units Lunch
novolog 22 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Senna 8.6 mg PO EVERY OTHER DAY
16. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
17. TraMADOL (Ultram) 50 mg PO BID:PRN pain
18. Vitamin A 10,000 UNIT PO DAILY
19. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral daily
20. Carbamide Peroxide 6.5% 4 DROP AU TWICE WEEKLY
21. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 140-100 mg oral daily
22. Miconazole Powder 2% 1 Appl TP BID
23. Natural Balance (artificial tear (hypromellose)) 0.4 %
ophthalmic daily
24. Senna 17.2 mg PO EVERY OTHER DAY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right Ischial Ulcer
Type 2 Diabetes
Right Calf Lesion concerning for Squamous Cell Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
You were admitted to the hospital for a biopsy of your bone
where you have an ulcer with concern for possible infection. The
orthopaedic surgeons took you to the operating room and on
closer examination, appears that it may not be infected.
However, final cultures are pending.
Our infectious disease doctors also saw ___ and recommended not
treating you with antibiotics unless the cultures grow.
As a result, if there is no infection, the plastic surgeons may
decide whether or not a flap over the area would be appropriate.
You will also need to follow-up with dermatology as an
outpatient as you might have a small skin cancer on your leg.
The doctors at the facility ___ also continue to help manage
your ongoing medical problems including blood sugars.
Take care.
- Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acyclovir 200 mg PO 5X/D Duration: 10 Days
RX *acyclovir 200 mg 1 capsule(s) by mouth five times a day Disp
#*20 Capsule Refills:*0
2. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Hydrocortisone Acetate 10% Foam ___ID
RX *hydrocortisone acetate [Cortifoam] 10 % 1 foam(s) rectally
twice a day Refills:*0
4. Lidocaine 5% Patch 2 PTCH TD QAM Please apply 1 patch to
each knee
RX *lidocaine 5 % apply to both affected knees daily Disp #*60
Patch Refills:*0
5. Psyllium Powder 1 PKT PO BID
RX *psyllium husk (aspartame) [Fiber (with aspartame)] 3.4
gram/5.8 gram 1 powder(s) by mouth twice a day Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
7. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg/2.5 mL 1 syringe(s) by mouth every six (6)
hours Disp #*12 Syringe Refills:*0
8. Gabapentin 200 mg PO BID
9. Lisinopril 5 mg PO DAILY
10. OxyCODONE (Immediate Release) 2.5 mg PO TID
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth three times
a day Disp #*3 Tablet Refills:*0
11. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed Disp #*6 Tablet Refills:*0
12. Acetaminophen 1000 mg PO Q8H
13. Ascorbic Acid ___ mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Levothyroxine Sodium 100 mcg PO DAILY
17. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
18. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
19. Mirtazapine 15 mg PO QHS
20. Multivitamins W/minerals 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q12H
22. Salonpas (camphor-methyl salicyl-menthol;<br>methyl
salicylate-menthol) ___ % topical DAILY
23. HELD- GlipiZIDE 5 mg PO DAILY This medication was held. Do
not restart GlipiZIDE until discussing with your primary care
doctor
24. HELD- Tamsulosin 0.4 mg PO QHS This medication was held. Do
not restart Tamsulosin until discussing with your primary care
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
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
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Ms. ___,
It was a pleasure caring for you at ___
___. You came to us with very low blood pressures and
very low blood sugar and were found to have several infections,
including an infection of your colon called Clostridium
difficile colitis and wound infections on your back (HSV 2). We
also switched your blood thinner from Coumadin to a medication
called apixaban because Coumadin was felt to be unsafe for you
with your nutritional deficit.
Please take all of your medications as detailed ___ this
discharge summary. If you experience any of the danger signs
below, please contact your primary care doctor or come to the
emergency department immediately.
Best Wishes,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
This medication can be constipating and can make your stools
dark. Take every other day.
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth every other day Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Midodrine 5 mg PO TID
RX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
tablet(s) by mouth once a day Disp #*30 Capsule Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
7.Outpatient Lab Work
Please obtain BMP, Cr, BUN, Na, K, Cl, HCO3.
Fax results to ___ , attention ___.7
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
-Alcoholic cirrhosis decompensated with ascites and esophageal
varices
-Acute kidney injury
Secondary diagnosis: alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for an enlarging belly,
belly pain, and dark stools
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- We started you on an antibiotic to protect you from infections
- You have been diagnosed with cirrhosis and underwent testing
for the cause of this. It is felt to be secondary to alcohol.
- We gave you some vitamin K to boost your blood functions
- You got some medication to decrease the amount of acid in your
stomach to protect you from bleeding
- We gave you some medication to help decrease the amount of
fluid in your belly
- We used a video camera scope to look at your esophagus to make
sure there wasn't any bleeding
- You developed a kidney injury during your stay, and we gave
you several medications to help improve blood flow to your
kidneys and keep your blood pressure up
- You received several procedures (paracentesis) to help remove
fluid from your belly to help you feel better
- Lab studies of the fluid removed from your belly did not show
any evidence of infection
- You had some fevers during your admission so we started you on
a course of antibiotics
- You had a discussion about possible liver transplant in the
future with the liver team
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Avoid drinking alcohol as it has caused your liver disease and
may result in premature death or other health complications
- Try not to drink more than 1 liter of fluids (half of a large
bottle soda) because it can make your belly larger
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- Eat a heart healthy diet (less than 2 grams of sodium per
day). This is important because it prevents your belly from
becoming bigger, which will help with pain, nausea, and
shortness of breath it may cause.
- Call your doctor or the liver doctors ___ your belly
becoming bigger, if you have shortness of breath, if you have
pain in your belly, or if you vomit blood.
We wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Hydroxychloroquine Sulfate 200 mg PO ONCE ON ODD DAY, TWICE
ON EVEN DAY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
9. Colchicine 0.6 mg PO DAILY
10. Desonide 0.05% Cream 1 Appl TP Q12H:PRN itching
Discharge Disposition:
Home
Discharge Diagnosis:
Hip Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to ___ for evaluation of hip pain. You had
an X ray and an MRI which showed ___ evidence of infection,
fractures, or muscle tears. Please follow up with your primary
care physician in the next ___ days.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>It was a pleasure taking care of you at ___.
You were admitted for abdominal pain. We felt that this was
consistent with your previous diagnosis of chronic pancreatitis.
You were given IV pain medications and your diet was held for 2
days to let your pancreas heal. After a few days, you were able
to tolerate food without worsening abdominal pain and were able
to take oral medications.
You are being discharged with the following changes to your
medications:
Please INCREASE
Omeprazole to 40mg by mouth once per day
Ranitidine to 300mg by mouth twice per day
Please STOP
Cinacalcet
Otherwise please take all medications as prescribed, including
your home doses of narcotics.
Due to your low blood sugars while in the hospital and at home,
we would like you to follow up with endocrinology.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Dapsone 100 mg PO DAILY
RX *dapsone 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Duloxetine 60 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO MWFSU
4. Hydroxychloroquine Sulfate 400 mg PO TTHSAT
5. Nortriptyline 10 mg PO HS
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID chest rash
RX *triamcinolone acetonide 0.1 % Apply to affected area twice a
day Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
8. Gabapentin 200 mg PO TID
9. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
10. Hydrochlorothiazide 25 mg PO DAILY
11. irbesartan 300 mg oral daily
12. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
13. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Secondary Diagnosis: lupus, +lupus anticoagulant antibodies,
+anti-cardiolipin antibodies
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were hospitalized due to symptoms of vertigo/dizziness.
These symptoms are likely caused by a lesion in your brainstem -
one of the places in your brain that helps to control balance.
The exact nature of this lesion is unclear, but it is probably
related to your lupus. It appears to be stable on 2 sets of
imaging (it did not increase in size during your
hospitalization).
Your warfarin (Coumadin) was held for several days during this
admission. Please restart this medication tomorrow.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Labetalol 300 mg PO BID
2. Allopurinol ___ mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Acetaminophen 650 mg PO TID
do not take more than 2000mg per day
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 by mouth at bedtime Disp #*60
Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
10. Aspirin 81 mg PO DAILY
11. GlipiZIDE XL 20 mg PO DAILY
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [OneTouch Verio] one ___ times daily
Disp #*1 Box Refills:*5
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 17
Units QID per sliding scale Disp #*2 Syringe Refills:*2
RX *lancets [OneTouch Delica Lancets] 33 gauge one ___ times
daily Disp #*1 Box Refills:*5
13. Pioglitazone 15 mg PO DAILY
14. Insulin Pen Needles
32 G, ___ (4mm Nano)
Use to inject insulin 4 times daily
Supply: #100
Refills: 2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatic abscess/perforated gallbladder
cholelithiasis
DM, uncontrolled
Lung Nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Please call Dr. ___ ___ if you have any of the
following: temperature of 101 or chills, nausea, vomiting,
jaundice (yellowing of whites of eyes/skin), abdominal
distension, incision redness/bleeding/drainage, constipation or
diarrhea
Empty abdominal drain when half full and record all output.
Change dry gauze dressing daily and as needed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*60 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary macroadenoma
Pituitary Appoplexy
Hypokalemia
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted for workup of a Sellar MAss consistent with
Pituitary macroadenoma found on imaging after you complained of
headache, anusea, and vomiting. You underwent a MRI of your
pituitary gland and had an endocrinology workup to assess if the
lesion was causing abnormal levels of hormones to be secreted.
All work-up shows that the lesion is non-secreting. Given its
size and compression of the optic nerve, Dr. ___ has
recommended surgical intervention.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
may cause dizziness, do no drive while on this medicaiton
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Omeprazole 20 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
qid
Discharge Disposition:
Home
Discharge Diagnosis:
laparoscopic appendectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>You were admitted to the hospital with abdominal pain. You
underwent cat scan imaging which was suggestive of appendicitis.
You were started on antibiotics and taken to the operating room
to have your appendix removed. You are recovering from your
surgery and you are preparing for discharge home with the
following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4-6H SOB
per ___, rarely uses
3. Aspirin 81 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
per ___, uses rarely.
5. Furosemide 60 mg PO BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Simvastatin 40 mg PO DAILY
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Docusate Sodium 100 mg PO BID
12. Enoxaparin Sodium 30 mg SC Q24H
please continue while at rehab. Can discontinue once pt
discharged to home.
13. FoLIC Acid 1 mg PO DAILY
14. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
15. Polyethylene Glycol 17 g PO DAILY:PRN constipatino
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
17. NIFEdipine CR 90 mg PO DAILY
please hold for SBP < 100 or HR < 60
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p fall
anemia
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear ___,
___ was a pleasure participating in your care. You were
admitted for a fall and found to have a small hip fracture. You
were also found to have anemia worse than your baseline, and
worsening kidney function. You were treated with your home
medications and improved. You were also seen by ___ who felt you
would benefit from ___ rehab.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Nadolol 20 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
Hold for sedation, RR<12
5. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute-on-chronic pancreatitis
Esophagitis
Discharge Condition:
Discharge condition: Improved, abdominal pain-free, tolerating
solid foods
Mental status: A0x3, appropriately interactive
Ambulatory status: Independent
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure taking care of you. You were admitted with
abdominal pain consistent with previous episodes of pancreatitis
in the setting of alcohol use and an episode of bloody vomiting.
A study of your upper gastrointestinal tract showed severe
inflammation of the esophagus, for which you were treated with
medication (pantoprazole), which you should continue to take
after discharge. You were treated with pain medication for
pancreatitis, and you were monitored, but did not show signs of
alcohol withdrawal. It is very important that you try to cut
down on your drinking in order to avoid further complications of
heavy alcohol use.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Levofloxacin 750 mg PO DAILY Duration: 1 Day
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
4. FoLIC Acid 5 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg IM Q6H:PRN Pain - Severe
6. Lisinopril 2.5 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Upper respiratory tract infection
Metastatic rectal carcinoma
Anemia
Thrombocytopenia
Secondary Diagnoses:
Sickle cell disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had an upper respiratory tract infection. You had a life
threatening reaction to an antibiotic administered to treat your
upper respiratory infection.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You required CPR to revive you following a dangerous reaction
to an antibiotic (Zosyn).
- You were monitored in the intensive care unit.
- Your blood counts were low and you required a blood
transfusion.
- You were treated with antibiotics for an upper respiratory
tract infection.
- You pain was controlled with IV pain medications.
- You improved and were ready to leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Pantoprazole 40 mg PO Q24H
2. Simethicone 40-80 mg PO QID:PRN gas pain
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach discomfort
RX *alum-mag hydroxide-simeth [Antacid] 200 mg-200 mg-20 mg/5 mL
___ mL by mouth four times a day Refills:*3
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. Ascorbic Acid ___ mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN neck pain
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*24 Tablet Refills:*3
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*3
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet(s) by
mouth daily Disp #*30 Packet Refills:*6
13. Docusate Sodium 100 mg PO BID constipation
14. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
15. Ondansetron 8 mg PO Q8H:PRN nausea
oral dissolving tablet
RX *ondansetron [___] 8 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*60 Tablet Refills:*3
16. Enoxaparin Sodium 130 mg SC Q24H
Start: Today - ___, First Dose: First Routine
Administration Time
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: orthostasis
Secondary diagnosis: nausea, vomiting, lung cancer,
constipation, dysuria/increased urinary frequency, vaginal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted for workup of your nausea, vomiting, and drop
in blood pressure. While you were here you received IV fluids
and medications to help with your symptoms. The palliative care
service was consulted and they helped us manage your symptoms.
You will follow up with Dr. ___ as an outpatient to discuss
further treatment for your lung cancer. We had considered doing
a lumbar puncture to look for causes of your dizziness, however,
as you were doing better, we decided not to do this in the
hospital.
We wish you the best,
Your ___ team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. CefazoLIN 2 g IV Q8H
Through ___
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV q8 hours
Disp #*90 Unit Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain, fever
3. Atenolol 25 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY
5. BuPROPion 200 mg PO QAM
6. BuPROPion 250 mg PO QPM
7. Citalopram 40 mg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
10. Maalox/Diphenhydramine/Lidocaine 30 mL PO TID mouth sores
11. Omeprazole 40 mg PO BID
12. Gabapentin 400 mg PO HS
13. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
RX *oxycodone [OxyContin] 40 mg 1 tablet extended release 12
hr(s) by mouth twice a day Disp #*60 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Pravastatin 20 mg PO DAILY
16. Ranitidine 300 mg PO DAILY
17. Senna 2 TAB PO BID
18. Vitamin D 1000 UNIT PO DAILY
19. ClonazePAM 0.25 mg PO TID:PRN anxiety
RX *clonazepam 0.5 mg ___ (one half) tablet(s) by mouth three
times a day Disp #*60 Tablet Refills:*0
20. Rifampin 450 mg PO Q12H
Through ___
RX *rifampin 150 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
RX *rifampin 300 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
21. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral DAILY
22. Celecoxib *NF* 400 mg ORAL DAILY
23. Estradiol 0.5 mg PO DAILY
24. MedroxyPROGESTERone Acetate 2.5 mg PO DAILY
25. Vesicare *NF* (solifenacin) 10 mg Oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Hip pain
Secondary Diagnosis:
1. hx of MSSA bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear. ___,
___ were admitted to the Internal Medicine service at ___
___ on ___ 7 regarding management
of your persistent left hip pain. CT imaging showed fluid in the
hip and thigh, which was likely from post-surgical changes.
Aspiration fo the fluid and fluid culture did not show signs of
infection. Therefore ___ were managed with PCA dilaudid and
ketorolac, before being transitioned to oral dilaudid and
oxycontin for the pain.
It is important to take all of your medications as prescribed.
In addition, please make every attempt to attend your follow-up
appointments, as scheduled.
Please call your doctor or go to the emergency department if:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* ___ develop new or worsening cough, shortness of breath, or
wheezing.
* ___ are vomiting and cannot keep down fluids, or your
medications.
* If ___ are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* ___ see blood or dark/black material when ___ vomit, or have a
bowel movement.
* ___ experience burning when ___ urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* ___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* ___ develop any other concerning symptoms.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Ampicillin 500 mg PO Q6H
RX *ampicillin 500 mg 1 capsule(s) by mouth four times a day
Disp #*100 Capsule Refills:*0
2. Senna 17.2 mg PO BID
3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
5. ClonazePAM 1 mg PO BID
6. MorphaBond ER (morphine) 15 mg oral BID:PRN
7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
septic shock
nephrolithiasis
obstructive uropathy
acute kidney injury
anemia
thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
It was a pleasure caring for you. You were admitted for a
serious infection and blockage in your urinary tract. For this
you received a tube to relieve the obstruction ("percutaneous
nephrostomy") and antibiotics. Please continue the antibiotics
as prescribed follow up with urology for definitive treatment of
the blocking stone.
Nephrostomy tube instructions: This no longer requires flushing.
You may change the external dressing if it becomes
soaked/saturated with liquid as needed.
Ostomy instructions: You and your wife have been instructed on
ostomy care. You are also going to have an ostomy nurse come to
your house to assist you.
We wish you the best in your recovery!
Sincerely, your ___ Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: [/INST] </s><s>Dear Mr. ___,
You were admitted to ___ due to reactivation of your Hepatitis
B Virus after you stopped taking your antiviral medications.
Your liver tests showed severe liver decompensation while on
tenofovir, so we added another antiviral medication, entecavir,
and your Hepatitis B viral load has continued to downtrend. Your
liver tests have been slowly improving, and you were evaluated
for a potential liver transplant should you need one in the
future.
It is vital that you continue taking all of your medications,
most importantly your two antiviral medications (tenofovir and
entecavir) every day indefinitely to prevent this from happening
again. Please also continue your tube feeds, as your nutrition
is vital for your recovery.
It was a pleasure taking care of you.
Sincerely,
Your ___ Liver Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. LeVETiracetam 500 mg PO BID
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Nystatin Oral Suspension 15 mL PO QID
4. Omeprazole 20 mg PO DAILY
5. Senna 1 TAB PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
6. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth q12hrs Disp #*60 Tablet
Refills:*0
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Docusate Sodium 200 mg PO DAILY constipation
RX *docusate sodium 100 mg 2 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
11. Tamsulosin 0.4 mg PO HS
12. Testosterone 4 mg Patch 1 PTCH TD Q24H
13. Zolpidem Tartrate ___ mg PO HS
14. Enoxaparin Sodium 50 mg SC Q12H
RX *enoxaparin 100 mg/mL Inject 50mg of enoxaparin two times per
day. q12hrs Disp #*30 Syringe Refills:*0
15. Glargine 15 Units Breakfast and Glargine 10 Units Dinner
16. Insulin SC Sliding Scale using HUM Insulin
17. Dexamethasone 6 mg PO DAILY
RX *dexamethasone 6 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- metastatic cutaneous melanoma
- pulmonary embolism
SECONDARY:
- acute confusional state
- diabetes
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___ [/INST] </s><s>Dear Mr. ___,
Thank you for choosing ___ for your medical care. You were
admitted to ___ on ___ for altered mental status and
confusion. You were evaluated by the neuro-oncology team, who
determined your confusion was probably caused by lesions in your
brain. You were started on a new medication, called bevacizumab
(Avastin) for this issue. Unfortunately, you experienced a
pulmonary embolism (a bloot clot in your lungs) probably as a
complication both from your melanoma and your new treatment with
Avastin. You will need to take anti-coagulation with Lovenox
injections twice per day to treat this (prevents worsening of
the clot).
You should keep your scheduled appointments with your doctors
for ___.
Please call Dr. ___ office at ___ or come
to the ER if you experience any of the following: Headache,
change in vision or taste or smell or hearing, numbness/tingling
in any part of your body, weakness or difficulty moving part of
your body, lightheadedness or dizziness, chest pain, trouble
breathing, abdominal pain, nausea, vomiting, diarrhea, new rash
or bleeding, or any other symptoms that concern you.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acyclovir 400 mg PO Q12H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Atovaquone Suspension 1500 mg PO DAILY
4. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
8. Nephrocaps 1 CAP PO DAILY
9. Ondansetron 4 mg IV Q8H:PRN nausea/vomitting
10. Simethicone 40-80 mg PO QID:PRN gas/bloating
11. Ursodiol 300 mg PO BID
12. PredniSONE 10 mg PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Fluticasone Propionate NASAL 1 SPRY NU BID
15. Omeprazole 40 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Atorvastatin 20 mg PO QPM This medication was held.
Do not restart Atorvastatin until your PCP tells you to do so.
18. HELD- NIFEdipine (Extended Release) 60 mg PO DAILY This
medication was held. Do not restart NIFEdipine (Extended
Release) until your PCP instructs you to do so.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=========
Diffuse large B cell lymphoma
Acute renal failure
Febrile neutropenia
SECONDARY
===========
Hyperbilirubinemia
Transaminitis
Malnutrition
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why were you admitted to the hospital?
- You were having fevers and a cough after recently finishing
treatment for a pneumonia.
What was done while you were in the hospital?
- You were found to have a type of cancer called Diffuse Large B
Cell Lymphoma.
- You were given chemotherapy to treat your cancer.
- During your hospitalization you developed kidney failure and
had to be started on dialysis.
- You had a low appetite and had a feeding tube for a while.
Your appetite improved so we let you eat on your own.
What should you do when you go home?
- You should take all your medications as directed.
- Please follow up with your outpatient providers as listed
below.
We wish you the best,
Your ___ Care Team</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Acetaminophen 1000 mg PO BID:PRN pain
2. Calcium Carbonate 500 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Divalproex (EXTended Release) 750 mg PO QHS
5. Divalproex (EXTended Release) 500 mg PO QAM
6. Felbatol *NF* (felbamate) 1200 mg ORAL TID Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Lorazepam 2 mg PO Q6H:PRN seizure >5 min or >7 head drops in
two hours, or generalized convulsive seizure or staring spell
longer than 5 min
Max 4mg in 12 hours
10. Montelukast Sodium 10 mg PO HS
11. Oxcarbazepine 600 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. Rufinamide 800 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY
15. Milk of Magnesia 30 mL PO PRN if no BM in 3 days
16. Pregabalin 150 mg PO QAM
17. Pregabalin 250 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
1. ___ Gastaut epilepsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
You were admitted to the hospital with a cluster of seizures.
You received ativan while hospitalized, but did not need any
changes in your home anti-epileptic drugs because your seizure
frequency was overall unchanged. We looked for causes of your
seizure cluster (such as infection) and did not find anything
concerning. You were monitored on EEG and did not have any
seizures.
.
Please attend the follow-up appointment listed below with your
neurologist Dr. ___.
.
We did not make any changes to your medications. Please continue
taking them as you were prior to hospitalization.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create discharge instructions of the following text: 1. Gabapentin 300 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH QID:PRN wheezing
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO AM ___
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Loratadine *NF* 20 mg Oral BID
10. Amitriptyline 25 mg PO HS
11. HydrOXYzine ___ mg PO QHS
12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
13. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Aspirin 81 mg PO DAILY
RX *aspirin [Aspirin Low Dose] 81 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
16. glimepiride *NF* 2 mg ORAL QHS
17. Outpatient Lab Work
please check chem 7(Na, K, Chl, Bicard, BUn, Cr) on ___ and
fax results to ___.
18. Glargine 30 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: coronary artery disease, diastolic heart
failure
Secondary diagnosis: hypertension, hyperlipidemia, diabetes
type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___ [/INST] </s><s>Dear Ms. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having chest pain. You
underwent a cardiac catheterization to evaluate your heart
vessels and your heart valves. No intervention was necessary.
You were also noted to have too much fluid in your body which
was likely causing some of your shortness of breath. We gave you
medications to help remove the fluid and optimized your home
medication regimen.
Please take your medications as prescribed and follow up with
your doctors as ___.
Please have your electrolytes checked on ___ and have the
results faxed to your primary care doctor. If you do not hear
back regarding the results for 2 days, the call the office to
ask about your results.</s> |