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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5600
} | Medical Text: Unit No: [**Numeric Identifier 72411**]
Admission Date: [**2159-3-9**]
Discharge Date: [**2159-3-9**]
Date of Birth: [**2159-3-9**]
Sex: M
Service: NB
ADMISSION NOTE: Baby [**Name (NI) **] [**Known lastname 41519**] is a 2860 gram product of
a 35-2/7 week gestation. He was born to a 22-year-old gravida
I, para 0, now I mother. Prenatal screens A positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, Rubella immune, GBS negative, hepatitis C
negative and cystic fibrosis negative. Mother was followed at
[**Hospital3 28900**] [**Hospital 65428**] clinic and cardiology clinic for
multiple fetal anomalies which include interrupted aortic
arch, large VSD, ASD and left club foot. There were normal
chromosomes by amniocentesis, Pregnancy was also notable for
maternal substance abuse and she was on a methadone rehab
program. Mother also has history of fetal thalassemia trait
and she also admits positive tobacco use during the
pregnancy. The infant was delivered by planned cesarean
section. He emerged with nuchal cord x1. Apgar score was 8 at
one minute and 8 at five minutes. He was
electively intubated in the delivery room for grunting,
perioral cyanosis and narrow chest. Then he was brought to
the Neonatal Intensive Care Unit for physical admission.
NICU PHYSICAL EXAMINATION: Temperature 100.8, pulse 150s,
respiratory rate 40s - 60s, blood pressure 56/44 with mean of
48. Oxygen saturation 92% preductal, 92, postductal room air.
Weight 2860 grams, length 51 cm. Head circumference 31.5%.
Four sequential blood pressures were noted and they were
comparable. Anterior fontanelle open and flat with
plagiocephaly dysmorphic features, fused eyes, low set ears.
Orally intubated with 3.5 ET tube. Clear breath sounds
bilaterally with pectus excavatum. Rate and rhythm regular
with good femoral pulses bilaterally. Abdomen soft,
nondistended, no hepatosplenomegaly. Pink and well perfused.
Left club foot. Patent anus. Normal male genitalia with
testes descended bilaterally. Moving all extremities,
slightly decreased tone.
ASSESSMENT ON ADMISSION: Newborn with prenatal diagnosis of
coarctation of the aorta and ventricular septal defect. Also with
dysmorphic features.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory system:
He was intubated electively in the delivery room and was
brought on a self inflated bag to the Neonatal Intensive Care
Unit. In the Neonatal Intensive Care Unit he was placed on
very low ventilator settings and an x-ray was done which
showed the endotracheal tube to be high, about 2 cm above the
carina. The tube was advanced 1 cm and he met target O2
saturation per cardiology in the mid 80s to low 90s. He continued
to remain stable on low ventilator settings and FIO2 was at room
air.
Cardiovascular system: His blood pressures were monitored as
stated above and he was started on prostaglandin P1 at 0.01 mcg
per kilogram per minute as per cardiology. Cardiology fellow
from [**Hospital3 28900**] was present at the bedside and he
agreed with the cardiologic management.
Fluid, electrolytes and nutrition: He was maintained n.p.o.
and started on IV fluids with D10 water at 60 ml per kg per
day and his Dextrostix remained stable.
Infectious Disease: A CBC and blood culture were drawn but
they were no disease risk factors and the antibiotics were
withheld pending CBC abnormality or culture results.
Neurology: He was to be scored for NAS scores given the
maternal substance abuse and history of genetics. The plan
was to obtain genetic consultation given the dysmorphic
features at [**Hospital3 28900**].
Orthopedics: Ortho was following the baby preoperatively and
the plan was to consult ortho for club feet.
Social: Parents were updated in the delivery room and the
plan was to transfer the patient to the [**Hospital3 28900**]
cardiac intensive care unit.
Sensory:
CONDITION AT TIME OF DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to level 3 hospital at
[**Hospital3 28900**] cardiac intensive care unit.
NAME OF PRIMARY CARE PEDIATRICIAN:
CARE RECOMMENDATIONS: Continue to be n.p.o. Continued on
prostaglandin P1 at 0.01 mcg per kg per minute. Continued on
IV fluids at 60 ml per kg per day.
DISCHARGE DIAGNOSES:
1. Coarctation of aorta, interrupted aortic arch.
2. Left club foot.
3. Maternal substance abuse.
4. Need for amnio [**Doctor Last Name **].
5. Rule out sepsis.
[**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 37305**], M.D. [**MD Number(2) 59540**]
Dictated By:[**Name8 (MD) 72412**]
MEDQUIST36
D: [**2159-3-14**] 08:24:15
T: [**2159-3-14**] 09:17:43
Job#: [**Job Number 39390**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5601
} | Medical Text: Admission Date: [**2108-8-19**] Discharge Date: [**2108-8-22**]
Date of Birth: [**2048-9-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endoscopy with banding
History of Present Illness:
59 yo man with previous hx of EtOH abuse and likely
long-standing cirrhosis, presented to [**Hospital **] Hospital earlier
today with epigastric pain followed by bloody emesis x3. Patient
went kayaking on the morning of admission and began to feel
lightheaded and nauseous, he pulled ashore and lost
consciousness (unwitnessed); denies head injury. He awoke and
was noted to have blood around his mouth by his brother. [**Name (NI) **]
[**Name2 (NI) 35261**] developed epigastric pain and bloody emesis x3, then
presented to OSH. Initial hct done at 3pm at [**Hospital1 **] was 36,
this trended down to hct of 25 at 9pm; during this time he
received no blood and possibly 2L crystalloid. EGD at [**Hospital1 **]
showed esophageal varices and erosions (location unknown), no
active bleeding seen. There was no intervention; indication for
transfer to [**Hospital1 18**] per OSH report was TIPS procedure (unclear
why). 4 U FFP were given prior to transfer and 1 U pRBC hung in
route to [**Hospital1 18**].
.
As pt does not not typically follow at [**Hospital1 **], little
information regarding his PMH was available at the time of
transfer. By his account, he has carried the diagnosis of
cirrhosis for ~30yrs and has recently been followed by Dr.
[**Last Name (STitle) 82939**] at [**Hospital 5871**] Hospital. 2 weeks ago he started taking
nadolol which he stopped several days ago. He is also
non-compliant with Prilosec. He claims to currently drink 2
glasses of wine twice per week, but his girlfriend suspects that
he consumes at least that much daily and possibly more. She
states that he had been sober for a decade and resumed drinking
w/in the last 3 years. Consumption increased after a reportedly
improved EGD w/in the last month. He has no hx of withdrawal. He
denies hx of previous UGIB or melena.
.
In the ED, initial vital signs were: T=98.9, P=106, BP=112/62,
R=22, O2sat=98% 3LNC. Patient was given 800cc NS and started on
octreotide drip prior to arrival to MICU. He was noted to have
several melanotic stools (at least 3) while in the [**Hospital1 18**] ED with
no further emesis. NG lavage cleared after 500cc. Per ED
signout, he may have aspirated in the setting of having bloody
emesis; both pt and girlfriend deny any recollection of this.
Total resuscitation at the time of arrival was 3.4L including 1u
pRBC and 4 UFFP.
.
In the ICU yesterday, patient underwent upper endoscopy that
showed 3 bands of grade II esophageal varices (all were banded)
in addition to portal hypertensive gastropathy. Post-procedure
he was continued on octreotide drip and ciprofloxacin per liver
service recommendations. His hematocrit remained stable in the
25-27 range without any further transfusions. His BP and HR were
stable 110-130s/50-60s and 50-60s respectively, and there were
no further episodes of bleeding. He continued to have dark
melanotic stools.
.
Speaking with him at time of transfer, he says he feels much
better. There is no nausea, no abdominal pain, no
lightheadedness or dizziness. His last drink, he says, was
Saturday afternoon at 1PM.
Past Medical History:
Alcohol abuse
Cirrhosis: Details unknown
Prior Hx of Varices: Last endoscopy 2 months ago
Social History:
Alcohol abuse until the present although to a lesser degree than
previously. Denied smoking. Denied illicit drugs. He says that
10+ years ago, he used to drink 6-7 beers/day in addition to [**2-3**]
hard drinks per day. He was then abstinent for 10 years and
started drinking 2-3 years ago, now a lesser amount but still
consuming [**2-3**] bottle of wine per day.
Family History:
non-contributory
Physical Exam:
Vitals: Tm: 99.9, Tc: 99.2, BP: 133/65 (111-135/49-60s), P: 72
(70-80s) R: 18-20, O2: 93% on 3L, UPO 1300cc over last 24 hours
General: Alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally
CV: regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no spider angioma, no varicose veins
Pertinent Results:
Labs on admission:
[**2108-8-19**] 12:10AM GLUCOSE-179* UREA N-34* CREAT-0.8 SODIUM-143
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-24 ANION GAP-15
[**2108-8-19**] 12:10AM ALBUMIN-2.9* CALCIUM-7.4* PHOSPHATE-3.5
MAGNESIUM-1.5*
[**2108-8-19**] 12:10AM ALT(SGPT)-22 AST(SGOT)-51* LD(LDH)-201 ALK
PHOS-114 TOT BILI-5.1* DIR BILI-1.7* INDIR BIL-3.4
[**2108-8-19**] 12:10AM LIPASE-27
[**2108-8-19**] 12:10AM WBC-10.9 RBC-2.92* HGB-9.5* HCT-28.2* MCV-97
MCH-32.6* MCHC-33.8 RDW-14.9
[**2108-8-19**] 12:10AM NEUTS-83* BANDS-0 LYMPHS-11* MONOS-4 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2108-8-19**] 12:10AM PLT SMR-LOW PLT COUNT-82*
[**2108-8-19**] 12:10AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2108-8-19**] 12:10AM PT-19.4* PTT-34.5 INR(PT)-1.8*
CULTURES:
Blood cultures ([**2108-8-19**]):
[**2108-8-19**] 3:52 am BLOOD CULTURE
Source: Line-piv.
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
BLOOD CX ([**2108-8-20**], [**2108-8-21**], [**2108-8-22**]) all with no growth to date;
PENDING
URINE CX ([**2108-8-22**]) negative
EKG ([**2108-8-19**]): NSR, rate 88
CXR ([**2108-8-19**]): IMPRESSION: No acute intrathoracic process.
ABDOMINAL U/S w/ DOPPLERS: IMPRESSION:
1. Coarsened hepatic architecture with no liver lesion
identified and no
biliary dilatation.
2. Cholelithiasis with no sign of cholecystitis.
3. Splenomegaly.
4. Patent hepatic vasculature.
5. Right pleural effusion.
6. Trace of ascites in the perihepatic space.
CXR ([**2108-8-20**]) FINDINGS: As compared to the previous radiograph,
there is an unchanged retrocardiac opacity. Its appearance,
however, suggests atelectasis rather than pneumonia. Mild
bilateral pleural effusions. Increased perihilar vascular
diameters indicate moderate overhydration. Otherwise, no
relevant changes.
TTE ([**2108-8-21**]): The left atrium is moderately dilated. The
estimated right atrial pressure is 10-20mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is no left ventricular outflow obstruction at
rest or with Valsalva. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild left ventricular cavity dilation. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Moderate pulmonary
hypertension. Mild mitral regurgitation.
CXR ([**2108-8-22**]): The heart size is mildly enlarged, stable. The
mediastinal position, contour and width are unchanged. There is
vascular engorgement demonstrated in the perihilar area although
unchanged as well as there is no change in the left retrocardiac
opacity that is concerning for left lower lobe atelectasis
versus infectious process. No new abnormalities are
demonstrated. No increase in pleural effusion or pneumothorax
have been demonstrated.
EGD: ([**2108-8-19**])
Findings: Esophagus:
Protruding Lesions 3 cords of grade II varices were seen in the
lower third of the esophagus and middle third of the esophagus.
There were stigmata of recent bleeding (cherry red spots). 3
bands were successfully placed.
Stomach:
Mucosa: Granularity, friability and mosaic appearance of the
mucosa with contact bleeding were noted in the stomach. These
findings are compatible with portal hypertensive gastropathy.
Duodenum: Normal duodenum.
Impression: Varices at the lower third of the esophagus and
middle third of the esophagus (ligation)
Granularity, friability and mosaic appearance in the stomach
compatible with portal hypertensive gastropathy
Recommendations: 1) Continue octreotide and ciprofloxacin.
2) Keep nil PO for 4 hours and then allow liquids.
3) Repeat EGD and banding in 2 - 3 weeks.
4) Doppler ultrasound of portal vein.
5) Images could not be captured for technical reasons.
Brief Hospital Course:
Assessment and Plan: This is a 57 yo man with known hx of heavy
EtOH, possible h/o cirrhosis, admitted to the ICU for upper GI
bleed s/p EGD and banding.
# Upper GI Bleed [**3-5**] Esophageal Varices: The patient received
4units of FFP and 1unit of PRBCs en route to [**Hospital1 **]. He then had an EGD with banding of three cords of
grade II varices. He was continued on octreotide and midrodine
drip during hospitaliazation. After banding, he had no further
episodes of hematemesis. On [**2108-8-20**], he was transfused an
additional two units of PRBCs and hematocrit increased
appropriately. At the time of discharge, hematocrit had
increased to 29.6, and had been stable since banding. He was
discharged on a PPI [**Hospital1 **]. He was also discharged on his home
dose of nadolol.
#E. coli bacteremia: The patient had 2/4 bottles growing
pan-sensitive e.coli on blood cultures drawn on [**2108-8-19**]. He was
started on IV ciprofloxacin inhouse, and had one temperature
spike while hospitalized. He was discharged on PO ciprofloxacin
for a total of 2 weeks therapy. UA and urine culture was
negative. CXR was negative for pneumonia. TTE showed no
vegetations. Surveillance cultures after [**2108-8-19**] have been
negative to date.
# Cardiac: TTE showed mild LV dilation, LVH, mod pulm HTN, mild
MR. There was no evidence of vegitations. He can follow up with
cardiology as outpatient
# History of cirrhosis. Limited records were available from his
outside hospital. Labs supported this diagnosis given limited
synthetic function and evidence of portal HTN on EGD. Doppler
with ultrasound was negative for portal vein thrombosis. Iron
studies were inconsistent with hemachromatosis and hepatology
serologies were pending at the time of discharge. Bilirubin was
trending down at the time of discharge, and LFT's, coags, and
platelets were stable. He will have labwork done on [**2108-8-24**], to
be followed up by Dr. [**Name (NI) **] and by his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **].
# EtOH abuse. Last drink per patient was on day prior to
transfer ([**2108-8-18**]) per patient. There was no evidence of
alcohol withdrawal while hospitalized. Social work consult was
obtained and patient was advised to stop alcohol use. He was
informed that he would be eligible for liver transplant
evaluation 3 months after cessation of alcohol. He will follow
with his outpatient hepatologist, Dr. [**Last Name (STitle) 61433**]. He was discharge
on MVI, folate, and thiamine supplements.
Medications on Admission:
nadolol (non-compliant)
prilosec (non-compliant)
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 10 days: Please take until [**2108-9-3**].
Disp:*20 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please have lab work drawn on Friday, [**2108-8-24**]:
CBC with Differential, PT, PTT, INR, Chem-7, ALT, AST, Total
Bilirubin, Alk Phos
Fax results to Dr. [**First Name (STitle) **]: [**Telephone/Fax (1) 82940**] and Dr. [**Name (NI) **]:
([**Telephone/Fax (1) 82941**]
Discharge Disposition:
Home
Discharge Diagnosis:
1. Esophageal Varices with upper GI bleed
2. Bacteremia
Discharge Condition:
Hemodynamically stable, tolerating PO well, afebrile.
Discharge Instructions:
You were admitted to [**Hospital1 **] on [**2108-8-19**] after
being transferred from an outside hospital for bloody vomit.
You received a total of 3 units of blood, and 4 units of other
blood products. You had an endoscopy performed and you had
banding done to stop the bleeding. You must continue to take
nadolol as prescribed to prevent future episodes of bleeding.
It is also important to completely abstain from alcohol use, as
was explained to you in the hospital.
You also had bacteria growing in your blood. This was probably
caused by the esophageal bleeding as well. You are being
discharged on an antibiotic called ciprofloxacin. You will need
to take this antibiotic until [**2108-9-3**] (a two week course).
While you were here, you also had an echocardiogram of your
heart. It showed that you have some mild changes in your heart
function. You should follow up with your PCP regarding the
results of this test.
After your endoscopy, you had no other episodes of vomiting. You
were tolerating a regular diet.
You should continue to take a daily multivitamin, folate, and
thiamine supplements.
Please return to the ER if you have any other episodes of bloody
vomiting, fevers/chills, severe abdominal pain, bloody stools,
chest pain, shortness of breath, or any other symptoms
concerning to you.
Followup Instructions:
Gastroenterology- Follow up with Dr. [**Last Name (STitle) 61433**]: ([**Telephone/Fax (1) 82942**],
on [**8-28**] at 1:45pm. You will need a repeat endoscopy in [**3-6**]
weeks.
PCP: [**Name10 (NameIs) 357**] follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 82943**] on [**9-4**] at 2pm
You have blood cultures to be followed up. Please inform Dr.
[**First Name (STitle) **] of this.
Please have lab work done on Friday, [**2108-8-24**]. This will be
forwarded to us and to your gastroenterologist.
ICD9 Codes: 7907, 2875, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5602
} | Medical Text: Admission Date: [**2111-8-26**] Discharge Date: [**2111-8-29**]
Date of Birth: [**2111-8-21**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**First Name5 (NamePattern1) 12584**] [**Known lastname 68597**] is a 5-day-
old, former 38-5/7 weeker, who was readmitted for evaluation
and treatment of hyperbilirubinemia. He is a former 6 pound 3
ounce (3100 gram) product of a 38-5/7 week gestation pregnancy
born to a 40-year-old, G1, P0 to 1 woman. The pregnancy was
uncomplicated. Prenatal screens were blood type O+, antibody
negative, rubella immune, RPR nonreactive, hepatitis B
surface antigen negative, group beta strep status negative.
The infant was born by elective cesarean section. Apgars were
8 at 1 minute and 9 at 5 minutes. He had an uncomplicated
course in the newborn nursery. His bilirubin on day of life
#3 was a total of 15.9/0.3 mg/dl. His blood type was B+ and
he was Coombs negative. He was not treated with
phototherapy. He was discharged home on day 4, [**2111-8-25**], with a serum bilirubin total of 18.5/0.3 mg/dl. On day
of life 5, he was seen by his pediatrician. The bilirubin at
that time was a total of 22.6 mg/dl. He was admitted to the
[**Hospital3 **] for treatment with phototherapy.
PHYSICAL EXAM UPON ADMISSION TO NICU: Weight 2.835 kg--8.5%
less than birthweight. General: Jaundiced infant in no acute
distress. Head, ears, eyes, nose and throat: Anterior
fontanel flat, nondysmorphic facies, moist mucous membranes,
palate intact. Chest: Breath sounds equal, clear.
Cardiovascular: Regular rate and rhythm, no murmur, normal
pulses. Abdomen soft, normal bowel sounds, no
hepatosplenomegaly, no masses. GU: Normal male genitalia,
status post circumcision, patent anus. Musculoskeletal: No
sacral dimple, no hip clicks. Neuro: Responsive to exam but
not very active, mildly decreased tone, good suck, slightly
high-pitched cry.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
SYSTEM #1 - RESPIRATORY: [**Doctor First Name 12584**] was in room air for
this Neonatal Intensive Care unit admission. He had no
respiratory concerns.
SYSTEM #2 - CARDIOVASCULAR: [**Doctor First Name 12584**] maintained normal heart
rates and blood pressures. No murmurs were noted.
SYSTEM #3 - FLUIDS, ELECTROLYTES AND NUTRITION: An
intravenous line was started upon admission to the Neonatal
Intensive Care unit for augmentative hydration. He was ad lib
breastfeeding or taking Similac if the mother was not
available. The intravenous fluids were discontinued on the
third day of admission. Serum electrolytes upon admission had
a serum sodium of 144, a potassium of 4.7, chloride of 111
and total carbon dioxide of 22. Weight on the day of
discharge is 2.86 kg. There was some concern because he has
still not shown a consistent weight gain since birth.
SYSTEM #4 - INFECTIOUS DISEASE: A complete blood count and
blood culture were sent upon admission. The blood culture was
no growth at 48 hours. The white blood cell count and
differential were normal. He was not treated with
antibiotics.
SYSTEM #5 - HEMATOLOGICAL: As previously noted, blood type
was B+, and the direct antibody test was negative. Hematocrit
upon admission was 54.6% with a reticulocyte count of 1.7%.
SYSTEM #6 - GASTROINTESTINAL: Intensive phototherapy was
started upon admission to the neonatal intensive care unit.
Repeat bilirubin within 4 hours was down to a total of 18.1
mg/dl. The bilirubin continued to fall gradually until
[**2111-8-29**] and was a total of 11 mg/dl. The
phototherapy was discontinued at 0800 hours, and a repeat
bilirubin at 1600 hours was unchanged at a total of 11.1
mg/dl, 0.3 mg direct, and an indirect of 10.8 mg/dl. The plan
was to discharge [**Doctor First Name 12584**] home with pediatric follow-up the
day after discharge.
SYSTEM #7 - NEUROLOGICAL: As the bilirubin level decreased,
[**Doctor First Name 68598**] activity level increased, and there were no
neurological concerns at the time of discharge.
SYSTEM #8 - SENSORY: Hearing screen was repeated due to the
high serum bilirubins, and [**Doctor First Name 12584**] passed in both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital1 2921**] - [**Location (un) 8985**], [**Street Address(2) 68599**], [**Location (un) 8985**],
[**Numeric Identifier 68600**], phone number [**Telephone/Fax (1) 63965**]. [**Doctor First Name 12584**] will be seen at
the [**Hospital1 **] office in [**Location (un) 15749**]
on [**2111-8-30**].
CARE AND RECOMMENDATIONS AT DISCHARGE:
1. Ad lib breastfeeding, supplementing with Similac
formula.
2. No medications.
3. Car seat position screening was not indicated.
4. State newborn screens were checked and were within normal
limits.
5. No additional immunizations administered.
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) Born at less
than 32 weeks; 2) Born between 32 and 35 weeks with 2 of
the following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
or school-aged siblings; or 3) with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
1. Follow-up appointments scheduled/recommended: 1)
Appointment with the [**Hospital1 **]
Pediatric office in [**Location (un) 15749**], MA on [**Last Name (LF) 1017**], [**8-30**], [**2110**]; 2) Follow-up with [**Hospital1 68601**] pediatrician in [**Location (un) 8985**] on Thursday,
[**2111-9-3**].
DISCHARGE DIAGNOSES:
1. Unconjugated hyperbilirubinemia.
2. Suspicion for sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2111-8-29**] 19:09:52
T: [**2111-8-29**] 21:00:19
Job#: [**Job Number 68602**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5603
} | Medical Text: Admission Date: [**2105-12-24**] Discharge Date: [**2105-12-31**]
Date of Birth: [**2063-7-4**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy
History of Present Illness:
The patient is a 42 year old male with HIV/AIDS (CD4 74, VL
96K), h/o toxo, anemia, and hep B, who presents to [**Hospital1 18**] ED with
fever, malaise and hemoptysis (per patient's brother). Per
patient, he's been having fevers for 6 months. He denies
abdominal pain, nausea, or diarrhea. He does report vomiting,
but denies hematemesis. He has been having chronic headaches. He
also reports episodes of bright red blood per rectum, though
this is not new. When asked why he came to the ED, he states he
is not sure.
.
Per patient's brother, the patient has communication problems,
particularly stuttering. He also states patient's right side is
not as strong as his left, particuarly after he got diagnosed
with the toxo. The brother also reports the patient has been
weak and coughing up blood for about one month.
.
In the ED, initial VS: 98.8, 108, 112/79, 18, 98%RA. He had a
CXR which showed multifocal patchy opacities, and a CT with
RML/LLL PNA, but too much motion artifact to comment on ground
glass opacity. His oxygenation remained stable. He was given
bactrim, levofloxacin, and prednisone in the ED. He also had
blood on his rectal exam, and an NGL was performed which was
negative. He was given 2L IVF and 1 unit of blood as well as
PPI. Vitals prior to transfer were 82, 101/70, 15, 100%2L NC.
.
The patient was transferred from the ED to the MICU Green
overnight on [**12-24**] for observation. His Hct remained stable and
he required no further transfusions. The bleeding was thought to
be secondary to hemorrhoids (he has a known history of
hemorrhoids). GI was consulted and recommended outpatient scope
as well as stool studies. Given the CT chest findings,
hemoptysis, and HIV status, he underwent BAL for TB, PCP, [**Name10 (NameIs) **]
this showed just blood. These studies are pending. He was
started on empiric levoflox, vanc, bactrim, and prednisone to
cover HCAP and PCP.
.
Currently, the patient is comfortable. He is without any
complaints. He denies pain. He notes only weakness prior to
admission. He does not know of any exposures to TB and has not
lived in a shelter or nursing home and has not been
incarcerated.
Past Medical History:
HIV/AIDS - CD4 74, VL 96K, diagnosed in [**2091**], h/o toxoplasmosis
([**10/2104**]) s/p treatment now on suppresive therapy (with
questionable compliance)
h/o MI, possible PCI placement
Anemia
h/o hematochezia with internal hemorrhoids
h/o Trigeminal Varicella Zoster
B thalassemia trait
Hepatitis B
Unknown speech / language disorder, communicates more by
writing.
Social History:
Cantonese speaking male. He is from [**Country 3992**] and came to the U.S
in [**2087**]. He lives alone in an apartment. Contracted HIV
previously from multiple sexual partners- unknown male, female
or both; denies IVDU.
Family History:
Mother with uterine Ca.
Physical Exam:
Vitals - T: 98.6 BP:96/64 HR:68 RR:16 02 sat:95%RA
GENERAL: Awake, lying in bed, in NAD
HEENT: Sclera anicteric, dry mucus membranes, OP clear
NECK: Supple, no LAD, no JVD
CARDIAC: RRR, normal S1&S2
LUNG: decreased breath sounds at the bases bilaterally, no
crackles or wheezes
ABDOMEN: +BS, soft, non-tender, non-distended, no guarding or
rebound
EXT: Warm, well-perfused, 2+ DP/PT pulses, no LE edema
NEURO: (difficult to assess even with interpreter) EOMI, PERRLA,
tongue protrudes midline, face symmetric, no pronator drift,
mild right sided weakness UE & LE.
Pertinent Results:
[**2105-12-24**] 02:35PM BLOOD WBC-4.3 RBC-3.44*# Hgb-7.7*# Hct-24.2*#
MCV-70* MCH-22.3* MCHC-31.6 RDW-17.8* Plt Ct-138*
[**2105-12-24**] 08:00PM BLOOD WBC-3.9* RBC-2.95* Hgb-6.6* Hct-20.6*
MCV-70* MCH-22.4* MCHC-32.1 RDW-17.5* Plt Ct-100*
[**2105-12-25**] 02:05AM BLOOD Hct-24.5*
[**2105-12-25**] 05:55AM BLOOD WBC-2.9* RBC-3.37* Hgb-7.8* Hct-23.4*
MCV-69* MCH-23.1* MCHC-33.3 RDW-17.3* Plt Ct-104*
[**2105-12-25**] 05:07PM BLOOD Hct-24.5*
[**2105-12-26**] 05:35AM BLOOD WBC-4.3 RBC-3.38* Hgb-8.0* Hct-24.3*
MCV-72* MCH-23.5* MCHC-32.7 RDW-17.9* Plt Ct-133*
[**2105-12-26**] 03:20PM BLOOD WBC-3.4* RBC-3.54* Hgb-8.1* Hct-25.9*
MCV-73* MCH-23.0* MCHC-31.5 RDW-18.3* Plt Ct-137*
[**2105-12-27**] 05:55AM BLOOD WBC-3.1* RBC-3.36* Hgb-7.8* Hct-24.3*
MCV-72* MCH-23.3* MCHC-32.3 RDW-18.0* Plt Ct-111*
[**2105-12-28**] 05:40AM BLOOD WBC-3.6* RBC-2.96* Hgb-6.7* Hct-21.3*
MCV-72* MCH-22.6* MCHC-31.4 RDW-18.1* Plt Ct-120*
[**2105-12-29**] 05:35AM BLOOD WBC-3.6* RBC-4.02*# Hgb-9.1*# Hct-29.0*#
MCV-72* MCH-22.7* MCHC-31.5 RDW-18.0* Plt Ct-116*
[**2105-12-29**] 10:50AM BLOOD WBC-4.1 RBC-3.92* Hgb-9.2* Hct-28.0*
MCV-72* MCH-23.4* MCHC-32.7 RDW-18.0* Plt Ct-104*
[**2105-12-30**] 05:40AM BLOOD WBC-4.0 RBC-3.84* Hgb-9.2* Hct-27.8*
MCV-72* MCH-24.0* MCHC-33.2 RDW-18.1* Plt Ct-128*
[**2105-12-31**] 05:40AM BLOOD WBC-6.8# RBC-3.80* Hgb-9.0* Hct-27.6*
MCV-73* MCH-23.7* MCHC-32.7 RDW-18.4* Plt Ct-120*
[**2105-12-24**] 03:58PM BLOOD PT-13.0 PTT-34.8 INR(PT)-1.1
.
WBC subtypes
[**2105-12-27**] 05:55AM BLOOD WBC-3.1* Lymph-31 Abs [**Last Name (un) **]-961 CD3%-89
Abs CD3-855 CD4%-7 Abs CD4-67* CD8%-80 Abs CD8-766* CD4/CD8-0.1*
.
Chemistries
[**2105-12-24**] 02:35PM BLOOD Glucose-94 UreaN-14 Creat-1.1 Na-132*
K-3.6 Cl-102 HCO3-25 AnGap-9
[**2105-12-31**] 05:40AM BLOOD Glucose-90 UreaN-10 Creat-1.2 Na-134
K-3.7 Cl-107 HCO3-19* AnGap-12
[**2105-12-30**] 05:40AM BLOOD Glucose-108* UreaN-12 Creat-1.5* Na-134
K-3.6 Cl-106 HCO3-17* AnGap-15
[**2105-12-24**] 02:35PM BLOOD ALT-14 AST-29 LD(LDH)-228 AlkPhos-51
TotBili-0.4
[**2105-12-25**] 05:55AM BLOOD Calcium-7.4* Phos-3.5 Mg-1.3*
[**2105-12-24**] 02:35PM BLOOD Iron-15*
[**2105-12-24**] 02:35PM BLOOD calTIBC-153* VitB12-280 Folate-11.2
Hapto-74 Ferritn-825* TRF-118*
[**2105-12-24**] 08:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2105-12-24**] 08:55PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2105-12-24**] 08:55PM URINE RBC-[**10-23**]* WBC-0-2 Bacteri-NONE
Yeast-NONE Epi-0-2
[**2105-12-25**] 01:22PM OTHER BODY FLUID Polys-10* Lymphs-58* Monos-27*
Eos-1* Macro-4*
Microbiology:
Blood Culture [**2105-12-24**]: Negative
Urine Culture [**2105-12-24**]: Negative
Urine Legionella Antigen: Negative
Bronchoalveolar Lavage [**2105-12-25**]:
GRAM STAIN (Final [**2105-12-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2105-12-27**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
POTASSIUM HYDROXIDE PREPARATION (Final [**2105-12-28**]):
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies if
pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2105-12-27**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Bronchial Washing [**2105-12-25**]:
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Respiratory Virus Screen and Culture [**2105-12-25**]:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus.
Sputum Culture [**2105-12-26**]:
[**2105-12-26**] 10:04 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2105-12-27**]): NEGATIVE for Pneumocystis jirovecii
(carinii).
Serum Cryptococcal Antigen [**2105-12-27**]: Negative
Serum RPR [**2105-12-27**]: Negative
Sputum Culture [**2105-12-27**]:
[**2105-12-27**] 8:49 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Stool Culture [**2105-12-28**]:
MICROSPORIDIA STAIN (Final [**2105-12-29**]): NO MICROSPORIDIUM SEEN.
CYCLOSPORA STAIN (Final [**2105-12-29**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2105-12-30**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2105-12-30**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2105-12-29**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final [**2105-12-29**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2105-12-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Sputum Culture:
[**2105-12-28**] 3:00 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2105-12-29**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Blood Culture (fungus/mycobacteria):
[**2105-12-29**] 5:35 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Imaging:
Chest X-ray [**2105-12-24**]:
PA and lateral views of the chest show stable cardiac,
mediastinal and hilar contours. Bibasilar ill-defined pulmonary
opacities, left worse than right, are more prominent since [**9-11**] and new from [**9-2**]/09. There is no pleural effusion or
pneumothorax. The spine is notable for an S-shaped scoliotic
curvature as well as an exaggerated kyphosis at the
thoracolumbar junction which is unchanged, related to wedge
compression deformities.
IMPRESSION: Bibasilar ill-defined pulmonary opacities. Given the
provided
history of HIV, pneumonia is favored and atypical organisms
including PCP
should be considered.
CT Chest [**2105-12-24**]:
FINDINGS: Airways are patent to segmental levels bilaterally.
Detail in the
lung bases (both parenchymal and vascular) is obscured secondary
to
respiratory motion. Within that constraint, there may be
bilateral
ground-glass opacity throughout the lower lobes with involvement
also noted in the upper lobes. In the right middle lobe
anteriorly are foci of nodular type opacities with indistinct
margination, suggesting possible inflammatory etiologies. The
right middle lobe is also notable for a more confluent
consolidation. More linear consolidation is present in the left
lower lobe. There is no pleural or pericardial effusion.
The heart and great vessels are notable for a coronary arterial
stent.
Multiple lymph nodes are present throughout the mediastinum and
axilla
bilaterally, these are prominent in their number, though no
single node
appears frankly enlarged.
Imaged portions of the upper abdomen are unremarkable. There is
no suspicious sclerotic or lytic osseous lesion. Note is made of
a mild scoliosis which may be positional.
IMPRESSION:
1. Markedly limited study secondary to patient motion,
nevertheless revealing right middle lobe consolidation and
smaller lingular/lower lobe consolidation.
Despite the presence of HIV/AIDS, diagnostic considerations
still favor
bacterial pneumonia, though atypical infections are not
excluded.
2. Background of bilateral pulmonary ground-glass opacity, these
are likely
related to the extensive motion artifact, however the
possibility of
pneumocystic infection is not excluded.
CT Head [**2105-12-26**]:
NON-CONTRAST HEAD CT: Since the prior head CT from [**2105-8-25**], there
has been increased calcification at the left thalamic lesion, at
the location
of previously biopsied area of toxoplasmosis. There is no
intracranial
hemorrhage, mass effect, or [**Doctor Last Name 352**]-white matter differentiation
abnormality.
Bilateral basal ganglia calcifications are grossly stable. No
definite new
lesions are seen.
POST-CONTRAST HEAD CT: On post-contrast images, there is minimal
to no
enhancement of this lesion. Minimal shift of midline structures
to the left
side and mild dilatation of the lateral ventricles and third
ventricle are
stable. No other focus of abnormal enhancement is seen.
Visualized paranasa sinuses demonstrate mildly increased mucosal
thickening and opacification of the posterior left ethmoid sinus
air cells as well as mucosal thickening in the bilateral
sphenoid sinuses, some of which are aerosolized. There is also
mucosal thickening in the posterior right ethmoid sinus air
cells. Opacification of bilateral mastoid air cells have also
increased since prior exam. Left frontal burr hole is unchanged.
There is no lytic or sclerotic bony lesion to suggest
malignancy.
IMPRESSION:
1. Increase calcification of the left thalamic toxoplasmosis
lesion, with
minimal or no enhancement.
2. Stable mild shift of the midline structures to the left and
dilatation of the lateral and third ventricles.
3. Opacification of the paranasal sinuses and bilateral mastoid
air cells has mildly increased since prior exam. Clinical
correlation is recommended.
Biospies:
BAL washings, cytology [**2105-12-25**]: Negative for malignant cells
Biopsies stomach and duodenum [**2105-12-30**]:
A. Stomach, antrum:
Chronic inactive gastritis. Negative for H. pylori.
B. Duodenum:
Small intestinal mucosa, no diagnostic abnormalities
recognized.
Endoscopy:
EGD:
Erythema and petechiae in the stomach body and antrum (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Colonscopy:
Findings:
Protruding Lesions: Large internal hemorrhoids were noted.
Impression: Internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
42yo M with HIV/AIDS (not on HAART, last CD4 count 74 and VL
96K), h/o toxoplamosis on suppressive therapy, and hemorrhoids
admitted with hemoptysis, anemia (thought [**1-5**] hemorrhoids now
s/p 1 unit prbcs), and RML/LLL PNA now transferred from the MICU
for TB rule out and treatment for pneumonia
.
# Pneumonia: On arrival to the floor, patient was afebrile and
hemodynamically stable. He was kept on negative pressure
repiratory isolation to rule out Mycobacterium tuberculosis.
Infectious disease was consulted. Patient was treated for
suspected community acquired pneumonia with ceftraixone and
azithromycin, and initally treated with therapeutic doses of
bactrim for possible pneumocystis. MTB was ruled out by
bronchoscopy and serial induced sputum. Pneumocystis jiroveci
was ruled out by bronchoscopy and induced sputum. Blood
cultures were negative for MTB and fungi. Urine legionella was
negative. Respiratory viral screen and culture was negative.
Patient completed a five day course of azithromycin and
ceftraixone while in house and was discharge with a two day
course of cefpodoxime.
.
# BRBPR/Anemia: Patient had blood on rectal exam. He has a known
history of internal hemorrhoids and chronic BRBPR. Stool
cultures were negative for C. difficile, giardia,
cryptosporidium, microsporidium, salmonella, shigella,
campylobacter. His hematocrit ranged between 22-26 during this
admission. Iron studies showed low Fe (15), low TIBC (153),
elevated ferritin (825), and a retic of 0.9%. Vit B12, folate,
hapto, LDH, and Tbili were normal. EGD and colonscopy were
performed and demonstrated mild gastritis and internal
hemorrhoids. Follow up was arranged with gastroenterology. It
was thought that his anemia was likely chronic and related to
his HIV disease.
.
# HIV/AIDS: Per out side records, his last CD4 count was 74, and
his HIVviral load was 96,000. Patient reports that he hasn't
been taking his medications for HIV. Through obtaining outside
records, he had been prescribed the following HAART regimen:
Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY, Ritonavir 100
mg PO DAILY, Atazanavir 300 mg PO DAILY and Raltegravir 400 mg
PO BID. It was unclear when he had stopped taking these
medications. He was also prescribed the following regimen for
toxoplasmosis prophylaxis: pryimethamine 25mg PO daily,
sulfadiazine 1g PO q12, & Leucovorin 10mg PO daily. Repeat
absolute CD4 count was 64. A Head CT was performed, that showed
some calcification of prior toxoplasmosis lesions, but no new
lesions. He was restarted on his toxoplasmosis prophylaxis
regimen and keppra for seizure prophylaxis. Once PCP was ruled
out, bactrim was stopped and he was left on his toxoplasmosis
regimen for PCP [**Name Initial (PRE) 1102**]. HAART was held, and re-initiation
of HAART was deferred to his PCP. [**Name10 (NameIs) 269**] was arranged to assist
with medication adherence.
.
# Otitis Externa: Patient was continued on his home
ciprofloxacin ear drops [**Hospital1 **]
.
# h/o Hep B: Liver function tests were followed and remained
within normal limits.
.
# CODE: FULL CODE
.
# CONTACT: Brother [**Name (NI) **] [**Telephone/Fax (1) 79897**]
Medications on Admission:
Daraprim 75 mg daily
Keppra 1000 mg [**Hospital1 **]
Leucovorin 10 mg daily
Sulfadiazine 1500 mg Q6H
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
3. Pyrimethamine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Leucovorin Calcium 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Sulfadiazine 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*120 Tablet(s)* Refills:*2*
6. Ciprofloxacin 0.3 % Drops Sig: Five (5) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural [**Hospital1 269**]
Discharge Diagnosis:
Primary Diagnosis:
Community Acquired Pneumonia
Secondary Diagnosis:
HIV/AIDS
Anemia
Internal Hemorrhoids
Discharge Condition:
Vital signs stable, taking PO well
Mental Status:Clear and coherent
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with fever, malaise, and
cough. You were found to have pneumonia and were treated with
antibiotics. You were also evaluated and ruled out for
tuberculosis and pneumocystis pneumonia. You improved with
antibiotics and no longer had a fever or cough at the time of
discharge.
Additionally, you were found to be anemic and had blood on
rectal exam. You received 1 unit of blood and underwent an
upper endoscopy and colonoscopy for further evaluation. The
colonoscopy revealed large internal hemorrhoids, which were
noted on prior colonoscopy. These are common.
You were also started on medicine to prevent pneumocystis
infection and suppress the toxoplasmosis infection in your
brain. It is extremely important that you take these medications
every day, as instructed.
New Medications:
Levetiracetam (500 mg Tablet): Two(2) Tablets PO BID (2 times a
day).
Cefpodoxime (200 mg Tablet): One(1) Tablet PO twice a day for 2
days.
Pyrimethamine (25 mg Tablet): One(1) Tablet PO DAILY (Daily).
Leucovorin Calcium (5 mg Tablet): Two(2) Tablet PO DAILY
(Daily).
Sulfadiazine (500 mg Tablet): Two (2) Tablet PO Q12H (every 12
hours).
Ciprofloxacin 0.3 % Drops: Five(5) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
Followup Instructions:
Please follow up with your primary care doctor:
[**1-7**] at 9am
Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 6420**]
[**Hospital1 778**] Health [**Telephone/Fax (1) **]
ICD9 Codes: 486, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5604
} | Medical Text: Admission Date: [**2108-8-13**] Discharge Date: [**2108-8-18**]
Date of Birth: [**2030-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
fevers, chills, 15 pounds weight loss, urinary frequency
Major Surgical or Invasive Procedure:
[**2108-8-13**] MV repair ( 30 mm CE band)
History of Present Illness:
77 yo male presented at OSH in [**7-13**] with acute prostatitis
diagnosed by urology with above sx in addition to anorexia and
diaphoresis. ID consult also revealed endocarditis with
hemolytic strep. Started on PCN and gentamycin and transferred
here for eval. then . Dental consult done and preop workup
completed. Discharged home for a few weeks with plan for MVR in
[**8-13**].
Past Medical History:
1. BPH
2. Hypertension
3. Chronic sinusitis
4. Sleep apnea - CPAP
5. s/p splenectomy 53 years ago secondary to trauma
6. Severe degenerative joint disease (shoulder and fingers)
7. S/P hernia repair
endocarditis
MR
prostatitis
Social History:
Widowed. Retired hairdresser, now works at a golf course. Quit
smoking in [**2059**]. Daily alcohol with no more than 2 drinks per
night.
Family History:
NC
Physical Exam:
5'[**09**]" 95.4 kg
HR 86 RR 16 right 130/76 left 130/76
NAD
skin unremarkable
wears glasses
neck supple, full ROM, no carotid bruits appreciated
CTAB
RRR no murmur noted
soft, NT, ND, + BS, scar left abdomen
warm, well-perfused, no edema or varocosities noted
neuro grossly intact
1+ bil. fem/DP/PTs
2+ bil. radials
Pertinent Results:
Conclusions
Prebypass
1. The left atrium is normal in size. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
2.Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
5.There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. There is
a moderate-sized vegetation with associated calcification on the
posterior leaflet (P2 P3 location) mitral valve. Moderate (2+)
mitral regurgitation is seen. Mitral annulus is 3.4 cm.
[**Known lastname 11991**],[**Known firstname **] [**Medical Record Number 78929**] M 77 [**2030-9-15**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-8-17**] 8:13
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2108-8-17**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 78930**]
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
77 year old man s/p MV repair
REASON FOR THIS EXAMINATION:
eval for pleural effusions
Final Report
HISTORY: Status post MV repair, to evaluate for pleural
effusions.
FINDINGS: In comparison with the study of [**8-16**], the PICC line is
poorly seen,
though it still appears to extend to the mid portion of the SVC.
Some low
lung volumes with continued increased opacification at the bases
and poor
definition of the hemidiaphragms.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: FRI [**2108-8-17**] 10:38 AM
Imaging Lab
7.There is no pericardial effusion.
8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2108-8-13**]
at 830 am.
Post bypass
1. Patient not on any vasoactive infusions
2. LV function remains good (EF 55%) with no wall motion
abnormalities.
3. Annuloplasty ring seen in the mitral position. Trace mitral
regurgitation present.
4. Aortic valve has no regurgitation after bypass.
5. Aortic contours appear smooth after decannulation.
6. Dr. [**Last Name (STitle) **] notified of findings at 1048 on [**2108-8-12**]
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2108-8-13**] 15:01
?????? [**2102**] CareGroup IS. All rights reserved.
[**2108-8-18**] 06:00AM BLOOD WBC-14.2* RBC-2.74* Hgb-8.2* Hct-24.4*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.8* Plt Ct-343
[**2108-8-13**] 10:43AM BLOOD WBC-26.7*# RBC-2.86*# Hgb-8.6*#
Hct-24.7*# MCV-86 MCH-30.0 MCHC-34.8 RDW-13.8 Plt Ct-247
[**2108-8-13**] 11:34AM BLOOD PT-14.4* PTT-32.9 INR(PT)-1.3*
[**2108-8-13**] 10:43AM BLOOD PT-15.6* PTT-29.3 INR(PT)-1.3*
[**2108-8-18**] 06:00AM BLOOD Glucose-115* UreaN-33* Creat-1.4* Na-140
K-3.6
[**2108-8-13**] 11:34AM BLOOD UreaN-30* Creat-1.5* Cl-105 HCO3-26
Brief Hospital Course:
Admitted [**8-13**] and underwent surgery with Dr. [**Last Name (STitle) **]. Noted to
have a difficult intubation. Transferred to the CVICU in stable
condition on phenylephrine and propofol drips. Had postop shock
with hypotension and epinephrine drip started. This was weaned
over the next day. PICC line was removed on POD #1 and extubated
early that morning. POD #2 Chest tubes removed and he was
transferred to SDU for telemetry monitoring and further
recovery. It was felt that he would require rehab for further
increase in activity and endurance, as well as close monitoring
and antibiotic administration (PCN G 2million units q4h x 2
weeks per ID) for his preoperative endocarditis. H eis scheduled
to follow up with the [**Hospital **] clinic on [**9-6**] for further
evaluation. WBC ct. and chemistry to be checked at rehab 2x
weekly. Mr. [**Known lastname **] has been instructed on all follow up
appointments.
Medications on Admission:
HCTZ 25 mg /Triamterene 37.5 mg daily
finasteride 5 mg daily
flomax 0.4 mg daily
tylenol prn
colace 100 mg [**Hospital1 **]
gentamicin 80 mg IV Q 8hr
heparin flush for PICC
PCN G potassium 3 million units IV q 4 hours
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Three (3) ML
Intravenous every eight (8) hours as needed for line flush.
12. Penicillin G Potassium 1,000,000 unit Recon Soln Sig: Two
(2) Injection every four (4) hours for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
Radius @ [**Hospital3 **]
Discharge Diagnosis:
MR s/p MV Repair
endocarditis
BPH
HTN
chronic sinusitis
DJD
sleep apnea/CPAP at night
s/p acute prostatitis
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams or powders on any incision
no driving for one month AND until off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5 , redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 31187**] in [**12-7**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Hospital **] clinic [**2108-9-6**]
Completed by:[**2108-8-18**]
ICD9 Codes: 5185, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5605
} | Medical Text: Admission Date: [**2161-3-9**] Discharge Date: [**2161-3-12**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
former smoker with hypertension but no other significant past
medical history who presented to an outside hospital on
[**3-7**] with months of increasing dyspnea on exertion.
The patient also complained of approximately two days of
intermittent left arm pain and throat tightness. The patient
reported that on the morning of her admission to the outside
hospital she woke up in a cold sweat with the left arm pain
and chest tightness and was brought to the Emergency
Department.
At the outside hospital, the patient ruled in for a
myocardial infarction by enzymes with a reported peak
troponin I of 17. Electrocardiograms at the outside hospital
reportedly with ST depressions in leads II, III, aVF, and V4
to V6.
The patient was transferred to [**Hospital1 188**] on [**3-9**] for cardiac catheterization. Cardiac
catheterization on [**3-9**] showed multivessel disease
including an 80% left main stenosis, tight stenosis at the
first diagonal with competitive flow, large ramus, but no
significant disease in the left circumflex, and 70% mid right
coronary artery, and 70% posterior descending artery origin
stenosis.
The patient was evaluated by Cardiothoracic Surgery but
refused coronary artery bypass graft, and instead opted for a
repeat cardiac catheterization with stent placement. Stents
were placed at the left main, mid right coronary artery, and
the posterior descending artery on [**3-9**] during her
second cardiac catheterization.
On admission to the Coronary Care Unit the patient had no
complaints and denied any shortness of breath, arm symptoms,
chest pain, or throat symptoms. The patient was in good
spirits and had no complaints.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Hypertension; treated with one lone outpatient medication
(presumably hydrochlorothiazide).
2. Smoking history of approximately one pack per day times
30 years.
3. History of cataracts.
MEDICATIONS ON ADMISSION: The only medication at home was
believed to be thiazide diuretic.
ALLERGIES: Reportedly allergic to PENICILLIN (with unknown
reaction, but the patient denies an anaphylactic reaction or
any breathing compromise as far as she knows).
PHYSICAL EXAMINATION ON PRESENTATION: Her blood pressure was
108/57, her heart rate was 90, her respiratory rate was 18,
and her oxygen saturation was 96% to 100% on room air.
Physical examination was notable for a small excoriation in
the upper drip with dried blood. No jugular venous
distention. The lungs were entirely clear. Heart was
regular in rate and rhythm. Normal first heart sounds and
second heart sounds. No murmurs were appreciated.
Guaiac-negative stool times one. Good pulses throughout; 1+
lower extremity pulses. No edema. A right sheath was in
place in the right groin.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed
sinus tachycardia, left anterior fascicular block, old T wave
inversion in aVL, and less than 1-mm ST depressions in V5 and
V6.
Electrocardiograms from the outside hospital were not
available.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her white blood
cell count was 5.4, her hematocrit was 26.5 (without previous
baseline available), her mean cell volume was 92, and her
platelets were 247. Her INR was 1.1. Chemistries were
notable for a sodium of 128, blood urea nitrogen of 24, and
creatinine was 0.8. Liver enzymes and bilirubin were normal.
Her albumin was 3.2.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is an 85-year-old female ex-smoker with hypertension
but no other significant past medical history who presented
to an outside hospital on [**3-7**] with worsening dyspnea
on exertion and days of left arm pain and throat tightness
and ruled in by enzymes at the outside hospital.
The patient was transferred to [**Hospital1 188**] for catheterization which showed multivessel disease
as outlined above. The patient refused a coronary artery
bypass graft, and status post stent times three on [**3-9**].
1. CARDIOVASCULAR ISSUES: (a) CORONARY ARTERY DISEASE
ISSUES: The patient was not on a beta blocker, statin, or
aspirin at home. The patient with a non-ST-elevation
myocardial infarction at the outside hospital.
The patient underwent catheterization (as mentioned above)
which she tolerated well without known complications. The
patient was maintained on Integrilin for approximately 18
hours after catheterization. The patient was also started on
metoprolol 12.5 mg by mouth twice per day, Lipitor 20 mg by
mouth once per day, Plavix 75 mg by mouth once per day, and
aspirin 325 mg by mouth once per day. The patient tolerated
these medications well. The patient had no episodes of
anginal symptoms such as her left arm pain or neck tightness
throughout the remainder of her hospital stay.
The patient's breathing remained comfortable on room air, and
she was able to ambulate comfortably on the day of discharge.
(b) PUMP ISSUES: The patient without known congestive heart
failure; however, she reportedly may have flashed at the
outside hospital which responded to Lasix. Per the left
ventriculography during cardiac catheterization, her ejection
fraction was preserved. A formal echocardiogram was
performed on [**3-10**] which showed an ejection fraction of
approximately 50%, probable anterior wall hypokinesis, and 1
to 2+ mitral regurgitation; but was otherwise normal.
The patient was started on an ACE inhibitor in the hospital
which was titrated up and was changed to lisinopril 10 mg by
mouth once per day at discharge. The patient tolerated this
well.
(c) RHYTHM ISSUES: The patient had a bradycardic arrest in
the Catheterization Laboratory likely related to increased
vagal tone during manipulation of her coronaries. This
bradycardic arrest responded [**Last Name (un) 18497**] traction and atropine.
The patient was in a normal sinus rhythm throughout the
remainder of her hospital stay without any significant events
on telemetry.
(d) HEMODYNAMIC ISSUES: Hemodynamics were stable. The
patient's blood pressure tolerated the beta blocker and ACE
inhibitor well and remained in the 100 to 130 range
throughout her hospital stay.
2. MELENA ISSUES: The patient was noted to have three to
four episodes of melanic stools in the Coronary Care Unit
which were grossly guaiac-positive. The patient did report
that she had a nose bleed that dripped into the back of her
throat for approximately two days; beginning approximately
two days prior to the cardiac catheterization.
Gastroenterology was consulted and followed the patient
throughout her hospital stay. The patient underwent an
esophagogastroduodenoscopy (EGD) on [**3-11**] which showed
gastritis of the stomach without any visible ulcerations.
The patient's melanotic stools were therefore thought to be
due to a combination of her nose bleeds and some minimal
oozing from her gastritis. The patient was started on a
proton pump inhibitor twice per day and was discharged with a
prescription for this. The patient's stools prior to
discharge had become dark brown as opposed to black. The
patient did not have any further episodes of melanic stools.
The patient received two units of packed red blood cells on
her first day of admission at [**Hospital1 188**] for her hematocrit of 26.5. Her hematocrit increased
appropriately and was stable in the low to mid 30s throughout
the remainder of her hospital stay. Her hematocrit was
checked serially due to the possible gastrointestinal bleed.
The patient was also maintained on two large-bore intravenous
lines due to this reason and initially nothing by mouth.
3. HYPONATREMIA ISSUES: The patient became slightly
hyponatremic while in the Coronary Care Unit likely due to
being on one-half normal saline and free water intake. This
resolved by the time of discharge after her fluids were
switched to normal saline and after the patient was resumed
her regular diet.
4. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
initially nothing by mouth due to her catheterization and her
esophagogastroduodenoscopy. The patient's diet was advanced,
and she tolerated a full cardiac low-sodium diet well.
5. PROPHYLAXIS ISSUES: The patient was maintained on a
bowel regimen as well as pneumatic boots in the Coronary Care
Unit. The patient also ambulated well.
6. COMMUNICATION ISSUES: Communication was maintained daily
with the patient as well as her family; including her
daughter. The patient's code status is full. The patient
lives alone in an eight bedroom house but with very good
family support. Physical Therapy was consulted and cleared
the patient for discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post catheterization
times two with stent placement.
2. Gastritis.
3. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Pantoprazole 40 mg by mouth twice per day times one month
and then once per day.
2. Aspirin 325 mg by mouth once per day.
3. Plavix 75 mg by mouth once per day.
4. Lipitor 20 mg by mouth once per day.
5. Toprol-XL 25 mg by mouth once per day.
6. Lisinopril 10 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient had an appointment to follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] (referring cardiologist) on Thursday,
[**2161-3-19**] at 3:30 p.m.
2. The patient was instructed to follow up with her primary
care physician within one month as well.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 6906**]
MEDQUIST36
D: [**2161-3-12**] 16:12
T: [**2161-3-13**] 07:37
JOB#: [**Job Number 52580**]
ICD9 Codes: 9971, 4275, 2761, 4280, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5606
} | Medical Text: Admission Date: [**2117-8-19**] Discharge Date: [**2117-8-20**]
Date of Birth: [**2056-1-27**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Inderal
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Patient referred for adnexal cyst discovered incidentally on CT
Major Surgical or Invasive Procedure:
Exploratory Laparoscopy, Bilateral Salpingo-oophorectomy
History of Present Illness:
Ms. [**Known lastname **] presented for a second opinion regarding an adnexal
mass. This is a 60-year-old woman with a number of medical
problems including peripheral vascular disease, coronary artery
disease, and angina, who reports weight loss or over the past
two years, which essentially has consisted of a 20 pounds where
she is now 96 pounds. She had an imaging study for her vascular
disease and on that CAT scan, a left ovarian cyst was noted.
Pelvic ultrasound was repeated and this revealed normal uterus
and a 6 x 3 x 5 cm septated mass within the left adnexa. It had
been seen previously and was noted to be persistent complex
ovarian cyst in a postmenopausal woman. That ultrasound was
performed in 05/[**2116**]. A repeat CT scan in [**Month (only) **] again
revealed the mass.
After a resection of lung cancer in [**Month (only) 956**], her left adnexal
mass has continued to enlarge. Her ultrasound in [**Month (only) 547**] showed a
cyst measuring 7 x 3.7 x 5.9 cm. Over the past few months, we
have been waiting for her to recover from lung surgery and she
has done that at this time. Detailed questioning reveals no
evidence of diffuse abdominal pain or symptoms concerning for or
suggestive of locally advancing ovarian cancer. She is
otherwise doing well and presents for surgical resection.
Past Medical History:
The patient has a long history of coronary artery disease. She
has significant coronary artery disease and has angina fairly
frequently. This is under fairly good control. She has a
pacemaker in place and has had that since [**2113**]. She denies
history of mitral valve prolapse, thromboembolic disorder, or
asthma. Her last mammogram was obtained in [**2-/2115**], and was
reportedly normal. Last Pap smear was in [**1-/2116**], and was
reportedly normal.
PAST SURGICAL HISTORY: In [**3-/2116**], she underwent a lumpectomy
and an angioplasty of her lower extremity. In [**2117-3-11**]
she underwent resection of a lung cancer.
OB/GYN HISTORY: Her last menstrual cycle was a year and a half
ago and was reportedly normal. She denies history of fibroids,
cysts, STDs, or abnormal Pap smears.
CURRENT MEDICATIONS: Toprol, lisinopril, Norvasc, Plavix, baby
aspirin, and Mevacor.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a 40-pack-year smoker. Denies alcohol
or drug use. She does not list an occupation.
FAMILY HISTORY: Denies any family history of cancer.
REVIEW OF SYSTEMS: Denies fever, weight change. She does
report weakness. Cardiovascular: Reports chest discomfort
associated with the incisions, but denies palpitations or
orthopnea. Respirations: Reports some decreasing cough but
denies dyspnea or hemoptysis. GI: Denies abdominal pain,
anorexia, nausea, vomiting, constipation, diarrhea, melena,
change in bowel habits. GU: Denies dysuria, frequency,
hematuria, or abnormal vaginal bleeding. Musculoskeletal:
Denies muscle, bone, or joint pain. Neuro: Denies syncope,
paresthesia, or muscle weakness. Hematology: Denies fatigue,
petechiae, or spontaneous bleeding.
Physical Exam:
HEENT: Negative.
NECK: Supple, no masses. Supraclavicular areas are negative.
CARDIOVASCULAR: Regular rate and rhythm, no murmurs.
RESPIRATIONS: Clear bilaterally.
ABDOMEN: Soft, nontender, nondistended. I do not palpate a
palpable mass.
EXTREMITIES: There is no clubbing, cyanosis, or edema.
PELVIC: Deferred.
Pertinent Results:
[**2117-8-19**] 09:40PM CK(CPK)-91
[**2117-8-19**] 02:25PM CK(CPK)-70
[**2117-8-19**] 09:40PM CK-MB-4 cTropnT-<0.01
[**2117-8-19**] 02:25PM CK-MB-4 cTropnT-<0.01
[**2117-8-19**] 02:25PM GLUCOSE-93 UREA N-15 CREAT-0.5 SODIUM-140
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
[**2117-8-19**] 02:25PM CALCIUM-8.8 PHOSPHATE-4.3 MAGNESIUM-2.0
[**2117-8-19**] 02:25PM WBC-10.1 RBC-3.30* HGB-10.8* HCT-31.4* MCV-95
MCH-32.8* MCHC-34.4 RDW-14.0
[**2117-8-19**] 02:25PM PLT COUNT-214
Peritoneal washings, cystic fluid, and ovary/fallopian tube
pathologies have not yet been determined.
Brief Hospital Course:
The patient underwent a planned exam under anesthesia,
exploratory laparoscopy, and a bilateral salpingo-oophorectomy
for a left ovarian mass. Gross examination of the left ovarian
cyst was benign. The cyst had no excrescences. The procedure
was uncomplicated. See note for details.
Ms. [**Known lastname **] hospital course was notable for postop hypotension
in the 80/50's and low urine output suggestive of hypovolemia.
Given her extensive cardiac history, she was ruled out for MI.
EKG and cardiac enzymes x 3 were negative. The patient's
hypotension and oliguria responded to fluid resuscitation. She
was discharged on post operative day 2 in stable condition.
Medications on Admission:
Troprol xl 100'
Plavix 75'
Lovastatin 20'
Lisinopril 5'
Norvasc 2.5'
Baby ASA 81'
Vit D po q2weeks
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Continue your home medications.
Discharge Disposition:
Home
Discharge Diagnosis:
Ovarian cyst
Discharge Condition:
Stable
Discharge Instructions:
You may resume your regular diet. Please start taking your home
medications tomorrow.
Do not lift anything heavier than ten pounds for three weeks.
Remove the outer bandages tomorrow. You may shower.
Please call Dr. [**Last Name (STitle) 2028**] if you have increased pain, shortness of
breath, lightheadedness, chest pain, nausea, vomiting or
increasing pain.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7614**]
Date/Time:[**2117-9-20**] 11:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
Completed by:[**2117-8-20**]
ICD9 Codes: 0389, 4280, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5607
} | Medical Text: Admission Date: [**2120-1-28**] Discharge Date: [**2120-2-2**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
Upper Endoscopy [**2120-1-28**]
History of Present Illness:
89 year old female with history of HTN and gastric ulcers
presents with nausea, vomiting, and coffee-ground emesis >10
episodes since last night. Pt developed acute onset
nausea/vomiting last night around 11pm, and after 2-3 episodes
of vomiting developed coffee-ground emesis. Symptoms did not
improve overnight, so she came in to the ED for evaluation
today. She denies any fevers, chills, chest pain, dyspnea,
lightheadedness, dizziness, abdominal pain or changes in bowel
habits, melena, or hematochezia. She takes aspirin 81 mg every
other day, but denies any recent NSAID or EtOH use. She has
otherwise has been feeling well without problem. [**Name (NI) **] previous
history of upper GI bleeding. Has had an upper endoscopy
previously, in [**2111**], for anemia, which showed multiple small
shallow gastric antral ulcers without bleeding, and she did not
have any follow-up EGD after that. She has no history of liver
disease.
.
In the ED, initial vs were: 99, 83, 147/83, 18, 97%. Patient was
noted to have a hematocrit of 43, BUN 24, lipase 74. NGT was
placed with immediate return of ~1.5L coffee grounds. After
lavage with 1 L of NS, return was still pink. Found to be
guaiac negative. She otherwise feels well, and her nausea has
been relieved by the NG tube placement. GI evaluated patient in
the ED, would like to perform EGD tonight. She received 1 L of
fluids, reglan, and zofran. Prior to transfer, her vitals were:
92, 129/86, 16, 97% RA
Past Medical History:
Hypertension
Osteopenia
h/o gastric ulcers - no active GI bleeds, seen in EGD in [**2111**].
Also had colonoscopy at that time
h/o PE [**2111**] - treated with coumadin, not currently taking
s/p hysterectomy
s/p elbow surgery
Social History:
Former salesperson. Lives at home. Denies ETOH, tobacco or
illicits.
Family History:
No known GI or liver disease
Physical Exam:
Admission Exam:
Vitals: T:98.9 BP: P:90 RR:18 O2:96%
HEENT: NC/AT, sclerae anicteric, dry MM
Neck: supple, no LAD or thyromegaly
Lungs: CTA [**Last Name (un) **]
Heart: RRR, nl S1-S2, no MRG
Abdomen: +BS, soft/NT/ND, no HSM
Rectal: Guaiac negative per ED
Extrem: WWP, no c/c/e
Discharge Exam:
Vitals: T99.5 BP144/84 P78 R18 94%RA.
HEENT: NC/AT, sclerae anicteric, OP clear, MMM, EOMI, PERRLA
Neck: supple, no LAD or thyromegaly
Lungs: CTA bilaterally without rales, rhonchi, or wheezes
Heart: RRR, nl S1-S2, +2/6 SEM at the second RICS, no radiation
Abdomen: +BS, soft/NT/ND, no HSM
Rectal: Guaiac negative per ED
Extrem: WWP, no c/c/e 2+ DP PT pulses
Pertinent Results:
Admission Labs:
[**2120-1-28**] 02:40PM PT-12.1 PTT-23.3 INR(PT)-1.0
[**2120-1-28**] 02:40PM PLT COUNT-227
[**2120-1-28**] 02:40PM NEUTS-87.1* LYMPHS-10.3* MONOS-2.0 EOS-0.3
BASOS-0.3
[**2120-1-28**] 02:40PM WBC-9.9# RBC-5.10 HGB-15.4 HCT-43.8 MCV-86
MCH-30.2 MCHC-35.2* RDW-13.4
[**2120-1-28**] 02:40PM LIPASE-74*
[**2120-1-28**] 02:40PM ALT(SGPT)-17 AST(SGOT)-23 ALK PHOS-103 TOT
BILI-1.3
[**2120-1-28**] 02:40PM estGFR-Using this
[**2120-1-28**] 02:40PM GLUCOSE-164* UREA N-24* CREAT-1.1 SODIUM-145
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-29 ANION GAP-18
[**2120-1-28**] 05:05PM URINE RBC-[**3-16**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2120-1-28**] 05:05PM URINE BLOOD-TR NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2120-1-28**] 05:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2120-1-28**] 09:20PM HCT-37.7
Discharge Labs:
[**2120-2-1**] 05:25AM BLOOD WBC-4.3 RBC-3.91* Hgb-11.6* Hct-33.1*
MCV-85 MCH-29.6 MCHC-35.0 RDW-13.0 Plt Ct-150
[**2120-2-1**] 05:25AM BLOOD Glucose-98 UreaN-7 Creat-0.9 Na-142
K-3.2* Cl-106 HCO3-28 AnGap-11
[**2120-2-1**] 05:25AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.7
EGD [**2120-1-28**]:
Diffuse esophagitis with patches of black discoloration and
overlying exudate suggestive of necrosis was noted throughout
the esophagus. An area of heaped-up and friable mucosa with a
central eschar but no obvious ulceration was noted in the
fundus. This lesion may be malignant but could also represent
severe localized inflammation. There was a significant amount of
retained food in the fundus but no fresh or old blood. The
stomach appeared deformed such that the scope repeatedly
retroflexed upon attempts to reach the antrum. Given the concern
for acute esophageal necrosis and retained food in the stomach,
the decision was made to abort the procedure.
.
KUB [**2120-1-28**]:
A hiatus hernia is present and gas is seen within the herniated
stomach. No evidence of dilated bowel is otherwise seen. No
evidence of gastric volvulus. Elsewhere the bowel gas [**Doctor Last Name 5926**] is
normal. Degenerative changes are noted within the lumbar spine.
.
CT ABDOMEN [**2120-1-28**]:
1. Herniation of the stomach into the thoracic cavity; somewhat
it takes a tortuous course within the thorax but does not
exhibit signs of volvulus.
2. Hepatic cysts.
3. Small bilateral pleural effusions with atelectasis.
4. Sigmoid diverticulosis without evidence of diverticulitis.
.
CXR [**2120-1-28**]
Nasogastric tube tip within the stomach. Large hiatal hernia
with adjacent atelectasis. No free air under the diaphragms.
Brief Hospital Course:
Ms. [**Known lastname **] is an 89 F with history of HTN and gastric ulcers who
presented with coffee-ground emesis in the setting of nausea,
and was found on EGD to have a black esophagus and inability to
pass the scope distally secondary to a significant hiatal
hernia.
ACTIVE ISSUES:
1. UPPER GI BLEED: An NG tube was placed in the ED with
immediate return of ~1.5L coffee grounds initially, without
clearing on lavage with 1L NS. She was admitted to the MICU
overnight and started on IV PPI. Her hematocrit remained stable
in the mid 30s. She underwent EGD the following morning, which
showed diffuse esophagitis with patches of black discoloration
and overlying exudate suggestive of necrosis, as well as an area
of heaped-up and friable mucosa with a central eschar in the
fundus. The scope could not be easily advanced beyond the
antrum. A gastric volvulus was suspected, though was not
detected on follow up CT abdomen the following day. Rather, a
large hiatal hernia was seen with much of the stomach taking a
tortuous course through the thorax. General surgery was
involved, and at that time, the patient had decided against a
surgical intervention due to high perioperative risk of
mortality given her age. She was transferred to the medical
floor where she was continued on PPI and sucralfate. Per
surgery recommendation, we advanced her diet slowly to assess
for functional signs of obstruction. She tolerated advancement
of her diet without nausea, vomiting, or abdominal pain. While
a definitive diagnosis of her blackened esophageal mucosa was
not obtained, it was felt to be possibly hemorrhagic from her
severe hiatal hernia causing intermittent volvulus or
obstruction. The minimally-invasive surgery team was consulted
as the patient became more amenable to intervention, and felt
that a correction of the hiatal hernia would be non-emergent
though appropriately managed in the outpatient setting after
undergoing repeat EGD to definitively establish a diagnosis of
her friable fundus mucosa and eschar via biopsy. She was
tolerating a regular diet at the time of discharge and had GI
and surgery followup in place. She was continued on her PO PPI,
sucralfate, and was instructed to stop aspirin.
2. HYPERTENSION: her antihypertensives were initially held
given concern for upper GI bleed. She was discharged on her
metoprolol and lisinopril.
PENDING LABS AT DISCHARGE: None
TRANSITIONAL CARE ISSUES:
- Will need repeat EGD as an outpatient to establish diagnosis
of esophageal and gastric abnormalities
- Will need to follow up with Dr. [**Last Name (STitle) **] following repeat
EGD. Patient was given the office phone number.
Medications on Admission:
carvedilol CR 80 mg daily
lisinopril 40 mg daily
aspirin 81 mg every other day
Discharge Medications:
1. sucralfate 100 mg/mL Suspension Sig: [**5-21**] mL PO four times a
day.
Disp:*QS bottle* Refills:*2*
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. carvedilol phosphate 80 mg Cap, Multiphasic Release 24 hr
Sig: One (1) Cap, Multiphasic Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Paraesophageal hiatal hernia
2. Hematemesis
3. Black esophagus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital after vomiting blood. You
underwent an endoscopy which revealed likely dark bleeding and
poor blood flow to the esophagus, and a mass-like object in your
stomach which may represent a compression of the stomach by a
hiatal hernia. This means that part of the stomach is extending
up into the chest through the diaphragm. You were evaluated by
the surgery team, who feels that you will eventually need
surgical repair, but you will need to have another endoscopy
prior to this procedure as an outpatient. We slowly allowed you
to eat more substantial foods, which you were able to tolerate
well.
The following changes were made to your medications:
1. START PANTOPRAZOLE 40mg twice a day until instructed to stop
2. START SUCRALFATE 1 gram four times a day until instructed to
stop. Do not take at the same time as your pantoprazole, as it
will decrease its effectiveness. Try to take it 1-2 hours apart.
3. STOP ASPIRIN and all other "non steroidal anti-inflammatory
drugs" like ibuprofen and naproxen.
Please continue all other medications as previously prescribed.
It was a true pleasure working with you, Ms. [**Known lastname **].
Followup Instructions:
You have the following appointments to see your PCP and GI
specialist:
Department: BIDHC [**Location (un) **]
When: MONDAY [**2120-2-5**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: 545A [**Street Address(1) **], [**Location (un) 538**]
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2120-2-21**] at 1 PM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Please call Dr. [**Last Name (STitle) **] after you meet with your GI specialist
and have a repeat endoscopy to discuss the surgical repair of
your hernia. His office can be reached at [**Telephone/Fax (1) 2359**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5608
} | Medical Text: Unit No: [**Numeric Identifier 73184**]
Admission Date: [**2186-4-2**]
Discharge Date: [**2186-5-21**]
Date of Birth: [**2186-4-2**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: The patient is a 34-4/7 week
gestational age triple, admitted for prematurity. Mother is
a 35-year-old, gravida 1, para 1 woman with unremarkable
pregnancy medical history. Prenatal screens were A+,
hepatitis B surface antigen negative, RPR nonreactive,
Rubella immune, GBS unknown and IAT positive (anti-[**Location (un) **] B).
The pregnancy was notable for in-[**Last Name (un) 5153**] fertilization with
dichorionic triamnotic triplet gestation. The pregnancy was
also complicated by preterm labor, leading to hospital
admission at 26 weeks, followed by magnesium sulfate
tocolysis and a complete course of betamethasone. Fetal
survey was normal for all 3 fetuses. The neonatal course was
notable for a vigorous infant at delivery who was orally and
nasally bulb suctioned, dried and received pre-facial CPAP.
Apgars were 8 and 8. Initial physical exam was within normal
limits. The patient was noted to be breech at presentation,
and present maternal [**Doctor Last Name **] antibodies with all 3 unremarkable
due to their inability to cross the placenta. At admission,
the patient's weight was 1335 grams, which was 10th
percentile for 31-4/7 weeks gestational age. Head
circumference was 28 cm and length was 29 cm.
PHYSICAL EXAMINATION AT DISCHARGE: The patient was 2805
grams weight at time of discharge.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
patient was on room air from time of birth and never required
supplemental or mechanical ventilation. The patient was
started on caffeine at day of life #3 for apnea of
prematurity, which was discontinued on day of life #18 with
resolution of apnea of prematurity.
Cardiovascular: The patient was hemodynamically stable
without need for pressors during the entirety of the hospital
stay. The patient was noted to developed a murmur at
approximately 3 weeks of age, which was clinically assessed
as peripheral pulmonic stenosis or PPS prior to discharge.
Fluids, electrolytes and nutrition: The patient began feeds
on day of life #2, up until which time the patient had been
entirely on parenteral nutrition. Feeds were advanced to
full on day of life #9 and calories were increased up to a
maximum of 28 kilocalories per ounce plus Beneprotein, after
which the patient showed good weight gain. The patient's
calorie concentration was weaned to Similac 20 kilocalories
per ounce at the time of discharge with good weight gain.
GI: The patient underwent phototherapy for mild
hyperbilirubinemia of prematurity, with last phototherapy
stopped on day of life #9 and rebound bilirubin level of 3.7
at that time. Peak bilirubin was 7.4 on day of life #7.
Hematology: The patient was on iron for anemia of
prematurity at the time of discharge. The last hematocrit
was 32 with a reticulocyte count of 5.1 on [**2186-5-15**], on
day of life #43.
Infectious disease: The patient was ruled out for sepsis at
the time of birth and underwent 48 hours of ampicillin and
gentamicin with a benign CBC and unremarkable blood culture.
Since that time, the patient was only treated topically for a
brief period of time with Nystatin to perineum for diaper
rash, which has been discontinued prior to discharge.
Neurology: The patient had an ultrasound on day of life #8,
showing a left sided choroid cyst, which was followed up on
day of life #30, showing a residual left sided cyst. This
was thought to be clinically insignificant.
Sensory/auditory: Hearing screen was performed with
automated auditory brain stem responses. The baby passed the
hearing screen on [**2186-5-18**].
Ophthalmology: The patient had the eyes examined on [**2186-4-24**], resulting in immature zone 3 with followup at 3 weeks,
on [**2186-5-15**], showing mature eye pattern.
Psychosocial: [**Hospital1 18**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **].
CARE RECOMMENDATIONS: Discharge on Similac 20 ad lib p.o.
Medications: Iron 2 mg per kilogram p.o. daily plus 25 mL
preparation. Iron supplementation as recommended for preterm
and low birth weight infants until 12 months corrected age.
All infants fed predominantly breast milk should receive
vitamin D supplementation until 12 months corrected age.
Vision screening passed. Newborn screening status normal on
[**2186-5-14**]. Immunizations received: Hepatitis B on [**2186-5-4**]. RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 4
criteria:
1. Born at less than 32 weeks.
2. Born within 32 and 35 weeks with 2 of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings.
3. Chronic lung disease.
4. Hemodynamically significant CHD.
Influenza immunization is recommended in the early fall for
all infants once they reach 6 months of age. Will defer this
[**Doctor Last Name 360**] for the first 24 months of the child's life.
Immunization against influenza is recommended for household
contacts and out of home caregivers. This infant has not
received rotavirus vaccine. The American Academy of
Pediatrics recommends initial vaccination of preterm infants
at or following discharge from the hospital if they are
clinically stable and at least 6 weeks but fewer than 12
weeks of age.
Followup appointments scheduled with primary M.D.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Rule out sepsis.
3. Peripheral pulmonic stenosis murmur.
[**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 72865**] [**Name8 (MD) **], MD [**MD Number(2) **]
Dictated By:[**Last Name (STitle) 72769**]
MEDQUIST36
D: [**2186-5-22**] 14:45:40
T: [**2186-5-22**] 15:34:41
Job#: [**Job Number 73185**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5609
} | Medical Text: Admission Date: [**2121-8-18**] Discharge Date: [**2121-8-29**]
Date of Birth: [**2062-1-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2121-8-18**] #29 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical MVR, CABG x 1(SVG->RCA)
History of Present Illness:
59 year old with history of CAD s/p MI in the past with PTCA and
stents to her LAD and RCA. She did relatively well until she
developed DOE and [**Male First Name (un) 1902**] at which time her MR was discovered.
Past Medical History:
lipids
[**Male First Name (un) **]
Skin Ca
[**Male First Name (un) 1902**]
MI [**2109**]
MR
tobacco abuse
s/p T&A
s/p tubal ligation
s/p stenting x [**Numeric Identifier 4719**] following MI
PTCA of RCA [**2109**]
Social History:
lives alone
.5 ppd x 40 years
occasioal Etoh
Family History:
Father deceased at age 68 of MI
Physical Exam:
WDWN in NAD
warm dry, no rashes
NCAT PERRL Anicteric OP benign teeth in good repair
no jvd
Lungs CTAB
3/6 systolic murmur RRR normal s1, split s2
Abdomen benign
superficial spider varicosities
Neuro grossly intact
Pertinent Results:
[**2121-8-28**] 07:15AM BLOOD WBC-8.3 RBC-3.61* Hgb-11.3* Hct-32.8*
MCV-91 MCH-31.3 MCHC-34.4 RDW-15.2 Plt Ct-358
[**2121-8-28**] 07:15AM BLOOD Plt Ct-358
[**2121-8-28**] 07:15AM BLOOD PT-22.6* INR(PT)-3.7
[**2121-8-27**] 05:34AM BLOOD PT-22.5* PTT-37.1* INR(PT)-3.7
[**2121-8-26**] 02:25AM BLOOD PT-19.9* PTT-83.2* INR(PT)-2.8
[**2121-8-25**] 03:17AM BLOOD PT-16.8* PTT-65.9* INR(PT)-1.9
[**2121-8-24**] 02:56AM BLOOD PT-14.3* PTT-71.2* INR(PT)-1.4
[**2121-8-23**] 02:17AM BLOOD PT-13.4* PTT-26.7 INR(PT)-1.2
[**2121-8-28**] 07:15AM BLOOD Glucose-91 UreaN-18 Creat-1.0 Na-137
K-4.1 Cl-96 HCO3-31 AnGap-14
[**2121-8-28**] 07:15AM BLOOD Mg-2.1
[**2121-8-29**] 03:23PM BLOOD PT-21.6* INR(PT)-3.4
Brief Hospital Course:
Post operatively she was transferred to the ICU in critical but
stable condition on milrinone, epinephrine and levophed. On POD
1 she was noted to be moving her left leg less than her right.
She was seen in consultation by the stroke team who recommended
CT, she was unable to get a CT scan and her LLE weakness
improved. She also had atrial fibbrilation for which she was
started on amiodarone. She was ready for discharge on POD 10.
Medications on Admission:
lipitor 10'5, lasix 80'', lopressor 50', lisinopril 20', asa
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
2. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): for 1 weeks, then 200 mg QD.
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6981**] Nursing Home
Discharge Diagnosis:
CAD, MR
MI s/p stents [**2111**]
lipids
tobacco abuse
MR
[**First Name (Titles) **]
[**Last Name (Titles) 1902**]
Skin Ca
s/p T&A
s/p Tubal ligation
Discharge Condition:
Good.
Discharge Instructions:
Shower daily, wash incision with soap and water and paty dry. No
lotions, creams or powders.
No lifting more than 10 pounds or driving.
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 23097**] 2 weeks
Completed by:[**2121-8-29**]
ICD9 Codes: 4240, 9971, 4280, 2875, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5610
} | Medical Text: Admission Date: [**2125-2-22**] Discharge Date: [**2125-3-1**]
Date of Birth: [**2102-9-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Code Sepsis
Major Surgical or Invasive Procedure:
Left IJ line
A line
History of Present Illness:
22yo F with no significant PMHx is transferred from [**Hospital 1474**]
Hospital with sepsis. The pt was in her USOH until Tues when
she started to develop some abdominal pain and n/v with
?diarrhea. She had several episodes of emesis that night with
improvement in her abdominal pain and discomfort. The following
day however she was found by her room mate to be lying in her
bed covered in emesis. She was lethargic and was difficult to
awaken and appeared confused. 911 was called and she was BIBA
to [**Hospital 1474**] Hospital at 20:00. At [**Hospital1 1474**], the pt was found to
be febrile to 103, tachycardic to 164 and hypotensive to 90/60
with RR of 24 and SaO2 of 96% on RA. She was A+O x1 and
appeared lethargic/sedated. Her pulse was noted to be weak and
thready and her skin was cool and dry. Her stool was described
as green, malodorous and heme positive (sent for cultures). Her
serum and urine tox screen was neg, she had a WBC count of 16.1
with 53% bands, her Hct was 45, Plt was 154 and lactic acid was
4.4. She was noted to be coagulopathic with INR of 1.8,
Fibriongen was 442 (nml 150-400) and D-dimer was 8400 (nml
0-499). Her BUN and Cr was 34 and 2.7 with Ca of 7.8, gap was
19 with Gluc of 93. UA was significant for [**5-2**] WBC, moderate
bacteria, moderate Lueks and neg Nitrite with rare coarse
granular casts and HCG was neg. She was given Toradol 30mg IV
x1 for pain and n/v. A Head CT was found to be wnl. An LP was
planned but due to coagulopathy was deferred. Instead the pt
was given Vanc/Ceftriaxone at 21:00. [**Last Name (un) **] also received 6L of NS
for BP support. The pt was intubated at the OSH for airway
protection due to lethargy prior to transfer to [**Hospital1 18**] -> ABG:
7.2/30/620. Just prior to leaving, the pt also received Zosyn
3.375g IV x1, Acyclovir 1g IV x1 as well as D5+150mEq of Bicarb
at 100cc/hour and was transferred with levophed (pt did not
require any but was sent with pressors in case she became
hypotensive).
.
Of note, a pelvic exam was performed at the OSH and a tampon
was removed as per verbal report. The tampon was not described
as particularly gross, bloody or mal-odorous. Pelvic exam was
otherwise wnl without significant discharge. As per the mother,
the pt recently had her period over the weekend. At [**Hospital1 18**] ED
from verbal report, there was no evidence of discharge or
vaginal bleeding on pelvic exam. Of note, her room mate also
had GI sx one day prior to development of her sx but is other
well. Her mother denied any recent travel hx, any change in
diet, or any other sick contact aside from room mate.
.
In the [**Hospital1 18**] ED, the pt was afebrile to 98.1, tachycardic to
129, and was normotensive at 143/76 and SaO2 was 100% on vent.
A code sepsis was called. A Left IJ was placed in ED under
sterile conditions. A CXR demonstrated acceptable positioning
of ETT and IJ line placement. Some evidence of pulmonary edema
was evident but n obvious pleural effusions or infiltrates. A
non-contrast (no PO or IV contrast) CT Abd was performed as was
a bedside RUQ US. Neither study demonstrated any significant
findings. The pt was given 1L of D5W with 3amps of Bicarb, 1L
of NS as well as two units of FFP and Mg. The pt produced
approximately 400cc of urine during her ED stay. Pt was seen by
surgery who agreed with cont. resuscitation and recommended
repeat Abd/Pelvic CT once ARF is resolved.
.
The pt was transferred to the [**Hospital1 18**] MICU directly from the
ED.
Past Medical History:
None
Social History:
The pt is a senior at [**Location (un) 1475**] College. She also student
teaches at [**Location (un) 1475**] HS. She lives with her room mate in
[**Location 8391**].
Tob: denies
EtOH: social
Illicit drugs: mother denies
Family History:
Mother: Similar episode of sepsis/?toxic shock 6 years ago at
[**Hospital 1263**] Hospital; thought to be due to toxic shock syndrome but
no clear dx was given. At the time, she also had GI sx and
facial flushing as well.
Father: CVA at age 40s with residual motor weakness
Sister: A+W
Brother: A+W
Physical Exam:
VS: Tc: 98.7, HR: 124, BP: 128/56, RR: 18, SaO2: 100% on Vent
FiO2: 100%
GEN: intubated, not sedated but not following commands
initially, later following commands, NAD
HEENT: PERRL, anicteric
CV: RRR, S1, S2, no m/r/g
Chest: CTA bilaterally, anteriorly and laterally
Abd: soft, NT, ND, BS+ bilaterally
Ext: cool, slightly erythematous - especially flushed face and
LE, but no obvious rashes, no petechiae, no splinter
hemorrhages.
Neuro: unable to assess
Pertinent Results:
STUDIES:
Significant labs at OSH:
WBC: 16.1 with 53% Bands
Hct: 45
Plt: 154
Lactic Acid: 4.4
.
INR: 1.8
Fibriongen: 442 (nml 150-400)
D-dimer 8400 (0-499)
.
BUN: 34
Cr: 2.7
Ca: 7.5
Gap: 19
.
UA: [**5-2**] WBC, mod Bacteria, mod Leuk, Neg Nitrite, rare coarse
granular casts. HCG: Neg
.
TB: 3.8
Direct bili: 2
Alk Phos: 53
AST: 121
ALT: 86
LDH: 396
.
Serum tox: Salicylate <2, Acetaminophen <10, Ethyl Alc <10
Urine tox: Opiate, Cocaine, Amphetamine, Cannabinoid,
Barbituates: neg
.
.
STUDIES AT [**Hospital1 18**]:
ECG [**2125-2-22**]: ST at 120s, nml axis, nml intervals, low voltage in
limb leads, no acute ST or T wave abnormalities.
CXR [**2125-2-22**]: There has been placement of a left IJ central
venous catheter with the distal tip at the caval atrial
junction. The endotracheal tube is at the level of the aortic
knob. The sideport and tip of the nasogastric tube is below the
gastroesophageal junction. Cardiac silhouette and mediastinum is
normal. There is prominence of the pulmonary vascular markings,
suggestive of mild pulmonary edema. There are no signs of focal
consolidation or pleural effusions.
Abd and Pelvic CT [**2125-2-22**]: 1. Peripancreatic fluid suggesting
pancreatitis. Small amount of ascites.
.
CT abd and pelvis [**2125-2-24**]: 1. Small amount of intrahepatic free
fluid; amount of peripancreatic free fluid has decreased since
the last examination.
2. Bilateral moderate pleural effusions and associated
compressive atelectasis.
3. Anasarca.
4. No discrete fluid collections to suggest intra-abdominal or
intrapelvic abscess.
5. Fatty liver.
2. Duodenal edema possibly representing duodenitis or other
primary process (i.e. ulcer), however, this exam is limited by
lack of oral and IV contrast. The presence of free fluid in the
abdomen could also explain this finding.
RUQ US [**2125-2-22**] (wet read): diffuse GB wall edmea (most likely due
to fluid), no sludge, no stones, no dilated CBD, no
pericholecystic fluid
Brief Hospital Course:
22yo F with no significant PMHx who presents with code sepsis
secondary to toxic shock syndrome .
.
# Sepsis/SIRS: The pt has severe SIRS with elevated WBC with
bandemia, tachycardia and what appears to be multi-organ failure
suggesting severe SIRS. The source of the inflammatory reaction
was felt most likely to be toxic shock from tampon use given
MSSA on vaginal culture and patient being unsure of how long her
tampon was in place. Patient was initially briefly on pressors
and aggressively resuscitated with 9-10 liters of isotonic
saline. OB/GYN and ID consults were obtained and the patient was
started in broad spectrum antibiotics. ID consult recommended
oxacillin and clindamycin for toxin. All cultures done at
[**Hospital1 1474**] were negative and with the exception of the above
mentioned and all cultures while at [**Hospital1 18**] were also negative
with the exception of the vaginal culture which grew MSSA.
Patient was transferred to the floor where she was tolerating
good PO and was cleared by PT to return home and autodiuresed
from her agressive fluid resuscitation. At discharge she was
advised to not use tampons in the future and was discharged with
a 14 day course of dicloxacillin and follow up in infectious
disease clinic. At discharge toxin assay sent to the CDC is
pending as is MRSA rectal swab screen.
# Coagulopathy: Most likely due to low grade DIC from sepsis.
Toxic shock syndrome can also cause thrombocytopenia. Lack of
schistocytes on smear argues against TTP/HUS. Fibrinogen
normalized and patient had no signs of bleeding.
.
# Pancreatitis: Initial CT scan showed peripancreatic fluid, but
initial amylase and lipase were WNL. Follow up CT showed
improvement of fluid and it was felt likely was secondary to
aggressive fluid resuscitation. A GI consult was obtained.
Amylase and lipase continued to trend down and her diet was
advanced.
.
# Elevated LFT's: This was felt likely to be secondary to toxic
shock syndrome which can cause hepatic dysfunction versus
sepsis/hypotension leading to shock liver. LFTs trended down as
her clinical status improved.
Medications on Admission:
MEDICATIONS:
1. Previfin (monophasic OCP)
.
ALLERGIES: NKDA
Discharge Disposition:
Home
Discharge Diagnosis:
1. Toxic shock syndrome
2. Sepsis
3. Pancreatitis
4. Transaminitis
5. Renal failure
Discharge Condition:
Hemodynamically stable, afebrile, tolerating PO
Discharge Instructions:
You were admitted to the hospital with toxic shock syndrome
likely secondary to an infection from a tampon. You should NOT
use tampons in the future. If you have any fevers, chills,
nausea, vomitting, abdominal pain, diarrhea or any other
concerning symptoms, call your doctor or come to the emergency
room.
Please finish your entire course of antibiotics.
Please keep all of your follow appointments.
Followup Instructions:
You should follow up with your primary doctor in [**12-25**] weeks.
You have a follow up appointment with the Infectious disease
clinic with DR. [**First Name (STitle) **] TAN Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2125-3-23**]
9:00. If you cannot keep this appointment, please call to
reschedule.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
ICD9 Codes: 0389, 5849, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5611
} | Medical Text: Admission Date: [**2101-6-2**] Discharge Date: [**2101-6-8**]
Date of Birth: [**2037-2-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Vicodin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
[**2101-6-3**]
Coronary artery bypass grafting x2 with
a left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to the first
marginal branch
History of Present Illness:
64yo man with no significant medical
history, presented to outside hospital w/weakness, nausea, and
syncope.
Patient was playing golf when he became weak and collapsed.
Bystanders performed CPR for about 1 minute. He was transported
to the emergency room and admitted for evaluation. He ruled out
for myocardial infarction, had positive stress test and cardiac
catheterization thet revealed 2 vessel coronary disease.
Past Medical History:
Coronary Artery Disease s/p CABG
PMH:
Coronary Artery disease s/p MI
dyslipidemia
Past Surgical History:
Hemilaminectomy [**2097**]
Left knee arthroscopy [**2-18**]
Social History:
Lives with: wife [**Name (NI) **]
Occupation: retired, worked as realtor
Tobacco: none
ETOH: none
Family History:
father w/CAD in 70's
Physical Exam:
Temp: 98 Pulse: 57 Resp: 16 O2 sat: 96%-RA
B/P Right: 131/69 Left:
Height: 6'0" Weight: 250 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no JVD or LA
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-none
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact-nonfocal exam
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right:cath Left:2+
Carotid Bruit Right:no Left:no
Pertinent Results:
[**2101-6-3**], Intra-op TEE
Conclusions
Prebypass
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is mild regional left ventricular
systolic dysfunction with hypokinesia of the mid portion of the
septal wall. Overall left ventricular systolic function is
mildly depressed (LVEF= 45 %). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. There is no aortic valve stenosis. No aortic
regurgitation is seen. Mild to moderate ([**1-9**]+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2101-6-3**] at 1445pm.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation persists. Aorta is intact post decannulation. .
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2101-6-4**] 10:17
[**2101-6-8**] 04:10AM BLOOD WBC-11.8* RBC-3.11* Hgb-9.3* Hct-26.7*
MCV-86 MCH-29.9 MCHC-34.7 RDW-13.6 Plt Ct-257
[**2101-6-7**] 05:10AM BLOOD WBC-15.2* RBC-3.33* Hgb-9.9* Hct-28.8*
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.6 Plt Ct-265#
[**2101-6-8**] 04:10AM BLOOD UreaN-24* Creat-1.1 Na-138 K-4.1 Cl-100
[**2101-6-7**] 05:10AM BLOOD Glucose-132* UreaN-19 Creat-1.1 Na-138
K-4.0 Cl-98 HCO3-30 AnGap-14
Brief Hospital Course:
The patient was brought to the Operating Room on [**2101-6-3**] where
the patient underwent CABG x 2. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery. He
did develop bradycardia in the 40s. Beta Blocker was
discontinued and would eventually be resumed after recovery.
Foley was re-placed for failure to void. This was discontinued
and he did void several times prior to discharge. Chest tubes
and pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 5 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with VNA services in good condition
with appropriate follow up instructions. He does have a history
of MI and ACE Inhibitor should be considered when blood pressure
allows.
Medications on Admission:
Meds on transfer:
ASA 325'
Plavix 75'
Meclazine 12.5"
Simvastatin 20'
Tylenol-prn
Colace [**Hospital1 **]-prn
NTG 0.4-prn
Zofran 4mg TID-PRN
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
PMH:
Coronary Artery disease s/p MI
dyslipidemia
Past Surgical History:
Hemilaminectomy [**2097**]
Left knee arthroscopy [**2-18**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Tylenol and Motrin
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2101-6-14**],
10:45am
Surgeon Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2101-6-30**] 1:00
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 13553**] in [**4-12**] weeks
Dr[**Name (NI) 61334**] office will call you with appointment
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2101-6-8**]
ICD9 Codes: 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5612
} | Medical Text: Admission Date: [**2151-1-3**] Discharge Date: [**2151-1-12**]
Date of Birth: [**2107-7-23**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillins / Gentamicin / Latex /
Iodine-Iodine Containing / Hydromorphone / Phenylbutazone /
Efavirenz / Quinolones / Macrolide Antibiotics
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central Venous Line
Bone Marrow Biopsy
History of Present Illness:
42F with past medical history of HIV not on HAART who presented
initally to [**Hospital3 **] for evaluation of right ankle pain after
a fall 1 week ago. States that while in the OSH ED began to have
fevers and headaches. Cough became worse as the day progresed.
With with fever, SOB, and cough. She was found to be febrile to
103.2, tachycardic, hypotensive, short of breath, and have a
right lower lobe infiltrate. Also had a CT head for headache and
diszziness that was negative. She was reported to be satting low
90s on RA. She was given doses of vanc and levo and transferred
to [**Hospital1 18**] for further management. In the [**Hospital1 18**] ED, initial VS
101.0 130 104/69 16 96% 2L. She recieved a dose of IV Bactrim.
Total, she recieved 2L on IVF before admission to the ICU. She
also recieved a dose of Zofran, Ativan, and morphine as well as
30mg Toradol for for pleuritic CP and headache. Ca, Mag were
repleted. VS prior to transfer were BP 105/62 HR 132 RR 30s O2
Sat 100%3-4L NC. Became hypotensive to low 80s just prior to
transfer, bolused another liter, R IJ placed, and started on
norepi. Increased diffuse infiltrate on line placement CXR.
ROS: No HA currently. Denies URI Sx. C/o right-sided mouth pain
from infected tooth. Sore throat [**3-3**] coughing. Cough productive
of blood-tinged sputum. R-sided pleuritic CP. SOB when talking.
Denies abd pain, nausea currently. RLE swelling and numbness.
Past Medical History:
1. HIV from blood transfusions in [**2120**], not currently receiving
HAART (CD4 17 [**1-8**])
2. Diabetes Mellitus
3. Uterine CA s/p hysterectomy
4. Chronic gastrointestinal problems including chronic diarrhea
5. h/o Nephrolithiasis
6. Asthma
Social History:
She is single. Lives alone, currently not working. She has never
smoked, no drug use. She rarely drinks wine.
Family History:
Father has a [**Last Name 4241**] problem, but is otherwise alive and well.
Mother has hepatitis C from a needle stick on her
job. She has two sisters and two brothers alive and well. She
has
two adult children who are alive and well.
Physical Exam:
Admission Exam:
.
VS: T:101, BP:112/65, HR:127, RR:32, SO2:100%
Gen: anxious female, speaks only [**1-31**] words before stopping to
take a breath, no accessory muscle use
HEENT: Pupils round and equil, dry MM
CV: S1, S2 tachycardic but regular
Pulm: Decreased inspiratory effort. Bibasilar crackles, R > L
Abd: soft, ND, mild epigastric tenderness
Ext: warm, no edema
.
Discharge Exam:
AVSS
General: well-appearing in NAD, AO x 3
HEENT: NC/AT, PERRL, EOMI. MMM
Neck: supple
Chest: CTA-B, no w/r/r
CV: RR slightly tachycardic, no m/g/r
Abd: soft, NT/ND, NABS
Ext: no c/c/e
Pertinent Results:
Admission Results:
.
[**2151-1-3**] 08:45PM BLOOD WBC-2.5* RBC-2.50*# Hgb-7.8*# Hct-24.1*#
MCV-96# MCH-31.2 MCHC-32.4 RDW-17.4* Plt Ct-82*#
[**2151-1-3**] 08:45PM BLOOD Neuts-41* Bands-40* Lymphs-12* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2151-1-4**] 02:58AM BLOOD PT-17.2* PTT-44.3* INR(PT)-1.5*
[**2151-1-4**] 02:58AM BLOOD WBC-2.6* Lymph-19 Abs [**Last Name (un) **]-494 CD3%-74
Abs CD3-366* CD4%-3 Abs CD4-17* CD8%-61 Abs CD8-300 CD4/CD8-0.1*
[**2151-1-3**] 08:45PM BLOOD Glucose-123* UreaN-9 Creat-0.5 Na-143
K-3.7 Cl-116* HCO3-17* AnGap-14
[**2151-1-3**] 08:45PM BLOOD ALT-58* AST-94* LD(LDH)-273* AlkPhos-342*
TotBili-0.5
[**2151-1-3**] 08:45PM BLOOD Calcium-6.9* Phos-2.1*# Mg-1.0*
.
CXR ([**2151-1-3**]):
1. Bibasilar airspace opacities, right worse than left,
concerning for
multifocal pneumonia.
2. Probable mild pulmonary edema.
.
CXR ([**2151-1-3**], s/p line placement):
In comparison with the earlier study of this date, there has
been
placement of a right IJ catheter that extends to the lower
portion of the SVC. Again, there is evidence of elevated
pulmonary venous pressure with more focal area of opacification
in the right mid and lower lung zones, concerning for pneumonia.
.
Interval Results:
.
CT Chest, Abdomen and Pelvis ([**2151-1-4**]):
1. Multifocal consolidation, worse in the right middle and lower
lobes,
concerning for multifocal pneumonia. No evidence of interstitial
or alveolar edema.
2. Bilateral pleural effusions, moderate on the right and small
on the left.
3. Lymphadenopathy, particularly in the left retroperitoneum and
mediastinum, which may relate to the patient's HIV disease.
.
Right Ankle XR ([**2151-1-4**]):
No evidence of acute fracture.
.
TTE ([**2151-1-5**]):
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. There is abnormal Doppler signal
at the right and left ventricular apices, throughout the cardiac
cycle (cine loops 36, 37, 54, 55). Although a Doppler artifact
is possible, this may also represent a congenital coronary
artery-to-ventricular fistula. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion. Mildly dilated
right ventricle with normal global and regional biventricular
systolic function. Possible coronary artery-to-ventricular
fistula.
.
Microbiology Data:
1. Blood cultures ([**2151-1-3**]): negative
2. Urine culutres ([**2151-1-3**]): negative
3. Urinary Legionella antigen ([**2151-1-3**]): negative
4. Influenza A/B DFA ([**2151-1-3**]): negative
5. Sputum PCP [**Name Initial (PRE) **] ([**2151-1-4**]): negative
6. Sputum Cultures ([**2151-1-3**]): negative
7. Sputum Cultures ([**2151-1-4**]): negative
8. CMV Viral Load ([**2151-1-4**]): negative
9. Toxoplasma IgM, IgG ([**2151-1-4**]): negative
10. Cryptococcal Antigen ([**2151-1-4**]): negative
11. Sputum AFB Smear ([**2151-1-4**]): negative
12. Sputum AFB Culture ([**2151-1-4**]): negative
13. Blood Fungal Cultures ([**2151-1-4**]): negative
14. Stool O&P, microsporidia/cyclospora ([**1-7**], [**1-9**]): negative
15. Stool AFB ([**2151-1-7**]): negative
16. Stool AFB ([**2151-1-9**]): PENDING
.
HIV VL 78,663
HIV Genotype pending
CMV IgG Ab positive
CMV IgM AB negative
.
PENDING DATA:
[**1-9**] Stool AFB cultures x 1 pending
[**1-8**] Bone Marrow Bx pathology, cytogenetics, cultures - pending
.
CXR [**2151-1-12**]: There is marked interval improvement in the degree
of opacity in the right lung and bilateral upper lobe venous
diversion, which likely represented right lower lobe pneumonia
with associated
pulmonary edema. The cardiac and mediastinal contours appear
normal.
.
Discharge labs:
[**2151-1-12**] 07:00AM BLOOD WBC-1.5* RBC-2.75* Hgb-8.5* Hct-26.0*
MCV-95 MCH-30.8 MCHC-32.6 RDW-17.3* Plt Ct-98*
[**2151-1-12**] 07:00AM BLOOD Neuts-51 Bands-0 Lymphs-37 Monos-8 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-1-11**] 06:10AM BLOOD WBC-1.3* RBC-2.64* Hgb-8.0* Hct-24.9*
MCV-94 MCH-30.2 MCHC-32.1 RDW-17.0* Plt Ct-102*
[**2151-1-11**] 06:10AM BLOOD Neuts-45* Bands-4 Lymphs-35 Monos-12*
Eos-2 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2151-1-10**] 07:15AM BLOOD WBC-1.7* RBC-2.80* Hgb-8.5* Hct-26.7*
MCV-95 MCH-30.5 MCHC-32.0 RDW-17.1* Plt Ct-110*
[**2151-1-8**] 10:15AM BLOOD Neuts-46* Bands-0 Lymphs-39 Monos-15*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2151-1-12**] 07:00AM BLOOD ALT-56* AST-66* LD(LDH)-278* AlkPhos-569*
TotBili-0.3
Brief Hospital Course:
43 y/o HIV+ female who was transferred from an OSH with a
community-acquired pneumonia with sepsis.
.
#. Pneumonia with Sepsis: Patient presented with productive
cough and CXR evidence of RLL pneumonia. Fevers, bandemia of 40%
and tachycardia were consistent with sepsis without evidence of
end-organ ischemia. Patient with no recent concerning
health-care contacts so was started on Levofloxacin for CAP
coverage, as well as Vancomycin and Cefepime for broader
coverage given septic physiology and history of HIV with unknown
CD4 count. Blood and urine cultures, and urinary legionella
antigen were sent prior to giving antibiotics. Urine cultures
came back negative. Patient was on Bactrim for PCP prophylaxis
as an outpatient and increasing to treatment dosing was
considered but not pursued given CXR appearance and high oxygen
saturation on room air. Influenza DFA was checked and was
negative. Sputum for PCP was negative by immunofluorescence and
a CT of the chest was inconsistent with PCP [**Name Initial (PRE) 1064**].
Cryptococcal antigen was sent and was negative. Toxoplasma IgM
and IgG were negative. Legionella culture was also negative.
Sputum AFB stain was negative. With regards to the patient's
sepsis, the patient initially responded to normal saline boluses
alone but eventually required the addition of pressors, first
with Norepinephrine but then was switched to Phenylephrine as
the patient was persistent tachycardic. The patient was able to
be weaned from her pressors several days into her hospital
course and eventually required no further fluid boluses. After
blood cultures were negative for 48 hours and the patient
continued to improve clinically, the Cefepime was discontinued
and the patient was transferred to the medicine service,
whereupon Vanco was discontinued. Sputum cultures were negative.
She completed a full course of Levofloxacin through [**2151-1-10**].
.
#. Pancytopenia: On admission patient had WBC of 2.5, hematocrit
of 24.1, and platelet count of 82. The only records in the [**Hospital1 18**]
system on admission were from [**2146**] with the admission results
demonstrating a significant change. There was concern for an
HIV-associated pancytopenia but also for DIC, specifically with
regard to the anemia and thrombocytopenia, so DIC labs were
checked but showed no signs of DIC with fibrinogen always > 200,
and coags were slightly elevated on admission but remained
stable with no significant elevations. Haptoglobin and bilirubin
were within normal limits. The PCP was [**Name (NI) 653**] for further
information who stated that the pancytopenia has been a problem
for years. The patient's leukopenia was attributed to her
HIV/AIDS with a possible septic component. Her anemia was likely
anemia of chronic inflammation from her HIV/AIDS.
Thrombocytopenia was attributed to HIV/AIDS. Her counts were
followed closely throughout her ICU stay. The patient did
require on transfusion for a hematocrit of 19 with an
appropriate bump to 24. Stool guaiacs were negative and the
change was attributed to vigorous IV hydration with a reported
significant blood loss during central line placement. BMBx was
performed on [**2151-1-8**] to rule out pathology or BMInfection.
Pathology was still pending at the time of discharge but prelim
results showed no abnormal cells. Bone marrow AFB,
cytogenetics, and culture were PENDING at the time of discharge,
will be followed up by our hematology team here. Bactrim was
discontinued as noted below in the event this was contributing
to her pancytopenia. At the time of discharge, her WBC was
stable but low at 1.5 with functional neutropenia (50%
neutrophils). The patient was advised of neutropenic
precautions and to watch for fevers > 100.5.
.
# Orthostatic Hypotension: When out of ICU. AM fasting cortisol
was normal, TSH normal, was fluid responsive. With increased
ambulation, this improved. She may typically run lowish blood
pressure. Prior to discharge this remained stable and she was
no longer orthostatic
.
#. Chronic Diarrhea: Long standing for >1yr with exhaustive
work-up by Dr. [**Last Name (STitle) 67812**] at [**Hospital1 2177**]. Here, C. diff, microsporidia,
O&P, Cryptosporidia all negative. AFB culture (for MAC)
negative x 1 (2nd culture pending). DDx largely is MAC vs HIV
enteropathy. As above, stool studies were negative though AFB
culture for MAC are pending for the last stool culture.
Loperamide given prn.
.
#. HIV / AIDS: Not currently on HAART. Last CD4 count in our
system was 37 in [**2146**] with CD4 of 17 this admission, and mildly
recent 20 (as outpatient). This indicates advanced HIV WHO Stage
IV. ID conuslt [**Year (4 digits) 653**] here to arrange followup. HIV VL and
gentoype was sent and results are noted in the results section.
Prefer to rule out MAC infection prior to HAART if possible to
determine need to treat or to prophylax. BMBx for AFB Cx also
pending. Will follow up with [**Hospital **] Clinic on [**2-1**]. Importance of
HAART therapy underscored to patient, who understood. She was
continued on Bactrim for PCP [**Name9 (PRE) 31424**] but this was changed to
Atovaquone given her pancytopenia, in case Bactrim was
contributing to this. She will require prior authorization for
the Atovaquone, so both her pharmacy and insurance company were
[**Name9 (PRE) 653**] to expedite this and we will be notified in the next
24 hours of their decision. She was provided with 2 extra doses
to take at home on [**1-13**] and [**1-14**], and will follow-up with her
PCP [**Last Name (NamePattern4) **] [**1-14**], who will follow-up in regards to the Atovaquone in
the event the prior authorization is not settled in the next
24-48 hours.
.
# Elevated LDH / Transaminitis: Could be sign of underlying
MAC. No abnormal imaging and clinically asymtpomatic from
hepatobiliary standpoint. LFTs remained stable but elevated,
this should be trended to ensure no worsening.
.
#. Candidal Esophagitis (presumed): Patient was complaining of
mild odynophagia several days into her hospitalization. She was
initially treated with Nystatin swish and swallow with minimal
improvement. She was then started on Clotrimazole troches with
improvement in her symptoms.
.
#. Right Ankle Pain: Patient has been walking with crutches
prior to admission. Presented to an outside hospital for this
reason. Ankle x-ray was negative for fracture at [**Hospital1 18**]. She
worked with PT and will need home PT services.
.
#. Diabetes Mellitus: Patient takes Novolog at home for her
diabetes when needed. Stated that blood sugars have been
well-controlled recently in the 100-120s without insulin.
Patient was maintained on a Humalog insulin sliding scale while
in the ICU but never required any sliding scale coverage during
her ICU stay and on the medical floor, so this was discontinued.
She was encouraged to check her sugars regularly at home and to
use her Novolog sliding scale as needed.
Medications on Admission:
Lutein
Albuterol
Bactrim 1 tab daily
Prochlorperazine
[**Name (NI) **] (Pt says hasn't been taking her insulin lately as sugars
have been good)
Novolog sliding scale
Iron 325 daily
Multivitamin
Opium 10% eye drops
KCl 40mEq daily
omeprazole 20mg daily
loratidine 10mg daily
Vitamin D 1000 units daily
Vitamin E 400 units daily
Flax Seed Oil 1000 daily
Fish Oil 1000 daily
Budesonide nasal spray 2 sprays [**Hospital1 **]
Vicodin 1-2 tabs q6 hrs PRN
Discharge Medications:
1. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) milliliters
PO DAILY (Daily).
Disp:*qS (for one month) mL* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
4. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
5. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Comm Aquire Pneumonia w/ sepsis
Chronic diarrhea - final evalation pending
Pancytopenia
HIV / AIDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with sepsis from pneumonia and hospitalized in
ICU. This has been fully treated. You have low blood counts
concerning for side effect of sepsis, or due to bone marrow
process. A Bone marrow bx was done and pathology showed
preliminarily did not show any abnormal cells. However,
cultures are still pending. You were evaluated for causes of
chronic diarrhea which may be due to infection or HIV
enteropathy. Studies are pending. You met with an infectious
disease clinician and will need to be on anti-HIV meds for
advanced AIDS. You were evaluated by physical therapy who felt
you were safe to go home with a walker and home services.
If you develop any fevers > 100.5, please call your doctor or
return to the hospital immediately. Please avoid contact with
people who any upper respiratory illnesses, given your low white
count.
MEDICATION RECONCILIATION:
1. START Atovaquone 1500 mg daily for PCP [**Name Initial (PRE) 1102**]
(AIDS-related infection).
2. STOP Bactrim
3. Continue loperamide and compazine as needed for diarrhea and
nausea, respectively.
4. Continue insulin sliding scale as needed for your blood
sugars based on your home dose of sliding scale.
5. STOP potassium supplements
6. Continue omeprazole twice daily
Followup Instructions:
PCP [**Name Initial (PRE) **]: Tuesday, [**1-14**] at 11:15am
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 67813**],[**First Name3 (LF) **]
Location: PRIMACARE
Address: [**Street Address(2) 17177**], [**Location (un) **],[**Numeric Identifier 33806**]
Phone: [**Telephone/Fax (1) 67814**]
Department: INFECTIOUS DISEASE
When: MONDAY [**2151-2-1**] at 10:00 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2151-1-12**]
ICD9 Codes: 0389, 2762, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5613
} | Medical Text: Admission Date: [**2119-8-14**] Discharge Date: [**2119-8-23**]
Service: CARDIOTHORACIC
Allergies:
Morphine / Percocet / Codeine
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Shoulder pain
Major Surgical or Invasive Procedure:
PICC placement [**2119-8-15**]; Surgery for hiatal hernia
[**2119-8-16**] 1. Laparoscopic reduction of giant paraesophageal
hernia.
Primary repair of diaphragm. Laparoscopic G tube. Endoscopy.
History of Present Illness:
[**Age over 90 **] year-old female with CAD, thoracic aortic aneurysm, large
hiatal hernia, and gastritis admitted with shoulder pain. Pain
began approximately 3PM on day prior to admission. Described as
'ache', not associated with movement, chest pain, palpitations,
shortness of breath, or palpitations. Patient also with nausea.
Reports she has had previous pain in the past, but not to this
severity or duration. Per discussion with patient's daughter
([**Name (NI) **]) and review of [**Name (NI) **], pain previously attributed in part
to uncontrolled GERD. Following onset of pain, patient took 2
[**Name (NI) 9181**] without relief. Given persistence of pain, she called EMS.
Unclear if this is her anginal equivalent. Per discussion with
patient's daughter, daughter-in-law, often has 'attacks' of
gassy pain with radiation to left shoulder, at times associated
with nausea. Episodes often precipitated by eatting out. This
episode different due to severity/persistence of pain.
.
In the ED, 98 68 106/63 16 100%RA. Left shoulder pain initially
thought to be cardiac equivalent. BP came down to 90/50s soon
after admission, attributed to [**Name (NI) 9181**]. Blood pressure improved
with fluid bolus. First set cardiac biomarkers within normal
limits. EKG showed atrial fibrillation (known), without acute
ischemic changes. CTA showed stable thoracic aortic aneurysm.
Patient subsequently developed abdominal pain, nausea. Lipase
mildly elevated at 65; LFTs within normal limits. CT
abdomen/pelvis noncontrast showed large hiatal hernia and many
renal cysts, no acute change from prior imaging studies. She
received antiemetics (Zofran, Ativan, compazine, phenergan),
acetaminophen, IVF NS 2-3L. On transfer, 98.6, 95 (afib),
106/52, 16, 97%RA. HR occasionally to 120s, hemodynamic
stability.
.
On the floor, patient is drowsy and unable to provide history.
She reports left shoulder pain, nausea. She denies chest pain,
shortness of breath, abdominal pain.
.
Review of sytems: (limited because patient is drowsy)
(+) Per HPI. Reports intermittent constipation, last BM
yesterday morning.
(-) Denies fever, chills. Denies sinus tenderness, rhinorrhea.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. No recent change in bowel or bladder
habits. No dysuria.
Past Medical History:
Atrial fibrillation on coumadin
- Hypertension
- Hyperlipidemia
- Esophageal varices, grade I-II
- CAD s/p inferior MI ([**2108**])
- Gastritis
- Large hiatal hernia s/p UGI with barium in [**2113**] with normal
motility
- Multiple pulmonary nodules (non-calcified granulomas on CT
[**2111**])
- h/o left nephrolithiasis (uric acid stones)
- Chronic heart failure, systolic (EF 35%)
- Osteoporosis s/p multiple fractures
- Hypothyroidism
- Gout
- Ascending aortic aneurysm (4.5 cm on [**2115**] MRA)
- Chronic renal insufficiency
Social History:
(from [**10-29**] discharge summary)
"Pt lives alone, has home health aide 4x/week and a VNA 1x/wk.
Can perform ADLS and is fairly independent. Quit tobacco 30yrs
ago. Denies alcohol, illicit drug use."
Family History:
(from [**10-29**] discharge summary)
"Her mother died of a heart attack at age 59."
Physical Exam:
On admission [**2119-8-14**]:
96.7, 97, 137/67, 14, 98% 4L NC
LUE 128/71; RUE 110/64
General: Sedated; AOx3; comfortable
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: Supple, JVP not elevated
Lungs: Limited by anterior auscultation; no wheezes, rales,
ronchi
CV: Irregularly irregular; normal S1/S2; no murmurs
Abdomen: Hypoactive bowel sounds; soft, nontender, not
distended
Ext: Warm, well-perfused; no lower extremity edema.
.
On Discharge
97.7 80 afib 110/70 18 96% 2L NC
General: Pleasant, conversational, comfortable
HEENT: Sclera anicteric, dry mucous membranes
Neck: Supple
Lungs: bilateral crackles L>R
CV: Irregularly irregular; normal S1/S2; no murmurs
Abdomen: Hypoactive bowel sounds; soft, nontender, not
distended
Ext: Warm, well-perfused; [**12-23**]+ lower extremity edema
Neuro: awake, alert and oriented
Pertinent Results:
[**2119-8-22**] WBC-9.3 RBC-2.82* Hgb-9.0* Hct-27.4 Plt Ct-131*
[**2119-8-21**] WBC-9.5 RBC-2.76* Hgb-8.8* Hct-27.5 Plt Ct-111*
[**2119-8-16**] WBC-12.3* RBC-3.03* Hgb-9.5* Hct-29.3 Plt Ct-153
[**2119-8-14**] WBC-6.6 RBC-3.55* Hgb-11.4* Hct-34.0* Plt Ct-211
[**2119-8-22**] Glucose-165* UreaN-33* Creat-0.9 Na-142 K-4.0 Cl-105
HCO3-30
[**2119-8-21**] Glucose-243* UreaN-39* Creat-0.9 Na-144 K-3.6 Cl-111*
HCO3-26
[**2119-8-14**] Glucose-149* UreaN-37* Creat-1.7* Na-145 K-3.9 Cl-107
HCO3-24
[**2119-8-22**] Calcium-8.5 Phos-3.3 Mg-1.8
[**2119-8-21**] calTIBC-192* Ferritn-136 TRF-148
CXR: [**2119-8-22**] FINDINGS: Since the previous study, the left
paraesophageal thoracic hernia is unchanged which is distended
with air and contains barium. This is associated with a large
left pleural effusion with atelectasis and displacement of the
mediastinum to the right.
There is also a moderate right pleural effusion with fluid in
the horizontal fissure.
Esphogus: [**2119-8-19**] FINDINGS: With the patient at approximately
45-degree incline, thin barium was orally administered which
transited through the esophagus, passed the GE junction and into
the proximal stomach. There was approximately one hour delay of
transit of contrast from the proximal stomach, which was now
supradiaphragmatic, into the more distal stomach, which was
subdiaphragmatic. The more subdiaphragmatic portion of the
stomach is approximately one-third of the total volume of the
stomach and contains a PEG tube. Residual contrast from prior
examinations is present in the colon. Marked bibasilar
atelectasis is present. On the initial fluoroscopic image, no
contrast was present in the intrathoracic stomach from the prior
examination one day ago.
CCT/Pelvic [**2119-8-18**]: IMPRESSION:
1. No evidence of bowel obstruction, or herniation of bowel
loops through the hiatal defect. Fluid density structure at the
right lower mediastinum appears to represent fluid filling the
previous intrathoracic hernia sac, or possibly postsurgical
change secondary to mobilization of omentum.
2. Complex air and oral contrast-filled structure in the left
lower chest
could represent re-herniated stomach, with areas of redundant
folds collapsed on itself. However, gastric perforation/leak
cannot be excluded, and contrast-swallow evaluation is
recommended for further evaluation.
3. Stable appearance of ascending aortic dilatation, better
characterized on recent contrast-enhanced CTA of the chest.
CCT/Pelvic:[**2119-8-14**] Minimal interval enlargement of the
ascending thoracic aortic aneurysm, now measuring 4.9 x 4.4 cm.
There is no evidence of dissection or pulmonary embolism.
2. Interval enlargement and a large hiatal hernia
PICC line [**2119-8-15**]: Left PICC line passes deep into the right
atrium, at least 8 cm beyond the superior cavoatrial junction. N
Brief Hospital Course:
[**Age over 90 **]F with CAD, thoracic aortic aneurysm, gastritis, GERD admitted
with left shoulder pain, nausea with transient relative
hypotension in context of [**Name (NI) 9181**]. Pt c/o abdominal pain during ED
course and CT imaging obtained with results above.
.
# Respiratory: she was extubated on [**2119-8-16**] for the operating
room and extubated on [**2119-8-17**]. Her improved over the course of
her hospitalization with nebs and pulmonary toileting. Her
oxygen saturations were 93% in 3L upon discharge.
# Hiatal hernia: Pt with large hiatal hernia. On [**2119-8-16**] she
was taken to the operating room for Laparoscopic reduction of
giant paraesophageal hernia. Primary repair of diaphragm.
Laparoscopic G tube. Endoscopy.
# Nutrition: She was maintained on TPN until she could tolerate
PO's. On [**2119-8-21**] she was started on clears and advanced to
puree with thin liquids. She tolerated small amounts. She did
not tolerate Tube feeds secondary to shortness of breath. They
were discontinued.
#. Atrial fibrillation: Dilated left atrial noted on TTE [**4-24**].
s/p cardioversion x3, most recent [**4-28**]. rate controlled with
metoprolol.
Coumadin restarted [**2119-8-23**] 0.5 mg.
.
#. CAD s/p inferior MI ([**2108**]): Cardiac catheterization [**12-27**]
with diffuse atherosclerosis. Pt on beta-blocker IV. Aspirin and
statin held as pt not taking PO meds. Careful use of [**Month/Year (2) 9181**] for
chest pain given relative hypotension after doses (2) prior to
admission.
#. Chronic heart failure, systolic (EF 35%): Appears euvolemic,
although pulmonary exam was limited by poor inspiratory effort.
Patient does have oxygen requirement at this time. Beta blocker
continued. Lasix restarted.
.
#. Ascending aortic aneurysm: Based on imaging in ED, slightly
enlarged in size. No evidence of dissection.
.
#. Chronic renal insufficiency: Stable. Current 0.9. Baseline
1.5-1.6.
.
#. Anemia: Borderline macrocytic. Baseline 28-32. Currently
27.0. Known esophageal varices from EGD [**2119-6-13**]. Colonoscopy at
same time with hyperplastic polyp, diverticuli. Iron studies
normal in [**2115**]. B12, folate not checked in our system.
Hct was trended.
.
#. Hypertension: Pt had relative hypotension in [**Name (NI) **] following
[**Name (NI) 9181**], improved on admission. Amlodipine held for SBP 100-116.
.
#. Hyperlipidemia: statin restarted
.
#. Gastritis/GERD: large hiatal hernia. PPI [**Hospital1 **].
.
#. Osteoporosis: Unclear why patient is not taking vitamin D or
calcium supplement.
.
#. Hypothyroidism: Continued Levothyroxine
.
#. Gout: allopruinol restarted
#. PICC line was placed Left [**2119-8-15**] chest film revealed
placement at the cavo-atrial junction and was pulled back 8 cm
per radiology recommendations.
.
Code status: FULL CODE
.
Communication: [**Doctor First Name **] (daughter), ([**Telephone/Fax (1) 98148**]; [**Name (NI) **]
(daughter-in-law), ([**Telephone/Fax (1) 98149**]
.
Disposition: She was seen by physical therapy who recommended
rehab.
Medications on Admission:
(confirmed with patient's daughter)
- Vitamin C
- Aspirin, coated
- MVI
- Norvasc 2.5mg PO daily
- Allopurinol 100mg PO daily
- Lipitor 40mg PO QHS
- Toprol 12.5mg PO daily
- Esomeprazole 40mg PO BID - **she's not taking the evening dose
- Zantac 150mg PO BID - **may not be taking at night
- Klorcon 10meq PO BID
- Levoxyl 75mcg PO daily
- Coumadin 1-2mg PO daily
- Lasix 20mg PO daily
- [**Telephone/Fax (1) 9181**]
- Miralax
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day): oral thrush.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4H (every 4 hours) as needed for pain.
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) packet PO DAILY (Daily): hold for loose stool.
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily).
13. Regular Insulin Sliding Scale
Glucose Insulin Dose
0-70 mg/dL 4 oz. Juice
71-150 mg/dL 0 Units
151-200 mg/dL 4 Units
201-250 mg/dL 9 Units
251-300 mg/dL 14 Units
301-350 mg/dL 19 Units
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
15. Warfarin 1 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4
PM: to maintain INR 2.0-2.5 for Afib.
16. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. Hep Flush-10 10 unit/mL Solution Sig: Two (2) mL Intravenous
as needed as needed for PICC line: Flush with 10 cc normal sale
following heparin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Giant paraesophageal hernia.
Atrial fibrillation: rate control
Hypertension/Hyperlipidemia
Esophageal Varices
CAD s/p inferior MI [**2108**]
Systolic Heart Failure: EF 35%
Gastritis
Hypothyroidism
Gout
Osteoporosis
Chronic renal failure
Ascending Aorta Aneurysm (4.5 cm on [**2114**] MRA)
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience:Fevers > 101
or chills, Increased painful or difficulty swallowing.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**9-7**] at 10:00am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a chest x-ray
45 minutes before your appointment
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**] for coumadin follow-up after
discharge from rehab
Completed by:[**2119-8-24**]
ICD9 Codes: 5070, 5789, 2760, 5180, 4280, 2449, 2749, 5859, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5614
} | Medical Text: Admission Date: [**2135-4-1**] Discharge Date: [**2135-4-11**]
Date of Birth: [**2054-2-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Darvocet-N 50 / Phenothiazines / Percocet
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2135-4-1**]: s/p Open reduction internal fixation, right femur.
History of Present Illness:
81 year old female who fell on [**2135-4-1**] resulting in a right
distal femur periprosthetic fracture requiring surgical
management. 81 year old female with past medical history of
dementia, epilepsy, cerebellar ataxia (wheelchair bound), and
s/p remote right TKR who presented yesterday from nursing home
after fall and femur fracture. Pt now POD # 1 s/p right TKR
with acute mental status change. Patient was interactive,
verbal, and responsive, althought not A and O x 3, prior to
surgery. Post-operatively has been easily arousable but
disoriented and non-verbal. Intra-op course uncomplicated,
received 2 units PRBCs in OR.
.
Currently, patient opens eyes to name, but is not able to
provide history. Per family, patient was interactive prior to
ORIF. They did endorse a steady decline in mental status over
the past 1-2 months, with increasing perseveration and some
short term memory deficits. Son also notes intermittent
episodes of confusion over many decades.
.
ROS: unable to obtain [**1-18**] altered mental status.
Past Medical History:
1. Dementia.
2. Depression with a history of suicide attempts (last
hospitalized on the Psychiatric Unit at [**Hospital1 18**] in 11/[**2132**]).
3. Multiple falls with subdural hematoma [**2128**].
4. Seizure disorder.
5. Paroxysmal atrial fibrillation, not on any anticoagulation
due to history of falls.
6. Hypothyroidism.
7. Hypertension.
8. Prior STH.
PAST SURGICAL HISTORY:
1. currently POD #1 s/p right distal femur ORIF
2. Right cataract surgery [**2132**].
3. s/p right TKR
9. Tardive dyskinesia.
10. Cerebellar degeneration with chronic ataxia.
11. History of alcohol abuse.
12. Hepatitis B.
13. Iron deficiency anemia.
Social History:
The patient is widowed; has 2 children (son and daughter). Went
to [**University/College **]where she majored in English with a minor
in history and worked a number of different jobs after
graduating but primarily worked in editing for a publishing firm
and at one point as a medical researcher. She ultimately had to
quit work when she became psychiatrically ill in her 30s (also
reports this is when her seizures started), and it appears this
was all after she found her mother hanging after a suicide
attempt, and her son says she has "PTSD" from this event). She
has not worked since the early [**2104**], and was divorced from her
husband around this time as well. She had been living
independently in her own apartment until about 4 years ago but
had been failing for about the last five years of that stretch
with multiple falls which went undiscovered for days at a time.
She has been wheelchair bound for falls and cerebellar ataxia
(possibly related to extended phenytoin use) for the last 6
years or so. Her first placement was at [**Hospital1 **], where she
stayed for a year and did not like, and she has been at [**Last Name (un) **]
for the last three years.
Substance Abuse History: Per son history of alcoholism, now has
occasional weekly drinks at [**Last Name (un) **] with other residents and
son. [**Name (NI) **] is unable to specify amount. Distant history of tobacco
use, none in past 40 years. Denied knowledge of illicits.
Possible distant history of valium abuse in 70s.
Family History:
[**Name (NI) **] mother with completed suicide, son unsure of etiology
half sister who has been depressed and frequently hospitalized
Physical Exam:
PHYSICAL EXAMINATION
Temp:97.0 HR:66 BP:112/95 Resp:20 O(2)Sat:98
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Neck NT, Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: Tender at R knee with deform; NV intact
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Exam on transfer to medicine:
Vitals - T: 99 T max 100.6 BP: 122/76 HR: 82 RR: 16 02
sat: 98% RA
GENERAL: alert, easily arousable to name, non-verbal, tracking
HEENT: atraumatic, normocephalic, no scleral icterus
CARDIAC: RRR s1, s2, II/VI SEM at USB, apex
LUNG: rales at left base
ABDOMEN: soft, ? tender suprapubic region (grimace), active BS,
non-distended
EXT: 2+ radial and DP pulses bilat, no LE edema; right knee
dressed in splint
NEURO: CNs intact, DTRs 2+ UEs, unable to complete remainder of
exam [**1-18**] mental status
Pertinent Results:
[**2135-4-1**] 04:45AM URINE AMORPH-OCC
[**2135-4-1**] 04:45AM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-0
[**2135-4-1**] 04:45AM URINE BLOOD-NEG NITRITE-POS PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-9.0* LEUK-SM
[**2135-4-1**] 04:45AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.023
[**2135-4-1**] 04:45AM PT-12.7 PTT-29.4 INR(PT)-1.1
[**2135-4-1**] 04:45AM PLT COUNT-363
[**2135-4-1**] 04:45AM NEUTS-81.2* LYMPHS-13.7* MONOS-4.2 EOS-0.5
BASOS-0.4
[**2135-4-1**] 04:45AM WBC-9.5# RBC-3.50* HGB-10.4* HCT-32.7* MCV-93
MCH-29.6 MCHC-31.7 RDW-13.5
[**2135-4-1**] 04:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2135-4-1**] 04:45AM URINE HOURS-RANDOM
[**2135-4-1**] 04:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2135-4-1**] 04:45AM FREE T4-1.4
[**2135-4-1**] 04:45AM TSH-1.4
[**2135-4-1**] 04:45AM estGFR-Using this
[**2135-4-1**] 04:45AM GLUCOSE-106* UREA N-34* CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14
[**2135-4-1**] 03:22PM PLT COUNT-270
[**2135-4-1**] 03:22PM WBC-14.6*# RBC-2.51*# HGB-7.8* HCT-24.0*#
MCV-96 MCH-31.1 MCHC-32.6 RDW-13.8
[**2135-4-1**] 03:22PM GLUCOSE-153* UREA N-25* CREAT-0.7 SODIUM-143
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-23 ANION GAP-13
IMAGING/STUDIES:
CT head- No acute intracranial abnormality
Right knee- Displaced and angulated fracture of the distal femur
CT C spine- No evidence of acute injury to the cervical spine.
In case of clinical concern for cord-ligamentous injury, an MRI
can be obtained.
[**2135-4-3**] Chest PA lateral- IMPRESSION: PA and lateral chest
compared to [**4-2**]: Multifocal pulmonary consolidation and
generalized interstitial abnormality continued to improve in all
areas except the perihilar right mid lung. Heart size is normal
and the mediastinal vasculature is no longer engorged. Overall
the findings are most likely due to resolving atypical edema.
Continued surveillance of a possible pneumonia in the right mid
lung; however, is appropriate. No pneumothorax. Pleural effusion
if any is minimal.
[**2135-4-4**] ECG: Sinus rhythm with atrial premature beats. Consider
left atrial abnormality. Low limb lead QRS voltage. Modest ST-T
wave changes. Findings are non-specific and baseline artifact
makes assessment difficult. Since the previous tracing of
[**2135-4-2**] there is probably no significant change.
[**2135-4-4**] portable CXR: IMPRESSION: AP chest compared to [**4-3**]:
Detail is severely obscured by respiratory motion. The caring
physician declined [**Name Initial (PRE) **] repeat examination when offered at 11 a.m.
on [**4-4**]. Cardiac silhouette has enlarged, and it is difficult to
exclude interstitial edema but right perihilar consolidation has
not cleared and remains a concern for pneumonia. Similarly
pleural effusion is hard to exclude. There is no large
pneumothorax but a small volume of pleural air would be missed.
[**2135-4-4**] CTA chest: CTA OF CHEST WITH AND WITHOUT CONTRAST: There
is marked atherosclerotic disease of the thoracic arch and arch
vessels. Coronary artery calcification is also seen. The main
pulmonary artery measures 3.9 cm, consistent with pulmonary
artery hypertension. There is a moderate hiatal hernia
containing both stomach and colon. There is no axillary,
mediastinal, or hilar lymphadenopathy. There is patchy bilateral
ground-glass opacification throughout both lungs consistent with
pulmonary edema. There is a very small left pleural effusion.
There is no pulmonary embolism within the main, lobar, or
segmental pulmonary arteries. Within segment VII of the liver,
there are three small enhancing lesions, the largest measuring
1.6 cm. These are nonspecific, but appearance is suggestive of
peripheral shunts or vascular anomalies. BONES: There is
degenerative disc disease throughout the thoracic spine. No
osteolytic or osteoblastic lesion is seen. IMPRESSION: 1. There
is no pulmonary embolism. 2. Bilateral patchy ground-glass
opacifications consistent with pulmonary edema. 3. Pulmonary
artery hypertension. 4. Three small peripheral segment VII liver
lesions, nonspecific, but may represent small peripheral AVMs.
If desired MRI may provide further assessment. 5. Hiatal hernia
containing stomach and colon.
[**2135-4-5**] TTE: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Doppler parameters are most
consistent with Grade II (moderate) left ventricular diastolic
dysfunction. Right ventricular chamber size is difficult to
assess but free wall motion is normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
The pulmonic valve leaflets are thickened. The main pulmonary
artery is dilated. There is an anterior space which most likely
represents a prominent fat pad. IMPRESSION: Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild aortic and mitral
regurgitation. Mild ascending aortic dilation. Moderate
tricuspid regurgitation. At least moderate pulmonary
hypertension. Compared with the report of the prior study
(images unavailable for review) of [**2130-2-8**], pulmonary
hypertension has progressed. There is more tricuspid
regurgitation.
[**2135-4-5**] Portable CXR: FINDINGS: As compared to the previous
radiograph, no motion artifacts are present. The lung volumes
have slightly decreased. There is unchanged cardiomegaly.
Indications of mild pulmonary edema are present and similar to
the image from [**4-3**]. In addition, a pre-existing right basal
parenchymal stone shows increased opacity that has slightly
progressed as compared to the radiographs from [**4-3**] and
[**4-4**]. Blunting of the left costophrenic sinus, potentially
suggestive of small left pleural effusion. No other focal
parenchymal opacities are present.
[**2135-4-6**] Portable CXR: FINDINGS: In comparison with study of
[**4-5**], there is little change. Cardiac silhouette is at the upper
limits of normal in size and there is mild tortuosity of the
aorta. Again, there is diffuse prominence of interstitial
markings consistent with pulmonary edema as shown on the CT of
[**4-4**]. The possibility of an underlying substrate of chronic
interstitial lung disease must certainly be considered. Some
atelectatic changes are seen at the left base. Of incidental
note is diffuse osteopenia of the visualized bony elements.
Micro data:
[**2135-4-1**] 4:45 am URINE Site: CATHETER
**FINAL REPORT [**2135-4-3**]**
URINE CULTURE (Final [**2135-4-3**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2135-4-2**] 8:55 pm BLOOD CULTURE Blood Culture, Routine (Pending)
[**2135-4-3**] Legionella urinary antigen - negative
[**2135-4-3**] MRSA screen - negative
[**2135-4-4**] Stool for C. difficile toxin - negative
ABG on 5 liters n/c and shovel mask- 7.54/31/44 with O2 sats
near 80%
ABG on NRB- 7.49/35/65 with O2 sats in mid 90s%
Brief Hospital Course:
Ms. [**Known lastname 100930**] was admitted to the Orthopedic service on
[**2135-4-1**] for a right distal femur periprosthetic fracture after
being evaluated and treated with closed reduction in the
emergency room. She underwent open reduction internal fixation
of the right femur without complication on [**2135-4-1**]. She was
extubated without difficulty and transferred to the recovery
room in stable condition. In the early post-operative course
Ms. [**Name14 (STitle) 100936**] was transfused 2 units of packed red blood cells
in the recovery room for post operative blood loss anemia and
subsequently transferred to the floor in stable condition. She
was then transferred to Medicine for evaluation and management
of acute mental status changes.
.
81 year old female with h/o dementia, epilepsy, cerebellar
ataxia (wheelchair bound), and s/p remote right TKR who p/w fall
and right distal femur fracture, now POD # 2 s/p right femur
ORIF with acute mental status change. Triggered for hypoxia
overnight.
.
# Hypoxemia- difficult to record accurate pleth given Tardive
dyskinesia. Pt likely hypoxemic from V/Q
mismatch/intra-pulmonary shunt, as overt e/o pulm edema on most
recent Chest AP portable. Patient still (+) 2 liters for LOS,
despite lasix 20 mg x 2. No e/o hypoventilation. Aspiration
pneumonia and PE were on differential, but patient not meeting
SIRS criteria (only white count), and on post-op
anticoagulation. During the course of the day on [**2135-4-3**], the
patient had difficulty tolerating the shovel mask and n/c to
maintain oxygen saturation in the
setting of tardive dyskinesia. She triggered again for hypoxia
and required a non-rebreather to maintain oxygenation. Her A-a
gradient was greater than 600, see above blood gases. V/Q
mismatch with shunt physiology was suspected as etiololgy, as
patient had no evidence of infection. A third dose of lasix 20
mg was given, and antibiotics were changed to vanc/cefepime for
empiric coverage of HCAP. Repeat AP portable chest films showed
improving atypical pulm edema with possible infiltrate in RML.
Given worsening hypoxia, patient was transfered to the MICU on
[**2135-4-3**]. She was initially on NRB but weaned to face mask and
then to nasal cannula over 2-3 days in the setting of diuresis
with IV furosemide. She was not treated for pneumonia, as it was
felt that other etiologies could explain the patient's
leukocytosis (recent surgery, UTI) and hypoxia (volume
overload). She did not have cough and was unable to make a
sputum sample for analysis. Urine legionella antigen was
negative. An echocardiogram was obtained to assess for CHF
(results as above). Once the patient was stable on O2 by nasal
canula, she was transferred back to the medicine floor on
[**2135-4-6**]. Following transfer, patient was given one more dose of
lasix. Her renal function worsened in the setting of diuresis.
There was a concern for aspiration, and the decision was made by
the patient's family to defer speech and swallow eval and to
allow her to eat despite risk of aspiration; she was maintained
on aspiration precautions. Hypoxia persisted, and the patient
was treated for aspiration pneumonia. Oxygen requirement did
improve over the next few days, with oxygen weaned from shovel
mask and 6 liters nasal cannula to 2 liters nasal cannula.
Aspiration coverage was converted from IV to PO cefpodoxime and
metronidazole. It is unclear what patient's baseline O2
requirements are, but even with aggressive diuresis, she has
been requiring 2L and may need to be continued on that
.
# Leukocytosis- No evidence of infection aside from Proteus UTI.
Proteus species was found to be resistant to ciprofloxacin.
Blood cultures show no growth to date however, blood cultures
were drawn after receiving peri-op clindamycin. C. diff toxin
returned negative. Leukocytosis trended down without any other
intervention. Patient will complete 5 more days of cefpodoxime
and metronidazole on discharge.
.
# Altered Mental Status- Highest on differential was infection,
given >[**Numeric Identifier 4856**] Proteus bacteriuria. Aspiration pneumonia,
bacteremia also on differential. Hct stable, no signs of
hemorrhage, with normal vascular exam. Patient on extensive
psychotropic regimen, but do not expect acute withdrawal at this
time. Peri-op anesthesia also may be contributing. The patient
was kept NPO. Hypoxemia also likely contributing to AMS, see
above for management. During her stay in the MICU, the patient
became progressively more alert. She was oriented to person and
place as "[**Hospital **] Hospital," but although she could name month
as [**Month (only) 547**] she repeatedly stated the year as [**2116**].
.
# Right distal femur fracture - patient underwent ORIF on
[**2135-4-1**] and will need to complete 4 weeks of lovenox. She is
scheduled to follow up with orthopedic as an outpatient for
further management.
.
# Guaiac positive stool- The patient was noted to have guaiac
positive stool while in the MICU, and anticoagulation with
Lovenox was held for 2 days, but then resumed in the setting of
stable Hct.
.
# h/o depression/dementia/cerebellar ataxia- Initially PO meds
were held, but subsequently restarted on her oral medications
while in the MICU after improvement of her mental status
.
# h/o hypothyroidism - patient was continued on levothyroxine
.
# h/o HTN- patient was continued on amlodipine
.
# CODE: DNR, but intubation is permitted
.
# CONTACT: daughter [**Name (NI) **], designated HCP, [**Telephone/Fax (1) 100937**]
son [**Name (NI) **], [**Telephone/Fax (1) 100933**] home, or [**Telephone/Fax (1) 100938**]
Medications on Admission:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
2. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Rivastigmine 3 mg Capsule Sig: One (1) Capsule PO daily ().
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
11. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
2. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Rivastigmine 3 mg Capsule Sig: One (1) Capsule PO daily ().
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
11. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 5 days: last day is [**2135-4-15**].
18. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days: last day [**2135-4-15**].
19. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
1. Right distal femur periprosthetic fracture.
2. post operative blood loss anemia.
Discharge Condition:
Mental Status: alert and oriented x 3.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Improved condition at discharge.
Discharge Instructions:
You were admitted to the hospital after falling. You suffered a
broken right leg. Your leg was repaired in the operating room.
After the operation, you were confused, which was thought to be
due to a urinary tract infection. You were given antibiotics.
You also developed the need for extra oxygen, which was thought
to be due to excess fluid in your lungs. You received
medication to help remove the fluid. You were also given
antibiotics to treat a possible pneumonia. You became less
confused, and your oxygen requirement improved. You were
discharged back to [**Hospital3 537**] on [**2135-4-11**] in improved
condition.
Please see below for your follow up appointments.
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
Activity:
-Continue to be touch weight bearing on your right leg.
-Elevate right leg to reduce swelling and pain.
-Do not remove brace. Keep brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 7967**] orthopedic
clinic on [**2135-4-26**] at 10 AM. The number for the orthopedic
clinic is [**Telephone/Fax (1) 1228**]
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2135-4-14**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 5849, 5070, 2851, 5990, 4280, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5615
} | Medical Text: Admission Date: [**2109-5-9**] Discharge Date: [**2109-5-15**]
Service:
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
male with no prior cardiac history and generally active, who
experienced chest pain while watching T.V. He went to
[**Hospital1 1474**] Emergency Room where he was ruled out for MI but he
had a positive stress test. He was transferred to the [**Hospital1 1444**] for further work-up with
catheterization.
PAST MEDICAL HISTORY: Status post TURP 6 years ago,
osteoarthritis of back.
MEDICATIONS: None prior to admission. Was transferred on
Aspirin 325 mg q d and Nitroglycerin 1 inch paste q 6 hours.
ALLERGIES: None known.
FAMILY HISTORY: Positive for father dying of MI at age 54.
SOCIAL HISTORY: Married, no etoh, no tobacco.
HOSPITAL COURSE: The patient was admitted under the cardiac
medicine service prior to his catheterization. He underwent
his catheterization on the day of admission and that revealed
severe three vessel coronary artery disease. Cardiac surgery
was consulted at this point and the decision to operate was
made. He was taken to the operating room on [**2109-5-10**] and
underwent a CABG times three with LIMA to LAD, SVG to OM1,
SVG to PDA. His intraoperative course was unremarkable and
he was taken to the CSR unit intubated. He was extubated in
the evening of the same day. He was stable hemodynamically.
On postoperative day #1 he had a few episodes of PACs and
atrial fibrillation. He was started on Amiodarone. He was
transferred to the floor on postoperative day #1.
Subsequently he had smooth postoperative course. He was a
little confused overnight on postoperative day #2 but
recovered in the morning hours. He required chest PT to
clear secretions. He continued to do well and ambulated at
physiotherapy. He cleared level V with physiotherapy and was
declared ready to go home. He is comfortable on his po
analgesics. He is currently ready for discharge on [**2109-5-15**].
DISCHARGE MEDICATIONS: Lopressor 25 mg [**Hospital1 **], Lasix 20 mg q d
times one week, KCL 20 mEq q d times one week, Colace 100 mg
[**Hospital1 **], Aspirin enteric coated 325 mg q d, Amiodarone 400 mg q
d, Niferex 150 mg q d, Percocet 1-2 tablets q 4-6 hours prn.
He will be discharged home with visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **]
monitoring.
FOLLOW-UP: With primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17025**] in
two weeks and with Dr. [**Last Name (STitle) 70**] in 6 weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2109-5-15**] 15:40
T: [**2109-5-16**] 10:23
JOB#: [**Job Number 6288**]
ICD9 Codes: 4111, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5616
} | Medical Text: Admission Date: [**2114-7-30**] Discharge Date: [**2114-8-4**]
Date of Birth: [**2033-1-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2114-7-31**]
Coronary bypass grafting x4: Left internal mammary artery to
the left anterior descending artery; and reverse saphenous vein
graft to the distal right coronary artery, obtuse marginal
artery, and diagonal artery.
History of Present Illness:
81 year old female with a history of hypertension and GERD
presented to OSH [**7-29**] with epigastric pain described as [**10-22**]
without radiation. She reports this pain began while sitting on
the beach, at rest, with associated slight
dyspnea. She denies other associated symptoms. Paramedics were
called and she was taken to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. Cardiac cath was
performed and revealed severe multivessel coronary disease. She
was transferred to [**Hospital1 18**] for evaluation of coronary
revascularization.
Past Medical History:
Coronary Artery Disease
PMH:
Hypertension
Gastroesophageal Reflux Disease
PSH:
Right knee replacement x 2
Cholecystectomy ~[**2108**] c/b pancreatitis
Social History:
Lives with: son-[**Name (NI) **]
Contact: [**Name (NI) **] Phone # [**Telephone/Fax (1) 88762**]
Occupation:
Cigarettes: Smoked no [x]
ETOH: denies
Illicit drug use
Family History:
mother with breast cancer otherwise noncontributory
Physical Exam:
Pulse:66 Resp:20 O2 sat: R/A=99%
B/P 159/82
Height: 5'2" Weight:178 LBs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] 1+(R)LE
_____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none Right: 2+ Left:2+
Pertinent Results:
[**2114-7-31**] Intra-op TEE
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2114-7-31**]
at 1100 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation present. Aorta is intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2114-8-1**] 13:05
Pre-op labs:
[**2114-7-30**] 08:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-7-30**] 09:25PM PT-12.7 PTT-40.0* INR(PT)-1.1
[**2114-7-30**] 09:25PM PLT COUNT-275
[**2114-7-30**] 09:25PM WBC-7.1 RBC-4.08* HGB-11.6* HCT-35.2* MCV-87
MCH-28.4 MCHC-32.9 RDW-14.4
[**2114-7-30**] 09:25PM %HbA1c-5.9 eAG-123
[**2114-7-30**] 09:25PM ALBUMIN-4.2
[**2114-7-30**] 09:25PM LIPASE-31
[**2114-7-30**] 09:25PM ALT(SGPT)-14 AST(SGOT)-17 LD(LDH)-152 ALK
PHOS-50 AMYLASE-28 TOT BILI-0.4
[**2114-7-30**] 09:25PM GLUCOSE-136* UREA N-21* CREAT-1.2* SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-26 ANION GAP-12
Discharge labs:
[**2114-8-3**] 05:49AM BLOOD WBC-10.5 RBC-3.65* Hgb-10.5* Hct-30.6*
MCV-84 MCH-28.8 MCHC-34.3 RDW-14.1 Plt Ct-173
[**2114-7-31**] 03:58PM BLOOD PT-13.7* PTT-29.5 INR(PT)-1.2*
[**2114-8-4**] 05:19AM BLOOD Glucose-99 UreaN-29* Creat-1.3* Na-135
K-4.8 Cl-98 HCO3-31 AnGap-11
[**Known lastname 88763**],[**Known firstname 4092**] [**Medical Record Number 88764**] F 81 [**2033-1-20**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2114-8-2**] 2:55
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2114-8-2**] 2:55 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 88765**]
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman s/p cabg and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
Final Report
CHEST RADIOGRAPH
INDICATION: Post CABG with removal of chest tube drains, to look
for
pneumothorax.
FINDINGS: Comparison was made with prior radiograph with the
recent from [**8-1**], [**2114**]. There is no demonstrable pneumothorax. Right PICC line
is seen with
the tip in the mid SVC. The findings in the bilateral lung
including bibasal
atelectasis and the right mid lung atelectasis are relatively
unchanged. No
new consolidation. Patient is status post CABG with a stable
cardiomediastinal
outline.
Brief Hospital Course:
The patient was admitted to cardiac surgery service with 3
vessel coronary artery disease for surgical evaluation. After
the usual preoperative workup she was brought to the Operating
Room on [**2114-7-31**] where the patient underwent CABG x4 with Dr.
[**Last Name (STitle) **].
Please see the operative report for details, in summary she had:
Coronary bypass grafting x4: Left internal mammary artery to
the left anterior descending artery; and reverse saphenous vein
graft to the distal right coronary
artery, obtuse marginal artery, and diagonal artery. His bypass
time was 90 minutes.
with a crossclamp time of 75 minutes. She tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition on Propofol an Neosynephrine infusions, for
recovery and invasive monitoring. She remained hemodynamically
stable in the immediate post-op period, woke neurologically
intact and was extubated on the day of surgery. She remained
hemodynamically stable, and weaned from vasopressor support
following extubation. On POD 1 beta blocker was initiated and
the patient was begun on diuretic therapy. She was transferred
to the telemetry floor for further recovery.
The remainder of her hospital course was uneventful, all tubes,
lines and epicardial pacing wires were discontinued per cardiac
surgery protocol and without complication. The patient worked
with physical therapy service for assistance with strength and
mobility. She continued to make progress and was discharged to
[**Hospital 88766**] Rehab at [**Location (un) 22287**] on POD 4.
She is to followup with Dr [**Last Name (STitle) **] on [**2114-8-29**] at 1:15PM.
Medications on Admission:
Lisinopril 10(1),Omeprazole 20(2),HCTZ 25(1)
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. potassium chloride 20 mEq Packet Sig: One (1) PO Q12H (every
12 hours) for 7 days.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 30191**] Rehabilitation & Nursing Center - [**Location (un) 22287**]
Discharge Diagnosis:
Coronary Artery Disease s/p cabg
PMH:
Hypertension
Gastroesophageal Reflux Disease
PSH:
Right knee replacement x 2
Cholecystectomy ~[**2108**] c/b pancreatitis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Tramadol
Sternal Incision: healing well, no erythema or drainage
Left Leg incision: healing well, no erythema or drainage
Edema ****
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
[**Telephone/Fax (1) 409**] Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2114-8-8**]
10:00AM
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**Hospital Ward Name **] BLDG [**Hospital Unit Name **] [**2114-8-29**] at
1:15PM
Cardiologist Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] pls call for appt in 4
weeks.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 26717**] in [**4-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Provider: [**Name10 (NameIs) **] CARE NURSE #Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2114-8-8**] at 10Am
Completed by:[**2114-8-4**]
ICD9 Codes: 4111, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5617
} | Medical Text: Admission Date: [**2152-12-3**] Discharge Date: [**2152-12-5**]
Date of Birth: [**2078-6-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old man with a
history of hypertension and an atrophic right kidney who
presents for rehydration for renal artery angiography and
stenting. He has a baseline creatinine of 2.6. An MR
angiogram on [**10-5**] showed bilateral high grade renal artery
stenosis with near complete occlusion of the right renal
artery and an atrophic poorly functional right kidney. He
also had a focal segment of high grade stenosis in the
proximal left renal artery.
Mr. [**Known lastname 3794**] [**Last Name (Titles) **] headache, fever, chills, nausea, vomiting,
diarrhea, chest pain, shortness of breath, orthopnea, PND,
dysuria, bright red blood per rectum, melena, or abdominal
pain. He notes muscle pain since switching from Zocor to
Lipitor.
PAST MEDICAL HISTORY: Hypertension for 14 years,
hypercholesterolemia, gout, diverticulosis with a flare in
[**2150**], bilateral renal artery stenosis with an atrophic right
kidney and an 11.4 cm left kidney. His baseline creatinine
is 2.6. Arthritis. Status post transurethral resection of
the prostate in [**2140**]. Cardiac catheterization in [**2150-4-28**]
with no coronary artery disease and an EF of 63%.
MEDICATIONS: Lipitor 10 mg q day, Allopurinol 300 mg q day,
Cardizem CD 240 mg q day, Amiloride/HCTZ [**3-/2101**] one tablet q
day, Coreg 12.5 mg q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **]
uses no tobacco or intravenous drugs. He has social alcohol
use. He is a former firefighter and football coach. He is
independent with no restrictions on his activity at home.
PHYSICAL EXAMINATION: This is an elderly gentleman in no
acute distress who is afebrile with a blood pressure of
143/64, a pulse of 64 and oxygen saturation of 99% on room
air. He weighs 83.9 kg. His HEENT exam was unremarkable.
He has no jugulovenous distension or carotid bruits. His
lungs are clear to auscultation bilaterally, and his heart is
regular rate and rhythm with no murmurs. His abdomen is
benign. His extremities are without edema and with 2+
dorsalis pedis and posterior tibial pulses bilaterally. He
has no groin bruits. His neuro exam is grossly intact.
LABORATORY DATA: Reveal a white count of 7.5, hematocrit
39.7 and platelet count of 178,000. His Chem 7 is within
normal limits except for a BUN of 61 and creatinine of 2.9.
His coagulations are within normal limits. His calcium is
9.3, magnesium 2.2 and phosphorus 3.3. His CK is 58. Repeat
CKs after his procedure were 50 and 42. These CKs are
suggestive of his muscle aches not being from side effects
from his Lipitor. His baseline creatinine is 2.6.
HOSPITAL COURSE: Mr. [**Known lastname 3794**] was admitted and hydrated with
normal saline and received Mucomyst prior to catheterization.
The procedure revealed a proximal total occlusion of his
right renal artery which was his known atrophic kidney. He
had a 90% proximal tubular lesion of his left renal artery
that was angioplastied and stented with 0% residual stenosis
and normal flow. He was then admitted to the CCU for
observation due to complications in the cath suite. He was
noted initially to be bradycardic with a heart rate in the
40's but normotensive with a blood pressure of 107/51 at the
start of the case. He required 0.6 mg of Atropine at three
separate times during the procedure for his low heart rate.
His case was also complicated by hypotension during injection
of the left renal artery and during angioplasty of that
artery. His blood pressure dropped as low as 79/48. For
this reason, Dopamine was started and titrated up to 10 mcg
per kg per minute. After left renal artery stent placement,
the Dopamine was successfully weaned off with a systolic
blood pressure in the 90's to 100's before the case was
concluded. At this time he complained of chest pain and some
ST depressions were noted. Coronary angiography was
performed at that time that revealed no evidence of
significant coronary disease. He had a normal left main, LAD
and left circumflex arteries. He had a 30% mid right
coronary artery stenosis with normal flow.
In the CCU, he was bradycardic with a heart rate in the 40's
and on the low end of normotensive with a blood pressure in
the 100's/50's. His antihypertensives were held with an
increase in his heart rate and blood pressure over the next
12 hours to a heart rate in the 80's and a blood pressure in
the 130's/60's by the morning. He suffered no further
complications of his procedure. His hematocrit remained
stable at around 37-38. His creatinine returned to its
baseline of 2.6 after catheterization.
He was discharged home on Aspirin for life and Plavix for
thirty days for his stent. A new antihypertensive regimen
was discussed with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who
follows him for blood pressure control as he did not appear
to be tolerating two AV nodal blocking agents well as
evidenced by his bradycardia. His Cardizem was stopped and
replaced by Norvasc. He will follow-up with Dr. [**First Name (STitle) **] who
performed the procedure in [**3-3**] weeks and follow-up with Dr.
[**Last Name (STitle) **] regarding his blood pressure in one week. He will also
have a follow-up creatinine checked in two days with the
results faxed to Dr.[**Name (NI) 29343**] office.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home to follow-up with Dr. [**Last Name (STitle) 95174**] in
[**3-3**] weeks and to follow-up with Dr. [**Last Name (STitle) **] in one week.
DISCHARGE DIAGNOSIS:
1. Hypertension.
2. Bilateral renal artery stenosis, status post left renal
artery stent placement.
3. Hypercholesterolemia.
4. Gout.
5. Diverticulosis.
6. Arthritis.
7. Status post transurethral resection of the prostate.
DISCHARGE MEDICATIONS: Lipitor 10 mg q day, Allopurinol 300
mg q day, Amiloride/HCTZ [**3-/2101**] one tab q day, Coreg 12.5 mg q
day, Norvasc 5 mg q day, Aspirin 325 mg q day, Plavix 75 mg
for 30 days.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2152-12-5**] 18:15
T: [**2152-12-8**] 09:51
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern1) 95175**]
ICD9 Codes: 9971, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5618
} | Medical Text: Admission Date: [**2110-5-2**] Discharge Date: [**2110-5-7**]
Date of Birth: [**2067-9-8**] Sex: M
Service: MEDICINE
Allergies:
Depakote / Ibuprofen
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: [**Name10 (NameIs) **] [**Name10 (NameIs) **] (ATRIUS)
Mr. [**Known lastname 66658**] is a 42 year old man with history of chronic back
pain, spinal stenosis, on chronic pain medications, as well as
hypertension, morbid obesity, and asthma, who is admitted with
acute exacerbation of his back pain. He reports that the day
prior to admission, he had returned from running errands and
started to watch the basketball game. He was lying down when he
noticed pain in his neck radiating down the spine to his
feet/legs. The pain was so intense that he had to rush to the
car (he reports that his son carried him to the car). He has
numbness and tingling in his feet but is able to ambulate with
severe pain. This had never happened before. He says that he has
had surgery in the past, and has seen multiple surgeons for
While in the ED, triage vitals were T99F, BP 170/117, HR 110, RR
14, Sat 97%. He complained of chest pain, sharp, substernal,
without radiation or associated symptoms. CXR and CTA showed no
obvious etiology. He was given Toradol x 1 and dilaudid x 1 and
subsequently admitted to the hospital for further pain control.
All systems were reviewed and are negative except as noted
above.
Additional information was obtained from the PCP: [**Name10 (NameIs) **] has a long
history of acute episodes of back pain; most of which do not
result in admission. He is quite concerned about the "tumors" in
his back (epidural lipomatosis), but his most recent MRI shows
no evidence of cord compression. He has a narcotics contract
with her.
Past Medical History:
-Hypertension, benign
-Morbid obesity
-Obstructive sleep apnea
-Esophageal reflux
-Lumbar spinal stenosis: surgery [**2-23**] at BUMC ([**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], M.D.)
L3-L5 decompress lami, L2-S1 medial hemi-faectectomies, debulk
lipomatosis [**2105**] extensive w/u for ongoing pain: no further
surgical intervention recommended; last MRI at [**Hospital1 18**] [**3-1**]
-Epidural lipomatosis
-Asthma
-Erectile dysfunction
-Leukocytosis, unspecified
-Plantar fasciitis
Social History:
Tobacco: Yes
Alcohol: Yes
Lives with wife and son
Family History:
Noncontributory
Physical Exam:
General: Well appearing obese man in no acute distress
Vitals: T97.4F, BP 118/83, HR 74, RR 20, Sat 97%RA, pain [**8-31**]
HEENT: EOMI, PERRL
Neck: Unable to appreciate JVP due to body habitus
Heart: RRR normal S1/S2, no m/r/g
Lungs: CTA bilaterally
Abd: Soft, diffuse mild tenderness, + bowel sounds
Back: Diffuse spinal tenderness and paraspinal tenderness
Neuro: Strength 5/5 in both upper and lower extremities
bilaterally. 1+ reflexes bilaterally
Ext: Warm, well-perfused, no c/c/e
Pertinent Results:
[**2110-5-2**] 03:53AM WBC-12.3* RBC-5.02 HGB-13.9* HCT-41.6 MCV-83
MCH-27.6 MCHC-33.3 RDW-15.5
[**2110-5-2**] 03:53AM NEUTS-52.7 LYMPHS-41.1 MONOS-2.9 EOS-2.0
BASOS-1.2
[**2110-5-2**] 03:53AM PLT COUNT-366
[**2110-5-2**] 03:53AM CK-MB-1
[**2110-5-2**] 03:53AM cTropnT-LESS THAN
[**2110-5-2**] 03:53AM CK(CPK)-148
[**2110-5-2**] 03:53AM GLUCOSE-134* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-23 ANION GAP-23*
.
CTA: No evidence of acute aortic syndromes.
.
CXR: As compared to the previous radiograph, the lung volumes
have
decreased. Newly occurred bilateral basal areas of opacity.
Although
atelectasis is the most likely diagnosis, early pneumonia cannot
be excluded. Short-term PA and lateral confirmatory radiographs
should be performed.
.
MRI OF THE THORACIC SPINE: Vertebral body height, signal, and
alignment are preserved. There is no STIR signal abnormality.
There is no disc herniation. There is prominent posterior
epidural fat, unchanged, suggestive of epidural lipomatosis.
There is thickening and calcification of the ligamentum flavum
at several levels.
There is no abnormal STIR signal in the paraspinal soft tissues.
The thoracic cord is normal in signal and morphology.
Sag T2 weighted images of the cervical spine demonstrate normal
sagittal
alignment and no cord signal abnormality. There is right neural
foraminal
narrowing at T2-3 due to prominent calcified ligamentum flavum.
MRI OF THE LUMBAR SPINE: Vertebral body height and sagittal
alignment are
preserved. The conus terminates at L1. There is normal signal
within the
conus medullaris and the cauda equina. There have been prior
laminectomies at L3 through S1. The axial images are overall
degraded by motion. There is no high-grade canal or foraminal
stenosis. Disc bulges are suggested at L4-5 and L5-S1 which do
not cause significant canal or foraminal stenosis. There does
not appear to be abnormal enhancement after the administration
of gadolinium. Given the motion degradation on the axial, it is
difficult to discern the epidural scarring described on the
prior MRI. There are some foci of susceptibility artifact in the
surgical postoperative bed at the L5-S1 level which appears
unchanged. There is subcutaneous STIR signal abnormality in the
area of the lumbar spine which is nonspecific.
IMPRESSION:
No evidence of infection involving the thoracic or lumbar spine.
No evidence of drainable fluid collection. Stable post-surgical
changes at L3 through S1.
.
ANKLE FILM:
Three views of the foot and three of the ankle show no evidence
of
acute fracture or dislocation. There is a small bony
opacification projected between the medial aspect of the talus
and the inferior projection of the medial malleolus. This most
likely represents a sequela of previous injury. No associated
soft tissue swelling is seen.
Small inferior calcaneal spur is seen. There is also a spur
arising from the posterosuperior aspect of the navicular.
.
SHOULDER FILM:
No previous images. Degenerative changes are seen about the
glenohumeral joint. The acromioclavicular joint is not
adequately assessed on any view presented, and the possibility
of subluxation cannot be excluded.
.
CTA:
1. Normal thoracic aorta with no evidence of dissection.
2. One perifissural nodule and one subpleural nodule measuring 4
mm each. If the patient has no risk factors for malignancy no
further follow up is
required.
Brief Hospital Course:
42 male with multiple medical problems including obstructive
sleep apnea and chronic back pain admitted on [**2110-5-2**] for
worsening back pain with hospital course complicated by fever
and altered mental status.
.
BACK PAIN: Patient with a longstanding history of chronic lower
back
after sustaining a fall s/p multiple spinal surgeries at outside
hospital admitted with worsening back pain with relatively
normal neurological exam. He was initially admitted to the [**Location 66659**] service and later transferred to the West service
following a brief ICU stay. During this hospital course, he
spiked a temperature to 103 requiring a cooling blanket. The
neurosurgery service was consulted for concern for infectious
spinal processes given his back pain and fever. An MRI was
performed that showed no evidence of fluid collection or
infectious spinal process or any other process requiring acute
intervention. His pain was controlled with his home dose
narcotics in addition to ketorolac, which he received for 48
hours, and lidocaine patch. On discharge he was ambulating
without assistance and felt his back pain was well controlled.
He declined follow up with the pain service to manage his back
pain as an outpatient.
.
ALTERED MENTAL STATUS: He was given higher doses of opiates in
addition to his home neurontin and benzodiazepines for pain
control. He became obtunded responding only to sternal rub. His
mentus improved with narcan and being transiently placed on
Bipap given his history of obstructive sleep apnea. Blood gas in
the ICU was consistent with chronic respiratory acidosis. He was
transferred to the ICU given his fever, worsening back pain, and
altered mental status. His mental status slowly improved over 24
hours and he was called out to the general medicine floor where
his mental status was at baseline.
.
ELEVATED CK LEVEL: The patient complained of muscle weakness and
right shoulder and foot pain during the admission. As part of
evaluation for muscle weakness and myalgia CK have been
monitored. His CK went from 100s (normal) on [**2110-5-2**] to 4500 on
[**2110-5-6**]. Several etiologies for this were considered. It is
possible that he developed rhabdomylosis in the setting of being
obtunded and not mobile for >24 hours although renal function
was at baseline at that time and electrolytes were largely
normal (urine myoglobin pending at d/c). Medication induced
secondary to increased doses of opiates was considered. An
infectious myopathy, such as a viral illness, was considered
given his fever and reports of malaise and myalgia/arthralgia.
His exam was not consistent with septic joints and blood
cultures were negative. Neuroleptic malignant syndrome was
considered given his use of risperidol although there was no
evidence of muscle rigidity or autonomic instability. The CK was
trending down to 3400 at discharge. He will follow up with his
PCP on [**Name9 (PRE) 2974**] to get his CK and chem-10 checked.
.
ACUTE RENAL FAILURE: His creatinine increased from baseline of 1
to 1.8 also with evidence of urinary retention. Urinalysis
showed trace blood with normal culture.
This was likely due to increased doses of opiates. A foley
catheter was temporarily placed and his renal function improved.
Medications were renally dosed. His renal function returned to
baseline and there he was voiding without difficulty at
discharge.
.
? PNEUMONIA: The patient had was found to have a perihilar
infiltrate on his chest film when he was being evaluated for
altered mental status and fever. He was started on broad
spectrum antibiotics in the ICU, which were transitioned to
ceftriaxone and azithromycin on the medicine floor for 48 hours.
Given the absence of respiratory complaints these were
discontinued.
.
HYPOTHYROID: TSH was borderline high and T4 was pending on
discharge. He will follow up with PCP to get rechecked in 6
weeks.
.
SHOULDER PAIN: He complained of right shoulder pain in the ICU.
Bacteremia and possible septic joint considered given joint pain
and fever but blood cultures no growth to date and exam was not
consistent with infectious etiology. An x-ray showed
degenerative changes. He was given his home dose narcotics and
ketorolac for the pain. There was rapid improvement in pain and
range of motion within 24-36 hours and he was at baseline on
discharge.
.
#ELEVATED LFT: He had a mildly elevated hepatocellular pattern
LFTs as well as LDH. This was likely due to myolysis. These will
be followed as an outpatient.
.
#
NOTE: The Chest CTA showed pulmonary nodules that needs to be
followed up with interval CT as he is a smoker and at risk for
cancer.
Medications on Admission:
- Oxycontin 80mg [**Hospital1 **]
- Percocet 5-325, 1-2 tablets Q4-6 hours PRN pain (takes 8
pills/day)
- Valium 5mg PRN back pain (takes up to 8 pills/day)
- Omeprazole 40mg [**Hospital1 **]
- Cialis 20mg PRN
- Hydrochlorothiazide 25mg daily
- Amlodipine 10mg daily
- Risperdal 4mg [**Hospital1 **]
- Fluticasone 50mcg 1-2puffs daily
- Neurontin 1200mg TID
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back spasm.
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
5. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Outpatient Lab Work
Chem-10, CK level
11. Risperidone 4 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 66658**]. You
were admitted to [**Hospital1 18**] for back pain and fever. You had an MRI
that showed no evidence of infection or abscess. You were
evaluated by the neurosurgery service who felt there was no
indication for surgery at this time. Your pain was controlled
on your home pain regimen. You are able to walk without
assistance using your walker. Please follow up with your
primary care physician within one week.
There was evidence of temporary muscle damage during your stay
here (elevated CK level on blood test). That value was improving
at discharge. It is possible that it was due to the higher doses
of narcotics and lying in bed for several days. Please follow up
with your primary care physician this [**Name9 (PRE) 2974**] to get the level
re-checked.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] MEDICAL ASSOC - [**Location (un) 2277**]
INTERNAL MEDICINE DEPT
Address: [**Location (un) **], BLDG 2, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
This Friday at 9:30AM
ICD9 Codes: 5849, 2762, 4019, 2859, 3051, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5619
} | Medical Text: Admission Date: [**2133-11-30**] Discharge Date: [**2133-12-22**]
Date of Birth: [**2091-7-7**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Vancomycin And Derivatives / Benadryl / Morphine
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Perintoneal dialysis, daily
History of Present Illness:
42F with CAD s/p IMI, ESRD believed to be [**12-22**] SLE, cadaveric
renal transplant now rejected, and now on PD with a history of
peritonitis who presents with 1.5 days of abdominal pain,
fevers, chills, nausea, and malaise which feels exactly like her
previous bouts of peritonitis. A week ago she had her catheter
repleaced and has some tenderness at the site as well. She
denies any trouble with her PD machine, damaged dialysate bags,
or sick contacts. She denies CP, LE edema, or SOB.
In the ED her initial vital signs were 97.8 107/63 95 12 100% on
RA. Her initial WBC was 10.4 with 88% PMN. BCx x2 were drawn.
Her peritoneal fluid was sampled and came back with [**Numeric Identifier 97094**] WBC,
95% PMNs. Peritoneal fluid was not sent for culture. She
received ceftriaxone 1g IV x1, vancomycin 1g IV x1, and
metronidazole 500mg IV x1 for antibiotic coverage. She was
anxious in the [**Last Name (LF) **], [**First Name3 (LF) **] she received lorazepam 0.5mg PO x1. Her
SBP fell to 98/58, and she received NS 500mL IV bolus with
improvement of her BP to 105/64. Her venous lactate was 1.7. She
was admitted to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] liver/kidney service for
further management.
On ROS, she denies fever, chills, night sweats, recent weight
loss or gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. No feelings of depression or anxiety.
Past Medical History:
- ESRD thought to be d/t Lupus nephritis
- S/P cadeveric renal transplant in [**2115**] which lasted about 8
years
- SLE
- CAD s/p IMI in [**9-/2128**] with a BMS to the RCA for total
occlusion
- CHF with an EF of 35% as of [**9-/2132**]
- S/P Subtotal parathyroidectomy in [**2109**] for tertiary
hyperparathyroidism
- R hip fracture [**2128-1-20**] s/p ORIF and girdlestone hip athroplasty
for infected non [**Hospital1 **] hip fx
- Osteoporosis d/t renal osteodystrophy
- HTN
- MRSA colonized
Social History:
She lives with her two children, whom she raises as a single
parent (husband has moved out). She has good social support from
her father.
- Tobacco: Smoked 1 ppd age 15-35, so around 20 pack years
- EtOH: Denies
- Illicits: Denies
Family History:
No significant CAD. No family history of thryoid, parathyroid,
or calcium disease. Mother with ESRD.
Physical Exam:
Admission physical exam:
GEN: NAD, appears uncomfortable
VS: 99.0 118/80 88 18 99% on RA
HEENT: MMM, supple, no LAD
CV: RR, III/VI low pitched holosystolic murmur loudest at the
LUSB
PULM: CTAB
ABD: BS+, diffusely tender, nondistended, no erythema or
exudates at PD catheter, no masses or HSM
LIMBS: No edema, no clubbing
SKIN: No skin breakdown, no rashes
NEURO: Grossly non-focal
Pertinent Results:
Labs on admission:
[**2133-11-30**] 02:35AM PLT SMR-NORMAL PLT COUNT-264
[**2133-11-30**] 02:35AM HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL
[**2133-11-30**] 02:35AM NEUTS-88* BANDS-0 LYMPHS-5* MONOS-5 EOS-1
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2133-11-30**] 02:35AM WBC-10.4# RBC-3.39* HGB-10.0* HCT-31.4*
MCV-93 MCH-29.4 MCHC-31.8 RDW-15.5
[**2133-11-30**] 02:35AM ALBUMIN-2.5*
[**2133-11-30**] 02:35AM LIPASE-30
[**2133-11-30**] 02:35AM ALT(SGPT)-23 AST(SGOT)-57* ALK PHOS-102 TOT
BILI-0.2
[**2133-11-30**] 02:35AM GLUCOSE-92 UREA N-65* CREAT-8.7* SODIUM-131*
POTASSIUM-6.5* CHLORIDE-91* TOTAL CO2-27 ANION GAP-20
[**2133-11-30**] 02:45AM LACTATE-1.3
[**2133-11-30**] 03:25AM ASCITES WBC-[**Numeric Identifier 97094**]* RBC-0 POLYS-95* LYMPHS-1*
MONOS-4*
[**2133-11-30**] 03:30AM GLUCOSE-85 UREA N-64* CREAT-8.8* SODIUM-134
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-27 ANION GAP-17
EKG [**2133-11-30**]: Sinus rhythm. There are Q waves in the inferior
leads consistent with prior myocardial infarction. There is an
early transition consistent with posterior involvement. ST-T
wave changes consistent with left ventricular hypertrophy,
although ischemia or myocardial infarction cannot be excluded.
Compared to the previous tracing inferior Q waves are more
prominent and early transition is new.
KUB [**2133-12-1**]: Three views of the abdomen and pelvis including two
obtained in the left lateral decubitus position demonstrate
nonobstructive bowel gas pattern. No free air is seen. A
peritoneal dialysis catheter is in place. Indistinctness of the
abdominal structures is consistent with ascites. A total right
hip prosthesis is in place. There are degenerative changes of
the left hip and lumbar spine. Vascular calcifications are
noted. IMPRESSION: No obstruction, ileus, or free air
identified.
Brief Hospital Course:
# Peritonitis.
Ms. [**Known lastname 97063**] was admitted to the renal service, where she
underwent repeat fluid check through her IP line that showed WBC
count > 28K. She was started on ceftazidine IP (dwell x 6 hours)
and given 2 g of vancomycin IP (also dwell x 6H). she also
received 200 mg fluconazole. The morning following admission,
she became febrile to 101.2. A 3rd peritoneal fluid sample
showed marked decreased in WBC count to 1900. She was continued
on her same antibiotics (no vanco on hospital day 2 given level
of > 50). She showed occasional signs of confusion throughout
the day (difficulty reciting months of the year backward, slow
response time), and had continued abdominal pain worse with
palpation but was otherwise in NAD. Overnight that evening, she
developed a new oxygen requirement and chest pain with possible
EKG changes. CXR showed a questionable new opacity, generating
concern for possible aspiration. She became hypotensive to
70s/40s and felt lightheaded. She was transferred to the MICU at
that time. She was given IV fluids and her blood pressure was
restored. With concern for pneuomonia, given a possible new
right middle lobe opacity, she was started on IV ceftazadine and
IV flagyl. She became hemodynamically stable and was transferred
to the general medical floor. IV flagyl was transitioned to PO
form. She continued on an eight day course of IV ceftaz, flagyl,
and renally dosed IP vancomycin. Cefttaz and flagyl were
discontinued at this time as well as fluconazole. IP vancomycin
and IP ceftaz were discontinued after a 14 day course was
completed. Throughout this course, blood and peritoneal cultures
did not grow anything. It was felt she had a significant
infection, but unfortunately, no organism was identified.
Approximately, four days after completion of antibiotics,
patient developed a wbc with left shift to 14,000. Patient
remained afebrile and was clinically without a focus of
infection. With concern for indolent infection, chest x-ray,
blood and peritoneal cultures were sent. Chest x-ray
demonatrated a retrocardiac opacity. A non-contrast
Chest/Abdominal CT was performed. She received on dose of
vancomycin and cefepime empirically. An opacity was again
demonstrated in the right lower lobe. Since patient was not
showing any signs of pneumonia and white count normalized the
following day, she was not continued on antibiotics.
A calcified fluid collection was demonstrated on CT
posterolateral to her right hip prosthesis. With concern for
abscess, this collection was drained. Ortho was consulted and
felt no further intervention was needed. All cultures remained
negative. Patient did not show any further signs of infection
and it was felt that she did not need any antibiotic treatment.
She will followup with orthopedics. ID recommended repeat
imaging in [**12-24**] weeks if the patient's hip complaints persist.
# Delirium: Patient was felt to be delirious secondary to
morphine she received in the emergency room, as she is
exquisitely sensitive to opiates and strong sedating medication.
Also, other contributing factors were severe infection, missing
some PD in the setting of hypotension, pain, and high doses of
beta lactam antibiotics. With time, the waxing and [**Doctor Last Name 688**]
quality to patient's delirium decreased. She was alert and
oriented x3 on discharge, though irritable.
# ESRD. Ms. [**Known lastname 97063**] was continued on peritoneal dialysis with
the guidance of nephrology. She was maintained on four, two hour
dwells at volumes of 1300 mLs. Used 1.5% dextrose alternating
with 2.5% dextrose. She was noted to have hypovolemic
hypnotremia which improved with PD. Sevelemer was up titrated to
3200 mg TID due to increased phosphorus. On discharge, her
calcitriol was discontined since she was hypercalcemic
(information relayed to nephrologist).
# CAD: H/o IMI, CHF with EF 35% ([**2131**]). EKG changes in setting
of hypotension likely demand ischemia. Pt without CP or
shortness of breath. CE flat x 3. New Echo showing depressed EF
from prior and worsening MR. Since patient was asymptomatic with
no overt signs of decompensated heart failure, she will follow
up in the outpatient for further management.
# Mitral regurgitation: The patient had severe mitral
regurgitation on an Echo from [**12-10**]. She will be referred to
cardiology to evaluate if she would be a candidate for mitral
valve repair.
# Normocytic Anemia: HCT remained stable. Felt likely to be
secondary to ESRD. She received one unit of packed red blood
cells as her Hct was drifting down. She was also given epo
injections q weekly to substitute for her Darbopoeitin
injections she receives in the outpatient as this medication is
not on formulary in house.
# Right hip pain: Patient has known chronic right hip pain. She
is s/p right hip ORIF and arthroplasty for infected non-[**Hospital1 **]
hip fracture. Patient complained that she was unable to walk at
times. With concern for septic joint, hip x-ray was performed
and did not show any obvious source of concern. Orthopedics were
consulted and felt patient did not have a septic joint. Further
workup described as above.
# Depression and anxiety: She was continued on citalopram. Her
home diazepam was held in the setting of delirium.
# Hypertension: The patient was noted to be hypertensive. Her
valsartan was uptitrated to 80 mg. Renal will change her
dialysate to encourage more fluid removal.
# Dysuria: The patient complained of dysuria on the last day of
her hospitalization. Normally, she does not produce urine. She
was bladder scanned and it showed around 50 cc of fluid. Nursing
was concerned about introducing infection in her bladder with a
straight cath, so a urine sample was not obtained. If the
patient has further complaints of dysuria, it might warrant an
outpatient workup.
# Vaginal bleeding: The patient stated on the last day of her
hospitalization that she had vaginal bleeding in low amounts x 2
weeks. She will followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpatient.
Outpatient followup:
1. BP: Started on higher dose of valsartan
2. Assess dysuria, vaginal bleeding
3. Calcium check: Stopped calcitriol
4. Followup with renal, ID, cardiology and ortho
5. For cardiology, candidate for mitral valve repair?
Medications on Admission:
- Metoprolol Tartrate 100 mg PO BID
- Aspirin 81 mg PO daily
- Citalopram 20mg PO HS
- Pantoprazole 40 mg PO DIALY
- Calcitriol 1mg PO daily
- Nephrocaps PO daily
- Sevelamer Carbonate 2400 mg PO TID with meals
- Darbepoetin [Aranesp] 60 mcg Qmonth
- Diazepam 2mg QHS PRN anxiety, insomnia
- Fluticasone 50 mcg nasal IH PRN congestion
- Mupirocin 2 % Ointment TP to open areas [**Hospital1 **] PRN
- Nitroglycerin 0.3 mg SL PRN chest pain
- Olopatadine [Patanol] 0.1 % Drops OU daily PRN dry eyes
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Sevelamer Carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
Inhalation once a day as needed for congestion.
Disp:*1 inhaler* Refills:*0*
10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Aranesp (Polysorbate) Injection
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Peritonitis
ESRD on [**Hospital **]
Hospital Acquired Pneumonia
Delirium
.
Secondary:
SLE
Anxiety
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted because you were found to have an infection in
your abdomen. You were started on antibiotics to treat this
infection. While you were in the hospital, your blood pressure
became very low and you needed extra oxygen to breath. You were
sent to the Medical Intensive Care Unit for close monitoring.
You were given fluids through your veins and this helped your
blood pressure. Another antibiotic was started as there was a
concern that the antibiotics you were taking were not covering
the infection. Your infection improved.
.
Since you needed more oxygen to breath comfortably, a chest
x-ray was performed which showed a possible pneumonia. You were
given antibiotics through your veins to treat this infection.
You were eventually able to breath comfortably on room air.
.
You were also confused during your hospital stay. It was felt
this was due to the morphine you received in the emergency room,
and the decreased clearance of this medication, given your
kidney disease. Also, your infections, abdominal pain,
antibiotics, and kidney disease on its own could have made you
confused. We treated all of these causes and with time, your
mental status improved.
.
You had an echocardiogram of your heart. There was a slightly
worsening leakiness to one of your heart valves. You have a
cardiology appointment scheduled to follow up on this. The
details of this appointment are below.
.
You were complaining of pain in your right hip. Orthopedics
evaluated your hip and felt that nothing concerning was
occurring. No intervention needed to be done. If you continue to
have pain or worsening pain, you should follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
.
Approximately 3-4 days after your antibiotics were stopped you
developed a rise in your white blood cell count. With concern
for another infection a non-contrast CT of your chest and
abdomen were performed. You were found to have a fluid
collection near your right hip prosthesis concerning for
infection. Orthopedic surgery was again consulted and this
collection was drained. It did not grow any bacteria and this
was felt to not be infected. You no longer had elevated white
blood cell counts and you remained without fevers. It was felt
you did not have another infection.
.
You will go home and have your peritoneal dialysis done there. A
nurse will be trained with you.
.
You complained of burning with urination.
.
You complained of a persistent period for two weeks. You should
have this evaluated as an outpatient.
.
Your new medications include:
-Change Valsartan to 80 mg daily
-Stop calcitriol
Followup Instructions:
You have the following appointments scheduled:
.
Appointment #1
Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], orthopedics
Date/Time: Monday, [**12-28**] at 8:00 am
Buidling: [**Location (un) 830**], [**Location (un) 86**], [**Numeric Identifier 718**], [**Hospital Ward Name **]
building [**Location (un) **]
Phone number: ([**Telephone/Fax (1) 2007**]
.
Appointment #2
Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Nephrology
Date/Time: [**12-29**] at 1:00 pm
Building: [**Location (un) 830**], [**Location (un) 86**], [**Numeric Identifier 718**], [**Hospital Ward Name 23**]
building, [**Location (un) 436**]
Phone number: ([**Telephone/Fax (1) 10135**]
.
Appointment #3
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine
Date/ Time: Wednesday, [**12-30**], 1:20pm
Location: [**Location (un) **], [**Hospital Ward Name 23**] building, [**Location (un) **] central
suite
Phone number: [**Telephone/Fax (1) 250**]
.
Appointment #4
MD: [**First Name8 (NamePattern2) 1026**] [**Doctor Last Name 1016**]
Specialty: Cardiology
Date/ Time: Thursday, [**2133-12-31**]:40am
Location: [**Location (un) **], [**Hospital Ward Name 23**] [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 62**]
.
Infectious disease recommends if you're still having symptoms in
your hip to repeat imaging in [**12-24**] weeks.
ICD9 Codes: 5856, 486, 2761, 4280, 4019, 412, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5620
} | Medical Text: Admission Date: [**2184-5-1**] Discharge Date: [**2184-5-6**]
Date of Birth: [**2101-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 78794**] is an 83YO M w/ PMH of metastatic melanoma to lungs
and now brain (2wk ago) who presented this evening w/
hallucinations and altered MS today. The patient has recently
been neutropenic, in an OSH for 5 days 2 wk ago, found to have
brain mets w/ some swelling. Also, exposure to flu A positive
grand daughter last week - thought to be likely "swine flu" as
per family. Has cough, but chronic but no new symptoms
concerning for flu although did spend a great deal of time w/
granddaughter. [**Name (NI) **] given 2 weeks ago, WBC 30's on D/C [**4-16**].
In the ED, initial vitals 16:00 0 97.2 116 124/85 20 96. Given
vanc, zosyn for possible pulmonary source and tamiflu 75 mg po.
Tested for flu. Admitted w/ flu precautions.
On arrival to the floor, his wife and son state he has been
increasingly tired over the past week. He has a chronic cough
that has not increased. Denies f/c. No n/v/constipation/
diarrhea or dysuria. They [**Last Name (un) 4662**] him into the ED today as he
started hallucinating. First, he awoke w/ a bad dream. Then
thought the TV was playing when it wasn't. Then thought monkeys
were eating his [**Country 1073**] [**Location (un) 6002**]. Also w/ increasing DOE and
general lethargy.
Around 1AM, the pt ambulated to the bathroom without
supplemental oxygen. He noted significant DOE with returning to
bed and was found to have desaturated to as low as the mid 60s.
With NRB, ABG was 7.23/87/78/38. The pt was transferred to the
[**Hospital Unit Name 153**] for ongoing monitoring and care.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Mr. [**Known lastname 78794**] [**Last Name (Titles) 1834**] biopsy of a scalp lesion with pathology
revealing a 5.5 mm thick desmoplastic melanoma with evidence of
focal ulceration. He subsequently [**Last Name (Titles) 1834**] an excision on [**5-7**], [**2182**] with pathology revealing residual desmoplastic melanoma
extending close to the deep margin. He had a wide excision of
the area on [**2183-6-23**] with reconstruction on [**2183-7-3**] with no
sentinel lymph node identified. Pathology revealed no remaining
melanoma. In [**2183-11-1**], a small nodule was identified behind
his left ear. CT scan of his neck and torso was performed
revealing multiple pulmonary nodules and mediastinal and hilar
lymphadenopathy, concerning for metastasis. In addition, he had
an FNA of his enlarged cervical lymph node confirmed recurrent
melanoma. He began the Phase 3 Trial of STA-4783 in Combination
with Paclitaxel vs. Paclitaxel Alone on [**2183-12-30**] with
progression after 2 cycles. He began dacarbazine off protocol on
[**2184-3-2**] with his first cycle c/b neutropenia.
.
He was recently admitted to [**Hospital **] hospital on [**2184-4-16**] with
severe anemia, thrombocytopenia, neutropenia, dehydration and
severe fatigue and was discharged [**2184-4-21**]. He received
granulocyte stimulating factor, RBC and platelet transfusion
while in the hospital. Upon admission, he [**Month/Day/Year 1834**] CT scan of
chest revealing innumerable pulmonary parenchymal metastases in
the bilateral lungs, extensive
mediastinal and hilar lymphadenopathy, osseous lesion in the
left
second and third ribs and T7 vertebral body. He also had CT scan
of head. This revealed a 7 mm hyperdense focus with surrounding
vasogenic edema in the right centrum semiovale and a smaller
enhancing nodule in the right corona radiata. He was placed on
phenytoin 100 mg IV, every 8 hours and dexamethasone 4 mg every
6
hours until discharge.
.
PAST MEDICAL HISTORY:
====================
*diabetes mellitus two
*hypercholesterolemia
*hypertension
*heart murmur
*clavicular fracture and a right shoulder dislocation in the
remote past
*cholecystectomy performed 30 years ago.
Social History:
Lives w/ wife in [**Name (NI) 932**]. He is married with 2 adopted children.
He is retired from the meat cutting business. He does not smoke,
and has a remote history of heavy alcohol use, but none
recently. Has been able to ambulate but w/ a lot of assistance.
Family History:
There is no family history of melanoma or other cancers. He has
4 siblings, the oldest of which died at age 89 from old age.
Physical Exam:
VS: 96.6, BP 142/60, HR 99, RR 15, O2sat 98%
GENERAL: Lethargic appearing, open-mouthed breathing w/
intermittent apnea, awakens to voice. Oriented to person, place,
year but not month. Very limited history from him.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva
w/ yellow exudate, patent nares, MMM, good dentition, nontender
supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no focal wheezes or rhonci but fell asleep during
exam
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, downgoing toes bilaterally
Pertinent Results:
Labs:
[**2184-5-1**] 04:45PM BLOOD WBC-16.2*# RBC-3.39* Hgb-10.3* Hct-31.4*
MCV-93 MCH-30.2 MCHC-32.6 RDW-19.2* Plt Ct-438#
[**2184-5-6**] 07:15AM BLOOD WBC-10.7 RBC-3.20* Hgb-10.0* Hct-30.1*
MCV-94 MCH-31.3 MCHC-33.3 RDW-19.2* Plt Ct-358
[**2184-5-1**] 04:45PM BLOOD Glucose-146* UreaN-29* Creat-0.9 Na-141
K-4.4 Cl-100 HCO3-31 AnGap-14
[**2184-5-6**] 07:15AM BLOOD Glucose-196* UreaN-23* Creat-0.8 Na-136
K-4.2 Cl-95* HCO3-33* AnGap-12
[**2184-5-1**] 04:45PM BLOOD ALT-27 AST-17 CK(CPK)-39 AlkPhos-93
TotBili-0.2
[**2184-5-1**] 04:45PM BLOOD cTropnT-0.02*
[**2184-5-1**] 04:45PM BLOOD TSH-5.3*
[**2184-5-2**] 01:11AM BLOOD Type-ART pO2-78* pCO2-87* pH-7.23*
calTCO2-38* Base XS-5
[**2184-5-2**] 04:58PM BLOOD Type-ART pO2-97 pCO2-67* pH-7.30*
calTCO2-34* Base XS-3
[**2184-5-5**] 11:53AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2184-5-5**] 11:53AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2184-5-5**] 11:53AM URINE RBC-566* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
[**2184-5-6**] 08:12AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2184-5-6**] 08:12AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2184-5-6**] 08:12AM URINE RBC-16* WBC-3 Bacteri-FEW Yeast-NONE
Epi-<1
[**2184-5-6**] 08:12AM URINE CastGr-1* CastHy-3*
[**2184-5-6**] 08:12AM URINE Uric AX-RARE
[**2184-5-5**] 11:53AM URINE CaOxalX-FEW
Urine cx: 1 of 2 contaminated, 2 of 2 negative
Urine legionella ag: negative
Blood cx: negative x2
Influenza DFA: negative
Respiratory viral ag and culture: negative
Imaging:
CT head [**5-1**]:
1. Increasing vasogenic edema associated with tiny metastatic
lesion in the right centrum semiovale. Consider MRI to further
assess.
2. Probabe skin metastasis posterior to the left pinna.
CT chest [**5-2**]:
1. Marked bronchial compression and malacia, particularly at the
upper lobes, without evidence of endobronchial spread.
2. Innumerable pulmonary nodules, hilar, mediastinal, and left
axillary adenopathy consistent with metastatic disease, slightly
progressed since the prior study. New nodule is seen in the
paraspinal subcutaneous tissues
posterior to the right T11 rib.
3. Bilateral pleural effusions and basilar atelectasis, right
more than left, significantly increased on the left and slightly
increased on the right.
4. Nonspecific hepatic hypodensity, largely unchanged.
5. Unchanged left-sided rib metastases.
EEG [**5-2**]:
This is an abnormal portable EEG recording due to the slow and
disorganized background suggestive of a widespread
encephalopathy.
Metabolic disturbances, medications, and infection are the most
common
causes. There were no lateralized or epileptiform features seen
in this
recording. Of note is the sinus tachycardia.
CXR [**5-3**]:
Partially obscuring many of the large nodules in both lungs is a
process which could be pulmonary edema or rapidly developing
pneumonia, worse in the right lung and all new since [**5-1**].
Small bilateral pleural effusions are presumed. Heart size top
normal. No pneumothorax.
MRI head [**5-5**]:
1. Infra- and supra-tentorial areas of abnormal enhancement as
described above involving the right cerebellar hemisphere, three
lesions in the subcortical white matter of the right cerebral
hemisphere.
2. Punctate areas of restricted diffusion noted on the left
frontal region, possibly related with restricted diffusion
versus metastasis, pattern of enhancement is identified in the
lesions on the right cerebral hemisphere and cerebellum likely
consistent with metastatic disease.
Brief Hospital Course:
1. Altered mental status: Initially on vanco, cefepime, ACV, and
ampicillin for possible meningitis but all were discontinued as
his mental status improved with decadron. His AMS was most
likely due to increased edema from cancer mets seen on CT and
MRI head, as well as from acute hypercapnia (see below). Before
discharge, the patient noted his mentation felt back to normal
and he was A+O x3. He was given instructions on gradually
tapering his dexamethasone dose.
2. Hypoxia: Had an episode of desaturation on initial arrival to
the floor, probably related to progression of metastatic
disease. He was initially treated for possible HAP with Vanc and
Zosyn, although CT was not suggestive of PNA and these were
stopped. He was started on oseltamavir for possible influenza,
as his granddaughter had confirmed swine flu, but this was
discontinued as DFA and viral culture were negative. He was
initially on on BiPAP for hypercapnia, but weaned to nasal
cannula. His CO2 improved but remained elevated, suggesting a
chronic component, possibly OSA given his body habitus. However,
the patient did not tolerate an attempt at CPAP ovrenight. He
was satting well on room air prior to discharge. He was started
on albuterol and ipratropium nebulizers to use for shortness of
breath or wheezing from obstructing tumor.
3. Metastatic melanoma: Patient has tolerated chemo poorly in
the past. He was started on dexamethasone for brain vasogenic
edema due to metastases, as seen on CT and MRI head. Neuro onc
and rad onc saw the patient, and he will follow up as an
outpatient for radiation therapy.
4. Hematuria: Initially had a negative UA, but repeat UA due to
initial culture being contaminated showed many RBCs with few
calcium oxalate crystals. He was not treated for nephrolithiasis
as he was asymptomatic. This was repeated after Foley removal,
and showed less blood, no calcium crystals, but a few uric acid
crystals. These abnormalities can be follow up as an outpatient.
Medications on Admission:
ATORVASTATIN 40 mg daily
GLIPIZIDE 10 mg daily
LISINOPRIL 5 mg daily
METFORMIN 1000 mg [**Hospital1 **]
NAPROXEN
NIFEDIPINE 30 mg SR daily
PIOGLITAZONE 45 mg daily
PROCHLORPERAZINE 10 mg TID PRN
ASA 81 mg daily
MAGNESIUM OXIDE 400 mg daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
8. Naproxen 500 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
Disp:*360 ml* Refills:*1*
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*300 ml* Refills:*1*
13. Devices
Please provide patient with a nebulizer machine for breathing
treatments.
14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO as directed
below: Take 4mg twice daily for the next five days (starting
[**5-6**]). Then take 4mg once daily (starting [**5-11**]).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Physicians Health Care
Discharge Diagnosis:
Primary:
Altered mental status due to hypercapnia
Malignant melanoma, metastatic to the lung and brain
Secondary:
Diabetes mellitus
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with confusion that was likely from
poor gas exchange in the lungs leading to a high carbon dioxide
level (CO2). This resolved after using a type of breathing mask
called BiPAP. We did an MRI to characterize your brain
metastases, and you will follow up with radiation oncology for
treatment.
Please take all medications as prescribed and go to all follow
up appointments. We made the following medication changes:
- Started albuterol and ipratropium nebulizers to use for
shortness of breath or wheezing.
- Started dexamethasone, a steroid to decrease swelling around
the brain.
If you have difficulty breathing, headache, confusion, seizures,
chest pain, fevers, chills, or any other concerning symptoms,
please seek medical attention or return to the ER immediately.
Followup Instructions:
You will be seen in the radiation oncology clinic on Tuesday [**5-11**]. They will contact you tomorrow ([**Name (NI) 2974**]) with the time and
location details. Phone: ([**Telephone/Fax (1) 8082**].
Please follow up with Dr. [**Last Name (STitle) 724**] on [**6-7**] at 9:30 am. [**Location (un) **]. Office Phone: ([**Telephone/Fax (1) 6574**].
You should follow up with Dr. [**Last Name (STitle) 1729**] after you complete your
radiation therapy. Please discuss with your Radiation Oncologist
the optimal timing for this follow up.
Please call Dr. [**Name (NI) 41688**] for a follow up appointment for
within the next 3-4 weeks. Phone: [**Telephone/Fax (1) 74396**].
Completed by:[**2184-5-8**]
ICD9 Codes: 2762, 5119, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5621
} | Medical Text: Admission Date: [**2200-4-28**] Discharge Date: [**2200-5-5**]
Date of Birth: [**2129-6-16**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Briefly, this is a 70-year-old
male with a history of hypertension, who was admitted to the
Medical service for a positive stress test, which led him to
get a cardiac catheterization. A cardiac catheterization
showed left main disease as well as two-vessel coronary
artery disease. Patient reported a history of
lightheadedness, which occurred mostly on exertion. No loss
of consciousness or fall, and would resolve with rest. No
chest pain, however, he did have some mild dyspnea. Denied
any nausea or vomiting. No PND or orthopnea. He had been
getting a workup by his primary care physician at that time,
which included a Holter monitor and stress test, which showed
a drop in his blood pressure during exertion.
PAST MEDICAL HISTORY:
1. Hypertension.
2. High cholesterol.
3. Positive stress test as noted previously.
MEDICATIONS ON ADMISSION:
1. Accupril 40 p.o. q.d.
2. Hydrochlorothiazide 12.5 p.o. q.d.
3. Nifedipine 10 mg.
4. Lipitor 10 p.o. q.d.
ALLERGIES: He had no known drug allergies.
PHYSICAL EXAM UPON ADMISSION: He was afebrile with stable
vital signs. His neck was supple. His lungs were clear.
His heart was regular rate with no murmurs, rubs, or gallops.
Abdomen was soft, nontender, and nondistended. Bowel sounds
were present. Extremities were warm and well perfused.
LABORATORIES: Unremarkable.
HOSPITAL COURSE: Patient was admitted to the Medical
service, and he was continued on his medications as well as
started on aspirin. Cardiothoracic Surgery was consulted for
evaluation for CABG. After reviewing the results of the
cardiac catheterization as well as the disease, it was
decided that the patient would undergo a two-vessel CABG,
which he underwent on [**2200-4-30**]. Please see operative report
for further details.
Patient was transferred to the CSRU postoperatively. On
postoperative day #1, the patient was doing well. He was on
Neo-Synephrine for blood pressure support. He was extubated
and doing well from that standpoint. His Neo-Synephrine was
weaned off and he continued to improve. He was started on
Lasix for diuresis. Physical Therapy was consulted while the
patient was in the CSRU for evaluation and function, and they
continued to follow him throughout his hospital course.
Prior to discharge, he showed adequate improvement, and it
was decided the patient could be discharged home safely.
Patient continued to improve. His chest tube and wires were
removed postoperatively, and his Foley catheter was also
removed. His diet was advanced. He was able to tolerate
regular food, and he was urinating on his own without the
Foley catheter.
On postoperative day #5, the patient was doing well, and he
was cleared by Physical Therapy, and it was decided that the
patient could be discharged home.
DISCHARGE STATUS AND CONDITION ON DISCHARGE: He was
discharged home in stable condition.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. b.i.d.
2. Potassium 10 mEq p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Aspirin 325 mg p.o. q.d.
5. Percocet 1-2 tablets p.o. q.4h. prn.
6. Lipitor 10 mg p.o. q.d.
7. Lopressor 25 mg p.o. b.i.d.
FOLLOW-UP INSTRUCTIONS: Instructed to followup with his
primary care doctor in [**1-3**] weeks, cardiologist in [**3-6**] weeks,
and with Dr. [**Last Name (STitle) 70**] in six weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft times two.
2. Hypertension.
3. High cholesterol.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2200-5-6**] 08:25
T: [**2200-5-6**] 08:24
JOB#: [**Job Number 105932**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5622
} | Medical Text: Admission Date: [**2118-2-4**] Discharge Date: [**2118-2-10**]
Date of Birth: [**2061-8-5**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
back pain and leg pain
Major Surgical or Invasive Procedure:
L3 to ilium posterior spinal fusion using OP1
History of Present Illness:
This is a
previous patient of Dr. [**Last Name (STitle) 548**] who underwent an L3-L4, L4-L5
decompression and transforaminal interbody fusion. She is
complicated patient, she has renal transplant, immunosuppressed
with a presumed osteoporosis who has been on narcotics. The
notes from Dr. [**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) **], neurologist as well as Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) 739**] were all reviewed. She has
primarily
back pain with bilateral leg pain with standing. Of note, she
has, by her report multiple kidney infections about once a
month.
Her renal transplant cysts are on the left side by her report.
On examination, she has primarily right-sided weakness with
3-4/5
[**Last Name (un) 938**], anterior tib and quadriceps. Her left side seems to be
maintained. This may be variable to some degree as it is in
contrast with Dr.[**Name (NI) 4674**] exam.
On examination of her CT scan, she has fragmentation of her L5
vertebral body with loosening of the screws in L5, L4, and L3.
The intervertebral spacer at L3-L4 appears to be in good
position. The intervertebral spacers at L4-L5 on the right side
in particular seems to be at the back edge of the bone if not
beyond.
This is a challenging patient with a pseudoarthrosis at L3-L4
and
L4-L5 mostly related to her renal osteodystrophy, osteoporosis
in
her immunosuppression and her ability to consolidated fusion.
The revision procedure for this will be challenging; however, I
suggested an aggressive approach as possible in order to get her
heal. I would prefer to do this through an anterior posterior
approach, but limited by the location of her kidney transplant.
I will discuss this with Dr. [**Last Name (STitle) **] preoperatively. The
discussion will be around whether it is even possible to get
safely to the retroperitoneal space and what challenges that
entails. My preferred approach would be an anterior procedure
with revision of the cage at L3-L4 and placement of BMP-2 at
L4-L5 not attempted to get the cages up disk space and apply
BMP-2 into that area and also put a cage in L5-S1 with BMP-2 as
well. This will be followed by a posterior revision where the
hardware will be taken out of L3, L4, and L5. The L3 screws
would most likely be replaced as well as the L4 screws larger
screws, L5 screws would be left or salvaged if possible with S1
screws placed and possibly iliac screws. I will contact Dr.
[**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) **] concerning this case.
Past Medical History:
1) ESRD since [**2102**] - HD x 7 years s/p cadaveric renal transplant
[**2110-8-11**] at [**Hospital1 2177**]
2) Stroke [**2106**] - Sxs were L-sided hemiparesis, some residual -
uses a cane at times
3) h/o obesity
4) h/o HTN d. [**2097**]
5) R shoulder rotator cuff tear - repair [**1-12**] (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **])now w/ recurrent tear awaiting completion of fistula
removal prior to return to OR
6) Epilepsy - since stroke in [**2106**]; last sz > 1 [**Last Name (un) **]
7) Depression/Anxiety
8) s/p multiple UTIs since transplant
9) s/p varicose vein stripping on Left
10) post-partum cardiomyopathy
11) small hiatal hernia
12) grade II hemorrhoids
13) h/o colitis [**2107**]
14) s/p CCY [**2082**]
15) L leg abscess 995 s/p I&D
16) LMP - 8 years ago (when started dialysis)
17) LGIB s/p colonoscopy on [**2107-4-19**]
18) bursitis in the knees and ankles
19) migraines
20) toxemia of pregnancy [**2095**]
21) gastroesophageal reflux disease
Social History:
Lives at home
Family History:
NC
Physical Exam:
AVSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: [**5-14**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative [**Doctor Last Name 937**], 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
She has primarily right-sided weakness with 3-4/5
[**Last Name (un) 938**], anterior tib and quadriceps. Her left side seems to be
maintained.
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
[**2118-2-10**] 07:54AM BLOOD WBC-6.8 RBC-3.14* Hgb-9.5* Hct-29.8*
MCV-95 MCH-30.3 MCHC-32.0 RDW-14.5 Plt Ct-210
[**2118-2-9**] 04:36AM BLOOD WBC-8.4 RBC-2.94* Hgb-8.9* Hct-26.9*
MCV-92 MCH-30.1 MCHC-32.9 RDW-14.9 Plt Ct-144*
[**2118-2-7**] 05:17PM BLOOD Hct-31.5*
[**2118-2-7**] 04:22AM BLOOD WBC-9.5 RBC-2.83* Hgb-8.4* Hct-25.9*
MCV-91 MCH-29.7 MCHC-32.5 RDW-15.0 Plt Ct-129*
[**2118-2-6**] 02:31AM BLOOD WBC-9.8 RBC-3.05* Hgb-9.0* Hct-27.3*
MCV-90 MCH-29.4 MCHC-32.9 RDW-15.2 Plt Ct-145*
[**2118-2-5**] 04:46AM BLOOD WBC-8.0 RBC-3.55* Hgb-10.6* Hct-31.1*
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.4 Plt Ct-192
[**2118-2-4**] 12:15PM BLOOD WBC-7.4# RBC-3.21* Hgb-9.5* Hct-28.9*
MCV-90 MCH-29.6 MCHC-32.8 RDW-14.7 Plt Ct-270
[**2118-2-10**] 07:54AM BLOOD Plt Ct-210
[**2118-2-8**] 05:34AM BLOOD Plt Ct-131*
[**2118-2-6**] 02:31AM BLOOD Plt Ct-145*
[**2118-2-5**] 04:46AM BLOOD Plt Ct-192
[**2118-2-10**] 07:54AM BLOOD
[**2118-2-9**] 04:36AM BLOOD
[**2118-2-10**] 07:54AM BLOOD Glucose-89 UreaN-27* Creat-1.4* Na-145
K-4.1 Cl-114* HCO3-20* AnGap-15
[**2118-2-9**] 04:36AM BLOOD Glucose-84 UreaN-28* Creat-1.6* Na-143
K-4.4 Cl-114* HCO3-21* AnGap-12
[**2118-2-8**] 05:34AM BLOOD Glucose-100 UreaN-23* Creat-1.5* Na-139
K-4.1 Cl-111* HCO3-21* AnGap-11
[**2118-2-7**] 04:22AM BLOOD Glucose-94 UreaN-24* Creat-1.4* Na-139
K-4.1 Cl-112* HCO3-22 AnGap-9
[**2118-2-5**] 04:46AM BLOOD Glucose-97 UreaN-38* Creat-1.3* Na-143
K-3.9 Cl-116* HCO3-20* AnGap-11
[**2118-2-4**] 12:15PM BLOOD Glucose-99 UreaN-52* Creat-1.7* Na-140
K-3.0* Cl-109* HCO3-20* AnGap-14
[**2118-2-10**] 07:54AM BLOOD Albumin-3.3* Calcium-9.5 Phos-3.3 Mg-2.3
[**2118-2-9**] 04:36AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.3
[**2118-2-7**] 04:22AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
[**2118-2-4**] 09:30PM BLOOD Calcium-8.7 Phos-4.2 Mg-1.5*
[**2118-2-5**] 04:46AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1
[**2118-2-10**] 01:19PM BLOOD Type-[**Last Name (un) **] pO2-202* pCO2-34* pH-7.31*
calTCO2-18* Base XS--8
[**2118-2-4**] 09:36PM BLOOD Type-ART pO2-196* pCO2-34* pH-7.39
calTCO2-21 Base XS--3
[**2118-2-4**] 06:32PM BLOOD Temp-34.8 pO2-263* pCO2-31* pH-7.39
calTCO2-19* Base XS--4
[**2118-2-4**] 02:50PM BLOOD Type-ART Rates-/8 Tidal V-500 FiO2-50
pO2-241* pCO2-29* pH-7.45 calTCO2-21 Base XS--1
Intubat-INTUBATED Vent-CONTROLLED
[**2118-2-5**] 04:53AM BLOOD Glucose-97
[**2118-2-4**] 07:33PM BLOOD Glucose-104 Lactate-1.5 Na-142 K-4.0
Cl-114*
[**2118-2-4**] 05:19PM BLOOD Glucose-94 Lactate-1.3 Na-141 K-4.0
Cl-114*
[**2118-2-4**] 07:33PM BLOOD Hgb-9.3* calcHCT-28 O2 Sat-100
[**2118-2-4**] 05:19PM BLOOD Hgb-9.1* calcHCT-27 O2 Sat-98
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet.Physical therapy was consulted for
mobilization OOB to ambulate.
Postoperatively patient was observed in ICU for 2 days.
On [**2-7**] Urine cultured E Coli and patient was started on iv
antibiotics in consultation with Renal. one unit blood was
transfused for acute blood loss anemia.
Drains were discontinued and patient was mobilized without brace
On [**2-8**] patient failed Foley trail and went into retention
(bladder scan 500cc) and therefore was recatheterised.
On [**2-9**] Creatinine was 1.6 (increasing trend) and renal were
consulted for the same. According to renal her baseline values
are high and the currentl renal function is within this range.
On [**2-10**] Creatinine was 1.4. Renal recommeded oral cepodoxime for
UTI for 7 days. Foley trail was given again today which was
successful.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
aripiprazole [Abilify]
10 mg Tablet
1 Tablet(s) by mouth once a day
azathioprine
50 mg Tablet
2 Tablet(s) by mouth once a day
clonazepam
1 mg Tablet
2 Tablet(s) by mouth q am and 3 tabs q pm
ergocalciferol (vitamin D2) [Vitamin D] 50,000 unit Capsule
1 Capsule(s) by mouth q12 weekly
folic acid
1 mg Tablet
1 Tablet(s) by mouth [**Month/Day (2) **]
hydrocodone-acetaminophen
7.5 mg-500 mg Tablet
1 Tablet(s) by mouth q 4-6 hours as needed for pain
hydroxyzine HCl
25 mg Tablet
1 Tablet(s) by mouth three times a day as needed for itch
levetiracetam (Not Taking as Prescribed: not on current med list
from [**Month/Day (2) 269**])
500 mg Tablet
1 Tablet(s) by mouth twice a day
omeprazole
40 mg Capsule, Delayed Release(E.C.)
1 Capsule(s) by mouth daily
paroxetine HCl [Paxil]
30 mg Tablet
2 Tablet(s) by mouth once a day
prednisone
5 mg Tablet
1 Tablet(s) by mouth [**Month/Day (2) **]
prochlorperazine maleate [Compazine] 5 mg Tablet
1 Tablet(s) by mouth twice a day as needed for nausea
tacrolimus [Prograf] 1 mg Capsule
5 Capsule(s) by mouth twice a day
topiramate
25 mg Tablet
6 Tablet(s) by mouth in am and 6 at bedtime
aspirin (OTC)
81 mg Tablet, Delayed Release (E.C.)
1 Tablet(s) by mouth [**Month/Day (2) **]
ensure supplement * patient unable to identify actual drug name
*
as needed
Dosage uncertain
TYLENOL
500MG Tablet
2 TABLETS BY MOUTH THREE TIMES A DAY AS NEEDED FOR PAIN
Discharge Medications:
1. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO twice a day.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for itching.
6. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. prochlorperazine maleate 10 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours) as needed for nausea.
9. topiramate 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
10. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q 8H (Every
8 Hours) as needed for fever or pain.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
13. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*150 Tablet(s)* Refills:*0*
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
18. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Nonunion following lumbar fusion surgery at L34 L45 level
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10
lbs for 2 weeks.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes
as part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3736**]
Date/Time:[**2118-2-18**] 1:20
Provider: [**First Name4 (NamePattern1) 3049**] [**Last Name (NamePattern1) 8155**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1652**]
Date/Time:[**2118-2-24**] 1:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2118-3-8**] 1:20
FU with Dr [**First Name (STitle) **] at [**Hospital1 2177**] for your renal condition within one
week of discharge.
ICD9 Codes: 5990, 2851, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5623
} | Medical Text: Admission Date: [**2119-12-26**] Discharge Date: [**2120-1-11**]
Date of Birth: [**2074-1-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2119-12-26**] Aortic Valve Replacement(19mm St. [**Male First Name (un) 923**] mechanical),
Mitral Valve Replacment(25mm St. [**Male First Name (un) 923**] mechanical), and Tricsupid
Valve Repair(28mm Annuloplasty Band). Repair of Innominate Vein
with Pericardial Patch. Lymph Node Biopsy.
History of Present Illness:
Mrs. [**Known lastname **] is a 45 year old female with history of Hodgkins
Lymphoma treated with splenectomy as well as mantle radiation.
She has known aortic insufficiency and recently complainted of
worsening shortness of breath. A recent echocardiogram revealed
mild aortic stenosis, [**2-6**]+ aortic insufficiency, 3+ mitral
regurgitation, 2+ tricuspid regurgitation, with normal left
ventricular function. Subsequent cardiac catheterization
confirmed 3+ mitral regurgitation and 3+ aortic insufficiency
with normal LV function. Mean pulmonary artery pressure was
50mmHg. Coronary angiography showed only minimal coronary artery
disease. Based on the above results, she was referred for
cardiac surgical intervention.
Past Medical History:
Congestive Heart Failure, Hypercholesterolemia, History of
Hodgkins Lymphoma - s/p MANTLE radiation, Bipolar Disorder,
History of Endometriosis, s/p Thyroidectomy, s/p Splenectomy,
s/p Tubal Ligation, History of Bowel Obstruction - s/p repair
Social History:
Active smoker, 1PPD for the last 30 years. She denies ETOH. She
is married with children. She is currently on disability.
Family History:
Negative for premature coronary artery disease.
Physical Exam:
Vitals: BP 96/54, HR 98, RR 16
General: well developed female in no acute distress
HEENT: oropharynx benign, PERRL
Neck: supple, no JVD, transmitted murmurs
Heart: regular rate, normal s1s2, diffuse 3-4/6 systolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: alert and oriented, CN 2-12 intact, nonfocal
Brief Hospital Course:
On the day of admission, Dr. [**Last Name (STitle) 1290**] performed aortic and
mitral valve replacements along with repair of the tricuspid
valve. Given history of Hodgkins lymphoma, mediastinal lymph
node biopsy was also obtained at time of the operation. For
further surgical details, please see seperate dictated operative
note. Following the operation, she ws brought to the CSRU for
invasive monitoring. She initially required Epinephrine,
Neosynephrine and volume for hemodynamics instability. She was
gradually weaned from sedation and eventually awoke
neurologically intact. On postoperative day two, she was
extubated without incident. Inotropes were weaned without
difficulty. She otherwise maintained stable hemodynamics and
transferred to the SDU on postoperative day two. She continued
to experience a drop in platelet count for which the Hematology
service was consulted. Platelet count dropped as low as 23K.
Initial HIT assays were negative and there was no evidence of
DIC or ongoing hemolysis. Given double mechanical valves,
anticoagulation with intravenous Argatroban was initiated and
titrated for a PTT between 60-80 seconds. Warfarin was not
started until platelet count reached over 100K. Over several
days, platelet count improved and Warfarin anticoagulation was
started. Her target INR is between 3.0 - 3.5. She was
aggressively diuresed during her stay. During the
post-operative period she experiences atrial fibrillation and
was therefore seen in consultation by the cardiology service.
She was placed on amiodarone and ordered for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts
monitor upon discharge. The rest of her hospital course was
unremarkable. She continued to make clinical improvements with
diuresis and made steady progress with physical therapy. She was
cleared for discharge to home on postoperative day 17.
Medications on Admission:
Levothyroxine 175 mcg qd, Toprol xl 75 qd, Lasix 20 qd, Tegretol
200 [**Hospital1 **], Valium 5 qd, Zyprexa 15 qd, Seroquel 100 qd, Lipitor 20
qd, Lisinopril 2.5 qd, Nicotine patch
Discharge Medications:
1. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: Take 80 mgs two times per day for ten days, then 80 mg
once per day for ten days .
Disp:*20 Tablet(s)* Refills:*30*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days: Take 40 mEq daily for ten days and then 20 mEq for ten
days.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take as long as you are taking percocet.
Disp:*60 Capsule(s)* Refills:*0*
4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Take
as directed by Dr. [**Last Name (STitle) 23684**].
Disp:*60 Tablet(s)* Refills:*0*
5. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO Q 24H (Every
24 Hours).
Disp:*30 Tablet(s)* Refills:*0*
7. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Olanzapine 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
11. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Congestive Heart Failure, Aortic, Mitral and Tricuspid Valve
Regurgitation - s/p Aortic Valve Replacement, Mitral Valve
Replacment, and Tricuspid Valve Repair, Postop Thrombocytopenia,
Hypercholesterolemia, History of Hodgkins Lymphoma - s/p MANTLE
radiation, Bipolar Disorder, History of Endometriosis,
Thyroidectomy, Splenectomy, Tubal Ligation, History of Bowel
Obstruction - s/p repair
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions. Dr. [**Last Name (STitle) 23684**] will manage your Warfarin as
an outpatient. Please have PT/INR checked within 48-72 hours of
discharge with results faxed to Dr. [**Last Name (STitle) 23684**] [**Name (STitle) **]:[**Doctor First Name **]
([**Telephone/Fax (1) 107479**]. Warfarin should be adjusted for goal INR between
3.0 - 3.5.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**5-10**] weeks - call for appt
Dr. [**Last Name (STitle) **] in [**3-10**] weeks - call for appt
Dr. [**Last Name (STitle) 23684**] in [**3-10**] weeks - call for appt
Follow with Thyroid function test Levothyroxine increased
[**2120-1-9**]
Please return in 1 week to [**Hospital1 18**] for a chest x-ray.
Completed by:[**2120-1-11**]
ICD9 Codes: 9971, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5624
} | Medical Text: Name: [**Known lastname 3784**],[**Known firstname 448**] Unit No: [**Numeric Identifier 3785**]
Admission Date: [**2192-5-3**] Discharge Date: [**2192-5-12**]
Date of Birth: [**2132-8-7**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Iodine; Iodine Containing / Latex Gloves
Attending:[**Doctor Last Name 147**]
Addendum:
Please not that the patient's previous discharge summary was
signed as final in error prematurely. This addendum serves as
the complete and accurate discharge summary for patient [**Known firstname **]
[**Known lastname **] ([**Numeric Identifier 3785**]) who expired on [**2192-5-12**].
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
[**2192-5-3**]: Anterior L1-S1 interbody fusion
[**2192-5-4**]: Posterior instrumented fusion T10-S1, L2 pedicle
subtraction ostoetomy
History of Present Illness:
59M with persistent back pain and bilateral anteiror thigh pain
and discomfort. He underwent a lumbar laminectomy approximately
10 years ago and has noted progressive deformity as well as
anterior thigh pain. No distal weakness. Denies numbness or
tingling. The patient was made aware of the risks and benefits
of surgical intervention given the extent of his deformity and
elected to proceed with surgical intervention.
Past Medical History:
NIDDM
HTN
GERD
s/p ACDF
s/p prior lumbar laminectomy
Social History:
Non-contributory
Family History:
Non-Contributory
Physical Exam:
The patient expired on [**2192-5-12**].
He had an open abdomen after emergent exploratory laparotomy on
[**5-11**].
The posterior spine wound on [**5-11**] had some moderate
serosanguinous drainage without significant surulence or
erythema.
Pertinent Results:
[**2192-5-11**] 11:30AM BLOOD WBC-20.8* RBC-2.87* Hgb-8.2* Hct-24.4*
MCV-85 MCH-28.7 MCHC-33.7 RDW-16.0* Plt Ct-310
[**2192-5-11**] 06:55AM BLOOD WBC-20.0* RBC-3.39* Hgb-9.3* Hct-28.9*
MCV-85 MCH-27.3 MCHC-32.0 RDW-15.3 Plt Ct-326
[**2192-5-10**] 06:45AM BLOOD WBC-22.4* RBC-3.45* Hgb-9.6* Hct-28.9*
MCV-84 MCH-27.9 MCHC-33.3 RDW-15.6* Plt Ct-322
[**2192-5-9**] 07:05AM BLOOD WBC-18.1* RBC-3.54* Hgb-9.8* Hct-29.7*
MCV-84 MCH-27.6 MCHC-32.9 RDW-15.4 Plt Ct-280
[**2192-5-8**] 06:35AM BLOOD WBC-13.8* RBC-3.86* Hgb-10.8* Hct-32.1*
MCV-83 MCH-28.1 MCHC-33.7 RDW-14.8 Plt Ct-255
[**2192-5-7**] 09:00AM BLOOD WBC-12.8* RBC-3.84* Hgb-11.0* Hct-31.7*
MCV-82 MCH-28.7 MCHC-34.9 RDW-14.8 Plt Ct-224
[**2192-5-6**] 05:40AM BLOOD WBC-10.9 RBC-3.15* Hgb-8.9* Hct-26.4*
MCV-84 MCH-28.3 MCHC-33.8 RDW-14.7 Plt Ct-189
[**2192-5-5**] 09:20AM BLOOD WBC-10.7 RBC-3.34* Hgb-9.6* Hct-27.8*
MCV-83 MCH-28.6 MCHC-34.3 RDW-14.8 Plt Ct-163
[**2192-5-4**] 11:07PM BLOOD Hct-29.0*
[**2192-5-4**] 05:17PM BLOOD WBC-11.4* RBC-3.61* Hgb-10.4* Hct-29.9*
MCV-83 MCH-28.8 MCHC-34.7 RDW-14.5 Plt Ct-160
[**2192-5-4**] 09:00AM BLOOD WBC-10.7 RBC-3.35* Hgb-9.5* Hct-27.5*
MCV-82 MCH-28.2 MCHC-34.5 RDW-14.3 Plt Ct-203
[**2192-5-3**] 02:00PM BLOOD WBC-11.4*# RBC-3.72* Hgb-10.5* Hct-30.6*
MCV-82 MCH-28.3 MCHC-34.4 RDW-13.8 Plt Ct-209
[**2192-5-11**] 06:55AM BLOOD Neuts-93* Bands-1 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2192-5-11**] 11:30AM BLOOD PT-20.0* PTT-29.5 INR(PT)-1.9*
[**2192-5-5**] 09:20AM BLOOD PT-15.0* PTT-26.2 INR(PT)-1.3*
[**2192-5-11**] 11:30AM BLOOD Glucose-103 UreaN-39* Creat-1.9* Na-148*
K-3.7 Cl-118* HCO3-19* AnGap-15
[**2192-5-11**] 06:55AM BLOOD Glucose-97 UreaN-39* Creat-1.7* Na-148*
K-3.6 Cl-116* HCO3-19* AnGap-17
[**2192-5-10**] 06:45AM BLOOD Glucose-144* UreaN-28* Creat-1.0 Na-149*
K-3.3 Cl-117* HCO3-23 AnGap-12
[**2192-5-9**] 07:05AM BLOOD Glucose-156* UreaN-28* Creat-1.0 Na-147*
K-3.8 Cl-116* HCO3-23 AnGap-12
[**2192-5-8**] 06:35AM BLOOD Glucose-163* UreaN-24* Creat-0.9 Na-143
K-3.6 Cl-111* HCO3-22 AnGap-14
[**2192-5-7**] 09:00AM BLOOD Glucose-112* UreaN-24* Creat-0.9 Na-142
K-3.9 Cl-110* HCO3-21* AnGap-15
[**2192-5-5**] 09:20AM BLOOD Glucose-222* UreaN-24* Creat-1.1 Na-141
K-4.2 Cl-113* HCO3-19* AnGap-13
[**2192-5-4**] 05:17PM BLOOD Glucose-220* UreaN-23* Creat-1.3* Na-140
K-4.3 Cl-115* HCO3-16* AnGap-13
[**2192-5-3**] 02:00PM BLOOD Glucose-195* UreaN-27* Creat-1.1 Na-143
K-3.9 Cl-112* HCO3-23 AnGap-12
[**2192-5-11**] 11:30AM BLOOD Calcium-7.5* Phos-3.6 Mg-1.6
[**2192-5-11**] 03:12PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.26*
calTCO2-20* Base XS--7
[**2192-5-11**] 11:38AM BLOOD Type-ART pO2-109* pCO2-41 pH-7.31*
calTCO2-22 Base XS--5
[**2192-5-11**] 09:30AM BLOOD Type-ART pO2-70* pCO2-30* pH-7.44
calTCO2-21 Base XS--1
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 8**] Spine Surgery Service on
[**2192-5-3**] and taken to the Operating Room for the above procedures
performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please
refer to the dictated operative note for further details. The
surgery was without complication and the patient was transferred
to the PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. His hematocrit was monitored
daily and he received transfusions of PRBCs as needed. His diet
was advanced slowly and he began to develop symptoms of an
ileus. KUB showed dilated loops of bowel and the patient still
had persistent nausea and abdominal pain. An NGT was placed on
[**5-7**] with bilious output. He was kept NPO while the NGT was in
place and was trialed on POs once passing flatus and had a bowel
movement. Physical therapy was consulted for mobilization OOB
to ambulate. He was out of bed with PT in a TLSO brace.
On [**2192-5-10**], the NGT was removed when he passed a clamp trial with
low residuals and he was started on a slow PO trial. He
tolerated POs throughout the day and then had an episode of
emesis overnight and was made NPO again. He spiked a temp of
102.7 on the evening of [**5-10**] and a fever workup was initiated.
Blood cultures returned as positive with gram negative rods on
the morning of [**5-11**] in addition to some tachypnea and increased
abdominal pain. A medicine consult was obtained and he began to
have increased work of breathing, tachypnea, hypotension, and
increased abdominal pain and distension. He began to
decompensate rapidly and was started on Vanco/Zosyn/Cipro. He
was transferred emergently to the SICU
and an NGT and central line were placed. He was rescusitated
with pressors and fluid but remained hypotensive. General
surgery was consulted and decided to take the patient emergently
to the OR for an exploratory laparotomy by Dr. [**Last Name (STitle) **]. In the
OR, he was found to have diffuse small and large bowel ischemia.
It was determined by multiple vascular and general surgeons
intra-operatively that there was no obvious salvagable bowel or
any indication for resection. He remained intubated and was
transferred back to the ICU where a family meeting was held
including all involved surgeons, social work, and the ICU team.
The patient's family elected to make him DNR/DNI. He was then
extubated and made CMO and expired on [**2192-5-12**].
Medications on Admission:
Glipizide ER 10mg [**Hospital1 **]
Doxazosin 8mg QD
Quinipril 10mg QD
Avandia 8mg QD
Protonix 40mg TID
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Rigid kyphoscoliosis
Septic shock due to diffuse ischemic bowel
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**]
Completed by:[**2192-5-12**]
ICD9 Codes: 5185, 5849, 2851, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5625
} | Medical Text: Admission Date: [**2152-10-11**] Discharge Date: [**2152-10-13**]
Date of Birth: [**2084-2-24**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Vancomycin / Iodine / Nsaids / Lyrica
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Aspirin Desensitization
Major Surgical or Invasive Procedure:
cardiac catheterization and stents to RCA.
History of Present Illness:
Patient is a 68 y/o W with history of CAD, w/ CABG in [**2143**] w/
LIMA to LAD and SVG from RIMA to Marginal branch of circumflex,
DM (last A1c 8.9), recurrent CVA's in past w/o residual
weakness, COPD (on 3L NC at baseline) who presented to [**Hospital 1514**]
Hospital on [**2152-10-4**] c/o chest pain. Patient described the
acute onset of sharp substernal chest pain with radiation to her
left arm while getting up to use the bathroom at home. This
episode was associated with dizzyness, some diaphoresis, nausea,
mild shortness of breath but without syncope emesis or other
complaints. She activated EMS and was brought to [**Hospital 1514**]
Hospital where she was admitted as a ROMI.
.
Additionally, patient reports history of intermittent chest pain
over several years with multiple hospitalizations in the past.
Also reports increasing chest pain about once per month over the
past year but increasing in severity and frequency. In
addition, she describes requiring less exertion to precipitate
her episodes. Patient reports orthopnea at baseline and sleeps
upright in her recliner as a result. Reports baseline
peripheral edema as well with occasional PND. Is wheelchair
dependent at baseline. Cardiac review of systems is notable for
absence of palpitations, syncope or presyncope.
.
At the OSH, patient's cardiac enzymes were negative, but repeat
EKG's showed TWI's in V2-V5 stable over several EKG's. Cards
consult recommended performing diagnostic cath which was
performed [**10-9**] demonstrating:
- Severe 3 vessel CAD
- High Grade Stenosis (85%) of dominant RCA which is
non-revascularized.
- Diffuse narrowing of the distal RCA with 70% stenosis.
- Proximal LAD w/ 30% stenosis and stent, and mid-LAD with 100%
occluded stent, but distal LAD with supply from LIMA.
- Circumflex with Mid 45% stenosis.
.
Impression at OSH was that the patient would benefit from
stenting of the proximal RCA stenosis with a DES. Patient was
then transferred to [**Hospital1 18**] for aspirin desensitization and
stenting.
.
On review of symptoms, she denies any prior history of bleeding
at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. She denies exertional buttock or calf pain.
She does report occasional headaches.
Past Medical History:
Cardiac Risk Factors:
- Diabetes Type II, last A1c 8.9 [**9-/2152**], complicated by
diabetic gastroparesis and peripheral neuropathy
- Dyslipidemia, on zocor 40mg qd
- Hypertension, on metoprolol 50 [**Hospital1 **]
.
Cardiac History: CABG in [**2143**], w/ LIMA to LAD (patent [**2152-10-9**]),
SVG to Marginal branch of circ (patent [**2152-10-9**])
- Prior stents to proximal and mid-LAD as evidenced by most
recent Cath - dates/types not known.
.
Additional PMH:
- Chronic Renal insufficiency, Cr at OSH 1.6
- DVT w/ PE, now s/p IVC filter, and on coumadin
- Psoriasis
- COPD on 3L NC at baseline
- Hiatal Hernia
- Hypothyroidism
- Left subclavian stenosis [**2-/2150**]
- Depression
- Anemia, baseline Hct 27.8%
Social History:
Patient lives alone in [**Location (un) 1514**] NH. Has visiting nurse and home
health aid who helps with medications. Has two daughters who
she is involved with and does not mind if we discuss her care
with them. She is a retired police officer. Smoked 1 ppd for
nearly 40 years. Denies history of etoh use or IVDU.
Family History:
Family History notable for DM in father and mother. [**Name (NI) 6419**] with
CAD first diagnosed in their 60's. No family history of SCD,
aspirin allergy that she is aware of.
Physical Exam:
VS: T 97.6. , BP 130/50 LA, BP 150/60 RA , HR 59, RR 15,
O2 99 % on 3L
Gen: obese elederly woman in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate but at times a bit odd.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mild conjunctival
pallor. Wears dentures at baseline.
Neck: Supple, no significant JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. Systolic murmur II/VI at LUSB.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, non-distended. Mild discomfort with palpation
in RUQ, RLQ, LLQ, no rebound, no guarding, no masses.
Skin: Mild dermatitis under breasts bilaterally.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without hematoma or
bruit; DP dopplerable, PT pulses dopplerable b/l.
Neuro: AO, CN II - [**Doctor First Name 81**], tongue deviates to left with protrusion,
speech is mildly dysarthric at baseline (without dentures in
place on exam). No focal weakness on exam, extremities grossly
4+/5 upper and lower.
Pertinent Results:
[**2152-10-11**] 12:23PM PT-13.2* PTT-150* INR(PT)-1.2*
[**2152-10-11**] 12:23PM PLT COUNT-301
[**2152-10-11**] 12:23PM WBC-7.3 RBC-2.65* HGB-8.9* HCT-26.3* MCV-100*
MCH-33.7* MCHC-33.9 RDW-16.8*
[**2152-10-11**] 12:23PM GLUCOSE-406* UREA N-21* CREAT-1.4* SODIUM-135
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-31 ANION GAP-13
[**2152-10-11**] 12:23PM estGFR-Using this
[**2152-10-11**] 12:23PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-2.1
[**2152-10-11**] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2152-10-11**] 08:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
Brief Hospital Course:
Patient was admitted to the CCU for management:
.
#1)ASA Desensitization was accomplished using the standard
protocol without complication.
.
#2)CAD: Performed [**2152-10-12**] and 2 drug eluting stents were placed
in the RCA. Pt. remains chest pain free. Lopressor, Zocor and
Imdur were continued. She will need Plavix 76 mg daily,
uninterrupted for 12 months. It may only be stopped under the
direction of Dr. [**Last Name (STitle) **]. She will need to take aspirin
lifelong. EKG shows Sinus rhythm and is without changes.
#3)Diabetes: NPH dose was adjusted in [**Location (un) 1514**] Hopsital due to
glucose elevations. Glucose remained elevated with NaHCo3
infusion during and after cardiac cathetherization. NPH dose now
resembles home dose. Glucose values ranged from 133,265,335, 406
during this admission and she was given Regular insulin sliding
scale as needed. She will require continued monitoring and
treatment.
Pt. continues with multiple medications for peripheral
neiropathy. She is wheelchair bound. She declined Physical
Therapy evaluation on [**2152-10-13**]. She has a history of falls. Most
recent fall at home was 2 weeks ago. She will need further
evaluation of this staus prior to returning home safely. She may
benefit from rehabilitation, however she declines this option at
this time.
#4) HTN: Norvasc was added for improved blood pressure control.
We recommend considering Ace inhibitor after settling from
cardiac cath if creatinine is stable. Blood pressure range is
from 109/52-209/73. She will need continue monitoring and
treatment.
#5) Chronic renal insufficiency: Creatinine was 1.4 on [**2152-10-12**].
She was prehydrated with NaHCo3 before and during
catheterization procedure.
Medications on Admission:
metoprolol 50mg PO BID
Heparin gtt at 1300 units/hr
combivent 2 puff INH [**Hospital1 **]
docusate Na 100mg [**Hospital1 **]
duloxetine 60mg qd, 30mg qd
advair 100ucg [**Hospital1 **]
furosemide 20mg PO qd
gabapentin 300mg qhs, 600mg [**Hospital1 **]
gemfibrozil 600mg [**Hospital1 **]
insulin lispro SS
insulin NPH 37 units qhs
insulin NPH 42 units qam
imdur 30mg [**Hospital1 **]
levothyroxine 75 ucg qd
lidocaine patch 5% 2 patches each day (one each leg)
metoclopramide 5mg PO qachs
nortiptyline 25mg qhs
nystatin top [**Hospital1 **]
pantoprazole 40mg PO BID
quetiapine 50mg qhs
simvastatin 40mg PO qd
.
PRN
butalbital/APAP/CAFF
cyclobenzaprine
fentanyl
glucagon
lactulose
lorazepam 0.25mg q8
morphine
nitroglycerin
propoxyphene-APAP
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QPM (once a day (in the
evening)).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
13. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
14. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
20. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
21. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS (TH,FR)
for 2 days: INR on [**2152-10-14**] for further Coumadin dose.
22. Methadone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
23. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
24. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
25. Insulin NPH Human Recomb Subcutaneous 42 units in am, and
37 units in evening.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Coronary artery dsease.
Hypertension
Diabetes.
Hyperlipidemia
IVC filter and hx. of CVA-. on Coumadin therapy
Left subclavian stenosis
Chronic renal insufficiency
Discharge Condition:
VS; 97.6-[**Numeric Identifier 75961**] 168/78
Labs:
groin: no hematoma or bruit
Followup Instructions:
Dr. [**Last Name (STitle) 75962**] in 1 week.
Dr. [**Last Name (STitle) **] [**2152-10-18**] 10:45am.
Completed by:[**2152-10-13**]
ICD9 Codes: 4111, 2449, 496, 3572, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5626
} | Medical Text: Admission Date: [**2192-6-4**] Discharge Date: [**2192-6-6**]
Date of Birth: [**2157-11-27**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
Extubated
History of Present Illness:
Mr. [**Known lastname **] is a 38 y.o. man w/ an unknown PMH who was transferred
from [**Hospital6 8283**] w/ altered mental status. He was
reportedly observed trying to enter a bar, after which he
flashed a taxi, and then he hid under a park bench. The
police/EMS were called. He was screaming, spitting, and biting
himself, requiring sedation and restraints.
In the [**Hospital3 4298**] ED, VS: T97.7, HR 103, BP 144/58, RR
18, O2 sat unable to assess. He was anxious, uncooperative, and
hostile. ALT 34, AST 51, Alk phos 49, Tbili 0.2, albumin 4.7.
EtOH 384. Serum osmolality 407. U/A negative for ketones. He
received haldol, lorazepam, cogentin, as well as midazolam and
succinylcholine for intubation to receive a CT head. CT head was
negative for an intracranial process. He was transferred to the
[**Hospital1 18**] ED for further evaluation.
In the [**Hospital1 18**] ED, VS: T 97.6, HR 61, BP 91/43, RR 16, 100% on
100% FiO2. Exam was significant for no sign of traumatic
injury. Na was found to be 152. EtOH 377. 4L of NS were given.
400cc urine emptied in the ED.
On arrival to the MICU, T 98.3, HR 70, BP 87/44, RR 20, 98%
intubated on CMV Tv 550, RR 20, FiO2 40%, PEEP 5. His Na was
still elevated to 146. He was sedated on fentanyl/midazolam. He
was given IV thiamine, folate, MV, and 1L NS bolus. He was also
started on D5 1/2 NS + 20 mEq K at 150 cc/hr.
Past Medical History:
Alcoholism
S/P Splenectomy 16 years ago for car accident
Anxiety
Social History:
Single and lives alone in [**Doctor First Name **]??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. He is a bartender.
In AA for alcoholism ?????? has been hospitalized for EtOH 5x. Has a
history of delirium tremens. Started drinking 1.5 mo ago. He
used cocaine and ecstacy 2 mo ago. He also used 1 Adderall pill
yesterday.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL
Vitals: T98.3, HR 70, BP 87/44, RR 20, 98% intubated FIO2 40%
General: sedated, not diaphoretic
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: JVP not elevated, no LAD
CV: RRR, nl S1/S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: midline abdominal incision, soft, NT, ND, BS+, no
organomegaly
Ext: WWP, no cyanosis, clubbing, edema
Neuro: sedated, pupils round and minimally reactive, minimally
reflexic in UE and LE, Downgoing Babinski b/l, rest of exam
deferred due to sedation
.
DISCHARGE PHYSICAL
VS 97.8, 120/62, p58, R20, 96%RA
GEN: Alert. Cooperative. In no apparent distress. Appears
comfortable
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist. No
icterus or pallor.
LUNGS: Clear to auscultation B/L. No wheezes or crackles.
CV: S1, S2. Regular rate and rhythm. No murmurs/gallops/rubs
appreciated. No JVD.
ABDOMEN: BS present. Soft. Musculoskeletal tenderness to
palpation over lower abdomen. Nondistended. No organomegaly
noted. Well healed midline surgical scar c/w old splecectomy
EXTREMITIES: No gross deformities, clubbing, or cyanosis. No
edema
NEURO: CNII-XII intact, motor and sensory grossly normal. No
tremors.
Pertinent Results:
ADMISSION LABS:
[**2192-6-4**] 11:45PM TYPE-[**Last Name (un) **] PH-7.33* COMMENTS-GREEN TOP
[**2192-6-4**] 11:45PM LACTATE-1.5 K+-5.1
[**2192-6-4**] 11:45PM freeCa-0.99*
[**2192-6-4**] 11:17PM GLUCOSE-95 UREA N-11 CREAT-1.0 SODIUM-146*
POTASSIUM-5.4* CHLORIDE-116* TOTAL CO2-22 ANION GAP-13
[**2192-6-4**] 11:17PM CALCIUM-7.1* PHOSPHATE-4.5 MAGNESIUM-2.1
[**2192-6-4**] 11:17PM WBC-6.2 RBC-3.63* HGB-11.4* HCT-34.2* MCV-94
MCH-31.5 MCHC-33.3 RDW-13.4
[**2192-6-4**] 11:17PM PLT COUNT-301
[**2192-6-4**] 11:17PM PT-11.7 PTT-29.7 INR(PT)-1.1
[**2192-6-4**] 09:42PM TYPE-ART TIDAL VOL-500 PEEP-5 O2-100 PO2-449*
PCO2-54* PH-7.29* TOTAL CO2-27 BASE XS--1 AADO2-208 REQ O2-43
-ASSIST/CON INTUBATED-INTUBATED
[**2192-6-4**] 08:20PM URINE HOURS-RANDOM
[**2192-6-4**] 08:20PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
[**2192-6-4**] 08:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2192-6-4**] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2192-6-4**] 08:14PM GLUCOSE-104 NA+-152* K+-3.7 CL--113* TCO2-25
[**2192-6-4**] 08:08PM UREA N-12 CREAT-1.0
[**2192-6-4**] 08:08PM estGFR-Using this
[**2192-6-4**] 08:08PM LIPASE-55
[**2192-6-4**] 08:08PM ASA-NEG ETHANOL-377* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-6-4**] 08:08PM WBC-5.3 RBC-3.80* HGB-11.8* HCT-35.6* MCV-94
MCH-31.1 MCHC-33.2 RDW-13.4
[**2192-6-4**] 08:08PM PLT COUNT-308
[**2192-6-4**] 08:08PM PT-11.2 PTT-30.1 INR(PT)-1.0
[**2192-6-4**] 08:08PM FIBRINOGE-180
.
pH 7.29/pCO2 54/pO2 449/HCO3 27/BaseXS -1
Type:Art; Intubated; FiO2%:100; AADO2:208; Req:43; TV:500;
PEEP:5; Mode:Assist/Control
.
Micro:
None
.
Imaging:
CXR [**2192-6-4**] Wet Read:
No evidence of acute disease. ET tube terminating 5 cm above
carina, could be advanced slightly. OG tube terminating barely
in stomach with sidehole in esophagus; advancing the tube by
10-12 cm suggested.
.
CT Head [**2192-6-4**] (OSH) Wet Read:
No evidence of intracranial mass lesion, acute infarction, or
acute intracranial hemorrhage. The brain parenchyma appears
normal. The ventricles, sulci, and cisterns are unremarkable.
There is no extra-axial collection. There is no mass effect or
midline shift.
.
EKG: [**Hospital3 4298**] EKG: NSR, T wave inversion and RSR' in
V1, borderline elevated QRS.
DISCHARGE LABS:
[**2192-6-6**] 07:10AM BLOOD WBC-10.4# RBC-3.98* Hgb-12.5* Hct-37.1*
MCV-93 MCH-31.3 MCHC-33.6 RDW-13.1 Plt Ct-306
[**2192-6-6**] 07:10AM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-142
K-3.9 Cl-108 HCO3-29 AnGap-9
[**2192-6-6**] 07:10AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8
[**2192-6-6**] 07:10AM BLOOD ALT-45* AST-88* CK(CPK)-1807* AlkPhos-41
TotBili-0.7
Brief Hospital Course:
38 year old male with history of alcohol use/abuse, depression
and anxiety who presented with altered mental status secondary
to alcohol intoxication. The patient arrived as an outside
hospital transfer intubated. He was admitted to the MICU and
extubated once his mental status improved. He was transferred to
the general medicine floor for further monitoring, and stable by
day of discharge.
.
ACTIVE PROBLEMS:
1)[**Name2 (NI) **] Intoxication/Altered Mental Status:
The patient's alcohol Level was 377, which was high enough alone
to be responsible for stupor, loss of consciousness, and airway
depression. He was initially intubated at outside hospital but
extubated shortly after arriving to the ICU as mental status
improved. Urine tox screen was also positive for
amphetamines,(the patient reports using one tablet of adderall
the day before admission) and benzodiazepines. However, sedation
involved benzodiazepine use, and he denied illicit use of this
class of medication. He presented w/ hypertension and
tachycardia. Acute intracranial process such as hemorrhage was
ruled-out w/ head CT. He remained afebrile, and infectious
etiology for his altered mental status was unlikely. Mental
status improved after IV fluids. There were no seizures/tremors,
or other signs of withdrawal throughout his hospital course.
.
2) History of Alcohol Use vs Abuse - The patient stated he would
like to be sober again and plans on returning to AA and, when
allowed, his sober house. He was seen by social work during his
stay. Of note, patient stated that he works as a bartender, and
had been sober for 6 weeks prior to this episode (of which he
has no recollection of even his first drink).
3) Hypernatremia of 146-149 early in admission, likely due to
dehydration. The patient's free water deficit was calculated to
be ~3L and he was treated with IV fluids with good response. By
day of discharge, his electrolytes were within normal limits.
.
4) Mild Transamnitis, which AST 88, ALT 45 - The patient's liver
enzyme pattern follows a probable alcoholic induced cause. The
patient was counseled on alcohol induced liver injury and was
advised to follow up with his PCP.
.
5) Elevated Creatine-Kinase - Likely secondary to time down on
ground or secondary to restraints during period of agitation.
His CK initially increased from 1753 to 2437 but began trending
downwards after treatment with IV fluids. He did not present
with any muscle weakness or hematuria and there were no other
signs of rhabdomyolysis.
.
6) Neck and Abdominal Muscle soreness- Likely musculoskeletal,
secondary to mechanical ventilation verses straining against
restraints or during intubation. The patient's symptoms were
controlled with Ibuprofen during his stay.
.
7)Hypotension on presentation to the MICU. This was likely in
the setting of sedation with midazolam and fentanyl. He was
hypertensive in the [**Hospital3 4298**] ED in the setting of
agitation before being sedated and intubated. Since he is a
young, fit man, he may have a low BP at baseline. His
hypotension resolved during his stay and he was stable by
discharge.
.
8)Normocytic anemia of unknown etiology. The patient's Hb/Hct
was between 11.4-12.5/34.2-37.1, possibly secondary to alcohol
abuse combined with aggressive IV fluid resuscitation. The
patient was advised to follow up with his primary care
physician. [**Name10 (NameIs) **] remained clinically stable with no evidence of
active bleeding during his stay.
.
CHRONIC ISSUES:
1) History of Depression/Anxiety - The patient remained
clinically stable throughout his stay and his home Celexa 30mg
was reinitiated on transfer from the MICU to the floor.
.
2) History of insomnia - The patient reported trouble sleeping
but did not receive or ask for his PRN written medication in his
overnight stay on the general medicine floor
.
Transitional issues:
1) Alcohol use/abuse: The patient was advised to discuss this
admission with his PCP and to return to AA for recovery
2) The patient was advised to followup with his PCP regarding
his elevated liver enzymes.
Medications on Admission:
Celexa 30 mg
Discharge Medications:
1. Citalopram 30 mg PO DAILY
2. Ibuprofen 400-600 mg PO Q8H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Alcohol Intoxication, Altered Mental Status,
Hypernatremia, Elevated CK enzymes
SECONDARY: Depression, Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted because you had an altered
mental status secondary to your use of alcohol and amphetamines.
You were sedated and ventilated with a breathing tube at an
outside hospital before being transferred here for further care.
We noticed that you had high sodium, probably secondary to
losing too much water (dehydration) and also that some blood
values relating to muscle breakdown were also elevated (possibly
due to an extended period laying down or from being in
restraints). We treated you for these with IV-Fluids and you
responded well. We also noticed elevations of your liver
enzymes, indication some damage most likely related to your
alcohol use. As a precaution, we monitored you for any signs of
withdrawal. You sore throat and muscle aches are likely related
to the breathing tube and mechanical ventilation. The aches may
also be related to injury while you were intoxicated. We
strongly urge you to continue AA and stop drinking alcohol, and
you should followup with your primary care physician regarding
your liver and other care. We also recommend you stop smoking.
.
Please note the following changes to your medications:
You may START taking Ibuprofen for pain, as needed
You may continue your home medications as previously prescribed.
Followup Instructions:
Please followup with your primary care physician. [**Name10 (NameIs) **] have made
you the following appointment:
Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 50481**] NP
When: Wednesday [**6-13**] at 9:15am
Where:Island Health [**Hospital3 **], Ma
Phone:([**Telephone/Fax (1) 111872**]
Completed by:[**2192-6-6**]
ICD9 Codes: 2760, 2762, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5627
} | Medical Text: Admission Date: [**2104-11-19**] Discharge Date:
Service: [**Hospital1 139**]
CHIEF COMPLAINT: Dehydration, nausea, vomiting and increased
ostomy output.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female with history of ulcerative colitis status post
ileostomy in [**2087**] with severe COPD and a past admission for
severe diarrhea which led to acute renal failure, who was in
her usual state of health until 4-5 days prior to admission
when a VNA nurse noted increased output from her ostomy. She
also was complaining of decreased po intake and post tussive
vomiting at that time. Dr. [**Last Name (STitle) **] went to the patient's
house on the day of admission and felt she should come to the
Emergency Room for evaluation. She was also stating that she
had a slight increase in shortness of breath above baseline.
In the Emergency Room she was orthostatic but afebrile and
was found to have acute renal failure with a BUN of 71,
creatinine up to 3.8 and a potassium of 6.6. ABG at that
time showed PH of 7.18, PCO2 31 and a PO2 of 114. EKG showed
peaked T waves. She was given bicarbonate and Albuterol nebs
and hydrated with four liters of normal saline. She then was
transferred to the MICU for further care.
PAST MEDICAL HISTORY: 1) Ulcerative colitis status post
ileostomy in [**2097**]. 2) Left BKA. 3) Aortic stenosis status
post porcine valve replacement. 4) Cardiac catheterization
in [**3-6**] showed no evidence of coronary artery disease. 5)
History of acute renal failure secondary to dehydration. 6)
Chronic obstructive pulmonary disease with the most recent
PFTs on [**2104-7-15**] showing an FVC of 54% predicted value and
FEV1 of 24% predicted value and an FEV1 to FVC ratio of 45%.
Patient's O2 sat is 91% at baseline on room air. 7)
Perioperative MI in [**2097**] with persistent Q's in leads 2, 3
and AVF.
ALLERGIES: Patient is allergic to Penicillin, Codeine,
Demerol, Procardia and Aspirin.
MEDICATIONS: On admission, Albuterol and Atrovent nebs,
Atenolol 25 mg po bid, Vanceril MDI 4 puffs [**Hospital1 **], Zantac 150
mg po q d, Isordil 10 mg po tid, Elavil 10 mg po q h.s. prn
and a Multivitamin po q d.
FAMILY HISTORY: The patient's daughter and her grandchildren
have a history of asthma. She also has a daughter with
emphysema.
SOCIAL HISTORY: The patient currently lives alone. She has
nine children. She uses a wheelchair as well as a prosthesis
to ambulate. She is a retired customer service analyst at
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 15 years ago. She has a 30 pack year smoking
history. She quit approximately 10 years ago. She denies
any alcohol use.
PHYSICAL EXAMINATION: Temperature 95.5, heart rate 85, blood
pressure 120/70, respiratory rate 25, pulse ox 99% on two
liters. In general the patient is an elderly female who is
tachypneic at rest. HEENT: Revealed dry mucus membranes,
pupils are equal, round and reactive to light, extraocular
movements intact. Conjunctiva are pink and non injected.
The sclera are anicteric. The neck has no JVD. There was no
lymphadenopathy. The carotids are 2+ bilaterally. There are
no bruits. The heart has a 2/6 systolic murmur heard best at
the right upper sternal border. S1 and S2 are normal. There
was a regular rate and rhythm. The lungs have decreased
breath sounds bilaterally. There are dry crackles at the
bases bilaterally. The abdomen shows mild right lower
quadrant tenderness. There is no rebound. It is non
distended. There are hyperactive bowel sounds. There is an
ostomy in the right lower quadrant. The back has no CVA or
spinal tenderness. There is a Foley draining scant, turbid
urine. There is a right groin triple lumen catheter in
place. The extremities are without edema. The hands and
feet are cool. The distal pulses are 1 to 2+ throughout.
Neurologic exam is grossly non focal.
LABORATORY DATA: On admission showed white blood cell count
11, hematocrit 46.1, platelet count 394,000. Differential
has 86% neutrophils, no bands, 10.5% lymphs, sodium 134,
potassium 6.6, chloride 106, CO2 11, BUN 71, creatinine 3.8,
glucose 122, lactate 1.4. Urinalysis shows turbid urine with
a specific gravity 1.023, there are trace ketones, a large
amount of blood, protein 100, nitrites are negative, glucose
negative. Microscopic urine exam shows [**4-7**] RBC per high
power field, there is greater than 50 WBC per high power
field and bacteria present. Urine sodium is 30, urine
creatinine is 275. Chest x-ray shows flat diaphragms
bilaterally, there are no effusions or infiltrates. EKG
shows normal sinus rhythm at 92 beats per minute, there is
left axis deviation, Q waves in leads 2, 3, and AVF which are
old. There are T wave inversions in leads 1 and AVL which
are old. There are new peaked T waves in V1 through V6.
HOSPITAL COURSE: The patient was admitted to the MICU for
further evaluation and monitoring.
1. Renal: The patient's urinalysis was suggestive of a
urinary tract infection so she was started on a 3 day course
of Bactrim. In addition, her creatinine was 3.8 which is up
from her baseline of 1.3 to 1.5. This renal failure was felt
to be secondary to dehydration as her [**Doctor First Name **] was 0.1%. She had
been hydrated in the MICU and her creatinine rapidly began to
normalize as well as her potassium. By the time she had been
transferred out to the floor on the second hospital day, her
creatinine had come down to 1.9 from its admission value of
3.3. Her creatinine continued to improve after being on the
regular medical floor. At the time of this discharge summary
her most recent BUN and creatinine values are BUN of 15 and
creatinine of 1.0 measured on [**11-26**]. Repeat urinalysis and
culture only showed some yeast which was likely secondary to
colonization from the Foley catheter. The Foley catheter was
discontinued on the 7th hospital day as it had been left in
while the patient still had the femoral triple lumen catheter
in place. The patient is incontinent at baseline.
2. GI: The patient was admitted with what was felt to be a
possible gastroenteritis and stool studies were sent which
eventually all came back negative. Her ostomy output
decreased during her hospital stay and it was felt that
possibly her original increase in ostomy output may have been
secondary to ostomy dysfunction. In addition, her ostomy
output was guaiac'd as she had a fairly significant drop in
hematocrit after her hospital admission from 46 down to 33
which was felt to be unlikely all due to dilutional effects.
The ostomy output was guaiac positive so GI was consulted for
possible EGD. The GI recommendations include having an EGD
to look for possible upper source of bleeding as well as an
ileoscopy and a colonoscopy. The ileoscopy is to evaluate
for possible ostomy dysfunction secondary to adhesions and
the colonoscopy should be done in order to screen for
possible cancer given the patient's longstanding history of
ulcerative colitis. The patient did not want to undergo
these tests while an inpatient and as her hematocrit had
stabilized, it was felt this could be done as an outpatient.
Her ostomy output became guaiac negative and at the time of
this dictation it has been guaiac negative for several days.
3. Pulmonary: The patient has a history of severe COPD.
She was getting some relief with nebulizer treatments upon
her transfer out to the floor but she still seemed more short
of breath than she usually is at baseline so a chest x-ray
was ordered. The chest x-ray revealed a hydropneumothorax
secondary to the central line attempt of the internal jugular
vein when the patient was first admitted. The
hydropneumothorax was found on the third hospital day after
the patient had been transferred out to the regular floor.
Given her low pulmonary reserve, the patient was transferred
back into the MICU for chest tube placement. She tolerated
the procedure without any complications and was transferred
back out to the medical floor on the fourth hospital day.
She has been tolerating the chest tube well and at the time
of this discharge summary, she has had the chest tube in
place for 6 hospital day and the chest x-ray done today
showed residual pneumothorax. She still has a chest tube in
place. This may be removed despite the residual pneumothorax
and the patient may be observed for tolerance of this small
residual pneumothorax. This will be discussed with
cardiothoracic surgery. Otherwise the patient is satting
well in the mid 90's on 1 liter of oxygen. In reality she
sats okay without oxygen but she states she feels more
comfortable while wearing the oxygen. In addition, she
states that the nebulizer treatments are most effective when
she receives them just before eating.
4. Cardiovascular: The patient has a history of aortic
stenosis with a porcine valve replacement done in [**2099**]. She
also has a history of a perioperative MI during her ileostomy
surgery, however, she has no evidence of coronary artery
disease. She was ruled out for an MI while in the MICU
secondary to some chest and arm pain. Her Lopressor was
originally held given her poor respiratory status, however,
it was restarted and she is tolerating her 25 mg [**Hospital1 **] dose
well. She is also continued on her Isordil. She remains
hemodynamically stable although slightly tachycardic in the
90's to 100's secondary to Albuterol treatments.
5. Heme: As already stated, the patient had a drop in
hematocrit from 46 down to 33 after hydration. She was then
found to have guaiac positive ostomy output. She received a
total of 2 units of packed red blood cells. Her most recent
hematocrit is 33.8 and has been stable for 5 days now.
6. Dermatology: The patient developed a pruritic rash on
[**11-24**]. She states she has a slight rash at baseline but this
was increased and very pruritic which it is not usually. She
had received Lasix the day before which she has received in
the past without incident. She also received magnesium and
Neutro-Phos. The rash did appear to be a drug reaction. She
was given Benadryl with some relief of her itching. Her
sheets were also changed to bleach free which seemed to help
her significantly. At the time of this discharge summary her
rash is back to baseline and it is not pruritic. She also
has a reddened right ankle which the patient states is at her
baseline. She claims her ankle has looked like this ever
since taking Procardia several years ago. There was no edema
associated with it.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Will be dictated in an addendum.
DISCHARGE FOLLOW-UP: The patient is going to be discharged
to a rehab which is yet to be determined and she will
follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**]
within a week after discharge.
DISCHARGE DIAGNOSIS:
1. Dehydration.
2. Acute renal failure.
3. Pneumothorax.
4. Chronic obstructive pulmonary disease.
5. Urinary tract infection.
6. Upper GI bleed.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (NamePattern1) 6859**]
MEDQUIST36
D: [**2104-11-27**] 12:27
T: [**2104-11-27**] 13:01
JOB#: [**Job Number 6860**]
ICD9 Codes: 5849, 2765, 5990, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5628
} | Medical Text: Admission Date: [**2116-9-20**] Discharge Date: [**2116-9-30**]
Date of Birth: [**2116-9-19**] Sex: F
Service: NB
HISTORY: 33 and 4/7 weeks gestation, twin B, delivered
preterm by cesarean section due to prolonged premature
rupture of membranes and presentation.
Mother is a 40 year old, Gravida II, Para now II, IVF
conception; estimated date of confinement of [**2116-11-3**].
PRENATAL SCREENS: A positive, antibody negative, RPR
nonreactive, Rubella immune; hepatitis B surface antigen
negative. GBS unknown.
Pregnancy was uncomplicated until prolonged premature rupture
of membranes of twin A on [**2116-9-15**]. Mother was
admitted at that time and started on antibiotics on [**2116-9-16**]. No betamethasone was given because of gestational
age greater than 32 weeks. Knownbreech/breech lie. Therefore, the
decision was made todeliver by cesarean section. Mother never
developed a fever.AROM at delivery, clear fluid. Difficult
extraction with need to pull legs to deliver the rest of the
body. This twin emerged with spontaneous cry but overall poor
respiratory effort, requiring C-Pap for about two minutes in
delivery room. Apgars were six at one minute and seven at five
minutes. Infant was transferred to Neonatal Intensive Care
Unit in free flow oxygen.
PHYSICAL EXAMINATION: Birth weight 2210 grams (50 to 75
percentile); length 45 cm (50 percentile); head circumference
31.75 cm (50 to 75 percentile). Anterior fontanel soft, open
and flat. Positive red reflex bilaterally. Palate intact.
Nasal flaring. No grunting. Breath sounds clear. Slightly
diminished throughout. Moderate retractions. Regular rate
and rhythm without murmur. 2 plus peripheral pulses
including femorals. Abdomen benign without
hepatosplenomegaly. No masses. Three vessel cord. Normal
female external genitalia. Normal back and extremities
except swelling and bruising of both legs; right greater than
left. 2 cm by .5 cm brown macular lesion on right flank,
positive pustules on face and left toe. Skin pink and
slightly delayed capillary refill. Normal tone and strength.
HOSPITAL COURSE:
Respiratory: Infant was placed on CPAP shortly after
delivery and required 6 cm of water/room air. Infant
transitioned to room air by day of life two and has remained
in room air during this hospitalization with oxygen
saturations greater than 95 percent. Respiratory rate 30 to
50. Infant's last apnea and bradycardia spell was on
[**9-29**], quickly self-resolved. Infant is not being
treated with Methylxanthine.
Cardiovascular: Infant has remained hemodynamically stable
this hospitalization. No murmur. Heart rate 130 to 160.
Mean blood pressure 41 to 49.
Fluids, electrolytes and nutrition: Infant was initially
receiving nothing by mouth, 80 cc per kg per day of D10W.
The glucoses have been stable. Enteral feedings were started
on day of life one and infant advanced to full volume
feedings by day of life five. Calories were increased on day
of life six to 24 calories per ounce. Infant is currently
receiving 140 cc per kg per day of breast milk 24 calories
per ounce or Similac Special Care 24 calories per ounce p.o.
or per gavage. The most recent weight is 2185g. The most recent
electrolytes on day of life four showed a sodium of 141;
chloride 108; potassium of 6.3 (hemolyzed); TC02 of 23.
Gastrointestinal: Infant received phototherapy from day of
life two to day of life six. Maximum bilirubin level on day
of life three was 13.7 with direct of 0.5. Rebound bilirubin
level on day of life seven was 5.2 with direct of 0.3.
Hematology: Infant had not received any blood transfusions
this hospitalization. Most recent hematocrit on admission
was 57 percent.
Infectious disease: Infant's CBC on admission 14,600 white
blood cells, hematocrit of 57 percent, platelets 173,000; 19
neutrophils, 0 bands. The infant received Ampicillin and
Gentamycin for a total of 48 hours, for rule out sepsis.
Blood cultures remained negative to date.
Dermatology: Two congenital nevi, on right flank and forehead,
were noted. These have not yet been assessed by the dermatology
service.
Sensory: Hearing screening is recommended prior to discharge
home.
Psychosocial: Parents involved.
CONDITION ON DISCHARGE: 34 and 4/7 weeks gestation, now 35
week corrected, stable in room air.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. telephone number
[**Telephone/Fax (1) 40499**].
DISCHARGE DISPOSITION: To Level II nursery, [**Hospital6 **].
CARE RECOMMENDATIONS: Feedings at discharge: 140 cc per kg
per day of breast milk 24 calories per ounce or Similac
Special Care 24 calories per ounce p.o. or per gavage.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Recommended prior to discharge
home.
STATE NEWBORN SCREENS: Sent on [**9-22**] with a result
revealing an elevated 17OHP. A repeat specimen was sent on
[**9-26**]. Results are pending.
Infant has not received any immunizations this hospitalization.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Status post respiratory distress.
3. Apnea of prematurity.
4. Status post rule out sepsis, ruled out.
5. Status post indirect hyperbilirubinemia.
6. Congenital nevi
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 57000**]
MEDQUIST36
D: [**2116-9-29**] 23:30:08
T: [**2116-9-30**] 04:40:24
Job#: [**Job Number 57002**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5629
} | Medical Text: Admission Date: [**2115-4-30**] Discharge Date: [**2115-5-6**]
Date of Birth: [**2064-10-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
-Bedside left foot wound debridement by Podiatry
-Operating room left foot wound debridement by Podiatry
History of Present Illness:
Mr. [**Known lastname 100110**] is a morbidly obese 50 y.o. Male with a history of
line infections, ESRD on HD, OSA, GERD, h.o. C Diff who presents
from HD for initially hypoxia, fever from dialysis. Admitted to
the ICU for concern for septic shock.
.
Per pt on Sunday he noted the onset of low grade fevers to 99,
diarrhea 2-3 times, brown, liquidy with no abdominal pain. He
also noted nausea and was vomiting "spit". He did not feel
hungry and had decreased PO intake, on Monday he felt the same
had the same episodes of low grade fever, diarrhea with same
pattern/consistency, vomiting with spit only. He again did not
feel like eating, he also noted some pain in his left foot since
Monday. Per him his rt foot has been banadaged since his
dermagraft placement and was not supposed to be evaluated until
tomorrow with podiatry. The VNA looked at his left foot and said
it looked good.
.
ROS: Denies night sweats, cough, rhinorrhea, sore throat, SOB,
chest pain, abdominal pain.
.
Per ED signout pt was in dialysis this morning and was noted to
be febrile to 100, diaphoretic with a reported O2 sat of 100%.
As he was not feeling well he was referred to the ED.
.
In the ED his initial VS were noted to be HR 101, BP 118/59, RR
19, Sat 100% on RA. Per ED they have had a hard time obtaining
BP 40 minutes into his ED visit, after having a temp of 103.3
his BP dropped to 74-86/50s per vitals sheet. Per ED signout his
systolic BPs were in the 40s though he was noted to be mentating
well and conversing with the ED team. They checked a CXR which
was limited [**12-26**] technique but showed no infiltrates. His labwork
was notable for profound electrolyte abnmlties, K 8.4, Na 127,
HCO3 17, Cl 87, BUN/Cr 84/13.8. He was noted to have peaked
Twaves in lateral leads. He was given 10units IV Insulin and Amp
D50, 1 Amp Calcium Gluconate. Repeat lytes showed a K of 5.4.
Renal were notifed by the ED and are aware of admission. With
regards to the hypotension, ED were concerned about sepsis given
presence of fevers. Suspected sources were foot ulcer (pt has
chronic foot ulcers followed by vascular) vs HD line infection,
he was given Zosyn/Vanc for borad coverage. He was also given
1gm Acetaminophen and Zofran 2mg for nausea. Though ED suspected
some of the hypotension was [**12-26**] cuff size given level of
mentation, he was given 4L of NS with BPs now in the 90s. They
attempted a central line placement, decided L IJ given pt's HD
line in the right. They were able to get drawback but had a
difficult time threading the line. Groin line was thought to be
difficult to place given obesity.
.
Prior to transfer to the ICU his VS were noted to be HR 76, RR
25, 96/40, 100.7, Sat 98% on 2L.
.
Of note his last hospitalization was [**2115-3-2**], he was
hospitalized for a day for a HD R IJ line placement, his
pressures were noted to be markedly elevated in the 140s-170s.
He was recently seen by podiatry on [**2115-4-24**] for follow-up of rt
lateral TMA ulceration, wound was noted to be 3.8 x 2.7 cm with
dermagraft placed. Per note the wound has shown granulating
tissue with no signs of infection. He was also seen in vascular
clinic who recommended ABI studies.
Past Medical History:
- Non-insulin dependent diabetes mellitus
- History of line infections
- Peripheral neuropathy and peripheral vascular disease
- Leukocytoclastic Vasculitis
- Hypertension
- Obstructive sleep apnea
- Obesity
- GERD
- Anemia in setting of ESRD
- Secondary hyperparathyroidism in setting of ESRD
- Low-attenuation lesions in kidneys detected by CT in [**12/2111**]
- C. difficile infection in [**2110**] and [**2111**]
- S/p open cholecystectomy in [**2099**]
Social History:
The patient is unemployed and receives income via social
security. Formerly, he worked as an electrician but he has been
unemployed for many years. He lives in the [**Location (un) 4398**] in a
facility owned by the city of [**Location (un) 86**] for elderly and disabled
people. The patient does not use tobacco products. The patient
does not drink alcohol. The patient does not use intravenous or
other recreational drugs.
Family History:
NIDDM in both parents and two siblings. Mother with additional
high. Hyperlipidemia, hypercholesterolemia, hypertension, and
Alzheimer's.
Physical Exam:
GEN: Morbidly obese African American Male sitting up in NARD
HEENT: PERRL, EOMI, anicteric, Mucous membranes dry
RESP: Distant but CTA b/l
CV: Distant S1 and S2, RRR
ABD: 1 abdominal hernia, umbilical hernia noted, easily
reducible, NT, ND, +BS x 4
[**Location (un) **]: Rt foot shows healing ulceration, pink granulating tissue,
palpable DP, PT b/l.Left foot ulcer is dry, with ?eschar
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
.
Discharge Exam: Unchanged except
[**Location (un) **]: Right and left feet with c/d/i dressings
Pertinent Results:
Admission Labs:
[**2115-4-30**] 06:40AM PLT COUNT-230
[**2115-4-30**] 06:40AM NEUTS-84.3* LYMPHS-7.9* MONOS-5.9 EOS-0.9
BASOS-1.0
[**2115-4-30**] 06:40AM WBC-10.2 RBC-3.70* HGB-10.8* HCT-31.9* MCV-86
MCH-29.1 MCHC-33.8 RDW-17.7*
[**2115-4-30**] 06:40AM estGFR-Using this
[**2115-4-30**] 06:40AM GLUCOSE-200* UREA N-84* CREAT-13.8*
SODIUM-127* POTASSIUM-8.4* CHLORIDE-87* TOTAL CO2-17* ANION
GAP-31*
[**2115-4-30**] 06:45AM LACTATE-1.3 K+-6.7*
[**2115-4-30**] 06:45AM COMMENTS-GREEN TOP,
[**2115-4-30**] 09:00AM CALCIUM-8.1* PHOSPHATE-2.8# MAGNESIUM-2.0
[**2115-4-30**] 09:00AM UREA N-79* CREAT-13.7* TOTAL CO2-17*
[**2115-4-30**] 09:15AM GLUCOSE-225* LACTATE-1.2 NA+-129* K+-5.4*
CL--99*
[**2115-4-30**] 09:33AM VoidSpec-NOTIFIED T
[**2115-4-30**] 09:33AM COMMENTS-GREEN TOP
[**2115-4-30**] 12:16PM PLT COUNT-205
[**2115-4-30**] 12:16PM WBC-8.6 RBC-3.46* HGB-9.9* HCT-30.0* MCV-87
MCH-28.7 MCHC-33.1 RDW-17.5*
[**2115-4-30**] 12:16PM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-2.2
[**2115-4-30**] 12:16PM GLUCOSE-97 UREA N-82* CREAT-14.0* SODIUM-133
POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-20* ANION GAP-22*
[**2115-4-30**] 03:03PM SED RATE-93*
[**2115-4-30**] 03:03PM CRP-GREATER TH
[**2115-4-30**] 05:25PM UREA N-24*
[**4-30**] Chest
Imaging:
IMPRESSION: No acute cardiothoracic process. Very limited study.
[**4-30**] Right Foot
IMPRESSION: Multiple amputations and changes of neuropathic
osteoarthropathy. Interval appearance or increase in left
lateral soft tissue ulceration & equivocal bone destruction (is
this area of concern/).
[**5-1**] Art Rest
IMPRESSION: Bilateral tibial arterial disease and possible
inflow disease.
[**5-1**] Left Foot
THREE VIEWS OF THE LEFT FOOT: There are amputations of the
fourth and fifth digits. Chronic fracture at the base of the
third proximal phalanx is unchanged. There is a large soft
tissue defect that appears to extend to the surface of the bone.
The underlying bone is sclerotic with interval
development of cortical irregularity. The findings raise concern
for
osteomyelitis.
[**5-1**] Path
Soft tissue, left foot, debridement (A):
Squamous epithelium with subcutaneous fibrous tissue with acute
and chronic inflammation and focal necrosis consistent with
ulcer bed.
Discharge Labs:
[**2115-5-6**] 08:00AM BLOOD WBC-7.8 RBC-3.37* Hgb-10.1* Hct-30.2*
MCV-90 MCH-29.9 MCHC-33.3 RDW-18.0* Plt Ct-253
[**2115-5-6**] 08:00AM BLOOD Neuts-68.2 Lymphs-23.2 Monos-3.4 Eos-4.0
Baso-1.3
[**2115-5-6**] 08:00AM BLOOD Glucose-192* UreaN-52* Creat-9.1*# Na-136
K-4.4 Cl-88* HCO3-32 AnGap-20
[**2115-5-6**] 08:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.4
Brief Hospital Course:
50 yo M with hx of long-standing Type II diabetes, line
infections, ESRD on HD, OSA, obesity, GERD, hx of C Diff who was
referred to [**Hospital1 18**] ED from HD on [**4-30**] for fever, admitted to the
ICU with SIRS likely attributed to osteomyelitis of left foot
called out to floor in stable condition but with possible
bacteremia.
ACTIVE ISSUES
.
# Artifactual Hypotension: The patient presented with
hypotension, prompting concern for SIRS/Sepsis, but this was
subsequently attributed to artifact, with even the largest cough
only fitting on his forearm and requiring exquisite positioning
for an accurate pressure.
.
# Osteomyelitis: The patient underwent a bedside evaluation of
his left foot by podiatry demonstrating probing to bone; he was
then taken to the OR for debridement. Cultures grew MRSA. The
patient was treated with vancomycin HD protocol and discharged
for a total course of 6 weeks. He was discharged with a vac
dressing in place and appropriate ancillary services.
.
# Bacteremia: Culture from the ED grew S.Epi and a 2nd culture
grew anaerobic GPCs attributed to contaminant. Since the patient
had a history of difficult access, a collective decision was
made between the patient's primary nephrologist, the IV access
nurse ([**Doctor First Name 8817**]) and the primary medicine team to discharge the
patient with plans for a wire changeover as an outpatient.
.
# Diarrhea: C.dif negative. Work-up unrevealing. Supporive care
was given.
.
# DM2: Well controlled as an inpatient. Discharged on home dose
scale.
.
# ESRD: Continued HD as an inpatient. Renal medications were
unchanged on discharge.
.
INACTIVE ISSUES:
# OSA: Remained on CPAP.
.
TRANSITIONAL ISSUES:
# Tunneled dialysis catheter: To be changed over a wire after
discharge.
# Osteomyelitis: Patient will continue Vancomycin to complete
prescribed course and follow-up with podiatry.
Medications on Admission:
Sensipar 90mg daily
PhosLo 667 with meals
Renagel 800mg with meals
ISS
NPH 22u qAM, 18u qPM
Lisinopril 5mg daily
Nifedipine ER 60mg daily
ASA 325mg daily
Nexium 40mg daily
Discharge Medications:
1. Sensipar 90 mg Tablet Sig: One (1) Tablet PO once a day.
2. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day.
3. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: per sliding scale.
5. NPH insulin human recomb 100 unit/mL Suspension Sig: 22 qAM,
18 qPM units Subcutaneous twice a day.
6. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Non-weight bearing status
Non-weight bearing status on both left and right feet; OK to
transfer
10. Right foot
Wet to dry dressing daily.
11. Left foot
Wound vac changes q3 days black sponge. Pressure continuous at
125.
12. vancomycin 1,000 mg Recon Soln Sig: One (1) Administration
Intravenous every other day for 6 weeks: Per HD protocol.
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY:
-Osteomyelitis
-Bacteremia
.
SECONDARY:
-Diabetes type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
.
You were hospitalized for a bone infection of the foot called
osteomyelitis. You are being treated with antibiotics, which you
will continue to receive with dialysis after discharge.
.
Your blood was found to be growing bacteria when you were first
admitted to the emergency department; you are being treated for
this with the same antibiotics for osteomyelitis. Your HD line
will be exchanged over a wire this Wednesday at Advanced
Vascular Care. **Do not put weight on either foot until you
follow-up with Podiatry, who will oversee the management of your
feet.**
There was initially some concern about your blood pressure being
low, but the low pressure was likely due to artificat due to
blood pressure cuff size and placement. Your blood pressure has
remained stable since admission.
.
No changes were made to your medications other than as detailed
below.
START
-Vancomycin antibiotics administered with dialysis
Followup Instructions:
Advanced Vascular Care
[**Street Address(2) 111327**], Briton MA
[**Telephone/Fax (1) 5537**]
9:30AM
.
Department: PODIATRY
When: WEDNESDAY [**2115-5-8**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) 5533**],[**First Name3 (LF) **] M.
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
When: Tuesday, [**5-14**], 2:30PM
ICD9 Codes: 7907, 2762, 5856, 3572, 2767, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5630
} | Medical Text: Admission Date: [**2124-11-20**] Discharge Date: [**2124-11-26**]
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Trauma - fall from standing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a [**Age over 90 **]-year-old female who was transferred from
[**Hospital **] Hospital after falling at home. She had loss of
conciousness and was found approximately four hours later by a
friend. She had a CT scan done at [**Hospital **] Hospital that
demonstrated a left sided SAH and she was transferred to [**Hospital1 18**].
[**Age over 90 **] y/o female transferred from [**Hospital **] hospital Patient found
down this morning by Bed. Scan at outside CT reveals a Traumatic
SAH. Patient amnestic to the fall, recalls being found down
around 2pm today.
Past Medical History:
PMH: constipation, kyphosis, hypothyroid, multiple myeloma, HTN,
?CHF (on lasix), GERD
PSH: cholecystectomy (open)
Social History:
Lives independently.
Family History:
Non-contributory.
Physical Exam:
96.0 92 162/84 16 94 2LNC
NAD/AAO
RRR
coarse bs bilaterally
soft, ND, NT
bruise to left shoulder
Pertinent Results:
[**2124-11-20**] 04:05PM BLOOD WBC-7.4 RBC-3.14* Hgb-10.0* Hct-30.3*
MCV-96 MCH-32.0 MCHC-33.2 RDW-16.9* Plt Ct-144*
[**2124-11-21**] 01:55AM BLOOD WBC-6.7 RBC-2.83* Hgb-9.2* Hct-28.1*
MCV-99* MCH-32.6* MCHC-32.8 RDW-16.6* Plt Ct-128*
[**2124-11-22**] 04:57AM BLOOD WBC-18.9*# RBC-2.61* Hgb-8.5* Hct-26.3*
MCV-101* MCH-32.5* MCHC-32.2 RDW-16.6* Plt Ct-109*
[**2124-11-23**] 01:22AM BLOOD WBC-20.3* RBC-2.87* Hgb-9.5* Hct-28.6*
MCV-99* MCH-33.1* MCHC-33.3 RDW-16.6* Plt Ct-105*
[**2124-11-24**] 01:48AM BLOOD WBC-11.0 RBC-2.57* Hgb-8.5* Hct-25.7*
MCV-100* MCH-33.0* MCHC-33.1 RDW-16.2* Plt Ct-108*
[**2124-11-25**] 01:56AM BLOOD WBC-11.6* RBC-2.71* Hgb-8.8* Hct-27.0*
MCV-100* MCH-32.4* MCHC-32.5 RDW-16.4* Plt Ct-175#
[**2124-11-26**] 01:56AM BLOOD WBC-12.2* RBC-2.82* Hgb-9.0* Hct-27.5*
MCV-97 MCH-31.9 MCHC-32.7 RDW-16.4* Plt Ct-214
Brief Hospital Course:
The patient was initially admitted to the trauma ICU.
Neurosurgery was consulted from the ED and recommended
conservative management. Orthopedia surgery was also consulted
and recommended a sling for comfort. She was started on cipro
for UTI. She did well in the unit and was transferred to the
floor on HD 1. She triggered for a desaturation event on
[**2124-11-22**] and was transferred back to the unit. She was
intubated and bronched twice. Her right lung was nearly [**Last Name (un) 57454**]
out and an aspiration was suspected. She was extubated on
[**2124-11-23**] and expressed her wish not to be reintubated. In
conjunction with her family she was made DNR/DNI. Her
respiratory status continued to decline and on [**2124-11-26**] the
decision was made to change her code status to CMO. She expired
a few hours later.
CT Cspine ([**2124-11-20**]) - No fracture or malalignment.
CT Chest ([**2124-11-20**]) - Right upper lobe pulmonary opacity,
compatible with contusion injury and/or aspiration(given few air
bronchograms). Underlying infection not
excluded, although felt less likely given history. Adjacent
pleural
thickening. There are adjacent rib fractures as described, both
acute and
chronic. Bibasilar consolidations with secretions in the right
lower lobe bronchus
concerning for aspiration pneumonia. Small bilateral pleural
effusions. Right clavicular fracture, minimally displaced.
Atherosclerotic disease. Breast calcifications.
Echo ([**2124-11-21**]) - Mild symmetric left ventricular hypertrophy
with normal biventricular systolic function. Mild mitral
regurgitation. Mild aortic stenosis.
Medications on Admission:
Avapro (irbesartan) 150', cardizem SR 360', levothyroxine 88',
omeprazole DR 20', lasix 20', procrit (dose unknown), colace
100''
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Trauma - s/p fall with respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
ICD9 Codes: 5070, 5185, 5990, 4280, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5631
} | Medical Text: Admission Date: [**2129-11-11**] Discharge Date: [**2129-11-12**]
Date of Birth: [**2069-1-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This 60 year old male is s/p CABG [**2129-10-24**]. He was discharged
to home on [**10-28**] and presented to the ED on [**11-5**] with shortness
of breath. He was admitted and was diuresed for fluid overload.
He was discharged on [**11-7**] and had been doing well at home. On
the day of admission he felt short of breath when he lay down
and came to the ED.
Past Medical History:
Paroxysmal Atrial Fibrilation
Mitral Valve Prolapse
Hypertension
h/o remote Gastric ulcer
Depression
h/o deep vein thromboplebitis
hyperlipidemia
s/p CABGx4 [**2129-10-24**]
Social History:
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Maternal grandfather with lung cancer.
Paternal grandmother with GI cancer.
Mother with breast cancer, died at age 62. Has 1 brother who is
healthy.
Physical Exam:
Pulse: 86 Resp: 16 O2 sat: 98%RA
B/P 108/67
General:
Skin: Dry [x] intact [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pertinent Results:
[**2129-11-12**] 03:15AM BLOOD WBC-4.9 RBC-3.40* Hgb-10.4* Hct-32.0*
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.1 Plt Ct-677*
[**2129-11-12**] 03:15AM BLOOD Glucose-125* UreaN-28* Creat-1.4* Na-137
K-4.5 Cl-99 HCO3-29 AnGap-14
[**2129-11-11**] 04:55PM BLOOD proBNP-1851*
[**Known lastname **],[**Known firstname **] [**Age over 90 87342**] M 60 [**2069-1-27**]
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2129-11-11**] 9:20 PM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2129-11-11**] 9:20 PM
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 87343**]
Reason: Eval PE
Contrast: OPTIRAY Amt: 100
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with dyspnea, recent CABG
REASON FOR THIS EXAMINATION:
Eval PE
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Preliminary Report !! WET READ !!
Right greater than left moderate pleural effusions.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2483**]
[**Known lastname **],[**Known firstname **] [**Age over 90 87342**] M 60 [**2069-1-27**]
Radiology Report CHEST (PA & LAT) Study Date of [**2129-11-11**] 5:56 PM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2129-11-11**] 5:56 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 87344**]
Reason: Evala cute process
Final Report
INDICATION: 60-year-old man, status post CABG with dyspnea.
COMPARISON: Chest radiograph from [**2129-11-5**].
TWO VIEWS OF THE CHEST:
There is improvement in left lower lobe atelectasis with
persistent small left
pleural effusion; underlying consolidation not excluded. A small
right
pleural effusion is now present. Sternal wires are intact. The
remaining
lung parenchyma appears clear.
The cardiomediastinal silhouette and hilar contours are normal.
IMPRESSION:
Improvement in left lower lobe atelectasis with persistent small
to moderate
left pleural effusion; underlying consolidation not excluded.
Small right
pleural effusion is now present.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2483**]
Brief Hospital Course:
The patient underwent CTA of chest to rule out pulmonary
embolism and it was found to be negative. He had small
bilateral effusions, and was admitted for observation and an
echo. He had an echo the following morning which revealed no
significant pericardial effusion. His shortness of breath
resolved, his oxygen was saturated 96% on room air. He was
discharged to home with VNA follow-up.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) as needed for cad.
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for cholesterol.
5. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
6. ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO four times a
day as needed for pain.
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day) as needed for cad.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Paroxysmal Atrial Fibrillation
Mitral Valve Prolapse
Hypertension
h/o remote Gastric ulcer
Depression
s/p Coronary artery bypass graft x4 with left internal mammary
artery to left anterior descending artery and saphenous vein
graft to diagonal artery and saphenous vein sequential graft to
ramus and obtuse marginal arteries [**2129-10-24**].
h/o deep vein thromboplebitis
hyperlipidemia
Discharge Condition:
Good. Pt. ambulating well and pain controlled with Percocet,
Ultram, and Motrin.
Discharge Instructions:
Follow previous discharge instructions from [**2129-10-28**], [**2129-11-7**].
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2129-11-28**] 1:15
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2129-11-24**] at 8:10 pm
Completed by:[**2129-11-12**]
ICD9 Codes: 4019, 4240, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5632
} | Medical Text: Admission Date: [**2132-12-4**] Discharge Date: [**2132-12-9**]
Date of Birth: [**2077-5-30**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname 92613**] is a 55 year-old RHM who presented by ambulance to
[**Hospital1 18**] emergency room after he had sudden onset of left sided
numbness and then weakness. He states that he had just come home
from work at CVS where he is a manager and had been sitting down
and watch television (NCIS). At 12:45 am he noticed a sudden
numbness of his left hand that felt like pins and needles. He
was
able to open and close the hand and became frightened and stood
up. When he got up he noticed that he was having difficulty
standing on his left foot and that it had a numb feeling as
well.
He shouted out for help from his brother who he lives with and
he
called 911. On arrival to the the hospital a code stroke was
called and he scored a 2 on the NIHSS for left sided sensory
deficits and tactile extinction on the left. Blood glucose was
368. A CT was performed, but revealed a hemorrhage so tPA was
not
given.
According to the patient he was hospitalized in [**2131-12-29**]
when he said that he had been feeling "off". He was found to
have
significant diabetes and CHF and had been started on insulin,
antihypertensives, lasix and warfarin but has not taken any of
the medications since [**Month (only) 404**] as he says that he cannot afford
the copay. He was recently transitioned to a part-time employee
at CVS and lost his medication benefit.
He says that he wakes up almost every hour during the night to
urinate, and has been extremely tired, but otherwise reports no
recent changes in his health.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Hypertension - noncompliant w/ meds
type II DM diagnosed in [**2131-12-29**] - noncompliant and
supposed to be on insulin
? of atrial fibrillation (started on warfarin - but says he's
never heard this diagnosis)
CHF (unknown EF)
Social History:
Works as a manager at the CVS in [**Hospital1 **]. Lives w/ his brother.
Divorced. Non-[**Hospital1 1818**]. Occassional beer drinker (not significant
amount)
Family History:
Father - DM, HTN
Mother - healthy, [**Name2 (NI) 1818**]
2 daughters - healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98 110 BP initially 230/128 R 14 SpO2 95% ra
General: Awake, cooperative, NAD. obese
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: elevated JVp at 7 cm, RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: significant pedal edema, pulses palpated
Skin: psoriatic rash over right lower leg.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**2-28**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Mildly diminished pinprick sensation on the left face.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: dimished pinprick and temperature sensation on the
left
hemibody w/ no agraphesthesia. Right side intact.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
DISCHARGE EXAM:
Vitals: T 98 BP 149/83 HR 60 RR 18 O2 96% RA
General: Awake, cooperative, NAD. obese
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: elevated JVp at 7 cm, RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: significant pedal edema, pulses palpated
Skin: psoriatic rash over right lower leg.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**2-28**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: dimished pinprick and temperature sensation on the
left
hemibody w/ no agraphesthesia. Right side intact.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: ambulates steadily with walker
Pertinent Results:
ADMISSION LABS:
[**2132-12-4**] 01:48AM BLOOD WBC-9.4 RBC-5.44 Hgb-16.1 Hct-45.6 MCV-84
MCH-29.6 MCHC-35.3* RDW-13.4 Plt Ct-187
[**2132-12-4**] 01:48AM BLOOD PT-11.3 PTT-30.1 INR(PT)-1.0
[**2132-12-4**] 07:37AM BLOOD Glucose-265* UreaN-26* Creat-1.9* Na-139
K-3.9 Cl-98 HCO3-33* AnGap-12
[**2132-12-4**] 07:37AM BLOOD ALT-20 AST-20 LD(LDH)-283* CK(CPK)-92
AlkPhos-96 TotBili-0.4
[**2132-12-4**] 07:37AM BLOOD CK-MB-5 cTropnT-0.02*
[**2132-12-4**] 07:37AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.3 Mg-2.1
Cholest-252*
[**2132-12-4**] 07:37AM BLOOD %HbA1c-10.4* eAG-252*
[**2132-12-4**] 07:37AM BLOOD Triglyc-263* HDL-38 CHOL/HD-6.6
LDLcalc-161*
[**2132-12-4**] 01:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2132-12-4**] 02:03AM BLOOD Glucose-335* Lactate-2.4* Na-136 K-3.9
Cl-95* calHCO3-27
DISHCARGE LABS:
[**2132-12-8**] 05:30AM BLOOD WBC-9.3 RBC-4.94 Hgb-15.0 Hct-42.1 MCV-85
MCH-30.3 MCHC-35.6* RDW-13.4 Plt Ct-185
[**2132-12-8**] 05:30AM BLOOD Glucose-128* UreaN-35* Creat-1.9* Na-139
K-3.9 Cl-99 HCO3-32 AnGap-12
[**2132-12-8**] 05:30AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.2
IMAGING:
ECHO [**2132-12-4**]: Conclusions
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. There is
moderate symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: No cardiac source of embolism seen. Normal global
and regional biventricular systolic function. Negative bubble
study. Moderate symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No significant valvular abnormality seen. Mildly dilated
ascending aorta.
CT HEAD [**2132-12-5**]: IMPRESSION: Right basal ganglia hemorrhage. No
significant mass effect or midline shift or herniation. The
small acute hematoma mentioned above is the region of right
thalamus and internal capsule rather than in the basal ganglia.
No significant surrounding
edema or mass effect. Correlate clinically to decide on the need
for further workup for underlying lesion.
CXR [**2132-12-5**]: IMPRESSION: Limited exam. Mild pulmonary vascular
congestion.
MRA [**2132-12-5**]: IMPRESSION:
1. Evolution of the right thalamic hemorrhage.
2. No evidence of acute infarct.
3. Changes of chronic small-vessel ischemic disease.
4. No evidence of stenosis, occlusion or arteriovenous
malformation, as
described.
5. There is a small infundibulum at the origin of the right
posterior
communicating artery.
CXR [**2132-12-5**]: Cardiomegaly is severe. Widening of the upper
mediastinum could be due to mediastinal fat deposition and
vascular engorgement. Pulmonary vasculature is normal, and there
is no edema or appreciable pleural effusion. No pneumothorax.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 92613**] is a 55 year-old RHM who presented with sudden onset
of left sided numbness and then weakness in the setting of
uncontrolled hypertension, diabetes and CHF.
.
# NEURO: On arrival his NIHSS was 2 and initial CT image
revealed a 1cm right thalamic hemorrhage. His examiantion showed
left sided sensory loss to pinprick/proprioception but no
cortical signs (no agraphesthesia). He also had subtle weakness
on the left arm>leg. He was transfered to the ICU for HTN
control with plan to be placed on a nicardipine gtt, but was
noted to have SBP 172 without nicardipine gtt. His BPs were then
better controlled on an oral regimen (see below), and he was
able to be transferred out of the ICU. There he remained very
stable, with well controlled blood pressures (although his BP
meds had to be adjusted to obtain goal SBP's - see below).
.
# CVS: In order to control pt's BP's, we started him on 20mg
lasix for his CHF and BP control. We started him on lisinopril,
which was uptitrated to 40mg QD. We started him on lasix 20mg
QD and metoprolol which was uptitrated to 75mg Q6H. We started
pt on simvastatin.
.
# Renal: Unclear Cr baseline, possibly elevated given risk
factors but then throughout admission was downtrending in the
setting of diuresis. Therefore, pt was likely volume
overloaded. His Cr will need to be monitored in the future
though to ensure it continues to decrease,
.
# Resp: significant sleep apnea and CXR showing mild volume
overload. He was started on lasix as above with improvement in
his apnea. Continue auto CPAP for now, pt will need sleep study
after discharge.
.
# Endo: - A1c was 10.4 and LDL was 161, [**First Name8 (NamePattern2) **] [**Last Name (un) **] was consulted
and recommended changing his NPH to lantus, which we did. He
was also put on an ISS while here.
#Code Status: full
TRANSITIONAL CARE ISSUES:
Patient was on warfarin prior to [**Month (only) 404**] (when he stopped taking
his meds) for possible atrial fibrillation. Given his recent
intracerbral hemorrhage he was not put on anticoagulation while
here, but this issue will need to be addressed at his neurology
follow-up appointment. His telemetry did not demonstrate any
evidence of atrial fibrillation while here.
Pt will also need sleep study performed - our sleep department
will be in contact to set this up. Please continue auto CPAP
during rehab.
Medications on Admission:
non-compliant w/ all meds but thinks he was on:
lisinopril
warfarin
insulin
furosemide
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
6. lisinopril 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for skin redness.
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
10. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per insulin sliding scale.
11. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
Right thalamic hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
NEURO EXAM: very mild L-sided weakness
Discharge Instructions:
Dear Mr [**Known lastname 92613**],
You were seen in the hospital for left sided weakness. We
determined that you had a bleed in your brain.
We started you on the following medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
6. lisinopril 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for skin redness.
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
10. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per insulin sliding scale.
11. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
You have an appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday
Decemebr 23rd at 3pm. His office is located at [**Street Address(2) 72550**] #
151 in [**Hospital1 **], MA. If you have any questions about this
appointment you can call him at [**Telephone/Fax (1) 30445**].
Please call [**Telephone/Fax (1) 10676**] to update your demographic information
prior to coming to your neurology follow-up appointment.
Department: NEUROLOGY
When: TUESDAY [**2133-1-27**] at 2:00 PM
With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 431, 5849, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5633
} | Medical Text: Admission Date: [**2149-1-11**] Discharge Date: [**2149-1-14**]
Date of Birth: [**2075-1-6**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
urosepsis
Major Surgical or Invasive Procedure:
Fluoroscopic Nephrostomy Tube Placement
History of Present Illness:
History of Present Illness: Please refer to the MICU admission
note dated [**1-12**] for full details. Briefly, Mrs. [**Known lastname **] is a 74F
with HTN and COPD admitted to an outside hospital on [**1-11**] with
RLQ and right CVA pain, chills, and anorexia. CT abdomen/pelvis
with contrast showed an obstructing 8mm stone in the proximal
right ureter with moderate hydronephrosis and perinephric
stranding. Treated with levofloxacin and transferred to [**Hospital1 18**] ED
for urological consultation. Initial labs here notable for WBC#
9.1 with 44% bands and +U/A. Had asymptomatic HoTN to SBP 70s, R
IJ placed, treated with zosyn and IVF with improvement in BP.
CXR showed LLL and possible RML infiltates. Given zosyn. Treated
empirically with ceftriaxone upon arrival to MICU. Never
required pressors. Right nephrostomy tube placement [**2149-1-11**] was
complicated by dissection along the renal pelvis.
Past Medical History:
COPD/Asthma
Hypertension
Hyperlipidemia
Social History:
History of smoking but quit more than 10 yrs ago, no
IVDU, drinks EtOH daily
Family History:
noncontributory
Physical Exam:
Vitals: T98.4 BP105/44 HR90 RR14 O2sat 93%3LNC
General: calm, NAD, sitting in chair
HEENT: EOMI, MMM
CV: RRR tachycardic, no murmurs
Lungs: CTAB, decreased breath sounds at bases bilaterally,
prolonged expiratory phase, no wheeze
Abdomen: soft, minimally tender RUQ, +BS
Back: perc nephrostomy tube in place s surr erythema. dressing
c/d/i.
Ext: 1+ pitting edema, chronic venous stasis changes
Neuro: moving all extremities
Pertinent Results:
[**2149-1-11**] 04:30PM WBC-9.1 RBC-4.44 HGB-13.4 HCT-39.0 MCV-88
MCH-30.1 MCHC-34.3 RDW-14.2
[**2149-1-11**] 04:30PM NEUTS-44* BANDS-44* LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-2* METAS-1* MYELOS-3* NUC RBCS-1*
[**2149-1-11**] 04:30PM GLUCOSE-106* UREA N-28* CREAT-1.0 SODIUM-141
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15
[**2149-1-11**] 09:43PM PT-11.4 PTT-20.5* INR(PT)-0.9
[**2149-1-11**] 07:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2149-1-11**] 07:55PM URINE RBC-[**4-4**]* WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2149-1-11**] 07:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.038*
[**2149-1-11**] 07:15PM URINE BLOOD-LG NITRITE-POS PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2149-1-11**] 07:15PM URINE RBC-0-2 WBC-[**12-20**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
UCx pending at time of discharge (growing proteus s to levoflox
from [**Hospital3 635**] hospital)
BCx pending at the time of discharge
perc nephrostomy tube placement: IMPRESSIONS:
1. Moderate-to-severe right hydronephrosis, to the level of the
proximal
right ureter, as seen on same-day CT from outside hospital.
2. 8 French pigtail right nephrostomy tube placed, with
decompression of the
renal collecting system.
3. Some contrast is noted to pass into the mid ureter beyond the
level of the
proximal ureteral stone, which was visualized on CT.
Brief Hospital Course:
#. Pyelonephritis/Nephrolithiasis/urosepsis: Urology consulted
in the ED. Given presence of obstructing nephrolithiasis, and
hemodynamic compromise pt was taken to IR for percutaneous
nephrostomy tube drainage and placement. Pt was fluid
resuscitated blood pressure medicines held. She responded well
and never required pressors and was transitioned to the floor on
the day after admission. Pt was initially treated with
ceftriaxone and narrowed to levofloxacin when cultures from OSH
grew 10-50,000 proteus sensitive to levofloxacin. Pt was started
on flomax and toradol which was transitioned to ibuprofen on the
day of discharge. Pt's blood pressure remained stable after the
first 12 hours of her hospitalization.
.
#. COPD/Pneumonia: Pt noted to be mildly hypoxic in the ED to
89%, pt does have COPD c baseline oxygen saturations of 92-95%
per pt. There is concern of possible LLL infiltrate which on
review of CXR is unimpressive. She was covered for both the
pyelonephritis and ? pna with levofloxacin. She initially
required supplemental oxygen but on the day of discharge was
able to walk c saturations of 89-93%.
.
#. Tachycardia: Per patient she always has a fast heart rate.
Infection could also be contributing. Pt takes diltiazem prn
palpitations which her cardiologist recently suggested she take
daily for BP control. This medicine was held throughout
hospitalization.
.
#. Hypertension: Pt was admitted to ICU for hypotension.
Antihypertensives were held throughout admission
.
#. Hyperlipidemia: continued on atorvastatin.
.
# DM: diet controlled at home. on insulin sliding scale in
hospital but required very little.
.
#. Hepatic nodules: Will need follow up CT abd as an outpatient
in 6 months for comparison films.
Medications on Admission:
Avapro 300mg daily
ProAir PRN
?Symbicort 2 puffs [**Hospital1 **]
Cardizem 150mg daily
Lipitor 10mg qHS
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*56 Tablet(s)* Refills:*0*
3. Symbicort Inhalation
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
Disp:*10 Capsule, Sust. Release 24 hr(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain. Tablet(s)
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. nephrostomy bags
Dispense 14.
10. 4x4 dressings c slit for nephrostomy tube
please dispense 2 boxes
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 635**]
Discharge Diagnosis:
R kidney stone obstructing ureter
pyelonephritis
pneumonia
secondary: COPD
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital for a bad kidney infection and
a kidney stone and a pneumonia. You initially were admitted to
the intensive care unit because your blood pressures were low.
You got a tube from your back into your kidney to drain the
urine from your kidney because you have a stone blocking the
normal drainage of the kidney into the bladder. You are on one
antibiotic which treats both your kidney infection and your
pneumonia. It is called levofloxacin. You are also being given a
strainer to strain your urine. If you find a kidney stone,
please save it and bring it to your urology appointment.
When you get home please stop taking your avapro because your
blood pressures are still low. Please don't take the cardizem
either unless you are having the palpitations.
We are giving you several new medicines:
1. levofloxacin (an antibiotic) to take for 2 weeks
2. ibuprofen for pain
3. flomax (to help pass the kidney stone) You should talk to Dr
[**Last Name (STitle) **] [**Last Name (STitle) **] stopping this medicine after your kidney stone is gone
4. we added iron to your medicines because you had anemia, we
also added a stool softener called colace because iron can be
constipating
Please continue your healthy diabetic diet.
Because of your anemia, please discuss with your primary doctor
whether it is time for a colonoscopy.
** you will have a visiting nurse and a physical therapist
visiting you at home.
Followup Instructions:
You have the following appointments:
[**First Name8 (NamePattern2) 161**] [**Doctor Last Name 162**] [**Doctor Last Name 163**] (Urology), MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2149-1-20**] 8:00
Dr [**First Name (STitle) 65453**] (Your primary doctor) #[**Telephone/Fax (1) 77632**] [**2149-1-21**] at 4pm.
You will need a repeat CT scan of your liver in 6 months to
further evaluate the abnormalities found on your liver during
your most recent CT scan. Please discuss this with your primary
care doctor. You also have anemia and may require a screening
colonoscopy if you have not had one lately.
Completed by:[**2149-1-15**]
ICD9 Codes: 0389, 486, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5634
} | Medical Text: Admission Date: [**2104-11-30**] Discharge Date: [**2104-12-2**]
Date of Birth: [**2047-12-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Acute Coronary Syndrome
Major Surgical or Invasive Procedure:
Cardiac Catheterization with PCI
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS: Pt is a 56y.o M with PMH
of HTN, DM and hyperlipidemia transferred from [**Hospital3 3583**]
with ACS. He reports awakening from sleep at 12:30 AM [**11-30**] with
substernal, central "gassy, burning" chest pain radiating to his
L arm and his back. He returned to bed but kept awakening
through the night. In the morning, he reported his symptoms to
his wife and PCP who encouraged him to go the ED. He reports
having this type of pain approx 1-2 times a year at random; he
denies any specific association with activity.
.
At the OSH, his EKG showed no specific changes c/w ischemia. He
was started on lovenox and ASA on admission. He continued to
have waxing and waining pain overnight [**2107-1-5**] and was started on
nitro gtt. AM glucophage was held. His biomarkers returned
positive: CPKs 605, 552, Troponin I 0.10, 6.44, 11.76. Pt was
started on Heparin gtt, Intergrilin gtt, Plavix 300 load,
Lopressor 25mg po X2, 10mg IVP X1 5mg IV X1 (6am-12am [**12-1**]). He
was transfered to [**Hospital1 18**] CCU for further care.
.
On arrival to the CCU the patient reports mild pain [**12-11**] in
intensity. NTG gtt held due to SBP 90-100. Small q waves in
inferior leads on ECG. No changes on R sided leads.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Hypertension
Hyperlipidemia
Diverticulosis
Diabetes Mellitius - diagnosed [**2087**]
Social History:
Pt is married and has 3 daughters. [**Name (NI) 1139**] - 1ppd X 30 years, No
EtOH, no illicit drug use
Family History:
Father- MI age 79
No history of premature CAD or sudden death
Physical Exam:
VS: T 98.2, BP 107-133/60-82, HR 80-85, RR 20-24, O2 97% on NC 3
LPM
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no elevation of JVP
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral basilar
crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG on arrival demonstrated NSR 80 bpm, nl axis, nl intervals,
questionable ST elevations of 1 mm in III, F. Right sided leads
do not demonstrate any ST elevation in V4R. No evidence of AV
blocks.
.
CARDIAC CATH (230 cc contrast) performed on [**12-1**] demonstrated:
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DIFFUSELY DISEASED 50
2) MID RCA DIFFUSELY DISEASED 80
3) DISTAL RCA DIFFUSELY DISEASED
4) R-PDA DISCRETE 100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DIFFUSELY DISEASED 60
7) MID-LAD DIFFUSELY DISEASED 50
8) DISTAL LAD DIFFUSELY DISEASED
9) DIAGONAL-1 DISCRETE 70
12) PROXIMAL CX NORMAL
13) MID CX TUBULAR 50
**PTCA RESULTS
RCA PDA
PTCA COMMENTS: Initial angiogrpahy revealed a 100% lesion in
the mid
PDA and an 80% lesion in the mid rca. We planned to treat these
lesions
with ptca and stenting of the pda and direct stenting of the mid
rca.
Heparin and integrilin were started prophlyactically for the
procedure.
A 7fr JR4 provided adequate support for the procedure. A
prowater wire
crossed both lesions with minimal difficulty. The PDA lesion was
pre-dilated with a 2.5x12mm voyager balloon at 4atm. A 2x15mm
mini
vision stent was then deployed at 14 atm. Next, a 3.0x18mm
cypher stent
was direct-stented and deployed in the mid rca lesion at 14 atm.
Final
angiography revealed 0% residual stenosis, no angiographically
apparent
dissection and timi 3 flow. The patient left the lab free of
angina and
in stable condition.
COMMENTS:
1. Coronary angiography of this right dominant system revealed
2 vessel
coronary artery disease. The LMCA was without angiographically
evident
flow limiting stenosis. The LAD was diffusely diseased with a
60%
stenosis prior to D1 and a 70% stenosis of the proximal D1. The
LCx had
a 50% tubular mid lesion. The RCA was diffusely disease with an
80% mid
stenosis and a totally occluded proximal PDA with left to right
collaterals.
2. Resting hemodynamics revealed mild systemic hypotension with
aortic
systolic pressure of 90mm Hg.
3. Left ventriculography was not performed.
4. [**Name (NI) 9927**] ptca and stenting of the PDA with a 2.5x15mm mini
vision
stent and successful direct stenting of the midrca with a 3x18mm
cypher
stent. Final angiography revealed 0% residual stenosis, no
angiographically apparent dissection and timi 3 flow (see ptca
comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease
HEMODYNAMICS: Ao 91/56/72 HR 81
.
LABORATORY DATA (prior to cath): See below; notable for CK 439,
MB 21, MBI 4.8, Trop 0.91. WBC 14.4. PTT 145.6
.
Biomarkers over time:
[**12-2**] 05:40 Trop T 0.74 CPK 294 MB 12 MBI 4.1
[**12-1**] 20:00 Trop T 1.71 CPK 486 MB 20 MBI 4.1
[**12-1**] 13:30 Trop T 0.91 CPK 439 MB 21 MBI 4.8
[**12-1**] 07:32 Trop I 11.76 CPK 552 (OSH)
[**11-30**] 22:00 Trop I 6.44 CPK 605 (OSH)
[**11-30**] 13:52 Trop I 0.10 CPK 102 (OSH)
.
[**2104-11-30**] 12:30PM WBC-14.4* RBC-4.92 HGB-15.9 HCT-44.2 MCV-90
MCH-32.3* MCHC-36.0* RDW-13.8
[**2104-11-30**] 12:30PM PLT COUNT-169
[**2104-11-30**] 12:30PM GLUCOSE-233* UREA N-9 CREAT-0.9 SODIUM-135
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-11
[**2104-11-30**] 12:30PM CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-1.7
[**2104-12-1**] 10:16AM BLOOD %HbA1c-10.7*
[**2104-12-1**] 05:04AM BLOOD Triglyc-222* HDL-29 CHOL/HD-5.2
LDLcalc-79
.
TTE [**12-2**]
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.8 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.41 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Stroke Volume: 69 ml/beat
Left Ventricle - Cardiac Output: 6.29 L/min
Left Ventricle - Cardiac Index: 2.95 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 12 < 15
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.90
Mitral Valve - E Wave deceleration time: 189 ms 140-250 ms
TR Gradient (+ RA = PASP): *28 to 31 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC
diameter (<2.1cm) with >55% decrease during respiration
(estimated RAP (0-5mmHg).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
regional LV systolic dysfunction. Overall normal LVEF (>55%).
Estimated cardiac index is normal (>=2.5L/min/m2). No resting
LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No 2D or Doppler evidence of distal
arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Mild mitral annular calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with mid to distal inferior
wall hypokinesis. Overall left ventricular systolic function is
normal (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Mild focal left ventricular systolic dysfunction
with overall preserved EF.
Brief Hospital Course:
56 y/o/ M c multiple cardiac risk factors presenting with NSTEMI
involving distal RCA.
.
# CAD/Ischemia: The patient was transferred to [**Hospital1 18**] after
ruling in for ACS by biomarkers, symptoms, questionable EKG
changes. On arrival he was evaluated in the CCU and then taken
to the cath lab. He was continued on intergrillin, heparin gtt
and plavix. Cardiac cath revealed 2 vessel coronary artery
disease. The LAD was diffusely diseased with a 60% stenosis
prior to D1 and a 70% stenosis of the proximal D1. The LCx had a
50% tubular mid lesion. The RCA was diffusely disease with an
80% mid stenosis and a totally occluded proximal PDA with left
to right collaterals. The patient underwent successful PTCA and
stenting of the PDA and direct stenting of the mid-RCA. Post
procedure the patient had a soft stable hematoma of the R groin.
His lisinoprol 10mg was held on the evening post procedure due
to a large dye load in the cath lab. He received fluids and
mucomyst post-cath. Cr stable throughout his hospitalization. He
was chest pain free until discharge. TTE on [**12-2**] demonstrated
mild focal left ventricular systolic dysfunction with overall
preserved EF. Given his multivessel disease; further stress
testing 6-8 weeks post cath is recommended. He was continued on
metoprolol 25mg [**Hospital1 **] through his hospitalization and then
transitioned back to his home dose of atenolol 50mg daily on
discharge. The patient was advised to discontinue smoking. His
HBA1C - 10, recommended continued follow up with PCP for tighter
glucose control. He should continue ASA for life and Plavix
until advised to DC by his cardiologist. The patient requested
referral to a cardiologist closer to his home per his PCP's
recommendation. He should follow up with cardiology in 2 weeks.
.
# Rhythm: The patient had 4 beats of NSVT overnight post cath.
No further events on telemetry.
.
# HTN: The patient was maintained on metoprolol 25mg [**Hospital1 **]
throughout his hospitalization, transitioned back to atenolol
prior to DC. Lisinopril held post cath as above. Restarted the
morning after admission.
.
# DM: Metformin and glyburide held post cath, patient
maintained on SSI and lantus at home dose. Home meds restarted
prior to discharge. He should follow up with PCP for continued
management. HBA1C 10.
.
# Hyperlipidemia - on admission the patient was started on
atorvastatin 80mg daily. His home dose of pravastatin was
discontinued.
.
The patient was discharged home in good condition. Chest pain
free post cath. He will follow up with his PCP for continued
management. His PCP was [**Name (NI) 653**] in regard to recommending
follow up with cardiology.
Medications on Admission:
Atenolol 50mg daily
Pravastatin 40mg daily
Glyburide 10mg [**Hospital1 **]
Metformin 1000mg [**Hospital1 **]
Lantus 10U SC QHS
Lisinopril 10mg daily
ASA 325mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) Units
Subcutaneous at bedtime.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual As directed as needed for chest pain: 0.4mg under the
tongue. [**Month (only) 116**] repeat every 5 minutes for up to three doses in 15
minutes. If you continue to have chest pain after 2nd dose
please call 911 or go to ED.
Disp:*10 QS* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute Coronary Syndrome
Secondary:
Hypertension
Hyperlipidemia
Diabetes Mellitus Type 2
Discharge Condition:
Good, Discharge home
Discharge Instructions:
You were admitted with chest pain and were found to have a heart
attack caused by a blockage of one of your coronary arteries.
You underwent a cardiac catheterization and had 2 stents placed
to open the blockage of your right coronary artery.
You have started the medication Plavix to prevent clot formation
in your heart stents. It is extremely important that you take
this medication daily. You should only stop this medication if
instructed to by your cardiologist.
You should follow up with a cardiologist in [**12-3**] weeks. You have
declined to be scheduled with a cardiologist at [**Hospital1 18**] and would
prefer to follow up with someone closer to your home. You have
agreed to discuss a referral with your primary care physician.
You should undergo a stress test to evaluate your heart function
in [**5-10**] weeks. You should follow up with a cardiologist to
schedule this test.
Your medication pravastatin has been stopped and you are now
taking the medication atorvastatin 80mg daily for your high
cholesterol.
Your blood glucose is under poor control. Please continue to
follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for
continued management.
You have been advised to quit smoking to reduce your risk of
future heart attack.
Followup Instructions:
You should follow up with your Dr. [**Last Name (STitle) **], on Thursday [**2103-12-5**] or
Friday [**2103-12-6**]. His office has been [**Month/Day/Year 653**] to schedule the
appointment. Please call [**Telephone/Fax (1) 18509**] to confirm your
appointment.
.
You should discuss a follow up appointment with a cardiologist
for 1-2 weeks.
.
Continue to take Plavix unless instructed to stop by your
cardiologist
.
You should have a stress test in [**5-10**] weeks to further evaluate
your coronary artery disease.
ICD9 Codes: 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5635
} | Medical Text: Admission Date: [**2181-12-25**] Discharge Date: [**2181-12-30**]
Date of Birth: [**2142-5-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
drug overdose/suicide attempt
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
39 yo female who was found unresponsive with pillboxes of
trileptal, fluoxetine, and baclofen lying in her car. Her
mother states that she last saw the patient around 2 pm when the
patient stated she was going to run errands and would be back
shortly. Ms. [**Known lastname 34821**] friend later [**Name (NI) 653**] her mother when
she had not been seen for the entire afternoon and the patient
was then found around 8pm laying in her car. In the ED, she had
intermittent agitation and was intubated for airway protection.
Her mother states that the patient had been depressed recently
with stressors being adjusting to a new country, financial
difficulties, her husband's infidelity, a recent ectopic
pregnancy, and obsession over the death of her cat.
Past Medical History:
depression/anxiety. No history of mania or psychosis. No
history of prior suicide attempts. No history of self-injurious
behavior.
Social History:
Supportive parents. Both are college professors and have [**Name5 (PTitle) 19301**] in
the US a lot longer. Pt was a nurse assistant in [**Country 532**] and has
been working part time in the US. Is apparently in the process
of looking for a new job.
Family History:
n/c
Physical Exam:
PE: 96.0 121/78 85 98% on AC 550/16/50/
Gen: non-reponsive to verbal stimuli, withdrawing to pain.
HEENT: dilated pupils, minimally reactive, OP clear, MMM,
anicteric sclerae
Neck: no masses, no LAD, no JVD, no carotid bruit
CV: S1S2, RRR, no m/r/g
Chest: cta b/l, no crackles or wheezes.
Abd: soft, nd, +bs, no organomegaly, no rebound, no guarding, no
pelvic tenderness, no tampon in place
Extr: no cyanosis, no clubbing; no edema, 2+ pulses b/l.
neuro: funduscopic exam intact, no neck stiffness, withdrawing
to pain in all extremities, reflesxes 1+ bilaterally, no
rigidity
Skin: pressure ulcer on R dorsum of foot, mild erythema around
.
On discharge: similar exam, not intubated. Patient carries on
appropriate conversation with Russian interpreter.
Pertinent Results:
PLT COUNT-290#
WBC-10.0# RBC-4.05* HGB-12.7 HCT-36.8 MCV-91 MCH-31.2 MCHC-34.4
RDW-13.8
ASA-NEG ETHANOL-29* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
CALCIUM-8.4 PHOSPHATE-2.2* MAGNESIUM-1.9
GLUCOSE-96 UREA N-9 CREAT-0.8 SODIUM-140 POTASSIUM-4.1
CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
UA negative
URINE bnzodzpn-NEG barbitrt-POS opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
HCG-<5
.
[**12-26**] Urine Cx + for E coli (pansensitive)
.
1 sputum + for coag + staph and e coli(pan sensitive); repeat
sputum negative.
.
bld cx [**2-4**] + coag+ staph.
.
[**12-27**] CXR: faint RUL density suspicious for PNA
Brief Hospital Course:
A/P 39 yo with no records and no contactable family member, who
presents with Baclofen, trileptal, and fluoxetine overdose.
.
# Baclofen overdose is known to cause intermittent coma and
delirium, consistent with her admission presentation. Trileptal
causes sedative effects; fluoxetine can cause serotonin syndrome
but the patient had no evidence of this. Neither did she have
EKG changes suggestive of SSRI overdose. Ms. [**Known lastname **] was
intubated for airway protection and toxicology was called who
recommended supportive care for all sedatives. Baclofen can
lower seizure threshhold, but Ms. [**Known lastname **] did not have seizure
activity and was not prophylaxed for this. She had a fairly
prolonged course of delerium/agitation and was thus kept on the
ventilator for 3 days. She was sedated with propofol rather than
benzodiazepines. when she was alert with improved agitation she
was extubated and has done well from a respiratory stand point.
She has since expressed anxiety/fear and depression but no
active suicidal ideation. Psychiatry has been following and
recommended prn haldol for anxiety.
.
# Ms [**Known lastname **] had an isolated fever on HD 3 and had sputum,
urine, and blood cultures sent. Her urine and sputum were + for
E coli (pan-sensitive) and her sputum was also + for staph
aureus (pan-sensitive). She was therefore treated with Bactrim
but refused the medication and then was switched to levofloxacin
for three days.
.
# Code: full
.
.
After discussion with the patient and the medical staff, all
were in agreement that Ms. [**Known firstname 34822**] [**Known lastname **] was a suitable
candidate for transfer to inpatient psychiatry.
.
Medications on Admission:
fluoxetine (unknown dose)
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
baclofen, trileptal, and fluoxetine overdose
depression/suicide attempt
pneumonia
urinary tract infection
Discharge Condition:
stable
Discharge Instructions:
In addition to your medication overdose, you were treated for a
urinary infection and possible pneumonia. If you have fevers,
chills, back pain, worsening cough, you should be reevaluated
for this.
Followup Instructions:
please call to make a followup appointment with your PCP and
with your psychiatrist within the next 1 week following
psychiatric discharge.
Please have a CXR repeated in [**5-3**] weeks. You had increased
interstitial markings on your CXR in the hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2182-1-24**]
ICD9 Codes: 5990, 486, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5636
} | Medical Text: Admission Date: [**2160-5-8**] Discharge Date: [**2160-5-13**]
Date of Birth: [**2115-11-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
synovial sarcoma of right groin
Major Surgical or Invasive Procedure:
Radical resection of synovial sarcoma of right groin with en
bloc resection of right common femoral artery. Exploration of
right vertical rectus myocutaneous flap. Transposition of left
myofascial flap. Reconstruction of inguinal ligament.
Reconstruction of lower abdominal wall with bioprosthetic mesh.
Split-thickness skin graft of 0.014-inch, 10 x 2 inches. Right
common femoral artery with interposition 6 mm PTFE from distal
EIA to distal CFA.
History of Present Illness:
Ms. [**Known lastname **] is a 44-year-old Vietnamese female who presented with a
painful right groin mass in [**2159-11-29**]. A CT scan
demonstrated a 3.7 cm soft tissue mass closely adherent to her
common femoral artery. A core needle biopsy demonstrated a
monophasic type synovial sarcoma. She underwent preoperative
radiation therapy to a dose of 5000 cGy that was completed
approximately 5-6 weeks ago. She presents at this time for
definitive surgical resection of this sarcoma. Preoperative
consultation with Dr. [**First Name (STitle) **] of plastic surgery was obtained for a
planned rotational flap coverage of the soft tissue defect. The
risks and
benefits of the procedure were discussed in detail with the
patient with the aid of a translator and the consent was signed.
Past Medical History:
[**Doctor Last Name 933**] dz s/p RAI, hypothyroidism, HTN, monophasic-type
high-grade synovial sarcoma
Social History:
She does not smoke. She works as at Marshalls in the fitting
rooms. Vietnamese speaking female.
Family History:
Significant for diabetes in her mom
Physical Exam:
afebrile, VSS
NAD, A and O x3
HEENT: NC, NT
Chest: CTAB
CV: RRR, -MRG
Abd: soft/NT/ND, +BS
RLE: confluent mass of the right groin
Pertinent Results:
[**2160-5-12**] 06:40AM BLOOD Hct-32.3*
[**2160-5-11**] 08:10AM BLOOD Hct-32.3*
[**2160-5-10**] 06:50AM BLOOD WBC-7.3 RBC-3.51* Hgb-9.9* Hct-28.1*
MCV-80* MCH-28.1 MCHC-35.1* RDW-13.1 Plt Ct-190
[**2160-5-9**] 04:57AM BLOOD WBC-9.9 RBC-3.66* Hgb-10.0* Hct-29.4*
MCV-80* MCH-27.3 MCHC-34.1 RDW-13.4 Plt Ct-224
[**2160-5-8**] 07:59PM BLOOD WBC-14.4* RBC-4.06* Hgb-11.0* Hct-33.3*
MCV-82 MCH-27.0 MCHC-32.9 RDW-12.9 Plt Ct-281
[**2160-5-8**] 11:45AM BLOOD WBC-12.8* RBC-3.87* Hgb-10.7* Hct-31.0*
MCV-80* MCH-27.7 MCHC-34.6 RDW-13.0 Plt Ct-283
[**2160-5-8**] 07:59PM BLOOD PT-11.5 PTT-26.4 INR(PT)-1.0
[**2160-5-11**] 09:30PM BLOOD Glucose-120* UreaN-11 Creat-0.6 Na-134
K-4.0 Cl-99 HCO3-25 AnGap-14
[**2160-5-10**] 06:50AM BLOOD Glucose-114* UreaN-7 Creat-0.5 Na-136
K-4.1 Cl-101 HCO3-27 AnGap-12
[**2160-5-9**] 04:57AM BLOOD Glucose-130* UreaN-11 Creat-0.5 Na-136
K-4.2 Cl-103 HCO3-25 AnGap-12
[**2160-5-8**] 07:59PM BLOOD Glucose-194* UreaN-10 Creat-0.6 Na-136
K-4.6 Cl-103 HCO3-20* AnGap-18
Brief Hospital Course:
The patient tolerated the surgery well and was initially moved
to the ICU overnight after her surgery for frequent pulse
checks.
Neuro: The patient received IV PCA with dilaudid initially after
the surgery with good effect and adequate pain control. As her
diet was advanced she was switched to oral oxycodone with good
pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. She had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 55863**] palpable
DP and PT pulse following surgery bilaterally. This was
monitored throughout her hospital stay.
Pulmonary: The patient was stable from a pulmonary standpoint
after extubation from the OR; vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout this
hospitalization.
GI/GU/FEN:
The patient's diet was advanced to clears on POD1, because of
nausea/small amounts of emesis this continued over the following
day. She was eventually switched to a regular diet which she
tolerated well. The patient's intake and output were closely
monitored, and IVF were adjusted when necessary. The patient's
electrolytes were routinely followed during this
hospitalization, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of systemic infection. She was
afebrile at the time of discharge.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Plastics: A VAC dressing was kept in place over the skin graft
site for 5 days following her surgery. It was removed on POD5
by plastic surgery and the skin graft looked healthy and was
inplace. This was dressed with xeroform and multiple fluffs.
She will receive VNA care for further dressing changes.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. She will receive home VNA for dressing changes and
JP care.
Medications on Admission:
levothyroxine
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Synovial sarcoma of right groin,
status post preoperative radiation therapy.
Discharge Condition:
good/stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* 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.
* Continue to ambulate several times per day.
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
please continue dressings over your skin graft as instructed by
the VNA nursing staff.
Followup Instructions:
Please call Dr.[**Name (NI) 12822**] office to schedule a follow-up
appointment for the next 1-2 weeks at ([**Telephone/Fax (1) 55864**].
Please call Dr.[**Name (NI) 27488**] office to schedule a follow-up appointment
for for the next 1-2 weeks at ([**Telephone/Fax (1) 9144**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5637
} | Medical Text: Admission Date: [**2181-7-29**] Discharge Date: [**2181-8-15**]
Date of Birth: [**2147-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 15237**]
Chief Complaint:
Fever, respiratory failure, AIDS.
Major Surgical or Invasive Procedure:
Endotracheal intubation (at OSH)
Central Line Placement
Bronchoscopy x 2
History of Present Illness:
34 y/o male with a h/o HIV, visceral Kaposi's sarcoma,
Castleman's disease, and pancytopenia who presented to an OSH
with weakness, anemia, and FTT. He was hydrated with IVF and
closely monitored for any signs or symptoms of infection.
He was recently admitted to [**Hospital 5279**] Hospital (NH) from
[**Date range (3) 74583**] for FUO workup, diffuse adenopathy and
splenomegaly. A left cervical LNB revealed metastatic Kaposi's
sarcoma and Castleman's disease. He had a follow up appointment
made with Dr. [**Last Name (STitle) 2148**] ([**Hospital1 18**]) for further management of his
metastatic Kaposi's sarcoma/Castleman's disease but he did not
keep that appointment. He again presented to [**Hospital 5279**] Hospital on
[**2181-7-26**] with anemia, weakness, and FTT. He was ordered for a
blood transfusion. There was concern that the pt sustained a
transfusion reaction because shortly after receiving his first
unit of blood. He spiked a temp to 103, and became tachypnic,
hypotensive, HR 140.
.
The decision was made to transfer him to [**Hospital1 18**] for further
management.
.
ROS: Unobtainable, pt arrived intubated and sedated at OSH.
Past Medical History:
1. HIV, recent CD4 104, undetectable viral load, on HAART since
[**2-4**], developed resistance to efavirenz
2. Castleman's Disease
3. Metastatic Kaposi's sarcoma, no skin lesions, Stage IIIB,
plan to proceed with Cytoxan, vincristine, Doxil, and prednisone
along with Rituximab
4. Massive splenomegaly
5. Pancytopenia
6. Recurrent hyponatremia (? [**1-5**] to SIADH)
7. N/V
8. Intractable hiccups
9. Recent EGD showed AFB microorganisms
10. G6PD deficiency
11. Chronic interstitial infiltrates on CXR
Social History:
No tobacco or alcohol. Originally he is from the [**Country 7018**].
Family History:
N/C.
Physical Exam:
Vitals:
T 103.4 HR 131 BP 106/59 RR 30
100% AC TV 500 FiO2 1.00 PEEP 5
General: 34M intubated and sedated.
HEENT: NC/AT. MMM. ET tube in place.
Neck: No JVD.
CV: ST, S1, S2 without any m/r/g.
Pulm: Coarse BS B/L. No wheezes.
Abd: Soft, NT/ND with normoactive BS.
Ext: No c/c/e.
Neuro: Sedated.
Skin: No rash.
Pertinent Results:
CT Abdomen: Massive splenomegaly with adenopathy
.
BMB: hypercellular marrow
.
Left cervical LNB: Castleman's disease, metastatic Kaposi's
sarcoma, positive HHV-8 titers
.
Head CT: Negative
.
EKG: ST at 131, no axis deviation, no acute ST changes
.
CXR: B/L interstitial infiltrates. Final read pending.
.
PET Scan [**2181-7-25**] (performed at [**University/College **])
"Increased metabolic activity seen within the lymph nodes of the
right and left anterior and posterior cervical chain extending
into the supraclavicular regions. Increased activity noted in
both axillary regions where lymphadenopathy is present exceeding
1 cm in size. increased metabolic activity is seen in the lymph
nodes of the right paratracheal region. Mild increased metabolic
activity seen in the lymph nodes of the paraaortic, left and
right hilar, and subcarinal lymph nodes. Lung parenchyma is
unremarkable, as is the spine.
.
Abdomen shows a normal-appearing liver, shows and enlarged
spleen which has increased metabolic activity. Spleen length
approximately 20 cm.
.
Increased metabolic activity seen in lymph nodes which begins
at
the crural level and are to the right and left and in front of
the lumbar vertebrae. The increased metabolic activity within
the
lymph nodes is seen within the paraaortic, the common iliac, and
the inguinal on the right and left. The scan extends to the
proximal thigh; no abnormal increased metabolic activity is seen
in the muscle or bone."
.
CXR [**2181-7-29**]
Findings most consistent with diffuse pulmonary edema likely due
to fluid overload in the setting of apparent anasarca and
ascites. Underlying infectious process such as PCP is not
excluded and correlation with initial outside hospital
radiographs as well as follow up after diuresis may be helpful
in this regard.
.
TTE [**2181-7-30**]
The left atrium is mildly dilated. The estimated right atrial
pressure is
11-15mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the basal half of the
inferolateral wall. The remaining segments contract normally
(LVEF = 50%). Right ventricular chamber size is normal with mild
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. An eccentric, anteriorly directed jet of mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Mild mitral regurgitation. Mild pulmonary artery systolic
hypertension.
.
Bronchial washings were negative for malignant cells.
.
Abdominal U/S [**2181-8-2**]
1. Massive splenomegaly with infiltrative intrasplenic lesion
concerning for lymphoma. KS would be less likely but should also
be considered.
2) 1.4 cm echogenic lesion in segment II of the liver may
represent a hemangioma. Though rare, hepatic Kaposi's sarcoma
cannot be excluded.
3) Sludge in the gallbladder.
4) Echogenic kidneys suggesting interstitial renal disease.
5) Ascites and bilateral pleural effusions.
6) Normal Doppler examination.
.
Bone marrow biopsy results pending.
.
Bone marrow from the OSH revealed a hypercellular marrow.
Brief Hospital Course:
34 y/o male with a h/o HIV, metastatic Kaposi's sarcoma,
Castleman's disease, and G6PD who presented to an OSH with
weakness, anemia, and FTT. He was later transferred to [**Hospital1 18**] for
further management of fever and respiratory failure along with
metastatic Kaposi's sarcoma and Castleman's disease.
# Respiratory failure
The patient was intubated [**1-5**] to respiratory distress at the OSH
prior to transfer. Per OSH records, he has had B/L pulmonary
infiltrates for several weeks. However, given his fever,
tachycardia, and respiratory distress along with his CXR finding
of B/L pulmonary infiltrates, there was an initial concern for
ARDS/sepsis. He was hypotensive as well and there was concern
for progression to septic shock. In addition, there was an
outside hospital report of AFB organisms cultured on recent EGD
as part of his FUO workup. He was moved to respiratory isolation
given concern for possible pulmonary TB. After further
information was obtained regarding the above pathology, it was
found to be an acid-fast organism. However, he did complete a
r/o for TB. He was initially started on broad spectrum ABx given
concern for an infectious etiology for his respiratory failure
and clinical decompensation. After all cultures returned
negative, his ABx were gradually D/C. On his second
bronchoscopy, there was evidence of Kaposi's sarcoma. His
malignancy is the most likely etiology for his respiratory
failure and B/L infiltrates on CXR. The patient was eventually
weaned off of the ventilator and was transferred to the OMED
service. Here, he was followed by PT, and was off of O2 with
normal oxygen saturations. The patient continued on his HAART
therapy and continued to improve until dishcage.
# Metastatic Kaposi' sarcoma/Castleman's disease
The patient was diagnosed with metastatic Kaposi's sarcoma and
Castleman's disease during recent admission at the OSH when he
was evaluated for FUO. A left cervical lymph node biopsy was
consistent with Kaposi's sarcoma and Castleman's disease. After
infection as an etiology for his clinical deterioration and
respiratory failure was unrevealing, the most likely etiology
for his fever and respiratory failure was his malignancy. On the
second bronchoscopy that was performed, there was evidence of
Kaposi's sarcoma in his bronchial tree. On [**2181-8-2**], he underwent
chemotherapy with DR[**Last Name (STitle) 74584**]. He did not receive vincristine [**1-5**] to
his liver failure. Thus far, he has tolerated the chemotherapy
well. He no longer required pressor support for his hemodynamic.
Heme/Onc was following from admission for further
recommendations. He also underwent a repeat BMB on [**2181-8-1**]. He
completed a course of neupogen, and was discharged with an
ANC>1000. The patient will continue his current HAART therapy
and will follow up with Dr. [**Last Name (STitle) 2148**] as an outpatient. Social
services followed the patient and set him up with transportation
to assist the patient so he can make his appointments.
# Fever
Initially, there was a concern for an infectious etiology
causing his fever, respiratory failure, and clinical
decompensation. He was started on broad spectrum ABx (vanc,
zosyn, azithromycin x 1, and levofloxacin). As his cultures
became negative and it was clear that his metastatic Kaposi's
sarcoma was the reason for his respiratory failure and B/L
infiltrates on CXR, ABx were gradually D/C. He was started on a
brief course of doxycycline for concern for tick borne illness
but this was also D/C. His fever curve trended down. He was
ruled out for TB. All cultures to date have been negative,
including his BALs. At discharge, he was afebrile and his
ANC>1000.
# HIV
The patient was continued on his HAART regimen at the OSH and
during this admission. His HAART regimen dose was adjusted for
his renal function. Last CD4 count was 104 so there was no need
for MAC Px with azithromycin (did receive a couple doses). He
was started on Mepron for PCP Px as he has a h/o G6PD deficiency
and Bactrim would not be the best choice. He continued his HAART
therapy, and at discharge was given prescriptions for all of his
medications. He will follow up with Dr. [**Last Name (STitle) 2148**] for further
management.
# Anemia/Thrombocytopenia
The above are most likely [**1-5**] to his HIV and metastatic Kaposi's
sarcoma/Castleman's disease. There was a question of TROLI at
the OSH after receiving blood; however this is unclear and a
full panel of tranfusion reactions labs were ordered at the OSH.
He was given 2 units of PRBCs thus far during this admission for
anemia. He has also received 3 PLT transfusions thus far. PLT
goal after chemotherapy is > 20 given concern for pulmonary
hemorrhage. As his bone marrow recovered, the patient's counts
improved and he was no longer required transfusions at
discharge.
# Acute renal failure
The patient's acute renal failure is thought to be [**1-5**] to
ATN/intrinsic renal disease. His renal function was monitored
and it has not improved or worsened as yet. He was given
aggressive IVF along with diuresis to maintain adequate renal
perfusion in light of his recent chemotherapy treatment. At
discharge, his renal function had markedly improved. He will
continue to followup as an outpatient for any changed that may
be necessary in the future regarding his management.
# DIC
The patient had evidence of DIC on his labs. He was supported
hemodynamically and was weaned off pressors. DIC was secondary
to his metastatic Kaposi's sarcoma/Castleman's disease/systemic
inflammatory process. At discharge, his counts had stabilized.
# The patient has a girlfriend in the US as well as a daughter.
They visited the patient prior to discharge. Social services
contact[**Name (NI) **] the patient's case manager to discuss future options
for the patient so that he can make appointments and get his
medications. The patient's case manager is very involved with
his case. At discharge, the patient's mental status was at
baseline and he was completely congnizant of his surroundings.
Medications on Admission:
Medications (outpatient):
Erythropoietin 40,000 units SQ Qweek
Fentanyl patch 50 mcg Q72H
Folic acid 2 mg PO daily
Kaletra 2 TAB PO BID
Combivir
Viread 300 mg PO daily
KCl 20 mEq PO BID
Metoclopramide QID
.
Medications upon transfer:
Tylenol PRN
Benadryl PRN
Fentanyl
Folic Acid
Lasix
Hydrocortisone
RISS
Combivir 1 TAB [**Hospital1 **]
Kaletra 2 TAB PO BID
Reglan 10 mg PO QACHS
Versed
Protonix 40 mg IV BID
Potassium Sliding Scale
Sodium Chloride Tablets
Tenofovir 300 mg PO daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
Disp:*qs mg* Refills:*2*
4. Lopinavir-Ritonavir 400-100 mg/5 mL Solution Sig: Five (5) ML
PO BID (2 times a day).
Disp:*300 ML(s)* Refills:*2*
5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QTHUR
(every Thursday).
Disp:*8 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 12017**] [**Hospital **] Home Health
Discharge Diagnosis:
Primary Diagnosis: Castleman's Disease
Kaposi's Sarcoma
HIV/AIDS
Secondary Diagnosis:
G6PD deficiency
Pancytopenia
Discharge Condition:
good, stable, afebrile
Discharge Instructions:
You were admitted from an outside hospital with respiratory
distress, low blood pressure requiring intubation and ICU stay.
You were given antiobiotics and chemotherapy for your
castleman's syndrome and kaposi's sarcoma. You were then
admitted to the inpatient oncology service where you continued
to improve. You were seen by physical therapy who felt you were
safe to go home at discharge.
Please take all medications as prescribed. You will need to
followup and keep all future appointments with your physician as
it is important for the management of your disease.
If you develop any of the following concerning symptoms, please
call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**], or go to the ED: fevers, chills,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, weakness, or inability to walk.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2181-8-22**] 2:00
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 56612**] for followup
appointment within the next 2-4 weeks.
ICD9 Codes: 5849, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5638
} | Medical Text: Admission Date: [**2116-9-8**] Discharge Date: [**2116-9-22**]
Date of Birth: [**2036-9-28**] Sex: F
Service: NEUROSURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
s/p fall 1 week prior to admission, nausea
Major Surgical or Invasive Procedure:
1. Stereotactic ventriculocisternostomy [**2116-9-10**]
2. Stereotactic serial biopsy on [**2116-9-10**]
3. Percutaneous endoscopic gastrostomy insertion on [**2116-9-19**]
History of Present Illness:
79 yo right handed female w/ PMHx significant for hypertension
non-Hodgkin's lymphoma stage IV diagnosed in [**1-13**] s/p
chemotherapy felt to be in remission on low molecular heparin
transferred from [**Hospital **] Hospital for ICH. The patient
apparently had a fall at some point in the last week without
LOC. Over the last 2-3 days she has been fatigued with poor po
intake and emesis. She was brought to [**Hospital **] Hospital where a
head CT showed a L frontal lesion with probable vasogenic edema
and intracranial blood trapping the anterior [**Doctor Last Name 534**] of the L
lateral ventricle with ventricular extension of blood product.
Past Medical History:
Stage IV NHL s/p chemotherapy felt to be in remission - started
with [**Doctor Last Name **] sized lesion of left popliteal fossa and diagnosed
from biopsy of lesion on left foot, negative PET scan 1 month
ago, hypertension.
Social History:
Widowed, lives with son on [**Name (NI) **]. Smoked x 20 years, quit 20
years ago.
Family History:
non-contributory
Physical Exam:
On Admission:
Vitals: T 97.9; BP 150/76; P 72; RR 16;
General: lying in bed, appears lethargic
HEENT: dry mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: surgical scar on L popliteal fossa. no c/c/e.
Neurological Exam:
Mental status: Non-verbal, does not answer questions, opens eyes
to sternal rub. R hemiplegia with some with triple flexion of
RLE to nail bed pressure. Purposeful movements of LUE and LLE
but does not comply with formal strength testing. Grimaces to
nail bed pressure in all extremities.
Upon Discharge:
Opens eyes to voice, mumbles sounds and "ouch", PERRL, left
facial droop, moves left side spontaneously, moves RLE to light
stim, no RUE movement but grimaces to noxious stim of the RUE.
Head incision C/D/I, PEG site C/D/I.
Pertinent Results:
Labs on Admission:
[**2116-9-8**] 07:00PM BLOOD WBC-4.3 RBC-3.42* Hgb-10.5* Hct-30.9*
MCV-90 MCH-30.7 MCHC-34.0 RDW-15.6* Plt Ct-280
[**2116-9-8**] 07:00PM BLOOD Neuts-64.3 Lymphs-23.8 Monos-9.8 Eos-1.9
Baso-0.2
[**2116-9-9**] 01:30AM BLOOD PT-11.5 PTT-28.1 INR(PT)-1.0
[**2116-9-8**] 07:00PM BLOOD Glucose-102 UreaN-13 Creat-0.7 Na-131*
K-4.0 Cl-98 HCO3-24 AnGap-13
[**2116-9-9**] 01:30AM BLOOD Calcium-10.4* Phos-3.4 Mg-1.5*
Labs on Discharge:
[**2116-9-22**] 12:44PM BLOOD WBC-5.1 RBC-3.08* Hgb-9.6* Hct-27.8*
MCV-90 MCH-31.3 MCHC-34.7 RDW-16.6* Plt Ct-245
[**2116-9-22**] 12:44PM BLOOD Plt Ct-245
[**2116-9-22**] 12:44PM BLOOD Glucose-118* UreaN-11 Creat-0.5 Na-136
K-3.3 Cl-103 HCO3-27 AnGap-9
[**2116-9-22**] 12:44PM BLOOD Calcium-9.7 Phos-2.0* Mg-1.8
----------------
IMAGING:
----------------
Head CT [**9-8**]:
IMPRESSIONS:
1. No interval change from prior outside hospital CT obtained 12
hours
earlier, with extensive intraventricular hemorrhage,
particularly in the left lateral ventricle, with heterogeneity,
hemorrhage and vasogenic edema of the adjacent left parietal
cortex.
2. No interval change in approximately 9 mm of rightward midline
shift,
impending uncal herniation, and sulcal effacement.
3. No new hemorrhage or new abnormality since the earlier study.
4. Mottled appearance of the calvarium.
CT Chest/Abdomen/Pelvis [**9-9**]:
IMPRESSION:
1. Numerous thyroid nodules bilaterally. Recommend comparison to
a thyroid
ultrasound.
2. Endotracheal and nasogastric tubes as described above. The
nasogastric
tube must be advanced.
3. Pancreatic hypodensities as detailed above. These would be
best evaluated
with MRI.
4. Bilateral renal hypodensities, most likely cysts, though
inadequately
characterized on this study.
6. Left anterior abdominal wall hypodensity. Possibly resolving
intramuscular hematoma or seroma.
7. Punctate foci of free gas in the right lower pelvis without
apparent
etiology.
8. Compression deformity of the T12 vertebral body which is
severe.
9. Extensive atherosclerotic disease.
CT HEAD [**2116-9-10**]:
IMPRESSION:
1. Status post ventriculostomy with decompression of the
temporal [**Doctor Last Name 534**] of the left lateral ventricle.
2. No significant new hemorrhage.
CTA [**2116-9-11**]:
The CT angiography of the head demonstrates no evidence of
vascular
occlusion, stenosis, or abnormal vascular structures. No
definite abnormal
vascular structure seen as suspected on the previous MRI. No AVM
nidus is
identified.
Brief Hospital Course:
Patient is a 79F who was admitted to [**Hospital1 18**] Neurosurgery
following transfer from OSH for fatigue and nausea. CT scan at
OSH revealed a left frontal mass, and intraventricular
hemorrhage, and subsequently transferred to [**Hospital1 18**] for definitive
care. She was admitted to the NSURG ICU for frequent
neurological monitoring. On [**2116-9-10**] she underwent a stereotactic
left ventriculocisternostomy and lesion biopsy. Postoperative CT
showed good decompression of the entrapped ventricle. She
returned to the ICU where she remained intubated for airway
protection. When not sedation she would spontaneously move her
left side and would withrdraw he RLE to light stim.
She was extubated in the ICU on [**9-11**]. An Ng tube was placed for
nutrition.
A CTA Head was performed for ? vascular lesion on final MRI
report. This was negative for vascular anomaly. She needed to be
placed on lopressor and lisinopril on [**9-13**] for hypertension.
She takes these medications at home. She was transfered to the
floor on this date.
On [**9-14**], she removed her Dobhoff. She was started on salt tabs
for hyponatremia to 130. Gi was consulted on [**9-15**] for a PEG
placement. On [**9-16**] her pathology was blood clot and gliotic
brain. Her sodium improved to 132 ans stablilized to 133 on
[**2116-9-18**]. PEG placement on [**2116-9-18**] with Dr. [**Last Name (STitle) **]. On [**9-20**] and
[**9-21**] had low K levels and received K replacement. On [**2116-9-22**]
levels normalized. Discharged to rehab on [**2116-9-22**].
Medications on Admission:
Lisinopril, Metoprolol, Omeprazole, Fragmin 7500units sc bid,
Timolol eye drops
Discharge Medications:
1. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
2. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
3. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
4. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation .
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for DVT prophylaxis.
7. HydrALAzine 10 mg IV Q6H:PRN SBP>160
8. Metoprolol Tartrate 10 mg IV Q4H:PRN sbp > 150
hold heart rate < 60
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
11. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane TID (3 times a day).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3
times a day).
15. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
16. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Left frontal Intraperenchymal hemorrhage
Left Intraventricular hemorrhage
Obstructive Hydrocephalus
Discharge Condition:
neurologically stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
??????You or a family member should inspect your wound every day and
report any of the following problems to your physician.
??????You may wash your hair with a mild shampoo.
??????Do NOT apply any lotions, ointments or other products to your
incision.
??????DO NOT DRIVE until you are seen at the first follow up
appointment.
??????Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
??????Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
??????Do not use alcohol while taking pain medication.
??????An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
??????If you are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
??????Follow the activity instructions given to you by your doctor
and therapist.
??????Increase your activity slowly; do not do too much because you
are feeling good.
??????You may resume sexual activity as your tolerance allows.
??????If you feel light headed or fatigued after increasing activity,
rest, decrease the amount of activity that you do, and begin
building your tolerance to activity more slowly.
??????DO NOT DRIVE until you speak with your physician.
??????Do not lift objects over 10 pounds until approved by your
physician.
??????Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
??????Use your incentive spirometer 10 times every hour, that you are
awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
??????Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
??????Double, or blurred vision. Loss of vision, either partial or
total.
??????Hallucinations
??????Numbness, tingling, or weakness in your extremities or face.
??????Stiff neck, and/or a fever of 101.5F or more.
??????Severe sensitivity to light. (Photophobia)
??????Severe headache or change in headache.
??????Seizure
??????Productive cough with yellow or green sputum.
??????Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
??????Sudden difficulty in breathing.
??????New onset of seizure or change in seizure, or seizure from
which you wake up confused.
??????A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
??????If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
??????Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
** Your sutures were removed on [**2116-9-21**]**
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) **]:
CT scan [**2116-10-20**] 08:45 am [**Hospital1 18**] [**Hospital Ward Name **]
Clinical Center [**Location (un) **] Radiology
Office appt with Dr. [**Last Name (STitle) **] [**2116-10-20**] 9:30 am [**Hospital1 18**] [**Hospital Ward Name **]
[**Hospital **] Medical Center, [**Location (un) **], [**Hospital Unit Name 12193**]
Follow up with Dr [**Last Name (STitle) **] on [**9-23**] @1230pm for labs then 1:20
pm for appointment at [**Hospital1 2025**] Yawkey Building [**Location (un) 436**] [**Hospital Unit Name **]
[**Telephone/Fax (1) 12267**]
Completed by:[**2116-9-22**]
ICD9 Codes: 431, 2761, 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5639
} | Medical Text: Admission Date: [**2194-7-28**] Discharge Date: [**2194-8-11**]
Date of Birth: [**2153-3-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Sulfa (Sulfonamides) / Tetracyclines / Lopid / Demerol
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
+ ETT / Chest discomfort
Major Surgical or Invasive Procedure:
[**2194-7-28**] CABG x2
History of Present Illness:
41-year-old patient with prior percutaneous coronary
intervention and stenting of the right coronary artery presented
with symptoms of further ischemia
and was investigated and was found to have a lesion in the left
anterior descending artery as well as in-the-stent stenosis and
disease in the posterior descending artery distal to the stents.
She was electively admitted for
coronary artery bypass grafting.
Past Medical History:
1. Hypercholesterolemia.
2. Obesity.
3. Hypertension.
4. Tobacco history.
5. Coronary artery disease: [**2192-7-6**] non-ST-elevation
myocardial infarction, 100% RCA, three stents, 50% mid LAD.
[**2193-1-6**] instent restenosis status post
brachytherapy.
6. GERD.
7. Asthma.
8. Sciatica.
9. Degenerative joint disease.
10. Glomerulosclerosis.
Social History:
Patient is on disability; lives at home with her 8 y.o.
daughter. Sister and mother live nearby, but not in same house.
Family History:
Mother had heart valves replaced
Physical Exam:
GEN: WDWN in no acute distress
HEENT: NCAT, PERRL, EOMI, OP benign
NECK: Supple no JVD, no bruit
LUNGS: Clear
HEART: RRR, Nl S1-S2
ABD: Obese, benign
EXT: no edema, 2+ pulses, no varicosities.
Pertinent Results:
[**2194-8-9**] 06:10AM BLOOD WBC-16.8* RBC-4.09* Hgb-12.5 Hct-37.5
MCV-92 MCH-30.6 MCHC-33.4 RDW-13.4 Plt Ct-520*
[**2194-8-9**] 06:10AM BLOOD Plt Ct-520*
[**2194-8-11**] 02:19PM BLOOD Glucose-101 UreaN-27* Creat-1.3* Na-136
K-4.3 Cl-98 HCO3-23 AnGap-19
[**2194-8-4**] 03:01AM BLOOD ALT-29 AST-40 LD(LDH)-447* AlkPhos-136*
Amylase-18
CXR [**2194-7-28**]
There is mild postoperative widening of the superior
mediastinum. Heart size is normal. A pleural tube overlies
region of previous nodule in the left lower lung. There is no
pneumothorax or pleural effusion. ET tube, right jugular
introducer, and nasogastric tube are in standard placements. The
tip of the endotracheal tube is probably less than 2 cm from
either the carina or the underside of the clavicles, with the
chin extended. Withdrawal of the tube by approximately 15 mm
would put it in optimal placement.
CXR [**2194-8-6**]
Nasogastric tube should be advanced at least 6 cm to move all
the side ports into the stomach. ET tube is in standard
placement. Moderate enlargement of the postoperative cardiac
silhouette is stable and unremarkable. There is no pleural
abnormality. Pulmonary edema has resolved since [**8-4**]. No
pleural abnormality.
ECHO [**2194-7-31**]
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is
difficult to assess but is probably normal (LVEF>55%).
3. There is no pericardial effusion.
4. Compared with the findings of the prior study of [**2194-7-10**],
there has been no significant change.
[**2194-7-28**] EKG
Normal sinus rhythm, without diagnostic abnormality
Brief Hospital Course:
Ms. [**Known lastname 32857**] was electively admitted to the [**Hospital1 18**] on [**2194-7-28**]
for surgical management of her coronary artery disease. She was
taken directly to the operating room where she underwent
coronary artery bypass grafting to two vessels. Postoperatively
she was taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Ms. [**Known lastname 32857**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. The pulmonology service
was consulted for hypoxia. An echo was obtained which ruled out
tamponade. Subcutaneous heparin was started for pulmonary
embolism prophylaxis. As no ventilatory problems were
identified, other findings were consistent with pulmonary edema
and diuresis was optimized. She continued to be hypoxic and
BIPAP was started. She was transfused with red blood cells for
postoperative anemia. On postoperative day three, Ms. [**Known lastname 32857**]
was reintubated for respiratory failure. A bronchoscopy was
performed which showed normal airways and a bronchoalveolar
lavage was sent for culture. Vancomycin and Zosyn were started
given her fevers and she was pan cultured. A blood cultured
revealed coagulase negative staph in one bottle and she
clinically improved on antibiotics. Ms. [**Known lastname 32857**] slowly weaned
from the ventilator and was again extubated on postoperative day
ten. Diuresis was continued. On postoperative day eleven, Ms.
[**Known lastname 32857**] was transferred to the step down unit for further
recovery. The physical therapy service was consulted for
assistance with her postoperative strength and mobility. Her
drains and pacing wires were removed per protocol. Ms. [**Known lastname 32857**]
made slow but steady progress and was discharged home on
postoperative day fourteen. She will follow-up with Dr. [**Last Name (Prefixes) **] her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Prilosec
Lopressor
Urecholine
Plavix
Tricor
Flexeril
Aspirin
Wellbutrin
Trazadone
Colace
Zyrtec
Vicodin
Diovan
Singulair
Prozac
Zetia
Gabapentin
Guaifenex
Ativan
Crestor
Senekot
Compazine
Metformin
Actos
Zocor
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*30 Tablet(s)* Refills:*2*
4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
5. Lansoprazole Oral
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
CAD
HTN
Hypercholesterolemia
Asthma
Diabetes Melitus type II
DJD
GERD
Obesity
Fibromyalgia
s/p TAH
s/p Appendectomy
s/p cholecystectomy
s/p lysis of adhesions
Respiratry Failure
Bacteremia
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Shower daily, wash incision with mild soap and water and pat
dry. No lotions, creams, powders, or baths. No lifting more than
10 pounds or driving until folloup with surgeon.
Call with temperature more than 101.4, redness or drainage from
incision, or weight gain more than 2 pounds in one day or five
in one week.
Shower daily, wash incision with mild soap and water and pat
dry. No lotions, creams, powders, or baths. No lifting more than
10 pounds or driving until folloup with surgeon.
Call with temperature more than 101.4, redness or drainage from
incision, or weight gain more than 2 pounds in one day or five
in one week.
Followup Instructions:
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 29557**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**] Call to schedule
appointment should be in 1 week
Completed by:[**2194-8-12**]
ICD9 Codes: 5185, 5070, 2859, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5640
} | Medical Text: Admission Date: [**2113-2-17**] Discharge Date: [**2113-2-26**]
Date of Birth: [**2054-1-15**] Sex: F
Service: MEDICINE
Allergies:
Anzemet
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
febrile neurtropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 year old female with hypothyroidism, HTN, and recently
diagnosed ALL(Precursor B-phenotype, [**Location (un) 5622**] chromosome
negative) discharged recently after an admission from ([**2113-1-6**]-
[**2113-1-26**]) after induction chemotherapy consisting of hyper-CVAD-
cyclophosphamid, mesna, mtx, doxorubicin, vincristine,
dexamethasone 40 mg/d dys [**12-22**] and [**11-1**]. She was then admitted
from [**Date range (1) 93815**] for part B hyper CVAD and developed febrile
neutropenia with fevers to 101.7 in the clinic. She developed
rhinorrhea and nasal congestion 2 days after being d/c'ed. She
then developed fevers to 101. She received Ertapenem as an
outpatient from [**2-13**] but her fever persisted to 101.7 on [**2-17**] in clinc and thus she was admitted. Her abx were changed to
Vanco/Cefepime on admission. She continued to experience
dyspnea, and CT scan performed on [**2-18**] showed bilateral
infiltrates/opacities, concerning for infection (? bacterial,
fungal, PCP). She was was started on antifungals receiving her
first dose on [**2-17**] along with levofloxacin on [**2-19**] for
atypical coverage.
.
On the day of transfer to the ICU pulmonary was consulted who
recommended sending a DFA, sputum for PCP and [**Name9 (PRE) 93816**] treatment
for PCP consisting of solumedrol and IV bactrim. Later that day
she had an an increasing O2 requirement from 94% on 2L to 90% on
3L to 100% on NRB. She remained febrile. ABG at this time (on
3.5 L) was 7.53/33/56. She was put on 100% NRP, and ABG on this
was 7.55.37.175). Pt was visibly tachypneic and using accessory
muscles to breathe. She was given 40mg IV lasix with net
negative = 1070. She was then transferred to the ICU for further
managemtnt. In the ICU pt improved overnight with gentle
diuresis. Her sputum was negative for PCP, [**Name10 (NameIs) **] did grow GNRs and
GPC. Her fungal coverage was discontinued. She is currently on
Levofloxacin/Cefepime as double coverage of GNR, and Vancomycin
given GPC. She is no longer neutropenic. She denied cough,
headache, abdominal pain, dysuria, n/v, diarrhea, blurred
vision.
.
Past Medical History:
1) ALL, Precursor B-phenotype (Induction with Hyper-CVAD
[**2113-1-7**], Negative for [**Location (un) 5622**] Chromosome)
ONCOLOGIC HISTORY: Obtained from chart review: 58 yo female with
a h/o hypothyroidism who presents for evaluation of possible
ALL. Pt was in USOH until [**12-12**], when she had a cold with dry
cough, fevers and chills, all improved by [**12-18**]. After a few
days, pt had vomiting, abdominal pain, and fatigue increasing
for about a week until [**12-28**], when the pt went to [**Hospital1 3793**] for the above symptoms. She was found to have an
enlarged spleen and thrombocytopenia. Bone marrow biopsy was
suggestive of pre-B ALL. She was discharged [**12-30**] in stable
condition and followed up with Dr. [**First Name (STitle) 1557**] in clinic [**1-5**],
and felt the biopsy should be repeated here to confirm the
diagnosis and possibly begin treatment if positive for ALL.
.
The patient was admitted on [**2113-1-6**] for diagnosis and initiation
of treatment. Bone marrow biopsy was performed on admission and
interpreted as markedly hypercellular bone marrow with
involvement by Acute Lymphoblastic Leukemia, Precursor
B-phenotype. Cytogenetics were negative for [**Location (un) 5622**]
chromosome. A central line was placed, an trans-thoracic ECHO
was performed on admission. Her ECHO revealed cardiac function
within normal limits. Subsequently, induction chemotherapy with
Hyper-CVAD was initiated on [**2113-1-7**]. Her course was complicated
by febrile neutropenia with blood cultures showing
vancomycin-sensitive enterococcus. Her right subclavian line was
removed on [**1-20**]. Screening blood cultures were subsequently all
negative after initiation of vancomycin. A TTE was negative for
endocarditis. On [**2113-2-3**], the patient received 12 mg of
intrathecal methotrexate at 15 mg and intrathecal hydrocortisone
and part B hyper CVAD.
.
2) Vancomycin SENSITIVE enterococcus faecium bacteremia during
induction chemotherapy
3) Hypothyroidism
4) HTN
Social History:
Unmarried, lives with her mother (85) and brother (64). Retired
clerk for insurance company. Rare EtOH use, no smoking, no IVDU.
Family History:
Aunts and Uncles with breast CA and asbestos related lung CA by
report. Father with diabetes.
Physical Exam:
.
98.0, 127/67, RR = 20, HR =80. 96% on 4L, 18,
GENERAL: Overweight caucasian female appearing well, though
slightly tachypneic, resting comfortably in bed.
HEENT: Anicteric sclerae, moist mucous membranes.
NECK: No JVD.
COR: nml S1, S2, 2/6 SEM at LUSB. tachycardic
LUNGS: Dry inspiratory crackles to 2/3 up from the bases.
ABDOMEN: Normoactive bowel sounds, soft, non-tender.
EXTR: No edema. 2+ DP pulses b/l
.
Pertinent Results:
.
CXR [**2113-2-19**]: Worsening appearance of the chest with an appearance
which is suggestive of developing fluid overload or edema.
.
Chest CT with contrast [**2113-2-18**]
When compared with the prior study from [**2113-1-24**], new
small bilateral parenchymal opacities are noted associated with
ground glass opacities and septal thickening. These are present
bilaterally.
.
Echo [**2113-1-25**]
Left Atrium 4.0 cm x 4.5 cm, right atrium 4.6 cm, LV thickness =
1.3 cm, Ejection Fraction = 70% to 80%, nml TRTR Gradient (+ RA
= PASP): 19 to 21 mm Hg (nl <= 25 mm Hg) Conclusions: The left
atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and hyperdynamic
systolic function (LVEF>70-80%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The slightly increased transaortic
gradient is likely related to high cardiac output. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
.
Brief Hospital Course:
.
58 year old female with hypothyroidism, HTN, history of
vancomycin sensitive enterococcus, and ALL (Precursor
B-phenotype, [**Location (un) 5622**] chromosome negative) who was admitted
for febrile neutropenia. She was then transferred to the ICU
with hypoxia and febrile neutropenia.
.
# Respiratory Distress: The patient was on room air on admission
but on her second hospital day as her ANC rose to > 500, she was
found to have a new oxygen requirement with desaturation to 89%
on room air. A chest CT showed new bilateral parenchymal
pulmonary opacities consistent with an infectious process. No
PE was seen on the CT chest. The patient's oxygen requirement
worsened and she was transferred to the ICU for further
monitoring. The patient was on Cefepime, Vanc and Caspo. On
transfer to the ICU, Levofloxacin was added for double coverage
of gram negatives. She was also started on IV Bactrim with
steroids for possible PCP [**Name Initial (PRE) 1064**]. An induced sputum showed
gram negative rods but these were consistent with mouth flora
per the microbiology lab. She did not require intubation. Upon
transfer back to the BMT floor, a repeat CT scan showed
worsened, extensive bilateral ground glass opacities sparing the
lower lobes which appeared to be consistent with an infectious
process. A B-glucan was found to be positive at > 500. Her
Levofloxacin was discontinued and her Cefepime was changed to
Ceftriaxone. The patient was continued on Bactrim and steroids
for presumed PCP [**Name Initial (PRE) 1064**]. Her oxygen requirement decreased
steadily until she was back on room air. Her Vancomycin and
Ceftriaxone were discontinued. The patient will continue
Bactrim and Prednisone to complete a 21 day course for treatment
of PCP [**Name Initial (PRE) 1064**].
.
# Pulmonary edema: A chest xray in the MICU showed evidence of
developing fluid overload or edema. The patient was diuresed
and had some improvement in her O2 saturation. A recent echo
was noted to have a normal EF.
.
# Febrile Neutropenia: Given her history of vancomycin sensitive
enterococus, the patient was continued on Vancomycin and started
on Cefepime. She was given Neulasta as an outpatient. On
admission, her ANC was 40 but jumped to 660 the following day.
Also at this time, the patient's pulmonary status declined
markedly requiring transfer to the ICU. She was initially
covered with Levofloxacin and Cefepime given the GNR in her
sputum culture but per micro lab these were consistent with
normal oral flora. Caspofungin was added when the patient began
to have worsening respiratory function. This was discontinued
in ICU after improvement in her oxygen saturation and a CXR not
c/w fungal pneumonia. RSV was found to be negative.
Additionally, Bactrim was started for concern of PCP. [**Name10 (NameIs) 616**]
transfer back to the BMT service, Levo and Cefepime were
discontinued. The patient was continued on Bactrim and
Vancomycin and switched to Ceftriaxone. She completed
Ceftriaxone x 7 days. A Beta-glucan was found to be positive
with CT scan showing ground glass opacities sparing the bases.
She will be treated for a total 21 day course of Bactrim for
presumed PCP [**Name Initial (PRE) 1064**].
.
# Leukocytosis: The patient's WBC climbed to as high as 42.2.
The patient had gotten Neulasta as an outpatient and
additionally was started on IV Methylpred in the MICU and
continued on Prednisone for treatment of PCP [**Name Initial (PRE) 1064**]. A
differential was checked to ensure that this was not [**1-20**] the
patient's leukemia. Hematopath reviewed the diff and found
early neutrophil precursors consistent with Neulasta effect and
not consistent with leukemia.
.
# ALL: Patient has ALL, Precursor B-phenotype. She has negative
cytogenetics for [**Location (un) 5622**] Chromosome and has completed Part
B of Hyper-CVAD. She receieved intrathecal MTX and intrathecal
hydrocortisone on [**2113-2-3**].
.
# Hypothyroidism: Last TSH in [**Month (only) 404**] normal. Continued on
Levothryoxine.
.
# HTN: Hydralazine was continued as per outpatient regimen.
.
# Prophylaxis: She was discharged on Acyclovir for ppx. Her
Fluconazole and Levofloxacin were discontinued given that she
was no longer neutropenic..
.
# Code Status: Full.
.
Medications on Admission:
Levothyroxine 75 mcg PO daily
Hydralazine 25 mg PO Q6
levofloxacin 500 mg PO daily
Fluconazole 200 mg PO BID
ertapenem IV daily x 1 week
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO TID (3 times a day) for 14 days.
Disp:*84 Tablet(s)* Refills:*0*
2. Heparin Flush (10 units/ml) 5 ml IV PRN
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
6. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
11 days: Please start after you complete the Prednisone 30mg
daily for 3 days.
Disp:*22 Tablet(s)* Refills:*0*
7. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
.
Primary:
Febrile Neutropenia
PCP Pneumonia
ALL
.
Secondary:
Hypothyroidism
Hypertension
.
Discharge Condition:
Good: On room air, ambulating independently, taking good PO
intake
Discharge Instructions:
Please take all medications as prescribed. The following
changes were made in your medication regimen:
- You were started on two new medications for PCP pneumonia,
Bactrim and Prednisone and you should continue to take these
medications for 14 more days after your discharge.
- You were also started on Acyclovir for prevention of HSV.
- You may stop taking Levofloxacin and Fluconazole now that your
WBC has come back up.
.
Please attend all followup visits as listed below.
.
Please call your doctor immediately if you begin to experience
increasing shortness of breath, fevers, nausea, vomiting or
diarrhea.
.
Followup Instructions:
.
You will need to call Dr.[**Name (NI) 6168**] office on Monday at
([**Telephone/Fax (1) 6179**] to set up an appointment to see them on Wednesday,
[**3-1**] for a count check.
.
Completed by:[**2113-2-26**]
ICD9 Codes: 4280, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5641
} | Medical Text: Admission Date: [**2114-6-14**] Discharge Date: [**2114-6-20**]
Date of Birth: [**2041-10-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
incontinence/lower extremity pain/weakness
Major Surgical or Invasive Procedure:
Posterior cervical laminectomy
Decompressive lumbar laminectomy
History of Present Illness:
72-year-old woman who has a history of mild
mental retardation who lives and works in a monitored care
setting. She has a complex past medical history including a
distant left frontal meningioma resection as well as a previous
anterior cervical discectomy with fusion in [**2107**] by Dr. [**Last Name (STitle) 1338**]
(C4-C7). The patient is unable to recall the majority of her
past medical history. She now presents with progressive urinary
incontinence and fecal incontinence. Urinary incontinence was
noticed for at least a year. Fecal incontinence seems to be
present for about 3-4 weeks only. The patient has, in addition,
felt a decrease in her ability to walk but is mobile with a
walker. She complains about bilateral lower extremity
paresthesias, left greater than right. She has intermittent
bilateral upper extremity numbness. She also complains about
progressive right-sided thigh pain when she is going down the
stairs. She walks with a
walker. The patient takes home medications including
hydrochlorothiazide, Protonix, Fosamax, and naproxen. She is
not
known to have any drug allergies. She is a nonsmoker,
nondrinker.
Past Medical History:
The patient has a past medical history that is relevant
for hypertension, GERD, osteoporosis. Surgical history remains
relevant for a distant left frontal meningioma resection, status
post ACDF C4-C7 in [**2107**] and a right-sided THR.
Social History:
The patient takes home medications including
hydrochlorothiazide, Protonix, Fosamax, and naproxen. She is
not
known to have any drug allergies. She is a nonsmoker,
nondrinker.
Family History:
noncontributory
Physical Exam:
Physical examination reveals that she is awake and alert and
interactive. She is slightly retarded and slow, but pleasantly
interactive. She walks into the office with a walker. She has
an obvious kyphosis, but is more mobile with a walker and shows
no signs of imbalance. The cranial nerves are remarkable for a
prominent right-sided exotropia at rest. Bilateral pupils are
reactive to light and accommodation. Extraocular movements are
full despite disconjugate gaze. There is no nystagmus. She has
good visual fields. Facial strength and sensation are normal.
Hearing is intact. Tongue is midline and shows no signs of
atrophy of fasciculation. Motor exam is somewhat limited but
shows mild to moderate wasting of hand intrinsic muscles as well
as thenar. Tone is increased in both legs with signs of
spasticity. She has weakness in the distal upper extremity
approximately [**5-2**] bilaterally. She has good strength
approximately bilaterally except the right-sided deltoid. She
has bilateral lower extremity weakness 4/5 with more prominent
weakness in the toe bilaterally. Fine motor control is not
testable. She has no drift. Sensory exam reveals no obvious
deficits bilaterally. She complains about dysesthesias in a
nonradicular pattern. Symmetric reflexes were elicited. She
has
bilateral upgoing toes.
Pertinent Results:
[**2114-6-14**] 08:30PM WBC-12.5* RBC-3.29* HGB-10.3* HCT-29.1*
MCV-88 MCH-31.3 MCHC-35.4* RDW-14.1
[**2114-6-14**] 08:30PM PLT COUNT-224
[**2114-6-14**] 08:00PM CK(CPK)-136
[**2114-6-14**] 08:00PM CK-MB-9 cTropnT-<0.01
[**2114-6-14**] 08:00PM CALCIUM-8.5 PHOSPHATE-4.6* MAGNESIUM-2.0
[**2114-6-14**] 08:00PM PT-13.0 PTT-23.8 INR(PT)-1.1
[**2114-6-20**] 03:33AM BLOOD WBC-11.8* RBC-3.37* Hgb-10.0* Hct-29.1*
MCV-86 MCH-29.6 MCHC-34.3 RDW-16.2* Plt Ct-273
[**2114-6-20**] 03:33AM BLOOD Plt Ct-273
[**2114-6-20**] 03:33AM BLOOD Glucose-104 UreaN-14 Creat-0.9 Na-134
K-3.6 Cl-99 HCO3-26 AnGap-13
[**2114-6-20**] 03:33AM BLOOD Calcium-8.2* Phos-4.0# Mg-1.9
Brief Hospital Course:
Pt was admitted and brought to the OR electively where under
general anesthesia she underwent posterior cervical laminectomy
and lumbar decompressive laminectomy. Intra-op toward end of
the case she had some labile HR and BP became pressure
dependent. She was transferred to the PACU and seen in
consultation with cardiology who recommended EKG, echo in
several days (not emergent)and to replete lytes and follow hct.
She was weaned off the vent on post op day #1, she was
hemodynamically stable. She had hemovacs which were placed
intraop which were patent and draining - she remained on
prophylactic antibxs while these were in. The drains were
removed on [**6-17**] without difficulty. She had 1 unit PRBC on [**6-16**]
for hct of 24. This came up to 28 post transfusion. Hct was 26
on [**6-19**] and a second PRBC was given. Her incisions were clean
dry and intact with sutures. Her activity and diet were
increased. She was tacycardic post op which was treated
initially with fluid boluses but continued and she was started
on lopressor which was gradually increased. Medicine followed
her throughout her hospitalization. She had CXR on [**6-18**] which
showed LLL pneumonia and levoflox was started. She also had
chest CTA on [**6-19**] to r/o PE for her continued tachycardia. She
was evaluated by PT/OT and needs acute rehab stay once medically
cleared. She did have an episode of desaturation to the mid 80's
that was relieved with iv lasix. Cardiology recommended close
electrolyte monitoring to keep her potassium above 4.0. They
thought her tachyarrhhythmia was likely an atrial tachycardia
and that it would likely resolve over time as the patient
recovers from her operation.
Her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] recommended transfer to
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] where she will be available to manage the
patient's remaining medical issues. The patient was discharged
to the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] on POD6 in stable condition and will be
followed by Dr. [**Last Name (STitle) **] and will follow up in clinic with Dr.
[**Last Name (STitle) **].
Medications on Admission:
The patient takes home medications including
hydrochlorothiazide, Protonix, Fosamax, and naproxen.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], Inc.
Discharge Diagnosis:
cervical stenosis
lumbar stenosis
pneumonia
hypotension
atrial tachycardia
Discharge Condition:
Neurologically stable
Discharge Instructions:
Call for fever or any signs of infection - redness, swelling or
drainage from wound. No heavy lifting. Keep incisions dry while
sutures are in.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] for suture removal in approximately 10
days, call [**Telephone/Fax (1) 2731**] for appt.
ICD9 Codes: 9971, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5642
} | Medical Text: Admission Date: [**2158-12-18**] Discharge Date: [**2159-1-9**]
Date of Birth: [**2091-7-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Intraortic balloon pump
Pacemaker placement and ICD placement
Right IJ line
History of Present Illness:
67M h/o HTN, seizure disorder, inferior NSTEMI ([**2150**]) with
unsucessful PTCA of RCA (TIMI I flow), thoracic AAA repair
complicated by cardiac arrest/femoral artery repair ([**2150**]), who
presents to [**Location (un) **] @ 1407 [**2158-12-18**] after increasing chest pain /
shortness of breath x several days. He reports no chest pain
until about 9 days ago when he had one of the worst seizures he
has had in a long time. After that he reports that it felt as
though he had a pressure on his chest. He continued to do push
up and other exercising, but could not do as many given the
pain. He took garlic which helped relieve his pain until today
when it became unbearable. His pain was [**5-15**] on arrival to the
OSH. VS=98.0 78 24 103/78 88%RA. Trop 5.59 at OSH, noted to
have 1.5mm anterior STE in v2-v4, CXR concerning for widened
medisteinum. Rythym was initially regular, then noted to be in
"heart block" on nursing flow with BP 80/58 at 1700 after
receiving nitro, ativan 1mg, asa, lopressor 25mg po @ 1600,
lasix 20mg x 1. Per report given 600cc IVF bolus without
benefit. Pt transfered to [**Hospital1 18**] for cath.
.
Upon arrival to [**Hospital1 18**], pt found to have proximal LAD occlusion,
with incomplete revascularization after POBA, and was started on
IABP [**1-6**] hypotension. A foley was placed tramatically and he
developed hematuria.
.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain
currently, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- CAD - s/p MI ([**2151-1-13**]) - discrete 100% lesion of the distal
RCA and normal left main. LAD and left circumflex had mild
irregularities. RCA was occluded distally, and a large
filling defect consistent with thrombus was present. Mild
left to right collaterals observed. Intervention with
percutaneous transluminal coronary angioplasty and angio-jet,
thrombectomy of the distal RCA was unsuccessful. large aortic
aneursym noted.
- resection of aortic arch aneurysm ([**2151-2-1**]) - c/b right
common
femoral artery repair.
- HTN
- h/o seizures x 40y - tonic-clonic, evaluated by neurology
[**4-10**], felt [**1-6**] ?traumatic brain injury, failed Dilantin and
phenobarbital in past, on lamictal prophylaxis.
- h/o right occipatal bleed - observed x24hr by neurosurg [**1-10**]
- OSA
- s/p transurethral prostatectomy
Social History:
Social history is significant for the absence of current or past
tobacco use. There is no history of alcohol abuse.
Family History:
There is a family history of premature coronary artery disease
in his parents.
Physical Exam:
VS: T 98, BP 100/82, HR 94, RR 21, O2 93% on L NC%; On IABP 1:1
with PAP 62/35 and mean PAP 48.
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple. No JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Difficult to hear over IABP
Chest: Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi.
Abd: +BS, Obese, soft, NTND, no tenderness.
Ext: No c/c/e. Sheath in place from cath
Pulses:
Right: Carotid 2+ without bruit; dopplerable DP
Left: Carotid 2+ without bruit; dopplerable DP
Pertinent Results:
EKG demonstrated sinus rhythm, nl axis, nl intervals, STE in
V1-5. STD in III and aVF.
[**2158-12-19**] 01:00AM BLOOD WBC-9.6 RBC-3.81* Hgb-12.3* Hct-36.4*
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.5 Plt Ct-310#
[**2158-12-19**] 01:00AM BLOOD PT-16.7* PTT-35.4* INR(PT)-1.5*
[**2158-12-19**] 01:00AM BLOOD Glucose-112* UreaN-26* Creat-0.9 Na-137
K-4.4 Cl-108 HCO3-20* AnGap-13
[**2158-12-19**] 01:00AM BLOOD ALT-46* AST-36 CK(CPK)-268* AlkPhos-46
TotBili-0.4
[**2158-12-19**] 05:00AM BLOOD ALT-46* AST-39 CK(CPK)-269* AlkPhos-47
TotBili-0.5
[**2158-12-20**] 04:25AM BLOOD CK(CPK)-176*
[**2158-12-19**] 01:00AM BLOOD CK-MB-6 cTropnT-2.81*
[**2158-12-19**] 05:00AM BLOOD CK-MB-6 cTropnT-2.36*
[**2158-12-20**] 04:25AM BLOOD CK-MB-4 cTropnT-2.06*
[**2158-12-19**] 05:00AM BLOOD %HbA1c-5.8
[**2158-12-19**] 05:00AM BLOOD Triglyc-74 HDL-23 CHOL/HD-6.4 LDLcalc-110
[**2158-12-18**] 07:52PM BLOOD Glucose-96 Lactate-0.9 K-4.5
.
Cath [**12-18**]:
COMMENTS: 1. Selective coronary angiography in this right
dominant
patient revealed two vessel CAD. The LMCA had a distal taper.
The LAD
had moderate proximal calcification and a ostial occlusion with
faint
filling by collaterals. The large LCX was without critical
lesions.
The RCA was occluded mid-segment with distal vessel filling via
left to
right collaterals. The RCA was felt to be chronically occluded.
2. Resting hemodynamics revealed elevation of PCWP with mean
wedge of
31mmHG. The cardiac index was low at 1.9. We did not obtain RA
or RV
pressures but the PA pressure was elevated at 48/28. The
hemodynamics
were consistent with cardiogenic shock.
3. Placement of IABP via RFA for cardiogenic shock.
4. Balloon angioplasty of origin and proximal LAD with 3mm
balloon
resulting in TIMI 2 flow.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Anterior MI of greater than 24 hour duration
3. Cardiogenic shock with placement of IABP
4. Successful POBA of ostial LAD.
.
CXR [**12-19**]:
IMPRESSION: Tip of the aortic balloon pump 2.2 cm from the
aortic arch. Although it appears somewhat lateral, this is
likely due to the patient positioning. Recommend close attention
to patient positioning on any subsequent followup exams.
.
TTE [**12-19**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is severe regional left ventricular systolic
dysfunction with akinesis of the anterior wall, septum and apex,
as well as basal and mid-inferolateral wall (c/w multivessel
coronary disease). There is moderate hypokinesis of the
remaining segments (LVEF = 15-20%). There is a large left
ventricular thrombus, layering along the distal anterior and
lateral walls and apex. The clot is mural and not mobile. Right
ventricular chamber size is normal. with normal free wall
contractility. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is mild mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricle with severe regional and
global left ventricular systolic dysfunction, c/w multivessel
CAD. Large left ventricular mural thrombus.
Compared with the report of prior study (images not available
for review) of [**2151-1-14**], anterior/anteroseptal wall motion
abnormalities are new, and left ventircular function has
deteriorated. Left ventricular thrombus is new.
.
.
Brief Hospital Course:
The patient is a 67-year-old man with a past medical history
significant for hypertension, seizure disorder, inferior NSTEMI
in [**2150**] with unsuccessful PTCA of the RCA (TIMI I flow), who
presents with a late LAD STEMI s/p cardiac catheterization with
unsuccessful PTCA complicated by cardiogenic shock, now
resolved.
.
# STEMI: On cardiac catheterization, the patient was found to
have a large anterior MI, where the LAD had moderate proximal
calcification and an ostial occlusion with faint filling by
collaterals. PTCA was unsuccessful and complicated by
cardiogenic shock for which an IABP was placed. CT surgery was
consulted and felt the patient is not a candidate for CABG.
Patient was vasopressor dependent post-MI and was gradually
weaned off IABP, Milrinone and Levophed. Because of his large
infarction, he will require cardiac rehabilitation at the time
of discharge. He will also require close follow up of digoxin
levels within 1 week from discharge.
.
# Pump: After MI, a TTE was obtained and revealed EF of 15-20%
with a dilated left ventricle with severe regional and global
left ventricular systolic dysfunction, and a large left
ventricular mural thrombus. He is anticoagulated, currently on
coumadin daily, and his INR will need to be monitored by his
outpatient cardiologist. He is scheduled for a low level stress
test at [**Hospital3 7569**] on [**2159-1-15**] at 10:15 AM in prepartion
for cardiac rehabilitation.
.
# Bradycardia / Asystole: Post MI, the patient experienced 2
episodes of asystole associated with increased vagal tone.
Patient underwent successful placement of permanent pacemarker
with ICD function secondary to his severely depressed ejection
fraction. In the post-implantation period, the patient developed
a hematoma at the subcutaneous site of pacemaker implantation,
which was monitored closely and resolved spontaneously. He was
closely monitored on telemetry and did not experience any
further events; he is not pacemaker dependent but is
episodically paced. He will follow-up in device clinic.
.
# Anxiety: The patient has baseline anxiety and was well
controlled with anxiolytics as needed.
.
# Hypertension: The patient is known to have chronic
hypertension as an outpatient. Post-MI, however, the patient
experienced profound hypotension requiring vasopressor and IABP
support as above. Although normotensive at the time of
discharge, the patient did not tolerate ACE-inhibitor therapy
because of his hypotension. It is recommended that he re-start
and ACE-inhibitor as an outpatient, as his blood pressure
tolerates.
.
# Fevers: During the immediate post-MI period, the patient
experienced fevers and was empirically treated with broad
spectrum antibiotics without any identified infectious source.
He did not have any further febrile episodes and likely
experienced the fevers because of his MI.
.
# Hematuria: The patient experienced painless hematuria after a
difficult Foley catheter placement and while on anticoagulation.
The hematuria resolved spontaneusly and the patient's hematocrit
remained stable during the hospitalization. If this recurs, the
patient should have outpatient evaluation.
.
# Seizure disorder: Neurology was consulted while the patient
was hospitalized, and the patient was started on Keppra and
Lamictal with good response. He did not experience any seizure
episodes while hospitalized. He will require close follow-up of
his Keppra levels within 1 week of discharge, and further
management will be deferred to the patient's outpatient
neurologist and/or PCP.
.
# FEN: Patient tolerated a cardiac diet without difficulty.
.
# Prophylaxis: lovenox, PPI
.
# Code: Patient remained FULL CODE during hospitalization.
.
# Communication: wife - [**First Name8 (NamePattern2) **] [**Known lastname 29741**] - [**Telephone/Fax (1) 29742**].
.
.
Medications on Admission:
CURRENT MEDICATIONS:
lamictal 150mg po bid
.
.
MEDS ON TRANSFER:
ativan 1mg po
asa 81 mg po x 1
sl ntg 0.4 x 1
lopressor 25mg @ 4PM
lasix 20mg iv @ 4PM
lovenox 80mg SC @ 420PM
plavix 600mg x 1
morphine 2mg iv x1
aggrastat bolus + gtt started at 415PM
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) for 7 days: Take as directed.
Disp:*7 Tablet(s)* Refills:*0*
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily) for 7
days.
Disp:*7 Tablet Sustained Release 24 hr(s)* Refills:*0*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM and
QPM for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO QAM and QPM for
7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Please check PT, PTT, INR. Please fax results to Dr.[**Name (NI) 27809**]
office fax [**Telephone/Fax (3) 29743**]. Also fax copy to Dr. [**First Name4 (NamePattern1) 1123**] [**Last Name (NamePattern1) 29744**]
office [**Telephone/Fax (1) 29745**]
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual Take up to 3 times 5 monutes apart as needed for
chest pain as needed for chest pain.
Disp:*30 tablets* Refills:*0*
11. Outpatient Lab Work
Please check Chem 7 on [**2159-1-11**]. Please fax results to Dr. [**Last Name (STitle) 11493**]
fax [**Telephone/Fax (3) 29743**]. Also send fax copy to Dr. [**Telephone/Fax (1) 29745**]
12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Primary
1. STEMI s/p PCI
2. Cardiogenic shock s/p intraaortic balloon pump
3. LV thrombus
4. Bradycardia
5. CHF
6. Hematuria
7. UTI
Secondary
1. Anemia
2. Epilepsy
3. Hypertension
4. OSA
Discharge Condition:
HD stable, afebrile
Discharge Instructions:
You were admitted to the hospital for a heart attack. You also
had a blood clot in your heart. During your hospitalization a
pacemaker and defibrillator was placed.
Please take all of your medications as directed. You are now
taking coumadin. You need to have you INR checked and your dose
will be adjusted accordingly.
Please keep all of your follow-up appointments.
If you develop chest pain, shortness of breath, dizziness,
palpitations, fevers, pain at your pacemaker site or any other
concerning symptoms, you should call your doctor or come to the
emergency room.
You should check your weight daily, if you gain more than 3 lbs
you should call your doctor. Please maintain a low salt diet.
Followup Instructions:
You have an appointment with your cardiologist Dr. [**Last Name (STitle) 11493**]
[**Telephone/Fax (1) 11767**] on Wednesday, [**1-24**] at 2:20 pm. At that time
you should discuss starting on an ACE inhibitor, which was
started while you were in the hospital because your blood
pressure was too low.
You have a follow up appointment with your primary doctor, Dr.
[**First Name4 (NamePattern1) 1123**] [**Last Name (NamePattern1) **] [**2159-1-25**] at 2 pm. At that time you should discuss
having your urine checked as you had some blood in your urine
during your hospitalization.
You have a follow up appointment for your pacemaker in the
device clinic [**Telephone/Fax (1) 59**] on Date/Time:[**2159-1-16**] 10:30
Stress test (low level): [**Hospital 29746**] clinic ([**Telephone/Fax (1) 29747**]
[**2159-1-15**] at 10:00 am. This is necessary to arrange for the
cardiac rehabilitation you require.
ICD9 Codes: 4275, 4280, 5990, 2851, 4019, 412, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5643
} | Medical Text: Admission Date: [**2163-2-18**] Discharge Date: [**2163-2-24**]
Date of Birth: [**2080-6-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2163-2-18**] Coronary artery bypass grafting x3; left internal
mammary artery grafted to left anterior descending, reverse
saphenous vein graft to the ramus intermedius and marginal
branch.
History of Present Illness:
2 year old russian speaking female with complaints of substernal
chest pain with minimal exertion. She has refused cardiac
catheterization for the past 3 years, but has recently agreed.
Catheterization showed severe 3VD and she was referred for
surgical revascularization. Today she presents for pre-operative
testing prior to surgery [**2-18**].
Past Medical History:
Hypertension
Chronic Kidney Disease
Diabetes Mellitus
Gout
s/p Cholecystectomy
Social History:
Race: Caucasian
Last Dental Exam: many years ago
Lives with: alone
Occupation: previously worked in food store
Tobacco: denies
ETOH: denies
Family History:
non-contributory
Physical Exam:
Height:5'6" Weight:150 LBS
General: No acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema trace bilat
Varicosities: multiple superficial bilateral lower extremities
Neuro: Grossly intact oriented per interpretter
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2163-2-18**] Echo: PRE BYPASS The left atrium is moderately dilated.
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. Left ventricular wall thicknesses and cavity size
are normal. At the start of the study, in the presence of
downsloping inferolateral ST segments on EKG, the left ventricle
displayed severe global hypokinesis with an ejection fraction
near 20%. At that time, the mitral regurgitation was moderate.
The patient was treated with IV nitroglycerin and esmolol and
this improved global function such that the patient was left
with moderate to severe septal and apical hypokinesis. The
inferior and lateral walls had just mild hypokinesis. The mitral
regurgitation improved to mild to moderate. The right ventricle
displayed focal hypokinesis of the apical free wall. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study. POST
BYPASS: The patient is not receiving inotropic support post-CPB.
Biventricular systolic function is similar to pre-bypass
function. All other finding are consistent with pre-bypass
findings. The aorta is intact post-decannulation. All findings
communicated to the surgeon.
[**2163-2-18**] 02:09PM BLOOD WBC-18.3*# RBC-3.44*# Hgb-9.4*#
Hct-28.3*# MCV-82 MCH-27.2 MCHC-33.1 RDW-14.3 Plt Ct-168
[**2163-2-23**] 05:22AM BLOOD WBC-10.7 RBC-3.29* Hgb-9.1* Hct-27.8*
MCV-85 MCH-27.8 MCHC-32.8 RDW-14.5 Plt Ct-235
[**2163-2-18**] 02:09PM BLOOD PT-16.2* PTT-52.5* INR(PT)-1.4*
[**2163-2-18**] 03:19PM BLOOD UreaN-48* Creat-1.4* Cl-118* HCO3-18*
[**2163-2-23**] 05:22AM BLOOD Glucose-99 UreaN-51* Creat-1.6* Na-143
K-4.1 Cl-106 HCO3-30 AnGap-11
[**2163-2-21**] 02:30AM BLOOD Calcium-8.7 Phos-5.1* Mg-2.2
Brief Hospital Course:
Ms. [**Known lastname 8554**] was a same day admit after undergoing
pre-operative work-up as an outpatient. On [**2-18**] she was brought
directly to the operating room where she underwent a coronary
artery bypass grafting x 3. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition. On post-op
day one she was weaned from sedation, awoke neurologically
intact and extubated. Patient remained in CVICU for several more
days because of altered mental status. This improved with
discontinuation of narcotic pain medications. Chest tubes and
epicardial pacing wires were removed per protocol. On post-op
day four she was transferred to the telemetry floor. She worked
with physical therapy for strength and mobility during her
recovery. She did receive an albumin for orthostatic
hypotenstion and lightheadedness with walking. She continued to
make steady progress and was discharged to rehabilitation on
[**2163-2-24**]. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
Hyzaar 50 mg-12.5mg qd, Metoprolol Succinate 50 mg qd, Crestor
10mg qd, Aspirin 81mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House
Discharge Diagnosis:
Coronary artery disesae s/p coronary artery bypass graft x 3
Past Medical History:
Hypertension
Chronic Kidney Disease
Diabetes Mellitus
Gout
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Acetaminophen prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Date/Time:[**2163-3-24**]
1:30PM
Primary Care Dr. [**Last Name (STitle) **] in [**1-8**] weeks
Cardiologist Dr. [**Last Name (STitle) 171**] in [**1-8**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2163-2-24**]
ICD9 Codes: 5180, 5119, 5859, 2749, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5644
} | Medical Text: Admission Date: [**2167-4-26**] Discharge Date: [**2167-5-2**]
Date of Birth: [**2095-9-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
septic shock
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
71 y/o male with PMH of HTN, Afib, CVA, MVR, Seizure Disorder
presented to [**Hospital3 13313**] on [**2167-4-5**] with weakness,
abdominal discomfort, mild jaundice, and constipation, found to
have icterus and distended abdomen, with bilirubin of 3.1, WBC
count of 14 with 82% polys, lactate of 5.8, AST 83, ALT 100, AP
387, INR 12.2, KUB showing ileus, given levo and flagyl, and had
a laparoscopy showing 3 sections of nectrotic jejunum which were
resected and a large hematoma in the mesentary which had
ruptured into the abdomen. Post surgical course complicated by
respiratory distress and intubation on [**2167-4-13**], fevers despite
antibiotics without positive cultures. All antibiotics stopped
on [**2167-4-24**]. Transferred for continued ileus, rising Tbili and
rising AP and LFT's for ERCP.
Past Medical History:
HTN
Hyperlipidemia
Atrial Fibrillation
h/o CVA at age 62 with left hemiparesis
s/p MVR 29 mm St Jude Valve (Dr. [**Last Name (STitle) **]
s/p TV annuloplasty with [**Doctor Last Name **] life sciences MC-3 band (Dr.
[**Last Name (STitle) **]
Seizure Disorder
GERD
Depression
Diverticulosis
s/p tonsillectomy
Social History:
Per records- Lives at home with wife. [**Name (NI) **] very involved family.
Does not smoke. No alcohol use since stroke.
Family History:
Per [**Name (NI) 71902**] Father died at 82 y/o from MI. Brother with
Diabetes. Grandfather with CAD. Mother died of [**Name (NI) **]
Disease.
Physical Exam:
Severely jaundiced male, intubated, sedated, with NG tube and
foley catheter in place.
T 99.6 HR 74 BP 125/50 (Cuff- on Dopamine) RR 29 SAT 100%
SKIN: Jaundiced. No rashes
HEENT: PERRL, icteric sclera, NG tube in place, ET tube in
place.
NECK: Normal carotids, no LAD. RIJ in place.
CHEST: No axillary LAD. Lungs rhoncherous.
HEART: Irregular. 2/6 Systolic murmur over precordium.
ABD: Distended, tympanic, midline healing scar, no palpable
masses, no audible bowel sounds. Rectal without stool.
EXT: Pitting edema of legs to calf bilaterally. Good peripheral
pulses.
NEURO: Awakens to noxious stimuli. Moves right hand and leg
spontaneously. Left sided decreased tone. Reflexes increased
left patellar compared to right, and right bicepts compared to
left.
Pertinent Results:
[**2167-5-1**] 06:06AM BLOOD WBC-46.6* RBC-2.55* Hgb-8.1* Hct-22.4*
MCV-88 MCH-31.9 MCHC-36.3* RDW-25.8* Plt Ct-392
[**2167-4-26**] 07:44PM BLOOD Neuts-85* Bands-4 Lymphs-4* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1* Promyel-1* NRBC-9*
[**2167-4-30**] 04:50AM BLOOD PT-13.8* PTT-71.2* INR(PT)-1.2*
[**2167-5-1**] 06:06AM BLOOD Glucose-71 UreaN-63* Creat-1.4* Na-138
K-3.7 Cl-106 HCO3-21* AnGap-15
[**2167-5-1**] 06:06AM BLOOD ALT-127* AST-157* LD(LDH)-380*
AlkPhos-817* TotBili-27.1*
[**2167-4-27**] 02:11AM BLOOD Lipase-131* GGT-2492*
[**2167-5-1**] 06:06AM BLOOD Albumin-2.0* Calcium-7.8* Phos-3.2 Mg-2.1
Head CT: Intraventricular blood within the occipital horns of
the lateral ventricles bilaterally as well as blood within a
large area of encephalomalacia involving the right middle
cerebral artery territory. Above findings were discussed with
Dr. [**Last Name (STitle) 18721**] immediately after the completion of the study.
Echo: No thrombus/mass is seen in the body of the left atrium.
No atrial septal
defect is seen by 2D or color Doppler. There is symmetric left
ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are
complex (>4mm) atheroma in the aortic arch. There are complex
(>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets are
mildly
thickened. No masses or vegetations are seen on the aortic
valve. Trace aortic
regurgitation is seen. A bileaflet mitral valve prosthesis is
present. The
motion of the mitral valve prosthetic leaflets appears normal.
The transmitral
gradient is normal for this prosthesis. No mass or vegetation is
seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. The degree
of mitral
regurgitation seen is normal for this prosthesis. The tricuspid
valve leaflets
are mildly thickened. There is no pericardial effusion.
CT abd: 1. Findings strongly suggest high-grade distal small
bowel obstruction, with likely transition point in the left
lower abdomen, likely adhesive. Continued observation
recommended.
2. Bibasilar opacities most likely pneumonic, less likely
atelectasis.
3. Mild periportal and peri-cholecystic edema for which
hepatitis or other intrinsic liver disease remains likely
etiology. Small ascites.
4. Biliary stent in situ.
COMMENT: Dr. [**Last Name (STitle) **] and I have discussed the case tonight on the
telephone.
Brief Hospital Course:
A/P: 71 y/o male s/p recent resection of necrotic jejunum at
OSH, transferred for suspected biliary obstruction as well as
hypotension and respiratory failure. Went into MOD and
overwhelming MRSA septic shock.
.
## Septic shock secondary to MRSA bacteremia: We contimuied him
on pressors thoughout his stay. His sputum ended up growing MRSA
which was thought to be the source of his bacteremia and septic
shock. TTE/TEE showed no evidence of vegetations. Nonetheless,
his leukocytosis persisted in spite of continuous broad spectrum
antibiotics
.
## Hyperbilirubinemia: His bilirubinemia persisted throughout
his stay, in spite of having a biliary stent placed during ERCP.
.
## ARDS: He became progressively more difficult to oxygenate and
his CXR and ventilator numbers were consistent with ARDS.
.
## Small bowel obstruction seen on CT scan: Surgery consult was
involved. Felt that he was not an op candidate at the time due
to his multisystem organ failure. When he finally did have a
small BM, the stool was positive for C. Diff toxin and he was
started on metronidazole.
.
## Acute blood loss anemia: No longer seems to be significantly
GI bleeding. Very likely to be bleeding into subcutaneous tissue
over left chest/arm
- hand surgery consult appreciated; no compartment syndrome;
A-line re-sited
- decrease goal PTT level for heparin gtt to 50-70 sec
- q6h Hct; active T&S
- continue IV pantoprazole q12h for any residual GI bleeding
.
## Pupillary changes: now larger and sluggish whereas they had
been fixed and constricted before; R toe upgoing (L nonreactive)
- Head CT showed hemorrhage into the site of his old CVA.
.
## Acute Renal Failure: Postualted to be ATN at [**Hospital 71903**]
Hospital because of muddy brown casts. Worsening again
- IVFs for hypotension should improve renal perfusion; follow
UOP
- renally-dose meds
.
## Hyperglycemia:- cont insulin drip for tight glycemic control
.
## Atrial Fibrillation: currently bradycardic off meds
- digoxin level no longer elevated; cont to hold
- EP recs appreciated; [**Hospital1 1516**] pads on, atropine at bedside
- cont anticoagualtion with Heparin drip
.
## s/p MVR St Jude Valve:
- anticoagulation with IV heparin, though he developed
intracranial bleeding at the site of his old CVA
- TEE and TTE without evidence of vegetations
.
## HOCM: Dicsovered on echo on [**4-29**]. Severe resting LOVT
gradient. Pressors likely not helping, but are necessary given
his sepsis
.
## Seizure Disorder:
- continue dilantin; total phenytoin level low, but albumin also
low so corrected level likely wnl
.
## h/o HTN: currently hypotensive on pressors; no
antihypertensive meds at this time.
.
## Hyperlipidemia: holding statin given elevated LFT's
.
## GERD: continue IV protonix
## Depression: holding zoloft
## Access: LIJ placed on [**2167-4-27**]
## Diet: cont TPN
## Prophylaxis: Heparin Drip for MVR, Afib, and DVT prophylaxis,
IV protonix for stress ulcer prophylaxis
## Due to his progressively worsening ARDS and multisystem organ
failure in the setting of an acute intracranial hemorrhage, the
patient's family (including HCP [**Name (NI) **] [**Name (NI) **]) chose to pursue
comfort measures only on [**2167-5-2**]. Antibiotics, fluids, and
pressors were stopped, and the patient expired shortly
thereafter.
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock, ARDS, intracranial hemorrhage, small bowel
obstruction, C. Difficile colitis
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 5845, 431, 5185, 2851, 2761, 4019, 2724, 4589, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5645
} | Medical Text: Unit No: [**Numeric Identifier 67674**]
Admission Date: [**2183-6-29**]
Discharge Date: [**2183-7-1**]
Date of Birth: [**2183-6-29**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 67675**] is a [**2122**] gram premature female
who was admitted to the Neonatal Intensive Care Unit for
management of prematurity. She was delivered at 35-3/6 weeks
to a 33 year-old gravida I, now para I mother. Mother's
prenatal screen included blood type B positive, antibody
negative, hepatitis B surface antigen negative, RPR
nonreactive, Rubella immune and group B strep unknown. The
pregnancy was complicated gestational diabetes. Fetal surveys
were within normal limits. Maternal medications included
prenatal vitamins, iron and Tums. Mother presented with
spontaneous rupture of membranes 10 hours prior to delivery
with clear fluid. There was no maternal fever. Intrapartum
chemoprophylaxis was initiated 7 hours prior to delivery.
When mother presented she was noted to have preeclampsia.
Labor was augmented with Pitocin and the mother received
magnesium sulfate for preeclampsia. Due to worsening of
pregnancy-induced hypertension and arrest of dilation
delivery was done by cesarean section with epidural
anesthesia.
PHYSICAL EXAMINATION: Upon admission revealed weight of [**2122**]
grams equaling the 10th to 25th percentile, head
circumference 31 cm, 25th percentile, and length 43 cm, 10th
to 25th percentile. The infant was [**Year (4 digits) **] and comfortable in no
distress. Her appearance was slight in size but
nondysmorphic. Anterior fontanelle soft and flat. Red reflex
present bilaterally. Ears were normally set. Intact palate.
Neck is supple. Clavicles intact. Lungs clear to auscultation
with equal breath sounds. Cardiovascular: Regular rate and
rhythm, no murmur, 2+ femoral pulses. Abdomen soft with bowel
sounds present. GU: Normal premature female. Anus was patent.
No sacral anomalies. Hips were stable. Extremities [**Year (4 digits) **] and
well perfused. Neurologic: Active with symmetric tone and
reflexes.
HOSPITAL COURSE BY SYSTEMS:
CARDIOVASCULAR: Infant remained hemodynamically stable with
baseline heart rates in the 130s to 150s. Blood pressure
74/48 with a mean of 57. There was no murmur appreciated.
Baby was [**Name2 (NI) **] and well perfused in room air.
RESPIRATORY: Infant remained in room air throughout the
Neonatal Intensive Care Unit stay, breathing comfortably in
the 30s to 50s. No apnea of prematurity was appreciated.
FLUID, ELECTROLYTES AND NUTRITION: Feedings were ad lib with
Similar 20 or breast milk. Due to maternal pregnancy-induced
hypertension mother was not up to feed the baby and the baby
bottle fed well. She had a PG feedings overnight on day of
life 1 and has been p.o. feeding for 24 hours with an intake
of 69 ml per kilo per day. She is voiding and passing
meconium stools.
GASTROINTESTINAL: She appears slightly jaundiced on day of
life 2 and is having a bilirubin checked with a state screen
on [**7-2**] which is day of life 3.
ID: Due to maternal chemoprophylaxis and minimal sepsis risks,
the baby did not have a sepsis evaluation (CBC and blood
culture) upon admission. She has remained clinically well
without antiobiotics.
NEUROLOGIC: The baby has maintained her temperature in an
open crib, is active and appropriate for her post menstrual
age.
SENSORY: Audiology screening has not yet been performed but
will be done in the newborn nursery.
PSYCHOSOCIAL: Father has been present in the nursery and
has been updated on care of the baby.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To the newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Has not yet been determined by
the parents. They are in the process of selecting a
pediatrician. They live in [**Location (un) 1110**]. Several names were given
to them by the staff earlier today.
CARE AND RECOMMENDATIONS AT DISCHARGE: At time of transfer
feedings include breast feeding ad lib or Similac 20 with a
minimum of 80 per kilo per day recommended.
No medications at this time.
Car seat position screening is recommended before discharge.
State newborn screen will be obtained on [**7-2**].
Immunizations received are none to date.
Follow up appointments will be with primary pediatrician.
DISCHARGE DIAGNOSES: Prematurity at 35-3/7 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2183-7-1**] 18:45:13
T: [**2183-7-1**] 19:25:35
Job#: [**Job Number 67676**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5646
} | Medical Text: Admission Date: [**2129-3-18**] Discharge Date: [**2129-3-28**]
Date of Birth: [**2071-10-31**] Sex: M
Service: NEUROSURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
unsteadiness and Headache
Major Surgical or Invasive Procedure:
[**3-18**]: Bedside External Ventricular Drain placement
[**3-23**]: 3rd ventriculostomy
History of Present Illness:
Mr. [**Known lastname 11950**] is a 56-year-old RH man with a PMH remarkable for
recurrent neurocysticercosis involving his fourth ventricle
(initially diagnosed in [**2114**]), s/p VP shunt placement *2 (last
time 2 years ago), with secondary seizure disorder who p/w
unsteadiness and headache. He had been seen last time in the
neurology clinic in [**Month (only) 1096**]. His exam was basically reflecting
a normal mental status and no focal deficits. The ID team
followed him. Concern was raised by his new headaches in
[**Month (only) 1096**]. He had imaging in [**2128**] which revealed a new
cyst;suggestive of recent exposure to and oral ingestion of T.
solium
eggs. However, he had completed three O and P examinations of
the stool which were negative, arguing strongly against an
autoinfection cycle. In addition, he has been seizure controlled
on LEV. The ID team has been considering the possibility of
getting the relatives checked to rule them out as a source for a
re-infection. It was thought that the lesion was calcified and
hence not active. Therefore, treatment was held to avoid an
abrupt lysis of the parasite that could possibly worsen his
symptoms. On the day of admission, he recalls having a constant
headache of pressure quality in is retro-orbital area
bilaterally that would wake him up. He has been nauseous without
vomiting. According to his family he has been yowning often. In
addition, he has been
feeling tired and unsteady, though he has not fallen as per pt's
report. He has remained afebrile. No diarrhea, no productive or
dry cough. no sick contacts.
Past Medical History:
1. Neurocysticercosis:
*Diagnosed in [**2115**] with cyst in 4th ventricle, resected
at [**Hospital 1263**] Hospital (path confirmed dx), reportedly received
anti-parasite treatment
*[**12-8**] at [**Hospital 1263**] Hospital reportedly treated again
(albendazole/prednisone); worsened dizziness at this time
*[**2124**] multiple admits for severe HA: persistent lymphocytic
pleocytosis and actually treated empirically for TB
meningitis; ventriculitis vs trapped 4th ventricle on MRI
*[**5-9**] VP shunt placed
*[**8-9**] VP shunt revised
2. Seizure disorder: [**3-13**] possible new seizure activity; Keppra
initiated [**5-13**]
3. Dyslipidemia
4. Hypertension
5. Anxiety
6. Low Back Pain
Social History:
Immigrant from [**Country 3587**] to US in [**2112**];
He previously worked handling food, is not currently working.
He lives with his wife and has 5 children; 4 children currently
live at his home. He does not use tobacco, alcohol, or other
drugs.
Family History:
Non-contributory
Physical Exam:
On Admission:
O: T: 98.7F BP: 140 / 74 HR: 57 R 12 100% O2Sats in RA
Gen: WD/WN, comfortable, NAD.
HEENT: NO JVD
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Bradyphrenic.
Orientation: Disoriented. Inattentive.
Language: Speech fluent (Portuguese), comprehension intact. No
dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
Pupils: 5 mm bl and symmetrical, sluggishly reactive to direct
and consensual stimuli.Paralysis of upgaze. Accommodative
paresis
and pupils become mid-dilated and show light-near dissociation.
Convergence-Retraction when attempting upward gaze down-going
stripes on an optokinetic drum. Eyelid retraction, "setting-sun
sign". Early papiledema.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: unable to perform.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Mobilizing 4 limbs at antigravity level. No pronator
drift.
Sensation: Intact to noxious stimuli.
Reflexes: 2+ overall. Toes downgoing bl
Coordination: normal on finger-nose-finger. Gait unsteady, wide
based, slow cadence, short stride, unable to perform tandem
gait.
On Discharge:
XXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2129-3-18**] 03:50PM BLOOD WBC-8.5 RBC-4.96 Hgb-15.4 Hct-45.6 MCV-92
MCH-31.1 MCHC-33.9 RDW-13.6 Plt Ct-174
[**2129-3-18**] 03:50PM BLOOD Neuts-43.2* Lymphs-45.4* Monos-5.8
Eos-4.9* Baso-0.7
[**2129-3-18**] 09:47PM BLOOD PT-13.3 PTT-27.2 INR(PT)-1.1
[**2129-3-18**] 03:50PM BLOOD Glucose-106* UreaN-14 Creat-1.2 Na-143
K-4.2 Cl-107 HCO3-24 AnGap-16
[**2129-3-19**] 01:07AM BLOOD ALT-30 AST-18 LD(LDH)-181 CK(CPK)-146
AlkPhos-64 TotBili-0.3
[**2129-3-19**] 01:07AM BLOOD Triglyc-321* HDL-40 CHOL/HD-6.2
LDLcalc-142*
[**2129-3-19**] 01:07AM BLOOD Albumin-4.4 Calcium-9.4 Phos-4.6* Mg-1.7
UricAcd-8.2* Cholest-246*
[**2129-3-19**] 01:07AM BLOOD TSH-1.1
[**2129-3-19**] 06:21AM BLOOD Vanco-11.6
[**2129-3-18**] 09:49PM BLOOD Lactate-2.6*
[**2129-3-19**] 01:07AM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-3-19**] 09:05AM BLOOD CK-MB-1 cTropnT-<0.01
[**2129-3-19**] 06:19PM BLOOD CK-MB-1 cTropnT-<0.01
[**2129-3-19**] 01:07AM BLOOD Lipase-164*
[**2129-3-19**] 01:07AM BLOOD ALT-30 AST-18 LD(LDH)-181 CK(CPK)-146
AlkPhos-64 TotBili-0.3
Labs on Discharge:
XXXXXXXXXXXXXXXX
Imaging:
Head CT [**3-18**]:
HEAD CT WITHOUT IV CONTRAST: Again demonstrated is a
ventriculoperitoneal
shunt, now with an additional catheter tip in comparison to
[**2126-8-6**]. There has been interval decrease in size of the
right lateral ventricle, and no longer is seen transependymal
migration of CSF or surrounding vasogenic edema. However, there
is interval increase in size of the left lateral ventricle,
previously measuring 10 mm, and now measuring 21 mm (2:15). The
tip of the first ventriculostomy catheter terminates in the
frontal [**Doctor Last Name 534**] of the right lateral ventricle. The tip of the
second terminates just to the left of the left lateral
ventricle, and no interval comparison is available to
demonstrate whether this represents a change in position. There
has been interval development of encephalomalacia surrounding
the catheter tract via right frontal approach (2:19). In
addition, the third ventricle is now dilated, with convex
curvatures on both sides of midline, measuring 19 mm (2:11). No
site of hemorrhage or edema is identified. The fourth ventricle
is not dilated. The osseous structures demonstrate a right
frontal burr hole at the site of
catheter placement, and a large midline suboccipital subtotal
cranial defect measuring 4.2 cm (2:6). The visualized paranasal
sinuses and soft tissues also are unremarkable.
IMPRESSION:
1. Non communicating hydrocephalus suggestive of shunt failure.
Interval
increase in size of left lateral ventricle and third ventricle
with a non-
dilated 4th ventricle.
2. No hemorrhage or site of edema.
3. Unchanged postsurgical skull defects.
SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING [**3-18**]:
FINDINGS:
There are two intracranial ports of the shunt on the current
radiograph,
whereas there was only one port on the prior radiograph. The
apparent
discontinuity in the shunt immediately before the intracranial
course most
likely represents the non-radiopaque portion of the shunt
immediately before the burr hole in the skull vault. The
visualized cervical, thoracic, and abdominal course of the shunt
appears intact. The shunt terminates in the left lower quadrant.
The heart is enlarged, lungs are clear. The visualized bowel gas
pattern is unremarkable.
CONCLUSION:
Two intracranial ports visualized of the VP shunt with apparent
discontinuity in the shunt at the level of the burr hole which
may represent non-radiopaque tubing. The remaining visualized
shunt appears intact. Please also correlate with the report of
CT brain done today.
Head CT [**3-18**]:
HEAD CT WITHOUT IV CONTRAST: As in the prior study, a right
frontal approach ventriculoperitoneal shunt is in place, with
non-communicating hydrocephalus suggestive of shunt failure. The
left lateral ventricle is dilated greater than the right,
measuring 23 mm (2:37). Allowing for slice selection, this is
not clearly changed since the prior study, where the measurement
was 22 mm. However, a new left frontal approach ventriculostomy
drain is in place, and there is apparent decrease in degree of
dilation of the third ventricle, now measuring 12 mm (2:34).
There is no hemorrhage, edema, mass effect, shift of midline
structures, or evidence of major vascular territorial
infarction. There is expected pneumocephalus in the left frontal
lobe at the site of ventriculostomy drain placement. The
remainder of soft tissues and osseous structures are
unremarkable.
IMPRESSION:
1. Continued evidence for non-communicating hydrocephalus, with
dilated
lateral and third ventricles and non-dilated fourth ventricle.
2. Interval placement of left frontal approach ventriculostomy
drain with
catheter tip terminating in third ventricle. An associated
decrease in degree of third ventricle dilation.
3. No site of hemorrhage.
EEG [**3-19**]:
negative for any abnormal signal.
Head CT [**3-22**]:
VP shunt is unchanged. Left frontal catheter has been removed,
with expected pneumocephalus along the tract. Minimal blood
products were present previously and likely unrelated to tube
removal. However, there is a new low-density fluid collection
along the left frontal lobe that appears to cause some sulcal
effacement in the left cerebral hemisphere. Close interval
followup with repeat imaging is recommended as clinically
indicated. Ventricular size has decreased compared to prior
study.
Brief Hospital Course:
Mr. [**Known lastname 11950**] is a 56-year-old RH man with a PMH remarkable for
recurrent neurocysticercosis involving his fourth ventricle
(initially diagnosed in [**2114**]), s/p VP shunt placement *2 (last
time 2 years ago), with secondary seizure disorder who p/w
unsteadiness and headache. On the day of admission, he reports
that he has been having a constant headache of pressure quality
in is retro-orbital area bilaterally that would wake him up. He
has been nauseous without vomiting. According to his family he
has been yawning often. In addition, he has been feeling tired
and unsteady, though he has not fallen as per pt's report.
Upon admission, an external ventricular drain was placed to
alleviate the elevated pressure in his head. He was also started
on acyclovir, which unfortunatley infiltrated and caused a
reddened blister reaction. Plastic surgery was consulted, and
made recommendations to apply bacitracin and xeroform to the
area, but no further treatment was indicated. His examination
revealed soft compartments.
On [**3-21**], his external drain was raised to 20cm H20, which was
tolerated well. Early in the morning of [**3-22**], the patient
disconnected himself from the drain tubing. Upon rounds at 6:30
am, the external drain was removed uneventfully, and skin was
approximated with several skin staples. The wound was clean,
dry and intact. Post-procedure head CT was also done, and
without acute consequence from drain removal.
He did not tolerate the EVD removal and 24h later presented with
a right partial 6th cranial nerve palsy (new onset). His mental
status was mildly depressed (oriented *3) but more drowsy and
bradyphrenic. An urgent CT scan w/o contrast evidenced increased
hydrocephalus and severe dilatation of his 3rd ventricle. He
received an emergent 3rd ventriculostomy.
On [**3-25**] the patient had a fever of 102. He also had pain in the
neck with mild stiffness of the neck. Blood cultures were
negative till date [**3-28**].
PT evaluated the patient and felt that he was safe to be
discharged home without services.
Medications on Admission:
1. HTN: ATENOLOL - 25 mg qd, HYDROCHLOROTHIAZIDE - 25 mg qd
2. HLP: ATORVASTATIN 20 mg qhs
3. Seizure Disord: LEVETIRACETAM 750 mg [**Hospital1 **]
4. MECLIZINE - 25 mg [**Hospital1 **]
5. RANITIDINE 150 mg [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] of [**Location (un) **]
Discharge Diagnosis:
VP Shunt Failure
Elevated Intracranial Pressure
Discharge Condition:
Neurologically Stable. Right partial 6th cranial nerve palsy.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**7-15**] days(from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast.
Completed by:[**2129-3-28**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5647
} | Medical Text: Admission Date: [**2183-11-27**] Discharge Date: [**2183-12-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr [**Known lastname 3271**] is a 84y/o M with recently dx right frontal
glioblastoma who presented to Dr[**Name (NI) 6767**] onc clinic today with
increased giat instability. The patient was had worsening
weakness and psychomotor slowing since monday. He presented to
clinic on monday and recieved a avastin infusion with some
improvement in symptoms. Starting [**11-25**] his Decadron was
decreased from 8mg to 4mg daily.
Since monday he has had intermittant diarrhea. Per family he did
recieve abx around brain bx on [**2183-11-5**]. This am he had
difficulty swallowing his pills. Pt reports hiccups partially
controled with ativan. Dr [**Known lastname 3271**] also has swelling of his R eye
lid and new lesions on his chin noted today. No trauma noted.
He denies F/C/S, HA, visual changes. No cough, sorethroat, sob,
abd pain, N/V. No urinary symptoms.
In clinic VS, T 99.8, BP 90/60, p 72, R 18. PT noted to have
magnetic gait and abulia on neuro exam. He was sent for further
evaluation including MRI of the brain.
Past Medical History:
Onc Hx:
-In end of [**2183-9-29**] presented with imbalance, short-term
[**Last Name **] problem, flat affect, and urinary urgency.
-[**2183-11-3**] MRI showed Large heterogeneous infiltrative mass in the
right frontal lobe, extending into the left anterior corpus
callosum
-a stereotaxic brain biopsy by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D., Ph.D. on
[**2183-11-5**] confirming Glioblastoma
-started temozolomide chemo-irradiation on [**2183-11-18**].
-started C1D1 bevacizumab on [**2183-11-24**]
- pt opted not to persume debulking
PMHx:
presumed small renal cell ca followed by Dr
[**Last Name (STitle) 261**]
melanoma of his left eye s/p enucleation in [**2181**]
retinal detachment in OD.
cataractsurgery in right eye
hypertension typical values of 150/80.
Social History:
He is a physician, [**Name10 (NameIs) **] Chief of Medicine;
married with adult children (a cardiologist and a psychiatrist).
He drinks 2 glasses of wine per night; he does not smoke
cigarettes or use illicit drugs.
Family History:
noncontributory
Physical Exam:
PE: VS: T95.4, BP 147/93, R 16, P 75, 95%RA, wt 129lb
GEN: elderly man apearing frail
HEENT: erythematous scalp. Left eye is prostetic. R pupil post
surgical and non-responsive. EOMI impaired superior rightward
gaze in left eye. Retina exam, optic disk not clearly
visualized. Throat erythematous dry MM. multiple 1cm brown
ulceration on chin. Slight R periorbital swelling.
neck: supple
CV: RRR, no m/r/g nl S1 and S2
lungs: CTA BL
abd: ND, NT +BS, no HSM
ext: no edema
neuro: Pt speech is slow but appropriate, however not responding
to all questions. Eye exam as above. Left facial droop. weakness
in L SCM. no tongue deviation. Strength 5/5 on right, [**5-3**]
diffusely on Left. DTR 3+ LUE, 2+ RUE. 2+ DTRs in [**Name2 (NI) **]. normal
babinski. Pt to weak to safely access gait.
Pertinent Results:
[**2183-11-27**] 02:45PM PLT COUNT-244
[**2183-11-27**] 02:45PM NEUTS-92.6* LYMPHS-3.3* MONOS-3.9 EOS-0.1
BASOS-0.1
[**2183-11-27**] 02:45PM WBC-17.2* RBC-4.89 HGB-15.1 HCT-42.8 MCV-88
MCH-31.0 MCHC-35.4* RDW-13.1
[**2183-11-27**] 02:45PM OSMOLAL-277
[**2183-11-27**] 02:45PM ALT(SGPT)-104* AST(SGOT)-27 ALK PHOS-67 TOT
BILI-0.7
[**2183-11-27**] 02:45PM UREA N-37* CREAT-1.1 SODIUM-129*
POTASSIUM-4.8 CHLORIDE-88* TOTAL CO2-25 ANION GAP-21*
[**2183-11-27**] 02:45PM GLUCOSE-151*
.
[**2183-11-27**]: MRI head: 1. Infiltrative right frontal mass lesion
consistent with glioblastoma
multiforme as suggested in the history.
2. New areas of slow diffusion in the posterior [**Doctor Last Name 534**] of the
right lateral
ventricle and in the subarachnoid space along the falx of the
right vertex
(which appears to be associated with enhancement) may represent
tumor seeding,
however, these findings are concerning for infection and
clinical correlation
is recommended.
.
[**2183-11-28**]:
EEG: This is an abnormal portable EEG due to the slow and
disorganized background and the multifocal intermittent slowing.
The
first abnormality suggests a mild encephalopathy, whereas the
second one
suggests multifocal subcortical dysfunction. There were no
epileptiform
features seen. Note is incidentally made of occasional PVC's.
.
[**2183-11-28**] CXR: Since [**2183-11-25**], lungs remain clear. The
cardiomediastinal silhouette
and hilar contours are normal. There is no pleural effusion.
.
[**11-29**] CT head: No interval change from [**2183-11-24**], with a
large right
frontal lobe necrotic mass, extending into the corpus callosum
with associated
vasogenic edema.
Brief Hospital Course:
Dr [**Known lastname 3271**] is a 84 y/o with a h/o of suspected renal cell ca, L
eye melenoma s/p enucleation, recent dx of GBM s/p temozolomide
chemo-irradiation on [**2183-11-18**], bevacizumab on [**2183-11-24**] presents
with giat instability, dyspahagia, diarrhea, left sided
weakness.
.
#. Glioblastoma: Presenting with evidence of frontal lobe
dysfunction, magnetic gait and slowed speech. In additiona
diffuse left weakness concerning for worsening brain edema.
Edema may be worsening in setting of recent decrease in
decadron. s/p recent becacizumab making hemmorhage likely
although [**11-24**] ct without evidence of bleed.
MRI brain prelim showed no hemmorhage, edema similar to previous
imaging. He was put on increased ICP precautions, head bed > 30
degrees, ppx zofran, autoreg bp, serum na goal > 130. He
received decadron IV 10mgx1 and 4mg [**Hospital1 **], later increased to 4mg
q6h. He MS continued to deteriate. An EEG was obtained which did
not show any seizure activity but had evidence of
encephalopathy. The encephalopathy could be radiation induced vs
herpes vs [**3-1**] hyponatremia. Despite high dose acyclovir and
correction of his hyponatremia Dr.[**Known lastname 87904**] MS deteriorated to
the point that he could no longer protect his airway. When
reversible causes of his altered MS had all but been corrected,
it was determined that he should be made comfortable. However,
upon [**Location (un) 1131**] his article entitled "The Role of the Physician in
the Preservation of Life", vital signs were monitored, physical
exams were performed and labs were measured in a tribute to this
great teacher of the art of medicine. On [**2183-12-3**], Dr.
[**Known lastname 3271**] expired.
.
#. Hyponatremia: differential includes SIADH or hypovolemic
hyponatremia [**3-1**] poor po intake. Urine lytes consistant with
SIADH. He was placed on fluid restriction. Started on hypertonic
saline, transfered to [**Hospital Unit Name 153**] for worsening hyponatremia. As
above, correction of his sodium did not correct his mental
status and Dr. [**Known lastname 3271**] expired on [**2183-12-3**].
Medications on Admission:
Dexamethasone 4mg Tablet [**Hospital1 **] (recently decreased from TID)
Fluoxetine 10mg PO daily
Keppra 750mg [**Hospital1 **]
Lisinpril 5mg daily
lorazepam 1mg q6h prn anxiety/hiccups
pantoprazole 40mg daily
prochlorperazine 5mg prn nausa
ambien 6.25mg hs prn
Temodar 125mg PO daily
Cyanocobalamin 1000mcg PO daily
Allergies:
NKDA
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Glioblastoma Multiforme.
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
Completed by:[**2183-12-6**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5648
} | Medical Text: Admission Date: [**2136-4-10**] Discharge Date: [**2136-4-21**]
Date of Birth: [**2069-9-8**] Sex: M
Service: MEDICINE
Allergies:
Methadone / Dilaudid
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
elective toe amputation and ulcer debridement
Major Surgical or Invasive Procedure:
PROCEDURE PERFORMED:
1. Amputation of the first and second digits of the right
foot.
2. Debridement of right lower extremity anterior ulcer.
.
PICC line Placement
History of Present Illness:
66 yo M with ESRD on HD, CHF, COPD and severe PVD originally
admitted for right 1st and 2nd toe amputation with pre-op
pneumonia, and post-op loculated pleural effusions and a fib
with RVR.
.
The patient initially was admitted to the [**First Name3 (LF) 1106**] surgery
service for right 1st and 2nd toe amputations as well as right
lower leg ulcer debridement with VAC dressing placement on
[**2136-4-11**] On pre-op testing the patient was found to have a right
middle lobe pneumonia. Subsequent CT chest on [**2136-4-11**] revealed
bilateral loculated pleural effusions and pneumonia. He received
multiple antibiotics including nafcillin, clindamycin,
vancomycin and levofloxacin. The patient had a CT guided
thoracentesis with pigtail catheter placement on [**2136-4-13**].
Cultures on this fluid to date are without growth. Sputum
culture has growth only from [**2136-4-11**] with moraxella. The
patient was transitioned to vancomycin and zosyn and is now on
approximately day 6 of an expected 10 day course of zosyn
monotherapy.
.
On post-op day #2 the patient developed a fib with RVR with a
rate to the 130-150's. He developed hypotension to the systolic
70-80's and required transfer for the medical ICU. The patient
transiently required pressors. He was started on an amiodarone
load on [**2136-3-18**].
.
On the day of transfer from the ICU to the floor, the patient
underwent PICC line placement which failed and ended in midline
placement. He is scheduled to undergo revision by IR tomorrow.
In addition, he made his code status DNR/DNI by ICU team report.
.
Currently the patient complains of persistent shortness of
breath and lower extremity pain.
Past Medical History:
ESRD on HD (on Tue-Thurs-Sat schedule)
PVD
HTN
CHF sys/diastolic(EF 55%)
COPD
Crohn's
chronic anemia
hyperlipidemia
CAD/MI/PCI in [**2097**]'s
Paroxysmal AFib
.
PSH: left axillary-bifem bpg [**7-/2128**] (rest pain), L BKA [**12-24**] trauma,
L AKA for ischemia gangrene, right AVF with revision, right
CFA-BK [**Doctor Last Name **] with NRSVG in [**7-29**] with 4 compartment fasciotomy in
[**7-29**], appendix, rotator cuff repair, bladder surgery
Social History:
see previous d/c summeries
Family History:
Mother died of gastric cancer in her 80's. Father died at
85 from ESRD. # siblings, one died of liver disease. Married
with
4 children.
Physical Exam:
In ICU:
Vitals: 95.8 84/50 68 20 95% 2L NC
GEN: NAD, appearing older than stated age
HEENT: EOMI, PERRL. MM dry.
Lungs: Diffuse rhonchi with bronchial breath sounds in the R
middle lung field.
Heart: RRR S1, S2, no MRG
Abdomen: soft NT, ND, L-sided axillary-fem bypass palpable
[**Month/Year (2) **] AKA
[**Month/Year (2) **] 2+ edema at ankle, necrotic [**11-23**] toes, open wound of dorsal
foot, open wound with moderate purulence of anterior shin
.
On transfer from the ICU:
PE 95.6-96.2 68-104 84-110/40-60 13 99% 2L NC I/O: +315 in 24
hrs, 6.5L length of stay
Gen: NAD, comfortable.
HEENT: PERRL.
CV: Systolic ejection murmur loudest at the right sternal
border. Regular rate and rhythm.
Pulm: Coarse crackles in bilateral lung fields.
Abd: Soft, nontender, no organomegaly.
Ext: S/p Left BKA, VAC dressing in place in right shin. Surgical
wound dressing in place over right 1st and 2nd toes. Large [**Month/Day (2) **]
bullae.
.
Pertinent Results:
[**2136-4-10**] 05:45PM BLOOD WBC-12.2* RBC-3.54* Hgb-8.9* Hct-29.0*
MCV-82 MCH-25.1* MCHC-30.6* RDW-17.8* Plt Ct-300
[**2136-4-12**] 12:04AM BLOOD WBC-10.6 RBC-3.32* Hgb-8.4* Hct-27.8*
MCV-84 MCH-25.2* MCHC-30.1* RDW-16.5* Plt Ct-226
[**2136-4-13**] 03:52AM BLOOD WBC-23.6*# RBC-4.30* Hgb-10.4*#
Hct-38.5*# MCV-89 MCH-24.1* MCHC-26.9* RDW-16.1* Plt Ct-388#
[**2136-4-14**] 04:20AM BLOOD WBC-39.5*# RBC-3.86* Hgb-9.2* Hct-33.0*
MCV-86 MCH-24.0* MCHC-28.0* RDW-16.6* Plt Ct-296
[**2136-4-15**] 04:52AM BLOOD WBC-23.5* RBC-3.78* Hgb-9.2* Hct-32.4*
MCV-86 MCH-24.3* MCHC-28.4* RDW-16.8* Plt Ct-302
[**2136-4-17**] 04:09AM BLOOD WBC-9.3 RBC-3.52* Hgb-8.6* Hct-30.8*
MCV-88 MCH-24.4* MCHC-27.8* RDW-17.0* Plt Ct-222
[**2136-4-18**] 06:50AM BLOOD WBC-10.4 RBC-3.63* Hgb-9.1* Hct-30.7*
MCV-85 MCH-25.1* MCHC-29.7* RDW-18.9* Plt Ct-250
[**2136-4-19**] 06:00AM BLOOD WBC-9.7 RBC-3.75* Hgb-9.3* Hct-32.3*
MCV-86 MCH-24.7* MCHC-28.7* RDW-17.9* Plt Ct-254
[**2136-4-20**] 06:30AM BLOOD WBC-10.3 RBC-3.69* Hgb-9.3* Hct-31.2*
MCV-85 MCH-25.2* MCHC-29.8* RDW-19.8* Plt Ct-281
[**2136-4-21**] 04:07AM BLOOD WBC-14.3* RBC-3.61* Hgb-9.1* Hct-30.7*
MCV-85 MCH-25.3* MCHC-29.8* RDW-19.7* Plt Ct-347
[**2136-4-10**] 05:45PM BLOOD Neuts-84.9* Lymphs-7.6* Monos-5.8 Eos-1.6
Baso-0.2
[**2136-4-13**] 03:52AM BLOOD Neuts-83* Bands-0 Lymphs-13* Monos-2
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2136-4-19**] 06:00AM BLOOD Neuts-70 Bands-0 Lymphs-13* Monos-9 Eos-2
Baso-1 Atyps-0 Metas-2* Myelos-3*
[**2136-4-12**] 08:33PM BLOOD PT-16.4* PTT-45.2* INR(PT)-1.5*
[**2136-4-20**] 06:30AM BLOOD PT-18.6* PTT-34.5 INR(PT)-1.7*
[**2136-4-21**] 04:07AM BLOOD PT-15.2* PTT-32.3 INR(PT)-1.3*
[**2136-4-10**] 05:45PM BLOOD Glucose-142* UreaN-26* Creat-4.7* Na-141
K-3.7 Cl-98 HCO3-28 AnGap-19
[**2136-4-12**] 07:01PM BLOOD Glucose-108* UreaN-19 Creat-3.6*# Na-141
K-4.0 Cl-105 HCO3-22 AnGap-18
[**2136-4-21**] 04:07AM BLOOD Glucose-88 UreaN-21* Creat-4.9*# Na-140
K-4.3 Cl-100 HCO3-29 AnGap-15
[**2136-4-21**] 04:07AM BLOOD ALT-31 AST-17 LD(LDH)-172 AlkPhos-277*
TotBili-0.7
[**2136-4-14**] 04:20AM BLOOD Lipase-58
[**2136-4-19**] 06:00AM BLOOD GGT-238*
[**2136-4-11**] 01:10AM BLOOD CK-MB-NotDone cTropnT-0.79*
[**2136-4-11**] 09:10AM BLOOD CK-MB-NotDone cTropnT-0.74*
[**2136-4-18**] 04:10PM BLOOD CK-MB-NotDone cTropnT-0.38*
[**2136-4-18**] 11:40PM BLOOD CK-MB-NotDone cTropnT-0.40*
[**2136-4-19**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2136-4-12**] 09:48AM BLOOD TotProt-6.1* Albumin-3.0* Globuln-3.1
[**2136-4-14**] 04:20AM BLOOD TotProt-6.1* Albumin-2.9* Globuln-3.2
Calcium-9.4 Phos-7.5* Mg-2.0
[**2136-4-19**] 06:00AM BLOOD Albumin-2.9* Calcium-10.1 Phos-4.6*
Mg-1.7
[**2136-4-21**] 04:07AM BLOOD Calcium-10.0 Phos-4.6* Mg-1.6
[**2136-4-20**] 07:00AM BLOOD ANCA-PND
[**2136-4-17**] 04:09AM BLOOD Vanco-13.8
[**2136-4-14**] 04:20AM BLOOD Vanco-5.2*
[**2136-4-12**] 07:01PM BLOOD HoldBLu-HOLD
[**2136-4-14**] 10:37PM BLOOD Lactate-1.4
Imaging:
PREOP PA AND LATERAL CHEST, [**2136-4-10**]
IMPRESSION:
1. Dense right middle lobe consolidation, new since [**8-28**],
likely pneumonic.
2. CHF with interstitial edema; new small right pleural effusion
may relate to either process.
.
CT CHEST W/O CONTRAST [**2136-4-11**] 4:23 AM
IMPRESSION: Bilateral loculated pleural effusions, right more
than left. Right lower lobe and middle lobe _____ pneumonia.
Moderate apical emphysema. Moderate mediastinal adenopathy.
.
IMPRESSION:
CT THORACENTESIS W/TUBE PLACMENT [**2136-4-13**] 2:49 PM
1. Successful CT-guided subcutaneous catheter drainage
placement.
2. Incidental 6 mm right middle lobe pulmonary nodule and
emphysema.
_____ catheter care and findings of this _____ pulmonary nodule
discussed with Dr. [**Last Name (STitle) **] at 4:30 p.m. on [**2136-4-13**].
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2136-4-14**] 8:20 PM
IMPRESSION:
1. Ascites and pulsatile flow within the portal vein which may
relate to congestive heart failure.
2. Extensive sludge within the gallbladder (which may relate to
the patient's overall clinical status), but no evidence of acute
cholecystitis.
.
CHEST (PORTABLE AP) [**2136-4-14**] 7:03 AM
IMPRESSION: New right-sided chest tube. No evidence of
pneumothorax. Interval improvement in right pleural effusion
with residual small amount of fluid remaining in the right major
fissure.
.
CHEST (PORTABLE AP) [**2136-4-16**] 3:22 AM
Portable AP chest radiograph was compared to [**2136-4-14**],
obtained at 2:18 p.m.
The pigtail catheter inserted in the upper pleural space in the
right upper lobe is unchanged. There is no interval change in
small amount of intrafissural pleural fluid on the right as well
as there is no change in the right basal areas of atelectasis.
There is interval progression of the [**Year (4 digits) 1106**] engorgement in the
left perihilar area which may represent mild volume overload
with asymmetric distribution due to patient's position.
Bibasilar retrocardiac atelectasis are unchanged. No
pneumothorax or left effusion is demonstrated.
.
ECG: Study Date of [**2136-4-10**] 9:28:38 PM
Sinus rhythm. Left ventricular hypertrophy with secondary ST-T
wave changes although myocardial ischemia cannot be ruled out.
Compared to the previous tracing of [**2135-9-15**] left ventricular
hypertrophy is more prominent and ST segment depressions in the
lateral leads are also more prominent. TRACING #1
.
ECG: Study Date of [**2136-4-12**] 9:45:50 AM
Atrial fibrillation with rapid ventricular response. Left
ventricular
hypertrophy. ST segment depression in leads V4-V6 which may be
related
to ischemia in the setting of left ventricular hypertrophy.
Clinical
correlation is suggested. Compared to the previous tracing of
[**2136-4-11**]
atrial fibrillation persists with a slightly slower ventricular
response.
.
ECG:Study Date of [**2136-4-18**] 1:06:08 PM
Atrial fibrillation with rapid ventricular response
Slight nonspecific intraventricular conduction delay
Nonspecific ST-T abnormalities
Since previous tracing of [**2136-4-12**], precordial QRS voltage less
prominent and ST-T wave changes decreased
Brief Hospital Course:
.
#Pneumonia: Patient found to have consolidation on admission,
with CT scan demonstrating loculated pleural effuions. Sputum
cultures grew moraxella. Patient was started on zosyn in house.
Pig-tail catheter was placed to drain pleural effusion, and
cultures sent, but were without growth. Moraxella felt to be an
unlikely pathogen, and patient was clinically improving on
zosyn, so was continued on this regimen for plan of full 14 day
course. Pig-tail catheter was pulled on the floor after several
days and consultation with thoracics. CXR following removal
demonstrated no pneumothorax, or significant reaccumulation of
fluid. Plan to complete course of zosyn via picc as directed
below for full 14 days.
- Patient should have repeat CXR in [**1-24**] weeks time to document
resolution of his infiltrate.
- Please remove PICC upon completion of antibiotics.
.
#Atrial Fibrillation: Patient with A. Fib with RVR. During
initial presentation did not tolerate this rhythm well and was
hypotensive requiring ICU stay. As a result, patient was loaded
with amiodarone with goal of maintaining sinus rhythm. Patient
tolerated amio load well and converted to sinus rhythm prior to
call-out from the ICU. Did have [**11-23**] recurrence of A. Fib with
RVR on the floor that second of which required IV diltiazem to
break. Patient was then started on low dose oral diltiazem for
rate control and remained in sinus rhythm for the remainder of
his hospital stay and 48 hours prior to discharge. Plan to
continue amiodarone and diltiazem and f/u with outpatient [**Month/Day (2) 3390**]
for further management. [**Month (only) 116**] not require long term amiodraone
for rhythm control and would consider discontinuation once his
pneumonia resolved. Patient was not anticoagulated given he his
only indication was history of CHF.
.
#Hypotension: In setting of A. Fib with RVR and pneumonia.
Consistent with sepsis and unstable tachycardia. Improved with
IVF's and rhythm control of his A. Fib. Recommend monitoring
blood pressures by mentation, and L-forearm given AV fistula on
R-arm and picc proximal on the left.
.
#Amputation: Patient had successful 1st/2nd toe amputation with
debridement of his arterial ulcer. Patient followed closely by
[**Month (only) 1106**] surgery in house who recommended outpatient follow-up
on discharge. continue current wound-care and wound vac with
changes as directed.
.
#ESRD: Continued on HD in house. Last session on day of
discharge - Saturday. Continue T/H/Sat dialysis.
.
#Sacral Wound: Seen by wound care nurse in-house. continue
dressing changes as directed.
.
#Coagulopathy: Mild coagulopathy in house on antibiotics.
Thought [**12-24**] to abx and nutriotional status. Given PO vitamin K
with subsequent improvement.
.
#Transaminitis/Liver: Developed in-house. Thought [**12-24**] to
hypotension/shock liver. Normalized prior to discharge. If
recurs would consider amiodarone toxicity. Patient with
persistent Alk Phos elevation and GGT confirming it to be
hepatic and not from recent amputation. Liver USD with biliary
sludge but no e/o cholecystitis/ductal dilation or other acute
pathology. Would consider outpatient ERCP/MRCP in future given
h/o Crohn's disease and elevated alk phos - concern for PSC.
Sent P-ANCA in house - pending at time of discharge.
.
#Crohn's Disease: Continued on outpatient regimen. No diarrhea.
#Leukocytosis: Mild new leukocytosis on day prior to discharge.
Vitals stable, afebrile, and without e/o infection. If develops
diarrhea would have concern for C. Diff in this hospitalized, HD
patient on zosyn.
.
#Lung nodule: Patient had several CT scans in house. On one
occasion a scan found a 6 mm right middle lobe pulmonary nodule.
Recommend repeat evaluation w/ CT scan of this nodule as an
outpatient once acute pneumonia has resolved to better ascertain
size of nodule and assess for interval change.
# Chronic anemia. Stable, likely anemia of chronic disease.
# CAD s/p MI with PCI in the [**2097**]'s. No signs of active
ischemia. ST depressions on EKG correlated with A. Fib w/ RVR
and enzymes stable. Troponin mildly elevated but [**12-24**] to ESRD
and demand from rapid rate.
- Continue aspirin, nitroglycerin PRN.
.
# Psych. Continue buspirone and sertraline. Stable.
# Prophylaxis. Heparin subcutaneously, PPI. Antiemetics PRN.
# Access: Tunnelled line, midline. Please remove midline after
completion of antibiotics.
# Code: DNR/DNI
.
Medications on Admission:
Oxygen 2L/min
Carvedilol 25 [**Hospital1 **]
Omeprazole 20 [**Hospital1 **]
Asacol 1200 tid
Phoslo 3 caps tid
Alprazolam [**Hospital1 **]
Buspar [**Hospital1 **]
Zoloft qhs
EC-ASA 325 qd
Nitro 0.4 sl prn
Fe pills
.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
6. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: through [**4-23**], and then begin reduced dose
prescription.
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
to start on [**4-24**] after completion of loading phase.
15. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours): hold for SBP < 100.
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
17. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q12 () for 5 days: through [**2136-4-26**]
for total of 2 weeks.
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
1st and second toe amputation
arterial ulcer
atrial fibrillation with rapid ventricular response
Pneumonia
Sepsis
End stage renal disease
Transaminitis
Sacral Ulcer
Discharge Condition:
Stable, non-weight bearing.
Discharge Instructions:
You were admitted to the hospital for a toe amputation. On
admission it was found that you had a pneumonia. Your amputation
was performed successfully and your leg ulcer was surgically
debrided. You were then treated for your pneumonia.
.
You also developed an irregular heart rate known as atrial
fibrillation and required the intensive care unit for monitoring
and control of your heart rate. You were started on 2 new
medications for control of this heart rate - Amiodarone and
diltiazem. You should discuss these with your doctor as you may
not need to take them long term. In the short term however,
please take all new medications as directed upon leaving the
hospital.
.
Please call your physician should you develop any new lower
extremity pain, chest pain, palpitations, shortness of breath,
fever > 101 or any other symptom concerning to you.
.
You must take the following medications:
1. Piperacillin/tazobactam - for total of 2 weeks through [**4-26**] [**2135**]
2. Amiodarone - 400mg twice daily and then 200mg daily
thereafter. Please do not discontinue this medication without
discussing it with your doctor.
3. Diltiazem 15mg by mouth every 6 hours. Please do not
discontinue this medication without discussing it with your
doctor.
4. Please continue all other medications as directed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2136-5-1**] 12:30 on the [**Location 74518**] [**Hospital Ward Name 121**] building,
Chest Disease Center, [**Location (un) 453**], [**Hospital1 **] building. You will
see the NP [**Location (un) 1439**] or [**Female First Name (un) **]
Report to the [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology
for a Chest X-Ray 45 minutes before your appointment.
..
Provider: [**Name10 (NameIs) **] Surgery -> [**2136-5-2**] at 11:45AM, with
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**], [**Hospital Unit Name **] 110 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 5c,
([**Telephone/Fax (1) 14585**]
.
Provider: [**Name10 (NameIs) 3390**], [**Name11 (NameIs) 4392**],[**Name12 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 74519**], please call for an
appointment in the next 1 month.
ICD9 Codes: 5856, 0389, 5119, 486, 496, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5649
} | Medical Text: Admission Date: [**2185-7-31**] Discharge Date: [**2185-8-17**]
Date of Birth: [**2109-1-31**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Bronchoscopy
s/p repair of incarcerated ventral hernia w/o necrotic bowel
([**7-30**]) at OSH
Tracheostomy
PICC
History of Present Illness:
76 F originally presented to [**Hospital1 **] ER with ambdominal pain
and distension, known umbilical hernia, underwent open repair of
incarcerated hernia (no necrotic bowel) on HD2, on HD3 (POD2)
patient went into respiratory failure requiring intubation and
ventilation, and was transferred here.
Past Medical History:
(1) Type II DM
(2) Hypertension
(3) MI x 2
(4) morbid obesity
Social History:
not available
Family History:
not available
Physical Exam:
V/S: 100.3, 90 131/69, 16, 95% RA
Neuro: sedation c propofol
CV: RRR
Pulmonary: intubated, low O2 sats in the 90%.
Abdomen: obeses, soft abdomen, incision [**Last Name (un) **] and intact. Abd
binder in place. NGT in place
Ext: +2 edema bilat
Pertinent Results:
[**2185-7-31**] 02:46PM BLOOD WBC-9.5 RBC-3.73* Hgb-11.1* Hct-34.7*
MCV-93 MCH-29.7 MCHC-32.0 RDW-14.2 Plt Ct-297
[**2185-8-8**] 03:32AM BLOOD WBC-14.9* RBC-3.13* Hgb-9.5* Hct-28.7*
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.8 Plt Ct-333
[**2185-8-16**] 06:05AM BLOOD WBC-11.4* RBC-3.35* Hgb-10.2* Hct-32.0*
MCV-96 MCH-30.4 MCHC-31.9 RDW-14.3 Plt Ct-493*
[**2185-8-16**] 06:05AM BLOOD Glucose-174* UreaN-36* Creat-1.1 Na-144
K-4.1 Cl-104 HCO3-32 AnGap-12
[**2185-8-16**] 06:05AM BLOOD Calcium-9.2 Phos-5.8* Mg-2.5
[**2185-7-31**] 02:46PM BLOOD Triglyc-190*
[**2185-8-5**] 02:00AM BLOOD TSH-2.6
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-7-31**] 3:27
PM
FINDINGS: In comparison with the earlier study of this date,
there is little
overall change in the appearance of the right hemithorax. There
is still
extensive opacification along the right side of the trachea. For
further
evaluation, CT would be required.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-8-5**] 7:43
AM
IMPRESSION: Little change.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-8-9**] 4:29
AM
FINDINGS: In comparison with the study of [**8-8**], there is little
change in the
appearance of the endotracheal tube. Nasogastric tube extends
well into the
stomach.
There is enlargement of the cardiac silhouette with some
vascular engorgement
consistent with elevated pulmonary venous pressure. Atelectatic
changes are
seen at the bases and there are also small pleural effusions.
.
Radiology Report PORTABLE ABDOMEN Study Date of [**2185-8-12**] 6:53 PM
Final Report
HISTORY: Assess position of nasogastric tube.
Single portable radiograph of the abdomen excludes the right
lateral
hemithorax and right lateral abdomen. There is a nasogastric
tube present
with its tip in the stomach. The visualized bowel is
unremarkable. The
regional soft tissues are unremarkable.
.
[**2185-8-16**] 06:05AM BLOOD WBC-11.4* RBC-3.35* Hgb-10.2* Hct-32.0*
MCV-96 MCH-30.4 MCHC-31.9 RDW-14.3 Plt Ct-493*
[**2185-8-16**] 06:05AM BLOOD Glucose-174* UreaN-36* Creat-1.1 Na-144
K-4.1 Cl-104 HCO3-32 AnGap-12
[**2185-8-16**] 06:05AM BLOOD Calcium-9.2 Phos-5.8* Mg-2.5
[**2185-7-31**] 02:46PM BLOOD Triglyc-190*
Brief Hospital Course:
This is a 76 F transferred from [**Hospital1 **] [**Location (un) 620**] s/p repair of
incarcerated ventral hernia w/o necrotic bowel on [**7-30**], with
acute respiratory decompensation @ [**Location (un) 620**], requiring
intubation. Transferred for further management. Possible h/o
aspiration perioperatively.
Resp: She was transferred here intubated and sedated. She had
partial right lung collapse and atelectasis. A Bronchoscopy
showed some mucous plugs. She continued with aggressive
pulmonary toilet and the ICU team was attempting to wean. She
was trach'd on [**8-9**] after having difficulty weaning.
On [**8-7**] BAL - staph aureus coag +, 3+ GPCs - Nafcillin
sensitive. This was switched to Augmentin and should continue
thru [**2185-8-20**].
She was then transitioned to a trach mask and was tolerating a
Passe Muir Valve.
CV: Stable with frequent PVC's. Continue with Lopressor.
GI/ABD: She was NPO with NGT in place. She was started in
tubefeedings via the NGT. She was evaluate by Speech and Swallow
and started on pureed solids and thin liquids.
Her incision was C/D/I with steri strips in place.
Renal: After receiving initial fluid resuscitation, she was then
diuresis with Lasix. Continue with diuresis as needed.
Endo: She required insulin for post-op hyperglycemia. As she is
able to tolerate more PO's, her home PO diabetic meds can be
restarted and the NPH can be weaned down.
Activity: She will continue to need PT as she had a prolonged
ICU course and is morbidly obese.
Medications on Admission:
Insulin 38U qhs, HCTZ 25', procardia 30', amitriptyline 100',
atenolol 100', plavix 75', synthroid 150', zocor 40', glyburide
ER 10'', cozaar 50', isosorbide Mon (120 qam, 60 qhs), metformin
500''
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 4 days.
12. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED).
13. Furosemide 10 mg/mL Solution Sig: Two (2) Injection DAILY
(Daily).
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
incarcerated ventral hernia w/o necrotic bowel
subsequent acute respiratory decompensation requiring
tracheostomy
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* 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.
* Continue to increase activity daily.
* No heavy lifting (>[**10-26**] lbs) until your follow up
appointment.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**3-15**] weeks. Call
[**Telephone/Fax (1) 1231**] to schedule an appointment.
Completed by:[**2185-8-17**]
ICD9 Codes: 5070, 496, 4019, 2724, 412, 5185, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5650
} | Medical Text: Admission Date: [**2142-8-30**] Discharge Date: [**2142-9-6**]
Date of Birth: [**2105-3-30**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
[**2142-9-4**] Open reduction, internal fixation of right angle
mandible fracture, extraction of teeth (two mandible incisors).
History of Present Illness:
Ms. [**Known lastname **] is a 37yo woman s/p assault, found walking around
confused/incoherent. She initially presented to [**Hospital3 19345**] where a noncontrast head CT demonstrated a right
subarachnoid hemorrhage. She also had significant face and mouth
lacerations and swelling. She was intubated for airway
protection. She was given one unit of packed red blood cells at
the outside hospital, reportedly for low blood pressure. On
arrival to [**Hospital1 18**], she was intubated and sedated. Toxicology
screen was positive for cocaine, barbituates, opiates, and
alcohol.
Past Medical History:
Depression, bipolar disorder
Social History:
Lives with son, has multiple family members nearby. Reports not
taking any psychiatric medications xseveral months [**3-1**] lack of
insurance. Daily heroine use, frequent cocaine, EtOH.
Family History:
noncontributory
Physical Exam:
On admission:
HR: 108 BP: 100/p Resp: 16 O(2)Sat: 100 Normal
Constitutional: intubated, sedated
HEENT: ecchymosis, crepitance, edema to face, dried blood,
laceration to R cheek. , Pupils equal, round and reactive to
light, no proptosis or evidence of obvious globe rupture
ett in place, ccollar on
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended
Pelvic: no evidence trauma on external exam
GU/Flank: ecchymosis to R thigh
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: intubated/sedated, purposeful movements of all exts
Psych: intubated, sedated
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Vitals at time of discharge:
T 98.2, HR 73, SBP 118/60, RR 16, sat 99%
Pertinent Results:
[**2142-8-30**] 05:48AM BLOOD WBC-17.6* RBC-4.25 Hgb-10.5* Hct-32.7*
MCV-77* MCH-24.7* MCHC-32.2 RDW-16.1* Plt Ct-415
[**2142-8-30**] 10:15PM BLOOD Neuts-88.5* Lymphs-8.4* Monos-1.8*
Eos-1.2 Baso-0.2
[**2142-8-30**] 10:15PM BLOOD Glucose-95 UreaN-8 Creat-0.8 Na-135 K-3.4
Cl-103 HCO3-25 AnGap-10
[**2142-8-30**] 10:15PM BLOOD ALT-21 AST-43* LD(LDH)-168 AlkPhos-75
TotBili-0.9
[**2142-8-30**] 05:48AM BLOOD Lipase-13
[**2142-8-30**] 10:15PM BLOOD Albumin-3.5 Calcium-8.2* Phos-3.4 Mg-2.3
[**2142-8-30**] 10:15PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE IgM
HBc-NEGATIVE
[**2142-9-1**] 05:41AM BLOOD HIV Ab-NEGATIVE
[**2142-8-30**] 05:48AM BLOOD ASA-NEG Ethanol-108* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-8-30**] 10:15PM BLOOD HCV Ab-POSITIVE*
Imaging:
CT C-Spine Wet Read: No acute traumatic C-spine injury.
CT Head Preliminary Report
1. Trace subarachnoid hemorrhage along the right sylvian
fissure,
without evidence of interval increase. No intraventricular
hemorrhagic extension. No evidence of mass effect.
2. Extensive right facial soft tissue contusion with a sizable
right temporal subgaleal hematoma.
3. Minimally displaced fracture of the right lamina papyracea,
with mild/small pockets of intraconal air. No rectus muscle
entrapment.
4. Minimally displaced right nasal bone fracture.
No CT mandible available. However, CT Scout Head view
demonstrates Right Open Angle Fracture through distal of tooth
#31.
[**2142-9-5**] Mandible series
Status post ORIF of right mandibular fracture, in overall
anatomic alignment.
Brief Hospital Course:
Ms. [**Known lastname **] was transferred to the trauma ICU for close monitoring
and management.
N: She was initially intubated and sedated. When sedation was
weaned, she was appropriately responsive, moving all
extremities, following commands. Neurosurgery was consulted, she
was initially kept on dilantin for seizure prophylaxis per
recommendations, and will follow up with an outpatient CT scan
in four weeks. Plastic surgery was consulted for her facial
lacerations and facial fractures. Ophtho was consulted for her
orbital fracture. OMFS was consulted for her mandibular
fracture. She was given peridex mouthwashes. Her intra-oral
laceration and facial lacerations were sutured by plastic
surgery. She was given narcotic medication for pain control. She
was taken to the OR on [**9-3**] by OMFS for her mandibular fracture
and underwent ---
CV: She remained hemodynamically stable. She was placed on
methadone [**Hospital1 **] for her tachycardia, which improved.
Pulm: She was initially intubated for airway protection. She was
weaned off the vent and successfully extubated. She was febrile
on HD1 and sputum cultures were sent, which grew strep pneumo.
She was started on ceftriaxone and switched to azithromycin.
GI: Once extubated, she was placed on a soft mechanical diet.
She was on a bowel regimen.
Heme: Her hematocrit remained stable
ID: Her sputum grew strep pneumo and 1 of 2 blood culture
bottles grew strep pneumo as well. She was placed on
azithromycin [**2142-9-1**], with a planned 7 day course. She remained
afebrile for the rest of her ICU course. A sexual assault screen
was done and she was given a dose of metronidazole,
azithromycin, and ceftriaxone on [**2142-8-30**]. She was HCV positive as
well and given HIV post-exposure prophylaxis.
On [**2142-9-4**], Mrs. [**Known lastname **] was taken to the operating room with OMFS
for ORIF of her mandibular fracture and removal of her two
mandibular incisors. She was recovered in the PACU and
transferred to Mrs. [**Known lastname **] was transferred to the surgical floor.
She was continued on azithromycin for a total course of four
days. Pain was controlled with narcotic and non-narcotic
analgesics. Methadone was also started due to patient's history
of opioid dependence.
The patient's diet was ordered as full liquids and she will
continue to follow that diet until she follows up with OMFS as
an outpatient. She was started on subcutaneous heparin for DVT
prophylaxis.
During her inpatient stay, plastics, opthalmology, neurosurgery,
and OMFS were consulted for various issues. Folllow up
appointments have been made with all those services as an
outpatient basis within the next month of discharge. Because
Mrs. [**Known lastname **] continues on anti-retroviral therapy, a follow-up
appointment was also made with Infectious Disease within the
upcoming week.
Social Work has made plans for the patient to attend a methadone
clinic. As part of that arrangement, prescriptions for
narcotics were only administered to cover the patient until her
first visit to the clinic, which is [**Last Name (LF) 766**], [**9-10**]. Social
work also made arrangements for the patient to [**Hospital1 12671**].
At the time of discharge, Mrs. [**Known lastname **] was hemodynamically stable
and afebrile. She has finished her course of antibiotics. All
necessary prescriptions have been provided and discharge
instructions have been provided by myself and the bedside nurse.
The patient was being discharged with the assistance/care of
her sister.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
RX *chlorhexidine gluconate 0.12 % Swish and spit with 15ml
twice a day Disp #*240 Milliliter Refills:*1
3. Darunavir 600 mg PO BID
RX *Prezista 600 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
hold for loose stools
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *Truvada 200 mg-300 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Methadone 10 mg PO BID
RX *methadone 10 mg 1 tablet by mouth twice a day Disp #*7
Tablet Refills:*0
7. OxycoDONE (Immediate Release) 10-15 mg PO Q3H:PRN pain
RX *oxycodone 10 mg 1 - 1.5 tablet(s) by mouth every three (3)
hours Disp #*40 Tablet Refills:*0
8. Ritonavir (Oral Solution) 100 mg PO BID
RX *Norvir 100 mg 1 tablet by mouth twice a day Disp #*60 Tablet
Refills:*0
9. Senna 1 TAB PO BID:PRN constipation
hold for loose stools
Discharge Disposition:
Home
Discharge Diagnosis:
Right subarachnoid hemorrhage
Right mandible fracture
Right nasal bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital on
[**2142-8-30**] after being assaulted. Your injuries include: Right
mandible (jaw) fracture, right nasal bone fracture, right
subarachnoid hemorrhage (bleeding in the brain).
You were initially sent to the ICU because you were intubated
(on a ventilator/breathing machine). Once you were stabilized
and taken off the ventilator, you were sent to the surgical
floor for further management and observation.
You were taken to the operating room on [**9-4**] for repair of
your right jaw fracture and the removal of two of your mandible
(lower jaw) incisors.
The following are your discharge instructions:
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications. Do not smoke.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
30-45 minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first 2-3 days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
Healing: Normal healing after oral surgery should be as follows:
the first 2-3 days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If you do not see continued improvement, please call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first 2-3 days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the 3rd or 4th day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: You have been given a prescription for Peridex.
Rinse with a tablespoon of the solution twice a day. Your
surgery will tell you how long you should continue to do this
when you go to your follow up appointment.
Showering: You may shower 1-2 days after surgery, but please ask
your surgeon about this. If you have any incisions on the skin
of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As you may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist you in case if you may need help.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
If your jaws are wired shut with elastics, you may have been
prescribed liquid pain medications. Please remember to rinse
your mouth after taking liquid pain medications as they can
stick to the braces and can cause gum disease and damage teeth.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, you can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
If your jaws are not wired shut, then after one week, you may be
able to gradually progress to a soft diet, but ONLY if your
surgeon instructs you to do so. It is important not to skip any
meals. If you take nourishment regularly you will feel better,
gain strength, have less discomfort and heal faster. Over the
counter meal supplements are helpful to support nutritional
needs in the first few days after surgery. A nutrition guidebook
will be given to you before you are discharged from the
hospital. Remember to rinse your mouth after any food intake,
failure to do this may cause infections and gum disease and
possible loss of teeth.
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better. If your jaws are wired shut with elastics and you
experience nausea/vomiting, try tilting your head and neck to
one side. This will allow the vomitus to drain out of your
mouth. If you feel that you cannot safely expel the vomitus in
this manner, you can cut elastics/wires and open your mouth.
Inform our office immediately if you elect to do this. If it is
after normal business hours, please come to the emergency room
at once, and have the oral surgery on call resident paged.
Graft Instructions: If you have had a bone graft or soft tissue
graft procedure, the site where the graft was taken from (rib,
head, mouth, skin, clavicle, hip etc) may require additional
precautions. Depending on the site of the graft harvest, your
surgeon will [**Month (only) 8146**] you regarding specific instructions for
the care of that area. If you had a bone graft taken from your
hip, we encourage you to ambulate on the day of surgery with
assistance. It is important to start slowly and hold onto stable
structures while walking. As you progressively increase your
ambulation, the discomfort will gradually diminish. If you have
any problems with urination or with bowel movements, call our
office immediately.
Elastics: Depending on the type of surgery, you may have
elastics and/or wires placed on your braces. Before discharge
from the hospital, the doctor [**First Name (Titles) **] [**Last Name (Titles) 8146**] you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office.
Medications: You will be given prescriptions, some of which may
include antibiotics, oral rinses, decongestants, nasal sprays
and pain medications. Use them as directed. A daily multivitamin
pill for 2-3 weeks after surgery is recommended but not
essential.
Followup Instructions:
Infectious Disease Clinic
When: [**Last Name (LF) 766**], [**2142-9-11**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]), basement level
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Phone: [**Telephone/Fax (1) 457**]
OMFS (oro-maxillo-facial surgeon), Dr. [**Last Name (STitle) 6993**]
When: [**2142-9-10**] at 2pm
[**Hospital6 **], [**Hospital Ward Name 23**] Building
[**Location (un) **].
[**Telephone/Fax (1) 110271**]
Department: [**Hospital3 1935**] CENTER
When: THURSDAY [**2142-9-20**] at 4:00 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Name6 (MD) 112334**] [**Name8 (MD) **], MD
Specialty: Primary Care
Location: [**Hospital **] COMMUNITY HEALTH CENTER
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 59034**]
Phone: [**Telephone/Fax (1) 30953**]
We have left Dr. [**Last Name (STitle) **] office a message that you will need an
appt to be seen within the next 3 weeks. If you have not heard
within 2 business days or have questions, please call the number
listed above.
Department: DIV. OF PLASTIC SURGERY
When: FRIDAY [**2142-10-5**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD and DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **],MD
Phone: [**Telephone/Fax (1) 6331**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: TUESDAY [**2142-10-9**] at 8:15 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2142-10-9**] at 9:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2142-9-6**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5651
} | Medical Text: Admission Date: [**2142-4-29**] Discharge Date: [**2142-5-11**]
Date of Birth: [**2064-2-6**] Sex: F
Service: MEDICINE
Allergies:
Doxycycline / lisinopril
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. [**Known lastname 4886**] is a 78-year-old female with past medical history
significant for hypertension,type 2 DM, distant breast cancer,
TTP (lengthy hospitalization [**4-/2141**] which required
corticosteroids, plasmapheresis, and rituximab), relapsing
polychondritis and ANCA positive pulmonary vasculitis.
The patient was in her usual state of health this evening at
6:30
PM, speaking to her son on the phone. He said, to EMS (from whom
we got direct sign-out), that his mother sounded slightly tired,
but this is her baseline and otherwise was normal. He then came
to see her after running errands about 1 hr later and found her
lying
in emesis and stool. She was unreponsive and he could not wake
her. EMS called and found to develop a generalized tonic-clonic
seizure. The seizure lasted about 3.5 mintues, then stopped
spontaneously. She was then given Ativan 2mg, then intubated
with succinylcholine 100mg and etomidate 20mg, followed by
Versed 2.5 mg given concern about airway protection. She was
then brought to [**Hospital1 18**]. Of note, son reports that this
presentation is almost identical to her prior presentation last
year, which required pheresis, and believes this was TTP.
In the field EJ and IO access was obtained. She was in sinus
rhythm, in the 80s, blood pressure was 200/80 mmHg, and
breathing spotaneously (before intubation and medications).
Finger stick was 175.
In the ED CT head/Neck showed no acute intracranial hemorrhage.
She does have subtle areas of hypodensities in left basal
ganglia, pons, and midbrain maybe artifactual or represent
ischemia. CTA basilar artery appears patent. Sedation was
continued with propofol. EKG showed 1st degree avb. She was
noted to be febrile to 102. CXR without pna. She was started
on vanc/ctx/amp/acyclovir, but no LP was done due to low plt.
UA showed no bacteria or leuks, but did have large blood, 300
glucose, 300 protein
Of note, pt noted to have trop of 1.03, with flat MB.
Cardiology was conuslted who felt no need for urgent cardiac
intervention in setting of unchanged EKG.
On transfer, VS were 106 146/80s, 99% on CMV fi02 100, peep 5,
RR 16, TV 500.
On arrival to the MICU, VS were 100.1 109 106/63 100% on
above vent settings
Past Medical History:
- Diabetes, likely II
- Hypertension, on several agents
- Breast cancer, s/p left mastectomy, [**2100**]'s
- GERD (inference, on omeprazole), and peptic ulcer disease
- Gout
- Coronary artery disease
- H/o Shingles
- Carpal tunnel
- ANCA positive pulmonary vasculitis
- S/P appendectomy
- S/P cholecystectomy
- S/P TAH-BSO, mastectomy,
- S/P bilateral carpal tunnel release
- Bone spurs
Social History:
Lives with her son. Doesn't smoke or drink.
Family History:
No early coronary artery disease. No other cancers
Physical Exam:
INITIAL PHYSICAL EXAM
Vitals:
Tmax: 37.8 ??????C (100.1 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 86 (80 - 110) bpm
BP: 144/88(102) {103/60(71) - 144/88(102)} mmHg
RR: 20 (17 - 20) insp/min
SpO2: 100%
Heart rhythm: 1st AV (First degree AV Block)
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 450 (450 - 500) mL
RR (Set): 14
RR (Spontaneous): 1
PEEP: 5 cmH2O
FiO2: 50%
PIP: 24 cmH2O
Plateau: 17 cmH2O
SpO2: 100%
ABG: 7.42/31/126/19/-2
Ve: 9.8 L/min
PaO2 / FiO2: 252
General: intubated, sedated, not waking up or following
commands. withdraws to pain in all 4 extremeties
HEENT: Sclera anicteric, c-collar on
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-tender, slightly distended, bowel sounds
present, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No petichae
Pertinent Results:
INITIAL LABORATORY DATA
[**2142-4-29**] 09:46PM BLOOD WBC-6.6 RBC-3.13* Hgb-9.9* Hct-30.7*
MCV-98 MCH-31.7 MCHC-32.2 RDW-16.4* Plt Ct-33*
[**2142-4-29**] 09:46PM BLOOD Neuts-80.9* Lymphs-11.9* Monos-6.2
Eos-0.5 Baso-0.6
[**2142-4-29**] 09:46PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+
Target-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2142-4-29**] 09:46PM BLOOD PT-12.5 PTT-42.1* INR(PT)-1.2*
[**2142-4-30**] 01:01AM BLOOD Glucose-370* UreaN-42* Creat-2.0* Na-134
K-4.4 Cl-100 HCO3-19* AnGap-19
[**2142-4-29**] 09:46PM BLOOD ALT-31 AST-97* LD(LDH)-2419* CK(CPK)-307*
AlkPhos-85 TotBili-3.1* DirBili-0.8* IndBili-2.3
[**2142-4-29**] 09:46PM BLOOD CK-MB-10 MB Indx-3.3 cTropnT-1.03*
[**2142-4-29**] 09:46PM BLOOD Albumin-3.2* Calcium-7.7* Phos-3.4
Mg-1.3*
[**2142-4-29**] 09:46PM BLOOD Hapto-<5*
[**2142-5-1**] 02:18PM BLOOD Vanco-22.5*
[**2142-4-30**] 01:02AM BLOOD Type-ART Rates-/16 Tidal V-500 PEEP-5
FiO2-50 pO2-126* pCO2-31* pH-7.42 calTCO2-21 Base XS--2
-ASSIST/CON Intubat-INTUBATED
[**2142-4-29**] 09:54PM BLOOD Glucose-241* Lactate-1.6 Na-136 K-4.6
Cl-103 calHCO3-21
RADIOGRAPHIC REPORTS
[**2142-4-29**]
CTA Head
INDICATION: 77-year-old woman with altered mental status and
seizures.
COMPARISON: None.
TECHNIQUE: Contiguous axial CT images through the head were
obtained without
contrast in the axial plane. After intravenous administration of
contrast,
MDCT images of the head and neck were obtained in the arterial
phase and axial
plane. MIPs, volume-rendered images, and curved reformats were
generated and
reviewed.
FINDINGS:
CT HEAD: There is no acute intracranial hemorrhage, vascular
territorial
infarction, edema, or mass effect seen. However, hypodense
regions in left
basal ganglia (2:14), pons (2:10) and midbrain maybe artifactual
or represent
edema, difficult to characterize further. Smaller hypodensities
are seen in
bilateral periventricular white matter concerning for small
vessel ischemic
disease. There is no hydrocephalus or midline shift. Dense
atherosclerotic
calcifications are seen in bilateral intracranial vertebral
arteries and
cavernous carotid arteries. No fracture is seen.
CTA HEAD: Bilateral intracranial internal carotid arteries,
vertebral artery,
small basilar artery and their major branches are patent with no
evidence of
stenosis, occlusion, dissection, or aneurysm formation. Right
vertebral
artery is dominant.
CTA NECK: There is a bovine arch configuration with a common
origin of the
innominate and left common carotid artery from the aortic arch.
Bilateral
common carotid arteries, internal carotid artery and vertebral
arteries in the
neck appear patent with no evidence of stenosis, occlusion,
dissection or
pseudoaneurysm formation. The right vertebral artery is
dominant. The left
vertebral artery appears congenitally hypoplastic. Both
vertebral artery
origins are patent. Visualized soft tissue structures in the
neck appear
unremarkable.
IMPRESSION:
1. While there is no evidence of hemorrhage or acute vascular
territorial
infarction, there is subtle hypoattenuation in the basal
ganglia, thalami,
pons and midbrain, suspicious for edema.
2. Evidence of small vessel ischemic disease.
3. Unremarkable CTA of the head and neck, with no evidence of
steno-occlusive
disease.
4. No finding to suggest cerebral venous thrombosis.
CT C-Spine
FINDINGS:
There is no evidence of acute fracture or malalignment.
Multilevel
degenerative joint changes are most pronounced at C6-C7 with
intervertebral
disc space narrowing, subchondral sclerosis and disc osteophyte
complex
formations. Evaluation of prevertebral soft tissue is limited
due to ET tube
placement. No critical central canal stenosis is noted.
Calcifications of
the ligamentum flavum are incidentally noted. Nonunion of the C1
posterior
arch is present. The esophagus appears patulous with moderate
amount of
secretions, which may predispose the patient to aspiration.
Imaged lung
apices are clear.
IMPRESSION:
1. No evidence of acute fracture or malalignment. Degenerative
changes are
most pronounced at C6-C7 level.
2. Dilated and patulous esophagus with moderate amount of
secretions, may
predispose patient to aspiration.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
78 yof admitted to MICU for unresponsiveness, concern for TTP.
Initially presented with thrombocytopenia, renal failure,
seizures, fevers, and hemolytic anemia consistent with TTP.
Intubated due to hypercarbic respiratory distress/ failure to
maintain air way. Plasmapharesis was initiated without much
improvement in clinical presentation. Head imaging revealed
multiple cerebral and brainstem infarcts in context of TTP.
Patient also sufferred a STEMI. Course was complicated by line
infections and ventilator associated pneumonia. Family meeting
was held which discussed poor prognosis and poor recovery given
multiple organ distress and cerebral pathology. Patient was
made DNR. On HD 13, sufferred a bradyarrhythmia, went into PEA
arrest, and passed away. Autopsy was declined by HCP.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth daily - No
Substitution
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
GLIPIZIDE - 2.5 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth daily
HYDRALAZINE - 50 mg Tablet - 1 Tablet(s) by mouth every eight
(8)
hours
ISOSORBIDE DINITRATE - 20 mg Tablet - 1 Tablet(s) by mouth three
times a day
METOPROLOL SUCCINATE - 200 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth daily take with 200mg tablets
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
SITAGLIPTIN [JANUVIA] - 100 mg Tablet - 1 Tablet(s) by mouth
daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - 1,000 unit Tablet,
Chewable - 1 Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - 1,000 mg Capsule - 1
Capsule(s) by mouth daily
Discharge Medications:
Patient Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Deceased
Discharge Condition:
Patient Deceased
Discharge Instructions:
Patient Deceased
Followup Instructions:
Patient Deceased
ICD9 Codes: 5849, 2760, 7907, 4275, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5652
} | Medical Text: Admission Date: [**2162-9-12**] Discharge Date: [**2162-9-14**]
Date of Birth: [**2086-9-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Inferior MI
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Patient is a 76 y/o make who presented today to [**Hospital3 **]
with chest pain. The family reports that the pt at 1:30 for the
first time complained of substernal chest prssure. He tried tums
without relief. He then went to the bathroom. When his daughter
opened the door a few minute later, he fell towards her. she was
able to catch him and lay him on the ground. He lost
consciousness for several secondas and then woke up again,
unable tp express himself, goaning only. 911 was called.
The pt was brought to [**Hospital3 **]. There on EKG he was found
to have ST elevations in II,III and aVF, as well as V3,v4, v5.
He was also in complete heart [**Doctor Last Name **],. Atropine was given.
Dopamine was started for hypotension. Heparin was started. he
was tranferred to [**Hospital1 18**] for urgent intervention.
.
At [**Hospital1 18**] the patient arrived hypotensive with systolic BP 59, HR
50. He went into asystole and was given stropine. A temporary
pacer wire was placed. Cardiac Catherization revealed a
completely accluded RCA and high grade stenosis of the LCX. The
pt had a BM stent placed to the RCA and amgioplasty of the Lt
Cx. A right heart cath showed PA pressure of 40/24, AO pressure
of 72/45. An IABP was placed., Dopamine was continued. Several
doses of Atrpine were given throughout the procedure. During the
prcedure the pt experienced vagal symptoms including pause of a
few seconds duration as well as nausea and vomiting. He had a
documented aspiratione vent and was intubated for airway
protection. The patietn then developed hypotension and was
started on neosynepherine and phenylepherine for pressure
support. A total of 6L NS was given. The pt was Plavix loaded
with 600mg. An ECHO did not reveal ventricular wall rupture,
acute valvular dysfunction or tamponade. The LV appeared largely
normal. 3 amps of NaHCO3 was given for acidemia.
.
On review of symptoms the family denies hx of stroke, DVT, PE,
bleeding at tiem of surgery, black or red stools.
.
Cardiac review of symptoms is notable for absence of chest pain,
PND, PA ,orthopnea, palpatations.
.
Pn arrival to the CCU, te pt was hypotensive. Intial ABG
revealed pH of 7.09. 3 amps of bicarb given. Neosynepherine,
dopamine and phynepherine were titrated to max doses. Pacing
rate increased to 86. MAP imorved to 60's./ Family was informed
of grave prognosis
Past Medical History:
COPD. no baseline O2 req
c/p cholecystectomy
s/p b/l knee surgery
h/o TIA on ASA
Macular degeneration, legally blind
Social History:
non contributory
Family History:
non contributory
Physical Exam:
VS: T 90.6, BP 83/43, HR 80, RR 38, o2 sat 100 on AC
600/28/5/0.4.
Gen: intubated, sedated, cool, cyanotic extremities
HEENT: sclera anicteric, chemtic conjuctiva, dilated pupils , +
corneal reflex, cyanosis of lips
NECK: supple with elevated JVP
CV: PMI in 5th intercostal space, midclavilcular line, distant
heart sounds.
CHEST: no chest wall deformaties, scoliosis or lyphiosis, resp
were labored with increased accessory muscle use to force
expiration. + wheezes. cracles at bases
ABD: Obsese, soft, distended, nontender, organs not maplated.
No abd bruits. ubilical hernia
Ext: no c/c/e. IABP with arterial sheeth in place on the Rt.
Venous sheath with PA cath on Lt.
Pertinent Results:
Cardiac cath [**2162-9-13**]
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Profound systemic arterial hypotension.
3. Acute inferior myocardial infarction, managed by acute PCI,
IABP, and
temporary pacemaker.
4. Successful PTCA and stenting of 100% proximal RCA lesion.
Brief Hospital Course:
Inferior MI:
PAtient was transferred from OSH for cardiac catheterization.
the RCA was stented, and following this, he had became
bradycardic, nauseous and vomited, with witness aspirtation. He
was unresponsive, and there was a code blue. He was given
atropine, and asytole resolved. He received a temporary pacer.
He was persistently hypotensive despite fuid hydration and was
put on levophed, dopamine and neosynepherine. He was transferred
to he ICU in critical condition. Repeat ABGs revieled pH below
7.2, and was given several amps of bicarb. The family was
informed of the grave prognosis, and they made the decision to
withdraw care. The pressors were discontinued, and the patient
was declared dead on [**2162-9-14**].
Medications on Admission:
ASA 325mg
Inhalers
Vitamins.
Discharge Medications:
none.
Discharge Disposition:
Expired
Discharge Diagnosis:
Inferior MI
Discharge Condition:
deceased
Discharge Instructions:
rest in peace
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2162-12-2**]
ICD9 Codes: 2762, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5653
} | Medical Text: Admission Date: [**2200-5-18**] Discharge Date: [**2200-5-30**]
Date of Birth: [**2140-12-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Wheezing and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo man with severe asthma who originally presented w/ 3 days
of worsening dyspnea c/w prior exacerbations, now transferred to
the Medicine team for ongoing care. He had asthma exacerbation 3
wks ago requiring prednisone taper, which he completed about 1
wk ago. Over the past few days, he has had productive cough and
pleuritic chest pain, but no F/C. Went to [**Location (un) **] HC on day
of admission and was treated w/ albuterol/atroven nebs and
solumedrol, but symptoms were unrelieved, prompting referral of
pt to the [**Hospital1 18**] ED. In ED, he was placed on continuous nebs and
given prednisone 40 mg, then admitted to the [**Hospital Unit Name 153**] for ongoing
care.
On arrival to the [**Hospital Unit Name 153**], ABG was 7.29/47/83, which was concerning
for respiratory fatigue. He was treated w/ heliox and
eventually offered BiPAP, though he refused BiPAP treatment.
Though he was afebrile, empiric treatment for CAP was begun w/
ceftriaxone and azithromycin. He was found to have RSV
infection on viral culture, which is a likely explanation for
his current asthma exacerbation. His respiratory status
improved steadily until the present time, when he is transferred
to the Medicine team for ongoing care.
Currently, the pt complains of ongoing dyspnea and cough that
are moderately controlled w/ nebulized albuterol. He complains
of lumbar back pain that is partially relieved by percocet.
Denies any fever, chills, abd pain, nausea, vomiting, diarrhea,
constipation, hematochezia, and melena.
Past Medical History:
1. MRSA lung abscess in [**3-14**] s/p tx with linezolid
2. Asthma FEV1 35% FVC 50%, intubation x 1
3. HTN
4. PAF
5. h/o pleural effusion
6. cocaine abuse
7. chronic pain
8. Adm [**3-14**] for syncope in setting of cocaine use, ruled out for
MI.
9. Negative HIV [**2-11**]
10. Laminectomy [**7-15**] yrs ago
Social History:
cocaine abuse, last used 6 day PTA. Lives with fiance. Denies
tobacco, denies any IVDU in past or present.
Family History:
Denies CAD, CA, DM. Brother with lymphoma.
Physical Exam:
VS T 98.0, BP 142/80, HR 89, RR 18, O2 sat 98% 4L/m
Gen: disheveled man sitting up in bed eating dinner, speaking in
full sentences in NAD
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD, no LAD
CV: reg s1/s2, no s3/s4/m/r
Pulm: fair air movement throughout; diffuse exp wheezing w/
prolonged exp phase, no crackles
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP B, 1+ pitting edema to the mid-leg B
Neuro: CN 2-12 intact, alert and oriented x 3, strength 5/5
throughout UE/LE B
Pertinent Results:
[**2200-5-19**] 04:45AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
[**2200-5-23**] 05:22AM BLOOD WBC-11.6* RBC-4.47* Hgb-13.6* Hct-40.8
MCV-91 MCH-30.5 MCHC-33.4 RDW-14.5 Plt Ct-245
[**2200-5-23**] 05:22AM BLOOD Plt Ct-245
[**2200-5-23**] 05:22AM BLOOD Glucose-83 UreaN-20 Creat-0.9 Na-140
K-3.8 Cl-96 HCO3-37* AnGap-11
[**2200-5-23**] 05:22AM BLOOD Calcium-9.7 Phos-2.7 Mg-2.1
CXR: Cardiac and mediastinal contours are normal. The lungs are
clear. Pulmonary vasculature is normal. The osseous structures
are unremarkable. There is apparent gynecomastia.
EKG: Sinus rhythm. Modest low amplitude lateral T waves - are
nonspecific and may be within normal limits. Since previous
tracing of [**2200-3-12**], lateral T wave amplitude lower.
Rapid Respiratory Viral Antigen Test (Final [**2200-5-20**]):
Positive for Respiratory Syncytial viral antigen.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
Brief Hospital Course:
1. Asthma Exacerbation: Pt's nasal washings returned positive
for RSV. On admission he had marked wheezing and poor air
movement, with ABG of [**2142-9-4**]/83. He gradually improved on
solumedrol, continuous nebs, advair, singulair, heliox, Azithro
(5 days) and Ceftriaxone. Pt did not require intubation, and
his nebs were spaced out to q4hrs. Pt's breathing was
comfortable and non-wheezy by HD#5 when observed from the door,
however, pt appears to exagerate end-expiratory wheezing and
laboured breathing when approached. He was felt to have a
component of psychogenic dyspnea overlying his asthma
exacerbation. He was slowly titrated down on his steroid dose,
and he frequently requested to be placed on higher doses of
steroids despite an improving exam and vitals. Eventually, he
had both subjectively and objectively improved to the point
where he was tolerating oral steroids and was able to be
discharged home on a taper with plans to follow-up with his
outpatient pulmonologist.
2. Psych/Neuro: Cocaine Abuse and Opioid Dependence. Pt's urine
tox screen was positive for cocaine and opioids. Pt was
requiring two percocets every 4 hours for low back pain s/p
laminectomy. Attempts to wean his percocets were made in effort
to minimize suppression of his cough. However, pt was unhappy
with this recommendation and insisted on his usual dose of
percocets, stating that the wheezing/coughing greatly
exacerbated the back pain. He was seen by the addictions
consult and social work while he was an inpatient; their
discussions culminated in an agreement that Mr. [**Known lastname **] would seek
outpatient counseling for his substance abuse difficulties,
which are both worsened by and worsen his chronic pain.
He was discharged on a brief course of oxycodone/acetaminophen,
with the understanding that should he have ongoing pain
medication requirements, he would need to finally establish a
primary care physician; he has been stating that this is
something he would do, but has failed to do so for months. He
was provided with multiple names and numbers of providers in his
area, and he informed the team that he was dedicated to being
seen by one of them.
3. Hypertension: Pt was hypertensive on admission in setting of
his acute asthma exacerbation. He continued to be hypertensive
and HCTZ was started, with a good effect and was tolerated well.
His electrolytes and renal function remained stable on this new
medication, and he was advised to see a primary care doctor to
follow both this and his numerous other medical issues.
Medications on Admission:
Singulair
Advair
Flovent
Albuterol
Percocet
Recent prednisone taper
Discharge Medications:
1. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
2. Guaifenesin 100 mg/5 mL Liquid Sig: 5-10 MLs PO q4-6h prn.
[**Known lastname **]:*50 ML(s)* Refills:*0*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*0*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q2H (every 2 hours) as needed.
[**Known lastname **]:*1 MDI* Refills:*0*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*qs 1 month supply* Refills:*0*
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
[**Hospital1 **]:*30 Capsule(s)* Refills:*0*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day:
for 2 days ([**Date range (1) 25243**]), then 5 tabs daily for 2 days
([**Date range (1) 25244**]), then 4 tabs daily for 2 days (4/26/05-4/27), then 3
tabs daily for 2 days ([**6-5**]/-[**6-6**]), then 2 ts daily for 2 days
([**Date range (1) 25245**]), then 1 tab daily for 2 days ([**Date range (1) 25246**]).
[**Date range (1) **]:*42 Tablet(s)* Refills:*0*
15. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
[**Date range (1) **]:*1 MDI* Refills:*0*
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every 4-6 hours as needed.
[**Date range (1) **]:*qs one month* Refills:*0*
17. one touch ultra lancets
use as directed
[**Date range (1) **]: 90
refills: 0
18. one touch ultra test strips
use as directed
[**Date range (1) **]: 90
refills: 0
19. space chamber
use as directed
[**Date range (1) **]: 1
refills: 0
20. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 5 days.
[**Date range (1) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: asthma exacerbation
Secondary: acute bronchitis, hypertension, hyperglycemia
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed. You have been started
on lisinopril and hydrochlorothiazide for high blood pressure.
Please follow-up as below. It is very important that you
follow-up with a new primary care physician.
[**Name10 (NameIs) 357**] check your blood sugars 2-3 times a day before meals. If
your fingersticks are persistently >250, please call your
primary care physician (see below)
Followup Instructions:
1) Pulmonary
- you will be contact[**Name (NI) **] by the pulmonary clinic regarding an
appointment with Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 575**]. If you have not heard
from them in the next week, please call [**Telephone/Fax (1) 612**].
2) Primary care: If you are unable to establish a new primary
care physician at [**Name9 (PRE) **] Care (1- [**Last Name (un) **]
[**Last Name (un) 25247**], East [**Numeric Identifier 25248**]) as you plan to, you have been schedule
for a new patient appointment as below:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 25249**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2200-6-4**] 1:30
ICD9 Codes: 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5654
} | Medical Text: Admission Date: [**2136-11-18**] Discharge Date: [**2136-11-21**]
Date of Birth: [**2085-2-15**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain, SOB, nausea
Major Surgical or Invasive Procedure:
percutaneous angioplasty PL branch of RCA
History of Present Illness:
Mr [**Known lastname **] is a 51yoM with h/o HIV/AIDS (in [**7-/2136**], CD4 582, HIV
VL non-detectable), pulmonary HTN (on sildenafil), HCV, who
presents with chest pain and STEMI in distal RCA. He initially
presented to [**Hospital1 18**] ED with 3 hours of severe ([**9-12**])substernal
burning chest pain/pressure radiating to his left arm.
Associated with nausea and shortness of breath. No pleuritic
component. No recent fevers, chills, or cough. Unable to
describe whether it is exertional because he has not really
exerted himself during the symptoms. The patient had gotten up
early in the morning and gone to church then participated in
church activities. He put his feet up when he got home and
began to experience the chest pain. No prior similar episodes.
No syncope or dizziness. No focal weakness, numbness, or
tingling. No recent catheterization or a stress test. He did
have a cardiac cath in [**2129**], that showed disease in LMCA and
LAD, but none in RCA.
Past Medical History:
1. CARDIAC RISK FACTORS: no Diabetes, no Dyslipidemia, no
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- prior cath [**2129-8-3**] (report is below): disease to LMCA and
LAD
- HIV/AIDS: last counts on [**7-/2136**], CD4 was 582, HIV VL non-
detectable, on Truvada/Kaletra.
- h/o disseminated [**Doctor First Name **]
- h/o rectal herpes
- Hepatitis C-completed 1 yr of ribavirin/PEG-IFV therapy; HCV
viral load undetectable in [**2130**]
- Pulmonary hypertension-on sildenafil
- HPV (perirectal) with anal dysplasia- He underwent transanal
microscopially assisted laser destruction of anal condyloma
excisional on [**2132-4-11**]. The path report of 2 biopsied lesions
demonstrated high grade squamous intraepithelial lesion (anal
intraepithelial neoplasia II-II) extending to peripheral
specimen margins. Initiated topical aldara therapy.
- Schatzki's ring - esophageal dilitation
Social History:
He lives with his non-[**Name (NI) 106973**] husband. They have been in a
monogamous in the relationship for over ten years. The patient
works at the front desk in his husband's hair salon in [**Location 9104**]. His husband is a world-reknowned hair colorist. He has
a prior history of smoking. He smoked 1 PPD for 15 years and
quit 20 years ago. He denies any current alcohol as it
interferes with his medications. No prior history of alcohol
abuse. He denies any present drug use. Distant marijuana use
- Tobacco history: former
- ETOH: none
- Illicit drugs: none
Family History:
- Adopted. Unknown history.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: 96.9, 76, 121/77, 16, 97%/2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Mildly
uncomfortable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-11**] holosystolic murmur best heard at
apex. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Post-cath cuff on
right wrist without any TTP or hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
PHYSICAL EXAMINATION ON DISCHARGE:
Vitals - Tm/Tc: 98.2 HR: 66 (53-66) BP: 102/64 (84-107/44-69)
RR: 16 02 sat: 94%RA (94-98% RA)
In/Out: not recorded
Weight: 83.5 kg
Tele: SR, no events
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Very
pleasant.
HEENT: NCAT. MMM.
NECK: Supple with JVP 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-11**] holosystolic murmur best heard at
apex. No thrills, lifts. No S3 or S4. no carotid bruits
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness. + bowel sounds
EXTREMITIES: No c/c/e. No femoral bruits. Dressing over RRA
C/D/I. No hematoma or oozing.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
[**2136-11-18**] 06:20PM WBC-7.7 RBC-4.51* HGB-16.1 HCT-47.3 MCV-105*
MCH-35.8* MCHC-34.1 RDW-12.2
[**2136-11-18**] 06:20PM GLUCOSE-87 UREA N-15 CREAT-0.9 SODIUM-135
POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-22 ANION GAP-17
[**2136-11-18**] 06:20PM NEUTS-49.3* LYMPHS-40.8 MONOS-7.5 EOS-1.9
BASOS-0.5
[**2136-11-18**] 06:20PM PT-12.6 PTT-28.3 INR(PT)-1.1
[**2136-11-18**] 06:20PM cTropnT-<0.01
.
Relevant labs:
[**2136-11-19**] 03:17 CK 485/CK-MB 63/TropnT 0.52
[**2136-11-19**] 09:11 CK 563/CK-MB 75/TropnT 0.73
[**2136-11-19**] 15:33 CK 372/CK-MB 52/TropnT 0.69
[**2136-11-20**] CK 153/CK-MB 18/TropnT 0.57
.
Labs on discharge:
[**2136-11-21**] WBC 6.5/RBC 4.08/Hgb 14.7/Hct 42.5/Plt 224
[**2136-11-21**] Gluc 92/BUN 19/Crea 1.1/ Na 134/K 4.0/Cl 99/HCO3 25/Ca
9.1/Mg 2.0/Phos 2.6
.
TTE:
[**2136-11-19**]
The left atrium is mildly elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
CARDIAC CATH:
[**2136-11-18**]
1. Selective coronary angiography of this right dominant system
demonstrated three vessel coronray disease. The LMCA had 40%
distal
stenosis. The LAD had 40% mid-vessel stenosis. The LCx had 60%
mid and 60% distal stenosis. The RCA had 50% mid-vessel
stenosis, 50% PDA
stenosis and 100% occlusion of the posterolateral branch.
2. Limited resting hemodynamics revealed normotension.
3. Perfusion of a small RPL branch successfully treated by PTCA
with 2.25 mm balloons.
Diagnosis: 3 vessel cardiac disease
.
[**2129-8-3**]
1. Selective coronary angiography demonstrated a right-dominant
circulation with mild coronary artery disease. LMCA had a
distal 40%
stenosis. LAD had a proximal 50% stenosis. LCx was diminutive,
and had no angiographically-apparent flow-limiting stenoses.
RCA was a large, dominant vessel without
angiographically-apparent stenoses.
2. Left ventriculography demonstrated no significant mitral
regurgitation, normal wall motion and EF of 60%.
3. Resting hemodynamics with patient breathing ambient air
demonstrated severe pulmonary hypertension (mean PA 51 mmHg).
Right-
and left-sided filling pressures were normal (mean RAP 3 mmHg,
RVEDP 7 mmHg, mean PCWP 3 mmHg). Cardiac output at baseline was
3.9 L/min with cardiac index of 1.9 L/min/m2. Baseline PVR was
calculated to be 2106 dynes-sec/cm5. After 15 minutes with
patient breathing 100% oxygen via a face mask, repeat
hemodynamics demonstrated no significant change in pulmonary
pressure. Cardiac output increased to 5.1 L/min, and calculated
PVR decreased to 1286 dynes-sec/cm5. After 15 minutes with
patient breathing nitric oxide at 40 ppm, repeat hemodynamics
demonstrated minimal reduction in pulmonary pressures (mean PA
45 mmHg), but no further increase in cardiac output, or decrease
in PVR beyond what was seen with 100% oxygen.
.
CXR:
[**2136-11-20**]
Previous mild interstitial pulmonary edema has improved. There
is no
consolidation or appreciable pleural effusion. Marked pulmonary
artery
dilatation and azygous distention are longstanding, evidence of
pulmonary
arterial hypertension and possible central venous hypertension.
Extensive
calcific hilar adenopathy as demonstrated by CT scanning is not
readily
appreciated on conventional radiographs.
.
[**2136-11-18**]
Single semi-erect AP portable view of the chest was obtained. No
evidence of a pneumothorax is seen. The right costophrenic angle
is not fully included on the image, however no large pleural
effusion is seen. There is no focal consolidation. Prominence of
the hila and AP window persists, stable. Cardiac and mediastinal
silhouettes are stable.
Brief Hospital Course:
Mr [**Known lastname **] is a 51yoM with h/o HIV/AIDS (in [**7-/2136**], CD4 582, HIV
VL non-detectable), pulmonary HTN and HCV presenting with chest
pain, SOB and nausea, found to have an inferior STEMI with 100%
occlusion of the RPLA, which was opened with balloon
angioplasty.
.
.
ACTIVE ISSUES:
# STEMI: A prior cath in [**2129**] showed mild CAD in LAD (50%) and
LMCA (40%) but otherwise his cardiac history is negative. This
was his first episode of chest pain. The only major known risk
factors being prior tobacco use and HIV infection. On admission
his EKG showed an inferoposterior STEMI with a negative Troponin
T. The patient was directly taken to the cath lab on [**2136-11-18**]
where 100% occlusion of RPL was found and opened by angioplasty.
Notably he was also found to have 40% stenosis in the LMCA and
LAD, 60% in the LCx, and 50% in the RCA and PDA. Prior to
catheterization, he had been treated with bivalirudin, which may
carry a significantly decreased risk of bleeding complications
(40% less than heparin + integrillin) after cath. He tolerated
the procedure well with resolving EKG changes after the
intervention. The cardiac markers where elevated up to a peak of
CK 563/CK-MB 75/TnT 0.73, finally trending down again prior to
discharge. However he had ongoing throbbing chest pain on day 1
post-cath which was responsive to 4mg Morphine but not to
Nitroglycerin. Several EKGs were obtained during these episodes
but did not support the idea of persistent ischemia and showed
normal sinus rhythm. A TTE on [**2136-11-19**] showed normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function (LVEF >55%). The thoracic aorta
was mildly dilated at sinus level. The patient was started on
Aspirin 325mg daily (for 2 weeks), Plavix 75mg daily (for 2
weeks), Metoprolol succinate 12.5mg daily, Lisinopril 2.5mg
daily and Atorvastatin 80mg daily (LDL goal: 70). Concerning the
work up of further risk factors his lipid panel showed
cholesterin 174/LDL 116/HDL 42/triglycerides 81. His HbA1c is
5.5%.
.
.
CHRONIC ISSUES:
# HIV/AIDS: The patient is compliant with home medications and
has excellent follow-up with his PCP, [**Name10 (NameIs) 1023**] manages his
antiretrovirals, Kaletra and Truvada. As of [**2136-7-30**], his CD4
was 582 and viral load <50. During this admission, his Kaletra
and Truvada were continued, but the patient's PCP may consider
changing antiretroviral regimen to medications with fewer
cardiac/metabolic side effects.
.
# Pulmonary Hypertension: Documented history of this problem,
which has been stable. The patient's sildenafil (with which he
has been treated since [**2129**]) was held for two days secondary to
hypotension, and restarted upon discharge.
.
# Depression/Anxiety: Documented history of this problem, for
which he was treated with citalopram and lorazepam prior to
admission. During this admission, he demonstrated a normal QTc
on EKG, so his citalopram was continued with low concern for
induction of Torsades de pointes.
.
.
TRANSITIONAL ISSUES:
- recommend reassessment of sildenafil therapy by PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] Aspirin 325mg for 2 weeks, then change to 81mg
- continue Plavix 75mg for 2 weeks
- PCP may consider changing antiretroviral regimen to
medications with fewer cardiac/metabolic side effects
Medications on Admission:
HOME MEDICATIONS: confirmed with patient
- albuterol 90mcg HFA inhaler 1-2 puffs INH [**Hospital1 **] PRN (takes [**2-5**]
x/week)
- citalopram 20mg PO qday
- truvada 200mg/300mg PO qday
- fexofenadine 60mg PO BID
- Kaletra 200-50mg 2 tablets PO BID
- Lorazepam 1mg QID and 2mg QHS
- Ranitidine 300mg [**Hospital1 **]
- Sildenafil 25mg TID (last at noon)
- Triancinolone groin prn
- Zolpidem 6.25 mg Tablet,Ext Release Multiphase QHS
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation twice a day as needed for shortness of
breath or wheezing.
7. ammonium lactate 12 % Lotion Sig: One (1) application Topical
twice a day.
8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for anxiety: [**Month (only) 116**] take additional pill at bedtime.
10. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. sildenafil 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
12. zolpidem 6.25 mg Tablet,Ext Release Multiphase Sig: One (1)
Tablet,Ext Release Multiphase PO at bedtime as needed for
insomnia.
13. lidocaine 4 % Cream Sig: One (1) application Topical twice a
day.
14. triamcinolone acetonide 0.1 % Lotion Sig: One (1)
application Topical twice a day.
15. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
17. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation myocardial infarction
Pulmonary hypertension
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had chest pain and a heart attack. A cardiac catheterization
was performed and found a 100% blockage in an artery that is an
extension of the right coronary artery. A balloon agioplasty was
performed to open the artery but no stent was placed. You also
had moderate blockages in the left anterior descending artery,
the left main artery and the right coronary artery itself. It is
important that you take all of your medicines as prescribed to
try to prevent these blockages from getting worse and causing
another heart attack.
We made the following changes to your medicines:
1. Start aspirin and plavix (clopidogrel) to help to prevent a
clot in your coronary arteries. Dr. [**Last Name (STitle) 911**] may stop the plavix
but you need to take an aspirin for the rest of your life.
2. Start taking Atorvastatin (Lipitor) every day to lower your
cholesterol
3. Start taking metoprolol to lower your heart rate and help
your heart recover from the heart attack.
4. Start taking lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
.
Please note that nitroglycerin interacts with the Sildenafil and
should be avoided.
Followup Instructions:
***Dr. [**Last Name (STitle) **] needs to know about your heart attack before this
test is performed.
Department: ENDO SUITES
When: TUESDAY [**2136-12-11**] at 10:00 AM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2136-12-11**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Please call Infectious Disease where you see your primary care
physician and book an urgent care appointment within 1 week of
hospital discharge.
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2136-12-5**] at 12:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2136-12-5**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2136-12-26**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4168, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5655
} | Medical Text: Admission Date: [**2178-1-28**] Discharge Date: [**2178-2-2**]
Date of Birth: [**2102-11-4**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Right thigh hematoma, pain limiting ability
to walk.
HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old
man with a history of CVAs with poor gait at baseline. He
suffered a fall on [**2178-1-23**] for which he came into the [**Hospital1 18**]
Emergency Room. He was found to have a right thigh hematoma
at that time. Hematocrit was 33.7. He had a plain film done
of the femur which did not show any fracture. He is on
Coumadin at baseline for stroke prophylaxis.
He returned to the Emergency Department on [**2178-1-28**] with
complaints of right thigh pain limiting his ability to walk.
He was observed to have a right thigh hematoma at that time.
His hematocrit was 25.7 on [**2178-1-28**]. This was felt secondary
to continued bleeding into his right thigh. Consequently, he
was given 3 units of fresh frozen plasma transfusion. During
infusion of the 3 units of fresh frozen plasma, he became
hypertensive, tachypneic, and tachycardiac. He required
elective intubation and was transferred to the Medical
Intensive Care Unit.
His clinical picture was consistent with
transfusion-associated acute lung injury. Benadryl and
Solu-Medrol were started. He extubated without difficulty on
[**2178-1-29**] and was transferred to the Medical Service
at that point. Further details available in the hospital
course stated later in this discharge summary.
PAST MEDICAL HISTORY:
1. Right parietal cortical stroke.
2. Right-sided weakness secondary to stroke. The patient
walks with a walker at baseline.
3. Chronic lower back pain.
4. Hypertension.
5. Depression.
6. Migraine headaches.
7. Seizure disorder.
8. Hypercholesterolemia.
9. History of falls.
MEDICATIONS ON ADMISSION:
1. Valproic acid 500 mg q.d.
2. Neurontin 300 mg t.i.d.
3. Coumadin 5 mg on Monday, Wednesday, and Friday, 2.5 mg
q.d. on the other days.
4. Zoloft 50 mg q.d.
5. Aspirin 325 mg q.d.
6. Lipitor 10 mg q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He use to smoke cigars, occasionally drinks
alcohol. He is married. He lives with his wife and his
daughter.
PRIMARY CARE MEDICAL DOCTOR: Dr. [**Last Name (STitle) 74869**] located at [**Hospital3 **]
in [**Location (un) 1439**], [**State 350**].
PHYSICAL EXAMINATION ON ADMISSION: Vital signs on admission
to the Intensive Care Unit: Temperature 103, blood pressure
112/72, heart rate 105, respiratory rate 21, 02 saturation
100% on assist control ventilation. General: He was
intubated and sedated. Chest: Bilateral rales. Cardiac:
Regular rate and rhythm with holosystolic murmur at the apex
at the right upper sternal border. Abdomen: Soft,
nontender, nondistended. Extremities: Right thigh hematoma.
On arrival to the Medicine floor on [**2178-1-29**], temperature
98.6, pulse 76, blood pressure 106/62, 02 saturation 96% on 2
liters. Chest: Minimal crackles at the bases, otherwise
clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm, normal S1, S2, with a systolic murmur.
Abdomen: Soft, nontender, nondistended. Extremities: Right
upper thigh had an ecchymosis that was tender to palpation.
Of note, on [**2178-2-2**], the borders of the ecchymosis had
regressed and the patient was also reporting less pain in the
area. The area was also noted to be less tense on [**2178-2-2**].
LABORATORY VALUES: Hematocrit 33.7 on [**2178-1-23**], 25.7 on
[**2178-1-28**], 22.1 on [**2178-1-29**], 21.2 on [**2178-1-30**], 32.2 (stable)
status post transfusion with 3 units of packed red blood
cells, RBCs transfused on [**2178-1-30**], hematocrit 32.2 on
[**2178-2-2**]. INR 3.6 on [**2178-1-23**], 2.1 on [**2178-1-24**], 2.3 on
[**2178-1-28**], 1.2 on [**2178-2-1**].
On [**2178-2-2**], WBC 11.7 (peak 18.7 on [**2178-1-30**]), hematocrit
32.2, platelets 322,000.
Reticulocyte percentage 5.2% on [**2178-1-28**].
The urinalysis was negative for infection on [**2178-1-28**].
Chem-7 on [**2178-1-28**] revealed a sodium of 141, K 3.5, CL 98,
C02 23, BUN 22, creatinine 0.8, glucose 122. On [**2178-2-2**],
sodium 141, K 3.7, CL 106, C02 26, BUN 20, creatinine 0.6,
glucose 126.
On [**2178-1-28**] CK 226, LDH 264, total bilirubin 1.5.
Troponin 0.7 on [**2178-1-29**], peak was 1.3 on [**2178-1-29**].
On [**2178-1-29**], haptoglobin 226, HDL 45, LDL 63, triglycerides
161.
IgA level 195 (normal).
EKG on [**2178-1-28**]: Sinus rhythm at 100 beats per minute, axis
normal. There is evidence of left ventricular hypertrophy.
There are ST depressions in leads V4, V5, and V6. Of note,
these ST depressions normalized on [**2178-1-29**].
IMAGING DATA:
1. Plain film of right femur and hip on [**2178-1-23**]: There is
no evidence of fracture. There is a small suprapatellar
effusion.
2. CT of the head on [**2178-1-28**]: There is an old infarction
in the right parietal lobe. There was bilateral low
attenuation of the periventricular white matter. There was
no evidence of acute hemorrhage or mass affect.
3. Cervical spine plain film [**2178-1-28**]: Carotid
calcifications are present. No cervical spine fracture is
seen.
4. Hip x-ray on [**2178-1-28**]: Possible left sacral strut
fractures. No abnormalities seen on the ankle film.
5. Ultrasound of right thigh hematoma on [**2178-1-28**]: There is
a small right thigh fluid collection consistent with a small
hematoma.
6. Chest x-ray on [**2178-1-28**]: Status post intubation,
interstitial pulmonary edema which is new compared with
[**2177-5-22**].
7. Cardiac echocardiogram on [**2178-1-30**]: Ejection fraction is
70-80%, TR gradient 47 mmHg. There was moderate symmetric
left ventricular hypertrophy. The LV systolic function is
hyperdynamic. These findings are consistent with
hypertrophic obstructive cardiomyopathy. There was 2+ mitral
regurgitation. There was moderate left ventricular outflow
tract obstruction at rest.
IMPRESSION/PLAN: The patient is a 74-year-old gentleman with
a history of mechanical falls who comes in with right thigh
pain status post mechanical fall and was found to have a
hematoma. He received fresh frozen plasma on [**2178-1-28**] and
subsequently developed respiratory distress during the third
unit of FFP transfusion.
1. RESPIRATORY DISTRESS: This was felt secondary to
transfusion-related acute lung injury. He was intubated on
[**2178-1-28**] and extubated easily on [**2178-1-29**]. He was given two
days of steroids, Solu-Medrol 100 mg q.i.d. He was evaluated
by the Transfusion Medicine attending who felt that his
clinical picture and findings were consistent with
transfusion-related acute lung injury. He made notes that
this event does not place patients at increased risk in the
future of recurrence of this event.
The patient did well from a respiratory standpoint status
post extubation.
2. ANEMIA: The patient's baseline hematocrit appears to be
30-32. The drop in his hematocrit to a nadir of 21-22 on
[**2178-1-29**] to [**2178-1-30**] was felt secondary to his bleed into his
thigh hematoma. He was transfused with 3 units of packed red
blood cells on [**2178-1-30**]. He tolerated this transfusion well
without any difficulty.
3. ELEVATED TROPONINS: The patient does not have a known
history of coronary artery disease. He had a cardiac
echocardiogram done on [**2178-1-30**] which showed evidence of
hypertrophic obstructive cardiomyopathy as stated in the
echocardiogram reports in this discharge summary.
EKG of [**2178-1-28**] showed depressions in V4 through V6. He had
a peak troponin of 1.3 when cardiac enzymes were cycled.
This picture was consistent with demand ischemia, likely felt
secondary to his anemia. This was another indication for his
transfusion of 3 units of packed red blood cells on [**2178-1-30**].
4. RIGHT THIGH PAIN/INABILITY TO WALK: The patient's
inability to walk was felt secondary to musculoskeletal and
soft tissue discomfort status post his fall. He was given
Percocet p.r.n. as needed with relief of symptoms. He also
was found to have a left sacral strut fracture on his plain
film.
He was evaluated by the Orthopedic Surgery Service and they
felt that no operative intervention was indicated.
5. HISTORY OF STROKES: The patient was maintained on
Coumadin for stroke prophylaxis as well as aspirin. Given
his history of mechanical falls as well as his drop in
hematocrit with this admission, we held the Coumadin while he
was in-house. We plan on holding the Coumadin indefinitely
until he is seen by his outpatient neurologist, Dr. [**Last Name (STitle) **],
who can decide at that time whether the benefits of Coumadin
anticoagulation for stroke prophylaxis may outweigh the
risks.
In general, the patient did well status post his extubation
and after his blood transfusion he is ready to go to
rehabilitation on [**2178-2-2**].
DISCHARGE DIAGNOSIS:
1. Transfusion-related acute lung injury.
2. Right thigh hematoma.
3. Sacral fracture.
4. Hypertrophic obstructive cardiomyopathy.
5. Anemia requiring transfusion complicated by evidence of
cardiac ischemia on EKG prior to transfusion.
DISPOSITION: The patient is discharged to rehabilitation.
DISCHARGE MEDICATIONS:
1. Valproic acid 500 mg q.d.
2. Neurontin 300 mg t.i.d.
3. Zoloft 50 mg q.d.
4. Aspirin 325 mg q.d.
5. Heparin 5,000 units subcutaneously b.i.d. (discontinue
when the patient is mobile).
6. Percocet (5/325) one to two tablets p.o. q. 4-6 hours
p.r.n. pain.
7. Ambien 10 mg q.h.s. p.r.n. insomnia.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2178-2-2**] 11:20
T: [**2178-2-2**] 11:37
JOB#: [**Job Number 100409**]
ICD9 Codes: 2851, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5656
} | Medical Text: Unit No: [**Numeric Identifier 76441**]
Admission Date: [**2201-1-11**]
Discharge Date: [**2201-1-26**]
Date of Birth: [**2201-1-11**]
Sex: M
Service: NB
PATIENT IDENTIFYING INFORMATION: The patient's discharge
name is [**Name (NI) **] [**Name (NI) **]. His [**Hospital3 1810**] medical
record number is [**Numeric Identifier 76442**].
HISTORY OF PRESENT ILLNESS: This is the former 585 gram
product of a 26 week twin gestation pregnancy, born to a 43
year-old, G2, P1 woman. Prenatal screens: Blood type 0
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
unknown. This was a vaginal insemination pregnancy with
donor sperm, resulting in monochorionic/diamniotic twins.
Twin-to-twin transfusion syndrome was noted at 17 weeks. The
mother underwent several amnioreductions for polyhydramnios
on the recipient twin. Two days prior to delivery, 1.9
liters of fluid was removed. On the day of delivery, there
was serious concern for the deteriorating status of the
recipient twin. The mother was taken to elective Cesarean
section under epidural and spinal anesthesia. This twin
number 2 emerged from the breech position. He required
bagged mask ventilation and was intubated for respiratory
distress. Apgars were 5 at 1 minute and 8 at 5 minutes. He
was transferred to the Neonatal Intensive Care Unit for
treatment of prematurity. This was the identified donor twin
in the twin-to-twin transfusion syndrome.
Anthropometric measurements upon admission to the Neonatal
Intensive Care Unit, weight was 585 grams; length 32 cm; head
circumference 22 cm, all less than 10th percentile for less
than 26 weeks gestation.
PHYSICAL EXAMINATION AT DISCHARGE: Weight 753 grams. Head
circumference 22.5 cm. Length 33 cm. General: Non
dysmorphic, intubated, preterm male. Skin: Bronze in color.
Warm and dry with flaking areas. Head, ears, eyes, nose and
throat: Anterior fontanel open and flat. Sutures apposed.
Eyes: Open with alert gaze. Orally intubated. Palate
intact. Symmetrical facial features. Neck supple without
masses. Chest: Breath sounds clear and equal, well aerated
with ventilator breaths. Cardiovascular: Regular rate and
rhythm. No murmur. Normal S1 and S2. Femoral pulses +2.
Abdomen: Full, slightly tense, nontender to palpation. Faint
bowel sounds. Cord remnant on and drying. Genitourinary:
Preterm male. Mild swelling in inguinal canal with extension
into the scrotum, noted to be air on
x-ray. Anus patent. Extremities: Moves all, straight with
normal digits. Neuro: Tone and reflexes consistent with
gestational age.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
Respiratory: This infant received 3 doses of surfactant. He
was initially managed on the conventional ventilator with
initial settings of peak inspiratory pressure of 34 over
positive end expiratory pressure of 6 and intermittent
mandatory ventilatory rate of 38 and 40 to 60% oxygen. He
was able to wean over the first 48 hours of life when he had
worsening of his respiratory status and was transferred to
the high frequency oscillating ventilator. He continued on
the oscillator until [**2200-1-25**], day of life 14, when he was
transitioned to the conventional ventilator. At the time of
discharge, his ventilatory settings were peak inspiratory
pressure of 21, positive end expiratory pressure of 26,
intermittent mandatory ventilatory rate of 22 and oxygen
requirement of 21 to 30%. His most recent capillary blood
gas had a pH of 7.27, a Pc02 of 61. He has been noted to have
old blood-tinged secretions from his endotracheal tube.
Cardiovascular: This infant had profound hypotension noted
at birth that persisted through the first week of life. He
was treated with multiple volume boluses and started on
Dopamine. His maximum Dopamine requirement was 25
mcg/kg/min. He received two, 3-dose courses of hydrocortisone
for his intractable hypotension.
A murmur had been noted on day of life 2 and the infant
received a single dose of indomethacin. Repeat
echocardiogram showed a patent ductus arteriosus with
intermittent bidirectional flow. A repeat echo on [**2200-1-20**]
showed a "huge" 3.5 mm patent ductus arteriosus with
continuous left to right flow. He was taken for patent
ductus arteriosus ligation on [**2201-1-21**]. He was able to wean
off the Dopamine within 16 hours of surgery.
At the time of transfer, his baseline heart rate is 140 to
160 beats per minute with a recent blood pressure of 69 over
38 mmHg. Mean arterial pressure of 50 mmHg. The rest of his
cardiac echo showed a patent foramen ovale, no other
structural heart disease noted and mild right ventricular
hypertension.
Fluids, electrolytes and nutrition: This infant was
initially n.p.o. and maintained on IV fluids. He had
umbilical arterial and venous catheters placed. The infant
has remained n.p.o. through his entire Neonatal Intensive
Care Unit. A percutaneously inserted central catheter was
placed in the left saphenous vein with its tip in the
inferior vena cava. At the time of discharge, he is
receiving parenteral nutrition of 16% glucose with amino
acids of 1.7%. Due to his cholestatic jaundice, his TPN was
being cycled off for 4 hours per day. Serum triglycerides
were stable on 2 grams per kg per day of intra-lipids which
was being held for one day due to the concern of the
cholestatic jaundice. Serum electrolytes were monitored
closely during admission and most recently were sodium of
131, potassium of 4.1, chloride of 90, carbon dioxide of 24.
Weight on the day of discharge is 753 grams.
This infant had significant renal insufficiency with little
to no urine output through the first 5 days of life. At the
time of discharge, his urine output is 3 to 4 ml per kg per
hour. His serum creatinine peaked at 3.6 and most recently
checked was 2.9 on [**2200-1-26**]. A renal ultrasound was
performed showing echogenic kidneys but otherwise normal
collecting system. The etiology for the renal insufficiency
was unclear.
Infectious disease: This infant was evaluated for sepsis
upon admission to the Neonatal Intensive Care Unit. A
complete blood count was notable for a white blood cell count
of 15,300 with 12% polymorphonuclear cells, 0% band
neutrophils. A blood culture was obtained and the infant was
started on IV ampicillin and gentamycin. With the onset of
his gastrointestinal perforation on day of life one, his
antibiotic coverage was switched to Zosyn. The Zosyn was
adjusted for dosing for his renal insufficiency and he
received 50 mg/kg per day. Blood cultures obtained on [**1-11**]
and [**2200-1-12**] were no growth.
Hematology: This infant is blood type 0 positive and direct
antibody test negative. He has received numerous transfusions
of all blood products including packed red blood cells, fresh
frozen plasma, cryoprecipitate and platelets. He had a mild
coagulopathy around the time of his gastrointestinal
perforation. His coagulation studies improved after infusions
of fresh frozen plasma. His most recent coagulation studies
were on [**2200-1-24**] with a PT of 14.8, PTT of 49.1 and
fibrinogen of 153. Of note, his most recent platelet count
was 429,000 with a white blood cell count of 37,100 with 76
polymorphonuclear cells, 3% band neutrophils. His lowest
white count occurred on day of life 4 at 4,600.
Gastrointestinal: As previously noted, this infant suffered
a gastrointestinal perforation which was temporarily related
to a single dose of indomethacin, given for a symptomatic
patent ductus arteriosus. The infant was evaluated by this
general surgery consultation team from [**Hospital3 1810**]
and 2 Penrose drains were placed. The perforation occurred
on [**2200-1-12**]. The drains were removed on [**2200-1-22**]. Then 24
hours after the drains were removed, free air was once again
noted on the abdominal x-rays. This was followed closely and
on [**2200-1-26**], there appeared to be substantially more free
air in the peritoneum with dissection down into the scrotum.
The surgical team from [**Hospital3 1810**] was reconsulted
and decision was made for the infant to be transferred to
[**Hospital3 1810**] for an exploratory laparotomy.
This infant also required treatment for unconjugated
hyperbilirubinemia with phototherapy. The phototherapy was
discontinued when the direct serum bilirubin began to rise.
It was first noted to be 1.4 on day of life #8 and
subsequently on day of life #5 was 2.2 mg/dl. On [**2200-1-24**],
it was 2.6 mg/dl and most recently on [**2201-1-26**], it was 5.0
mg/dl. The etiology of the elevated direct bilirubin is
unknown but is thought to be due to lack of feeding and
prolonged PN and IntraLipids. An abdominal ultrasound was
obtained on [**2200-1-23**] (his second) that showed echogenic
kidneys without hydronephrosis, a distended gallbladder
without stones or sludge, no gross biliary ductal dilatation.
Free intrabdominal air and air within the liver was also
noted.
Neurology: This infant has had 4 head ultrasound with all
results within normal limits, most recently on [**2201-1-19**]. He
has maintained a totally normal neurologic examination since
admission. He has been treated with Fentanyl intravenously
for pain and sedation. At the time of discharge, he is
receiving 1.2 mcg IV q. 2 to 3 hours.
Sensory:
Audiology: Hearing screening has not yet been performed but
is recommended prior to discharge.
Ophthalmology: This infant has not had his eyes examined for
retinopathy of prematurity. His first examination will be due
at 6 weeks of life.
Psychosocial: [**Hospital1 69**] social
worker has been involved with the family. Contact social
worker is [**Name (NI) 46381**] [**Name (NI) 36527**] and she can be reached at [**Telephone/Fax (1) 56048**]. This parenting situation is 2 mothers. They have a
15 month old child at home. They have been very involved in
[**Known lastname 43135**] care during admission. At one point, there was a
"do not resuscitate" order entered at the height of his
illness with his renal insufficiency and hypotension. The
order was rescinded prior to his patent ductus arteriosus
ligation.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**],
[**Location (un) 86**], for exploratory laparotomy surgery. The primary
pediatrician is Dr. [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) 59017**]. [**Hospital1 2921**] in [**Hospital1 3494**]. Telephone number [**Telephone/Fax (1) 76443**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. N.p.o./IV fluids at 140 ml/kg per day of peripheral
nutrition: Solution 16% glucose, 1.7% amino acids with 5
meq of sodium and 2 meq of potassium for 100 ml.
Reinitiate IntraLipds.
2. Medications:
Zosyn 30 mg IV q. 24 hours.
Vitamin A 5000 units IM q. Monday, Wednesday and Friday
for a total of 12 doses.
Iron and vitamin D supplementation: Iron supplementation
is recommended for preterm and low birth weight infants
until 12 months corrected age. All infants fed
predominantly breast milk should receive Vitamin D
supplementation at 200 i.u. (may be provided as a
multi-vitamin preparation) daily until 12 months
corrected age.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screens were sent on [**2200-1-16**]. No
notification of abnormal results to date.
5. Immunizations: No immunizations have been administered
thus far.
4. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received the rotavirus vaccine. The Americ
an Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 26 weeks gestation.
2. Small for gestational age.
3. Twin #2 of twin gestation.
4. Twin-to-twin transfusion syndrome. This is the donor
twin.
5. Respiratory distress syndrome.
6. Hypotension, resolved.
7. Suspicion for sepsis.
8. Patent ductus arteriosus, status post ligation [**2201-1-21**].
9. Indirect hyperbilirubinemia, resolved.
10. Gastrointestinal perforation with pneumoperitoneum, s/p
Penrose drain placement.
11. Anemia of prematurity.
12. Disseminated intravascular coagulopathy, resolved.
13. Renal insufficiency, improving.
14. Cholestasis
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37201**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2201-1-27**] 01:32:58
T: [**2201-1-27**] 05:10:42
Job#: [**Job Number 76444**]
ICD9 Codes: 769, 7742, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5657
} | Medical Text: Admission Date: [**2195-5-25**] Discharge Date: [**2195-6-4**]
Date of Birth: [**2117-6-13**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
s/p intubation
Cardiac catheterization
History of Present Illness:
77 year-old female with hypertension, renal sufficiency, CAD s/p
CABG ([**2174**]), SVT, diabetes mellitus type II, aortic stenosis
(valve area 1.0-1.2cm2 [**5-16**]), and frequent falls admitted with
fall (30 hours ago). Slipped out of bed Sunday (2am) and was
only able to get to telephone to call for help this morning; no
head trauma; no LOC. In the field, fs 226.
In the ED, initial vs were: 97.8 153 (regular) 133/75 18 100%
RA. Complained of left shoulder pain. Physical examination
notable for appearing dry. Laboratory data significant for HCO3
15 (anion gap 25), glucose 220, WBC 11.8 with left shift, CK/MB
2059/60 with troponin 0.33. Lactate 2.5>1.6 with IVF. Underwent
trauma series with showed no fractures. Intubated for flash
pulmonary edema after 1.5L. ET tube positioning confirmed with
CXR 1V. Received propofol, midazolam, and fentanyl. ABG at AC
500x14, 50%, 5 with pH 7.28, pCO2 45, pO2 325; rate increased to
16. Per cards evaluation in ED, atrial tachycardia; cardiac
biomarker rise suspected secondary to demand ischemia from
atrial tachycardia. On transfer to ICU, 96, 104/54, 16, 98% on
above ventilator settings.
On transfer to ICU, patient is intubated and sedated.
Review of systems:
Denies pain. Otherwise limited secondary to intubation.
Past Medical History:
Pulmonary carcinoid, s/p RML resection
Cataract
Diabetes mellitus, type II c/b retinopathy
CAD s/p mi, CABG ([**2174**])
Aortic stenosis
Hyperlipidemia
htn
Osteopenia
sleep apnea unable to use cpap
carpal tunnel surgery left hand
Colon: [**2193**] normal; BMD: [**3-17**] osteopenia; Eye Exam: Seeing Dr.
[**Last Name (STitle) 9955**] last saw her [**8-17**]; [**Last Name (un) **]: [**3-17**]
Social History:
Per review of OMR records, no tobacco, alcohol, or illicit drug
use. Smoked 15-20 years, quit [**2150**]. Resides at [**Hospital3 **].
Family History:
unable to obtain
Physical Exam:
Vitals: 138, 121/80, 99% on ventilator, 16
General: Intubated
HEENT: Sclera anicteric, left pupil slightly larger than left,
pupils reactive to light, dry mucous membranes
Neck: Supple, JVP not elevated, no LAD
Lungs: Anterior auscultation cleaer to auscultation bilaterally;
no wheezes, rales, rhonchi
CV: Tachycardic, regular, no murmurs appreciated
Abdomen: Obese, normoactive bowel sounds, non-tender
GU: Foley
Skin: Diffuse eccymoses at left leg; candidiasis below breasts,
in groin
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2195-5-25**] 08:22AM WBC-11.8*# RBC-4.05* Hgb-11.8* Hct-37.0 MCV-91
Plt Ct-297
[**2195-5-25**] 08:22AM Neuts-86.8* Lymphs-9.1* Monos-3.4 Eos-0.3
Baso-0.4
[**2195-5-25**] 10:00AM PT-13.0 PTT-21.7* INR(PT)-1.1
[**2195-5-25**] 08:22AM ESR-45*
[**2195-5-25**] 08:22AM Glucose-220 UreaN-20 Cr-1.1 Na-141 K-5.0 Cl-101
HCO3-15*
[**2195-5-25**] 08:22AM CK(CPK)-2059*
[**2195-5-25**] 08:22AM CK-MB-60* MB Indx-2.9 cTropnT-0.33*
[**2195-5-25**] 11:52AM Type-ART pO2-325* pCO2-45 pH-7.28* calTCO2-22
Base XS--5
[**2195-5-25**] 08:26AM Glucose-218* Lactate-2.5* Na-143 K-5.9* Cl-103
calHCO3-20*
CE TREND:
[**2195-5-25**] 08:22AM CK(CPK)-2059*
[**2195-5-25**] 04:26PM CK(CPK)-1508*
[**2195-5-26**] 02:41AM CK(CPK)-1126*
[**2195-5-26**] 11:53PM CK(CPK)-399*
[**2195-5-27**] 04:06AM CK(CPK)-395*
[**2195-5-27**] 11:54AM CK(CPK)-553*
[**2195-5-25**] 08:22AM CK-MB-60* MB Indx-2.9 cTropnT-0.33*
[**2195-5-25**] 04:26PM CK-MB-71* MB Indx-4.7 cTropnT-0.63*
[**2195-5-26**] 02:41AM CK-MB-82* MB Indx-7.3* cTropnT-1.48*
[**2195-5-26**] 11:53PM CK-MB-23* MB Indx-5.8 cTropnT-1.19*
[**2195-5-27**] 04:06AM CK-MB-19* MB Indx-4.8 cTropnT-0.74*
[**2195-5-27**] 11:54AM CK-MB-46* MB Indx-8.3* cTropnT-2.63*
URINE:
[**2195-5-25**] 08:15AM Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.021
[**2195-5-25**] 08:15AM Blood-LG Nitrite-NEG Protein-500 Glucose-TR
Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2195-5-25**] 08:15AM RBC-0 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
MICRO:
[**2195-5-25**] UCx: NEGATIVE
[**2195-5-25**] BCx: NGTD
[**2195-5-27**] BCx: pending
[**2195-5-27**] SputumCx: pending
Imaging:
CT Head/Chest/Abdomen: No ICH. No PE. No evidence of RP bleed. R
adrenal adenoma.
SHOULDER (AP, NEUTRAL & AXILLA; HUMERUS (AP & LAT) LEFT; ELBOW
(AP, LAT & OBLIQUE) LEFT
FINDINGS:
LEFT SHOULDER: The humeral head articulates within the glenoid
without
evidence of dislocation. The AC joint appears normal. There is
no fracture.
HUMERUS: There is no visible fracture. There are no focal lytic
or sclerotic lesions.
ELBOW: The radial head and the coronoid and olecranon processes
of the
proximal ulna articulate properly with the humerus. No anterior
or posterior sail sign is seen to suggest fracture.
IMPRESSION: No evidence of fracture or dislocation.
HIP UNILAT MIN 2 VIEWS LEFT PO; KNEE (2 VIEWS) LEFT
FINDINGS:
Three total images of the left femur are submitted. These are
limited
secondary to technique and patient positioning, but are the best
images
possible. No gross fracture is identified, but if clinical
suspicion
persists, then MRI is recommended for further assessment. There
is
tricompartmental osteophytes of the knee with narrowing of the
medial
compartment.
BILAT LOWER EXT VEINS PORT Study Date of [**2195-5-25**] 8:57 PM
IMPRESSION: No evidence of DVT in bilateral lower extremity.
Left [**Hospital Ward Name 4675**]
cyst.
CT C-SPINE W/O CONTRAST Study Date of [**2195-5-26**] 12:51 PM
IMPRESSION:
1. No fracture.
2. Grade 1 anterolistheses at C3-4 and C5-6, which could be
related to facet arthropathy. If there is a clinical concern for
ligamentous injury at these levels, then MRI could be obtained
for further evaluation.
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST; CT PELVIS
W/CONTRAST
IMPRESSION:
1. No PE or acute intrathoracic process. Small bilateral
effusions and
pleural parenchymal scarring.
2. No intra-abdominal hematoma or other acute process. Stable
gallstone,
right adrenal adenoma, and renal cysts.
WRIST(3 + VIEWS) LEFT PORT Study Date of [**2195-5-28**] 5:56 PM
IMPRESSION: There is no evidence of an acute bony injury.
CAROTID SERIES COMPLETE PORT Study Date of [**2195-5-27**] 3:35 PM
IMPRESSION: There is less than 40% stenosis within the internal
carotid
arteries bilaterally.
Cardiac Cath ([**2195-6-3**])
COMMENTS:
1. Successful PTCA and stenting of the proximal LCX stenosis
with a
2.5x8mm Promus stent that was postdilated to 2.75mm. Final
angiography
revealed no residual stenosis, no angiographically apparent
dissection
and TIMI III Flow (see PTCA comments).
2. Successful deployment of angioseal closure device.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal ventricular function.
3. Successful PCI of the LCX.
4. Successful deployment of angioseal closure device.
Brief Hospital Course:
77F HTN, hypertension, renal sufficiency, CAD s/p CABG, SVT,
DMII, moderate AS, presenting to ED with fall and to MICU after
flash pulmonary edema secondary to fluid resuscitation.
#. Hypoxic respiratory failure: Likely due to flash pulmonary
edema in the setting of fluid resuscitation, atrial tachycardia,
and aortic stenosis. Patient was emergently intubated in the ED.
CTA negative for PE. TTE performed showed no evidence of
worsening aortic stenosis. Patient remained intubated, was noted
to be apneic on fentanyl, versed, and propofol, so sedatation
was switched to presodex. diuresed with IV lasix. She was
extubated after 48 hours. Post-extubation she developed stridor.
ENT evaluated the airway, which was notable for mild
inflammation. She was given atrovent and dexamethasone with good
effect. Her respiratory status improved with diuresis. She was
discharged with daily PO furosemide.
.
#. NSTEMI: NSTEMI from severe CAD s/p CABG (likely various
grafts are down given patient is 20 years s/p CABG) worsened by
demand ischemia from her atrial tachycardia. Patient with ST
depression in pre-cordial leads. Enzymes were initially trending
down until another episode of atrial tachycardia for 1.5 hours
in the evening of [**5-26**]. She underwent catheterization for which
she was found to have three vessel disease. She received a
Promus stent to the LCx. She was discharged on ASA, plavix,
statin, beta blocker, and [**Last Name (un) **].
.
#. Atrial tachycardia: The patient would intermittently go into
an asymptomatic atrial tachycardia with a rate in the 160s. The
electrophysiology service was consulted. She was loaded with
amiodarone and continued on oral dosing. She was also started
on a beta blocker. Her rhythm control was improved; while she
still had brief episodes of asymptomatic atrial tachycardia, she
primilarily was in normal sinus at a rate in the 60s. Initially,
ablation was considered given that it was thought she was having
episodes of syncope due to the arrhythmia. However, after
further history it appeared that these episodes were mechanical
falls rather than true syncopal events.
.
#. Atrial stenosis: As above. Valve area in [**2193**] 1.0-1.2cm2 with
1+MR, symmetric left ventricular hypertrophy. Repeat TTE this
admission confirmed no change in aortic stenosis.
.
#. s/p fall: Patient with multiple falls. CT head and torso
without evidence of bleeding. DDx includes syncope from AS,
NSTEMI, mechanical falls. No evidence of fracture. Patient with
large ecchymoses on LLE. With muscle breakdown given elevated
CKs in the [**2185**] on admission, improved with IVFs. Per repeat
from ED, no head trauma or LOC. Slid to floor from bed.
.
#. Diabetes mellitus, type II: She was continued on an insulin
sliding scale and oral hypoglycemics were held while in house.
.
#. Hyperlipidemia: She was started on atorvastatin 80 mg PO
daily
.
#. Hypertension: Patient was hypotensive in the ICU, especially
when placed on esmolol gtt. Held home anti-hypertensives. On
metoprolol for atrial tachycardia.
.
# Nutrition: She was started on tube feeds while intubated but
these were stopped with extubation.
Medications on Admission:
Cozaar 50mg PO daily
Zoloft 100mg PO daily
Atenolol 25mg PO daily
Zocor 60mg PO daily
Metformin 1000mg PO BID
Glyburide 5mg PO BID
Actos 45mg PO daily
Verapamil XR 240mg PO daily
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take every day for one year.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day for one year.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Start on [**2195-6-7**].
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): under breasts and in groin area.
10. Outpatient Lab Work
Please check Chem 7 on Sunday [**6-7**] and call results to provider.
11. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Please hold HR< 60. Will need to titrate down as
amiodarone load finishes. .
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 3 days: Then decrease to 200 mg daily.
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please start after loading dose of 400 mg TID is finished. .
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety.
16. Delsym 12 hour 30 mg/5 mL Suspension, Sust.Release 12 hr
Sig: [**5-18**] ml PO twice a day as needed for cough.
17. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day: Hold
SBP< 100.
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Coronary Artery Disease
Acute on chronic Diastolic Congestive Heart Failure
Non ST elevation Myocardial Infarction
Atrial Tachycardia
Aortic Stenosis
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a fall at home and was admitted to the Medical Intensive
care unit with a rapid heart rate. You needed to be intubated
and put on a ventilator to breathe. We treated your rapid heart
rate with Amiodarone which has prevented the rapid heart rate
for the last 2 days. You also were noted to have some changes on
your EKG that showed there was not enought blood flow to your
heart. You had a cardiac catherization and two drug eluting
stents were placed in your left circumflex artery. You will need
to be on 325mg of Aspirin and 75 mg of Plavix every day for at
least one year. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix
unless Dr. [**Last Name (STitle) **] tells you to. You had some diarrhea that has
resolved, this was not an infection.
We made the following changes to your medicines:
1. Stop Atenolol, start Metoprolol 100mg twice daily instead.
2. Started aspirin and Plavix to keep the stent open.
3. changed Zocor to Atorvastatin
4. Started you on sliding scale Insulin while you are off your
Metformin and Actos
5. Hold Metformin until [**2195-6-7**], then restart.
6. Hold Actos until fluid status is stable, then can consider
restarting.
7. Start Miconazole powder under breasts and in groin to treat
fungal infection
8. Start Trazadone to help you sleep at night
9. Start Amiodarone to cotrol your rapid heart rhythm.
10. Resume cozaar at 1/2 your normal dose, this can be increased
if your blood pressure is high and your kidney function is
stable.
11. Start a multivitamin
12. Stop Verapamil.
.
Weight yourself every day, please call Dr. [**Last Name (STitle) **] if your weight
increases more than 3 pounds in 1 day or 6 pounds in 3 days.
Please eat a low sodium diet.
Followup Instructions:
Primary Care:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 507**] [**Name12 (NameIs) 508**] [**Telephone/Fax (1) 133**] Please make an appt to
see Dr. [**Last Name (STitle) **] after you get out of rehabilitation.
.
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 5768**] Date/time: [**6-22**] at 3:00pm
for ECHo, 4:00pm floor office visit.
Patient will need PFT's in one month
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2196-3-28**] 9:30
Completed by:[**2195-6-23**]
ICD9 Codes: 5849, 2762, 4280, 4241, 5859, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5658
} | Medical Text: Admission Date: [**2166-1-15**] Discharge Date: [**2166-1-30**]
Date of Birth: [**2086-8-16**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79F with locally advanced pancreatic CA on Xeloda and
oxaliplatin (C2D1 [**2166-1-8**]) who p/w diarrhea. Ms [**Known lastname 23815**] states
that over the past several days she has noted profuse watery
brown diarrhea without blood. Last night she was up every hour
to stool. She has had nausea although vomited only once last
night. She has had abdominal crampy pain. She normally lives
alone and takes care of herself and drives. Over the past couple
of days she has been weak and fatigued. The symptoms correlated
with the start of her second cycle of chemotherapy. She denies
f/c. No CP or SOB.
In the ED, she was noted to have stable vitals, although
potassium was 2.4. She was given potassium repletion 60 mEq IV
and 40 mEq PO. She was admitted to OMED service.
Past Medical History:
1. Locally-advanced pancreatic cancer - Initially diagnosed in
[**2162**] by abdominal ultrasound in the setting of crampy abdominal
pain. She received 31 cycles of gemcitabine without any grade
III or IV hematologic or non-hematologic toxicity, then
developed
radiologic and biochemical progression. She had a PORT-A-Cath
placed on [**11-30**]. She commenced XelOX on [**12-19**], Oxaliplatin 100
mg/m2 every 21 days and capecitabice (Xeloda) 1000 mg/m2 [**Hospital1 **] for
14 of 21 days.
2. Hypothyroidism.
3. Cerebrovascular accident in [**2155**], now on Coumadin.
4. Knee replacement.
5. Appendectomy at the age of 15.
6. Right cataract repaired on [**2165-11-27**]
Social History:
She is widowed, lives alone and cares for self. She drives. She
has two children, one of the age 58, the other 38. She does not
drink and she never smoked. She lives by herself in [**Location (un) 10059**].
Family History:
Significant at the age of 92 of heart disease.
Her father died at the age of 67 and a sister died at the age of
65 because of heart disease. There is no family history of
cancer that she knows of.
Physical Exam:
VS: Temp: 98.3 BP: 120/70 HR: 83 RR: 16 sat 96RA
GEN: awake, alert, NAD, hard of hearing
HEENT: surgical pupils, EOMI, anicteric, MM slightly dry
NECK: JVP flat no supraclavicular or cervical lymphadenopathy,
CHEST: port in place, c/d/i, CTAB
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, mild TTP diffusely
EXT: no c/c/e
SKIN: no rashes/no jaundice
Pertinent Results:
[**2166-1-15**] 10:15AM WBC-4.0 RBC-4.04* HGB-11.1* HCT-32.9* MCV-81*
MCH-27.4 MCHC-33.7 RDW-17.1*
[**2166-1-15**] 10:15AM NEUTS-55 BANDS-15* LYMPHS-15* MONOS-14* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2166-1-15**] 10:15AM PLT SMR-LOW PLT COUNT-110*
[**2166-1-15**] 10:15AM PT-18.3* PTT-26.9 INR(PT)-1.7*
[**2166-1-15**] 10:15AM GLUCOSE-103 UREA N-11 CREAT-0.7 SODIUM-135
POTASSIUM-2.4* CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
[**2166-1-15**] 10:15AM CALCIUM-8.0* PHOSPHATE-2.0*# MAGNESIUM-1.8
[**2166-1-15**] 10:29AM LACTATE-1.5 K+-2.4*
[**2166-1-15**] 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR
[**2166-1-15**] 01:15PM URINE RBC-[**2-26**]* WBC-[**6-3**]* BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2166-1-15**] 08:31PM WBC-4.4 RBC-3.63* HGB-9.9* HCT-30.5* MCV-84
MCH-27.3 MCHC-32.6 RDW-18.1*
[**2166-1-15**] 08:31PM PLT COUNT-108*
[**2166-1-15**] 08:31PM MAGNESIUM-1.8
[**2166-1-15**] 08:45PM UREA N-9 CREAT-0.7 POTASSIUM-3.0*
[**2166-1-20**] 12:00AM BLOOD WBC-11.3* RBC-4.31 Hgb-12.1 Hct-36.7
MCV-85 MCH-28.1 MCHC-32.9 RDW-19.0* Plt Ct-218
[**2166-1-25**] 12:00AM BLOOD WBC-16.1*# RBC-4.53 Hgb-12.2 Hct-38.6
MCV-85 MCH-26.9* MCHC-31.6 RDW-20.0* Plt Ct-211
[**2166-1-26**] 12:00AM BLOOD WBC-18.4* RBC-4.69 Hgb-12.4 Hct-39.7
MCV-85 MCH-26.4* MCHC-31.2 RDW-19.9* Plt Ct-129*
[**2166-1-26**] 07:50AM BLOOD WBC-10.2 RBC-3.43*# Hgb-9.1*# Hct-28.6*#
MCV-83 MCH-26.6* MCHC-31.9 RDW-20.8* Plt Ct-79*
[**2166-1-29**] 03:10AM BLOOD WBC-4.0 RBC-2.31* Hgb-6.4* Hct-19.9*
MCV-86 MCH-27.8 MCHC-32.3 RDW-19.3* Plt Ct-35*
[**2166-1-26**] 12:00AM BLOOD Neuts-41* Bands-33* Lymphs-8* Monos-7
Eos-0 Baso-2 Atyps-2* Metas-3* Myelos-4*
[**2166-1-15**] 10:15AM BLOOD Neuts-55 Bands-15* Lymphs-15* Monos-14*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2166-1-27**] 06:24PM BLOOD Neuts-90* Bands-2 Lymphs-6* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2166-1-15**] 10:15AM BLOOD PT-18.3* PTT-26.9 INR(PT)-1.7*
[**2166-1-19**] 12:11AM BLOOD PT-37.1* PTT-33.0 INR(PT)-4.0*
[**2166-1-22**] 05:41AM BLOOD PT-13.3 PTT-24.3 INR(PT)-1.1
[**2166-1-28**] 05:12AM BLOOD PT-39.4* PTT-45.9* INR(PT)-4.3*
[**2166-1-29**] 03:10AM BLOOD PT-17.7* PTT-36.8* INR(PT)-1.6*
[**2166-1-27**] 05:17PM BLOOD Fibrino-578* D-Dimer-2090*
[**2166-1-17**] 12:15AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-145
K-3.6 Cl-116* HCO3-18* AnGap-15
[**2166-1-26**] 12:00AM BLOOD Glucose-167* UreaN-69* Creat-1.6* Na-143
K-4.0 Cl-108 HCO3-18* AnGap-21*
[**2166-1-29**] 03:10AM BLOOD Glucose-138* UreaN-26* Creat-0.9 Na-146*
K-3.4 Cl-112* HCO3-29 AnGap-8
[**2166-1-22**] 05:41AM BLOOD ALT-7 AST-10 LD(LDH)-171 AlkPhos-52
Amylase-7 TotBili-0.4
[**2166-1-26**] 05:17AM BLOOD ALT-25 AST-39 CK(CPK)-176* AlkPhos-103
Amylase-16 TotBili-0.8
[**2166-1-26**] 12:57PM BLOOD LD(LDH)-352* CK(CPK)-157* TotBili-1.1
[**2166-1-26**] 08:45PM BLOOD LD(LDH)-307* CK(CPK)-112
[**2166-1-26**] 05:17AM BLOOD CK-MB-12* MB Indx-6.8* cTropnT-0.03*
[**2166-1-26**] 12:57PM BLOOD CK-MB-9 cTropnT-0.02*
[**2166-1-26**] 08:45PM BLOOD CK-MB-8 cTropnT-0.03*
[**2166-1-15**] 10:15AM BLOOD Calcium-8.0* Phos-2.0*# Mg-1.8
[**2166-1-29**] 03:10AM BLOOD Calcium-7.1* Phos-2.5* Mg-2.1
[**2166-1-26**] 07:54AM BLOOD Cortsol-114.7*
ECG Study Date of [**2166-1-15**] 10:23:46 AM
Baseline artifact. Sinus rhythm. Short P-R interval. Leftward
axis.
T wave abnormalities. Compared to the previous tracing of
[**2165-11-27**] no
significant change.
Reports:
CHEST (PORTABLE AP) [**2166-1-15**] 1:07 PM
IMPRESSION: No acute cardiopulmonary process.
KUB [**2166-1-21**]:
Given the clinical history findings are most compatible with
gastroenteritis.
CT Abdomen/Pelvis [**2166-1-25**]:
1. Gross distention of the distal esophagus, as well as small
and large bowel. No small bowel obstruction and no definite
large bowel obstruction is seen, suggesting generalized ileus.
Although nondistention of large bowel past the sigmoid may
represent physiolgic process, peritoneal spread of tumor or
nondistention from chronic inflammation, with obstruction at
this level cannot be entirely excluded.
2. No significant interval change in size or degree of local
invasion of the pancreatic head and neck mass.
3. Occlusion of the portosplenic confluence with venous
collaterals, unchanged since [**10-31**].
4. Bilateral pulmonary nodules consistent with metastases,
unchanged since [**10-31**].
5. Interval development of small bilateral pleural
effusions/atelectasis, as well as perihepatic and perisplenic
ascites since [**10-31**].
6. Mild intrahepatic biliary dilitaion.
CXR [**2166-1-26**]:
There is a new right IJ line with tip in SVC. The right
subclavian line is unchanged. The ET tube tip is 4 cm above the
carina. The NG tube tip is in the stomach. There are bilateral
pleural effusions, left greater than right, with bilateral lower
lobe volume loss. There is no pneumothorax.
CT Head [**2166-1-27**]:
No CT evidence of an acute territorial infarct. No intracranial
hemorrhage. No abnormal enhancing lesion identified. Area of
encephalomalacia involving the right cerebellar hemisphere.
Changes suggestive of chronic microangiopathic change.
CXR [**2166-1-28**]:
Slight increase in pulmonary edema; similar appearance of
bilateral moderate pleural effusions.
Brief Hospital Course:
79F with locally advanced pancreatic CA on Xeloda and
oxaliplatin (C2D1 [**2166-1-8**]) admitted with diarrhea.
# Diarrhea:
Most likely [**1-25**] chemotherapy, though infectious cause possible.
Cdiff was negative. She was given IV Fluids, prn antiemetics,
and her electrolytes were corrected prn. After cdiff was
negative x 1, she was given symptomatic treatment of her
diarrhea with loperamide. She continued to have nausea and
profuse diarrhea, and she was given tincture of opium as well as
octreotide.
# Sepsis:
After several days in the hospital, she became acutely
hypotensive, tachycardic and hypoxic. She was emergently
transferred to the ICU, where NG tube was placed with immediate
output of almost a liter of feculent material. She was put on
broad spectrum antibiotics and central line was placed for
aggressive fluid repletion. Blood pressure was supported with
levophed. She was intubated for airway protection given concern
for aspiration pneumonia. Cause of patient's acute
decompensation was unclear. The team considered infection from
bowel source (microperforation, SBP), aspiration event, or
possible PE. CTA was not done given patient's worsening renal
function and unstable clinical status.
Surgery was consulted and did not feel that the patient was a
candidate for surgical intervention.
Patient remained intubated and on pressors for several days.
Antibiotics were selected to cover possible bowel pathogens
given concern that she could have had microperforations or
perhaps SBP given new finding of ascites on imaging. Despite
aggressive care, the patient continued to deteriorate. Her
daughters (and health care proxy) agreed that the patient would
not wish to continue aggressive care given her poor prognosis.
The decision was made with the attending to make the patient
comfort measures only; she was extubated and died later that
day.
Patient's daughters agreed that they would want an autopsy to
help understand what had caused their mother to deteriorate.
# Acute renal failure - Oliguric on arrival to ICU. Cr quickly
improved with IV fluids and support of MAPs.
# Pancreatic CA - Metastatic to lungs, although with fairly good
functional status prior to admission. Onc fellow contact[**Name (NI) **] upon
ICU transfer. Chemotherapy was held and patient's family agreed
upon comfort care after discussing the matter with her
oncologists, the ICU team, and palliative care.
# Coagulopathy:
Patient's INR increased during admission despite holding
coumadin. DIC labs were negative. Patient's INR improved with
FFP and vitamin K.
#. UTI:
There is a postive UA and bandemia. She was afebrile and had no
urinary symptoms. UCx showed mixed flora. She was given a
three day course of cipro.
Communication
Daughter [**Name (NI) 553**] [**Telephone/Fax (1) 23816**]
Medications on Admission:
coumadin 2.5 mg daily (this dosage is currently being reduced
due to addition of chemotherapy agents which interact with
coumadin\
synthroid 25'
compazine PRN
MVI
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2166-2-1**]
ICD9 Codes: 5849, 5119, 5990, 2768, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5659
} | Medical Text: Admission Date: [**2158-8-25**] Discharge Date: [**2158-8-27**]
Date of Birth: [**2093-1-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD)
Transfusion of 4 units packed red blood cells
History of Present Illness:
65 year old female with a PMH significant for HTN and a R hip
hemiarthroplasty in [**4-1**] admitted on [**2158-8-25**] with melena that was
associated with nausea and fatigue. The patient reports that
she has been using 1200-2400 mg ibuprofen daily for the past
month s/p surgery, and that the day of admission she noted at
home that her BP was 80/50, with a hct of 20. In the MICU, the
patient received a total of 4 units PRBC, and an upper endoscopy
that demonstrated a 10mm non-bleeding ulcer in the pre-pyloric
region. The patient was then transferred to Medicine for
further management.
Past Medical History:
Right hip hemiarthroplasty ([**5-1**])
osteoarthritis righ knee
Hypertension
Hyperlipidemia
LVH, obstructive CM (EF >65%)
Osteopenia
Social History:
1 ppd x 40 years
2 glasses of wine nightly
Denies IVDU
Retired school administrator
Family History:
Father died of MI at age 61. Mother died of lymphoma at age 78.
Brother: CAD.
Physical Exam:
VS: 99.0 (Tm 99.9), 126/70 (126-146/62-78), 86-97, 94-95%RA
8H I/O: none / 1350
last 8H shift ON [**8-26**]: [**Telephone/Fax (1) 86504**]+ cc urine (missed hat)
Gen: sitting in bed, NAD
HEENT: PERRL, EOMI, MMM, oropharynx clear without erythema or
exudates, neck supple w/no JVD, sclerae anicteric
CV: RRR, nl S1+S2, III/VI holosystolic murmur heard best at LUSB
Pulm: CTAB
Abd: soft, NT/ND, +BS, no rebound or guarding, no HSM
Ext: warm, well perfused, no C/C/E, 2+ DP/PT pulses bilaterally
Neuro: CN II-XII grossly intact with no focal deficits. [**3-27**]
strength throughout. Gait not observed.
Pertinent Results:
Admission CBC:
[**2158-8-25**] 05:00PM BLOOD WBC-12.7* RBC-2.00*# Hgb-6.1*# Hct-18.7*#
MCV-93 MCH-30.4 MCHC-32.5 RDW-17.6* Plt Ct-346
.
Discharge CBC:
[**2158-8-27**] 08:15AM BLOOD WBC-9.1 RBC-3.26* Hgb-9.5* Hct-27.9*
MCV-86 MCH-29.1 MCHC-34.0 RDW-20.2* Plt Ct-279
.
[**2158-8-25**] 05:00PM BLOOD Neuts-76.0* Lymphs-19.7 Monos-3.3 Eos-0.5
Baso-0.4
[**2158-8-27**] 08:15AM BLOOD Glucose-103* UreaN-9 Creat-0.5 Na-141
K-3.6 Cl-108 HCO3-24 AnGap-13
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2158-8-29**]): POSITIVE BY
EIA.(Reference Range-Negative).
[**2158-8-26**] EGD Report
Impression: Ulcer in the pre-pyloric region
Otherwise normal EGD to third part of the duodenum.
Brief Hospital Course:
# Melena: Likely secondary to pre-pyloric ulcer, although not
found to have active bleeding. Patient has history of chronic
NSAID use since R hip arthroplasty in [**3-/2158**](ibuprofen and
aspirin), along with regular tobacco and occasional alcohol use.
Given hct of 18 and hypotension on presentation she was
admitted to the ICU for monitoring. Patient did well overnight
and received a total of 4 u pRBC and 3 L IVF. She underwent EGD
in the ICU on [**2158-8-26**] showing a 10mm shallow, clean based antral
ulcer without active bleeding. No interventions were made. She
was continued on IV PPI and transferred to medicine floor where
she remained hemodynamically stable and with stable hematocrit.
H. pylori antibody came back positive on the day after
discharge; patient, PCP (Dr. [**Last Name (STitle) 86505**], and GI fellow (Dr.
[**Last Name (STitle) **] alert and PCP will start patient on therapy.
.
# Pain Control: R knee osteoarthritis pain managed with
acetaminophen.
.
# Hypertension: Was initially hypotensive secondary to GI bleed.
Normotensive s/p IVFs and 4 units pRBCs. Lisinopril was held
during admission.
.
# Hyperlipidemia: Continued home simvastatin.
.
#PPX: pneumatic boots
.
#Code status: FULL CODE
Medications on Admission:
Lisinopril 10 mg daily
Simvastatin 20 mg daily
MVI
Caltrate 600 [**Hospital1 **]
Aspirin 81 mg One PO once a day.
Ibuprofen 1200-1400 mg /day
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Outpatient Lab Work
Lab work to be checked on Tues, [**8-29**]:
-Complete Blood Count (CBC)
Results to be faxed to Dr. [**Last Name (STitle) 85758**] [**Name (STitle) 86505**] at ([**Telephone/Fax (1) 86506**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Pre-pyloric ulcer
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. You were admitted to the hospital for further evaluation of
your dark, bloody stools, fatigue and nausea. You were found to
have low blood counts, also known as anemia. We treated you with
IV fluids and you were transfused 4 units of blood in the ICU.
2. You had a procedure, known as an EGD, which showed a 1 cm
ulcer in your stomach. This was likely caused by excessive NSAID
(non-steroidal anti-inflammatory drugs, such as ibuprofen) use.
You will need to have a repeat EGD in 6 weeks and follow up with
the GI doctors. You should also have a colonoscopy at that time.
3. We ordered an H. pylori blood test; the results were pending
at the time of discharge. We will call your with these results,
or you can follow them up with your PCP. [**Name10 (NameIs) **] it is positive, you
will need treatment.
4. You were started on a new medication: OMEPRAZOLE 40mg twice
daily by mouth. You did not receive your lisinopril in the
hospital; you should restart it when you go home (take 5mg the
first day, then 10mg daily after that). You should continue to
take your other home medications as prescribed EXCEPT for the
following:
- STOP taking aspirin. Please talk to your PCP about when to
re-start it.
- DO NOT take any NSAIDs for pain (ex. advil, ibuprofen, aleve,
motrin, naprosyn, naproxen, toradol, etc.). You can take tylenol
or acetaminophen for pain.
5. You should have blood work (CBC) checked on Tues, [**8-29**] and
faxed to Dr. [**Last Name (STitle) 85758**] [**Name (STitle) 86505**] at ([**Telephone/Fax (1) 86506**]. Please follow up
with your PCP [**Name Initial (PRE) 176**] 1 week.
Followup Instructions:
**You will be contact[**Name (NI) **] by the [**Hospital **] Clinic on Tuesday, [**8-29**] to
schedule an outpatient EGD and colonoscopy. If you have not
heard from them by the end of the week, please call ([**Telephone/Fax (1) 86507**].**
**Please schedule a follow up appointment with your PCP [**Name Initial (PRE) 176**] 1
week to follow up your lab work.**
Department: ORTHOPEDICS
When: THURSDAY [**2158-9-7**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2158-8-29**]
ICD9 Codes: 2851, 4019, 2720, 4240, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5660
} | Medical Text: Admission Date: [**2185-10-6**] Discharge Date: [**2185-10-28**]
Date of Birth: [**2113-3-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Hayfever
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
72 M s/p renal transplant and CRF, diastolic CHF EF 45-50%, s/p
CABG and [**First Name3 (LF) 1291**] on coumadin, DM2, vasculopath with L fem-[**Doctor Last Name **] bypass
and revisions, CHF, recently discharged from [**Hospital1 18**] [**2185-9-14**] after
a 2 month admission for osteomyelitis, ARF, and CHF
exacerbation. Today he was sent from NH to [**Hospital3 8544**] for
decreased responsiveness and AMS intermittantly over last week.
BG was found to be 34 with rapid recovery in responsiveness with
D50. Found him to be hyperkalemic in ARF, with TnT 0.367 (same
as Troponin here). Transferred to [**Hospital1 18**] today because of his 2
month admission here recently.
.
Family reported increasing full body swelling and worsening
dyspnea from baseline for the past week. EKG shows 1.5 mm STE in
V1-V3, 1mm on old EKGs for comparison. Patient is DNR/DNI,
patient and family did not wish to have cardiac cath performed.
Patient has never had CP, but has had intermittent dyspnea.
.
In the ED, HR60s, BP105-110, 99% 2L nc, BG108, received ASA,
plavix, did not give integrillin because of renal failure. INR
4.9 for anticoagulation for [**Hospital1 1291**], heparin gtt was not started.
For hyperkalemia of K 5.9 and 6.0, patient received calcium,
insulin, glucose, and he had received kayexylate at OSH. CXR
shows pulmonary edema and bilateral effusions. Trop 0.38, MB 8,
no CK drawn.
.
.
MICU course:
Found to be in oliguric renal failure with decreased urine
output for 5 days prior to admission. Started hemodialysis on
[**8-6**] for Uremia, volume overload. Supratheraputic INR on
admission, unable to biopsy kidney for diagnosis, given Vit K.
INR subtheraputic (with goal 2.5-3.5), restarted on coumadin and
Heparin GTT until coumadin theraputic. Also given solu-medrol
500mg x3 days to treat for rejection.
.
Past Medical History:
- IDDM
- PVD
- CAD (no MI)
- hyperlipid
- Hypertension
- CRI (baseline Cr 1.5-1.7)
- s/p L AK [**Doctor Last Name **]-DP spliced [**Doctor Last Name 5703**] BPG ([**2-4**])
- s/p LRKT ('[**79**])
- s/p CABG/Mech.[**Year (2 digits) 1291**]('[**77**])
- s/p Excise L metatarsal head
- s/p L AV fistula ('[**79**])
- s/p Excise colon polyp ('[**77**])
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
VS: 97.9 / 108/36 / 63 / 12 / 99% 2L nc
GENERAL: Alert, communicating, answering questions and directing
properly
HEENT: JVD to jawline, no LAD
LUNGS: Clear anteriorly but rales posteriorly, dull in bases bl
HEART: RRR, clear S1/S2, no m/r/g, CABG scar
ABDOMEN: Soft, dependent 4+ edema, thin, +BS
EXTR: 4+ edema on arms and legs, dopplerable pulses, larger R
arm than left, cellulitis and eschars in R and L feet
NEURO: Sensation present in legs and feet, cannot move legs well
SKIN: Skin breakdown areas
.
Pertinent Results:
[**2185-10-21**] Repeat Echocardiogram
Conclusions:
The left atrium is dilated. There is moderate symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. There
is moderate global left ventricular hypokinesis (LVEF = 30-40
%). Right ventricular chamber size and free wall motion are
normal. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. Mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is a trivial/physiologic pericardial effusion.
Suboptimal image quality - patient unable to cooperate.
Compared with the findings of the prior study (images reviewed)
of [**2185-10-8**], the findings are similar (ejection
fraction overestimated on prior study).
.
[**2185-10-20**] Head CT
IMPRESSION:
1. No evidence of hemorrhage or mass effect.
2. Central involutional changes and evidence of small vessel
angiopathy.
.
[**2185-10-8**] Echocardiogram:.
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild global left ventricular hypokinesis (LVEF = 50 %), no
regionality seen. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular systolic function
is borderline normal. There is
abnormal septal motion/position. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2185-8-23**], no
significant change.
.
[**2185-10-7**] CXR -
IMPRESSION: New consolidation in the right lower lobe that may
reflect aspiration. Followup radiographs will help distinguish
atelectasis from pneumonia. Interval improvement in pulmonary
edema.
.
[**2185-10-6**] Renal Transplant U/S
Doppler examination of the main transplant renal artery and
interpolar arterials demonstrates normal systolic upstroke with
absent diastolic flow. The resistive index is 1.0. This is not
significantly chnaged. The transplant renal [**Month/Day/Year 5703**] is patent.
IMPRESSION:
1. Stable appearance of transplant kidney with elevated
resistive indeces. No
evidence of hydronephrosis or perinephric collection
[**2185-10-6**] 02:20AM WBC-6.1 RBC-3.88* HGB-10.5* HCT-34.1* MCV-88
MCH-27.0 MCHC-30.7* RDW-18.8*
[**2185-10-6**] 02:20AM NEUTS-77.1* LYMPHS-13.5* MONOS-7.8 EOS-1.4
BASOS-0.2
[**2185-10-6**] 02:20AM PLT COUNT-241
[**2185-10-6**] 02:20AM PT-43.0* PTT-44.0* INR(PT)-4.9*
[**2185-10-6**] 02:20AM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-5.5*#
MAGNESIUM-2.0
[**2185-10-6**] 02:20AM CK-MB-8 cTropnT-0.38*
[**2185-10-6**] 02:20AM LIPASE-9
[**2185-10-6**] 02:20AM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-131*
AMYLASE-27 TOT BILI-0.2
[**2185-10-6**] 02:20AM GLUCOSE-88 UREA N-57* CREAT-4.8*# SODIUM-139
POTASSIUM-6.0* CHLORIDE-114* TOTAL CO2-13* ANION GAP-18
[**2185-10-6**] 06:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2185-10-6**] 06:00AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2185-10-6**] 06:00AM URINE HOURS-RANDOM UREA N-246 CREAT-176
SODIUM-25 POTASSIUM-56 CHLORIDE-17 TOT PROT-230 PROT/CREA-1.3*
[**2185-10-6**] 05:19AM LACTATE-1.1 K+-4.7
Brief Hospital Course:
72 yo M s/p renal transplant and CRF, systolic CHF s/p CABG and
[**Month/Day/Year 1291**] on coumadin, DM2, vasculopathy with L fem-[**Doctor Last Name **] bypass and
revisions admitted with mental status changes and acute renal
failure with volume overload admitted to the MICU.
.
MICU course:
Found to be in oliguric renal failure with decreased urine
output for 5 days prior to admission. Started hemodialysis on
[**8-6**] for Uremia, volume overload. Supratheraputic INR on
admission, unable to biopsy kidney for diagnosis, given Vit K.
INR subtheraputic (with goal 2.5-3.5), restarted on coumadin and
Heparin GTT until coumadin theraputic. Also given solu-medrol
500mg x3 days to treat for possibility of transplant rejection.
.
# Acute on chronic renal failure s/p renal transplant: He was
continued on dialysis MWF throughout admission to treat uremia
and volume overload secondary to acute renal failure. In
evaluating the cause of his renal failure, initially the concern
was for transplant rejection and he was given pulse steroid
treatment in the MICU. However, per report renal biopsy was
consistent with diagnosis of diabetic nephropathy, with
mod-severe scarring as well as ATN. Throughout the course of
the admission he did not regain any significant return of renal
function and continued to have a medical course complicated by
volumve overload between dialysis with hypotensive episodes
during dialysis. Tacrolimus was restarted approximately 2 weeks
in the admission and he was continued on mycophenolate and
prednisone which he had been taking all along. One week before
he expired he decided along with his family to be CMO. Dr.
[**Last Name (STitle) 4261**] was contact[**Name (NI) **] and spoke with the family.
Immunosupressants were initially left on his regimen for fear of
acute rejection which could be painful but were slowly taken
off. Morphine, Ativan and Ondansetron were used for comfort.
.
#Afib with RVR - On [**10-17**] he went into Afib with RVR following
dialysis thought most likely [**3-4**] to volume shifts. Initially
his rhythm was controlled with diltiazem however this was
changed over to digoxin for a brief time followed by metoprolol
for rate control. It was the feeling of the renal team that
diltiazem should be avoided as it effects tacrolimus levels. He
did not tolerated rapid atrial fibrillation and had associated
shortness of breath and tachypnea when his rate was poorly
controlled. Within one week of the development of Afib he
spontaneously returned to sinus rhythm. Lopressor 50mg po TID
was continued for rate control while BP tolerated. When he
was made CMO lopressor was discontinued.
.
#Altered mental status/delirium - Following the development of
atrial fibrillation he developed acute mental status change
characterized by fluctuating mental status, periods of confusion
and disorientation, visual hallucinations and inability to
speak. The etiology of this change was unclear however in
evaluation of this he was found to have suffered an NSTEMI with
troponins levle of 2.47 and trending down. Unclear when
original ischemic event occurred but was thought to be most
likely due to demand ischemia in the setting of rapid afib vs.
hypotension. Other likely contribution to delirium includes
medication effect with possible contributors including ativan
which he was taking prn for anxiety, digoxin which was given
briefly for afib and mirtazapine which was started for
depression and poor appetite. Infection was also a concern as
he is immunosuppressed and seriously ill. He was treated
empirically with vancomycin and levofloxacin. There was no
evidence of ICH on head CT and blood cultures remained negative.
One week before he expired, his mental status cleared and he
was awake, alert and oriented. It was at that point he made the
decision to be CMO.
.
#NSTEMI/CAD, s/p mechanical aortic valve replacement - as
discussed above in investigating his acute mental status change
he was found to have elevated troponin of 2.47 which was already
trending down. Unclear when original event occurred however it
was likely due to demand ischemia in the setting of episodic
hypotension or rapid atrial fibrillation. He was managed
medically as the family did not want any drastic intervention
given his multiple comorbidities. He was already on heparin gtt
to bridge until INR theraputic (goal 2.5-3.5 for [**Month/Day (2) 1291**]), statin
and metoprolol for rate control. Aspirin was restarted. He had
an echocardiogram to evaluate heart function following NSTEMI.
While the report shows decreased EF of 30-40% it was ready by
Dr. [**First Name (STitle) 437**] who stated that no significant change from prior
echocardiogram as he felt that EF was overestimated on prior
report.
.
#shortness of breath and periodic desaturation - multiple causes
of these symptoms throughout his admission including Afib with
RVR, increasing pulmonary edema associated with volume overload
in between dialysis sessions. In addition poor nutrition and
hypoalbuminemia likely contributing to his persistent pleural
effusions. He was treated with supplemental O2 via NC as
needed, dialysis for volume overload and rate control for Afib.
Dialysis was discontinued after his decision to be CMO,
supplemental O2 via NC and morphine were used for comfort.
.
# Systolic heart failure: EF 30-40% by most recent
echocardiogram with overal cardovascular status worsened by
volume overload associated with renal failure as well as
malnutrition and hypoalbuminemia. Not reponsive to lasix given
ARF. Treated for volume overload with hemodialysis.
.
#Constipation - treated with standing colace and senna, and
dulcolax suppository prn
.
#Yeast on UA/UC- foley catheter was removed and he was treated
with fluconzole
.
# Osteomyelitis: Recent 2 month admission for debridement of L
foot/amputation at level of metatarsals, also has R foot heel
eschar. Both appear as uninfected dry gangrene at this time. Has
had prior L fem-[**Doctor Last Name **] with revisions [**5-6**]. Seen by podiatry during
this admission with reccs for wound care as well as non weight
bearing on L foot. He should follow up with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 543**] within 1 wk of discharge
.
# DM2, insulin-dependent: he was continued on insulin sliding
scale, which was discontinued after he was made CMO
.
# Cdiff: completed course of flagyl
.
# Anemia: stable HCT throughout admission, Likely due to renal
failure and chronic disease.
.
# History of depression/anxiety/panic: pt reports occasional
anxiety, has been assessed by psychiatry in past admission, had
recommended ativan regimen. He was intially treated with ativan
0.5mg prn which helped his symptoms however ativan was
discontinued upon development of acute mental status change. In
addition he was started on remeron to treat symptoms of
depression and anorexia however this was also stopped in
evaluating cause of acute mental status change.
.
#Hypoalbuminemia/malnutrition - he had a very poor appetite and
limited oral intake throughout admission with low albumin and
malnutrition likely due to combination of chronic illness and
depression. Ntrition was consulted and he was started on liquid
meal supplements however he took in very little of this. Given
the severity of his illness and families resistance to invasive
treatment measures and consideration of CMO status tube feeding
was not started.
.
PPX: PPI, on heparin gtt while waiting for INR be 2.5-3.5 (goal
INR 2.5-3.5 for [**Telephone/Fax (1) 1291**])
.
CODE: DNR/DNI, family does not want pt transferred to ICU, made
CMO
Medications on Admission:
MEDICATIONS:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
6. insulin
take as directed by your PCP
7. glargine
take 13 units at night / if you are on SS please take as
directed by your PCP
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
have your INR followed. you must get this done beginning
tomorrow. Tablet(s)
9. Cefepime
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 weeks: last dose 9/18.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
19. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
21. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
22. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
23. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection QM-W-F ().
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure
acute on chronic renal failure
insulin dependant diabetes mellitus
- IDDM (may be DM2 insulin-dependent)
- PVD- CHF (EF 40-50% by [**8-9**] echo)
- CAD s/p CABG + [**Month/Year (2) 1291**] ('[**77**])
- hyperlipidemia
- Hypertension
- CRI (baseline Cr 1.5-1.7)
- s/p L [**Doctor Last Name **]-DP bypass followed by L TMA [**2-5**] with revision [**5-6**]
- s/p LRKT ('[**79**])
- s/p CABG/Mech.[**Year (2 digits) 1291**]('[**77**])
- s/p Excise L metatarsal head
- s/p L AV fistula ('[**79**])
- s/p Excise colon polyp ('[**77**])
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2185-10-28**]
ICD9 Codes: 5849, 2767, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5661
} | Medical Text: Admission Date: [**2159-4-4**] Discharge Date: [**2159-4-11**]
Date of Birth: [**2085-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
Transesophageal echo
History of Present Illness:
73 yo F with h/o poorly-controlled HTN, ESRD, and DM p/w SOB x1
day, started 1 day after regular HD session. SOB associated with
cough, white sputum for about a week. Pt attributes this to a
cold, although denies rhinorrhea, nasal congestion, sore throat.
+ sick contacts at dialysis center. Notes increased abdominal
girth for several days. Loose BM 3 days ago, passing flatus. +
subjective fever, low grade temp to 100.0 this morning. Slight
bleeding from fistula.
.
ED course: CXR with pulmonary edema, ? pneumonia - given ctx,
azithro. Recieved HD in preparation for CTA which was negative
for PE, + for pulmonary edema.
.
ROS: + low grade fever, no n/v/abd pain, + loose stools several
days ago, make urine, no dysuria or urinary frequency. +20 pound
weight loss over last 6 months
Past Medical History:
) Type 2 diabetes mellitus: Started insulin in [**2157**].
2) Hypertension: Poorly controlled with many admissions to
MICU/CCU for hypertensive urgency.
3) Renal artery stenosis: Last MRA [**1-6**] revealed 3 left renal
arteries, superior with question of stenosis and middle with
stenosis.
4) Hypercholesterolemia
5) ESRD on HD M/W/F. Followed by Dr. [**First Name (STitle) **]
6) Diastolic CHF
7) Osteoarthritis
8) Depression
9) Anxiety
10) Sickle cell trait
11) Hiatal hernia
12) Gastroesophageal reflux disease
13) Chronic constipation
14) History of mechanical falls.
15) Chronic anemia: Presumed secondary to renal failure.
16) Status post hysterectomy in [**2132**].
Social History:
Lives at home with her husband. Moved to the US in [**2124**].
Originally from Barbados, but lived in [**Location **] for 20 years as
well. She used to work as a medic in the PACU at [**Hospital1 18**], then
later as a recreational assistant at another facility. Denies
any alcohol use, no history of smoking, no IVDU. Has mother who
is sick in a hospital in Barbados.
Family History:
Mother alive at 89, with DM2, HTN. Father died of Alzheimer's
Disease. Brother with hypertension.
Physical Exam:
Vitals: T 98.8, BP 163/76, HR 110-120, RR 16, O2 sat 98% on RA
GEN: A&O x 3, pleasant, thin F sitting up in bed in NAD. No
accessory muscle use, talking in full sentences.
HEENT: EOMI, OP clear with MMM.
Neck: JVD to jaw
CV: irregular, tachycardic, nl S1/S2, II/VI SEM at LUSB
LUNGS: crackles at bases bilaterally, good air entry
ABD: soft, moderately distended, palpable hepatomegaly, 10cm
below costal margin, NT, +BS
EXT: tr pitting edema b/l, warm. L AVF with palpable thrill.
Pertinent Results:
[**2159-4-4**] 06:15PM HCT-28.8*
[**2159-4-4**] 01:30PM ASCITES TOT PROT-4.5 GLUCOSE-211 CREAT-4.2
LD(LDH)-119 AMYLASE-41 ALBUMIN-2.7
[**2159-4-4**] 01:30PM ASCITES WBC-261* RBC-[**Numeric Identifier 22475**]* POLYS-1*
LYMPHS-32* MONOS-54* MESOTHELI-3* MACROPHAG-10*
[**2159-4-4**] 06:35AM GLUCOSE-154* UREA N-33* CREAT-4.2* SODIUM-135
POTASSIUM-3.6 CHLORIDE-90* TOTAL CO2-33* ANION GAP-16
[**2159-4-4**] 06:35AM ALT(SGPT)-22 AST(SGOT)-30 LD(LDH)-215
CK(CPK)-55 ALK PHOS-123* AMYLASE-112* TOT BILI-0.5
[**2159-4-4**] 06:35AM LIPASE-141*
[**2159-4-4**] 06:35AM CK-MB-NotDone cTropnT-0.15*
[**2159-4-4**] 06:35AM TOT PROT-7.9 ALBUMIN-4.3 GLOBULIN-3.6
CALCIUM-9.7 PHOSPHATE-3.5 MAGNESIUM-2.1 IRON-67
[**2159-4-4**] 06:35AM calTIBC-231* FERRITIN-GREATER TH TRF-178*
[**2159-4-4**] 06:35AM WBC-10.3 RBC-4.41 HGB-10.4* HCT-33.0* MCV-75*
MCH-23.6* MCHC-31.5 RDW-21.8*
[**2159-4-4**] 06:35AM PLT COUNT-201
[**2159-4-4**] 06:35AM PT-17.1* PTT-30.4 INR(PT)-1.6*
[**2159-4-4**] 02:20AM CK(CPK)-57
[**2159-4-4**] 02:20AM CK-MB-NotDone cTropnT-0.14*
[**2159-4-3**] 04:15PM LACTATE-1.9
[**2159-4-3**] 04:00PM GLUCOSE-282* UREA N-29* CREAT-3.8* SODIUM-139
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-33* ANION GAP-17
[**2159-4-3**] 04:00PM estGFR-Using this
[**2159-4-3**] 04:00PM CK(CPK)-56
[**2159-4-3**] 04:00PM cTropnT-0.13*
[**2159-4-3**] 04:00PM CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2159-4-3**] 04:00PM CALCIUM-10.0 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2159-4-3**] 04:00PM WBC-9.0 RBC-4.32 HGB-10.5* HCT-32.5* MCV-75*
MCH-24.2* MCHC-32.2 RDW-21.8*
[**2159-4-3**] 04:00PM NEUTS-76.4* LYMPHS-14.2* MONOS-7.9 EOS-0.9
BASOS-0.6
[**2159-4-3**] 04:00PM HYPOCHROM-1+ ANISOCYT-2+ MICROCYT-3+
[**2159-4-3**] 04:00PM PLT COUNT-219 LPLT-1+
[**2159-4-3**] 04:00PM D-DIMER-1224*
.
Imaging:
.
[**4-3**] CXR: CHF, no PNA
.
[**4-3**] ABD XR: MPRESSION: Dilated loops of small bowel with
multiple "step-ladder" fluid levels, and paucity of large bowel
gas, highly concerning for small bowel obstruction; adynamic
ileus is less likely.
.
[**4-3**] CT Chest, ABD, Pelvis: IMPRESSION:
1) No pulmonary embolism or evidence of bowel obstruction.
2) Moderate amount of ascites.
3) Cardiomegaly with evidence of mild congestive heart failure
and passive hepatic congestion. Small right pleural effusion.
4) Coronary artery calcification.
5) Mild enlargement of the pulmonary arteries, suggestive of
pulmonary arterial hypertension.
6) At least one small cystic lesion in the head of the pancreas,
which appears likely to connect to the main pancreatic duct but
is not well evaluated on CT; this could be followed up in 6
months.
7) Adrenal lesions not well characterized on this study appear
consistent with adenomas on prior studies.
.
[**4-4**] RUQ U/S:
1. Liver Doppler findings consistent with right heart
failure/triscuspid regurgitation. Patent hepatic vasculature.
2. Hepatomegaly. No evidence of splenomegaly.
3. Limited evaluation of the gallbladder which may contain
stones.
.
[**4-4**] ECHO:
Conclusions:
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in the left atrium
or left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular ejection
fraction appears somewhat reduced. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen.
IMPRESSION: No left atrial or left atrial appendage clot, but
severe left atrial appendage spontaneous echo contrast
.
[**4-7**] CXR
IMPRESSION: Improvement in the congestive heart failure seen on
the prior examination.
.
Other Data:
.
HBcAb negative ([**1-6**])
HCV Ab negative ([**1-6**])
HEPATITIS BE ANTIBODY NON-REACTIVE ([**1-6**])
.
Ascitic Fluid [**2159-4-4**]
Cultures pending
WBC RBC Polys Lymphs Monos Mesothe Macroph
261* [**Numeric Identifier 22475**]* 1* 32* 54* 3* 10*
TotPro Glucose Creat LD(LDH) Amylase Albumin
4.5 211 4.2 119 41 2.7
.
SAAG greater than 1.1
Ascitic fluid total protein is 4.5 (greater than 2.5) indicating
a cardiac etiology for the ascites.
Brief Hospital Course:
This is a 73 yo F with DM II, HTN, ESRD on HD, who presented
with shortness of breath, found to have new onset atrial
fibrillation, cardiac ascites, course complicated by persistent
bleeding in the setting of attempted [**Numeric Identifier **] in
preparation for cardioversion, requiring transfer to the MICU.
.
On the floor patient underwent an abdominal CT scan which showed
moderate ascites as well as hepatomegaly. She also underwent
abdominal ultrasound as well as paracentesis with 800cc of fluid
removed, and ultimately it was thought that her ascites was c/w
cardiac ascites. Hepatology was consulted and agreed. Hepatitis
serologies have been negative.
.
She also had new onset atrial fibrillation, and patient was
started on a heparin gtt with the plan for TEE and subsequent
cardioversion. However, after TEE was performed, she had not yet
been dialyzed and it was thought that cardioversion would not be
successful in the setting of volume overload. Cardioversion was
postponed, and course was then complicated by continuous oozing
and bleeding, both from her nares as well as paracentesis site.
Topical thrombin was applied to paracentesis site which
eventually stabilized bleeding. The patient also had a
significant amount of epistaxis, which was eventually tamponaded
by ENT with packing and afrin. Paracentesis site again started
to ooze, and it was difficult to control bleeding on the floor.
Her hematocrit trended downwards over this course from 28 -->
23. She had been scheduled to receive blood transfusion with
dialysis, but HD would not accept her because she was bleeding.
Because nursing was not comfortable administering dDAVP on the
floor, the patient was transferred to the MICU. She received 1
unit of pRBCs prior to transfer to the unit.
.
Trauma surgery was consulted for persistent bleed, and it was
determined that she should no longer continue on a heparin gtt.
Heparin had not been supratherapeutic during this time, however,
she had been bleeding almost persistently despite this. She was
transfused one more unit of pRBCs with an appropriate
stabilization of her hematocrit.
.
# Bleeding: Initially patient was started on a heparin gtt and
Coumadin, was on ASA 325mg. In addition, she is a dialysis
patient and has platelet dysfunction at baseline. Heparin gtt
has been discontinued as well as Coumadin, and ASA was reduced
to 81mg given bleeding. Paracentesis site bleeding was initially
tamponaded and controlled with topical thrombin, but in the
setting of being on heparin gtt, bleeding has persisted,
requiring compression for >30minutes and dDAVP to control
bleeding. Epistaxis required ENT consult with nasal packing to
control. The patient received 2 u of pRBC with an appropriate
increase in her HCT and vital signs stable.
.
# Atrial fibrillation: No prior hx of AFib, prior EKG
interpreted as ? wandering atrial pacemaker. Pt is at risk for
developing AF in setting of stretched R atrium and ECG is
consistent with that. Unable to perform cardioversion as unable
to anticoagulate. Moderate to severe contrast echo seen in
atrium, representing likely very poor flow state, high risk for
thrombus formation. There are also complex (>4mm) atheroma in
the descending thoracic aorta. However, unable to anticoagulate
given high risk of bleeding. The patient will be treated with
aspirin 325mg po daily now that HCT is stable. For rate control
she is on metoprolol XL and verapamil SR. She had an episode of
tachycardia to the 140s during dialysis, likely due to the fact
that she was due for rate controlling medications. She has
outpatient follow up appointment with cardiology.
.
# Ascites: Patient is s/p paracentesis, ascitic fluid consistent
with portal hypertension from cardiac etiology. Abdominal
ultrasound also c/w liver enlargement from RHF, normal flow on
dopplers. Fluid cytology negative for malignancy. Appreciate
hepatology recommendations who also agree that ascites is most
likely from cardiac etiology.
.
# Diabetes Mellitus, type 2, well controlled: Glyburide
discontinued on admission, given renal failure. Likely should
not be continued as an outpatient. On admission was on lantus
45U qam and 15 units of lantus qhs. She had multiple episodes of
hypoglycemia during her admission and required a D10 gtt. Likely
hepatic impairment of gluconeogenesis as well as impaired renal
clearance are likely playing a role. [**Last Name (un) **] involved. Lantus
now decreased, made daily instead of [**Hospital1 **] dosing. The patient
was informed of insulin regimen changes for outpatient and to
continue to monitor blood glucose with fingersticks, primary
physician's direction.
.
# ESRD on HD: Renal failure likely secondary to DM and HTN. She
received hemodialysis while inpatient and also nephrocaps,
sevelamer, fluid restriction. Dr. [**First Name (STitle) 805**] is outpatient
nephrologist.
.
# Hypertension: Previously on regimen of labetalol, lisinopril,
nifedipine, hydralazine, clonidine, and isosorbide. We have
discontinued hydralazine, changed nifedipine to verapamil, and
decreased metoprolol, titrated down clonidine.
.
# Dyspnea: Likely a combination of fluid overload, atrial
fibrillation, mechanical stress of ascites. CTA negative on
admission for PE. No evidence of pneumonia on CXR. No evidence
of new coronary event, troponin at baseline. DFA for influenza
was negative. Continue dialysis for volume overload.
.
# Pancreatic lesion: ?cyst, consider MRI eval as outpatient.
Medications on Admission:
Labetalol 300 mg PO TID
Lisinopril 40 mg PO QD
Nifedipine 180 mg QD
Hydralazine 50 mg PO BID
Clonidine 0.3 mg PO BID
Isosorbide Mononitrate 90 mg Sustained Release PO DAILY
Atorvastatin 10 mg PO DAILY
Pantoprazole 40 mg PO once a day.
Ferrous Sulfate 325 PO DAILY
Clonazepam 1 mg PO BID
Folic acid 1 mg daily
Insulin Lantus 45 units QAM, 15 units Qpm
glyburide 2 mg [**Hospital1 **]
MVI 1 tablet daily
B12 50 mcg po daily
Tylenol prn arthritis
Sevelemer 400 mg TID
ASA 325 mg daily
Rhinocort Acqua
Discharge Medications:
1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Four (4) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous qam: Take as directed by your doctor. .
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*150 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
- Atrial fibrillation
- Diastolic congestive heart failure
.
Secondary diagnosis:
- Diabetes mellitus type 2
- Hypertension
- Hypercholesterolemia
- End stage renal disease on hemodialysis
- Osteoarthritis
- Gastroesophageal reflux disease
- Chronic anemia
Discharge Condition:
Atrial fibrillation on aspirin, respiratory status stable
Discharge Instructions:
You presented to the hospital with shortness of breath and were
found to have atrial fibrillation. You were originally treated
with [**Hospital **] (blood thinner) but due to increased
bleeding, the [**Hospital **] was held. You will need to go to
a follow up appointment with your cardiologist to reassess
[**Hospital **].
Please take all medications as directed. Some of your
medications have been changed:
a. Stop taking labetalol, nifedipine, hydralazine, glyburide.
b. New medications include metoprolol XL 150mg by mouth once
daily, verapamil SR 240mg by mouth once daily.
c. The doses have been changed on some of your medications.
- decrease clonidine to 0.2mg by mouth twice daily
- increase isosorbide mononitrate to 120mg by mouth once daily
- insulin glargine has been decreased to 20 units once each
morning. Do not take any insulin glargine (lantus) in the
evening.
Continue to check your blood sugar regularly and call your
doctor if your blood sugar is less than 60 or greater than 400.
Please attend all follow up appointments.
Continue to go to your regularly scheudle dialysis appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml per day.
If you develop fever, chills, shortness of breath, chest pain or
any other symptom that concerns you, call your primary doctor,
or if unavailable go to the emergency room.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 911**], MD Phone: [**Telephone/Fax (1) 22476**] Date/Time: [**2159-4-19**]
12:30
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2159-4-24**] 9:50
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 11595**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 19196**] Date/Time: [**2159-4-24**] 2:15pm
Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] (you
will have already seen your cardiologist prior to this
appointment), your blood sugar, and discuss a pancreatic cyst
seen on imaging and MRI may be indicated for further evaluation.
ICD9 Codes: 4280, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5662
} | Medical Text: Admission Date: [**2199-11-25**] Discharge Date: [**2199-12-9**]
Date of Birth: [**2131-12-4**] Sex: M
Service: Medical Intensive Care Unit
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
male with known alcoholic cirrhosis and Grade III esophageal
varices that were recently banded in [**2199-10-20**]. He
presented to the Emergency Department [**2199-11-25**] for sudden
onset of bright red hematemesis.
Patient denied chest pain and shortness of breath as well as
abdominal pain, however, did complain of nausea. In the
Emergency Department, the patient had a nasogastric tube
placed, however, bright red blood did not clear with lavage.
The patient was transfused 2 units of packed red blood cells
and given intravenous fluids and remained hemodynamically
stable. An esophagogastroduodenoscopy was attempted in the
Emergency Department, however, the airway was compromised by
hemorrhage, and patient was emergently intubated for airway
protection. The patient received Ativan, Demerol, vecuronium
for intubation in esophagogastroduodenoscopy.
PAST MEDICAL HISTORY:
1. Alcoholic cirrhosis with Grade III esophageal varices
status post banding in [**10-21**].
2. Portal gastropathy.
3. Hypertension.
4. Seizure disorder.
5. Type 2 diabetes.
6. History of prostate cancer status post prostatectomy.
7. History of chronic renal insufficiency with a baseline
creatinine of 2.1-2.3.
MEDICATIONS ON ADMISSION:
1. Propanolol 20 [**Hospital1 **].
2. Dilantin 500 once a day.
3. Univasc 30 once a day.
4. Aldactone 25 once a day.
5. Insulin.
6. Protonix 40 once a day.
ALLERGIES: IV contrast as well as to sulfa and codeine.
SOCIAL HISTORY: Notable for longstanding history of alcohol
abuse. Patient was actively drinking until his last
admission in [**10-21**]. No history of tobacco use. The patient
has a very close-knit and involved family including daughter,
[**Name (NI) 1404**] and son, [**Name (NI) 122**].
On admission, the patient had a heart rate of 100, blood
pressure of 117/60, saturation of 98% on FIO2 of 0.4. The
patient was ventilated with settings assist control tidal
volume of 600, rate of 12, PEEP of 10, FIO2 of 0.4.
Patient was in no apparent distress, sedated. Had no
evidence of jaundice. HEENT showed no scleral icterus.
Cardiovascular examination was tachycardic, but regular.
Chest examination was clear to auscultation bilaterally,
anteriorly and laterally. Abdomen was soft, slightly
distended, nontender. Extremities had no edema.
LABORATORIES ON ADMISSION: The patient had a white count of
9.6, hematocrit of 24 which was down from 31.6 on discharge
several days prior. Platelets of 231. Sodium of 136,
potassium 4.5, chloride 101, bicarb 22, BUN 21, creatinine
2.5 up from a baseline of 2.1. Glucose of 235. Liver
function tests: ALT was 15, AST 27, alkaline phosphatase 86,
T bilirubin 0.2, amylase 172, lipase 140, INR was 1.7, and
PTT 28. This is up from an INR baseline of 1.4.
Chest x-ray showed cardiomegaly and no evidence of pneumonia.
Electrocardiogram was notable for normal sinus at 94 with
normal axis, normal intervals, no Q waves, and no ST changes,
however, T-wave inversions in III and V that were unchanged
from [**2199-11-14**].
In short, this is a 57-year-old male with alcoholic cirrhosis
admitted for upper GI bleed, emergently intubated for airway
protection.
HOSPITAL COURSE:
1. Gastrointestinal bleed: The patient underwent emergent
esophagogastroduodenoscopy, which showed a [**1-21**] bands had
fallen off with typical banding ulcers and Grade IV varices
in his esophagus extending proximally. There was no acute
bleeding, however, there was stigmata of bleeding from the
banding ulcers. The patient had small cardiac and fundal
varices, a lot amount of clot in his fundus. No gastric or
duodenal ulcers were present.
The patient was started on intravenous Protonix as well as
octreotide transfused as necessary. The initial plan was to
take the patient for TIPS done by Interventional Radiology,
however, TIPS was attempted unsuccessfully.
Surgery was consulted regarding surgical intervention and
question of a portocaval shunt, however, the patient's
anatomy was inappropriate for a portocaval shunt using the
splenic vein. Patient also was not felt to have been
maximally medically managed at that time, thus plan changed.
The patient was eventually weaned off octreotide, however,
after rebled after being weaned off octreotide. The patient
was rescoped by the Hepatology Service, who found no evidence
of rebleeding, no stigmata of bleeding, and his banding
ulcers, just large clot in his fundus. No obvious varices
with stigmata of bleeding were noted, and his varices were
noted to be Grade II at the time of re-EGD on [**2199-12-3**]. The
patient was restarted on octreotide, and continued on
Protonix as well as Carafate, however, the patient continued
to require large volumes of packed red blood cells.
Patient's bleeding had not fully resolved at the time of his
death. Multiple surgical options were rediscussed as well as
consideration of repeat TIPS, however, it was felt that
patient would be unlikely to benefit from any of these
procedures given his poor mental status, and the increase
risk of encephalopathy. Also of great consideration, was the
patient's mortality from surgery, which was felt to be
astronomically elevated, thus making surgical intervention
not an option for this patient.
2. Pancreatitis: Patient was noted to have elevated amylase
and lipase. He underwent CT scan without contrast, however,
this did not adequately visualize the pancreas. Was started
on TPN and continued on TPN throughout the course of his
hospital stay. The patient's enzymes had started trending
downward, however, they never fully normalized.
3. Abdominal distention: Patient's abdominal distention
initially thought to be due to decreased portal hypertension
and ascites. It was tapped successfully on [**2199-12-3**], a liter
and a half of clear fluid was removed without complications.
This was not consistent by cell count or chemistry with being
notable for spontaneous bacterial peritonitis. Gram stain
and cultures of fluids remain negative.
Patient's belly continued to increase in size, and it was
again attempted to use paracentesis on [**2199-12-6**], however, it
was difficult to localize the pocket of fluid. Ultrasound
guided tap was attempted, which revealed only small to
moderate ascites, just large dilated loops of bowel. Flat
film showed some air within the bowel, however, film was
largely unremarkable and showed no evidence of obstruction.
The patient continued to have melena and output from his
nasogastric tube both suggesting that he was not obstructed.
Patient unfortunately continued to become more distended, and
his bladder pressures were in the high 20s. Surgery was
consulted regarding the question of surgical decompression as
his bladder pressures were not. Patient's creatinine
worsened as did his liver function tests, however, it is felt
that the patient's surgical mortality would be enormous and
surgical intervention was unlikely to be helpful to this
patient.
3. Mental status: Patient initially had been intubated for
airway protection only, and was sedated on Ativan as well as
propofol. The patient's sedating medications were stopped on
[**2199-12-1**], and it was thought that he would regain
consciousness as his system slowly metabolized the Ativan,
however, patient never regained consciousness or purposeful
movement. Unclear whether this is due to worsening
encephalopathy or whether patient had an acute cerebral
event.
4. Respiratory: Patient was maintained on mechanical
ventilation throughout the course of his hospital stay. He
was initially, when heavily sedated, maintained on assist
control, however, after his sedation was stopped, the patient
tolerated pressure support fine. The patient became
increasingly difficult to ventilate as his abdominal
pressures increased and required higher and higher levels of
PEEP. The patient, however, was electively extubated on
[**2199-12-9**] at the request of his family, who wished to make him
comfort measures only.
5. Code status: The patient's family was actively involved
with his care and supportive, however, they were concerned
that their father would not want aggressive surgical
intervention and prolonged hospitalization if at all
possible. They were willing to entertain TIPS as a
possibility, however, as the patient's situation became
worse, and it became clear that TIPS was not likely to be
helpful to their father, patient's family remained ambivalent
about surgery especially after hearing the high mortality
that would be associated with surgical options.
Family discussed what their father would want, and decided to
stop medications and medical intervention, and make the
patient comfortable. The patient was started on a Morphine
drip, and remained intubated for two days further at which
point patient's family decided to withdraw ventilatory
support. Patient expired later the same day with his family
present at the bedside.
The patient's official time of death was 8:55 pm on [**2199-12-9**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2199-12-26**] 09:22
T: [**2199-12-29**] 09:19
JOB#: [**Job Number **]
ICD9 Codes: 2762, 2767, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5663
} | Medical Text: Admission Date: [**2158-6-17**] Discharge Date: [**2158-6-21**]
Date of Birth: [**2102-1-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Babesiosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 M orthopedic physician, [**Name10 (NameIs) **] [**Name11 (NameIs) **] (good) until 7 Days PTA . 1
week prior to admission while in [**Country 18084**] he noticed sudden
onset of fatigue, no muscle pains, joint pains, denied cough,
fevers, sob, diarrhea, dysuria. On return, he had a cxr which
was negative per his report, and f/u blood work which
demonstrated intraerythrocytic parasites and he was admitted for
further treatment at an OSH.
.
While in [**Country 18084**] for 10 days, had been playing golf, no known
tick bites, however prior to trip, for the past month he had
noticed increasing fatigue, also multiple exposures to ticks,
which at [**Location (un) **], and in his gardens in [**Location (un) 1411**].
.
At OSH was noted to have WBC of 7800, 24% monos, ALT 102, AST
107, TBili 3.18 was started on clindamycin 1200mg q12h, quinine
650 PO. He was continued on clinda/quinine. Doxy was started for
possible ehrlichiosis co-infection. He was then transitioned to
atovaquone and azithromycin [**6-15**].
He was transferred to [**Hospital1 18**] [**6-17**] for possible plasma exchange
given high parasitemia (10-15% at OSH). Parasitemia here was 6%
and, in discussion with transfusion medicine and infectious
disease services, it was decided that he did not need plasma
exchange. ICU course also notable for continued high-grade
fever, CHF (received IV lasix) and hearing loss (attributed to
quinine).
Past Medical History:
MI s/p CABG
HTN
Hypercholesterolemia
Social History:
Lives at home, orthopedist at [**Hospital1 **], no smoking, social EtoH
Family History:
91 alive Father CAD, CABG, Prostate CA
[**15**] Mother deceased ALS, 1 healthy sister
Physical Exam:
VS 98.7, 102/52, 56, 18, 100%
Gen: NAD, pleasant, speaking in full sentences
HEENT: JVP nondistended, PERRL, anicteric sclera, OP Clear, no
LAD
CV: RRR no mrg
Chest: cta b/l
Ext: no c/c/e
Neuro CNII-CNXII intact, no focal deficits
Pertinent Results:
[**2158-6-21**] 05:45AM BLOOD WBC-7.3 RBC-3.63* Hgb-11.2* Hct-32.8*
MCV-91 MCH-31.0 MCHC-34.2 RDW-15.7* Plt Ct-230#
[**2158-6-20**] 05:40AM BLOOD WBC-7.1 RBC-3.45* Hgb-10.7* Hct-30.9*
MCV-90 MCH-31.1 MCHC-34.6 RDW-15.1 Plt Ct-153
[**2158-6-19**] 07:20AM BLOOD WBC-7.0 RBC-3.41* Hgb-11.0* Hct-29.9*
MCV-88 MCH-32.4* MCHC-36.9* RDW-15.0 Plt Ct-110*
[**2158-6-18**] 06:08AM BLOOD WBC-6.8 RBC-3.64* Hgb-11.7* Hct-32.3*
MCV-89 MCH-32.0 MCHC-36.2* RDW-14.8 Plt Ct-82*
[**2158-6-17**] 02:23PM BLOOD WBC-6.8 RBC-3.53* Hgb-11.2* Hct-31.6*
MCV-90 MCH-31.7 MCHC-35.4* RDW-15.2 Plt Ct-75*
[**2158-6-19**] 07:20AM BLOOD Neuts-51 Bands-1 Lymphs-25 Monos-19*
Eos-0 Baso-1 Atyps-2* Metas-0 Myelos-0 Plasma-1*
[**2158-6-19**] 07:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2158-6-21**] 05:45AM BLOOD PT-14.3* INR(PT)-1.3*
[**2158-6-19**] 07:20AM BLOOD Fibrino-779*
[**2158-6-20**] 12:35PM BLOOD Parst S-POSITIVE
[**2158-6-21**] 05:45AM BLOOD Glucose-100 UreaN-14 Creat-0.8 Na-130*
K-4.7 Cl-97 HCO3-25 AnGap-13
[**2158-6-20**] 05:40AM BLOOD Glucose-116* UreaN-15 Creat-0.8 Na-130*
K-4.1 Cl-96 HCO3-26 AnGap-12
[**2158-6-19**] 07:20AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-128*
K-4.1 Cl-94* HCO3-25 AnGap-13
[**2158-6-21**] 05:45AM BLOOD ALT-289* AST-204* LD(LDH)-732*
AlkPhos-127* TotBili-1.7*
[**2158-6-20**] 05:40AM BLOOD ALT-277* AST-243* CK(CPK)-144 AlkPhos-117
TotBili-2.0*
[**2158-6-18**] 06:08AM BLOOD ALT-269* AST-257* CK(CPK)-114 AlkPhos-114
TotBili-3.1*
[**2158-6-20**] 05:40AM BLOOD CK-MB-4 cTropnT-<0.01
[**2158-6-18**] 06:08AM BLOOD CK-MB-4 cTropnT-<0.01
[**2158-6-21**] 05:45AM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.4 Mg-2.5
[**2158-6-17**] 02:23PM BLOOD TotProt-5.1* Albumin-2.4* Globuln-2.7
Calcium-7.4* Phos-1.6* Mg-2.2
[**2158-6-19**] 07:20AM BLOOD Hapto-<20*
[**2158-6-18**] 06:08AM BLOOD calTIBC-122* VitB12-615 Folate-15.6
Ferritn-GREATER TH TRF-94*
[**2158-6-17**] 02:23PM BLOOD Hapto-<20*
[**2158-6-21**] 05:45AM BLOOD Triglyc-220*
[**2158-6-18**] 06:08AM BLOOD Osmolal-268*
[**2158-6-18**] 06:08AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2158-6-18**] 06:08AM BLOOD HCV Ab-NEGATIVE
[**2158-6-19**] 07:20AM BLOOD MISCELLANEOUS TESTING-PND
[**2158-6-18**] 06:08AM BLOOD LEPTOSPIRA ANTIBODY-PND
[**2158-6-18**] 06:08AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA [**Doctor Last Name **]) IGG/IGM-PND
[**2158-6-18**] 06:08AM BLOOD HUMAN MONOCYTIC AND GRANULOCYTIC
EHRLICHIA AGENTS IGG AND IGM-PND
TTE: Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is low
normal (LVEF 50-55%) with inferior hypokinesis suggested (poor
image quality). There is no ventricular septal defect. Right
ventricular chamber size is normal. Right ventricular systolic
function is borderline normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a fat pad
CTA CHEST: There is no pulmonary embolism. Thoracic aorta is
normal in caliber and contour, without evidence of dissection or
aneurysm. Heart, pericardium, and great vessels are normal.
There is no pericardial effusion. There is no enlarged
adenopathy within the chest. Central bronchi are patent to the
subsegmental level. There is evidence of previous median
sternotomy and cardiac surgery with CABG. Lung windows
demonstrate no pulmonary nodules or focal consolidations,
although evaluation of the left lower lobe and lingula is
slightly limited due to respiratory motion artifact. There are
small bilateral pleural effusions, and minor subsegmental
atelectasis at the lung bases bilaterally. Limited views of the
upper abdomen are notable for mild splenomegaly. Osseous
structures are unremarkable.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Small bilateral pleural effusions.
PORTABLE CHEST X-RAY
Recently described interstitial edema has resolved. Cardiac
silhouette remains mildly enlarged with upper zone vascular
redistribution. New discoid atelectasis developed at the left
lung base peripherally.
Brief Hospital Course:
Admitted initially to [**Hospital Unit Name 153**] then transferred to [**Hospital Ward Name 516**]
Hospitalist Service
1. Babesiosis
- ID consultation
- [**Hospital **] clinic f/u on [**6-27**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
- Patient is being continued on docycycline given we have not
recieved his leptospirosis serology. This is a less likely
co-infection but must be considered given the constellation of
Sx
- Patient to continue atovaquone and zithromax until instructed
by ID to stop
- Serial thick smears demonstrated clearing of babesia
parasites, last smear 0.2%
- Presumed etiology of hemolysis
- The infection really behaved as if the patient is asplenic,
and he is being recommended to have this worked up at his PCPs
office
- Special babesia serologies were sent to the CDC for
speciation. These were pending at discharge
2. Transaminitis
- Likely due to babesia, however several features are hard to
explain, especially his albumin of 2.4
- Given the level of transaminases his lipitor was held
- Recommend further workup at his PCP's office in [**1-28**] weeks for
repeat serologies to restart lipitor
- His bilirubins have improved steadily
3. Hemolysis NOS
- Presumed due to babesia, however further splenic workup in the
outpatient setting are recommended
- Hematocrit stabilized at 30
4. Hyponatremia
- Slowly improving, now at 130
- Recommend outpatient followup, more likely due to free water
with initially poor PO salt intake
5. Systolic CHF
- EF has improved from prior echo of 45% to new EF of > 55%
- Toprol XL was continued
- ACEI was held due to his BP being 110
- Patient will monitor his own BP at home and restart ACEI when
it > 120'
6. CAD/CABG Vessle
- Toprol XL was continued
- Lipitor was held as above
- When labs have returned to [**Location 213**] could resume aspirin
7. Benign Hypertension
- Toprol XL was continued
- ACEI was held due to his BP being 110
- Patient will monitor his own BP at home and restart ACEI when
it > 120'
Medications on Admission:
Albuterol/ipratropium
guaifensin 1200mg [**Hospital1 **] PO
doxycycline 100mg Q12H
Ibuprofen 400mg q6hrs PRN
Quinine Sulfate 650mg Q8H
Metoprolol XL 50mg DAILY
Folice Acid 1mg DAILY
MVI 1 TB
Zolpidem 10mg QHS
Ramipril 15mg DAILY
CaCarbonate 500mg [**Hospital1 **]
Omeprazole 20mg DAILY
Azithromycin 250 DAILY
Meperidine 50mg Q4Hrs PRN
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO BID (2
times a day) for 14 weeks.
Disp:*980 ml* Refills:*0*
2. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 14 days.
Disp:*28 Capsule(s)* Refills:*0*
3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 14 days.
Disp:*28 Capsule(s)* Refills:*0*
4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
5. Ramipril 5 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily): hold for SBP < 120.
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 14 days.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Babesiosis
Transaminitis
Hemolysis
Hyponatremia
Systolic CHF
CAD
Benign Hypertension
Discharge Condition:
Good
Discharge Instructions:
You are being discharged with some changes to your medications:
Do not restart your lipitor until cleared by your PCP due to
your liver enzymes
Measure your blood pressure each day and would not take your
ramapril if your blood pressure is < [**Age over 90 **]
You can continue to take your zetia
We are sending you out on doxycycline as we still do not have
your leptospirosis serologies back. Continue to take it until
you have seen the [**Hospital **] clinic
You should have a workup by your PCP for your spleen and liver
function, including why your albumin is so low.
Followup Instructions:
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2158-6-27**]
3:00 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Please make an appointment for the next 2 weeks with your PCP
[**Name9 (PRE) **],[**Name9 (PRE) 198**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 19980**]
ICD9 Codes: 2761, 4280, 2875, 4019, 2724, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5664
} | Medical Text: Admission Date: [**2148-2-11**] Discharge Date: [**2148-3-7**]
Date of Birth: [**2098-9-16**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 50-year-old female
with a history of hypertension and increasing headache over
six days who then developed some neck and back and lower
extremity pain on approximately the sixth day. The headache
was defined as diffuse, rated at 5/10 in intensity, and not
very responsive to pain medication. She went to an outside
hospital two days prior to admission where she was evaluated
and felt to have symptoms consistent with migraine headache.
A CT scan of the head was not obtained at that time. Neck
films were obtained at that time but were normal per report
and she was given naproxen and discharged home. At the time
of admission to the [**Hospital6 256**], she
stated that her headache awoke her from a sleep with
increasing headache, as well as some nausea and vomiting on
the morning of admission. There was no diplopia or visual
changes. She did complain of mild neck pain. Denied any
weakness and numbness or tingling.
PREVIOUS MEDICAL HISTORY: Includes a history of hypertension
and she is status post appendectomy as a 15 year old.
ALLERGIES: She has no known drug allergies.
CURRENT MEDICATIONS: Vasotec, Atenolol, Flexeril and
Naprosyn.
PHYSICAL EXAMINATION: She was afebrile. Vital signs: Blood
pressure 157/86. Heart rate 85. Respiratory rate 17. 02
saturation 100% on room air. She was awake and in no acute
distress. The neck showed bilateral bruises along the
lateral aspects of the neck and shoulders, but was supple to
motion. Chest was clear to percussion and auscultation.
There were no carotid bruits. There was a 2/6 systolic
ejection murmur but the heart was otherwise normal sinus
rhythm. Abdominal exam was unremarkable. Extremity exam was
unremarkable. Neurological exam showed mental status, the
patient was awake, alert and oriented times three with fluent
speech, normal naming of objects and normal repetition. She
was drowsy with her eyes closed sporadically throughout the
exam. Cranial nerves were intact. Muscles were normal bulk
and tone with full strength 5/5 throughout. There was no
drift and no asterixis and a sensory exam showed light touch
to be intact throughout. Deep tendon reflexes were equal
bilaterally. Toes appeared to be upgoing bilaterally and
there were slightly clumsy dystonia for finger to nose and
rapid alternating movements on the right.
At the time of admission, her white blood cell count was
13.4, hematocrit 35.5, platelet count 285,000. Coags: PT
was 11.8, PTT 21.9, INR 1.0. Chem-7 and urinalysis were
negative and a head CT showed a subarachnoid hemorrhage with
evidence to suggest an aneurysmal rupture. The patient was
seen in consultation by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Interventional
Neuroradiology who felt that a diagnostic angiogram was
indicated and the patient was taken to the Angiogram Suite
for diagnostic angiogram. A aneurysm was seen at that time
and the patient underwent a coiling of an anterior
communicating artery aneurysm during the initial procedure.
The patient tolerated the procedure well. She went to the
Neurological Intensive Care Unit for recovery in stable
condition. On the morning following the angiogram, the groin
sheath was removed and tolerated well. A vent drain was
placed at the time of the angiogram and the vent drain
drained clear cerebral spinal fluid for several days. On
attempts to wean the patient from the vent drain, her mental
status would deteriorate, therefore, the vent drain was
continued for several days.
On [**2-29**], cerebrospinal fluid cultures from [**2-27**], grew out one colony of gram positive rods in one plate
and due to this, the patient was begun on vancomycin and
cephalexin for meningitis and seen in consultation by the
Infectious Disease Service.
The patient tolerated the remainder of her hospitalization.
The drain was slowly elevated as the patient could tolerate
as clinically and the drain was clamped on the [**3-4**] and removed on the [**3-5**]. An lumbar
puncture was done on the [**3-6**] to measure opening
pressure and the opening pressure was 12 (closing pressure
was 10). The patient tolerated the procedure well and showed
no further mental status changes throughout the remainder of
the hospitalization. She was subsequently discharged home on
the morning of the [**2148-3-7**] with follow-up to
see Dr. [**Last Name (STitle) 1132**] in the Clinic in approximately two to three
weeks time. It is important to note, that the patient was
followed throughout her hospitalization by the Psychiatry
Service for history of anxiety and for dealing with her
recent illness.
CONDITION ON DISCHARGE: Stable and improved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 5474**]
MEDQUIST36
D: [**2148-6-9**] 14:05
T: [**2148-6-9**] 14:05
JOB#: [**Job Number 38882**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5665
} | Medical Text: Admission Date: [**2107-8-13**] Discharge Date: [**2107-8-15**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
Pt is a [**Age over 90 **]F with history of diastolic heart failure (EF 55%),
PAF not on Coumadin, critical AS valve area <0.8, congenital
VSD, mild dementia, and RLS who presents with shortness of
breath, and transferred to MICU for hypoxia, requiring BiPAP in
the ED. Beginning last night, she was sitting trying to fix the
cord on her phone, when she became frustrated, and became more
short of breath. She also had some palpitations but denied any
chest pain. She also started to feel some nausea, but had no
emesis and no abdominal pain. She says that this is similar to
previous admissions where she had SOB. She also had a mild
cough, non-productive. She denies any fever, chills or sweats.
She has been eating well, though over the last 2 months has lost
~ 20lbs. Also endorses some mild leg swelling, though this is
unchanged.
.
In the ED, initial VS T 96 HR 68 BP 182/81 RR 32 100% 15L. She
was 97% on 3L NC upon EMS arrival to [**Hospital1 599**] where pt is from. EKG
showed SR 95, LAD, RBBB, V3 now non-inverted. CXR read by the
resident as possible RLL PNA, for which she was given Vanc 1gm
x1, Zosyn 4.5mg x1. She was also given 700cc NS as she appeared
dry. She was subsequently put on BIPAP PEEP 8 Psupport 10 for
1hr. Blood cultures were sent. She had 1 20g for access, with
plans to place another prior to transfer. She was also given
Zofran 4mg IVx1 with resolution of her nausea. VS prior to
transfer 99.0 66 115/39 22 100% on BiPAP.
.
On the floor, she says that she feels much better and is no
longer SOB. She also no longer has any nausea.
.
Review of systems:
(+) Per HPI. Per her grandson, she also will occasionally "act
out her dream" but otherwise has been doing well. Last BM was
yesterday or day prior with no bloody or black stools.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, or weakness. Denies vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. diastolic dysfunction congestive heart failure (preserved EF
55% on last 2D echo [**2107-7-19**])
2. paroxysmal atrial fibrillation (on aspirin, amiodarone)
3. restless leg syndrome
4. dysphagia
5. hyperlipidemia
6. anemia
7. depression
8. macular degeneration
9. glaucoma
10. coronary artery disease
11. congenital VSD (cyanotic at birth, never repaired)
12. s/p THR ([**2107**])
Social History:
Patient lives at [**Hospital1 **] and has one son who lives in [**Name (NI) 7188**], RI
with four grandchildren. She is a former smoker up to 2-PPD but
stopped smoking years prior; she denies current alcohol use, and
rarely has a drink; denies recreational substance use
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
Vitals: T: 96.4 BP: 112/49 P: 65 R: 24 O2: 100% on 3LNC
General: pleasant elderly female, lying down in bed, NAD
HEENT: PERLL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no thyromegaly
Lungs: no use of access mm, decreased BS at bases with crackles,
no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic
murmur, loudest at LUSB, no apparent radiation, no rubs
Abdomen: hyperactive BS, soft, non-tender, non-distended, no
rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, dry, no cyanosis or edema
Neuro: oriented to person, place, states [**2106-6-29**], moving all
extremities, no gross deficits, gait deferred
ON DISCHARGE:
VITALS: 96.8/96.8 62 112/60 20 97% 2L NC I/O: sips/NR | 175
GENERAL: pleasant elderly female, lying down in bed, NAD
HEENT: PEERL, EOMI, Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD, no thyromegaly
LUNGS: decreased BS at bases with minimal crackles, no wheezes
or rhonchi
CVS: regular rate and rhythm, normal S1 + S2, 3/6 systolic
murmur, loudest at LUSB, no apparent radiation, no rubs
Abdomen: NABS, soft, non-tender, non-distended, no rebound
tenderness or guarding, no organomegaly
EXTR: warm, dry, without cyanosis or edema
NEURO: oriented to person, place, moving all extremities, no
gross deficits, gait deferred
Pertinent Results:
[**2107-8-15**] 06:45AM BLOOD WBC-6.1 RBC-3.72* Hgb-10.7* Hct-32.3*
MCV-87 MCH-28.9 MCHC-33.3 RDW-15.5 Plt Ct-255
[**2107-8-14**] 05:44AM BLOOD PT-12.5 PTT-33.7 INR(PT)-1.1
[**2107-8-15**] 06:45AM BLOOD Glucose-110* UreaN-29* Creat-1.2* Na-136
K-4.7 Cl-99 HCO3-27 AnGap-15
[**2107-8-13**] 08:10AM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 105670**]*
[**2107-8-15**] 06:45AM BLOOD Calcium-9.0 Phos-3.1 Mg-3.0*
[**2107-8-13**] 08:15AM BLOOD Glucose-319* Lactate-3.1* K-4.6
IMAGING:
[**2107-7-19**] 2D ECHOCARDIOGRAM - Symmetric LVH with normal global and
regional biventricular systolic function. Restrictive
perimembranous VSD. Calcific aortic valve disease with severe
stenosis and mild regurgitation. Calcific mitral valve disease
with mild stenosis and moderate to severe regurgitation.
Moderate tricuspid regurgitation. Moderate pulmonary
hypertension
.
[**2107-8-13**] CHEST (PORTABLE AP) - Persistent heart failure. Improved
but residual pulmonary edema with small bilateral pleural
effusions.
.
MICROBIOLOGY:
[**2107-8-13**] Urine culture - no growth (final)
[**2107-8-13**] Blood culture (x 2) - pending
Brief Hospital Course:
Pt is a [**Age over 90 **]F with history of heart failure (EF 55%), paroxysmal
atrial fibrillation not on Coumadin, severe AS valve area <0.8,
congenital VSD, mild dementia, and RLS who presents with
shortness of breath, and transferred to MICU for hypoxia,
requiring BiPAP in the ED. On admission to the MICU, was able to
be weaned to nasal cannula. At this point she was transfered to
the Medical floor for further care.
# Shortness of breath: Most likely [**3-2**] flash pulmonary edema as
similar to previous episodes. Possibly flashed [**3-2**] hypertension
as elevated BP to 180s in ED initially vs. afib with rapid rate.
Other ddx includes ACS vs. PNA. Pt denies any chest pain, ECG
unchanged, and clinical picture more c/w flash pulmonary edema.
Initial trop <0.01. PNA considered given mild cough; however,
without sputum production, fever or chills, in addition to the
fact that CXR findings are unchanged from recent CXR at last
admission, unlikely PNA. Antibiotics of Vanc/Zosyn were given in
the ED x1 dose, but were not continued in the ICU. She was
monitored, and able to be transitioned to nasal cannula the day
of admission. Cultures were sent and showed no growth on
discharge. She was maintained on 2L nasal cannula and this was
continued on discharge with plans to wean at [**Hospital1 **] facility.
.
# Hyperglycemia: Unclear etiology, though possibly [**3-2**] stress
response as pt seems to always come in hyperglycemic with her
flash pulmonary edema. Pt with trace ketones, concerning
initially for DKA, though now BG 77 on admission here prior to
any insulin. Resolved without further issues.
# Chronic renal insufficiency: Cr 1.3 on admission, at baseline.
# Elevated AG: Likely [**3-2**] elevated lactate of 3.1 on admission.
Also likely [**3-2**] CKD. Considered also DKA given hyperglycemia as
above & trace ketones, but as above, hyperglycemia resolved
without intervention. Lactate was repeated and was stable.
.
#. CHF, acute on chronic: Most recent TTE from [**6-/2107**], showing
EF EF>55%, critical aortic stenosis, mitral stenosis and severe
regurgitation, as well as pulmonary hypertension. Pt did not
appear clinically volume overloaded on admission. Lasix was
initially held given pt did not seem volume overloaded, and was
held on discharge with recommendation to consider PRN doses if
volume overload ensues, given her critical aortic stenosis. Her
beta-blocker was halved on admission and this was increased to
her home dose once she was improved. Her isosorbide dose was
decreased to 10 mg PO BID for discharge (but was initially held
while she was in the MICU).
# CAD: Continued ASA 81 mg and beta blocker. Halved dose of
bblocker given HR of 60 and resumed prior dose on discharge.
Held imdur given sever AS and BPs stable; will resume Imdur at
10 mg PO BID and hold if her systolic pressures become tenuous.
.
# Paroxysmal A-Fib: SR on admission. Possible, as above, that
afib with fast rate may have triggered flash pulmonary edema.
She was continued on Amiodarone 200mg daily and beta blocker.
She was continued on ASA, but no anticoagulation (as per prior).
Her rate was well-controlled during her brief hospitalization.
#. Glaucoma/macular degeneration: Continued eye drops as
previous.
#. Restless Legs syndrome: Continued pramipexole.
#. Dementia: Continued sinemet TID.
TRANSITIONAL CARE:
1. CODE: DNR/DNI, CONFIRMED WITH PT & FAMILY
2. CONTACT: Grandson, [**Name (NI) **] [**Name (NI) 6537**] [**Telephone/Fax (1) 105671**]
3. Medical management: continued home medications, no change
4. Outstanding labs/studies:
- blood cultures from admission (no growth at discharge)
5. Risks to rehospitalization:
- several admissions for flash pulmonary edema
Medications on Admission:
HOME MEDICATIONS (per nursing facility):
1. Timolol 0.25% eye drops in each eye daily
2. Travatan 0.004% eye drop in R eye at bedtime
3. Vitamin D 400 units tab PO daily
4. Acetaminophen 325 mg tab (2 tabs) Q4H PRN pain or fever
5. Bisacodyl supp 10 mg PR PRN constipation
6. Fleet enema 1 enema PR PRN constipation
7. Sinemet 25/250 1 tab PO three times daily
8. Tums 500 mg 1 tab PO BID
9. Aspirin 81 mg PO daily
10. Furosemide 40 mg PO daily
11. Isosorbide mononitrate 30 mg PO daily
12. Metoprolol succ 25 mg PO daily
13. MVI
14. Pramipexole 0.25 mg PO BID
15. Amiodarone 200 mg PO daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain, fever.
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
7. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. isosorbide mononitrate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation.
15. travoprost 0.004 % Drops Sig: One (1) gtt to Right eye
Ophthalmic at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnoses:
1. Flash pulmonary edema
2. Hyperglycemia
Secondary diagnoses:
1. Acute on chronic heart failure
2. chronic renal insufficiency
3. Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your critical aortic stenosis and heart failure with pulmonary
edema. You were treated with supplemental oxygen, given gentle
diuresis and clinically improved.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
CHANGES IN YOUR MEDICATION RECONCILIATION:
* Upon admission, we ADDED: no new medications
* The following medications were DISCONTINUED on admission and
you should NOT resume: Lasix 40 mg PO daily
* The following medications were CHANGED: we decreased your
Isosorbide mononitrate to 10 mg PO BID
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
You will be followed by Dr. [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) **] at the [**Hospital1 **]
facility. Please call her office at [**Telephone/Fax (1) 719**] for any
concerns.
Before discharge, we discussed the need for cardiology
assessment as an outpatient with a possible minimally-invasive
valve replacement procedure. We emailed Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5076**] regarding
your situation and one of his office staff will contact you
regarding an outpatient cardiology follow-up appointment at
[**Hospital1 18**].
ICD9 Codes: 4280, 4168, 2724, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5666
} | Medical Text: Admission Date: [**2157-9-2**] Discharge Date: [**2157-9-8**]
Service: MEDICINE
Allergies:
Sulfonamides / A.C.E Inhibitors / Protonix
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo M w CHF, CAD s/p CABG, CKD, DM2, CHF who presents with
increased shortness of breath. History obtained from son and
patient. Patient reports SOB the night before admission, could
not find a comfortable position and could not sleep. [**Name (NI) 1094**] son
reports [**5-31**] lb weight gain in past few days. Reports no dietary
of fluid indiscretions. As far patient/son knows he has been
getting his medication as prescribed. Baseline rate is
135-138lbs. Pt denies CP, palpations, fever/chills, or cough.
Reports increased DOE but functional capacity in general is
poor, cannot walk more than 4 steps without getting dyspneic. No
recent falls. Does report constipation and straining with BM at
baseline.
.
In ED, vs = 129/55 95%2L (h/o COPD), 24, not on home 2. Didn't
put out to 40 IV lasix, but after another 20 IV lasix, put out
1.2L. Per EMS, caretaker was concerned for change in MS. EMS
reported facial droop, however eval on arrival to ER, no facial
droop, Pt A&Ox3 without focal neurologic deficit beyond baseline
HOH. Neuro consult was cancelled. Of note, Hct steadily declined
since [**Month (only) 116**] - during CHF exaccerbation admission two weeks ago was
also anemic.
Past Medical History:
Type II diabetes mellitus
CAD s/p CABG in [**2127**]
Single chamber PPM for CHB
EF 40%, [**12-22**]+ MR/TR
Moderate pulmonary HTN
BPH s/p TURP
CKD baseline Cr 2-2.2
Gout
Partial Hip replacement last year after fall
Macular Degeneration on R eye
B/L vision loss
Hearing loss
Social History:
Used to work in a confectionary store in [**State 760**]. Now lives
in [**Hospital3 **] facility with his wife. [**Name (NI) **] two sons, one in
[**Name (NI) 86**], both involved in care. 30 pack year smoking history of
cigars and pipes. Rarely drinks EtOH. Denies illicits.
Family History:
Mother with CAD in her 50s died from myocardial infarction.
Physical Exam:
VS:T 97.5 HR 72 BP 100/60 R 30 O2sat100%2L
Gen: Short of breath, labored breathing with talking but does
not desat, pleasant elderly man
HEENT: NC/AT, EOMI, L pupil dilated >R from corneal transplant,
R sluggish but reacts to light, dry MM
neck: supple, JVD to jaw, no carotid bruits, no LAD
CV:S1S2+, RRR, no MRG
pulm: increased work of breathing but no accessory muscle use,
B/L crackles at bases, inspiratory wheezes anteriorly and upper
lung fields
abd:+BS, soft, tympanic throughout, nt, nd
ext:no c/c/e, 1+DP and PT pulses B/L, cold hand but warm feet
B/L
neuro:AAOx3, CN2-12 intact gross except II and VIII
symmetrically, moves all 4 extremities, down going toes,
nonfocal
skin: no ulcers, rash or lesion, no decubitus ulcer
psych: mood/affect appropriate
Pertinent Results:
[**2157-9-2**] 07:00PM GLUCOSE-144* UREA N-46* CREAT-2.7* SODIUM-134
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13
[**2157-9-2**] 07:00PM ALBUMIN-3.7
[**2157-9-2**] 07:00PM PT-17.3* PTT-38.3* INR(PT)-1.6*
[**2157-9-2**] 03:20PM CK(CPK)-25*
[**2157-9-2**] 03:20PM CK-MB-NotDone cTropnT-0.02*
[**2157-9-2**] 08:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2157-9-2**] 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2157-9-2**] 08:00AM URINE RBC-0-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2157-9-2**] 08:00AM URINE HYALINE-0-2
[**2157-9-2**] 07:09AM LACTATE-1.8 K+-4.4
[**2157-9-2**] 06:58AM GLUCOSE-88 UREA N-45* CREAT-2.6* SODIUM-133
POTASSIUM-6.6* CHLORIDE-100 TOTAL CO2-24 ANION GAP-16
[**2157-9-2**] 06:58AM estGFR-Using this
[**2157-9-2**] 06:58AM CK(CPK)-88
[**2157-9-2**] 06:58AM cTropnT-0.01
[**2157-9-2**] 06:58AM CK-MB-NotDone proBNP-3740*
[**2157-9-2**] 06:58AM WBC-7.6 RBC-2.93* HGB-8.6* HCT-26.4* MCV-90
MCH-29.4 MCHC-32.6 RDW-16.9*
[**2157-9-2**] 06:58AM NEUTS-77.6* LYMPHS-11.8* MONOS-6.6 EOS-3.6
BASOS-0.3
[**2157-9-2**] 06:58AM PLT COUNT-180
[**2157-9-2**] 06:58AM PT-17.1* PTT-36.5* INR(PT)-1.5*
.
[**2157-9-2**] FINDINGS: PA and lateral views of the chest are
obtained. Lung volumes remain low. Again noted in cardiomegaly,
pulmonary vascular congestion with diffuse interstitial
prominence and pulmonary vascular indistinctness. There is also
a small right pleural effusion. Allowing for slight differences
in technique, there has been no change. The single lead
pacemaker is stable in course and position, with a right
subclavian approach. Aortic calcifications are again identified.
The cardiac silhouette remains enlarged but stable.
IMPRESSION: CHF, not significantly changed from [**2157-8-14**] CXR.
.
[**2157-9-5**] CXR IMPRESSION: Worsening moderate congestive heart
failure.
.
[**2157-9-6**] CXR:FINDINGS: In comparison with the study of [**9-5**],
there is again substantial enlargement of the cardiac silhouette
with pulmonary vascular congestion and bilateral pleural
effusions. Increasing prominence in the azygos region could
reflect right-heart failure. Single lead pacemaker device
remains in place.
Brief Hospital Course:
[**Age over 90 **] yo M CHF, CAD s/p CABG, CKD, DM2, CHF who presents with SOB
and tachypnia thought to be due to CHF exaccerbation.
.
#SOB/Dyspnea: Patient was admitted to floor on [**9-2**] with dyspnea
secondary to CHF exacerbation as evidenced by elevated JVP,
increased weight ([**5-31**] lbs), cardiomegaly, pulmonary vascular
congestion and edema on CXR, BNP of 3740, and history of
diastolic & mild systolic heart failure. Patient was ruled out
for MI. Pt had normal O2 sat on RA on admission and low Well's
score for possibility of PE.
.
On the floor, patient was diuresed starting at 60 mg IV and
increased to 100 mg IV, with not enough urine output to get
fluid off of him. At the same time, patient's dyspnea and air
hunger was progressively worsening. To improve cardiac function
while on the floor, we added Metoprolol which dropped his BP too
low. Considered adding Losartan but BP could not tolerate it.
Added Morphine 0.5mgIV and Nitro paste to reduce preload but did
not help him symptomatically. Continued 81mg aspirin.
Progressively worsening dyspnea (Respiratory rate up to 34),
ineffective diuresis even with diuril addition, and respiratory
alkalosis prompted us to transfer him to the MICU on [**9-5**]. At
the MICU, patient received lasix drip and improved clinically
(RR=22) and diuresed more effectively (800cc). He never required
NIPPV. Patient was transferred back to the floor on [**9-7**], where
he was switched to PO Torsemide which he tolerated well.
Carvedilol was also added to regimen per Cardiology rec. Over
the course of the hospital stay, patient lost 1.5 L with 4-5 L
still up from baseline. Prior to dicharge, pt was clinically
stable, diuresing more effectively, and weighed (143.8) less
than admission weight (146lbs) PO Torsemeide and Carvidolol were
added to patient's medication regimen at discharge.
.
#Stage 4 CKD: Cr reached 3.0 with baseline at 2.5. GFR
according to Cockcroft-Gault Method is 15. Patient's renal
function worsened with increasing Lasix administration and
worsening CHF. Chronic renal failure likely from to diabetes
and chronic HTN. Patient's renal function should improve due to
lower dose diuretic and improvement of CHF. Pt has urology appt
on [**9-12**]. He should have outpatient labs to be followed up by his
PCP to monitor his renal function and volume status.
.
#Anemia: Patient's Hct has been dropping more significantly
since [**2157-4-21**] for unknown reasons. Iron studies on [**7-29**] were
not c/w iron deficiency. Patient's hct decrease did not
following any worseing in renal function. Patient's haptoglobin
and reticulocytes were wnl. Patient was guiac positive, but
colonoscopy was deferred due to pt's age. When patient's Hct
dropped to 23, patient was given 1 unit of blood but did not
increase Hct appropriately. We were hesitant to give him any
more blood due to possibility of volume overload and worsening
of CHF. Anemia was considered as possible explanation for SOB,
but unlikely due to severity of patient's signs and symptoms. At
discharge, patient's Hct was 25.7 which is close to Hct at
admission.
.
# Brief hematuria: Patient had a brief episode of hematuria in
the first few days on the floor after foley placement. Per OMR
reports, patient has a history of hematuria due to multiple
catheterizations for urinary retention. Hematuria was not
significant enough to explain for anemia.
.
# ?COPD: patient has no record of PFTs, and a CXR inconsistent
witht diagnosis. [**Name (NI) **] pt on admission Albuterol IH to use prn.
.
#Rhythm-pt s/p PPM for CHB, pt is [**Name (NI) 35205**].
.
#BPH: Patient should continue Flomax 0.4 mg po qhs at discharge
.
.
#INR elevated-since [**1-26**], likely nutritional given alb 2.9. No
h/o of liver failure. DIC unlikely as there no signs or symptoms
of bleeding or thrombosis, sepsis or malignancy. Gave dose of
VitK and trended.
.
# Diabetes: patient has well-controlled diabetes with HbA1c of
6.1% on [**8-28**]. In house was maintained on RISS but resumed
Glipizide 20mg PO qday upon discharge. Continued aspiring, did
not start statin as mortality benefit was not evident.
#General Care: followed at repleted electrolytes appropriately,
maintained on PO diabetic diet and low sodium heart healthy
diet, no IVFs required, in fact was fluid restricted to 1L/day,
PPx: sub Q hep, PO diet, Comm: son [**Name (NI) 1692**] [**Telephone/Fax (1) 35206**], son [**Name (NI) **]
[**Telephone/Fax (1) 35207**] both are HCPs, [**Name (NI) 7092**]: over course of his hospital
stay, patient became DNR but ok to intubate if the course of
intubation would be short.
Medications on Admission:
lasix 60mg PO qday
glipizide 20mg PO qday
aspirin 81mg PO qday
Senna [**Hospital1 **]
Albuterol IH prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Glipizide 10 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
6. Home oxygen
2L/min continuous, for portability pulse-dose system
7. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Torsemide 5 mg Tablet Sig: Two (2) Tablet PO every other day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Congestive Heart Failure
.
Secondary Diagnosis:
Type 2 Diabetes
Discharge Condition:
You are being discharged in good condition. You vital signs are
stable and you are ambulating with a walker at your baseline.
Discharge Instructions:
You were admitted to the hospital because of shortness of
breath. You were felt to have an exaccerbation of your
congestive heart failure.
.
You were treated with intravenous lasix to remove fluid from
your lungs. You were placed on a low salt diet, and your fluid
intake was restricted. The Cardiologist saw you and thought we
should change your home diruetic from lasix to tosemide.
.
Please go to the following appoints: 1)Urology Dr. [**First Name (STitle) **] [**2157-9-12**]
at 2:30pm, 2)Primary Care Dr. [**Last Name (STitle) 5717**] [**2157-9-21**] at 11:10am.
.
Please get basic labs drawn when you come back to see the
Urologist on [**2157-9-12**] so we can see your renal function on the
new medications. There is an order in the computer already.
.
The following changes were made to your medical regimen.
1. We added Coreg 6.25mg by mouth twice a day.
2. We added Torsemide 10mg by mouth once a day.
3. Please stop taking your home dose of lasix.
.
If you develop worsening symptoms of shortness of breath, chest
tightness or pain, lower extremity swelling, gaining more than 3
pounds in 1 day, fevers, chills, or other worrisome symptoms you
should contact your primary care physician or the emergency
department.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet, fluid Restriction: 1.5L
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2157-9-12**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2157-9-21**] 11:10
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2157-10-10**] 11:30
Completed by:[**2157-9-9**]
ICD9 Codes: 5849, 4280, 4168, 2749, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5667
} | Medical Text: Admission Date: [**2109-8-11**] Discharge Date: [**2109-8-19**]
Date of Birth: [**2109-8-11**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname 636**] [**Known lastname **] delivered at 40 weeks
gestation weighing 4005 grams and was admitted to the
Intensive Care Nursery from the Newborn Nursery for
management of respiratory distress.
mother with estimated date of delivery [**2109-8-11**]. Prenatal
screens included blood type B positive, antibody screen
negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, and group B Strep negative.
Mother's medical and antepartum history remarkable for
depression treated with Celexa. She was admitted for
testing. Membranes were ruptured two hours prior to delivery
for light meconium. No maternal fever. No maternal
antibiotics. Delivered by precipitous vaginal delivery
through light meconium. Emerged with a vigorous cry, was
dried, bulb suctioned and given free flow oxygen for about
two minutes to pink up. Apgar scores were eight and eight at
one and five minutes, respectively.
On admission to the Newborn Nursery, the infant was noted to
be grunting, flaring, retracting and so was admitted to the
Intensive Care Nursery.
PHYSICAL EXAMINATION: On admission, weight 4005 grams
(greater than 90th percentile), length 52 centimeters (90th
percentile), head circumference 37.5 centimeters (greater
than 90th percentile). Examination remarkable for pink term
infant with mild respiratory distress. Grunting, mild
flaring, minimal retraction, normal facies, intact palate,
soft anterior fontanelle, minimal molding, clear breath
sounds with good air entry, no murmur, present femoral
pulses, flat, soft, nontender abdomen without
hepatosplenomegaly, normal external genitalia, stable hips,
normal perfusion, normal tone and activity.
HOSPITAL COURSE:
1. Respiratory - Oxygen saturation on admission in room air
95% but the oxygen saturation decreased to less than 95%
following admission and required supplemental oxygen by nasal
cannula. Initially needed 50 cc flow and then slowly weaned
down to a 25 cc flow. Weaned off oxygen during the first 32
hours of life. Subsequent to that had intermittent episodes
of desaturation that required free flow oxygen that resolved
by discharge. The chest x-ray was normal. Initial
respiratory distress thought due to retained fetal lung
fluid. Etiology of subsequent desaturation not clear.
The question of maternal medication playing a role via
transplacental and/or breast milk transfer was raised. Extensive
discussions with parents regarding this took place, but in
considering all information, parents decided upon continuation
of breast feeding.
2. Cardiovascular - Remained hemodynamically stable
throughout hospital stay. No murmur.
3. Fluids, electrolytes and nutrition - Was breast feeding
well on admission. Mother stopped breast feeding on day of
life four due to the possibility of Celexa and breast milk
being related to desaturation. At discharge, taking Enfamil
20 with iron ad lib in good amounts. Discharge weight 3950
grams.
4. Gastrointestinal - No issues. No significant jaundice so
bilirubin not checked.
5. Hematology - Hematocrit on admission 43.0%.
6. Infectious disease - A complete blood count and blood
culture were drawn on admission but was not started on
antibiotics. Initially complete blood count showed a white
blood cell count of 19.1, 60 polys, 0 bands, 351,000
platelets. The blood culture was negative. Repeat complete
blood count and blood culture were sent again on day of life
three secondary to desaturation. The white blood cell count
at that time was 10.3 with 36 polys, no bands, 184,000
platelets. The baby was treated with Ampicillin and
Gentamicin for 48 hours for rule out sepsis. The blood
culture was negative. Attempts at obtaining CSF were unsucessful
in obtainign amounts sufficient for cell counts or culture, but
the small amount of CSF seen was not consistent with
intracranial hemorrhage.
Neurology - Examination age appropriate.
8. Sensory - Hearing screening was performed with automated
auditory brainstem response, passed both ears.
CONDITION ON DISCHARGE: Stable, eight day old term infant.
DISCHARGE DISPOSITION: Discharged home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **], [**Hospital **] [**Hospital6 2399**] in [**Location (un) 1456**], [**State 350**], telephone [**Telephone/Fax (1) 44515**], fax [**Telephone/Fax (1) 44516**].
CARE RECOMMENDATIONS:
1. Feeds - Ad lib demand feeds.
2. Medications - None.
3. Car seat position screening test passed.
4. State Newborn Screen sent and is pending.
5. Immunizations received - Received hepatitis B
immunization on [**2109-8-13**].
FOLLOW-UP APPOINTMENTS:
1. Follow-up appointment with pediatrician made for
[**2109-8-20**].
2. VNA referral made to [**Company 1519**].
DISCHARGE DIAGNOSES:
1. Large for gestational age term female.
2. Respiratory distress, resolved.
3. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36096**]
MEDQUIST36
D: [**2109-8-20**] 18:28
T: [**2109-8-20**] 18:45
JOB#: [**Job Number 44517**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5668
} | Medical Text: Unit No: [**Numeric Identifier 100960**]
Admission Date: [**2119-6-16**] Discharge Date: [**2119-6-29**]
Date of Birth: Sex: M
Service:
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 47-year-old male with
past medical history of hyperthyroidism and cocaine abuse,
who presents reporting intermittent chest pain for the past
three days. The patient was in his usual state of health
until three days prior to admission when he began developing
intermittent episodes of chest pain, which he describes as
substernal pressure, sometimes associated with pain in his
right shoulder that lasts for about one minute and then
usually resolves spontaneously. Sometimes the pain persisted
until he took sublingual nitroglycerin. The patient denies
any sensation of tearing or stabbing and denies any radiation
to the back, jaw, or left arm. He denies concomitant
shortness of breath. He reports that it occasionally occurs
at rest and is not exacerbated by physical activity. In
addition to the symptoms, the patient reports a one-week
history of diarrhea with loose, mustard-colored stools
without frank blood. He reports that he had a very similar
episode of diarrhea and intermittent chest pain two months
ago. The patient also reports that he stopped taking his
hyperthyroidism medications (Tapazole) at the advice of his
PCP about three months ago because of medication-related
hypothyroidism. At that time, the PCP had requested [**Name Initial (PRE) **] follow-
up appointment, for which the patient did not appear. Since
that time, the patient reports progressive development of
feeling warm, anxious, tremulous, diaphoretic, and reports a
25-pound weight loss within a period of three months. He had
additional complaints of increased anxiety, feeling more
emotional than usual, generalized weakness, heat intolerance,
hyperdefecation, and urinary frequency. He denies increased
appetite, gynecomastia, and erectile dysfunction. Also, of
note, the patient reports abusing cocaine about once or twice
per month and reports that his most recent use was one week
prior to admission.
REVIEW OF SYSTEMS: See HPI. In addition, he denies fevers,
chills, or night sweats. Denies palpitations, syncope,
dizziness, or orthostatic dizziness. Denies shortness of
breath. Denies flank pain, hematuria, dysuria, or
constipation. No rashes. Denies joint pain and joint
stiffness or myalgias. Denies changes in vision, tingling or
numbness in his extremities, or weakness.
PAST MEDICAL HISTORY: Hyperthyroidism ([**Doctor Last Name 933**] disease).
Hepatitis C.
Hypertension.
Coronary artery disease.
MEDICATIONS:
1. Aspirin 81 mg q.d.
2. Metoprolol 50 mg b.i.d., which was prescribed by the
patient's PCP before she had known that the patient is
abusing cocaine. The patient's PCP immediately requested
that the patient stop taking metoprolol when she found out
that he was using cocaine.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Sister with hyperthyroidism. Mother with
diabetes. Father died of myocardial infarction at the age of
67 and mother died of cancer at the age of 81.
SOCIAL HISTORY: He lives with his sister in [**Name (NI) 18600**]. He is
currently unemployed. Previously worked in construction. He
is heterosexual, sexually active with one partner and uses
condoms. Binge drinking (6-pack x2 per week). He uses
cocaine via inhalation once or twice per month. He also uses
marijuana and has a history of IV drug use, heroin and
cocaine, approximately 10 years ago.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.7
degrees, pulse 81, blood pressure 113/55 on the left arm and
108/61 on the right arm, respirations 16, O2 saturation 100
percent on room air. In general, alert and oriented x3 and
in no acute distress. HEENT: PERRL, mucous membranes moist,
oropharynx clear, sclerae with mild icterus, positive
exophthalmus and discoordinate gaze. Neck: Supple with mild
thyromegaly (approximately 80 g by palpation), no
lymphadenopathy. Lungs were clear to auscultation
bilaterally. Cardiovascular: Hyperdynamic precordium,
regular rate and rhythm; no murmur, rub, or gallop; radial
and pedal pulses 2 plus. Abdomen: Soft, mildly tender to
deep palpation in the left lower quadrant, palpable liver
edge approximately 3 cm below the costal border.
Extremities: Without pitting edema, capillary refill less
than 2 seconds, positive for mild tremors in hands. Skin:
Warm and moist without any rashes. Neuro: Cranial nerves II
through XII intact. Hyperreflexic in knees bilaterally.
Strength 4 out of 5 in elbow, hips, and knees with flexion
and extension.
LABORATORY DATA: White count 6.3, hematocrit 38.8, platelet
count 146, BUN 18, creatinine 0.8. Cardiac enzymes negative
and urine drug screen negative for cocaine use. TSH on
[**2119-6-16**] had been less than 0.02.
EKG showed early repolarization in V1 through V6 and sinus
rhythm.
HOSPITAL COURSE: The patient was admitted to Medicine with
hyperthyroidism and chest pain to rule out myocardial
infarction. His hospitalization course by systems was as
follows:
Endocrine: The patient was clinically and biochemically
hyperthyroid on admission. He was originally started on
methimazole, given his history of hepatitis C and the liver
toxicity of PTU. However, given his episode of chest pain
and ST-segment elevations on the morning of the second day of
admission (see below), the patient was treated with
increasing doses of methimazole and potassium iodide in order
to suppress the thyroid hormone synthesis and release from
his thyroid, and with iopanoic acid 500 mg q.d. to inhibit
the peripheral conversion of T4 to T3. During his
hospitalization, the patient's vital signs remained stable,
but because of his episodes of chest pain, he was felt to be
thyrotoxic and requiring immediate thyroid ablation. On
[**2119-6-26**], Dr. [**Last Name (STitle) **] performed a total thyroidectomy
without complications. Pathology was consistent with [**Doctor Last Name 933**]
disease. The patient was subsequently started on Levoxyl 50
mcg q.d. and his calcium was monitored and he was prescribed
to start calcium replacement for possible iatrogenic
hypoparathyroidism.
Cardiovascular: The patient presented with chest pain,
presumably related to his hyperthyroidism. Also, he has a
history of cocaine abuse, and his PCP told him to discontinue
his beta-blocker when she found out about it. Upon arrival
to the ED, urine toxicity screen was negative for cocaine.
The patient received aspirin and metoprolol. On the morning
of the second day of hospitalization, the patient experienced
chest pain, which lasted for less than three minutes and was
relieved spontaneously. However, during the period of the
chest pain, EKG was performed and revealed [**Street Address(2) **] elevations
anteriorly with preservation of heart rate. The beta-blocker
was discontinued and the patient was transferred to the CCU
for management of his condition. He was treated with IV
diltiazem and nitroglycerin drip. He was also started on IV
heparin. Cardiac catheterization was not performed
immediately, because of his hyperthyroidism and the
possibility of worsening hyperthyroidism after an iodide
contrast load. The patient's hyperthyroidism was managed
with increased doses of methimazole and potassium iodide as
mentioned before and the next day the patient had a cardiac
catheterization, which revealed a right dominant circulation
with no angiographically apparent coronary artery disease and
no wall motion abnormalities. EF was 67 percent. Given
these negative coronary catheterization findings, it was felt
that the patient's chest pain and transient ST elevations
were related to coronary vessel spasm secondary to
hyperthyroidism. The patient was transferred back to the
floor and was continued on his antithyroid treatment until he
was felt stable to have permanent treatment of his
hyperthyroidism with total thyroidectomy, as mentioned above.
Hepatitis C: Given the patient's history of hepatitis C and
his elevated transaminases, management of his hyperthyroidism
was complicated. PTU was avoided and the patient was treated
with methimazole. His LFTs were monitored during his
treatment and a liver consult was called.
DISCHARGE STATUS: To home.
DISCHARGE CONDITION: Asymptomatic, no chest pain. Stable
status post total thyroidectomy on postoperative day number
three. Calcium and magnesium levels are within normal
limits. Surgical staples have been removed and replaced with
Steri-Strips.
DISCHARGE MEDICATIONS:
1. Calcium carbonate 1000 mg b.i.d.
2. Amlodipine 10 mg p.o. q.d.
3. Levothyroxine 50 mcg p.o. q.d.
4. Isosorbide mononitrate 30 mg sustained release p.o. q.d.
MAJOR SURGICAL OR INVASIVE PROCEDURES: Cardiac
catheterization.
Total thyroidectomy.
DISCHARGE INSTRUCTIONS: The patient was advised to follow up
with his PCP as well as with his endocrinologist, Dr.
[**Last Name (STitle) 9287**]. Appointments were made for him for his PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], for [**2119-7-11**] at 2 p.m. and for Dr. [**Last Name (STitle) 9287**] on
[**2119-7-6**] at 2:45 p.m. It was strongly stressed to the
patient that it is very important that he avoids use of
cocaine or other illicit drugs. It was explained to the
patient several times that using cocaine or other illicit
drugs could have serious consequences, especially because of
his thyroid condition. He was also strongly advised to
follow up with his PCP and endocrinologist for management of
his thyroid condition as well as for management of his
calcium and magnesium levels, which might drop
postoperatively.
DISCHARGE DIAGNOSES: Hyperthyroidism/[**Doctor Last Name 933**]
disease/thyrotoxicosis.
Coronary vasospasm.
Hepatitis C.
Hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern1) 26045**]
MEDQUIST36
D: [**2119-9-17**] 15:40:33
T: [**2119-9-17**] 22:43:48
Job#: [**Job Number 100961**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5669
} | Medical Text: Admission Date: [**2177-5-16**] Discharge Date: [**2177-5-18**]
Date of Birth: [**2119-11-24**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Codeine / Penicillins / Amoxicillin / Risperidone /
Lisinopril
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
DKA, manic episode
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57F h/o insulin-dependent DM2, CAD, CKD, syncope, Bipolar
disorder presented with AMS. The patient states that she had
been walking home, and the police picked her up and had her go
to the hospital in an ambulance. Per report, the patient was
agressive, yelling at cars, throwing a doll towards passing
vehicles when she was picked up by the police and had her
brought to the hospital. The patient states she did not take her
insulin last night, but reports otherwise being compliant with
her medications. She reports taking her psych medications.
On arrival to the ED, the patient was agitated and aggressive,
requiring chemical and physical restraints. Vital signs: HR
90-100 and SBP 140s (of note, BP varies depending on location --
check on forearm rather than upper arm). Labs were drawn,
notable for WBC 11.8 with 77% polys but no bands, glucose 586,
AG 18, Cre 2.4, CK 715, CKMB 5, TnT 0.02, lactate 3.3. Concern
for DKA, and given 2L NS bolus, then 500cc/hr and started on
insulin gtt at 7 U/hr. U/A sent after IVF as UOP poor was
negative including ketones. CXR and ECG unremarkable. Serum and
urine tox screens negative. Believe psych-induced medication
noncompliance, possibly due to [**Last Name (LF) **], [**First Name3 (LF) **] discussed case with
psychiatry consult who deferred evaluation until acute medical
condition resolved. Admitted to [**Hospital Unit Name 153**] for DKA treatment.
Past Medical History:
1. Diabetes mellitus, type 2
2. Bipolar disorder
3. Hypercholesterolemia
4. Hypertension
5. Dystonia
6. Syncope (?vasovagal or volume depletion)
7. Chronic kidney injury (Cre 1.5 baseline)
Past Surgical History:
1. Status post total abdominal hysterectomy/right
salpingo-oophorectomy for benign fibroids. Status post
laparoscopy for ovarian cyst.
2. Status post cholecystectomy.
3. Status post hernia repair.
4. Status post tonsillectomy.
Social History:
Divorced in [**2163**] after 11 years of marriage. Lives alone and
worked as a nursing assistant, but is now on disability. Smoked
cigarettes for five years, but quit in [**2163**]. Endorses a history
of alcohol use of about one six pack per week, also quit that in
[**2163**]. Denies illicit drug use.
Family History:
Non-contributory
Physical Exam:
AF, VSS, on room air
Gen: obese female, NAD
HEENT: sclera anicteric, op clear, neck supple
CV: RRR, no murmurs
Lungs: CTA bilaterally
Abd: obese. well healed surgical scar. normal BS
Ext: trace edema
Neuro: alert, orient, nonfocal
Pertinent Results:
Admission LABS:
-------------
[**2177-5-16**] 01:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2177-5-16**] 01:55AM WBC-11.8*# RBC-4.56 HGB-11.8* HCT-37.8 MCV-83
MCH-26.0* MCHC-31.3 RDW-14.0
[**2177-5-16**] 01:55AM NEUTS-77.0* LYMPHS-19.7 MONOS-2.9 EOS-0.1
BASOS-0.2
[**2177-5-16**] 01:55AM PLT COUNT-431#
[**2177-5-16**] 01:55AM GLUCOSE-586* UREA N-27* CREAT-2.4*
SODIUM-130* POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-18* ANION
GAP-23
[**2177-5-16**] 03:20AM CK-MB-5 cTropnT-0.02*
[**2177-5-16**] 03:20AM CK(CPK)-714*
[**2177-5-16**] 03:20AM GLUCOSE-533* UREA N-28* CREAT-2.6*
SODIUM-131* POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-18* ANION
GAP-23*
[**2177-5-16**] 03:59AM LACTATE-3.3*
[**2177-5-16**] 04:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2177-5-16**] 04:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Reports:
-------
[**2177-5-16**]- HEAD CT-
CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial mass
lesion, hydrocephalus, shift of normally midline structures,
major vascular territorial infarct, or intracranial hemorrhage.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. Prominence
of the sulci and ventricles likely consistent with mild cerebral
atrophy. Hypodensities within the periventricular white matter
likely represent chronic microvascular ischemic changes. The
osseous and soft tissue structures are unremarkable. The
visualized paranasal sinuses are clear.
IMPRESSION: No acute intracranial process.
[**2177-5-16**] CXR-
FINDINGS: Portable AP view of the chest in upright position. The
cardiomediastinal silhouette is normal. The lungs are clear.
There is no pneumothorax or pleural effusion. The pulmonary
vasculature is normal. The osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
[**2177-5-16**] EKG- Sinus tachycardia. There are non-diagnostic Q waves
in the inferior leads. Compared to the previous tracing
non-diagnostic Q waves are new and the rate is faster.
========================================
Discharge Labs:
[**2177-5-18**] 06:05AM BLOOD WBC-8.1 RBC-4.02* Hgb-10.8* Hct-32.7*
MCV-81* MCH-26.9* MCHC-33.0 RDW-14.3 Plt Ct-323
[**2177-5-18**] 06:05AM BLOOD Glucose-123* UreaN-20 Creat-1.6* Na-139
K-4.8 Cl-106 HCO3-23 AnGap-15
[**2177-5-17**] 07:05AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7
Brief Hospital Course:
57F h/o insulin-dependent DM2, CAD, CKD, syncope, Bipolar
disorder presents with AMS, DKA.
# DKA: Although less common, occurs in DM2 especially given her
insulin dependence. Urine ketones may have been masked by
hydration. Likely precipitating factor was medication
non-compliance due to psychiatric disorder. No infectious
sourse identified. Blood cultures no growth to date on
transfer. She initially received IV insuling gtt in the [**Hospital Unit Name 153**],
and resumed her outpatient insulin regimen with Lantus 30 units
qhs and oral glyburide, glitazone on transfer to the floor.
This worked well. Her electrolytes were stable, and anion gap
closed. Her aspirin, statin were continued, [**Last Name (un) **] restarted one
day prior to transfer to psychiatry.
# AMS: Possibly due to manic episode, complicated by DKA.
Psychiatry consulted and recommended inpatient psychiatric
hospitalization. She was discharged to [**Hospital1 **] 4 after
medical clearance.
# Acute renal failure: Cre 2.4 on admission increased from
baseline 1.5, likely pre-renal due to osmotic diuresis and poor
PO intake. Improved to baseline with hydration. [**Last Name (un) **] resumed one
day prior to discharge.
# Hypertension: Stable.
#. Contact: [**Name (NI) **] [**Name (NI) 76796**] [**Name (NI) 4223**] [**Telephone/Fax (1) 105973**]
Medications on Admission:
1. Candesartan 16 mg PO BID.
2. Atorvastatin 20 mg PO DAILY.
3. Ziprasidone HCl 20 mg PO BID.
4. Glyburide 5 mg PO BID.
5. Pioglitazone 45 mg PO DAILY.
6. Lantus 30 units QHS
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
10. Ziprasidone HCl 20 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. Candesartan 16 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Humalog
Please give qAC, qHS. If BG<60, give juice/crackers. BG
60-120, give nothing. BG 121-150 give 2 units. BG 151-200 give
4 units. BG 201-250 give 6 units. BG 251-300 give 8 units. BG
301-350 give 10 units. BG 351-400 give 12 units. If blood
glucose greater than 400, please [**Name8 (MD) 138**] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**] -[**Hospital1 **] 4 - [**Hospital Ward Name 517**] (West Contact)
Discharge Diagnosis:
1. diabetc ketoacidosis
2. bipolar disorder, [**Hospital Ward Name **]
3. chronic kidney disease, stage III
4. coronary artery disease
Discharge Condition:
manic, Section XII, transferring to inpatient psychiatry,
medically cleared.
Discharge Instructions:
You were admitted to the hospital for diabetic ketoacidosis.
This improved with IV insulin and remained stable on your
previous medications. You will be discharge to inpatient
psychiatry. Please take all your medications as prescribed.
Call your primary physician with glucose >400, changes in your
mood, chest pain, fever greater than 101.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2177-6-3**] 8:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2177-8-5**] 10:00
Please arrange an appointment with [**Company 191**], urgent care at
[**Telephone/Fax (1) 250**] prior to discharge home for hospital follow up.
ICD9 Codes: 5849, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5670
} | Medical Text: Unit No: [**Numeric Identifier 74179**]
Admission Date: [**2196-7-6**]
Discharge Date: [**2196-7-25**]
Date of Birth: [**2196-7-6**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 1124**] [**Known lastname 74180**] is a 33 and [**5-16**]
week preterm infant, born to a 33 year-old prima gravida.
Prenatal screens: O+, antibody negative, HBsAg negative,
rubella immune, RPR NR, GBS negative. His mother was admitted
with premature prolonged rupture of membranes. She was
initially treated with magnesium sulfate due to uterine
irritability and no evidence of preterm labor. She was
treated with ampicillin, erythromycin and was given
betamethasone times 2 doses.
MATERNAL PAST MEDICAL HISTORY: Includes a sinus infection for
which she was treated with Azithromycin one week prior to
delivery.
Mother developed evidence of possible chorioamnionitis with
an increased white blood cell count, toxic granulations and
therefore, labor was induced. In the morning before
delivery, the fetal heart rate was noted to have variable
decelerations and infant did not tolerate labor. Therefore,
proceeded to delivery by Cesarean section. In the delivery
room, the infant emerged with a spontaneous cry, was bulb
suctioned, was given blow-by oxygen to improve color. He
required stimulation to reduce apnea. He was transferred to
the NICU with blow-by oxygen. His birth weight was [**2109**]
grams. Head circumference was 31 cm. Length was 43.5 cm.
Physical examination at discharge:
Weight at the time of discharge is 2.355 kg. Head
circumference was 32 cm. Length was 45.5 cm. HEENT:
Nondysmorphic features. Anterior fontanel open and flat.
Sutures approximated. Eyes with red reflex bilaterally. His
nares are patent. Intact palate. Mucous membranes moist and
pink. Neck is supple. No masses. Clavicles intact. Chest is
symmetric with clear and equal breath sounds. Comfortable
breathing pattern. CV: Regular rate and rhythm. No murmur.
Pulses +2 and equal. Abdomen soft with active bowel sounds.
Cord healed. No hepatosplenomegaly. Genitourinary:
Circumcised penis, healing. Testes in scrotum. Patent anus.
Back is smooth, straight. Hips are stable without clicks.
Extremities are well developed, moving all equally.
Neurologic: Active with good tone. Symmetric tone and
reflexes noted.
HOSPITAL COURSE:
Cardiovascular: [**Known lastname 1124**] remained hemodynamically stable with
heart rates 100s to 150s. Blood pressure on admission was
72/22 with a mean of 34. On discharge, 78 over 36, mean of
51. Access was established via peripheral IV without
incident.
Respiratory: Initially, [**Known lastname 1124**] was placed on CPAP of 6 cm in
room air due to transitional respiratory distress. This
improved rapidly over the first few hours of admission. A
chest x-ray was obtained which revealed normal cardiothymic
silhouette, good expansion and normal bony structures. [**Known lastname 1124**]
was taken off CPAP and has remained in room air since that
time.
[**Known lastname 1124**] had a relatively mature breathing pattern with
occasional bradycardias with feedings. His last desaturation
related to feedings was 4 days prior to discharge on [**7-21**]. He
is breathing 30s to 50s and is well saturated in room air
without spells at this time.
Fluids, electrolytes and nutrition: Initially, [**Known lastname 1124**] was
n.p.o. with IV fluids of D-10 infusing through a peripheral
IV. He required one D-10-W bolus for a serum glucose of 32
which improved with running IV fluids. He continued to be
euglycemic as IV fluids were tapered and enteral feeds were
introduced and advanced. Full feeds were achieved on day of
life 5 with breast milk or special care 20 calorie per ounce
formula fed po/pg. [**Known lastname 1124**] was also offered breast feeding and
gradually has improved his suck/swallow/breathing
coordination. He currently is breast feeding or p.o. feeding
breast milk 24 calorie enriched with Enfamil powder. He had
normal serum electrolytes drawn in the course of his
treatment and has passed meconium and is now stooling
regularly. He has demonstrated good urine output.
[**Known lastname 1124**] was started on iron supplements on day of life 7 as
full calories were achieved and will be discharged home on 2
mg/kg of supplemental iron. He was also started on a
multivitamin at 1 mL PO daily due to him receiving a
predominantly breast milk diet.
Gastrointestinal: [**Known lastname 1124**] was treated with phototherapy for
physiologic jaundice. He peaked on day of life 2 with a
serum bilirubin of 9.9 over 0.4. phototherapy was
discontinued on day of life 4 and rebound bili was 8.9 and
0.3. This issue has resolved.
Heme/Infectious disease: Initially, a CBC and blood culture
were obtained upon admission due to concerns for maternal
chorioamnionitis. Mother had received antepartum,
antimicrobial prophylaxis. Blood cultures remained negative.
CBC revealed a white blood cell count of 15.3 with 40 polys,
0 bands, 43 lymphs. Hematocrit 66.3% and platelets of
260,000. [**Known lastname 1124**] did receive 48 hours of antibiotics and has
remained clinically well off antibiotics.
His last hematocrit was on [**2196-7-10**] which was 60.1%. He
received no blood products during this hospitalization.
On [**2196-7-23**], [**Known lastname 1124**] was started on eryhthromycin eye
ointment for bilateral eye drainage. On his discharge exam,
there was no eye drainage and no palpebral or conjunctival
eryhthema. Mother reports improvement. [**Known lastname 1124**] is to complete
a 5 day course of treatment.
Neurologic: [**Known lastname 1124**] has an appropriate exam for his
gestational age. He was treated with Tylenol the day of
circumcision which was [**7-24**] for procedural discomfort with
good effect.
Sensory: Audiology screening was performed in this infant
and he passed hearing screen on both ears utilizing an
automated auditory brain stem response.
Ophthalmology: Ophthalmology examination was not indicated
in this moderately premature infant.
Psychosocial: Parents have been invested and involved,
participating in [**Known lastname 6417**] care on a regular basis and appeared
confident in his care at the time of discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: [**Hospital **] Pediatrics.
CARE/RECOMMENDATIONS:
Feedings at discharge are breast feeding or feeding with
breast milk 24 calories per ounce, enhanced with Enfamil
powder.
Medications include:
1. Iron 2 mg/kg per day.
2. Multivitamin 1 mL PO daily.
Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
Vitamin D supplementation at 200 i.u. (may be provided
as a multi- vitamin preparation) daily until 12 months
corrected age.
3. Erythromycin eye ointment TID x 5days.
Car seat position screening was performed on [**2196-7-25**] and
[**Known lastname 1124**] passed this challenge.
State newborn screening was sent on [**2196-7-20**], results of
which are pending at this time.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2196-7-19**].
FOLLOWUP: Follow-up appointments will be scheduled with
[**Hospital3 38797**] the week of [**2196-7-25**].
DISCHARGE DIAGNOSES:
1. Prematurity at 33 and 5/7 weeks.
2. Conjunctivitis, improved.
3. Transient tachypnea of the newborn, resolved.
4. Sepsis ruled out with antibiotics, resolved.
5. Physiologic jaundice, resolved.
6. Immature feeding pattern, resolved.
7. Hypoglycemia resolved, resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 61558**]
MEDQUIST36
D: [**2196-7-25**] 03:30:04
T: [**2196-7-25**] 04:45:35
Job#: [**Job Number 74181**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5671
} | Medical Text: Admission Date: [**2188-9-18**] Discharge Date: [**2188-10-2**]
Date of Birth: [**2111-12-1**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Decadron
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Atrial Fibrillation
Major Surgical or Invasive Procedure:
IVC filter [**2188-9-19**]
Pacer placement [**2188-9-23**]
Atrio-ventricular juncion ablation [**2188-10-1**]
History of Present Illness:
Mr. [**Known lastname 39015**] is a 76yo gentleman with h/o AFib not on coumadin
s/p recent craniotomy for resection of meningioma who presents
with recurrent AFib with RVR.
The patient was admitted to the cardiology service at [**Hospital1 18**] from
[**Date range (1) 17433**] with AFib/RVR. His medications were adjusted such that
he was discharged on metoprolol 50mg [**Hospital1 **], Amiodarone 200mg
daily, and digoxin 0.125 every other day. His blood pressure was
stable on this regimen and he was noted to be bradycardic in the
40s-50s. On the day of admission, his heart rate went back up to
130s-140s despite receiving his medications as ordered and
[**Hospital1 **] sent him to the ED.
In the ED, initial vitals were 97.1 130 123/77 17 95% RA. Tm was
99.9. He was given diltiazem 10mg IV without effect; increasing
dose to 20mg did not control HR. He was then put on diltiazem
gtt, which was increased to 15mg/hr without decreasing his HR.
His SBP remained in the 110s.
He is not able to answer ROS.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Afib s/p ablation on coumadin - Had Aflutter ablation [**2188-7-16**]
Atypical recurrent right frontal meningioma s/p radiation and
chemotherapy. Most recent resection [**2188-8-21**].
GERD
Hypothyroidism
Social History:
Per OMR, unable to answer questions. Married with two children.
Used to smoke a pack a day but quit in [**2151**]. Used to drink beer
but stopped when he was put on Coumadin.
Family History:
Per OMR, unable to answer questions. Family History: Mother died
at 80 from stroke. Father died at 60's, unclear cause. Bother
died 60 from lung cancer.
Physical Exam:
VS: Afebrile. Heart rate in 80s. BP 120/78.
GENERAL: NAD. Breathing well on room air. Moving all four
extremities.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular heart rate. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: +Kyphosis. Resp were unlabored, no accessory muscle use.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: +PEG tube. Soft, NTND. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: Left lower extremity edema to knee.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
CBC:
[**2188-10-2**] WBC-5.9 RBC-3.65* Hgb-11.6* Hct-33.4* Plt Ct-343
[**2188-9-17**] WBC-7.7 RBC-4.00* Hgb-12.9* Hct-36.4* Plt Ct-299
Coags:
[**2188-10-2**] PT-14.9* PTT-31.1 INR(PT)-1.3*
[**2188-9-17**] PT-13.2 PTT-25.8 INR(PT)-1.1
Chemistry:
[**2188-10-2**] Glucose-114 UreaN-12 Creat-0.9 Na-137 K-3.9 Cl-102
HCO3-29 AnGap-10
[**2188-9-17**] Glucose-127 UreaN-13 Creat-0.8 Na-136 K-3.9 Cl-103
HCO3-26 AnGap-11
[**2188-10-2**] Calcium-8.6 Phos-3.3 Mg-2.3
[**2188-9-18**] Calcium-8.2* Phos-2.1* Mg-2.1
LFTs:
[**2188-9-27**] ALT-35 AST-22 AlkPhos-77 Amylase-25 TotBili-0.3
CE:
[**2188-9-26**] CK(CPK)-49
[**2188-9-18**] CK(CPK)-36*
[**2188-9-26**] CK-MB-NotDone cTropnT-<0.01
[**2188-9-18**] CK-MB-NotDone cTropnT-<0.01
[**2188-9-17**] cTropnT-<0.01
TSH:
[**2188-9-27**] TSH-1.4
CXR [**2188-9-17**]: There is cardiomegaly which is stable. There is no
evidence of pleural effusion or consolidation. The lungs are
clear. The osseous structures are unremarkable.
ECHO [**2188-9-18**]: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is
dilated with borderline normal free wall function. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are structurally normal.
Physiologic mitral regurgitation is seen (within normal limits).
There is an anterior space which most likely represents a fat
pad.
Compared with the prior study (images reviewed) of [**2188-8-22**],
there is no pericardial effusion on the current study (the prior
study mentioned an effusion but this appearance may have been
due to a fat pad). The other findings are similar.
BILAT LOWER EXT VEINS [**2188-9-18**]: Extensive left lower extremity
deep vein thrombosis extending from the common femoral to the
calf veins. No DVT in the right lower extremity.
CT HEAD: FINDINGS: Examination is stable in comparison to
[**2188-9-25**]. The patient is status post resection of right frontal
lobe meningioma, with severe encephalomalacia in the surgical
site. There is persistent small foci of pneumocephalus, and
hyperdensity within the right frontal lobe, that was felt to
represent likely subacute hemorrhage. There is a stable small
extra-axial hyperdense collection overlying the right frontal
lobe. No new hemorrhage, shift of midline structures or vascular
territory infarct is identified.
Periventricular and deep white matter hypodensities, consistent
with small
vessel disease are stable. There is a soft tissue density within
the right
frontal lobe that is unchanged. Visualized paranasal sinuses and
mastoid air cells are otherwise well aerated.
IMPRESSION: Unchanged appearance of post-surgical changes, with
hyperdensity in the right frontal lobe resection bed. No new
mass effect or hemorrhage.
CAROTID ARTERY U/S:
Duplex evaluation was performed of both carotid arteries.
Minimal plaque is identified. On the right, peak systolic
velocities are 71, 85, and 88 in the ICA, CCA, and ECA
respectively. The ICA to CCA ratio is 0.8. This is consistent
with less than 40% stenosis.
On the left, peak systolic velocities are 66, 66, and 79 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This
is consistent with less than 40% stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
Brief Hospital Course:
76 year old male with history Atrial Fib s/p recent craniotomy
for resection of meningioma who presents with recurrent AFib
with RVR from [**Hospital **] Rehab. Patient was recently admitted for
A Fib with RVR.
# Atrial Fibrillation with RVR: Presented with HR 130s. Started
on Diltiazem drip in ER. On floor increased Amiodarone 400 mg
from 200 mg once a day, decreased Metoprolol 50 mg [**Hospital1 **] to 25 mg
[**Hospital1 **], and slowly weaned Diltiazem drip. Patient's third admission
for A Fib with RVR (120-130s), when converts enters sinus brady
(40s-50s). Decided pacer best option as we could then increase
rate control medications without worrying about brady-junctional
rhythm. Discussed with Neurosurgery, can monitor meningioma with
CT scan instead of MRI. Pacer placed on [**2188-9-23**], no complications
from procedure. Triggers for A Fib include infection, PE,
ischemia, recent surgery and thyrotoxicosis. Troponin negative
and no ischemia changes on EKG. CXR no sign of infection. Free
T4 increased last admission and consequently decreased
Levothyroxine 37.5 mg (TSH level normal). Patient had recent
neurosurgery [**2188-8-21**]. Patient still having persistent A-Fib
after pacer placement. Pt became hypotensive most likely from
increasing dose of beta blocker.
Brief MICU course: Pt transfered to MICU for low blood pressure
unresponsive to fluid bolus after increasing metoprolol to 75mg
three times a day. Received 6 liter of NS without responding to
fluids. He was started on an esmolol drip which converted him
to sinus rhythm. His blood pressure increased to 100-120/50-60
and his HR decreased to 60s. He was transfered back to the
flood on metoprolol 25mg three times a day.
On the floor he converted back into A-fib within 24 hours. His
rate remained in the 120s-140s despite increaing his metoprolol
to 100 three times a day. The decision was made to ablate his
atrial ventricular junction and have him be pacer dependant. He
under went successful ablation on [**2188-10-1**]. Since then he has
been at a constant rate of 80 with no events on telemetry.
# Deep Vein thrombosis: Patient's left leg swollen and warm on
admission. BILAT LOWER EXT VEINS demonstrated extensive left
lower extremity deep vein thrombosis extending from the common
femoral to the calf veins. No DVT in the right lower
extremity. Patient started on Heparin drip. Placed IVC filter
[**2188-9-19**]. Due to patient's neurosurgery history was concerned
that at some point patient's anticoagulation whould have to be
stopped. Patient could not be anti-coagulated since his
neurosurgery on [**2188-8-21**]. Per neurosurgery have to wait one month
post-op to re-start coumadin ([**2188-9-21**]). Coumadin was re-started
for A Fib and DVT s/p pacer placement on [**2188-9-23**], bridge on
Heparin drip. Because of re-bleed on heat CT anticoagulation
was stopped. It was discussed with neurosurgery who did not
think the bleed was significant and coumadin was restarted.
# Urinary tract infection: Developed hematuria. Ua demonstrated
signs of infection (+ nitrates + leukocytes, 11 WBC, moderate
bacteria). Urine culture positive E. Coli. Started 5 day course
of Bactrim from [**2188-9-20**] until [**2188-9-24**].
# Paraphimosis: Developed [**2188-9-20**] and immediately reduced by
Urology. Bacitracin for 3 days. Most likely related to patient
tugging at foley.
# Meningioma status post 5th resection on [**8-21**]: For full
meningioma history please see Dr.[**Name (NI) 6767**] note on [**2188-7-16**]. His
Keppra was continued for seizure prophylaxis. Kept head of bed
elevated. On [**2188-9-25**] Patient had a questionable TIA. His mental
status was wanning and it appeared as though he could not move
his left side. A head CT revealed a new focus of hemorrhage.
After the CT he began moving all four limbs spontaneously.
Anticoagulation was stopped in setting of new bleed.
Neurosurgery said there was not enough to intervene at this
time. We treated like a TIA and started him on high dose
statin. A repeat head CT two days later showed no increase of
the bleed. A family meeting was held on [**10-1**] to discuss his
overall prognosis. His code status was changed to DNR/DNI. The
decision was to attempt to get him to a rehab hostpital with the
possibility of hospice later.
.
# HTN: Well controlled, continued lisinopril and metoprolol.
.
# Hypothyroidism: TSH and free T4 checked on last admission.
Continue 37.5 mg levothyroxine.
.
# DM: Regular insulin sliding scale only.
.
#. Nutrition: Continue PEG tube with tube feeds. If patient
clinically improves and develops a will to eat, it would be
reasonable to obtain a speech and swallow evaluation and try
oral feeds.
.
# Code status: changed to DNR/DNI at family meeting on [**2188-10-1**].
.
# Medication changes:
1) Amiodarone 200mg daily
2) Atorvastatin 40mg daily
3) Stopped digoxin
4) Metoprolol changed to 50mg twice a day.
5) coumadin at 4mg daily.
6) Levothyroxine 37.5mg daily
7) Fametodine changed to lansaprazole 30mg daily.
8) Started Tamsulosin 0.4 mg daily
Medications on Admission:
Digoxin 125mcg every other day
Lisinopril 10mg daily
Metoprolol 50mg [**Hospital1 **]
Amiodarone 200mg daily
Keppra 1000mg [**Hospital1 **]
Levothyroxine 37.5mcg daily
Famotidine 20mg [**Hospital1 **]
NPH 14 units QAM, 12 units QPM
Humalog SS
Docusate
Senna
Nystatin 5ml TID
Discharge Medications:
1. Keppra 1,000 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
2. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: 100 mg PO BID (2
times a day).
4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).
8. Levothyroxine 75 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED).
14. Lidocaine HCl 2 % Gel [**Last Name (STitle) **]: One (1) Appl Mucous membrane PRN
(as needed).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
twice a day.
17. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Warfarin 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4
PM.
19. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Atrial Fib
DVT (left leg)
Secondary:
meningioma s/p frontal craniotomy [**2188-8-21**]
diabetes
hypertension
hypothyroidism
GERD
Discharge Condition:
Fair. Stable vitals and HR.
Discharge Instructions:
You were admitted to the hospital for a fast, irregular heart
rate. You had a pacemaker placed on [**2188-9-23**]. On admission we
found you had a blood clot in your left leg. A filter was placed
to prevent a clot in your lungs (pulmonary embolism).
You developed an infection in your urine during the admission
and that was treated with antibiotics.
You continued to have the fast heart rate despite medicaitons.
Because of [**Last Name (un) **] your blood pressure dropped and you were
transered to the intensive care unit for 2 days. You were
stabalized and transfered back to the floor.
A repeat CT scan of the head showed a small bleed around the
area of surgery. Your anticoagulation was immediatly stopped.
The neurosurgical team said it was not enough to intervene on.
A repeat CT showed that the bleed had stabalized. Because of
this you were restarted on coumadin.
You had a procedure done where they ablated the
atrio-ventricular junction of the heart to slow the heart rate
down. After the procedure your heart was at a regular rate.
We have made the following changes to your medications:
1) Your Metoprolol dose is now 25mg two times a day
2) Your Amiodarone dose is now 200mg daily
3) Stopped digoxin
4) Coumadin 4mg daily
5) Atorvastatin 40mg daily
Otherwise please take medications as prescribed.
Return to the ER if you experience dizziness, feeling like you
will pass out, chest pain, shortness of breath, bleeding or any
other concerning symptoms.
Attend the appointments below we have made for you:
1) CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-10-7**] 8:30
2) Dr.[**Last Name (STitle) **] of Cardiology on [**2188-10-16**] at 10:20am [**Hospital 273**], [**Location (un) **] CC7 CARDIOLOGY.
Followup Instructions:
Please attend the following appointments:
1) You have a CT SCAN scheduled [**2188-10-7**] 8:30am at Radiology, CC
CLINICAL CENTER, [**Location (un) **]. Following this, you have an
appointment with Dr. [**Last Name (STitle) **] of Neurosurgery at 9:30am [**2188-10-7**] in
the LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST.
2) You have an appointment with Dr.[**Last Name (STitle) **] of Cardiology on
[**2188-10-16**] at 10:20am [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY.
3) Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2188-10-27**] 1:00
ICD9 Codes: 5990, 431, 2449, 2720, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5672
} | Medical Text: Admission Date: [**2131-10-19**] Discharge Date: [**2131-11-5**]
Date of Birth: [**2084-7-31**] Sex: F
Service: [**Hospital Unit Name 153**]
This discharge summary covers the period from [**2131-10-19**] until [**2130-12-5**].
HISTORY OF THE PRESENT ILLNESS: The patient is a 47-year-old
female with a new diagnosis of large B cell lymphoma who was
transferred to the [**Hospital Unit Name 153**] from Bone Marrow Transplant Service
for respiratory distress, urgent need for central venous
access and initiation of CHOP chemotherapy in anticipation of
tumor lysis syndrome.
The patient was initially admitted to [**Hospital6 649**] on [**2131-10-19**] to the Medical Service
with the chief complaint of worsening shortness of breath and
fatigue. She was found to have prominent mediastinal
lymphadenopathy and bilateral pleural effusions. Of note,
the patient was suspected to have lymphoma prior to admission
to the hospital. She was suppose to be evaluated by the
Oncologist as an outpatient.
In the hospital, she was treated with broad spectrum
antibiotics for presumed pneumonia. Her pleural effusions
were tapped. Pathology from pleural fluid returned positive
for B cell lymphoma. The pathology of supraclavicular node
biopsy which was done as an outpatient prior to admission
also was consistent with B cell lymphoma.
One day prior to transport, the patient had worsening
shortness of breath and was ruled out for a pulmonary
embolism for CT angio. She also had a transthoracic
echocardiogram which showed normal cardiac function. She was
transferred to Bone Marrow Transplant for initiation of
chemotherapy on [**2130-11-23**]. Within a few hours after
transfer, she developed worsening tachypnea, shortness of
breath. Because of the lack for venous access and high
likelihood of deterioration after the initiation of
chemotherapy he was transferred to the [**Hospital Unit Name 153**].
Upon transfer, she was short of breath, denied any chest
pain, any nausea or vomiting. She was complaining of right
axillary and left knee pain. She had no other complaints.
PAST MEDICAL HISTORY:
1. SLE diagnosed in [**2112**] complicated by end-stage renal
disease requiring cadaveric renal transplant in [**2120**]. She
was receiving azathioprine, cyclosporin, and prednisone for
immunosuppression. Her kidney transplant was very close
match and she had no episodes of rejection.
2. Left hip avascular necrosis, status post replacement
times two in [**2126**] and [**2130**].
3. Hypertension.
4. Cataracts, status post surgery.
5. Status post cholecystectomy done by Dr. [**Last Name (STitle) **] at the
[**Hospital6 256**].
6. Hypothyroid.
7. Gout.
ALLERGIES: Plaquenil, Fosamax, Lipitor.
SOCIAL HISTORY: The patient is married. She has two
sisters, one daughter 16 years of age. She does not smoke.
She drinks alcohol occasionally.
OUTPATIENT MEDICATIONS:
1. Percocet.
2. Levothyroxine 50 once a day.
3. Verapamil SR 240 mg in the morning, 180 mg at night.
4. Colace.
5. Colchicine 0.6 mg once a day.
6. Senna.
7. Bisacodyl.
8. Zofran.
9. Ceftriaxone.
10. Levofloxacin.
11. Flagyl.
12. Protonix.
13. Ativan.
14. Prednisone taper.
15. Heparin subcutaneous.
16. Cyclosporin.
17. Atrovent.
18. Albuterol.
19. Allopurinol.
20. Morphine.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.9, heart rate 92, blood pressure 108/63, respirations 28,
oxygen saturation 98% on 4 liters nasal cannula. General:
The patient was in moderate respiratory distress, alert and
oriented times three. HEENT: The oropharynx had a wide
plaque on the hard palate, also a covered tongue and buccal
mucosal. The pupils were equal, round, and reactive to light
and accommodation bilaterally. The extraocular movements
were intact. Neck: No JVD. Cardiovascular: Regular, no
murmurs, rubs, or gallops. Pulmonary: Crackles two-thirds
down bilaterally with no wheezes. Abdomen: Obese,
nontender, nondistended, positive bowel sounds. Extremities:
No edema, 2+ dorsalis pedis pulses bilaterally, 2+ radial
pulses bilaterally. Neurologic: Cranial nerves II through
XII were intact.
LABORATORY/RADIOLOGIC DATA: White cell count 13.3,
hematocrit 35.7, platelets 273,000. PT 15, INR 1.5. Sodium
133, potassium 4.5, chloride 95, bicarbonate 23, BUN 43,
creatinine 1.4. ALT 40, AST 28, LDH 75, alkaline phosphatase
64, amylase 26, lipase 14, total bilirubin 1.2, CK 25,
albumin 2.8, troponin less than 0.01. Uric acid 15.
Cyclosporin level 270. White cell count 1,215, 40 red blood
cells, no polys, 4 lymphs, total protein 2.0, glucose 107, LD
341. ABG drawn on 4 liters of nasal cannula returned at
7.38, 42, and 37. Lactate 2.3.
Echocardiogram done in [**2129-10-22**] was normal.
A CT of the chest was done on [**2131-10-20**] which showed
massive axillary, mediastinal, and hilar lymphadenopathy,
with bilateral pleural effusions and collapse of posterior
left lower lobe.
CTA was done on [**2131-10-21**] and showed no pulmonary
embolism.
HOSPITAL COURSE: Upon transfer to the [**Hospital Unit Name 153**], the patient was
intubated for hypercarbic respiratory distress and CHOP
chemotherapy was started the same night.
1. LYMPHOMA: Diagnosed by chest CT confirmed by
supraclavicular node biopsy and malignant cells and pleural
effusion tap, large B cell lymphoma was positive for EBV
virus, Burkitt's type with 100% cells dividing. The
patient's large tumor burden in the chest and neck was
initially treated with the cycle of CHOP chemotherapy
followed by five days of Cytoxan and high-dose prednisone.
Tumor lysis laboratories were followed every six hours. She
received aggressive IV fluid hydration with sodium
bicarbonate to alkalinize the urine. The urine output was
maintained at 80-100 cc per hour. LDH initially was elevated
at 4,000. It subsequently decreased and reached a level of
500 at nadir.
On day number four post chemotherapy, [**2131-10-28**], a CT
of the chest was obtained to evaluate for the interval
change. All lymph nodes have decreased in size in general.
The patient indeed has severe mediastinal lymphadenopathy
with large lymph nodes compressing on the major airways and
great vessels of the chest. She developed
chemotherapy-induced pancytopenia on day number three
postchemotherapy, granulocyte colony stimulator factor was
started at 400 mg IV q.d.
On [**2131-11-2**], the patient was started on another
chemotherapy regimen with an AZT and hydroxyurea. Because of
the risk of AZT induced lactic acidosis per ABGs, the lactate
levels were followed closely.
RESPIRATORY FAILURE: Multifactorial, caused by airway and
great vessel compression and obstruction by tumor mass as
well as large and growing malignant pleural effusions,
hypoalbuminemia leading to third spacing and severe volume
overload as well as atelectasis. The patient was initially
thought to have pneumonia and was treated with antibiotics
without significant success. She was later ruled out for
pulmonary embolism with CTA. Her pleural effusion was tapped
on [**2131-10-20**] prior to transfer to the [**Hospital Unit Name 153**]; 600 cc
were drained with almost immediate reaccumulation of fluids.
During the course of her ICU stay on [**2131-10-26**],
another attempt was made at therapeutic thoracentesis;
however despite large pleural effusions bilaterally on the
chest x-ray only 10-15 cc of fluid were obtained. Follow-up
CT done on [**2131-10-29**] showed growing large pleural
effusions as well as persisting multiple lymph nodes,
described above.
The patient remained on assist-control ventilation, sedated.
The plan was to readdress therapeutic pleural tap versus
chest tube placement when she is more stable otherwise.
INFECTIOUS DISEASE: Soon after initial intubation, the
patient began complaining of abdominal pain. On [**2131-10-28**], the abdominal pain worsened. She developed diarrhea
positive for C. difficile colitis and was started on Flagyl
p.o. However, because of the ileus which developed soon
after, Flagyl had to be changed to IV vancomycin 125 mg p.o.
q. six hours was added for the treatment of C. difficile.
She developed a fever and was started on cefepime with
vancomycin IV. The patient remained afebrile on antibiotics
for three days. Therefore, AmBisome was added to her
antibiotic regimen. Her other positive cultures included
urine and sputum yeast speciated as [**Female First Name (un) 564**] on [**2131-11-4**].
At the time of this dictation, the patient was on cefepime,
Flagyl IV day number nine, vancomycin IV day number eight,
vancomycin p.o. day six, AmBisome day number four, AZT and
hydroxyurea day number three.
GASTROINTESTINAL/FLUIDS ELECTROLYTES AND NUTRITION: As
above, the patient developed abdominal pain with KUB
consistent with ileus on [**2131-10-28**]. This was followed
by abdominal CT scan which showed dilated sigmoid colon and
significant thickening of the jejunum. Surgery was consulted
due to the concern for typhlitis, infiltration of the small
bowel by lymphoma and/or ischemic bowel. The consult felt
that the presentation was consistent. Their recommendations
included conservative medical management and holding tube
feeds. Tube feeds were started two days after; however, due
to severe gastroparesis and ileus, the patient could not
tolerate even a minimal amount of tube feedings.
On [**2131-11-1**], the patient was taken to Interventional
Radiology and postpyloric Dobbhoff feeding tube was placed.
Of note, during this procedure, significant small bowel wall
thickening was also noted. It was also noted that the dye in
the small bowel did not move through into ours for the length
of the procedure.
On [**2131-11-2**], tube feeds were restarted at half
strength at 10 cc an hour. The patient was also maintained
on TPN.
CARDIOVASCULAR: Shortly after intubation, the patient
developed paroxysmal atrial fibrillation as well as atrial
ectopy. She was initially started on Diltiazem drip.
Subsequently, she required an Amiodarone drip times two and
one attempt at cardioversion. She was then started on
Lopressor IV every four hours, Amiodarone drip as well as
Diltiazem drip were discontinued.
With regards to her pump, the patient had three
echocardiograms done during this admission. The last
echocardiogram was done on [**2131-10-31**] and showed
hyperdynamic left ventricular function with mild outflow
obstruction and mild pulmonary artery hypertension, both new
compared with a previous study. She had two episodes of
hypotension requiring pressors. She was successfully weaned
off pressors during both episodes within 24 hours.
RENAL: Status post kidney-renal transplant in [**2119**]. Because
of the concern for post transplant proliferative disorder,
she was withdrawn of immunosuppression except for a low-dose
of Solu-Medrol. The patient's creatinine remained stable for
the first seven days; however, subsequently, it started
rising in the setting of some tumor lysis, multiorgan
failure, multiple nephrotoxic medications, and likely renal
hyperperfusion. She was maintained on Allopurinol. She
received blood transfusions to maintain hematocrit above 28.
The patient was followed by the Renal Transplant Team.
HEME: Secondary to pancytopenia induced by chemotherapy, the
patient required daily platelet transfusions and packed red
blood cells every other day. Her INR remained elevated
despite vitamin K administration. Laboratory data was
consistent with chronic diffuse intravascular coagulation.
ACCESS: Because of the severe lymphadenopathy, obtaining
access was a difficult task. Initially, a left femoral line
was placed. This was changed to a left internal jugular
central line under the ultrasound guidance. However,
secondary to thrombosis, the line needed to be discontinued.
A right subclavian line was placed on [**2131-10-31**] and
remained functional at the time of this dictation.
Communication was maintained with the patient's husband as
well as her sister. At the time of this dictation, a family
meeting was planned for [**2131-11-5**] with the patient's
oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as well as the Intensive Care
Unit attending to discuss the patient's prognosis and further
treatment plans.
The remainder of the patient's course will be dictated at a
later date by another physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern4) 26613**]
MEDQUIST36
D: [**2131-11-4**] 01:32
T: [**2131-11-4**] 14:39
JOB#: [**Job Number 97991**]
ICD9 Codes: 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5673
} | Medical Text: Admission Date: [**2173-1-6**] Discharge Date: [**2173-1-23**]
Date of Birth: [**2173-1-6**] Sex: F
Service: NEONATOLOGY
HISTORY: [**Known lastname 29633**] [**Known lastname **], Twin number II, was born at
31-6/7 weeks gestation by cesarean section for rupture of
membranes of Twin number I and progressive preterm labor.
Mother is a 37 year old Gravida 1, Para 0 now 2 woman whose
blood type is A negative, antibody negative, rubella immune,
RPR nonreactive, hepatitis B surface antigen negative and
Group B Streptococcus unknown. The mother had received a
complete course of betamethasone prior to delivery. This
pregnancy was achieved with in [**Last Name (un) 5153**] fertilization. A
cerclage was placed at 18 weeks gestation.
Cesarean section was performed under spinal anesthesia. This
infant emerged with Apgars of 8 at one minute and 8 at five
minutes.
PHYSICAL EXAMINATION: On admission, revealed a vigorous
non-dysmorphic premature infant, with moderate subcostal
retractions and some occasional grunting, normal S1, S2 heart
sounds, no murmur. Pink and well perfused. Normal hip
examination and age appropriate tone and reflexes.
The birth weight was 1,980 grams, 80th percentile. The birth
length was 44 centimeters, the 75th percentile and the birth
head circumference was 30.6 centimeters, in the 65th
percentile
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory Status: The infant was intubated soon after
admission to the NICU and received two doses of surfactant.
She weaned to room air on day of life one where she has
remained since that time. Her respirations are comfortable.
Her lung sounds are clear and equal. She has had no apnea,
bradycardia or desaturation.
2. Cardiovascular Status: She had remained normotensive
throughout her NICU stay. She has a normal S1, S2 heart
sound and no murmur. She is pink and well perfused.
3 Fluids, Electrolytes and Nutrition Status: She started on
enteral feeds on day of life number two and progressed
without difficulty to full volume feedings by day of life
five and then was advanced to calorie enhanced breast milk of
24 calories per ounce. She has been taking from 130 to 160
cc. per kilo per day on an ad lib feeding plan. At the time
of discharge, her weight is 2,200 grams; her length is 49.5
centimeters (19.5 inches) and her head circumference is 30.5
centimeters.
4. Gastrointestinal Status: Her peak bilirubin occurred on
day of life five and was total 12.1, direct 0.3; the last
bilirubin on day of life six was total 11.1, direct 0.4. She
never required phototherapy.
5. Hematological Status: Her hematocrit at the time of
admission was 45.4, platelets were 360,000. She is receiving
supplemental iron to provide 2 mg per kilo per day as
elemental iron. She has never received any blood products
during this NICU stay.
6. Infectious Disease Status: The infant was started on
Ampicillin and Gentamycin at the time of admission for sepsis
risk factor. The antibiotics were discontinued after 48
hours when the infant was clinically well and the blood
cultures remained negative.
7. Neurological Status: She had a head ultrasound on
[**2173-1-14**], that was completely within normal limits.
8. Psychosocial: The parents have been very involved in the
infant's care throughout her NICU stay. She is the first
twin to go home. The infant's first name is [**Name (NI) 29633**] and after
discharge the infant's last name will be [**Name (NI) 732**].
CONDITION ON DISCHARGE: Good.
DISPOSITION: The infant is being discharged home with her
parents.
Primary pediatric care will be provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38161**]
of [**Hospital1 **] Pediatric Group, [**Last Name (NamePattern1) 38165**], [**Hospital1 392**],
[**Numeric Identifier 38166**], telephone number is [**Telephone/Fax (1) 38162**].
CARE AND RECOMMENDATIONS:
1. Feedings: The infant is on breast milk with Enfamil
Powder to provide 24 calories per ounce and on an ad lib
feeding schedule.
2. Medications: Ferinsol 0.2 cc. to provide 5 mg a day.
3. The infant passed a car seat positioning test on
[**2173-1-23**].
4. State Screens were sent on [**1-9**] and [**2173-1-20**].
5. The infant received the hepatitis B vaccine on
[**2173-1-21**], and Synagis on [**2173-1-23**].
Immunization recommended:
1) Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: Born at less than 32 weeks; born between 32 and 35
weeks with plans for day care during the RSV season, with a
smoker in the household, with preschool siblings, or with
chronic lung disease;
2) Influenza immunization should be considered annually in
the Fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age, the family
and other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE INSTRUCTIONS:
1. Follow-up appointments, the parents have an appointment
with Dr. [**Last Name (STitle) 38161**] on Tuesday, [**1-26**].
2. Visiting Nurses Association of the [**Hospital3 **] will visit
on Sunday, [**2173-1-24**].
DISCHARGE DIAGNOSES:
1. Prematurity at 31-6/7 weeks gestation.
2. Twin II.
3. Sepsis, ruled out.
4. Status post respiratory distress syndrome.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2173-1-23**] 17:49
T: [**2173-1-23**] 18:43
JOB#: [**Job Number 38167**]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5674
} | Medical Text: Admission Date: [**2162-1-5**] Discharge Date: [**2162-1-15**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Arterial line
Tracheostomy
History of Present Illness:
65-year-old male with history of COPD (FEV1/FVC 28% of
predicted), mild mental retardation with schizophrenia and
recent admission with discharge on [**2161-12-10**] for COPD
exacerbation requiring intubation presenting in respiratory
distress. Patient reported increased cough and O2 requirement
over 1-2 days, completed steroid taper 1 week ago. VNA called
the [**Company 191**] to report found patient to have pOx of 65 % and called
911 for assistance and delivery of patient to [**Hospital1 18**] ED. He was
given a combivent neb at home. Baseline home O2 requirement of 2
L O2.
EMS found patient in respiratory distress, satting 70% RA, given
nebs.
In the ED, initial VS: HR 79 BP 109/69 RR 29 O2 sat 98 % on 40 %
O2 . CXR without clear infiltrate, had received empiric
vancomycin and levofloxacin. Given continuous albuterol,
methylprednisolone. ABG with PCO2 of 82, baseline of 60s. VS:
114/64 69 32 98% CPAP. Repeat ABG unchanged on BiPAP showing
hypercarbia and acidosis. Patient continued to appear somnolent
despite interventions including biPAP and subsequently intubated
with etomidate 20 mg IV and succinycholine 120 mg IV. He was
sedated with fentanyl/versed gtts but stopped in setting of
hypotension (lowest [**Location (un) 1131**] 52/34 HR 64) and given 2 L NS.
Of note, he refused intubation in ED initially. PCP states
patient was not ready for DNR/DNI per clinic note on [**2161-12-15**].
.
On the floor, patient intubated and sedated.
.
Review of systems:
Unable to obtain
.
Past Medical History:
- COPD: FEV1 23% predicted, home 1.5-2L O2 at night only
- Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
- Schizophrenia
- Hx GI bleeding
- Mental Retardation
- Pulmonary Hypertension
- s/p tonsillectomy
Social History:
Lives in [**Location **], unknown if alone. On disability since [**2149**]
for mental health issues. Has home nurse visit every morning and
evening. Reports ~50 pack-year smoking with current smoking.
Denies any ETOH/drug use.
Family History:
Patient unable to provide.
Physical Exam:
Vitals: HR 49 RR 20 BP 84/59 (MAP 65) SaO2 99 on CMV with FiO2
100, PEEP 6 PPeak 32 Vt 0.500
General: sedated
[**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: distant breath sounds, end-expiratory wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
I. Labs
A. Admission
[**2162-1-5**] 05:28PM BLOOD WBC-7.3 RBC-4.37* Hgb-13.5* Hct-39.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.4 Plt Ct-334
[**2162-1-5**] 05:28PM BLOOD Neuts-57.8 Lymphs-32.3 Monos-5.4 Eos-3.2
Baso-1.3
[**2162-1-5**] 05:28PM BLOOD PT-12.9 PTT-34.7 INR(PT)-1.1
[**2162-1-5**] 05:28PM BLOOD Glucose-121* UreaN-17 Creat-0.9 Na-144
K-4.2 Cl-102 HCO3-34* AnGap-12
[**2162-1-6**] 03:54AM BLOOD Calcium-7.4* Phos-2.0*# Mg-1.4*
[**2162-1-5**] 05:36PM BLOOD Type-ART FiO2-1 pO2-252* pCO2-82*
pH-7.26* calTCO2-39* Base XS-6 Intubat-NOT INTUBA
[**2162-1-7**] 02:10PM BLOOD O2 Sat-98
[**2162-1-5**] 10:20PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.027
[**2162-1-5**] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2162-1-5**] 10:20PM URINE RBC-0-2 WBC-[**7-16**]* Bacteri-FEW Yeast-NONE
Epi-0
[**2162-1-5**] 10:20PM URINE Mucous-MANY
B. Micro
[**2162-1-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2162-1-5**] BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY [**Hospital1 **]
[**2162-1-5**] BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY [**Hospital1 **]
C. Discharge
________________________________
________________________________
II. Radiology
A. CXR
XAM: Chest, single frontal view.
CLINICAL INFORMATION: 55-year-old male with history of shortness
of breath.
COMPARISON: Multiple priors including [**2161-12-8**], [**2161-12-6**] and
[**2161-12-4**].
FINDINGS: Subtle right lower lobe patchy opacity appears
slightly more
prominent compared to the study of [**2161-12-8**] but less prominent
compared to
[**2161-12-6**]. Findings could be due to aspiration or infectious
process. Left
infrahilar opacity is again seen. No pleural effusion or
pneumothorax is
seen. Cardiac and mediastinal silhouettes are stable and
unremarkable.
III. Cardiology
A. EKG
Sinus tachycardia. Slight ST-T wave changes are non-specific and
may be within normal limits. Since the previous tracing of
[**2161-11-29**] sinus tachycardia is now present and the marked ST-T
wave abnormalities have decreased
Pending studies
Blood culture x 2, urine culture
Brief Hospital Course:
65-year-old male with mental retardation, history of severe COPD
with multiple admissions for same complaint requiring intubation
presenting with hypercarbic respiratory failure likely secondary
to COPD exacerbation. Goals of care were discussed, and patient
subsequently underwent tracheostomy.
# Hypercarbic Respiratory failure
Etiology thought to be COPD exacerbation given symptoms of cough
in week prior, continued smoking, and absence of leukocytosis,
fever, and definitive infiltrate. He was treated with a 5-day
course of levofloxacin and placed on a prednisone taper.
Multiple pressure support trial were attempted resulting in
worsening hypercarbia and continued intubation. [**Name (NI) **] sister
and patient were involved in discussion regarding goals of care
and decided on undergoing a tracheostomy given multiple
intubations in the recent past for his severe COPD. It was felt
that patient has capacity to make this decision given he
demonstrated understanding risks and benefits of the procedure.
He spiked a fever to 101 on [**1-14**], but felt to be related to
post-procedure. Blood and urine cultures no growth to date and
CXR with no infiltrate. He remained afebrile for 24 hours
afterwards.
# Hypotension
Patient initially hypotensive on admission especially with
sedation after intubation but appeared euvolemic. Attributed to
intubation with sedatives and PEEP. He was treated with a 4 L NS
bolus and continued to produce adequate urine output.
Normotensive throughout rest of MICU course and at time of
dsicharge.
# Pyuria
Patient noted to have pyuria on admission and history of VRE.
Urine culture was negative.
# Glucose intolerance. The patient had elevated blood sugars
during last hospitalization, which may be secondary to steroid
usage vs. hyperglycemia of acute illness vs. a pre-diabetic
state. Patient remained of SSI in house. This should be
monitored closely as an outpt.
# Anemia
Patient noted to have anemia on admission (Hct 39.8). Advise
age-appropriate cancer screening on outpatient basis and
outpatient follow-up.
# Schizophrenia
Patient remained of zyprexa.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled twice a day and q 4 hours prn wheeze
FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth every twelve
(12) hours
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day
INHALATIONAL SPACING DEVICE [AEROCHAMBER] - Inhaler - use with
inhalers every time
OLANZAPINE [ZYPREXA] - (Prescribed by Other Provider) - 7.5 mg
Tablet - 1 Tablet(s) by mouth once a day
OXYGEN - - 1- 2 liters nasal canula to keep O2 sat above 90%
PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth once a day for
7
days
PREDNISONE - 10 mg Tablet - Taper as directed
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 1 Tablet(s) by mouth
every four (4) hours as needed for fever or pain
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
once a day
MULTIVITAMIN WITH MINERALS - Tablet - 1 Tablet(s) by mouth
once
a day
--------------- --------------- --------------- ---------------
Discharge Medications:
1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (4) **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
2. Advair Diskus 500-50 mcg/dose Disk with Device [**Month/Day (4) **]: One (1)
puff Inhalation twice a day.
3. oxygen
1-2 liters NC to keep O2 sat above 90 %
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Month/Day (4) **]:
One (1) capsule Inhalation once a day.
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (4) **]:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
6. olanzapine 7.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day.
7. prednisone 10 mg Tablet [**Month/Day (4) **]: Four (4) Tablet PO once a day:
Take 4 tablets daily until [**1-15**], take 3 tablets daily from
[**1-15**] to [**1-20**], take 2 tablets daily from [**1-20**] to [**1-25**]. Take 1
tablet from [**1-25**] to [**1-30**].
.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: chronic obstructive pulmonary disease exacerbation
Secondary: Mental retardation, schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were treated for a COPD exacerbation with respiratory
failure requiring intubation and mechanical ventilation. It was
decided by you and your sister that a tracheostomy would be a
good option given your recurrent COPD exacerbations requiring
intubation.
Medication changes:
START prednisone taper
START lansoprazole
Followup Instructions:
You should follow-up with your primary care doctor, Dr. [**First Name (STitle) 1022**]
([**Telephone/Fax (1) 250**]), after you leave the rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 4168, 3051, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5675
} | Medical Text: Admission Date: [**2195-3-20**] Discharge Date: [**2195-3-31**]
Date of Birth: [**2141-1-15**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
54 year old male with PMH significant for HIV (on HARRT, last
CD4 629), ESLD, HCV cirrhosis presents from clinic w/ AMS.
.
History taken from wife. Over 7-10 days, pt has been ill w/
nausea, vomiting and diarrhea. Wife thinks he's had at least 3
loose BM daily. He has had intermittent emesis, that she
believes is non-bloody, non-biliary. He has had worsening
abdominal distension as well, w/ very poor po intake. He was
also complaining of abdominal pain. She did not take his temp,
but states that he "felt hot." Per wife, pt drinking ETOH up
until 2 months ago, very heavily ~ 1pint of vodka and 4-5 beers
nightly. He has a h/o ivdu (heroin) but hasn't used in 2 years.
.
Pt was referred to Dr. [**Last Name (STitle) 497**] by his PCP. [**Name10 (NameIs) **] exam he was found to
be very altered and he was referred to the ED.
.
In the ED, VS were T 99.0, HR 94, BP 151/95, RR 20, O2 97%. On
exam, he had + asterixis, AMS, +abd distention/TTP. RUQ US
showed patent portal vein, cirrhotic liver with perihepatic
ascites (not seen in other quadrants), and GB sludge but no
signs of cholecystitis. CT head showed no acute intracranial
process. His labs were notable for a Na 127, K 5.4, Cr 1.5, t
bili 25.3, ALT 212, AST 473, alb 2.6, INR 3.6, wbc 13.7, hct
35.7, plt 149. He was seen by hepatology. He received lactulose,
ceftriaxone, albumin, and an amp of D5. He did not get
paracentesis b/c of INR. 2 units of ffps started. He was
subsequently transferred to the ICU
.
In the ICU, he was continued on ceftriaxone and lactulose. He
was also started on D5NS for hyponatremia/hypoglycemia. For his
coagulopathy, he received FFP as well as IV vitamin K. IR-guided
paracentesis was performed performed but did not show any signs
of SBP, but this was in the setting of having received IV
antibiotics.
.
Review of systems: unable to obtain as pt altered.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
HIV on HARRT
HCV cirrhosis
Polysubstance abuse
Social History:
- Tobacco: "heavy" [**Last Name (LF) 1818**], [**First Name3 (LF) **] wife
- Alcohol: 1pint of vodka and 4-5 beers nightly last drank 2 mo
ago
- Illicits: h/o ivdu (heroin), last used (per wife) ~ 2 yrs ago
Family History:
Unable to obtain
Physical Exam:
Admission Exam:
General: Thin appearing male, jaundice
HEENT: Sclera icteric, dry MM, oropharynx clear
Neck: supple, JVP elevated above mandible, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Distended, tense, minimally ttp, no spider angiomata
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: Oriented to self, able to state that he at [**Hospital3 **]
Deaconness. States the year is [**2195**] initially, then [**2194**], but
cannot state the month.
Pertinent Results:
Admission Labs:
[**2195-3-20**] 11:20AM PLT COUNT-149*
[**2195-3-20**] 11:20AM NEUTS-69.5 LYMPHS-24.4 MONOS-5.7 EOS-0.1
BASOS-0.3
[**2195-3-20**] 11:20AM WBC-13.7* RBC-3.43* HGB-12.6* HCT-35.7*
MCV-104* MCH-36.7* MCHC-35.2* RDW-16.2*
[**2195-3-20**] 11:20AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2195-3-20**] 11:20AM AFP-29.0*
[**2195-3-20**] 11:20AM ALBUMIN-2.6*
[**2195-3-20**] 11:20AM LIPASE-42
[**2195-3-20**] 11:20AM ALT(SGPT)-212* AST(SGOT)-473* ALK PHOS-250*
TOT BILI-25.3* DIR BILI-15.0* INDIR BIL-10.3
[**2195-3-20**] 11:20AM estGFR-Using this
[**2195-3-20**] 11:20AM GLUCOSE-48* UREA N-16 CREAT-1.5* SODIUM-127*
POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-24 ANION GAP-11
[**2195-3-20**] 12:41PM PT-35.3* PTT-43.1* INR(PT)-3.6*
[**2195-3-20**] 03:00PM AMMONIA-115*
[**2195-3-20**] 10:22PM PT-40.3* PTT-46.2* INR(PT)-4.2*
[**2195-3-20**] 10:22PM PLT COUNT-119*
[**2195-3-20**] 10:22PM WBC-10.1 RBC-2.86* HGB-10.6* HCT-30.0*
MCV-105* MCH-37.0* MCHC-35.3* RDW-16.2*
[**2195-3-20**] 10:22PM ETHANOL-NEG
[**2195-3-20**] 10:22PM CALCIUM-8.7 PHOSPHATE-2.0* MAGNESIUM-2.5
[**2195-3-20**] 10:22PM GLUCOSE-64* UREA N-14 CREAT-1.2 SODIUM-130*
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-26 ANION GAP-7*
[**2195-3-20**] 11:30PM URINE MUCOUS-RARE
[**2195-3-20**] 11:30PM URINE HYALINE-4*
[**2195-3-20**] 11:30PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2195-3-20**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-4* PH-5.5 LEUK-NEG
[**2195-3-20**] 11:30PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2195-3-20**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2195-3-20**] 11:30PM URINE OSMOLAL-389
[**2195-3-20**] 11:30PM URINE HOURS-RANDOM UREA N-578 CREAT-98
SODIUM-26 POTASSIUM-34 CHLORIDE-27
[**2195-3-21**] 15:05
ASCITES
WBC RBC Polys Lymphs Monos Mesothe Macroph
171* 93* 41* 6* 7* 3* 43*
PERITONEAL FLUID
TotPro Glucose Creat LD(LDH) Amylase
0.5 77 0.9 38 15
TotBili Albumin
2.3 LESS THAN 1
Discharge labs:
[**2195-3-31**] 05:30AM BLOOD WBC-7.6 RBC-2.62* Hgb-9.8* Hct-28.6*
MCV-109* MCH-37.5* MCHC-34.3 RDW-16.8* Plt Ct-76*
[**2195-3-25**] 05:00AM BLOOD WBC-10.9 Lymph-33 Abs [**Last Name (un) **]-3597 CD3%-95
Abs CD3-3408* CD4%-30 Abs CD4-1095 CD8%-56 Abs CD8-[**2200**]*
CD4/CD8-0.5*
[**2195-3-31**] 05:30AM BLOOD Glucose-99 UreaN-8 Creat-0.8 Na-134 K-3.7
Cl-103 HCO3-25 AnGap-10
[**2195-3-31**] 05:30AM BLOOD ALT-88* AST-179* AlkPhos-156*
TotBili-21.7*
[**2195-3-21**] 01:45PM BLOOD calTIBC-129* Ferritn-1686* TRF-99*
[**2195-3-21**] 05:25AM BLOOD VitB12-GREATER TH Folate-9.0
[**2195-3-22**] 07:30AM BLOOD Cortsol-6.7
[**2195-3-21**] 01:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
[**2195-3-21**] 01:45PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40
[**2195-3-20**] 11:20AM BLOOD AFP-29.0*
[**2195-3-21**] 01:45PM BLOOD IgG-2387*
Test Result Reference
Range/Units
HCV GENOTYPE, LIPA 1a
[**2195-3-24**] 06:25
CA [**02**]-9
Test Result Reference
Range/Units
CA [**02**]-9 14 <37 U/mL
Microbiology:
[**2195-3-20**] Blood cultures x 2 NEGATIVE
[**2195-3-20**] MRSA Screen NEGATIVE
[**2195-3-20**] VRE Screen NEGATIVE
[**2195-3-20**] Urine Culture NEGATIVE
[**2195-3-20**] C. Diff Toxin NEGATIVE
[**2195-3-21**] HCV Viral Load 2,260 IU/mL.
[**2195-3-21**] 3:05 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT [**2195-3-27**]**
GRAM STAIN (Final [**2195-3-21**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2195-3-24**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2195-3-27**]): NO GROWTH.
[**2195-3-25**] RPR NONREACTIVE
[**2195-3-25**] 11:40 am IMMUNOLOGY
HIV-1 RNA is not detected.
[**2195-3-31**] 12:20 pm URINE Source: CVS.
**FINAL REPORT [**2195-4-3**]**
URINE CULTURE (Final [**2195-4-3**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
Imaging:
CT HEAD NON-CON [**2195-3-20**]:
Some motion through the inferior most images. Otherwise, no
evidence of acute intracranial process. Please note that MRI is
more sensitive in detecting small intracranial lesions.
RUQ ULTRASOUND [**2195-3-20**]:
1. Doppler assessment of the main portal vein and their branches
shows patency and hepatopetal flow.
2. Cirrhotic liver and ascites.
3. Distended gallbladder with sludge without gallbladder wall
edema or pericholecystic fluid. Cholecystitis cannot be entirely
excluded based on this study, if there is high clinical concern.
If high clinical concern for cholecystitis, could further
evaluate with a HIDA scan.
CHEST XR [**2195-3-20**]:
Small bilateral effusions with associated atelectasis. Mild
pulmonary edema
PELVIS (AP ONLY) Study Date of [**2195-3-23**] 10:38 PM
FINDINGS:
There is an apparent urinary catheter in the urethra and
bladder. The tip of this is not well visualized. No metallic
radiopaque foreign body is seen. No bone lesion or fracture is
seen.
- LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2195-3-25**]
1:57 PM
ABDOMINAL ULTRASOUND:
Again noted is a heterogeneous nodular shrunken liver consistent
with a known history of cirrhosis. The largest hypovascular
nodule noted on MRI in segment2 was poorly seen despite multiple
attempts at positioning at visualizing this segment of the
liver. The lesion within segment [**Doctor First Name 690**] next to the gallbladder is
slightly hypoechoic in comparison to the surrounding parenchyma
measuring 2.5 x 2.5 x 3.8 cm and is in close proximity to the
main hepatic artery and the main portal vein. The other
peripheral lesion within segment VI, abutting the hepatorenal
space is also seen and hypoechoic in comparison to the
surrounding parenchyma measuring 2.1 x 2.6 x 3.7 cm. One
additional echogenic nodule within segment VII/VIII is noted
with no clear correlate on the MRI, measuring 7 x 11 x 14 mm.
The other lesions within segment V on the MRI are not clearly
seen. Moderate amount of ascites remains.
IMPRESSION:
1. Unchanged appearance to known cirrhotic liver. The segment
[**Doctor First Name 690**] and
segment VI lesions are son[**Name (NI) 5326**] visible and could be
attempted for
percutaneous biopsy. The lesion locations would make the
procedure
technically challenging and high risk given the proximity to
surrounding
vessels, gallbladder and kidney. The segment II and V lesions
are not clearly seen. A moderate amount of ascites persists and
a paracentesis would have to be done prior to the procedure to
minimize any risk of capsular bleeding.
2. 1 cm hyperechoic nodule, likely within segment VII or VIII
without clear
MRI correlate.
- CT ABD W&W/O C Study Date of [**2195-3-30**] 3:26 PM
IMPRESSION:
1. Four lesions displaying mild arterial enhancement and washout
meet imaging
criteria for HCC within segment V/VIII (one lesion), segment VI
(two lesions),
and segment [**Doctor First Name 690**] (one lesion). None is greater then 3 cm.
2. Two lesions within segment II display only washout but
without increased
arterial enhancement. The smaller more posterior lesion is more
concerning as
it shows washout to surrounding liver on portal and delayed
venous phases with
a more vague larger anterior lesion of uncertain significance
only seen on
most delayed phase. Both are hyperdense on non-contrast CT.
Additional small
segment VIII lesion also only seen on most delayed images
without arterial
enhancement. These may represent dysplastic nodules or
hypovascular HCC's.
3. Known cirrhotic-appearing liver with sequelae of portal
hypertension
including abdominal/esophageal varices and splenomegaly as well
as
mild-to-moderate amount of ascites. Edema within the large bowel
presumably
related to congestive enteropathy.
4. Biliary sludge and gallstones as seen on prior MRI. Small
pancreatic head
cyst is of doubtful significance for this patient and can be
watched on future
exams.
5. Small left pleural effusion.
Brief Hospital Course:
54 year old male with PMH significant for HIV (on HARRT, last
CD4 629), ESLD, HCV cirrhosis w/ possible left lobe liver
cancer, who was being admitted to the ICU w/ AMS
# Cirrhosis: The patient has known Hepatitis C, both by history
as well as by viral load in hospital, as well as a reported
heavy history of EToH use. On admission, given reported episodes
of fevers at home as well as abdominal pain, there was serious
concern for SBP, and the patient was started on empiric
antibiotics with ceftrixaone. RUQ U/S showed a cirrhotic liver
and ascities, but without evidence of cholecystitis or PVT.
Additionally, there was no evidence of GI bleed. Subsequent
diagnostic tap did not reveal any evidence of SBP, however, as
noted above, this was in the setting of having already received
antibiotics. The patient completed a course of Ceftrixaone for
presumed SBP, and subsequently started SBP prophylaxis with
Cipro.
The patient underwent an MRCP secondary to concerns from
patient's PCP about [**Name Initial (PRE) **] possible liver lesions. MRCP discovered
five liver lesions of various sizes, detailed in the results
section of this report. Two of these lesions were amenable to
biopsy, but given the patient's history, multiple lesions, and
potential complications of biopsy, the patient in consultation
with physicians here elected not to performed the biopsy, as the
results were felt to be almost certain to reveal malignancy
(perhaps HCC versus cholangiocarcinoma) that would not be
amenable to treatment; the patient indicated he did not want to
know if this were the case. Palliative care was consulted, and
provided counseling regarding resources for palliative care. The
patient was made DNR/DNI. A repeat triphasic CT confirmed that
the pattern of filling of the lesions in the liver was
consistent with HCC. Prior to discharge, the patient received a
therapeutic tap and was discharged on 20 mg of Furosemide as
well as 50 mg Spironolactone.
# AMS: On admission, the patient was noted to be altered. AMS
was felt to be secondary to decompensated liver failure as well
as a component of SBP. Some of the patient's alteration in
mental status was also presumed to medication effect, and
initially the patient's home dose of methadone was decreased;
however, this was up-titrated back to his home dose on
discharge. The patient also received hepatic encephalopathy
prophylaxis with lactulose and rifaximin. On discharge, the
patient was noted to be AAOx3, follwoing commands, and
conversant, and without any asterixis (he had had very prominent
asterixis on admission).
# HIV: The patient's HAART therapy was discontinued in house
secondary to concerns for liver toxicity, specifically from
abacavir. On discharge, the patient was noted to have a CD4
count in in the 1000s, with an undetectable viral load. HAART
therapy was not restarted on discharge, and was deferred to the
outpatient setting. The ID team indicated that the patient's
HAART could safely be restarted once the LFTs were less than 2 x
the ULN.
# HTN: The patient's amlodipine and lisinopril on hold given
initially the concern for the patient's illness in the setting
of presumed infection; he was not restarted on these medications
upon discharge as he had been normotensive in house.
# EtOH Abuse: Per wife's report, the patient has not had alcohol
in over two months. Patient did not exhibit any signs/symptoms
of withdrawal, and was discharged from the hospital on a
multivitamin.
# Renal Insufficiency: The patient's creatinine appeared to
normalize over the course of his admission with albumin and IV
fluid.
# HypoNa: The patient was noted to be hyponatremic on admission,
likely secondary to dehydration, which resolved with hydration.
# Hypoglycemia: The patient on inital admission to ICU was noted
to be hypoglycemic requiring a D5W gtt. This hypoglycemia was
presumed secondary to acute infection with SBP; the patient
remained normoglycemic throughout the remainder of his
admission. An AM cortisol was sent off to rule out adrenal
insuffiency as a cause of hypoglycemia, but AM cortisol was
within normal limits.
# Chest Pain: Not currently bothersome to patient. However, he
does describe a long history of intermittent chest pressure with
may require outpatient follow-up.
Medications on Admission:
Home meds (confirmed with girlfriend who read off of pill
bottles)
-Epzicom 1 tab q day
-Prezista 800 mg daily
-Norvir 100 mg softgel 1 q day
-Lisinopril 10 mg daily
-Ondansetron 4 mg 1 tab up to TID
-Omeprazole-20 mg [**Hospital1 **]
-Fluoxetine 10 mg daily
-amlodipine 5 mg daily
-ibuprofen 800 mg 3x daily
Discharge Medications:
1. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO once a day.
2. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
4. lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO three
times a day.
Disp:*1 quantity sufficient* Refills:*2*
5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day:
Please take this medication for hepatic encephalopathy
prophylaxis.
Disp:*60 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. methadone 10 mg Tablet Sig: Fifteen (15) Tablet PO once a
day.
8. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. methadone 10 mg Tablet Sig: Fifteen (15) Tablet PO DAILY
(Daily).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Primary Diagnosis:
- Spontaneous Bacterial Peritonitis
Secondary Diagnosis:
- Multiple Liver Lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Last Name (Titles) 13309**], it was a pleasure taking care of you in the hospital.
You were admitted to the hospital because you had been having
some abdominal pain and had some alteration in your mental
status. After performing some images, we believes that you had
an infection in the fluid which had accumulated in your abdomen,
and treated you with an appropriate course of antibotics. When
you finished these antibiotics, we started you on an antibiotic
you will need to take indefinitely to prevent you from getting
another infection.
Our HIV specialists saw you and indicated that your current
liver disease made it very dangerous for you to continue taking
your HIV medications, all of which have been stopped. You should
not restart these medications until you have consulted with your
HIV physician and your provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66037**].
We also performed some imaging of your liver; your primary
physician had noted that one of the lobes of your liver had a
lesion on it. When we took more pictures of of your liver, we
saw that your liver had five different lesions on it. After
discussions with you, you elected not to have us perform a
biopsy. We got a CT scan which showed that this is likely to be
liver cancer, however after discussion with you we decided that
treating it would likely not make your life better and
potentially make it worse.
When you leave the hospital:
- STOP Epzicom 1 tab DAILY (discuss with your primary care
doctor when and if to restart this)
- STOP Prezista 800 mg DAILY (discuss with your primary care
doctor when and if to restart this)
- STOP Norvir 100 mg DAILY (discuss with your primary care
doctor when and if to restart this)
- STOP Lisinopril 10 mg daily (discuss with your primary care
doctor when and if to restart this)
- STOP Amlodipine 5 mg daily (discuss with your primary care
doctor when and if to restart this)
- STOP Ibuprofen 800 mg 3x daily
- START Furosemide 40 mg Daily (this is for the fluid in your
abdomen and legs)
- START Spironolactone 100 mg Daily (this is for the fluid in in
your abdomen and legs)
- START Ciprofloxacin 250 mg Daily (you will need this to
prevent you from getting infections in the future)
- START Lactulose 30 ml three times a day; take this as needed
in order to have 3 bowel movements a day
- START rifaximin 550 mg Tablet twice a day
- START multivitamin Daily
We did not make any other changes to your medications, so please
continue to take them as you normally have been.
Followup Instructions:
Name: PA- [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 66037**]
Location: [**Hospital1 **] FAMILY HEALTH CENTER
Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 66039**]
Appointment: Wednesday [**2195-4-1**] 2:30pm
Department: LIVER CENTER
When: FRIDAY [**2195-4-17**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 2761, 5715, 496, 4019, 2859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5676
} | Medical Text: Admission Date: [**2135-4-12**] Discharge Date: [**2135-4-16**]
Date of Birth: [**2066-10-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization, stent placement
intra-aortic balloon pump placement
History of Present Illness:
Mr. [**Known lastname 13356**] is a 68 y/o male with a history of CAD s/p 2.5 X 18mm
Cypher DES in the LAD in [**2128**] and POBA to med LAD for restenosis
in [**2130**], HTN, and HLD who presented with sudden onset substernal
chest pain. He states that he was in his USOH at home when he
suddenly developed chest pain and became diaphoretic after he
was making a grilled cheese [**Location (un) 6002**]. The pain was located in
the middle of his chest but did not radiate. He describes the
pain as intense/sharp and was a [**5-31**] at its worst. He walked to
his wife and told her to call the ambulance. When EMS arrived he
was given nitroglycerin tabs x2 which helped with the pain. They
took an EKG and were concerned for ST elevations therefore they
called the ED with this concern.
.
In the ED a code STEMI was called and he was quickly transferred
to the cath lab. EKG showed a HR of 75 with hyperacute T waves
and anterior ST elevations. He was given aspirin 325mg and
plavix 300mg. His trop was noted to be 0.43. In the cath lab he
a 3.0 x 30 mm Resolute stent was deployed in his LAD. The
thombus migrated to the distal LAD and the patient became
temporarily bradycardic and hypotensive which was reversed with
IV Atropine. Intermittent slow flow was noted again and massive
amount of thrombus was noted in the LMCA, proximal LAD with some
protrusion into the Cx creating a "trap door" effect in the LAD
as the thrombus moved. A 4.0 x 18 mm Resolute stent was
deployed in the LAD and LMCA. After removal of the radial
sheath, he complained of worsening chest pain an he was noted to
have extensive STE in the anterior precordium. It was decided
that confirmatory angiography would be repeated to ensure that
the vessels were patent and IABP was inserted.
.
Patient states that when he was previously intervened he did not
have any symptoms. He notes that the first intervention was done
becuase of an abnormal stress test. He has never had chest pain
before.
.
On arrival to the floor, patient was awake and alert but was
having some continued chest pain. He rated the pain as a [**3-1**].
The pain was the same pain he presented with however the
intesity is better.
.
REVIEW OF SYSTEMS
On review of systems, he denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denied recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Decompressive Laminectomy
HTN
CAD s/p LAD stent [**2128**], POBA [**2130**]
HLD
Palpitations
Hyperhomocysteinemia
Prostate Cancer
Social History:
He is retired (former 4th grade teacher) and he lives with his
wife. [**Name (NI) **] drinks small amounts of alcohol and uses no illicit
substances. He is currently smoking [**11-22**] pack per day for 50+
years.
Family History:
Family history of MI and heart failure, brother MI at 58 years
of age.
Physical Exam:
Physical Exam on Admission:
VS: BP 166/81 HR 83 O2 sat: 100 2L
GENERAL: Comfortbale and in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. right lower extremity scarring from old
injury
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
.
Physical Exam on Discharge:
VS: BP 166/81 HR 83 O2 sat: 100 2L
GENERAL: Comfortbale and in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. right lower extremity scarring from old
injury
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
Labs on Admission:
[**2135-4-12**] 05:45PM WBC-11.6* RBC-4.29* HGB-12.0* HCT-36.9*
MCV-86 MCH-27.9# MCHC-32.4# RDW-14.0
[**2135-4-12**] 05:45PM NEUTS-82.6* LYMPHS-10.3* MONOS-3.4 EOS-3.6
BASOS-0.2
[**2135-4-12**] 05:45PM GLUCOSE-128* UREA N-13 CREAT-0.7 SODIUM-133
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-16
[**2135-4-12**] 05:45PM CK(CPK)-272
[**2135-4-12**] 05:45PM cTropnT-0.43*
[**2135-4-12**] 05:45PM PT-13.2* INR(PT)-1.2*
Relevant Labs:
[**2135-4-13**] 01:22AM BLOOD CK-MB-178*
[**2135-4-13**] 05:15AM BLOOD CK-MB-208*
[**2135-4-13**] 03:15PM BLOOD CK-MB-134*
[**2135-4-14**] 05:42AM BLOOD CK-MB-43*
Imaging/Reports:
EKG: HR 75, sinus rhythm, normal axis, hyperacute T waves and ST
elevations in the anterior leads.
.
CARDIAC CATH [**2131-9-5**]: 1. Selective coronary angiography in this
left dominant system revealed one vessel coronary artery
disease. The LMCA had minimal luminal irregularities. The LAD
had moderate instent restenosis with a possible mild thrombus.
The LCX had minimal disease and was noted to be a large dominant
vessel with multiple branches and a left LPDA. The RCA was a
small and non-dominant vessel. 2. Resting hemodynamics revealed
normal systemic blood pressure. 3. POBA of mid LAD in stent
restenosis with 2.75mm balloon 4. Groin closure with Angioseal.
FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. POBA
of LAD
CARDIAC MRI [**2130**]: Impression: 1. Normal left ventricular cavity
size with normal regional left ventricular systolic function.
The LVEF was normal at 62%. The effective forward LVEF was
normal at 57%. No CMR evidence of prior myocardial
scarring/infarction. 2. Normal right ventricular cavity size and
systolic function. The RVEF was normal at 55%. 3. Mild mitral
regurgitation. 4. The indexed diameters of the ascending and
descending thoracic aorta were normal and mildly increased,
respectively. The main pulmonary artery diameter index was
normal. 5. Biatrial enlargement. 6. An incidental finding of a
persistent left superior vena cava.
TTE [**2135-4-13**]:
The left atrium and right atrium are normal in cavity size.
There is moderate to severe regional left ventricular systolic
dysfunction with akinesis of the mid to distal anterior septum,
distal inferior and anterior segments and hypokinesis of the
distal anterior wall. The apex is not well seen but is probably
dyskinetic. Doppler parameters are indeterminate for left
ventricular diastolic function. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Moderate to severe regional left ventricular
systolic dysfunction consistent with mid-LAD infarction. No
significant valvular abnormality. Mildly dilated aortic sinus.
Labs on Discharge:
[**2135-4-16**] 06:34AM BLOOD WBC-11.2* RBC-3.69* Hgb-10.4* Hct-32.1*
MCV-87 MCH-28.2 MCHC-32.4 RDW-14.0 Plt Ct-258
[**2135-4-16**] 01:25PM BLOOD PT-18.4* PTT-31.3 INR(PT)-1.7*
[**2135-4-16**] 06:34AM BLOOD Glucose-95 UreaN-20 Creat-0.9 Na-136
K-4.1 Cl-103 HCO3-24 AnGap-13
[**2135-4-16**] 06:34AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 13356**] is a 68 y/o male with a history of CAD s/p 2.5 X 18mm
Cypher DES in the LAD in [**2128**] and POBA to med LAD for restenosis
in [**2130**], HTN, and HLD who presented with sudden onset substernal
chest pain with EKG consistent with STEMI.
.
# STEMI: Patient presented with EKG changes consistent with
STEMI. PCI showed significant LAD disease. Two stents were
deployed successfully. He had a balloon pump placed due to
persistent anterior ST elevations and continued pain. IABP was
removed on day after admission. Patient was started on aspirin
325mg qd and continued on plavix. Integrilin was on for 12
hours. Given some concern for HIT, patient was bridged with
bivalirudin to coumadin for low EF and high risk of thrombus
formation. He became asymptomatic without chest pain and the
Nitro drip was discontinued. Continued home lipitor, held
metoprolol temporarily as patient with bradycardic to the 50s
and new bundle branch block. Re-started metoprolol at 12.5mg
[**Hospital1 **] when he was no longer bradycardic and uptitrated to 25 mg
[**Hospital1 **]. Continued lisonopril at 10 mg daily and started eplerenone
25mg daily. Also started warfarin for prevention LV thrombus
formation. TTE showed moderate to severe regional left
ventricular systolic dysfunction consistent with mid-LAD
infarction. No significant valvular abnormality. Prior to d/c,
patient was fitted with life vest.
.
# Hypertension: Patient's blood pressure was noted to be
significantly elevated after the procedure and when he arrived
to the floor. Patient was having some angina as well. Started
nitro drip with goal SBP <150. This was discontinued as above.
Held home amlodipine. Home lisinopril was continued as above;
transiently held metoprolol as above, then restarted.
.
# Non Sustained Vtach: On [**4-13**], patient had several runs of 7 to
15 beats of NSVT. Patient was asymptomatic. Electrolytes were
repleted to K>4 and Mg >2. Plan was made to start lidocaine
drip if went into sustained vtach or had longer runs of it. he
was discharged with a life vest as above.
.
# Hyperlipidemia: Patient is on crestor and zetia as an
outpatient. Started on atorvastatin.
.
# Urinary retention: Patient has difficulty urinating at
baseline, with a history of prostate cancer and prostatic
radiation. His home Flomax was initially held but he complained
of some difficulty urinating so it was restarted.
TRANSITIONS OF CARE:
- will go home with life vest
- will f/u with EP at [**Hospital1 18**]
- will f/u with outpt cardiologist
- will f/u with PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] [**Name11 (NameIs) 13357**] will trend INRs and adjust dose as
needed (will have INR checked on [**4-18**] and results faxed to PCP)
Medications on Admission:
Plavix 75mg daily
Zetia
Crestor
Lisinopril
Amlodipine
Aspirin 325mg
Atenolol Vitamin D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
4. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Please have your INR managed by your primary care
physician. [**Name10 (NameIs) 2172**] warfarin dose should be managed according to
your INR level. .
Disp:*270 Tablet(s)* Refills:*0*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*0*
7. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime). Capsule, Ext
Release 24 hr(s)
9. Outpatient Lab Work
INR on [**2135-4-18**].
Please Fax to PCP [**Name9 (PRE) 13358**] at FAX number [**Telephone/Fax (1) 13359**]
10. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
anterior STEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 13356**],
It was a pleasure to take care of you.
You were admitted to the [**Hospital1 69**]
for a large heart attack. You were taken care of in the cardiac
intensive care unit.
It is important for you to follow our nutrition, lifestyle and
medication advice that we have provided you, and to maintain
close follow-up with your cardiologist. It is very important for
you to stop smoking, and never smoke again.
You should continue to take your home medications, except for
the following changes:
ADD atorvastatin 80mg every day
ADD warfarin 7.5 mg every day. You need frequent checks of your
INR, which should be faxed to your PCP, [**Name10 (NameIs) 1023**] will then adjust
your warfarin levels.
CHANGE lisinopril to 5mg every day.
STOP Atenolol
STOP amlodipine
START metoprolol succinate 50mg once per day
START eplerenone 25mg once per day
Followup Instructions:
Name: [**Last Name (LF) 2912**], [**First Name7 (NamePattern1) 2174**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] BLDG, [**Apartment Address(1) 8540**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 8543**]
Appt: [**4-21**] at 2:15pm
Name: [**Last Name (LF) 13358**],[**First Name3 (LF) 2747**] A.
Location: [**Hospital1 **] BLDG, [**Apartment Address(1) 8540**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 8543**]
Appt: [**5-5**] at 11am
Department: CARDIAC SERVICES
When: WEDNESDAY [**2135-5-18**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2135-4-17**]
ICD9 Codes: 4271, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5677
} | Medical Text: Admission Date: [**2116-11-17**] Discharge Date: [**2116-11-23**]
Date of Birth: [**2041-7-21**] Sex: M
Service: SURGERY
Allergies:
Flomax / Ace Inhibitors / Ativan
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Diverticulitis
Major Surgical or Invasive Procedure:
s/p Colectomy, colostomy closure, repair of
parastomal hernia
History of Present Illness:
This gentleman had perforated diverticulitis
with sepsis and required a colostomy with a colostomy
revision. He has finally recovered and wishes to have this
repaired. He also has a peristomal hernia which needs to be
repaired at the same time. Workup has shown that the patient
had some residual diverticula and a Hartmann closure which
really incorporates a portion of the lower sigmoid. There are
also a few diverticula seen in the descending colon on
colonoscopy. He presents now for reanastomosis and repair of
his hernia.
Past Medical History:
CAD w/ stent, Diverticulits, Hartmann's, Resp failure, Trach,
Afib, MRSA, DMII
Tracheal stenosis by bronch ([**2116-5-27**]),
Perforated sigmoid colon diverticulitis with peritonitis s/p
colostomty([**2116-3-8**])
Coronary Artery Disease
Paroxysmal atrial fibrillation
Transient Complete Heart Block
Diabetes Mellitus typeII
Peripheral Vascular disease
Hypertension
Hypothyroidism
Gout, DVT ([**3-7**])
Anxiety
Acalculous cholecystitis
MRSA Pneumonia
Social History:
Married lives with wife.
Family History:
non-contributory
Physical Exam:
Vitals T 97.6, P 53, R 16, Sat 98% RA, BP 141/56
Gen NAD
Lungs: CTA
Card: RRR 2/6 SEM
Abd: NT ND ostomy on L
Ext: no edema
Pertinent Results:
[**2116-11-18**] 05:15AM BLOOD WBC-11.7* RBC-4.59* Hgb-12.3* Hct-37.0*
MCV-81* MCH-26.9* MCHC-33.3 RDW-16.4* Plt Ct-227
[**2116-11-20**] 05:45AM BLOOD WBC-13.2* RBC-4.57* Hgb-12.3* Hct-36.9*
MCV-81* MCH-27.0 MCHC-33.4 RDW-16.4* Plt Ct-239
[**2116-11-23**] 06:25AM BLOOD WBC-7.2 RBC-4.01* Hgb-10.7* Hct-33.0*
MCV-82 MCH-26.7* MCHC-32.5 RDW-17.2* Plt Ct-335
[**2116-11-23**] 06:25AM BLOOD PT-13.8* PTT-25.9 INR(PT)-1.2*
[**2116-11-19**] 05:39PM BLOOD CK(CPK)-471*
[**2116-11-20**] 05:45AM BLOOD CK(CPK)-401*
[**2116-11-20**] 05:45AM BLOOD CK-MB-7 cTropnT-<0.01
[**11-22**]: CXR Fluid overload. Pericardial abnormality as previously
described.
[**11-19**]: Although top normal heart size is unchanged, there is new
engorgement of hilar upper lobe pulmonary and mediastinal
vasculature suggesting volume overload, though there is no
pulmonary edema. Small left pleural effusion is new. No
pneumothorax.
Brief Hospital Course:
The patient was admitted for a colectomy, colostomy closure, and
repair of peristomal hernia; for details, please see operative
note.
The patient was extubated, and taken to the PACU for initial
recovery.
Neuro: The patient was initially put on a dilaudid PCA for pain
control; he was transitioned to PO pain medications when
appropriate. On [**11-19**], the patient complained of hallucinations
with Benadryl which resolved.
CV: The patient was stable until [**11-19**], when he developed new
onset rapid response atrial fibrillation. The patient was put
on telemetry, labs were drawn, and the patient received
diltiazem with good initialy response. The patient was ruled
out for a myocardial infarction. The patient's home
cardiologist was consulted regarding this apparently new onse
atrial fibrillation; the patient has a history of paroxysmal
atrial fibrillation, which had been managed with coumadin as the
patient was usually in sinus rhythm. The cardiology recommended
cardioversion to sinus rhythm, and that his coumadin be
restarted.
On [**11-21**], the patient was chemically cardioverted with
amiodarone; he converted back into sinus rhythm, and was able to
be transferred to the floor. On the floor he was noted to be in
and out of atrial fibrillation but his rate was controlled. He
was kept on PO amiodorone on discharge 800 [**Hospital1 **] in consultation
with cardiology here. He had no received the full 10 g load.
He will follow up with his cardiologist within 1-2 weeks for
management of his PAF
Pulm: good pulmonary toilet was encouraged. Pulmonology was
consulted , and recommended chest PT for secretions, as there
were no other active airway issues. Please see results section
for chest x-ray details
GI: The patient was initially made NPO with IVF. His diet was
advanced when appropriate.
GU: The patient's urinary output was routinely followed, and his
IVF were adjusted accordingly. Post operatively, the patient had
a rise in his creatinine level; the team discussed the issue
with Nephrology, who felt that it was likely diabetic
nephropathy. The patient's baseline creatinine was 1.5-2.0 per
the patient's PCP. [**Name10 (NameIs) 39181**] was stopped given the patient's
renal dysfunction.
Endo: The patient was put on a sliding scale of insuling
Heme: The patient's hematocrit was routinely followed.
ID: The patient was cultured, and his fever curves were closely
followed.
Proph: The patient received GI and DVT prophylaxis throughout
his stay.
Medications on Admission:
Coumadin, Allopurinol, Diovan 80', Lopressor 50", Folic acid,
Biotin, Levoxyl 25', Lipitor 20
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks: please follow up with your cardiologist
regarding continuing this medication.
Disp:*56 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Colectomy, colostomy closure, repair of
parastomal hernia
Post operative paroxysmal atrial fibrillation
Chronic renal insufficiency
Discharge Condition:
stable
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* 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.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-3**] weeks; call ([**Telephone/Fax (1) 8818**] to schedule an appointment.
Please follow up with Dr. [**Last Name (STitle) **] in [**12-3**] weeks; call ([**Telephone/Fax (1) 8818**] to schedule an appointment.
Please follow up with your cardiologist about your atrial
fibrillation.
Please have an INR level drawn and faxed to your PCP for
coumadin management
Please follow up with your pulmonologist in [**2-2**] weeks as needed
ICD9 Codes: 5180, 5119, 4019, 2449, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5678
} | Medical Text: Unit No: [**Numeric Identifier 65834**]
Admission Date: [**2129-1-6**]
Discharge Date: [**2129-1-17**]
Date of Birth: [**2129-1-6**]
Sex: F
Service: NB
INTERIM SUMMARY
HISTORY OF PRESENT ILLNESS: [**Known lastname **] is twin No. 2 admitted to
the newborn intensive care unit for prematurity and
respiratory distress. She is the product of a monoamniotic,
monochorionic twin pregnancy to a 33-year-old prima gravida,
now para 2 mother.
PAST MEDICAL HISTORY: Remarkable for mother's diagnosis of
pituitary microadenoma that was treated with bromocriptine for
infertility until [**2128-5-21**] when she found out that she was
pregnant.
Prenatal screens: Blood type B positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune. Group B strep unknown.
Her EDC was [**2129-2-26**], giving an estimated gestational
age at delivery of 32 and 5/7 weeks.
This pregnancy was complicated by twin monochorionic,
monoamniotic gestation. Followed by closely by Dr. [**Last Name (STitle) **] of the
maternal fetal medical program at [**Hospital1 18**].
The mother was treated with betamethasone on [**2128-11-22**].
Delivery was an elective cesarean section on [**1-6**]
because of a high risk of complications and fetal demise
associated with monoamniotic gestation. The delivery was
uncomplicated. This baby had [**Name (NI) **] of 8 and 8 at 1 and 5
minutes. She responded well to treatment with blow-by oxygen
and bulb suction.
PHYSICAL EXAMINATION: Upon admission to the NICU, the baby
was noted to be grunting. She was placed on CPAP without
significant improvement; therefore was intubated and treated
with surfactant with good response.
Weight 1.805 kilograms, 60th percentile; length 46 cm, 75th
percentile; head circumference 30 cm, 50th percentile. HEENT:
Anterior fontanel soft and flat. Sagittal suture split
approximately 2 cm. Posterior fontanel also open. Palate
intact. EYES: Normal red reflex bilaterally. RESPIRATORY:
Breath sounds equal with reduced air movement in bases prior
to intubation. CARDIOVASCULAR: S1 and S2 normal. No murmur.
Well perfused. ABDOMEN: Soft without organomegaly.
GENITOURINARY: Normal female NEUROLOGIC: Alert. Tone appropriate,
symmetrical examination.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname **] was
intubated and received a single dose of surfactant. She
weaned on her settings to extubable settings with a arterial
blood gases: pH 7.26, PCO2 of 51, PAO2 of 50, 24 and minus
4. She self extubated and was placed on CPAP at about 24
hours of age and remained in room air throughout that time.
Mild retractions, breathing 30s to 60s. She was taken off
CPAP on day of life 2 and has remained in room air breathing
comfortably in the 40s to 60s. She has been noted to have 1
to 2 quickly self resolved episodes of apnea since that time.
She has not been treated with xanthines to date.
CARDIOVASCULAR: Hemodynamically from a cardiovascular
standpoint, she received 1 bolus of normal saline for
perfusion upon admission. Her mean blood pressure was 41 at
that time. She has continued to be hemodynamically stable
since then without murmur. APs 130 to 140 and blood pressure
average 68/39 with a mean of 49.
FLUIDS, ELECTROLYTES AND NUTRITION: IV access was by
peripheral IV for fluids and nutrition. She was maintained
NPO until respiratory stability achieved. She was started at
80 ml per kg of D10W. She had normal electrolytes at 24 hours
of age. Maintenance lights were added to her solution. She
was started on enteral feeds after extubation at 20 ml per kg
and has advanced 10 and 15 ml per kilo b.i.d. She tolerated
her enteral advance well and she had full enteral volume by
day of life 5. Since that time she has tolerated increase in
calories and currently is receiving a 150 ml per kg of breast
milk 26 calories made with HMF and MCT or premature Enfamil
24 with MCT oil to 26 calories. She has had normal urine
output and has passed meconium stool.
GASTROINTESTINAL: From a GI standpoint she required
phototherapy starting on day 3 through day of life 5 with a
peak bilirubin of 10.1/0.4 on initiation of therapy. Her
rebound bilirubin was 5.0/ 0.3 on day of life 6.
HEMATOLOGIC/ INFECTIOUS DISEASE: CBC and blood culture were
performed upon admission to the NICU. CBC revealed a white
count of 10.2 with 29 poly's and 0 bands. Hematocrit 50.5%
and platelets 376,000. Blood culture remained negative.
Ampicillin and gentamycin were discontinued after 48 hours in
view of clinical improvement and negative cultures.
NEUROLOGIC: From a neurologic standpoint, the baby has acted
appropriate for her gestational age and she also requires
thermal support and an isolette which she has been weaning
appropriately.
SENSORY: Audiology screening has not yet been performed but
will be performed prior to discharge home.
OPHTHALMOLOGY: The baby is not a candidate for retinal screen
due to gestational age and birth weight.
PSYCHOSOCIAL: [**Hospital1 18**] social work has been involved with this
family. Name after discharge [**First Name8 (NamePattern2) **] [**Last Name (un) 3892**] Krishanan.
NAME OF PRIMARY PEDIATRICIAN - undetermined.
CARE RECOMMENDATIONS:
1. Feedings are 150 ml per kilo breast milk 26 calorie made
with human milk fortifier and MCT by gavage.
2. Medications: None at this time.
3. Car seat position screening should be performed prior to
discharge home.
4. State newborn screens were obtained on [**1-9**], the
results of which are pending at this time.
5. Immunizations received: None to date.
6. Immunizations Recommended:
7. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants born between 32 and 35
weeks with 2 of the following:.
8. daycare during the RSV season.
9. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
10. infants with chronic lung disease.
1. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointments recommended:
With the primary pediatrician after discharge from nursery.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 and 5/7 weeks, twin No. 2.
2. Surfactant deficiency.
3. Rule out sepsis with antibiotics.
4. Physiologic jaundice.
5. Apnea of prematurity.
6. Anemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) 64470**]
MEDQUIST36
D: [**2129-1-16**] 02:23:00
T: [**2129-1-16**] 05:07:35
Job#: [**Job Number 65835**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5679
} | Medical Text: Admission Date: [**2192-9-12**] Discharge Date: [**2192-9-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Diaphoresis, Hypotension, Tachycardia
Major Surgical or Invasive Procedure:
RIJ central line placed on [**2192-9-12**]
History of Present Illness:
88M with h/o HOCM and GI bleed [**2-4**] AVMS who was tramsferred from
[**Hospital3 2558**] with hypotension, tachycardia and diaphoresis
overnight. Pt states that he awoke at 2am drnched in sweat. He
reports nausea, diaphoresis, positional dizziness and heart
palpitations. Earlier in the evening, he had had indigestion
and stomach discomfort for which he had taken Mylanta and Tums
with symptomatic relief. Pt states that he had been free water
restricted for his hyponatremia for the last several days and
had also noted limited appetite.
.
In the ED, vitals 100.4 99/60 102 20 99% on RA. Per ED, BPs
were labile ranging from high 70s to 100s. Patient received a
total of 4 liters fluid resuscitation with some reduction in
heart rate. CXR showed no acute cardiopulmonary process. Urine
and blood cultures were sent. Pt was guaiac negative. Cardiac
enzymes were negative x1. EKG sinus tachycardia, otherwise
unchanged from baseline. Labs were significant for a Na of 129
and INR 2.7. CBC showed elevation of WBC and HCT which are
unchanged from prior admission. Pt has been seen in
consultation by heme-onc at time of last admission who felt that
relative [**Name (NI) 47038**] was due to volume depletion and
over-[**Name (NI) **] during last admission.
Past Medical History:
1)Colon cancer ([**Location (un) **] A) s/p R hemicolectomy in [**2176**]
2)Multiple AVMs with 15 year history of recurrent GIB
3)CAD s/p stent to LAD in [**10-8**]
4)Hypertrophic cardiomyopathy
5)HOCM
6)GERD
7)h/o jejunal lipoma in [**2176**]
8)Hypertension
9)Hyperlipidemia
10) Spinal Stenosis
.
Past Surgical History:
1)s/p cholecystectomy in [**2178**]
2)s/p prostatectomy
3)L inguinal hernia repair [**2179**]
4)s/p hemicolectomy in [**2176**]
Social History:
Lives in [**Location **] with his wife. Originally from [**Country 3399**]. Has 2
sons, one of who lives in same apartment building. Remote
history of minimal social smoking, no alcohol.
Family History:
His father died elderly of lung cancer; his mother had
hypertension, and died at age 67 of a CVA.
Pertinent Results:
On Admission:
[**2192-9-12**] 03:00PM WBC-12.5* RBC-5.18 HGB-16.1 HCT-46.2 MCV-89
MCH-31.1 MCHC-34.8 RDW-16.3*
[**2192-9-12**] 03:00PM NEUTS-83.6* LYMPHS-11.6* MONOS-3.6 EOS-0.8
BASOS-0.4
[**2192-9-12**] 03:00PM PLT COUNT-301
[**2192-9-12**] 03:00PM PT-27.4* PTT-19.4* INR(PT)-2.7*
[**2192-9-12**] 03:00PM GLUCOSE-116* UREA N-24* CREAT-1.0 SODIUM-129*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16
[**2192-9-12**] 04:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2192-9-12**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2192-9-12**] 04:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2 TRANS EPI-<1
[**2192-9-12**] 05:20PM LACTATE-2.1*
[**2192-9-12**] 11:02PM FIBRINOGE-303
[**2192-9-12**] 11:02PM TSH-3.1
[**2192-9-12**] 11:02PM HAPTOGLOB-LESS THAN
[**2192-9-12**] 11:02PM CALCIUM-7.0* PHOSPHATE-2.1* MAGNESIUM-1.4*
[**2192-9-12**] 11:02PM CK-MB-4 cTropnT-<0.01
[**2192-9-12**] 11:02PM LD(LDH)-224 CK(CPK)-31*
[**9-12**] CXR
The lungs are of low volume likely due to poor inspiratory
effort. The
previously seen atelectasis at the left lung base has now
resolved.
Cardiomediastinal contour is unremarkable. There are no focal
consolidations.
[**9-14**]
Na 134
K 4.0
Cl 101
HCO3 26
BUN 17
Cr 0.9
Hgb 13.2
HCT 38.7
WBC 10.6
Plt 234
Brief Hospital Course:
MICU Course: Patient was admitted to the [**Hospital Unit Name 153**] overnight for
hypotension and tachycardia. While in the ICU he received IVFs
with improvement in his blood pressure. His metoprolol was
cautiously restarted given his HOCM with subsequent improvement
in his heart rate and blood pressure. His hydrochlorothiazide
was discontinued. He is transferred to the [**Hospital1 1516**] service for
further management.
Hypotension/Tachycardia: Most likely secondary to dehydration in
setting of free water restriction, especially in the context of
a patient with HOCM who is pre-load depent. On transfer to the
floor, patient was hemodynamically stable.
Hyponatremia: resolved with IV normal saline. Na 134 on
discharge.
.
Tingling - Patient reports that he has been having tingling of
his hands, thigh. face and mouth since his last admission.
Heme-onc attributed this to his relative polycythemia. Ionized
calcium was normal.
.
Medications on Admission:
Sucralfate 1 gram PO QID
Simvastatin 10 mg daily
Tylenol PRN
Maalox PRN
Spironolactone 25 mg daily
Atenolol 50 mg daily
Simethicone 120 mg QID:PRN
Detrol LA 2 mg daily
Clonazepam 0.5 mg PO BID:PRN
Hydrochlorothiazide 12.5 mg daily
Omeprazole 20 mg [**Hospital1 **]
Polyvinyl Alcohol drops
Ferrex 150 Oral
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
4. Simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables
PO QID (4 times a day) as needed.
5. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis: hypotension and tachycardia secondary to
hypovolemia
Secondary diagnosis:
Hyperobstructive cardiomyopathy
Aortic stenosis
Coronary artery disease
Hypertension
Hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with low blood pressure and high heart rate.
You were treated with IV fluids in the intensive care unit.
Your blood pressure and heart rate came back to normal. We
monitored you closely on telemetry.
We stopped your diurectics (HCTZ and aldactone) and have started
you on Lisinopril. Otherwise, continue your medications as you
were taking them.
Please see your primary care doctor or go the emergency room if
you feel light headed, palpitations, chest pain, or short of
breath.
Followup Instructions:
You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] NP on [**10-8**]
2:50pm, on the [**Location (un) **] of [**Hospital Ward Name 23**] building.
You have an appointment with Dr. [**Last Name (STitle) 120**] on [**10-24**] at
noon.
Completed by:[**2192-9-14**]
ICD9 Codes: 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5680
} | Medical Text: Admission Date: [**2134-2-16**] Discharge Date: [**2134-4-1**]
Date of Birth: [**2078-8-9**] Sex: M
Service: MEDICINE
Allergies:
Darvon / Percocet / Codeine / E-Mycin / Percodan / Darvocet-N
100 / Penicillins / Amoxicillin / Ampicillin
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
suprapubic pain, dysuria
Major Surgical or Invasive Procedure:
Right lung biopsy.
Left lung biopsy.
PICC line placement.
Suprapubic catheter change.
T9 CT guided biopsy
History of Present Illness:
Mr. [**Known lastname 96829**] is a 55 yo M w/long history of autonomic dysfunction
complicated by urinary retention and suprapubic catheter
placement who has multiple hospitalizations for recurrent UTI,
most recently 2/[**2133**]. Of note, the pt's last UTI was positive
for ESBL Klebsiella resistant to most abx except for
meropenem/imipenem. Pt lives in a [**Hospital1 1501**] and reports 5 days pta
noted onset of shaking chills, suprapubic pain/cramping, burning
in the penis/urethra, and clouding of his urine. Pt also noted
crusting material surrounding the catheter. He was not noted to
be febrile at his [**Hospital1 1501**]. He denies abdominal pain, back pain,
n/v/d. He does note intermittent chest pain x 1 wk. It is sharp,
left sided and lasts seconds to minutes. It is not exertional,
positional or pleuritic. Pt states it is different from his MI
pain. He denies SOB. He does c/o productive cough over past few
weeks, related to an episode 1 wk prior where he "stopped
breathing, felt like I was choking." Pt unable to give color of
sputum.
<BR>
Pt was taken from [**Hospital1 1501**] to the ED where a UA was positive. Pt was
given one dose of meropenem and admitted to medicine. In the ED,
a WBC was 8.5, lactate 1.2, temp was 99.4
Past Medical History:
- autonomic dysfunction c/b urinary retention requiring
indwelling Foley catheter, with recurrent UTIs
- CAD: s/p MI [**2107**], tx with angioplasty
- diffuse interstitial pneumonitis
- anemia
- autoimmune hepatitis
- autoimmune thyroiditis
- autoimmune peripheral neuropathy
- intradural t10 mass
- s/p cholecystectomy
- chronic pain
- depression
Social History:
Pt lived with wife and 30-year-old daughter prior to prolonged
hospital/[**Hospital1 1501**] stay; disabled, but formerly a truck driver; uses
wheelchair at home w/ bedside commode [**1-8**] autonomic dysfunction;
Previosly smoked 1ppd x 20years, then quit for ~10 yr, restarted
and now quit since [**10-12**]; no alcohol or IVDU.
Family History:
father had MI at 72; Sister had [**Location (un) 96830**] after vaccine
Physical Exam:
GEN: A&Ox3
HEENT: NCAT, PERRL, EOMI, OP clear, no LAD
CV: RRR
PULM: CTAB
ABD: Soft, diffusely ttp w/o rebound or guarding. SP catheter
site with mild erythema, crusting. +tenderness w/manipulation.
EXT: No c/c/e
NEURO: non-focal
Pertinent Results:
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with productive cough, history of ? aspiration
event.
REASON FOR THIS EXAMINATION:
please eval for infiltrate
HISTORY: 55-year-old male with productive cough, questionable
history of aspiration event. Evaluate for infiltrate.
Comparison is made to prior radiographs dated [**2133-10-28**],
[**2133-4-12**], and prior CT dated [**2132-9-26**].
AP AND LATERAL CHEST RADIOGRAPHS:
Since most recent film there appears to be interval appearance
to multiple ill-defined pulmonary nodules projecting over the
right and left lower hemithoraces with the largest ill-defined
opacity within the left mid hemithoraces measuring approximately
3.6 x 3.9 cm. Changes from previously noted interstitial lung
disease appear slightly improved on current radiograph. Multiple
calcified granulomas and calcified pleural plaques are better
appreciated on prior CT examination. No evidence of pulmonary
edema or pneumothorax. Cardiomediastinal silhouette and hilar
contours are stable. Tip of left-sided PICC catheter is
unchanged in appearance within the brachiocephalic confluence.
IMPRESSION:
Multiple new ill-defined pulmonary nodules with most dominant
nodule projecting over the mid thorax. Appearance of these
nodules is suspicious for neoplastic or metastatic involvement
with focal infectious or fungal etiologies felt to be less
likely. Recommend further evaluation with CT of the chest.
CT CHEST W/O CONTRAST [**2134-2-17**] 10:53 AM
CT CHEST W/O CONTRAST
Reason: please eval for masses
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with nodules seen on CXR, concerning for mets
REASON FOR THIS EXAMINATION:
please eval for masses
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Evaluate nodules seen on CXR. CareWeb notes reveal
the patient has a history of autoimmune hepatitis, thyroiditis,
peripheral neuropathy, and autonomic dysfunction.
TECHNIQUE: Multidetector helical scanning of the chest was
performed without IV contrast. Contiguous 5- and 1.25-mm thick
axial and 5-mm thick coronal images were presented for
interpretation.
COMPARISON: Chest x-ray [**2134-2-16**] and CTA chest [**2132-9-26**].
NON-CONTRAST CT OF THE CHEST: A new 1.6-cm nodule with somewhat
irregular borders is seen in the right upper lobe. Also, a
4.1-cm rounded solid appearing mass (soft tissue density), also
with irregular contours is seen in the left lower lobe. There
are no air bronchograms in this lesion. No other concerning
nodules or masses are seen.
There has been progression of the patient's interstitial lung
disease with interlobular septal thickening and traction
bronchiectasis, predominantly at the lung bases. Previously seen
diffuse ground- glass opacities have resolved.
Multiple tiny calcified granulomas are again noted reflecting
prior granulomatous disease. The bronchi are patent to the
subsegmental level. Coronary calcifications are noted.
Otherwise, the heart, pericardium, and great vessels are
unremarkable. No pathologically enlarged axillary, hilar, or
mediastinal lymph nodes. Left PICC terminates in the left
brachiocephalic vein.
This exam is not optimized for subdiaphragmatic evaluation. The
hypoattenuating lesion in the left lobe of the liver as well as
bilateral renal cysts are unchanged.
Bone windows reveal a 7-mm sclerotic lesion in the medial
clavicle, unchanged from [**2131**], and likely a bone island. No
other suspicious lytic or sclerotic lesions.
IMPRESSION:
1. 4.4-cm solid left lower lobe mass and 1.5-cm right upper lobe
nodule are new compared to CT from [**2132-9-6**]. The
differential diagnosis for these lesions is very broad and
includes infections (fungal infection or Nocardia), inflammatory
conditions (cryptogenic organizing pneumonia), vasculitis
(particularly as this patient has a history of autoimmune
disorders), and neoplasm (synchronous primary carcinoma,
metastasis, or pulmonary lymphoma). If the patient does not have
a clinical findings of infection, a PET/CT may be helpful.
2. Mild progression of fibrotic component of chronic
interstitial lung disease.
PATIENT/TEST INFORMATION:
Indication: Endocarditis.
Height: (in) 66
Weight (lb): 142
BSA (m2): 1.73 m2
BP (mm Hg): 80/42
HR (bpm): 53
Status: Inpatient
Date/Time: [**2134-2-18**] at 10:00
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W013-1:42
Test Location: West Echo Lab
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aorta - Arch: 2.9 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.17
Mitral Valve - E Wave Deceleration Time: 224 msec
TR Gradient (+ RA = PASP): 23 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2132-11-19**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Normal regional LV systolic function. No resting
LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or
vegetations on aortic valve. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
mass or
vegetation on mitral valve. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or
vegetation on tricuspid valve. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. No vegetation/mass on pulmonic valve.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Compared with the prior study (images reviewed) of [**2132-11-19**],
the findings are generally similar. The ASD is not visualized on
the current study.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2134-2-22**] 12:38 PM
CTA CHEST W&W/O C&RECONS, NON-
Reason: please eval for PE, and please eval for evolving LLL
mass.
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with nodules seen on CXR, concerning for mets,
mass evolving over weekend, ? now close enough to bronch? Also,
new O2 requirement over weekend, pulmonology concerned re: PE.
REASON FOR THIS EXAMINATION:
please eval for PE, and please eval for evolving LLL mass.
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: 55-year-old male with lung masses. New O2
requirement over weekend. Evaluate for pulmonary embolus.
COMPARISON: [**2134-2-17**].
TECHNIQUE: Non-contrast and contrast-enhanced multidetector CT
acquired axial images of the chest. Multiplanar reformatted
images were obtained.
CT OF THE CHEST: The previously identified nodule within the
right upper lobe and mass within the left lower lobe is
unchanged compared to recent CT from [**2134-2-17**]. There are
again interstitial abnormalities as evidenced by interlobular
septal thickening and traction bronchiectasis, predominantly at
the lung bases, the extent of which is not changed from [**2-17**], [**2133**]. Multiple tiny calcified granulomas are again noted
reflecting prior granulomatous disease. The airways are patent
to the subsegmental level. Coronary calcifications are noted
within the LAD. Otherwise the heart and great vessels are
unremarkable. There is no pericardial or pleural effusion. There
is mild pleural thickening with calcified pleural plaques. No
pulmonary embolus or thoracic aortic dissection is appreciated.
The previously seen left PIC line has been removed. Small
mediastinal lymph nodes are seen which do not meet CT criteria
for pathologic enlargement.
Osseous structures demonstrate no suspicious lytic or sclerotic
lesions. A bone island is seen within the right clavicle,
slightly increased in size from [**2127-10-6**], however,
unchanged from [**2132-9-26**].
The visualized upper abdomen demonstrates hypodensities within
the liver. The smaller hypodenisity in the left lobe of the
liver (series 3,image 86) is not worrisome, however, the subtle
hypoenhancing lesion in the right lobe of the liver, better seen
on prior CT from [**2134-2-17**] is concerning and should be
further evaluated with ultrasound.
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Compared to the prior CT from five days ago, there is no
significant change in chronic interstitial lung disease or
pulmonary mass/nodule. Again, the diagnostic consideration for
the mass/nodule are very broad and includes infections,
inflammatory and neoplasm. These lesions are ammenable to biopsy
if clinically warrented.
3. Subtle hypoenhancing lesion in the right lobe of the liver,
better seen on preious CT from [**2134-2-17**] and recommend
ultrasound for better characterization.
FNA, lung, left lower lobe mass, cell block:
H&E stain shows alveolar spaces lined by atypical mucinous
epithelium with intra-alveolar and background mucin, suspicious
for a well-differentiated adenocarcinoma, bronchioloalveolar
type.
See also cytology report C07-10734L.
Note: Slides reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**], with concurrence.
RUL biopsy: Suspicious for well-differentiated adenocarcinoma
with features suggestive of bronchioalveolar type.
T9 bx: Poorly-differentiated metastatic carcinoma
Brief Hospital Course:
Unfortunately the patient did not survive this hospitalization.
After an EGD that revealed food in the esophagus the patient
likely aspirated which precipitated a PEA arrest. A code blue
was called and per the wishes of the family the patient was
aggressively resuscitated for 1.5 hours. Despite the teams best
efforts the patient suffered irrepairable anoxic brain injury as
revealed by an extremely limited physical exam and the findings
on EEG. Per the family's wishes the patient was aggressively
treated for approximately one week without improvement in his
neurological status. Ultimately it became clear that the
patient was entirely dependent on the ventilator. The family
then decided to withdraw the ventilator which resulted in the
rapid passing of the patient.
Other issues addressed during this hospitalization were
recurrent UTI, autonomic neuropathy, initial diagnosis of
non-small cell lung cancer, anti-phospholipid syndrome, and
bactermia.
Medications on Admission:
--levothyroxine 50 mcg po daily
--midodrine 20 mg po at 6 am, 20 mg at noon, 10 mg at 2 pm, 10
mg at 5pm
--trazodone 150 mg po HS
--requip 0.5 mg po HS
--demerol 50 mg po PRN pain
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Lung Cancer
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2134-4-4**]
ICD9 Codes: 4275, 5990, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5681
} | Medical Text: Admission Date: [**2152-7-4**] Discharge Date: [**2152-7-8**]
Date of Birth: [**2091-7-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Tracheal Intubation
CVL placement
Arterial Line placement
History of Present Illness:
Patient is a 60 year old female with a history of HepC
cirrhosis, active HepC infection on ribaviron and interferon,
complicated by pancytopenia, has been on neupogen and promacta,
initially presented to the ED earlier today from the infusion
clinic for a scheduled transfusion with SOB.
On arrival to her infusion clinic appointment, she was notably
sob after walking from the parking garage to the
Infusion/pheresis unit. Her Resp rate was 30 with an o2 sat of
97% on room air. Her bp was 78/38 on the right arm and 82/50
on the left. She apparently attributes this to taking her
lisinopril for the last 2 to 3 days, even though she was
explicitly instructed not to by her NP, [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 805**], last
week as her blood pressures were low. She also reports the
development of pleuritic chest discomfort 4 days ago described
as sharp and made worse upon deep inspiration. A CXR was
ordered in clinic and showed new bilateral pleural effusions
L>R. She was sent over to the ED 98.2 80 26 o2 sat 97% bp
115/70.
On arrival to the ED, initial vitals were 98.2 93 103/57 18 99%
2L. Initial vitals were notable for a Cr 2.8 up from baseline
.7, INR 2.0. An ultrasound showed a moderately sized
pericardial effusion. Cardiology was consulted, did a bedside
echo, showed no tampnnade phsyiology, a circumferential
effusion, and a pulsus of 8. Trop .05. With the pleuritic
chest pain, a D Dimer was checked which was > 6,000. She also
endorsed increased abdominal distension; a bedside ultrasound
showed no fluid to tap. While in the ED, her pressures started
to decrease to the 80s systolic. She received 2 L IVFs,
vancomycin and zosyn, and admitted to the MICU for hypotension.
On arrival to the MICU, patient is alert and comfortable with
SBPs in the 90s. She does state that for the past 4 days, she
has also had diarrhea and has not been able to take POs. She
also states she has taken advil sporadically over the last few
days to help her chest pain.
Past Medical History:
HepC Cirrhosis
Pancytopenia on neupogen
Hypertension
GERD
Depression
Asthma
Bilateral leg swelling
Social History:
Patient denies current smoking or alcohol.
Family History:
NC
Physical Exam:
Discharge physical exam: Expired
Pertinent Results:
ADMISSION LABS:
[**2152-7-4**] 03:28PM BLOOD WBC-9.4# RBC-2.69* Hgb-8.4* Hct-28.0*
MCV-104* MCH-31.3 MCHC-30.0* RDW-20.3* Plt Ct-84*#
[**2152-7-4**] 03:28PM BLOOD Neuts-85.2* Lymphs-10.5* Monos-3.2
Eos-0.9 Baso-0.2
[**2152-7-4**] 03:20PM BLOOD PT-21.3* PTT-33.5 INR(PT)-2.0*
[**2152-7-4**] 01:45PM BLOOD Glucose-85 UreaN-40* Creat-2.8*# Na-134
K-4.4 Cl-105 HCO3-19* AnGap-14
[**2152-7-4**] 01:45PM BLOOD ALT-27 AST-59* AlkPhos-164* TotBili-1.9*
[**2152-7-5**] 12:17AM BLOOD Calcium-7.1* Phos-4.2 Mg-1.9
[**2152-7-5**] 11:01AM BLOOD Type-ART Temp-36.9 pO2-93 pCO2-33*
pH-7.31* calTCO2-17* Base XS--8 Intubat-INTUBATED
CXR:
1. Bilateral pleural effusions, left greater than right.
2. Moderate-to-severe cardiomegaly.
3. Peripheral parenchymal or pleural opacities bilaterally.
4. These findings appear to be new at least since [**2150-9-18**] when the lung bases were visualized on the CT. Further
evaluation with chest CT is recommended.
5. Bilateral widening of the glenohumeral joint spaces may be
indicative of rotator cuff laxity. Correlation with history and
physical examination is recommended.
ABDOMINAL ULTRASOUND:
1. Coarsened echogenic liver compatible with cirrhosis.
2. At least two and possibly three echogenic liver lesions are
new since
[**2152-4-27**]. These are concerning in a patient with
cirrhosis. Further assessment with multi-phasic CT or MRI is
necessary once the patient's renal function improves.
3. Small pockets of right upper and lower quadrant ascites.
4. Portal and hepatic veins are patent.
TTE:
There is a small to moderate sized circumferential pericardial
effusion primarily lateral, inferolateral and inferior to the
left ventricle and anterior to the right atrium, with relatively
little effusion anterior to the right ventricle. There are no
echocardiographic signs of tamponade.
TTE:
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened with probably mild mitral regurgitation (in limited
views). The tricuspid valve leaflets are mildly thickened. There
is borderline pulmonary artery systolic hypertension. There is a
small to moderate sized pericardial effusion (upto 1.4 cm
diastolic width lateral to left ventricle, smaller elsewhere).
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
TTE:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF 65%). Right ventricular
chamber size and free wall motion are normal. There is severe
mitral annular calcification. There is borderline pulmonary
artery systolic hypertension. There is a small to moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2152-7-5**], the size of the effusion is similar. The heart
rate is reduced.
Right Upper Quadrant Ultrasound:
FINDINGS: The liver is again noted to be coarsened and nodular
throughout consistent with the patient's known cirrhosis. Two
small slightly hyperechoic lesions are again seen in the left
lobe of the liver essentially unchanged from the prior
ultrasound. These lesions measure 1.1 to 1.2 cm in diameter
each. No cystic component is identified in either of these
lesions. Additionally, a tiny hypoechoic lesion is also seen in
segment VI of the liver measuring 1.0 cm. There is no cystic
component identified within this lesion. A small amount of
ascites is seen again in the right upper quadrant. The portal
vein is patent with hepatopetal flow. The gallbladder is normal
on limited views. There is an enlarged periportal lymph node
measuring 3.5 x 1.4 cm. No hydronephrosis is seen on limited
views of the right kidney. No biliary dilatation is seen and
the common duct measures 0.7 cm.
IMPRESSION: Nodular coarsened hepatic architecture consistent
with the patient's known cirrhosis. Three small solid liver
lesions are identified. Additional characterization of these
lesions with CT or MRI is suggested when feasible. There is no
evidence of an abscess. Small amount of ascites again seen in
the right upper quadrant.
Brief Hospital Course:
60 year old female with hepatitis C cirrhosis, treatment
complicated by neutropenia on Neupogen presenting with SOB,
pleuritic chest pain, and hypotension, managed for shock and
ARDS, subsequently intubated, who was later transitioned to
comfort measures only by her family given her worsening clinical
picture and expired during this hospitalization on [**Last Name (LF) 2974**], [**7-7**], [**2152**] at 22:08.
# Hypotension/Shock: Patients SBPs in the 80s/90s on
presentation. She received 2 L IVFs as well as one unit of
blood for a Hct 24, however reamined hypotensive. She was
covered emperically for infectious etiologies with Vanc/Zosyn,
then changed to Vanc/cefepime. Given pericardial effusion,
there was initial concern for impending tamponade, however, TTE
showed no tamponade physiology and pulsus was 8. She was
subsequently intuabted for respiratory failure, a CVL was
placed, and she was started on levophed, vasopressin, and
neosynephrine. It was also hypothesized that she may be in
decompensated cirrhosis causing her low blood pressures. An AM
cortisol was within normal limits. The patient was continued on
3 pressors, when the decision was made to transition to comfort
measures only, pressors were discontinued upon extubation.
# Respiratory failure: Patient initilly hypoxic, satting in the
low to mid 90s on 2L on admission. She had bilateral pleural
effusions on chest XRay. The morning after admission, her O2
sats were in the 90s, RR in the 40s-50s. She was subsequently
intuabted. CXR was consistent with ARDS versus TRALI versus
pulmoanry edema. She required high FiO2 and PEEP, and because
she was overbreathing on the vent, she was paralyzed and an
esophageal balloon was placed. Patient desaturated on the
ventilator to 60-70 percent. Her PEEP was increased, and her
oxygen saturation initially improved. With on-going discussion
with the family, the decision was made to transition to comfort
measures only. With this decision, paralytics were discontinued.
As paralytics were weaned, the patient was extubated, and she
died shortly there after.
# Anuric renal failure: Patient's Cr 2.8 up from a baseline .7
on admission. She was anuric. Possible etiologies included
taking lisinopril in the setting of NSAIDs and poor PO intake,
hepatorenal syndrome, ATN secondary to shock. She was started
on CVVH on HD number 2. The patient remained on CVVH until the
patient was transitioned to comfort measures only.
# Hep C Cirrhosis: On ribavirin and interferon, followed by Dr.
[**Last Name (STitle) **]. Abdominal ultrasound showed minimal ascites, 3 new
liver lesions were noted on RUQ ultrasound. Radiology felt that
these lesions likely represented hematomas as opposed to septic
emobli or abscess.
# Depression: Held sertraline.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 puffs po qid prn
ELTROMBOPAG [PROMACTA] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
EPOETIN ALFA [PROCRIT] - 40,000 unit/mL Solution - Inject 40,000
units SQ once weekly
FILGRASTIM [NEUPOGEN] - 300 mcg/0.5 mL Syringe - Inject
300mcg/0.5mL SQ once weekly
FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) -
220
mcg Aerosol - 1 puff po twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet -
one
Tablet(s) by mouth daily
PEGINTERFERON ALFA-2A [PEGASYS CONVENIENCE PACK] - (Prescribed
by Other Provider; recording only) - 180 mcg/0.5 mL Kit - Inject
180mcg/0.5mL SQ once weekly 90 mcg weekly
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq
Tablet, ER Particles/Crystals - 1 Tab(s) by mouth daily
RANITIDINE HCL - (Prescribed by Other Provider) - 300 mg
Capsule
- one Capsule(s) by mouth night
RIBAVIRIN - (Prescribed by Other Provider; recording only) -
200
mg Capsule - 6 Capsule(s) by mouth 3 capsules QAM and 3 capsules
QPM
SERTRALINE - (Prescribed by Other Provider) - 100 mg Tablet -
Tablet(s) by mouth
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply to affected
area
twice a day
Medications - OTC
BIOTIN-CALCIUM CARBONATE [BIOTIN 100+10] - (Prescribed by Other
Provider) - Dosage uncertain
CALCIUM CARBONATE [CALCIUM 600] - (Prescribed by Other
Provider)
- 600 mg (1,500 mg) Tablet - 1 Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (Prescribed
by Other Provider) - 600 mg calcium-200 unit Capsule - 1
Capsule(s) by mouth daily
GLUCOSAMINE-CHONDROITIN - (Prescribed by Other Provider) -
Dosage uncertain
MULTIVITAMIN - (OTC) - Capsule - one Capsule(s) by mouth
daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5119, 0389, 5845, 5715, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5682
} | Medical Text: Admission Date: [**2157-5-30**] Discharge Date: [**2157-5-31**]
Date of Birth: [**2117-6-6**] Sex: M
Service:
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male with a history of cirrhosis and portal hypotension
secondary to alcohol use who was admitted to the Medical
Intensive Care Unit status post TIPS procedure. The patient
has had ascites for approximately one year and has had
Clostridium difficile in the past with accompanying
hepatic-renal syndrome. The patient had come in to the
hospital for an outpatient TIPS procedure the morning of
admission. His arterial blood gases prior to the procedure
revealed an acidosis with pH of 7.28, pCO2 of 27, and pO2 of
102 to 120% O2. The patient received Versed and
succinylcholine for anesthesia. He also was given fresh
frozen plasma for his INR of 1.6 for paracentesis, liver
biopsy and TIPS placement. He had no obvious bleeding during
this procedure and two liters of fluid were removed.
The patient became hypotensive approximately one hour later.
Intravenous fluids were given aggressively and phenylephrine
was begun. The patient also continued to trail downward on
this level of phenylephrine, therefore epinephrine was added.
Hydrocort was given and the patient was sent up to the
Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Cirrhosis.
2. Portal hypertension.
3. Alcoholism.
4. Chronic ascites.
5. Hepatorenal syndrome with a baseline creatinine of 2.0.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. q. day.
2. Lasix 20 mg p.o. q. day.
3. Ciprofloxacin 750 mg p.o. q. Wednesday.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient continues to drink. He is
married and lives with his wife. [**Name (NI) **] smokes half a pack per
day.
PHYSICAL EXAMINATION: Vital signs are 115; 105/70; 98% and
14. General appearance: Intubated flushed male in no
apparent distress. HEENT: Pupils are equal, round and
reactive to light and accommodation, intubated. Neck:
Bilateral internal jugular lines in place; no bleeding.
Cardiac: Tachycardic, no murmurs, rubs or gallops;
hyperdynamic. Pulmonary: Bilaterally clear to auscultation
anteriorly. Abdomen: Positive bowel sounds, mildly
distended. Liver edge palpable below the inferior margin.
Extremities with no cyanosis, clubbing or edema. Weak
pulses, warm.
LABORATORY: White blood cell count 23.9, hematocrit 31.6,
platelets 355, coags 15.9, 52.3 and 1.7. Electrolytes are
135, 3.9, and 109, 12, 37, 1.6, 7.1, 7.8 and 1.1. Albumin
was 2.7. Alkaline phosphatase 208. ALT 23, AST 26. Total
bilirubin 1.5. Ethanol was negative. Lactic acid was 1.5
and an arterial blood gas revealed 7.32, 26 and 90.
HOSPITAL COURSE: Given the above, the patient was brought
to the Medical Intensive Care Unit. In terms of his
hypotension this was thought to be secondary to fluid shift
secondary to his paracentesis. Other etiologies considered
were transfusion reaction from the fresh frozen plasma given,
possible hypotension as a result of the benzodiazepines and
succinylcholine that he had received, or possible sepsis
versus a bleed from the procedure.
Therefore, the patient was initially continued on epinephrine
and phenylephrine, however, these were weaned within one to
two hours. The patient had been given Hydrocort,
epinephrine, therefore he was monitored for further signs of
a transfusion reaction. Enough time had passed for other
drugs such as benzodiazepine and succinylcholine to wear off.
He was cultured for possible sepsis with blood cultures
which were negative and urinalysis and urine culture which
were negative, and a chest x-ray which showed no signs of
infection.
Paracentesis fluid had already been discarded, therefore,
this could not be cultured. The patient had serial
hematocrits to rule out bleeding and a right upper quadrant
ultrasound to assess flow through the TIPS and to insure that
there had been no bleeding around the site of the TIPS. This
was all intact.
In terms of his pulmonary status, the patient was intubated
when he first came to the floor, however, he was extubated
within one to two hours as well and his repeat arterial blood
gas showed a similar acidosis. This was thought to be
secondary to his hepatorenal syndrome or possibly secondary
to alcohol, however, his alcohol level was negative while in
the hospital. He was also taking Lactulose immediately
afterwards and it was thought that the patient may have an
acidosis secondary to chronic diarrhea.
Otherwise, the patient was continued on Protonix,
pneumoboots. He was on a CIWA scale so that he would not go
into withdrawal and he had good intravenous access while in
the hospital.
The patient also had a chest x-ray done which revealed
congestive heart failure most likely secondary to the
aggressive intravenous hydration that he received after his
episode of hypotension. A repeat chest x-ray was performed
the next day which showed improvement in the congestive heart
failure. The patient was kept on a fluid restriction and a
low salt diet at this point.
As per the patient's request and once he was medically
stable, he was discharged from the Intensive Care Unit with
instructions to follow-up with Dr. [**Last Name (STitle) 497**].
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Name8 (MD) 234**]
MEDQUIST36
D: [**2157-6-4**] 20:25
T: [**2157-6-4**] 21:22
JOB#: [**Job Number 49956**]
ICD9 Codes: 2762, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5683
} | Medical Text: Admission Date: [**2183-8-22**] Discharge Date: [**2183-9-25**]
Date of Birth: [**2183-8-22**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **] is a former 30-4/7-weeks
gestational age twin 1, who is currently 34-days old with
corrective gestational age 35-3/7 weeks. Infant was born at
30-4/7 weeks of gestation with a birth weight of 1,650 grams
to a 35-year-old G2, P0 now 2 mother.
PRENATAL SCREENS: Blood group A-negative, antibody negative,
RPR nonreactive, rubella immune, HBS antigen negative, and
GBS unknown.
The pregnancy notable for concern in twin 2 including growth
restriction, oligohydramnios, and congenital heart disease.
Amniocentesis for both twins was normal with results of 46
XX. Betamethasone was completed on [**2183-8-5**].
On day of delivery, mother presented with spontaneous rupture
of membranes and in labor. Infant was delivered by cesarean
section. Apgars were 5 and 8.
PHYSICAL EXAM ON ADMISSION: Weight 1,650 grams (75
percentile), length 42 cm (75 percentile), head circumference
29.5 cm (75th percentile). Active infant, pink with
supplemental oxygen, and moderate respiratory distress.
Anterior fontanel is soft and flat. Red reflexes: Symmetrical
bilaterally. Normal set of ears. Intact palate. Neck: Supple
with intact clavicles. Lungs: Clear to auscultation with fair
aeration. Cardiovascular: Regular rate and rhythm, no murmur.
Femoral pulses 2+. Abdomen is soft with good bowel sounds.
GU: Normal preterm female. Patent anus. No sacral anomalies.
Hips: Stable. Extremities: Pink and well perfused. Normal
tone and activity.
HOSPITAL COURSE BY SYSTEMS: Respiratory. Infant was
intubated shortly after admission. Surfactant was given x2.
She was extubated to nasal CPAP on day of life 2. She weaned
to nasal cannula oxygen by day of life 14 and was on room air
since day of life 23 which is [**9-14**]. She was treated
for apnea of prematurity with caffeine. Caffeine was
discontinued on [**9-15**], day of life 24. She remained
spell free since [**2183-9-17**].
Cardiovascularly. Cardiac murmur was noticed on day of life
4. Echocardiogram was done and demonstrated large patent
ductus arteriosus. She was treated with indomethacin and a
repeat echocardiogram was done on [**8-28**], which
demonstrated small patent ductus arteriosus measuring 1-1.5
mm with continuous left-to-right flow. Since her PDA was
small and clinically insignificant as she was clinically
followed from that point, she remained with intermittent soft
systolic murmur. Initial echocardiogram also demonstrated a
possibility of small muscular VSD. Since she had otherwise
structurally normal heart, we will recommend clinical
followup. At the moment of discharge, Baby Girl [**Name (NI) **]
cardiovascularly stable with intermittent soft systolic
murmur.
FEN/GI. On admission, infant was started on IV fluids and
parenteral nutrition. She remained NPO for the 1st 3 days of
life. Feeds were introduced on day of life 3, and she slowly
advanced to full feeds by day of life 14. During the time of
feed advancement and NPO, she remained on parenteral
nutrition. Umbilical venous catheters was placed on admission
and removed on day of life 8. Throughout hospital stay, she
was treated for hyperbilirubinemia. Her bilirubin peaked up
at day of life 2 at 6.1. Phototherapy was discontinued on day
of life 5, and her follow-up bilirubin was 4.5.
At the moment of discharge, she is p.o. ad-lib Similac 24,
breast milk 24 supplemented with Similac powder. Her weight
at discharge is 2,510 grams.
Hematology. Initial CBC with hematocrit of 57.7. No blood
transfusions were given through her hospital course. She was
treated with iron and vitamin E during her initial course and
then vitamin E was substituted for multivitamins.
Infectious disease. On admission, CBC and blood cultures were
sent. CBC was with 8.5 thousand white blood cells, 21 polys,
0 bands, 65 lymphocytes. Ampicillin and gentamicin were
started while blood cultures were pending. Blood cultures
remained negative, and antibiotics were discontinued. She
remained clinically stable throughout her hospital stay. Her
surface cultures were positive for MRSA, and she was placed
on precautions on day of life 23. She remained on contact
precautions through the rest of her hospital stay.
Neurology. Head ultrasound was done on day of life 7 and was
within normal limits. Repeat head ultrasound was done on
[**9-24**] and was within normal limits. Two mm right
germinal matrix cyst was noted as an accidental finding and
is likely of clinical significance.
Audiology. Newborn hearing screen passed in both ears prior
to discharge.
Ophthalmology. She was followed for retinopathy of
prematurity. Her last exam was done on [**9-10**] and
demonstrated immature zone III retina bilaterally. She will
need a followup with ophthalmology. Her parents I expect to
call next week after discharge and see Dr. [**Last Name (STitle) **].
Social. Baby's twin was transferred to CH for further treatment
of congenital heart disease and unfortumately died from
complications of sepsis.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 24592**] [**Last Name (NamePattern1) 1349**], phone #1-
[**Telephone/Fax (1) 63954**].
CARE AND RECOMMENDATIONS:
FEEDS AT DISCHARGE: Breast milk/Similac 24 calories p.o. ad-
lib.
MEDICATIONS: Ferrous sulfate 25 mg per 1 cc. Please give 0.3
cc p.o. PG every 24 hours. Infant multivitamins 1 cc p.o.,
please give every 24 hours.
CAR SEAT: Passed prior to discharge.
STATE NEWBORN SCREEN: Initial newborn screen on admission
was remarkable for some immuno acids abnormality. Repeat
newborn screen was done on [**2183-8-31**] and was within
normal limits.
IMMUNIZATIONS: Hepatitis B vaccine was given on [**9-24**].
IMMUNIZATION RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1) born at less than 32
weeks; 2) born between 32-35 weeks with 2 of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-age
siblings. 3) With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED/RECOMMENDED: Dr. [**Last Name (STitle) 1349**] on
[**2183-9-26**], with Dr. [**Last Name (STitle) **] in ophthalmology a week
after discharge to be scheduled by parents.
DISCHARGE DIAGNOSES:
1. Prematurity, resolved.
2. Sepsis rule out, resolved.
3. Respiratory distress syndrome, resolved.
4. Patent ductus arteriosus, resolved.
5. Hyperbilirubinemia, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Name8 (MD) 69721**]
MEDQUIST36
D: [**2183-9-25**] 13:12:03
T: [**2183-9-25**] 13:51:51
Job#: [**Job Number 69722**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5684
} | Medical Text: Admission Date: [**2173-5-21**] Discharge Date: [**2173-5-28**]
Date of Birth: [**2096-11-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dizziness, nausea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The pt is a 76 year-old female with no significant past medical
history who presented with a several day history of generalized
weakness and lethargy. She was also noted to have three day
history of nausea, decreaseed appetite, crampy abdominal pain.
No fevers, chest pain or SOB. There were no other complaints on
review of systems.
In ED, T 98.9, HR 116, BP 116/69, RR 18, 98% RA. Found to have
elevated blood glucose to 600's with an anion gap of 34. She was
given 10 units of IV insulin, then started on insulin gtt at 5
units/hr. Titrated up to 9 units/hr. She also received 5 L NS,
then switched to 1/2 NS. In addition, she received on dose each
of levofloxacin and flagyl in ED. Transferred to MICU for
continued monitoring.
Past Medical History:
-s/p appendectomy
-s/p hysterectomy
Social History:
[**Doctor First Name **] scientist, lives in [**Name (NI) 86**], sister lives upstairs from
her.
Family History:
No history of diabetes mellitus.
Physical Exam:
vitals- T 97.8 BP 124/71, HR 140's , O2 Sat 99% 2L NC
gen- lethargic but arousable to voice, responds weakly to
questions
heent- EOMI. mucous membranes dry. no scleral icterus.
pulm- lungs CTA b/l. no r/r/w
cv- tachycardic, regular. no murmurs
abd- soft, mild mid-epigastric tenderness to palpation. no
rebound, guarding. old well-healed surgical scar
ext- no edema. no ulcerations or rash.
neuro- follows commands. A&O x person, place "hospital".
globally weak [**4-6**] b/l U/LE's. reflexes normal b/l.
Pertinent Results:
WBC 11.0 (90% N, 0 bands), Hct 48.6, PLT 177, MCV 90
Na 157 (corrected Na=166) K 5.8 CL 106 CO2 17 BUN 92 Cr 2.6 Glu
689; AG= 34
Ca 11.2 Mag 3.1 Phos 8.0
ABG=7.30/36/49
INR 1.1, PTT 21.2
U/A 1000 glucose, ket 15, leuk neg, nitr neg
Urine osm- pending , Effective sOSM=395
Cardiac Enzymes: Trop 0.01, MB 2
HIT antibody negative
PA AND LATERAL VIEWS OF THE CHEST: Cardiac silhouette,
mediastinal, and hilar contours are normal. The pulmonary
vasculature is normal. Both lungs are clear without infiltrates,
effusions, or consolidations. The surrounding soft tissue and
osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is minimal
bibasilar dependent atelectasis with some linear atelectasis in
the left lower lobe. A feeding tube terminates within the
stomach. On this unenhanced scan, the liver, spleen, adrenal
glands, pancreas, and gallbladder are normal. The right kidney
is normal. There is a tiny 2-3 mm left renal stone. There is
prominence of the left renal pelvis, which could represent an
extrarenal pelvis or a peripelvic cyst. The ureters are normal.
There is calcification of the descending aorta, which is normal
in caliber. No identified pathologically enlarged lymph nodes.
No free air or free fluid in the abdomen. The large and small
bowel are unremarkable.
CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is within
the bladder. The rectum and sigmoid colon appear normal. The
uterus and ovaries are not clearly identified. The appendix is
normal. There are no pathologically enlarged inguinal lymph
nodes. No free fluid in the pelvis.
BONE WINDOWS: No suspicious osteolytic or sclerotic lesions.
IMPRESSION:
1) No evidence of abscess or colitis or other significant
pathology on this unenhanced scan.
2) Small nonobstructing left renal stone.
Brief Hospital Course:
1. Diabetic Ketoacidosis, Type 1 Diabetes Mellitus: There was
no clear precipitating event leading to DKA in this pt. without
previous history of diabetes. Cardiac enzymes were cycled and
EKG were not suggestive of MI. There was no evidence to support
an infectious process. The pt. was admitted to the MICU and
placed on an insulin drip. Her anion gap closed within the
first 24 hours of hospitalization. The [**Last Name (un) **] diabetes service
consulted on the pt. She was on an insulin gtt for the first 72
hours of hospitalization. Once her p.o. intake improved on
hospital day 4, she was transitioned to sc insulin. At this
point she was transferred to the floor. The pt. underwent
diabetic teaching but showed a poor understanding of her disease
insofar as the need to check fingersticks and self-administer
subcutaneous insulin. C-peptide was sent and returned low,
supporting a diagnosis of type I diabetes mellitus. Insulin
antibodies were also sent and were pending at the time of
discharge.
2. ARF: On admission, the pt. was in acute renal failure. She
appeared dehydrated on physical examination and the pt. did
admit to antecedant decrease in oral intake. He serum sodium on
admission was 165, also supporting volume depletion. Serum
creatinine improved after aggressive administration of IVF.
3. Atrial flutter: No known prior history. Likely precipitated
by stress from DKA. No ischemic change by EKG. Patient was
asymptomatic (no chest pain, SOB, palpitations). She was started
low dose beta-blocker with effect. Anticoagulation was held
given guaiac positive stools.
4. Guaiac Positive Stool: There was no evidence of colitis by
abdominal CT. Her hematocrit remained stable for the duration of
the hospital stay. Iron studies were consistent with anemia of
chronic inflammation.
5. Thrombocytopenia: The pt was noted to have slowly declining
platelet count during the mid-portion of the hospitalization.
Over concern for heparin-induced thrombocytopenia, heparin
products were discontinued and a HIT antibody was sent. The HIT
antibody returned negative, but the pt's platelet count improved
after discontinuation of heparin notwithstanding.
Medications on Admission:
None.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Medication
Humalog and glargine insulin per attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
-Type 1 Diabetes Mellitus
-Diabetic Ketoacidosis, resolved
-anemia of chronic inflammation
-atrial flutter, resolved
Discharge Condition:
Afebrile, without complaint.
Discharge Instructions:
It is essential that you take all the medications as directed.
You you have any fevers, nausea or inability to tolerate food,
please call your PCP or go to the ED for evaluation.
Followup Instructions:
Please follow up in [**Hospital **] Clinic with Dr. [**Last Name (STitle) **] on [**2173-6-3**] at 12
Noon. You will also see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9973**] at 3:00pm on [**2173-6-3**]
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9974**], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2173-6-8**] 1:30
ICD9 Codes: 5849, 2765, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5685
} | Medical Text: Admission Date: [**2128-5-24**] Discharge Date: [**2128-5-25**]
Date of Birth: [**2045-3-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 41957**] is an 81 yo Russian speaking male with dementia,
h/o CVA previously on coumadin, left sided weakness, dysphyagia
s/p Gtube, HTN, hyperlipidemia transferred from [**Hospital **] rehab
with coffee ground emesis. Reportedly has had several days of
diarrhea and abdominal distention and then developed acute
vomiting of coffee ground emesis on the day of admission. He
also has history of constipation with recent reports of
hypoactive bowel sounds and abdominal distention.
.
In the ED T95.3 BP 130/80 HR 90 97% 2L RA. During EMS transport
he was noted to have large amount of coffee ground emesis. On
arrival in the ED he was given 3L NS, 16 gauge PIV placed and he
was given protonix 40mg IV and a protonix gtt was started. NG
lavage of G tube reportedly with coffee grounds with streaks of
red blood. GI fellow was notified and tentative plan for scope
in the morning unless concern for acute bleeding.
Past Medical History:
h/o CVA with left hemiparesis - previously on coumadin however
d/c'd due to falls
Dysphagia s/p G tube
Vascular dementia
Parkinson's Disease
type 2 diabetes
coronary artery disease
stage III chronic kidney disease
Left ankle decubitus ulcer
hypertension
hyperlipidemia
GERD
BPH
essential tremor
herpes zoster
constipation
Right Lung calcified granuloma
Restless leg syndrome
Pruritis
Social History:
lives at [**Hospital **] rehab facility
Family History:
n/c
Physical Exam:
On admission:
VS:BP 133/48 HR 77 RR 20 93% on 3L NC
Gen: sleeping quietly, awakens to voice, answers yes to russian
interpreter on the phone but no other verbal communication,
appears frightened
HEENT: NC AT
CV: regualr rate and rhythm, 2/6 systolic murmur
Lungs: bibasilar crackles, right > left otherwise CTAB no
wheezing
Abd: distended, firm to palpation, gtube in place with coffee
ground emesis on suction, hypoactive bowel sounds
Rectal: Guaiac positive in ED
Ext: warm, no pedal edema, DP's palpable bilaterally
Neur: contracted, lying on right side, only verbalizes yes with
the russian interpreter
.
On discharge:
T99.1 HR65 - 92 BP109/46 - 182/107 RR 20 SpO2: 97%
Gen: sleeping quietly, awakens to voice,
HEENT: NC AT
CV: regualr rate and rhythm, 2/6 systolic murmur
Lungs: bibasilar crackles, right > left otherwise CTAB no
wheezing
Abd: ABD; soft, NT/ND, G-tube in place, no coffee grounds in or
around G-tube, NABS
Ext: warm, no pedal edema, DP's palpable bilaterally
Neur: contracted, lying on right side, only verbalizes yes with
the russian interpreter
Pertinent Results:
EKG: NSR at 85 bpm, normal axis, RBBB, st segment depressions in
v2-v6 compared with prior from [**2125-7-12**]
.
[**2128-5-24**] 02:10AM BLOOD WBC-9.3 RBC-3.84* Hgb-12.0* Hct-36.3*
MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-357
[**2128-5-24**] 06:39AM BLOOD WBC-6.3 RBC-3.40* Hgb-10.8* Hct-32.4*
MCV-95 MCH-31.6 MCHC-33.3 RDW-13.9 Plt Ct-299
[**2128-5-24**] 12:28PM BLOOD Hct-31.0*
[**2128-5-24**] 06:08PM BLOOD Hct-32.3*
[**2128-5-25**] 12:56AM BLOOD Hct-30.8*
[**2128-5-25**] 03:45AM BLOOD WBC-5.6 RBC-3.22* Hgb-10.5* Hct-30.7*
MCV-96 MCH-32.5* MCHC-34.1 RDW-14.2 Plt Ct-296
[**2128-5-24**] 02:10AM BLOOD Glucose-144* UreaN-47* Creat-1.3* Na-142
K-4.5 Cl-103 HCO3-26 AnGap-18
[**2128-5-24**] 06:39AM BLOOD Glucose-114* UreaN-46* Creat-1.1 Na-141
K-4.5 Cl-109* HCO3-26 AnGap-11
[**2128-5-25**] 03:45AM BLOOD Glucose-101 UreaN-29* Creat-1.2 Na-147*
K-4.0 Cl-114* HCO3-24 AnGap-13
[**2128-5-24**] 02:10AM BLOOD ALT-6 AST-14 CK(CPK)-39 AlkPhos-45
TotBili-0.4
[**2128-5-24**] 06:39AM BLOOD CK(CPK)-34*
[**2128-5-24**] 06:08PM BLOOD CK(CPK)-32*
[**2128-5-24**] 02:10AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2128-5-24**] 06:39AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2128-5-24**] 06:08PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2128-5-25**] 03:45AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.2
Brief Hospital Course:
Pt was admitted with concern for GIB given coffee ground
material from G-tube. The patient was admitted to the ICU for
monitoring, but remained hemodynamically stable throught his
hospital stay. Initially, metoprolol, lisinopril and isosorbide
were held, but metoprolol and lisinopril were restarted once the
patient became slightly hypertensive. Isosorbide should be
restarted in [**2-6**] days if his BP remains stable. His aspirin was
also held and should be held for 7-10 days and can then be
restarted on a baby aspirin (rather than 325mg). The patient was
also placed on a pantoprozole drip and will need to be on the
drip for 72 hrs, until the morning of [**2128-5-27**] per
gasteroenterology consult. He can then be transitioned to a high
dose PPI [**Hospital1 **] for a month. The patient did not receive an EGD as
it was determined that the patient would require intubation and
as he is DNR/DNI. The decision not to perform EGD was discussed
with the patient's niece. On admission, the patient's HCT did
come down from 36->32 with fluids, but then remained stable at
30-32.
Medications on Admission:
Glargine 18 units qhs
simvastatin 20mg qhs
acetaminophen 975mg TID
citalopram 40mg daily
famotidine 20mg qpm
hydrocortisone cream
gabapentin 200mg [**Hospital1 **]
zinc oxide topical
metoprolol 25mg [**Hospital1 **]
terazosin 4mg qhs
lisinopril 2.5mg daily
aspirin 325mg daily
bisacodyl suppository prn
cetirizine 5mg daily
isosorbide dinitrate 10mg TID
lactulose 15 ml TID
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO three
times a day.
4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Hydrocortisone 1 % Cream Sig: AS DIRECTED Topical AS NEEDED.
7. Gabapentin 100 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. Zinc Oxide Lotion Sig: AS DIRECTED Topical AS NEEDED.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
10. Terazosin 2 mg Capsule Sig: Two (2) Capsule PO at bedtime.
11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
13. Cetirizine 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
three times a day.
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
16. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
three times a day.
17. Pantoprazole 8 mg/hr IV INFUSION until [**2128-5-27**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
1. Coffee-ground emesis
Discharge Condition:
afebrile, vital signs stable, hematocrit stable.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
bleeding in your G-tube, likely from your stomach. You were
treated with IV medications, and your hematocrit dropped to the
low 30s but remained stable. You did not require any blood
transfusions. The GI specialists were consulted, who recommended
medical management given the stable blood count. Your
medications and tube-feeds are being restarted now. The
following changes are being made to your medications:
.
1. CHANGE Famotidine to Omeprazole 40mg [**Hospital1 **].
1. HOLD Aspirin for 1 week before restarting.
2. HOLD Isosorbide mononitrate for 1-2 days before restarting,
as tolerated by blood pressure.
.
You should follow-up with your primary care physician. [**Name10 (NameIs) **] there
is further bleeding, you should call your doctor. You should
also call your doctor or return to the Emergency Room for:
* fevers, chills
* chest pain, shortness of breath
* abdominal pain, bloody stools or black tarry stools
Followup Instructions:
Primary Care Physician: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 250**]
.
Provider: [**Name10 (NameIs) 10160**] [**Name11 (NameIs) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2128-6-7**] 11:20
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5686
} | Medical Text: Admission Date: [**2180-2-4**] Discharge Date: [**2180-3-9**]
Date of Birth: [**2104-1-23**] Sex: M
Service: SURGERY
Allergies:
Amiloride / Atenolol / Cardura / Amoxicillin
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
1. Resection and repair of abdominal aortic aneurysm with 18 mm
Dacron tube graft.
2. Flexible sigmoidoscopy [**2180-2-7**]
3. Flexible sigmoidoscopy [**2180-2-15**]
History of Present Illness:
This 76-year-old gentleman has a 5.5 cm aneurysm of the
infrarenal aorta. The anatomy was unsuitable for endovascular
repair.
Past Medical History:
COPD,
asthma,
CAD recent angio for unstable angina,
Chronic afib,
HTN,
OSA,
GERD,
freq nose bleeds,
s/p pilonidal cyst
Social History:
pos smoker
pos alcohol
Family History:
non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE
Neg pronator drift
Sensation intact to ST
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM / Trach placed without signs of infection
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness, PEG tube
placed
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
INDICATION: 76-year-old man status post abdominal aortic
aneurysm repair. Please place PICC line.
TECHNIQUE/FINDINGS: The patient was placed supine on the
angiography table. Ultrasound demonstrated patent left brachial
and basilic veins. The left arm was prepped and draped in the
usual sterile fashion. 1% lidocaine was administered
subcutaneously for local anesthesia. Under ultrasound guidance,
at 21-gauge introducer needle was inserted into the left basilic
vein. A 0.018-inch guide wire was advanced through the needle
into the superior vena cava using fluoroscopic guidance. The
needle was exchanged for an introducer sheath and then a
4-French single lumen PICC was cut to a length of 48 cm based on
the markings on the wire. The PICC was placed over the wire
through the sheath and the wire and sheath were removed. The
catheter was flushed and aspirated, capped and heplocked. The
catheter was fixed in place using a statlock device, and sterile
transparent dressing was applied. A final limited chest
radiograph confirmed catheter tip position in the superior vena
cava/right atrial junction. There were no procedural, or
immediate post- procedural complications. The catheter is ready
for use.
IMPRESSION: Successful placement of a 48-cm 4-French single
lumen PICC by way of the left basilic vein, with the tip in the
superior vena cava. The catheter is ready for use.
[**2180-3-7**] 4:57 AM
CHEST (PORTABLE AP)
FINDINGS: The left lung base and extreme right lung base are
excluded from the radiograph. Allowing for this factor, the
cardiomediastinal silhouette appears stable. A tracheostomy tube
and right subclavian venous catheter remain unchanged in
standard positions. No pneumothorax or mediastinal widening is
present. A small to moderate right and smaller left pleural
effusion are unchanged. The pulmonary vasculature is normal.
There is continued right infrahilar opacity, which could
represent a small pneumonia.
IMPRESSION: Limited study secondary to exclusion of the lung
bases from the radiograph. Persistent small to moderate
bilateral pleural effusions with right perihilar opacity, which
could represent focal pneumonia.
If clinically indicated, the chest radiograph can be repeated
with no additional cost to the patient.
[**2180-2-25**] 11:11 AM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
No prior studies are available for comparison.
TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain
were obtained, with diffusion-weighted images.
MRI OF THE BRAIN: The study is somewhat limited by motion
artifact. The ventricles and sulci are prominent, consistent
with involutional change. There is no shift of normally midline
structures. There are no foci of restricted diffusion within the
brain to suggest acute infarction. There are small foci of
T2-hyperintensity within the cerebral periventricular white
matter, nonspecific, likely representing chronic micro-ischemic
change, and small chronic lacunes are noted within the right
basal ganglia and periventricular white matter. There are no
abnormal foci of susceptibility within the brain to indicate
either acute or chronic hemorrhage. Fluid is noted within both
mastoid air cells, perhaps related to prolonged supine position
and/or intubation.
MRA OF THE BRAIN: The intracranial vertebral and internal
carotid arteries are patent with normal signal. Minimally
attenuated middle cerebral arteries with mural irregularity,
bilaterally, consistent with mild atherosclerotic change. The
major vessels of the circle of [**Location (un) 431**] are patent, without
aneurysmal dilation or flow-limiting stenosis. The left
vertebral artery terminates in the left PICA, a common anatomic
variant.
IMPRESSION:
1. No evidence of hemorrhage, acute infarct or cerebral edema.
2. Foci of T2 hyperintensity within the cerebral periventricular
white matter, likely representing chronic microvascular ischemic
change. Small lacunar infarctions are noted particularly within
the right periventricular cerebral white matter.
3. Unremarkable cranial MRA with no flow-limiting stenosis.
EEG Study Date of [**2180-2-21**]
OBJECT: EVALUATE FOR SEIZURES.
FINDINGS:
ABNORMALITY #1: Throughout this recording, a generally slowed
background rhythm was seen. It was predominantly in the mixed
theta
frequency range. No sharp or epileptiform features were
observed. At
times, normal waking background rhythms were seen.
SLEEP: No stage II sleep was observed.
CARDIAC MONITOR: Showed an irregularly irregular rate and
rhythm.
IMPRESSION: This is a mildly abnormal EEG due to the presence of
theta
frequency background slowing seen predominantly throughout this
recording. No focal or epileptiform features were observed.
Common
causes of encephalopathies include medications, metabolic
processes,
infectious processes, and anoxic events. Note is made of an
irregular
cardiac rhythm
[**2180-2-14**] 11:32 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
INDICATION: Recent abdominal aortic aneurysm repair, now with
leukocytosis.
COMPARISON: CT of the abdomen and pelvis from [**2180-2-6**].
TECHNIQUE: Multidetector CT scanning was performed from the
level of the thoracic inlet to the level of the pubic symphysis
after the administration of oral and intravenous contrast (150
cc of Optiray).
CT OF THE CHEST: An endotracheal tube tip terminates 7.2 cm
above the carina on the scout image. Nasogastric tube tip is
seen within the fundus of the stomach. A right-sided Swan-Ganz
catheter tip is in the right main pulmonary artery. A left
central venous line tip is in the superior vena cava. Borderline
lymphadenopathy is seen in the paratracheal, precarinal,
subcarinal, and prevascular regions, the largest node measures
12 mm in short axis and is best seen on series 2, image 28.
There is a small pericardial effusion. The heart and great
vessels appear unremarkable. Again seen are extensive
emphysematous changes in the lungs bilaterally. Small bilateral
pleural effusions are seen with associated adjacent compressive
atelectasis. In the left lower lobe, fluid-filled bronchi are
seen within areas of atelectasis.
CT OF THE ABDOMEN: The liver, gallbladder, adrenal glands,
spleen, and pancreas appear unremarkable. There is a small
amount of fluid in the perihepatic region, as well as the right
and left paracolic gutters and anterior to Gerota's fascia on
the left. The loops of small and large bowel appear normal in
caliber and contour. The kidneys enhance and excrete contrast
symmetrically. Again seen is a right parapelvic cyst, which is
unchanged since the prior study. The previously seen
retroperitoneal stranding in the perirenal and pararenal spaces
is improved since the prior study. Again seen is thickening of
Gerota fascia, left greater than right. The patient is status
post open abdominal aortic aneurysm repair, with skin staples
seen along the lateral left abdominal wall. There is shotty
retroperitoneal and mesenteric lymphadenopathy, without
pathologically enlarged lymph nodes by CT criteria. No free air
is identified within the abdomen or within the subcutaneous soft
tissues.
CT OF THE PELVIS: There is a Foley catheter within the urinary
bladder, with an air- fluid level in the bladder lumen. The
prostate, seminal vesicles, and rectum appear unremarkable. Some
free fluid is seen within the pelvis as well as few scattered
borderline pelvic lymph nodes, which do not meet criteria for
pathologic enlargement. There is pronounced subcutaneous fat
stranding in the anterior soft tissues.
No concerning lytic or sclerotic lesions are identified within
the osseous structures.
IMPRESSION:
1. Improved retroperitoneal fat stranding with persistent free
fluid seen within the abdomen and the pelvis. Subcutaneous fat
stranding is seen in the distal anterior abdominal wall, which
may be related to subcutaneous edema although cellulitis in this
area cannot be excluded. Clinical correlation is recommended.
2. Small bilateral pleural effusions with associated compressive
atelectasis. In the left base, there are fluid-filled bronchi
within atelectatic lung; infected fluid within bronchi cannot be
excluded.
3. Extensive emphysematous changes in the lungs bilaterally.
4. Lines and tubes in appropriate positions.
[**2180-2-7**]
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
INTERPRETATION:
Findings:
Study done in the ICU secondary to hemodynamioc instability and
hypoxia
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the LA/LAA or the RA/RAA. All four pulmonary
veins identified and enterthe left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
Secundum ASD. The IVC is normal in diameter with appropriate
phasic respirator variation.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Low normal LVEF. No resting LVOT
gradient. No LV mass/thrombus.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal
inferior - normal; mid inferior - normal; basal inferolateral -
normal; mid inferolateral - normal; basal anterolateral -
normal; mid anterolateral - normal; anterior apex - normal;
septal apex -normal; inferior apex - normal; lateral apex -
normal; apex - normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. A secundum type atrial septal defect is present.
Overall left ventricular systolic function is low normal (LVEF
50-55%). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are mildly thickened. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no pericardial effusion.
[**2180-2-7**] 8:51 AM
UNILAT UP EXT VEINS US RIGHT P
TECHNIQUE: Right upper extremity venous ultrasound and Doppler
examination.
FINDINGS: The right internal jugular vein shows normal color and
spectral Doppler flow. The right subclavian vein also shows
normal flow characteristics. The right axillary, brachial and
basilic veins show normal compressibility, augmentation, and
Doppler flow and waveforms. There is no intraluminal thrombus
identified.
IMPRESSION: No evidence of deep vein thrombosis.
[**2180-3-9**] 03:36AM
COMPLETE BLOOD COUNT
White Blood Cells 11.0
Hemoglobin 9.2
Hematocrit 28.
MCV 92
MCH 29.9
MCHC 32.7
RDW 15.1
Platelet Count 531*
[**2180-3-9**] 03:36AM
RENAL & GLUCOSE
Glucose 100
Urea Nitrogen 19
Creatinine 0.5
Sodium 142
Potassium 3.7
Chloride 107
Bicarbonate 26
Anion Gap 13
CHEMISTRY
Calcium, Total 8.1
Phosphate 2.7
Magnesium 1.9
HEMATOLOGIC
Vitamin B12 790
PITUITARY
Thyroid Stimulating Hormone 4.0
OTHER ENDOCRINE
Cortisol 14.7
[**2180-2-19**] 3:51:30 PM
Atrial fibrillation
Anterior T wave changes are nonspecific
Repolarization changes may be partly due to rhythm
No change from previous
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 82 398/433.71 0 72 89
[**2180-2-18**] 08:51PM
GENERAL URINE INFORMATION
Urine Color Yellow
Urine Appearance Clear
Specific Gravity 1.009
DIPSTICK URINALYSIS
Blood NEG
Nitrite NEG
Protein NEG
Glucose NEG
Ketone NEG
Bilirubin NEG
Urobilinogen NEG
pH 8.0
Leukocytes NEG
[**2180-3-5**] 3:03 pm
Source: Left Subclavian CVL.
WOUND CULTURE (Final [**2180-3-7**]): No significant growth.
[**2180-2-28**]
MRSA SCREEN Source: Nasal swab.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
STAPH AUREUS COAG +
|
OXACILLIN------------- R
[**2180-3-5**] 12:41 am URINE
URINE CULTURE (Final [**2180-3-6**]): NO GROWTH.
[**2180-2-21**] 4:06 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2180-2-21**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2180-2-27**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
ENTEROBACTER CLOACAE. RARE GROWTH.
This organism may develop resistance to third generation
cephalosporins during prolonged therapy. Therefore, isolates
that
are initially susceptible may become resistant within three to
four days after initiation of therapy. For serious infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
KLEBSIELLA PNEUMONIAE
| ENTEROBACTER CLOACAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S <=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=20 S <=1 S
[**2180-3-6**]
ALT: 87 AP: 268 Tbili: 0.3 AST: 149
[**2180-3-6**]
URINE
UreaN: 1189
Creat: 111
Na: 23
Osmolal:675
[**2180-2-20**] 10:13 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2180-2-26**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2180-2-26**]): NO GROWTH.
Brief Hospital Course:
Pt had a difficult hospital course
Pt admitted on [**2180-2-4**]
[**2180-2-4**] - [**2180-2-5**]
Underwent a Resection and repair of abdominal aortic aneurysm
with 18 mm Dacron tube graft. The procedure went well. There
were no complications. Pt transfered to the PACU instable
condition / intubted, with epidural.
Pt recieved 6 ltrs fluid intra-op.
[**2180-2-6**]
Pt intubated / difficult wean transfer to the SICU for cont
care.
Pt drops O2 sats / with fevers to 104 / pan cx'd with cxr and
CTA
Requires increase in vent support.
Pt found to have pnuemonia / broad spectrum antibioticcs
started.
diuresed / serial ABG's followed
[**2180-2-7**] - [**2180-2-10**]
Swan placed
Flexible sigmoidoscopy to r/o bowel ischemia / neg for colitis
epidural stopped / requires pressors / vent support
Nutrition consult / TPN started / cw fevers and increase wbc
[**2180-2-11**]
Bronchoscopy performed (pos for exudate)
TPN s / cw fevers and increase wbc
pressors / vent support
Aggressive pulm toilet
[**2180-2-12**]
Bronchoscopy performed (pos for exudate)
TPN s / cw fevers and increase wbc
pressors / vent support
Aggressive pulm toilet
General surgery consulted / fevers and increase wbc
[**2180-2-14**]
Flexible sigmoidoscopy ( neg for colitis )
Bronchoscopy pos mucos plug RLL
TPN / cw fevers and increase wbc
pressors / vent support
Aggressive pulm toilet
[**2180-2-15**]
TPN / cw fevers and increase wbc
pressors / vent support
Aggressive pulm toilet
ID consult / Pulmonary consulted
Lines swithed / pan cx
[**2180-2-16**]
TPN / cw fevers and increase wbc
pressors / vent support
Aggressive pulm toilet
[**2180-2-17**] - [**2180-2-19**]
TPN off / Tube feeds started / insulin drip for increase BS
cw fevers and slight decrease in wbc
pressors / vent support
Aggressive pulm toilet
NGT DC'D - OGT placed
[**2180-2-20**]
Nuero consult / MRI / EEG
pressors / vent support
Aggressive pulm toilet
[**2180-2-21**]
Bronchcoscopy performed ( pos for exudate )
[**2180-2-22**] - [**2180-2-27**]
cw fevers and slight decrease in wbc
pressors / vent support
Aggressive pulm toilet
pt found to have increase in sodium / free water given / mental
status improves
Peep is decreased / lasix is DC'd / pt is even on pre-op weight
AB tailored to sesitivities / Vancomycin DC's / Cefipime
continued
[**2180-2-28**] - [**2180-2-29**]
cw fevers and slight decrease in wbc
pressors / vent support
Aggressive pulm toilet
pt found to have increase in sodium / free water given / mental
status improves
[**2180-3-1**] -
PEG / Trachea placement
cw fevers and slight decrease in wbc
pressors / vent support
Aggressive pulm toilet
increase in sodium / free water given /
[**2180-3-2**]
TF started
Pt mental / resp staus improves / teperature improves
pressors are weaned off / vent support
Aggressive pulm toilet
C-Diff neg x two
Pt allowed OOB to chair
OT / PT consult
[**2180-3-3**]
OOB
vent support
Aggressive pulm toilet / TF
[**2180-3-4**] - [**2180-3-5**]
vent support
Aggressive pulm toilet / TF
Decrease FiO2 / peep
OT / PT
[**2180-3-6**]
Cefipime DC'd / Zosyn started
pt kept negative with gentle diuresis
OOB
vent support
Aggressive pulm toilet / TF
[**2180-3-7**] - [**2180-3-10**]
TF at goal
Heparin DC'd / cw coumadin
WBC stable / Afebrile
Pt stable for DC to [**Hospital 5442**] rehab
Taking TF / OOB to chair / pos BM / foley to gravity
Medications on Admission:
Albuterol,
ASA,
Digoxin,
Diltiazem,
Diovan,
Lasix,
Protonix,
Simvastatin,
plavix
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) for 1 doses: moniter INR goal is [**1-7**].
6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous after meds / qid / as needed as needed.
7. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN
(as needed) as needed for K<4.0.
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
12. Lansoprazole Oral
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO QID (4 times a day) as needed for Ca<1.12.
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
15. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
16. Morphine Sulfate 2 mg IV Q4H:PRN
17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q4H
(every 4 hours) as needed for SBP>150.
18. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours).
19. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
21. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
22. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN
(as needed) as needed for Mg<2.0.
23. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-6**]
Puffs Inhalation Q4H (every 4 hours) as needed.
24. Insulin
Sliding Scale & Fixed Dose
Fingerstick Q1H
Insulin SC Fixed Dose Orders
Breakfast Bedtime
NPH 30 Units NPH 20 Units
Insulin SC Sliding Scale
Regular
Glucose Insulin Dose
0-59 mg/dL [**12-6**] amp D50
60-120 mg/dL 0 Units
121-160 mg/dL 3 Units
161-200 mg/dL 6 Units
201-240 mg/dL 9 Units
241-280 mg/dL 12 Units
281-320 mg/dL 15 Units
321-360 mg/dL 18 Units
> 360 mg/dL Notify M.D.
Adjust sliding scale as needed / wean off of q 1 hr / to qid
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast [**Location (un) 38**]
Discharge Diagnosis:
AAA
SIRS / septic shock likely pulm etiology.
Difficulty weaning from ventalator
bilateral lower lobe pneumonia.
unresponsiveness likely [**1-6**] encephalopathy (from PNA)
Stupor
ARF
ICU sinusitis
Discharge Condition:
Stable / vented / g-tube
Discharge Instructions:
Log term care:
G - tube care
Trach care
Vent support
Wound care
watch for:
respiratory problems
signs of infection
bowel problems
Followup Instructions:
When Stable
Follow-up with Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 51748**]
Completed by:[**2180-3-9**]
ICD9 Codes: 5185, 486, 5849, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5687
} | Medical Text: Admission Date: [**2126-9-25**] Discharge Date: [**2126-10-1**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Unresponsive, hypoglycemia
Major Surgical or Invasive Procedure:
Intubation [**2126-9-25**]
History of Present Illness:
45 year old male with a history of type 1 diabetes, chronic
kidney disease, and multiple episodes of hypoglycemia found
unresponsive at home by a friend.
On EMS arrival, cool and unresponsive but with pulse and
spontaneously breathing. FSBG 19, given 1amp D50 and 1mg
glucagon. Narcan without improvement. [**Month/Day/Year 4045**] to ED.
In the ED, vitals T 32.5, 65, 144/63, 17. Temp improved to 34.1
on bair hugger. Labs notable for WBC 18.3 without bands, Hct
25.2, AG 14, BUN 129, Cre 6.5, LFTs with mild transaminitis, CK
467, MB/MBI 12/2.6, TnT 0.13, lactate 1.6, serum and urine tox
screens negative. FSBG 109, remained normoglycemic while in ED.
U/A with mod bact, [**1-30**] WBC. Exam 'clamped down', cool, grossly
edematous, no evidence trauma, no gag, unresponsive to painful
stimuli, shivering. ABG 7.26/60/156. Intubated for airway
protection (reportedly very difficult due to edema). Given given
ativan and started on propofol gtt for ?seizure history. CXR
with no acute process. CT head negative. Not placed in C-collar
or spine imaging series given no concern for traumatic injury.
Covered with vanc 1gm IV, CTX 2gm IV. Admit to ICU.
Further history from the patient now that extubated and A&Ox3.
States that he awoke at 5:30am and ate breakfast, taking all his
meds including lasix, glargine and humulog. Went back to bed
around 8:30am then awoke later to go to the bathroom. The last
thing he remembers he was going back to bed. Denies seizure
history. Reports ultrabrittle diabetes with FSBG ranging 4 to
1300 at times. Had been feeling well the day prior and the
morning of admission. No cough, CP, SOB, nausea, diarrhea,
fevers, chills. No recent med changes or new meds. Denies h/o
prostate problems or change in urinary stream or frequency.
Past Medical History:
Diabetes type 1 (since age 16 on insulin, followed by Dr.
[**Last Name (STitle) 10088**]
-frequent hypoglycemic episodes
-high level of anti-insulin Ab
-complicated by nephropathy
-complicated by retinopathy (s/p right eye laser surgery,
repeated [**8-3**])
Vascular disease
Chronic renal insufficiency (baseline Cre ~4, followed by Dr. [**Name (NI) 5626**] at [**Last Name (un) **])
Hypertension
Hyperlipidemia
Anemia
Denies h/o seizure, heart problems (although sees cardiologist
Dr. [**Last Name (STitle) 20854**] at NEBH)
Graves' Disease
Diastolic CHF with LVH
Social History:
Lives with parents. Works in construction. No alcohol, drugs, or
tobacco.
Family History:
Mother has DM2 and RA. Maternal Aunt also c DM2. Nephew c DM1
Physical Exam:
T 35.1 HR 92 BP 129/68 RR 23 SaO2 100% on A/C 550x14x5, 60% FiO2
General: Intubated, sedated
HEENT: pinpoint pupils, scleral edema, anicteric
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR, s1s2 normal, soft SEM RUSB, no r/g, unable to
assess JVD
Pulmonary: diminished BS right base, crackles on left, no wheeze
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, 1+ bilateral pitting tibial
edema
Neuro: Unable to assess due to sedation
Pertinent Results:
[**2126-9-25**] CT HEAD W/O CONTRAST:
FINDINGS: There is no evidence for edema, hemorrhage, mass
effect, or territorial infarction. There is no shift of midline,
and there is preservation of the normal [**Doctor Last Name 352**]-white matter
differentiation. The ventricles and sulci are normal in caliber
and configuration. There are no fractures. There is mucosal
thickening of the left and right maxillary sinuses as well as
the ethmoid sinuses and nasal passages, which could be related
to patient's intubated status. Patient is status post right lens
surgery. There are extensive vascular calcifications of the
carotid and vertebral arteries.
IMPRESSION: No acute intracranial process.
[**2126-9-25**] CHEST (PORTABLE AP):
FINDINGS: The ET tube has its tip approximately 45 mm from the
carina. The NG tube has its tip projected over the stomach.
There is apparent cardiomegaly which may partly be due to AP
projection. The lungs are clear.
[**2126-9-25**] RENAL U.S.:
The right kidney measures 10.7 cm, and the left kidney measures
10.1 cm. The parenchymal echogenicity is somewhat increased,
suggestive of chronic renal disease. There is no evidence of
stones, mass, or hydronephrosis. The bladder demonstrates Foley
catheter instrumentation, but is otherwise unremarkable. There
is a small amount of perihepatic ascites.
IMPRESSION:
1. Echogenic kidneys suggest chronic renal disease.
2. No evidence of stones, mass, or hydronephrosis.
3. Small amount of perihepatic ascites.
MICROBIOLOGY:
[**2126-9-30**] URINE URINE CULTURE-FINAL <10,000 organisms
[**2126-9-25**] MRSA SCREEN MRSA SCREEN-FINAL negative
[**2126-9-25**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
negative
[**2126-9-25**] BLOOD CULTURE Blood Culture, Routine-FINAL no growth
[**2126-9-25**] BLOOD CULTURE Blood Culture, Routine-FINAL no growth
ADMIT AND DC HEMATOLOGY:
[**2126-9-25**] 11:15AM BLOOD WBC-18.3* RBC-3.12* Hgb-8.6* Hct-25.2*
MCV-81* MCH-27.7 MCHC-34.2 RDW-15.9* Plt Ct-230
[**2126-10-1**] 06:40AM BLOOD WBC-10.0 RBC-2.55* Hgb-7.1* Hct-20.3*
MCV-80* MCH-28.0 MCHC-35.1* RDW-15.5 Plt Ct-157
ADMIT AND DC CHEMISTRY:
[**2126-9-25**] 11:15AM BLOOD Glucose-86 UreaN-129* Creat-6.5* Na-141
K-4.5 Cl-102 HCO3-25 AnGap-19
[**2126-10-1**] 06:40AM BLOOD Glucose-243* UreaN-149* Creat-6.7* Na-134
K-4.7 Cl-99 HCO3-23 AnGap-17
[**2126-9-25**] 11:15AM BLOOD ALT-76* AST-46* CK(CPK)-467* AlkPhos-66
TotBili-0.2
[**2126-9-30**] 06:30AM BLOOD ALT-36 AST-26
[**2126-10-1**] 06:40AM BLOOD LD(LDH)-357* TotBili-0.2
CARDIAC ENZYMES:
[**2126-9-25**] 11:15AM BLOOD cTropnT-0.13*
[**2126-9-25**] 11:15AM BLOOD CK-MB-12* MB Indx-2.6
[**2126-9-25**] 05:33PM BLOOD CK-MB-13* MB Indx-3.3 cTropnT-0.12*
[**2126-9-25**] 08:38PM BLOOD CK-MB-16* MB Indx-3.6 cTropnT-0.13*
MISCELLANEOUS:
[**2126-9-25**] 11:15AM BLOOD VitB12-1454*
[**2126-9-26**] 04:21AM BLOOD calTIBC-267 Ferritn-42 TRF-205
[**2126-10-1**] 06:40AM BLOOD Hapto-156
[**2126-9-26**] 04:21AM BLOOD TSH-3.5
[**2126-9-26**] 04:21AM BLOOD Free T4-1.2
[**2126-9-25**] 11:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2126-9-30**] 12:50PM BLOOD THIOPURINE METHYLTRANSFERASE (TPMT),
ERYTHROCYTES-14.8 U/mL RBC
Brief Hospital Course:
# Unresponsiveness:
Patient was initially with concern for protecting airway and
thus was intubated. Hypoglycemia alone was most likely
explanation for initial unresponsive state. On night of
presentation patient had intermittently low fingersticks
requiring 1 amp of D50 on 2 separate occasions. At presentation
tox screens negative and patient did not arouse to narcan
administration. ROMI??????d with 3 sets of cardiac enzymes (elevated
enzymes likely due to CRI). CT head negative for intracranial
bleeding at presentation. Patient spontaneously awoke and
self-extubated in the MICU. After ensuring stabilization of
vital signs, he was transferred to the medical floor on night of
[**9-26**].
# Hypoglycemia / Diabetes:
After initial night in the MICU with several D50
administrations, the patient had no more hypoglycemia while
hospiatlized. Patient was subjected to Q2H fingersticks on the
floor to monitor for and acute drops in blood sugar; however,
the patient was never below mid-100s. Moreover, his blood sugar
climbed over 400 overnight every night after leaving the MICU
and coming to the medical floor (apart from night prior to
discharge when sugars remained under 300). Patient received
multiple doses of insulin overnight to keep sugars from climbing
over 400 (up to 20+ [**Location **]) and there was a concern for
stacking due to patient's poor renal function; however, the
patient's blood sugar never dropped. Given this information, the
patient's glargine doses were gingerly titrated up throughout
hospitalization until he had a night with no sugars over 300. He
discharge glargine dose was 8U in the AM and 6U in the PM.
# Insulin Receptor Autoantibody Syndrome:
Recently diagnosed with autoantibodies to the insulin receptor
and started on oral prednisone for immune suppression as an
outpatient; however, patient admitted that he only started
consistently taking the prednisone a few days prior to
admission. He had been frightened about side effects of
prednisone, most notably, the hypertension. Rheumatology
consulted on [**2126-9-26**] and they started patient on prednisone
20 mg twice daily in the hospital. Discussion with rheum consult
also revealed possibility that hypoglycemia could be attributed
to insulin autoantibodies that spontaneously release a large
pool of insulin rather than antibodies to the insulin receptor
itself. Regardless, given patient's uncontrolled hypertension
and hyperglycemia, dose of prednisone was reduced to 15 mg twice
daily and patient was started on azathioprine prior to
discharge. Allopurinol was decreased to 50 mg QOD in setting of
starting azathioprine. In order to adjust dosing of azathioprine
as an outpatient, a THIOPURINE METHYLTRANSFERASE (TPMT) level
was drawn and returned as 14.8 U/mL RBC after the patient was
discharged. He was scheduled to see his rheumatologist, Dr.
[**Last Name (STitle) 20863**], the week following discharge.
# Chronic kidney disease:
Patient presented with Cr of 6.5 up from his previous baseline
of 5.5 to 6.0; however, this dose not represent a significant
worsening of GFR. Nephrology was consulted and reported that the
patient had been approached about dialysis and about having a
fistula placed in preparation, but he had thus far refused the
idea of initiating preparation for dialysis. Nephrology consult
did feel that patient would benefit from a kidney and pancreas
transplant evaluation, thus he was set up to see Dr. [**Last Name (STitle) **]
the week following discharge.
# Hypertension:
Patient presented with an impressive outpatient regimen of
minoxidil, clonidine, metoprolol, diltiazem, doxazosin, and
furosemide. He had recently been discontinued from the ACE
inhibitor monapril in the outpatient setting for unclear
reasons. While hospitalized, his blood pressures initially
ranged from 160s to 190s systolic. His minoxidil and metoprolol
doses were increased as an inpatient. As his refractory
hypertension was thought to be partially associated with volume
status, the patient was started on [**Hospital1 **] 60 mg IV furosemide with
appropriate diuresis and a reduction in his edema. He was
discharged on oral furosemide at a dose of 80 mg [**Hospital1 **].
# Anemia:
Stable from previously. Likely secondary to CKD. Patient would
likely benefit from starting epo therapy; however, there are
reports from his nephrologist that he has been resistant to this
intervention. The epo clinic at [**Last Name (un) **] was called and patient
was provided with their number in order to set up a screening
appointment. Also, as his iron saturation was found to be 6.7%,
he was initiated on iron replacement therapy as an inpatient.
# Primary care:
Patient currently has no primary care and desperately needs a
physician to tie together his complicated medical presentation
and his multiple specialist visits. He has been arranged to see
Dr. [**First Name (STitle) 20866**] [**Name (STitle) 20867**] in [**Hospital 191**] clinic the week following
discharge.
Medications on Admission:
allopurinol 100mg po QOD
Lantus 3 [**Hospital1 **]
Humulog sliding scale
Lasix 30mg daily
Doxazosin 4mg qhs
Diltiazem 180mg [**Hospital1 **]
clonidine 0.3mg/hr q week
Toprol 100mg po daily
Toprol 50mg po QHS
Minoxidil 5mg po daily
calcitriol 0.25mg po daily
nephrocaps daily
sevelamer 800mg po tid
calcium carbonate 500mg po BIDWM
crestor 20mg po daily
colace
senna
Levothyroxine 75mcg daily
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Humalog 100 unit/mL Solution Sig: Administer by sliding
scale. units Subcutaneous four times a day.
3. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BIDWM (2 times a day (with meals)).
12. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
16. Allopurinol 100 mg Tablet Sig: one half Tablet PO EVERY
OTHER DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
18. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
19. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
20. Azathioprine 50 mg Tablet Sig: one half Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
21. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID with
meals.
Disp:*180 Tablet(s)* Refills:*2*
22. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
23. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous Every morning.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypoglycemia
Secondary Diagnoses:
2. Diabetes Mellitus
3. Chronic Kidney Disease
4. Hypertension
5. Anemia
6. Insulin autoantibodies
Discharge Condition:
afebrile, hemodynamically stable, blood sugars in 200s
Discharge Instructions:
You were admitted to the hospital after you were found
unreponsive at home. You were found to have a very low blood
sugar level. Your kidney function was found to be worse. You
were intubated and treated with glucose. Your blood sugars
improved and your breathing tube was removed. You were evaluated
by Rheumatology and instructed to take prednisone 15 mg by mouth
daily. They also started you on another medication called
azathioprine 25 mg daily.
Once you were transferred to the floor from the intensive care
unit, you were observed on the floor due to concern for high
blood pressure and low blood sugar. The doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] have
adjusted your Lantus and sliding scale insulin dosing as per the
attached flowsheet.
You have a complicated medication regimen and we have made
several changes and additions to your medication list. Please
review the attached medication list very carefully. Specifically
we have added the following medications:
1) Prednisone 15 mg by mouth twice a day
2) Azathioprine 25 mg by mouth once a day
3) Ferrous sulfate 325 mg daily
We have made changes to the following medications:
1) Glargine (Lantus) insulin 8 U in morning and 6 U at bedtime.
2) Metoprolol XL 100 mg in morning and 100 mg at bedtime.
3) Sevelamer 1600 mg three times a day with meals
4) Furosemide 80 mg by mouth twice a day
5) Allopurinol 50 mg by mouth every other day
6) Minoxidil 5 mg by mouth twice a day
You should follow-up this hospitalization with several doctor
visits:
1) We have arranged for you to see a transplant kidney doctor,
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 60**]) [**Last Name (NamePattern1) **]. on [**2126-10-7**] at
1:00 PM in order to be evaluated for the possibility of a
transplant to improve your health
2) You have an appointment with Dr. [**Last Name (STitle) 20863**] in rheumatology
([**Telephone/Fax (1) 2226**]) on [**2126-10-8**] at 12:30 PM
3) You have an appointment with your new primary care physician
at [**Name9 (PRE) 191**] on [**2126-10-10**] at 3:30 PM
4) You should call Dr.[**Name (NI) 4849**] to make an appointment to
follow-up on your kidney function.
5) We have contact[**Name (NI) **] the anemia clinic at [**Name (NI) **] so that you can
be evaluated by them. They should be calling you for an
appointment; however, you may also call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Doctor First Name 20868**] at
[**Telephone/Fax (1) 20869**].
Should you have any fever, chills, chest pain, diaphoresis, low
blood sugars, lightheadedness, or feeling that you may pass out,
please call your physician or report to the emergency room
immediately.
Followup Instructions:
1) We have arranged for you to see a transplant kidney doctor,
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 60**]) [**Last Name (NamePattern1) **]. on [**2126-10-7**] at
1:00 PM in order to be evaluated for the possibility of a
transplant to improve your health
2) You have an appointment with Dr. [**Last Name (STitle) 20863**] in rheumatology
([**Telephone/Fax (1) 2226**]) on [**2126-10-8**] at 12:30 PM
3) You have an appointment with your new primary care physician
at [**Name9 (PRE) 191**] on [**2126-10-10**] at 3:30 PM
4) You should call Dr.[**Doctor Last Name 4849**] to make an appointment to
follow-up on your kidney function.
5) We have contact[**Name (NI) **] the anemia clinic at [**Name (NI) **] so that you can
be evaluated by them. They should be calling you for an
appointment; however, you may also call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Doctor First Name 20868**] at
[**Telephone/Fax (1) 20869**].
Completed by:[**2126-10-6**]
ICD9 Codes: 5849, 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5688
} | Medical Text: Admission Date: [**2141-3-25**] Discharge Date: [**2141-3-29**]
Date of Birth: [**2060-11-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 80 yo female w/ PMHx sig for Parkinson's, HTN,
hypercholesterolemia medlflighted from [**Hospital1 6687**] after fall with
evidence of SAH and frontal contusions on head CT. The patient
was at home and fell backwards down a 8 stairs and landed on the
back of her head. Her GCS was 8 at the seen and she was noted
to
have hematoma a the back of her head. She was brought to
[**Hospital3 22439**] where she had a head CT that demonstrated
SAH,
b/l frontal contusions with IPH, R temporal pneumocephalus, and
non-displaced occipital bone fracture. She was intubated,
paralyzed, and medflighted to [**Hospital1 18**].
Past Medical History:
Parkinson's disease w/ signs of mild dementia, HTN,
hypercholesterolemia, Moh's procedure.
Social History:
Lives with husband on [**Name (NI) 6687**]. She has a visiting nurse 5
days/week. She walks with a walker.
Family History:
non-contributory
Physical Exam:
Upon admission:
Physical Exam:
Vitals: T 97.9; BP 131/66; P 58; RR 16; O2 sat 100%
General: intubated, sedated
HEENT: dried blood around mouth
Neck: c-collar
Extremities: no c/c/e.
Neurological Exam: intubated, does not repsond to voice, PERRL,
4-->2mm with light, + VOR, + corneal reflex, no spontaneous
movements, does not withdraw to pain, trace reflexes in UEs and
absent in LEs.
Pertinent Results:
CT Head [**2141-3-25**]:
Impression:
1. Extensive subarachnoid hemorrhage and parenchymal hemorrhagic
contusion, increased from prior outside examination.
2. Occipital bone fracture on the left, with concern for sinus
injury and
venous epidural hematoma along the left occipital bone. Subdural
blood layers along the tentorium.
3. Nondisplaced clivus fracture with possible involvement of the
right
carotid canal. CTA of the head is recommended for further
evaluation.
CT Chest/Abd/Pelvis [**2141-3-25**]:
Impression:
IMPRESSION:
1. Somewhat limited study given respiratory motion, especially
in the chest.
2. No evidence of acute traumatic injury in the chest, abdomen,
or pelvis.
3. Right adnexal cystic lesion and small amount of pelvic free
fluid. If
clinically indicated (based on patient's prognosis), non-urgent
pelvic
ultrasound can be performed for further evaluation.
4. Chronic degenerative changes of the lumbosacral spine, with
likely chronic malalignment at multiple levels as described.
MRA Brain [**2141-3-26**]:
IMPRESSION: No definite evidence of dissection. This is a
limited
examination related with motion artifacts, the distal branches
of the circle of [**Location (un) 431**] are not clearly identified, either
related with artifact or possible vasospasm secondary to
subarachnoid hemorrhage, please correlate clinically. Based the
axial source images, no dissection or major vascular occlusion
is identified.
CT Head [**2141-3-26**]:
IMPRESSION:
1. Extensive subarachnoid, intraparenchymal and subdural
hematoma, not
significantly changed. No shift of normally midline structures.
2. Mild prominence of the temporal horns which may represent
early
hydrocephalus although is unchanged when compared to prior exam.
3. Multiple skull fractures with possible involvement of the
right internal carotid artery canal.
4. Air-fluid levels in the
sphenoid and right maxillary sinus are similar in appearance.
CT head [**2141-3-28**]:
Mild decrease in the previously noted subarachnoid and
intraparenchymal
hemorrhage in the occipital lobes. No significant change in the
areas of
hemorrhage noted in the intraparenchymal, subdural and
subarachnoid
compartments, otherwise. No new hemorrhage.
Multiple skull fractures are inadequately assessed on the
present study.
Please see the detailed report on the prior CTs.
Brief Hospital Course:
Pt is a 80 yo female w/ PMHx sig for Parkinson's, HTN,
hypercholesterolemia medlflighted from [**Hospital1 6687**] after fall with
evidence of SAH and frontal contusions on head CT. The patient
was at home and fell backwards down a 8 stairs and landed on the
back of her head. Her GCS was 8 at the seen and she was noted
to
have hematoma a the back of her head. She was brought to
[**Hospital3 22439**] where she had a head CT that demonstrated
SAH, b/l frontal contusions with IPH, R temporal pneumocephalus,
and non-displaced occipital bone fracture. She was intubated,
paralyzed, and medflighted to [**Hospital1 18**]. Upon arrival to [**Hospital1 18**] a
repeat head CT was obtained. Pt was loaded with Dilantin. Her
levels were above 20 and this medication was held for this
reason on [**3-28**] and [**3-29**]. Her neurologic status did not improve
and the family had a meeting with Dr. [**Last Name (STitle) 739**]. She was
made CMO on [**3-29**]. She was extubated on this date and was
pronounced that evening.
Medications on Admission:
Sinemet, Mirapex, Midodrine
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid Hemorrhage
Subdural Hematoma
Intraparenchymal Hemorrhage
Hydrocephalus
Nondisplaced clivus fracture
Left Occipital bone fracture
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2141-4-6**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5689
} | Medical Text: Admission Date: [**2142-9-7**] Discharge Date: [**2142-9-12**]
Service: [**Hospital1 **]
CHIEF COMPLAINT: Horrible feeling in my stomach.
HISTORY OF PRESENT ILLNESS: Patient is an 87-year-old woman
with past medical history of guaiac positive stools, anemia,
diabetes type 2, hypertension, and congestive heart failure
recently admitted from a geriatric psychiatric facility where
she was admitted for two weeks for anxiety and depression.
On morning of admit, she woke up with abdominal discomfort
and feeling anxious. The pain was diffuse with no radiation,
no chest pain, shortness of breath. Positive nausea, but no
vomiting. She attributed her symptoms to depression.
On electrocardiogram she had T wave inversion in leads V2
through V6. She was given Lopressor 5 mg intravenous and 2
inch Nitropatch and hydralazine 10 mg intravenous. Her
hematocrit was 29.1. Baseline is 30 and she had three
melanotic stools that were guaiac positive. Nasogastric
lavage was not successful, periprocedure Ativan 2 mg made her
delirious and drowsy.
PAST MEDICAL HISTORY: Hypertension, congestive heart
failure, ejection fraction 45-50%, history of
gastrointestinal bleed. Hospitalized from [**7-25**] through
[**7-28**] for hematocrit of 20, received two units of packed red
blood cells.
At [**Hospital3 7**], esophagogastroduodenoscopy showed mild
gastritis. Colonoscopy showed polyps. Osteoporosis, status post
right hip fracture, depression with inpatient stay at [**Hospital6 18075**] Geriatric Psychiatry unit from [**8-29**] through
[**9-6**], noninsulin dependent diabetes mellitus, urinary
incontinence, status post appendectomy and cholecystectomy.
Guaiac positive stools for two years.
ADMISSION MEDICATIONS: Demadex 10 mg q.d., Zoloft 75 mg
q.d., Glucophage 500 mg b.i.d., folate 1 tablet q.d., iron
325 mg b.i.d., Ambien 5 mg q.h.s. prn, K-Dur 20 mEq,
glyburide 10 mg b.i.d., Tums 1 tablet b.i.d., Prevacid 30 mg
b.i.d., Serzone 100 mg q.a.m. and 50 mg at 1 p.m. and 150 mg
q.h.s., Zestril 10 mg q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in [**Hospital3 **]
facility.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: Temperature 99. Pulse 92.
Respiratory rate 20. Blood pressure 140/92. 02 saturation
95% on room air. General appearance: Frail elderly woman,
hard of hearing, alert and oriented times three. Head, eyes,
ears, nose and throat: Extraocular movements intact, pupils
are equal, round, and reactive to light and accommodation,
mucous membranes moist, anicteric sclera, impaired hearing
bilaterally, no jugular venous distention, no LAD.
Cardiovascular: Regular rate and rhythm, S1, S2, [**2-27**]
holosystolic murmur heard loudest at the apex left sternal
border. Pulmonary: Scattered expiratory wheezes, otherwise
clear to auscultation. Abdomen: Nontender, nondistended,
positive bowel sounds. Extremities: 1+ pitting edema up to
mid calf. Neurological: Somnolent but arousable. Cranial
nerves II through XII are intact. No sensory deficits
bilaterally.
ADMISSION LABORATORIES: White blood cell count 5.7,
hematocrit 29.1, platelet count 266. Sodium 136, potassium
4.4, chloride 101, bicarbonate 24, BUN 26, creatinine 0.7,
glucose 243.
HOSPITAL COURSE: By systems:
1. Cardiac: The patient was admitted to the Medicine Unit
on [**9-7**]. She was ruled out for myocardial infarction
with serial CKs. On [**9-8**], her hematocrit was 26.5. She
was asymptomatic, but given her cardiac history and the
thought that her electrocardiogram changes could represent
demand ischemia, she was transfused slowly with two units of
packed red blood cells. She was evaluated between units and
her lungs were clear to auscultation bilaterally. On [**9-9**], following the second unit, she developed shortness of
breath and her 02 saturations decreased to 87% on two liters
of oxygen. She was tired and on 100% nonrebreather and her
02 saturations elevated to 90%. She was given 240 mg Lasix,
put on BiPAP, and admitted to the Surgical Intensive Care
Unit. Her pressure was 188/100. She was started on
nitroglycerin drip. A post electrocardiogram showed ST
elevations in V2 and V3, and T wave inversions in V3 through
V6. She was ruled out for myocardial infarction again with
serial CKs. She was admitted back to the floor on [**9-10**]
after being weaned from her nitroglycerin drip and placed on
Isordil 10 mg po t.i.d.
On [**9-10**], she complained of chest pressure that was
persistent all night. A repeat electrocardiogram was
performed that was unchanged from her Surgical Intensive Care
Unit electrocardiogram. She was currently stable and
asymptomatic. Given patient's decreased functional status
and mild neurological dysfunction, Cardiology recommended
medical management of her ischemic disease.
2. Gastrointestinal: Patient had an
esophagogastroduodenoscopy and colonoscopy at this hospital
in the past showing gastritis and adenomatous polyps in the
colon. A small bowel follow through was performed on [**9-10**] and was negative for a source of bleed. Her hematocrit
remained stable until discontinued. She can follow-up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in his clinic in three months if she wishes or
if she has further symptoms. She will have weekly hematocrit
checks at rehabilitation.
3. Psychiatric: Psychiatry consult was called. The
discharge summary of her more recent geriatric psychiatric
unit was obtained. Her current medications were continued.
Psychiatric recommended no changes in medicine at this time.
DISCHARGE LABORATORIES: White blood cell count 9.1,
hematocrit 36.3, platelets 231,000. Sodium 141, potassium
3.8, chloride 103, bicarbonate 26, BUN 33, creatinine 0.9,
glucose 159.
DISCHARGE DIAGNOSES:
1. Congestive heart failure
2. Gastrointestinal bleed. Source unclear.
3. Depression.
4. Hypertension.
5. Noninsulin dependent diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Zoloft 75 mg q.d.
2. K-Dur 10 mEq b.i.d.
3. Glucophage 500 mg b.i.d.
4. Glyburide 10 mg b.i.d.
5. Folate 1 tablet q.d.
6. Tums 1 tablet b.i.d.
7. Iron 325 mg b.i.d.
8. Protonix 40 mg q.d.
9. Serzone 100 mg q.a.m., 50 mg at 1 p.m. and 150 mg q.h.s.
10. Zestril 20 mg q.d.
11. Insulin sliding scale.
12. Enteric coated aspirin 81 mg po q.d.
13. Trazodone 12.5 mg po q.h.s.
14. Isordil 10 mg po t.i.d.
15. Lopressor 50 mg po t.i.d.
DISCHARGE CONDITION: Stable. Patient to go to [**Hospital3 1761**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], M.D. [**MD Number(1) 1590**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2142-9-21**] 16:04
T: [**2142-9-21**] 16:04
JOB#: [**Job Number **]
ICD9 Codes: 5789, 4280, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5690
} | Medical Text: Admission Date: [**2111-7-16**] Discharge Date: [**2111-7-19**]
Date of Birth: [**2052-6-24**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 58 year-old
male with a history of an inferior wall myocardial infarction
status post coronary artery bypass graft done in [**2101**] with a
left internal mammary coronary artery to left anterior
descending coronary artery graft, saphenous vein graft to D2
graft, saphenous vein graft to obtuse marginal graft. He was
doing fine until [**4-/2109**] when he began to have exertional
chest pain. His catheterization on [**2109-4-25**] revealed
pathology in the mid right coronary artery, which was
stented. He returned in [**2110-11-24**] for
catheterization, which again was due to exertional angina.
This catheterization showed significant three vessel disease
with a patent saphenous vein graft to obtuse marginal two,
occluded saphenous vein graft to diagonal, patent left
internal mammary coronary artery to left anterior descending
coronary artery, patent stent to the mid right coronary
artery, proximal right coronary artery had a focal 80%
stenosis and the distal right coronary artery had a severe
focal 90% stenosis prior to the origin of the posterior
descending coronary artery, status post stent placement to
the proximal and distal right coronary artery.
The patient was doing well without any chest pain after this
most recent intervention in [**Month (only) **] of last year. However,
he does report having shortness of breath with exertion and
minimal exercise. The patient denies claudication,
orthopnea, edema, paroxysmal nocturnal dyspnea and
lightheadedness. A recent stress test revealed that the
patient had a down sloping ST depression in V5 and V6, 1 and
L with maximum ST depressions of 2.5 mm in V5 at 3 minutes.
A nuclear study revealed severe reversible defect in the
distal anterior and apical walls and severe partially
reversible defect in the inferior left ventricular wall with
global hypokinesis and an EF of 40%.
The patient was electively taken to the catheterization
laboratory on [**7-16**] where he was found to have a total
occlusion of the proximal left anterior descending coronary
artery, total occlusion of the proximal left circumflex, 60%
mid segment stenosis in the previously stented right coronary
artery, saphenous vein graft to D1 continued to be occluded
as had been previously, saphenous vein graft to obtuse
marginal one was mid segment 80% focal lesion. The left
internal mammary coronary artery to left anterior descending
coronary artery was found to be patent with the left anterior
descending coronary artery after the touch down showed a
total occlusion. The saphenous vein graft to obtuse marginal
one was stented, however, the inferior pole from the outflow
vessel of the obtuse marginal had moderate slow flow after
intervention and was recrossed with the BMW wire plus
dilation, which restored TIMI two flow. The superior flow
from the out flow of the obtuse marginal was dilated and
restored TIMI three flow.
Upon entering the wards after the catheterization, the
patient underwent a ventricular fibrillation arrest within a
few hours of his procedure. The patient responded to one
defibrillator shock, which returned a perfusing rhythm,
however, the patient was diaphoretic, short of breath with
chest pain after being revived. Electrocardiogram showed ST
elevations in the anterolateral leads, which led to the
patient immediately being taken back to the catheterization
laboratory. During the second PCI it was noted that the
recently placed stent was patent, but that the inferior pole
had TIMI two flow and the prior study was completely occluded
therefore the inferior pole lesion was crossed at the wires,
stented open and TIMI three flow was returned to the vessel.
The patient's symptoms resolved after the procedure.
PAST MEDICAL HISTORY: Coronary artery disease,
hyperlipidemia, hypertension.
MEDICATIONS PRIOR TO ADMISSION: Atenolol 50 mg po q day,
Lipitor 80 mg q day, Univasc 15 mg b.i.d., Norvasc 10 mg
q.d., Ascriptin 325 mg q day, vitamin C 1000 mg q day, folic
acid 1 mg q day and multivitamin.
PHYSICAL EXAMINATION: Temperature 97.4, pulse 72. Blood
pressure 121/62. Respirations 14. The patient was sating
97% on 2 liters. Generally, he was alert and oriented times
three. No acute distress. Moderately obese male. HEENT
examination pupils are equal, round and reactive to light.
Extraocular movements intact. The patient was normocephalic,
atraumatic. Mucous membranes are moist. Neck examination
there is no JVP. No thyromegaly. No bruits. No cervical
lymphadenopathy. Cardiovascular examination revealed a
regular rate. Normal S1 and normal S2 and a 2 out of 6
systolic decrescendo murmur best auscultated at the left
sternal border. No rubs. Pulmonary examination lungs were
clear to auscultation bilaterally with no wheezes. Abdominal
examination soft, nontender, nondistended and bowel sounds
were active. Extremities, the patient had 1+ dorsalis pedis
pulses bilaterally with 2+ capillary refill bilaterally. The
patient's groin site was free of hematoma, however, the
sheaths were still in place on the right when he was admitted
to the Coronary Care Unit.
HOSPITAL COURSE: 1. Cardiovascular: A: Coronary artery
disease, the patient has extensive coronary artery disease
based on his prior coronary artery bypass graft and most
recent angiography, which demonstrated three vessel disease
with restenosis to some extent of each of his bypass grafts.
Dr. [**First Name (STitle) **] was to discuss the possibility of a second
cardiothoracic surgery with the CT surgeons. The patient was
given Integrilin for 18 hours and started on Plavix for a
thirty day course and given aspirin and Lipitor q day per his
outpatient regimen for hypercholesterolemia. Folate was
continued throughout the hospitalization and the patient was
restarted on Univasc at 15 mg q day, which was half his
normal dose. The patient ruled in for myocardial infarction
with CK levels of 529, CKMB 88, with an index of 16.6 on the
11th after the patient's defib arrest. The patient's CKs
peaked at that level and had declined to a CPK of 396 with a
CKMB of 27 and an index of 6.8 on the [**7-18**]. These
enzymes elevations were thought to be a result of the
combination of the defibrillation shock and the occlusion of
the lower pole vessel, which was stented open in the
catheterization laboratory during the second percutaneous
intervention.
B: Pump, the patient was initially started on Lopresor 25
b.i.d. after returning from the catheterization laboratory.
His heart rate, however, on hospital day number two was
elevated in the high 90s and in to the 100s as high as 118.
The patient was given intravenous Lopresor, which brought his
rate down to the 60s and 70s. His Lopressor dose was
increased to 75 mg b.i.d., which is what he was discharged to
home on. This regimen can be modified to optimize his heart
rate and blood pressure, however, at the time of discharge
the patient's blood pressure could not tolerate an increase
in this dose. The patient's echocardiogram done on the [**7-17**] revealed a left ventricular cavity that was mildly
dilated with severe global left ventricular hypokinesis and
overall left ventricular systolic function that was severely
depressed. Additionally the aortic valve leaflets were found
to be mildly thickened. Mitral valve leaflets were also
found to be mildly thickened and there was 1+ mild mitral
regurgitation. The patient's ejection fraction had been
estimated to be 25 to 30%. It was recommended by Dr. [**First Name (STitle) **]
that a repeat stress echocardiogram be done in one month to
evaluate the patient's left ventricular ejection fraction in
light of the defibrillation and mild myocardial infarction
that the patient had suffered during his hospitalization. It
would be expected that the patient's ejection fraction
increase.
C: Rhythm, the patient experienced a V fibrillation arrest
after his first percutaneous intervention, which was likely
due to the thrombosis of the inferior pole vessel of the
obtuse marginal. When the vessel was stented open the
patient was not thought to have any residual risk of
arrhythmia after the twelve hour reperfusion arrhythmia
window had closed. The patient was kept on telemetry and
serial electrocardiograms were checked. Frequent ectopy was
noted in the first 24 hours after the catheterization.
However, with electrolyte correction his ectopy diminished
and the patient's rhythm was relatively regular. The patient
did have several hours of sinus tachycardia that was treated
with intravenous Lopressor as noted above.
2. Pulmonary: The patient sated well throughout his
hospitalization initially on 2 liters of oxygen, which was
weaned to off on hospital day two.
3. Renal: The patient's BUN and creatinine remained within
normal limits despite the dye load of two catheterization
procedures. The patient maintained good urine output
throughout the hospitalization.
4. Hematology: The patient's hemoglobin and hematocrit
remained stable and within normal limits throughout the
hospitalization.
5. Endocrine: The patient has no history of diabetes and
his blood glucoses were in the high normal range throughout
his hospitalization. It is recommended that the hemoglobin
A1C be checked on an outpatient basis to assess for
burgeoning diabetes picture.
6. Prophylaxis: The patient was given Docusate for
constipation and Protonix for peptic ulcer disease throughout
his hospitalization.
7. Activity: The patient was visited by the physical
therapist who evaluated the patient and helped arrange
outpatient cardiac rehabilitation. The patient was able to
tolerate significant activities such as climbing stairs and
walking the hallways without symptoms. The patient was
discharged to home in good condition.
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction.
2. Ventricular fibrillation.
3. Hypercholesterolemia.
4. Hypertension.
5. Coronary artery disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 11117**]
MEDQUIST36
D: [**2111-7-19**] 14:35
T: [**2111-7-22**] 07:26
JOB#: [**Job Number 8504**]
cc:[**Last Name (NamePattern1) 94128**]
ICD9 Codes: 9971, 4275, 4240, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5691
} | Medical Text: Admission Date: [**2126-7-25**] Discharge Date: [**2126-8-13**]
Date of Birth: [**2057-3-8**] Sex: M
Service: LIVER TRANSPLANT SURGERY SERVICE
BRIEF CLINICAL HISTORY: The patient is a 60 year old white
man who is status post orthotopic liver transplant on [**2126-2-22**] by Dr. [**First Name (STitle) **] for hepatitis C virus and
hepatocellular carcinoma, presenting as a transfer from [**Hospital3 15516**] Hospital after 36 hour history of upper GI bleed and
melanotic stool. At [**Hospital3 **] Hospital, patient's platelet
counts were reported to be 3 with hematocrit of less than 20.
By report by the patient, he began to vomit bright red blood
approximately 36 hours prior to his presentation to [**Hospital3 **]
Hospital and 2 days prior to his presentation to the [**Hospital1 18**].
This bright red blood vomiting was quickly followed by severe
nausea and diarrhea. The patient does have a history of
grade III esophageal varices, but otherwise there is no
history of GI bleed.
The patient has been on multiple immunosuppressants since his
transplant. He was initially started on cyclosporin and
mycophenolate mofetil. At some point, the cyclosporin had
been discontinued and he was started on rapamycin. He was
continued on rapamycin for many months. However,
approximately 1 week prior to admission, he was changed to
Prograf. He has also been taking Bactrim one single-strength
pill daily since [**2126-2-26**].
Patient had been noted to have episodic thrombocytopenia
since as early as [**2125-6-26**]. Platelet level has fluctuated
between 80 and 130. Over the last 2 to 3 months, the patient
has had several hospital admissions for malaises and nausea
and vomiting. He has undergone extensive work up with
multiple cultures to test for viral and bacterial etiologies.
All of these have been negative. Most recent discharge was
[**Hospital1 18**] on [**7-20**].
Upon arrival to [**Hospital1 18**] he was transported immediately to the
surgical intensive care unit where he was found to have an
extremely low platelet count of less than 5, hematocrit of
20.5. He has required at least 6 units of blood since his
arrival and 4 units of platelets immediately upon his
arrival.
PAST MEDICAL HISTORY:
1. Alcoholic cirrhosis.
2. Hepatitis C.
3. Hepatocellular carcinoma.
4. Aforementioned orthotopic liver transplant.
5. Portal hypertension.
6. Splenomegaly.
7. Esophageal varices.
8. Distant history of tuberculosis, 18 years ago.
9. Coronary artery disease status post CABG.
MEDICATIONS AT HOME:
1. Bactrim single-strength.
2. Protonix 40 mg p.o. q. day.
3. Caltrate 600 mg p.o. b.i.d.
4. Aspirin 81 mg p.o. q. day.
5. Isordil 15 mg p.o. q day.
6. Propranolol 10 mg p.o. b.i.d.
7. Pyridoxine 100 mg p.o. q. day.
8. Isoniazid 300 mg p.o. q. bedtime.
9. CellCept [**Pager number **] mg 2 b.i.d.
10. Prograf 6 mg p.o. b.i.d.
ALLERGIES: Penicillin.
LABORATORY DATA ON PRESENTATION: Laboratories on
presentation include a white count of 8.6, hematocrit of
20.5, platelets 5. Chem-7 is sodium 143, potassium 3.9,
chloride 112, CO2 23, BUN 53, creatinine 1.0, glucose 128.
AST was noted to be 26, ALT 24, alk phos 65. Total bilirubin
is 1.1.
PERTINENT EXAMINATION: On presentation, patient's vital
signs are temperature 99.9, pulse 91, blood pressure 133/47,
respiratory rate of 23, saturation 100%. In general, the
patient is alert and oriented x3. He is not in distress, but
he does appear sickly. Pupils are equal and reactive to
light bilaterally. There is no evidence of any scleral
icterus. Cranial nerves II through XII are noted to be
grossly intact. Pulmonary examination shows the lungs to be
clear to auscultation bilaterally. Cardiac examination shows
heart regular rate and rhythm with no evidence of any
murmurs, rubs, or gallops. Abdomen is soft, nontender, with
no evidence of any distention. There is a well healed
midline incision. No evidence of any distention or tympany.
Extremities are warm, well perfused.
CLINICAL COURSE: Shortly after arrival in the intensive care
unit, the patient had an internal jugular catheter to provide
central venous access placed without complication. Shortly
thereafter, consultations were requested from the
hematology/oncology service, gastroenterology service,
transplant service. Once a nasogastric tube could be placed,
it was seen that the patient continued to have bright red
blood upon lavage. On the night of admission, Dr. [**Known firstname **]
[**Last Name (NamePattern1) 131**] performed an upper GI endoscopy. This revealed a small
to medium size actively bleeding source on the lesser
curvature of the stomach. This was cauterized with
apparently excellent resolution of the bleeding. At that
time, possible etiologies for the patient's thrombocytopenia
included hemolytic urea mix syndrome, ITP, and a possibility
of graft versus host disease following liver transplant.
Care in the intensive care unit focused on re-establishing
physiologically safe levels of platelets and bringing
hematocrit back up. To that end, all immunosuppressants were
stopped on arrival. Per hematology/oncology recommendations,
patient was started on first course of IVIG. Likewise,
heparin induced thrombocyte antibodies were sent and
subsequently were returned negative. Despite several course
of IVIG, there was reportedly very little resolution or
improvement in the platelet count despite multiple
transfusion of platelets and other blood products. Platelets
very rarely extended above 20.
On hospital day 6, patient was continuing to be stable and
decision was made to move him out of intensive care unit.
Immunosuppression was restarted with Solu-Medrol 60 mg p.o.
q. day. The following day, this was supplemented with
cyclosporin 125 mg p.o. b.i.d. Although, patient's clinical
appearance continued to improve, his thrombocytopenia
persisted, staying refractory to multiple platelet
transfusions and additional courses of IVIG. On hospital day
7, the patient underwent bone marrow biopsy for assess for
graft versus host disease. At the time of this dictation,
those results were not available. On hospital day 12,
hematology/oncology was once again reconsulted and it was
felt the patient's thrombocytopenia might very well be due to
sequestration. This turned conversation to considering
splenectomy versus rituximab or splenic sequestration. After
much consideration, discussing between the various teams,
decision was made to undergo splenectomy. On [**2126-8-9**]
or hospital day 16, the patient underwent laparoscopic
splenectomy by Dr. [**First Name (STitle) **]. The procedure went well. The
patient was extubated in the operating room. He was
transported to the post-anesthesia care unit and ultimately
onto the floor that night. Total blood loss during the
procedure was minimal and the patient only required 2 units
of packed red blood cells. For the subsequent days, the
patient's clinical picture continued to improve. He
recovered from the surgery extremely well with a gradual rise
in his platelet counts.
On hospital day 20, after final evaluation by Dr. [**Last Name (STitle) **] and
the hematology/oncology service, it was deemed the patient
was an appropriate candidate for discharge. His platelets
had remained stable and his immuno regimen likewise had been
stable. The patient did have a drainage catheter still in
place. This remained in the bed of the splenectomy. In the
days prior to discharge, this had put out 300, 200, and 65 ml
a day respectively.
DISCHARGE DIAGNOSIS:
1. Idiopathic thrombocytopenic purpura.
2. Status post splenectomy, [**2126-8-9**].
3. Status post liver transplant, [**2126-2-21**].
4. Status post upper gastrointestinal bleed.
5. Status post coronary artery disease.
6. Status post hypertension.
MEDICATIONS ON DISCHARGE:
1. Pantoprazole 40 mg p.o. q. day.
2. Percocet 5/325, dispense 30, 1 to 2 tablets to be taken
every 4 to 6 hours p.o.
3. Prednisone 10 mg p.o. q. day.
4. CellCept [**Pager number **] mg p.o. b.i.d.
5. Cyclosporin 200 mg p.o. q. 12.
6. Isosorbide dinitrate 10 mg p.o. q. day.
7. Caltrate 1 tablet p.o. b.i.d.
FOLLOW UP: Patient will follow up with Dr. [**Last Name (STitle) **] in 1 to 2
weeks. He has a drainage catheter in placed. He has been
trained and VNA has been arranged for him to be able to drain
and measure this daily. He will record these outputs and
report them to Dr. [**Last Name (STitle) **] on his return.
DISPOSITION: The patient is discharged to home to the care
of his family with VNA service in place.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2126-8-13**] 17:01:42
T: [**2126-8-13**] 18:10:34
Job#: [**Job Number 56346**]
ICD9 Codes: 2851, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5692
} | Medical Text: Admission Date: [**2135-3-9**] Discharge Date: [**2135-3-14**]
Date of Birth: [**2104-9-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Nausea/Vomiting/Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30M with hypothyroidism x 5 years, presented 24 hours prior to
admission with diffuse lower abdominal pain, nausea, bilious
vomiting, and watery green/brown diarrhea associated with
fevers/chills. Temperature at home was 104. He was referred from
PCP's office. In the ED he was hydrated with 7 liters of saline,
and he continued to be tachycardic with SBPs in the 90's. He was
found to have a pancytopenia, ARF (CR 1.8), a coagulopathy (INR
= 2, PTT = 49), and an indirect hyperbilirubinemia (TB = 9). A
central line was placed in the ED and he was started on
levo/flagyl, then admitted to MICU. He was found to have serum
Cortisol of 0.1, and placed on stress-dose steroids as well.
.
Of note he was recently seen in the ED 2-3 weeks ago with
suspected gastroenteritis, admitted briefly for IVF and d/c'd
home. He had N/V and abdominal pain, but abdominal U/S was
negative. At that time he was diagnosed with [**Doctor Last Name 9376**] given an
isolated elevated indirect bili. He felt well between these
episodes. On ROS, parents may have noted skin darkening, wt
loss, fatigue over last 1-2 years
Past Medical History:
Hypothyroidism
Possible [**Doctor Last Name 9376**] Disease
Social History:
Pt works as an auditor. Is married with 2 children, ages 5 weeks
and 16 months. His wife had an episode of N/V 3 weeks ago which
resolved. Denies tobacco use, occ Etoh use. Originally from [**Location 10050**]. Denies recent travel.
Family History:
grandparents w/ colon ca and DM2; no [**Doctor Last Name 9376**], thryoid, or
known autoimmune disorders
Physical Exam:
VITALS: T=86.4, BP=87/39-105/59, HR=74-85, RR=13-17, O2=98-100%
on RA
PE:GEN: Pt is well appearing in NAD
HEENT: icteric, mm, OP clear
CHEST: CTA bilaterally
CV: RRR, mild I/VI SEM
ABD: soft, NT, ND; no stigmata of chronic liver disease
EXT: no LE edema
NEURO: CN's intact, nonfocal exam; no aterixis
Pertinent Results:
[**2135-3-9**] 03:40PM WBC-5.0 RBC-5.34 HGB-15.8 HCT-44.2 MCV-83
MCH-29.6 MCHC-35.9* RDW-13.3
[**2135-3-9**] 07:30PM PT-18.0* PTT-47.2* INR(PT)-2.0
[**2135-3-9**] 07:30PM FIBRINOGE-283
[**2135-3-9**] 07:30PM RET AUT-2.2
[**2135-3-9**] 07:30PM HAV Ab-NEGATIVE
[**2135-3-9**] 07:30PM CORTISOL-0.1*
[**2135-3-9**] 07:30PM TSH-0.74
[**2135-3-9**] 07:30PM HAPTOGLOB-<20*
[**2135-3-9**] 10:50PM CRP-5.09*
[**2135-3-9**] 10:50PM FDP-40-80
[**2135-3-9**] 09:14PM LACTATE-1.2
ABD CT - [**2135-3-10**] - Multiple prominent inguinal and pelvic lymph
nodes are seen, which do not meet CT criteria for pathologic
enlargement.
IMPRESSION: No evidence of colitis or obstruction. Moderate free
fluid at the level fo the pancreas. If clinically warranted, MRI
or CT with contrast should be performed.
Brief Hospital Course:
A/P: 30 yo male with hypothyroidism and [**First Name9 (NamePattern2) 10260**] [**Doctor Last Name 9376**], with
newly diagnosed adrnenal insufficiency and [**Doctor Last Name 10260**] gastroenteritis,
with resolving ARF, coagulopathy, and hyperbilirubinemia.
.
1. Hypotension - BP improved with IVFs and stress-dose steroids.
Intially there was suspected sepsis vs gastroenteritis with
underlying adrenal insufficiency. Initial temps to 104 were
concerning, but he quickly became afebrile off antibiotics.
Lactates were normal. He recieved >7L NS with good urine output.
After steroid replacement, he still had SBP's in 90's while
ambulating and was asymptomatic.
.
2. Endocrine - Endocrine was consulted. He was transitioned from
Hydrocort to Prednisone, and tapered to 5mg in AM and 2.5 in PM.
Multiple [**Last Name (un) 104**] stim tests revealed very low Cortisol levels of
0.1, 0.7, ans 2.0 without appropriate bump. ACTH was pending at
the time of d/c as well as Vit D level. He was increased per
Endocrine to 125mcg of Levoxyl, to f/u TSH, T4, and T3 at
[**Hospital 1800**] clinic. He was told to get a medical alert bracelet
and will be given IV Solumedrol prescription at [**Hospital 6091**]
clinic.
.
3. Hematology - he intially presented with elevated INR with
concern for slight DIC. DIC labs were negative, and his
coagulopathy improved. He also had evidence of mild pancytopenia
with low WBC and Hct, and borderline low platelets. Hematology
was consulted. It was felt that his sx's may be related to
underlying infection, and likely had resolving viral illness.
HAV and HIV were negative, CMV and EBV were ordered. His anemia
appeared to have combined picture with evidence of mild
hemolysis with low haptoglobin(but NL LDH and NL smear), but
also with retic count of 2.2. Iron studies not c/w clear iron
deficiency, vit B12/folate pending at the time of dischrage.
Haptoglobin normalized, and Hct began to rise. It was felt that
his elevated indirect bilirubin may be related to [**Doctor Last Name 9376**]
and/or mild hemolysis in setting of acute stress with
starvation/dehydration. He was also noted to have diffuse but
non pathological lyphadenopathy on abd CT of unclear
significance. This may due to his underlying infectious process.
He may recieve outpatient chest CT during Hematology follow-up.
If his pancypenia persists, he may get bone marrow biopsy as
well.
.
4. GI - stool studies were negative and hepatitis A was
negative. It was felt that his N/V/D may be related to
underlying adrenal insufficiency, or possible superimposed viral
gastroenteritis. Given degree of diarrhea and underlying
autoimmune disorders, anti-TTG was sent for Celiac Sprue which
pending at the time of discharge. He was guiac negative.
.
5. CARDIAC - upon presentation he has possible STE's in V1 and
V2, which then resolved as the patient clincally improved. The
patient had an episode of syncope earlier that day after severe
N/V/D (but no prior episodes), but there was concern for Brugada
syndrome. These EKG changes resolved after the patient
clinically improved. He was told to follow-up in cardiology
clinic with EP, and may need further cardiac evaluation with
Echo or Holter monitor.
Medications on Admission:
Levoxyl 25mcg QD
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Prednisone 2.5 mg Tablet Sig: 1-2 Tablets PO twice a day:
Please take 2 tablets (5mg) in the morning, and 1 tablet (2.5mg)
in the afternoon. This may be changed by Dr [**First Name (STitle) **].
Disp:*90 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Adrenal Insufficiency
Hypothyroidism
Possible Brugada Syndrome
Resolving Pancytopenia
Discharge Condition:
Stable
Discharge Instructions:
Please continue Prednisone, Fludricortsone, and Levothyroxine as
prescribed. Please be sure to arrnge for a Medical Alert
Bracelet because of your Adrenal Insufficiency. If you develop
any nausea/vomiting, fevers/chills, diarrhea, lightheadedness,
or any other concerning symptoms whatsoever please go directly
to the Emergency Department because of your severe adrenal
insufficiency.
Followup Instructions:
Please be sure to follow-up with your PCP [**Name Initial (PRE) 176**] 1 week of
discharge.
[**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 2660**]
Please be sure to follow-up with Dr [**First Name (STitle) **] from Endocrinology
within 1-2 weeks of discharge. Please call ([**Telephone/Fax (2) 25600**]for an
appointment. Please discuss a prescription for a Solumedrol in
times of stress.
Please be sure to follow-up with Hematology, please call
([**Telephone/Fax (1) 25601**] for an appointment. You should follow-up with Dr
[**Last Name (STitle) 25602**], in conjunction with Dr [**Last Name (STitle) **](Tuesday morning) OR Dr
[**Last Name (STitle) 410**] (Weds afternoon).
Please be sure to follow-up with Cardiology. Please make a
follow-up appointment with Dr [**Last Name (STitle) 2357**] and/or Dr [**Last Name (STitle) 171**] at
([**Telephone/Fax (1) 22784**]. You require require further cardiac testing such
as a cardiac Echo and/or Holter monitor.
Completed by:[**2135-3-14**]
ICD9 Codes: 5849, 2765, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5693
} | Medical Text: Admission Date: [**2186-1-26**] Discharge Date: [**2186-2-6**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
transfered for cath
Major Surgical or Invasive Procedure:
CABG
History of Present Illness:
88 y/o male w/ h/o angina, HTN, hyperlipidemia who originally
presented to OSH in [**Month (only) 1096**] with urinary retention. He
underwent TURP. During the post operative period, he developed
rapid afib, chest pain and ST segment depression. He had a mild
troponin elevation (3.14) as well. Cardiac cath on [**12-26**]
demonstrated 100% LAD with right to left collateral filling,
100% distal RCA with left to right collateral filling, 99%
proximal ramus, 90% stenosis in the bifurcation CX/OM branch.
Attempt at PCI w/ stent placement was unsuccessful. Patient is
transfered to [**Hospital1 18**] for further eval ct [**Doctor First Name **] vs high risk PCI.
Past Medical History:
BPH s/p TURP - postoperative course complicated by a-fib w/
non-ST elevation MI
HTN
Hyperlipidemia
TIA
Hypothyroidism
Renal insufficiency
Social History:
no ETOH, no tobacco, lives w/ daughter, wife
Family History:
father w/ MI at 68
Physical Exam:
97.4 132/61 60 18 97% RA
Gen: NAD, A+O x 3
HEENT: NC/AT, non-icteric slera, lazy left eye
Cardiac: RRR, no MGR
Pulm: CTAB
Abd: soft, flat, non-tender, nl BS
Ext: no edema
Neuro: non-focal
Pertinent Results:
EKG: sinus 54
Brief Hospital Course:
A/P: 88 y/o male w/ multiple cardiac risk factors who had non-ST
elevation MI in setting of post op a-fib. Cardiac cath
demonstrated significant 3VD. Patient transfered to [**Hospital1 18**] for
further eval, PCI VS CABG.
Pt. was taken to OR on [**1-30**] for CABG X 3 and maze procedure.
Post-operatively he required IV neo for BP support. He
transferred to the telemetry floor, and has had multiple
episodes of AFib with a controlled rate and stable BP. He is
being anticoagulated on Coumadin. He has progressed slowly with
physical therapy, and would benefit from short term rehab to
progress with mobility.
Medications on Admission:
atenolol 50 mg po qd
colace 100 mg po qd
ASA 81 mg po qd
Triamterene/HCTZ 37.5/25 po qd
lipitor 10 mg po qd
norvasc 5 mg po qd
synthroid 100 mcg po qd
MVI or Vit E on alternating days
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
11. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 weeks: then decrease to 200 mg PO QD.
12. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days: 3mg today & tomorrow ([**2-6**] & [**2-7**]), then check
INR and dose for target INR 1.5-2.0.
Discharge Disposition:
Extended Care
Facility:
golden View
Discharge Diagnosis:
CAD
AFib
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# or driving for 1 month
may shower, no bathing for 1 month
no creams or lotions to incisions
Followup Instructions:
with Dr. [**Last Name (STitle) 11250**] in [**2-2**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks
with Dr. [**Last Name (STitle) **] in 3 months for follow-up for Maze procedure
([**Telephone/Fax (1) 22784**]
Completed by:[**2186-2-6**]
ICD9 Codes: 4111, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5694
} | Medical Text: Admission Date: [**2168-2-9**] Discharge Date: [**2168-2-22**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: This is a 41 year old man with
end stage renal disease, dementia, hypertension, type II
diabetes, change in mental status five days prior to his
admission. At hemodialysis, the patient was noted to have
low grade fevers. Blood cultures were drawn and he was given
Vancomycin and Gentamycin doses times one. On arrival to the
Emergency Room, the patient was found to have a right lower
lobe consolidation and he was given one dose of Levaquin.
The patient was found to be in altered mental status.
Subsequently, his psychiatric medications were held. His
Levofloxacin was started on hospital day number two for
possible pneumonia. By hospital day number three, the
patient became increasingly lethargic and febrile to 101.5.
At this time, the patient became hypotensive his systolic
blood pressures dropped to the 70's. The patient's blood
pressure responded to intravenous fluids and he was given
Vancomycin and Flagyl. On hospital day number four, the
patient again became hypotensive and was sent to the
Intensive Care Unit and given aggressive hydration. In the
Intensive Care Unit, the patient was given Vancomycin and
Flagyl for suspected aspiration pneumonia. At that time, the
patient also had increasing rigors and muscle tone, thought
to possibly be secondary to his psychiatric medications.
In the Medical Intensive Care Unit, the patient was placed on
pressors and intravenous fluids. He was given Vancomycin,
Levofloxacin and Flagyl. A lumbar puncture was performed
without evidence of infection. Once the blood pressure was
stabilized, the patient was transferred to the [**Hospital1 139**]
Medicine Floor.
PAST MEDICAL HISTORY: 1.) Hypertension. 2.) End stage renal
disease, on hemodialysis. 3.) Arteriovenous fistula with a
history of pseudoaneurysm, status post repair in [**10-23**]. 4.)
Dementia. 5.) Gout. 6.) Questionable history of positive
PPD. 7.) History of Methicillin resistant Staphylococcus
aureus. 8.) Anemia of chronic disease. 9.) History of
hospitalization for syncope and mental status changes. 10.)
Dialysis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
Risperdal 0.5 mg p.o. three times a day.
Phos-Low two tablets with medications.
Remeron 30 mg once a day.
Zestril 40 mg once a day.
Hydralazine 50 mg four times a day.
Aspirin 81 mg once a day.
Imdur 60 mg once a day.
Nephro-Caps one tablet q. day.
Hytrin 2 mg p.o. q h.s.
Colchicine 0.6 mg p.o. q. day.
Allopurinol 100 mg p.o. q. day.
PHYSICAL EXAMINATION: Upon transfer, temperature was 98.9; T
maximum was 102; blood pressure was 125/70; pulse 88;
respiratory rate 20; oxygen saturation 96% on four liters.
On general examination, he is unresponsive to verbal stimuli.
He was lethargic but responded to pain. Cardiovascular:
Neck examination revealed jugular venous distention of about
6 cm. Cardiovascular: Distant heart sounds, regular rate and
rhythm. Pulmonary: Poor inspiratory effort. Abdomen was
nontender, nondistended. Positive bowel sounds, no masses.
Extremities: The patient is in multi-poultice boots for bed
sore blisters on feet. Neurologic: He is unresponsive;
decreased tone.
LABORATORY DATA: Sputum culture showed Methicillin resistant
Staphylococcus aureus, positive but consistent with
oropharyngeal flora. Cerebrospinal fluid showed one white
blood cell count, total protein of 44, glucose of 64. LDH of
39. White blood cell count was 10.9; troponin T of 0.30.
TSH of 0.94. All blood cultures were negative. Urine
cultures were negative. Cerebrospinal fluid cultures
negative.
HOSPITAL COURSE: 1.) Mental status changes: The patient was
thought to have poor mental status, secondary to his
infection. The patient during the earlier part of the
hospital course had hyponatremia which was repleted
cautiously with free water. Meningitis was ruled out by
lumbar puncture. His psychiatric medications were held as a
potential cause for his change in mental status. However, as
the patient's febrile illness subsided, the patient's mental
status increased. By the end of the hospital stay, the
patient was able to verbally respond to questions.
The patient continued to have elevated fevers after his
transfer from the Intensive Care Unit. Initially, the
patient was on Ceftriaxone and Flagyl for antibiotics. Given
the high likelihood of the patient's gram negative infection,
with the possibility of anaerobic infection from aspiration,
the patient was switched to Cefepime and Flagyl to also
include pseudomonal coverage. Given that the patient had a
Methicillin resistant Staphylococcus aureus positive sputum,
he was also continued on the Vancomycin.
The patient's fever curve continued to improve and the
patient became afebrile for over 72 hours. At this time, the
Flagyl was discontinued to prevent the selection of
Vancomycin resistant to enterococcus.
The patient's blood pressure remained stable during his
hospital course, after Medical Intensive Care Unit transfer.
The patient became hypertensive and his antihypertensive
medications were added gradually. The patient continued
hemodialysis on Monday, Wednesday and Friday. The patient
was given phosphate binders.
The patient had remained n.p.o. for several days. An
nasogastric tube placement was attempted but was
unsuccessful. Initial placement of nasogastric tube was
pulled out by patient. Subsequently placement was
unsuccessful. After discussion with the family, it was
decided that the patient would be a candidate for
percutaneous endoscopic gastrostomy placement, to receive
enteral nutrition. The patient had percutaneous endoscopic
gastrostomy placement by gastroenterology without
complications and tube feeds were started several hours after
placement of the tube.
The patient was evaluated by speech and swallow for
possibility of aspiration. A video swallow was performed
which showed that food of all consistencies were aspirated
down the trachea. The patient was deemed unable to take p.o.
and was made n.p.o. In addition, to prevent further
complications from tube feeds, the patient was kept upright
at 30 degrees during all times of tube feeds.
The patient had anemia of chronic disease. The patient was
given Erythropoietin.
The patient was immobile and chronically in bed. The patient
began to develop bed sores. The patient was placed in
multi-poultice boots for formation of new ulcers on the heels
of both feet, as well as a sacral ulcer, grade one.
The patient was given First Step air mattress and wounds were
managed with wet to dry dressings daily. The patient was
turned twice a day to avoid formation of bed sores.
The patient never complained of chest pain; however, the
patient's troponin T levels trended upwards. Despite this,
the patient's creatinine kinase and MB fractionation remained
stable. The patient's peak troponin T was 0.78. The patient
was given aspirin p.r. and intravenous beta blocker prior to
his percutaneous endoscopic gastrostomy placement.
Subsequent to percutaneous endoscopic gastrostomy placement,
the patient was given betablocker and aspirin via
percutaneous endoscopic gastrostomy tube. The patient's
cardiac enzymes were monitored.
CONDITION ON DISCHARGE: Afebrile; no hypoxia; good.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Ischemia.
3. End stage renal disease.
4. Delirium.
5. Dementia.
6. Hypernatremia.
7. Hypotension.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg once a day.
2. Isosorbide 60 mg once a day.
3. Terazosin 2 mg once a day.
4. Colace liquid.
5. Bisacodyl 10 mg once a day.
6. Subcutaneous heparin q. eight hours.
7. Allopurinol 100 mg p.o. q. day.
8. Senna 8.6 mg p.o. twice a day.
9. Sovalimir 1600 mg p.o. three times a day.
10. Bactroban ointment twice a day to scrotal sores.
11. Isosorbide dinitrate 30 mg p.o. three times a day.
12. Lisinopril 40 mg p.o. q. day.
13. Metoprolol 12.5 mg p.o. twice a day.
14. Acetaminophen.
15. Flumotadine 20 mg intravenous q. 24 hours.
16. Cefepime 500 mg intravenously once a day for seven days,
given after hemodialysis on Monday, Wednesday and Friday.
17. Vancomycin one gram dosed by Vancomycin levels daily for
the next seven days; if less than 15, then give 1 gram
dose and repeat the dose the next day.
18. Humalog sliding scale.
FOLLOW-UP PLANS: The patient is to follow-up with his
primary care physician. [**Name10 (NameIs) **] patient should get hemodialysis
every Monday, Wednesday and Friday. The patient should have
cardiac enzymes, white blood cell count and Vancomycin levels
followed on a regular basis. The patient should have tube
feedings, Nepro full strength, with a goal rate of 30 ml per
hour. 60 grams of ProMod should be added to the tube feeds
daily. Tube feeds should be flushaed with 200 ml of water
every four hours.
[**First Name11 (Name Pattern1) 402**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7463**]
Dictated By:[**Name8 (MD) 10402**]
MEDQUIST36
D: [**2168-2-22**] 01:42
T: [**2168-2-22**] 08:18
JOB#: [**Job Number 12096**]
ICD9 Codes: 5070, 2765, 2760, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5695
} | Medical Text: Admission Date: [**2148-5-8**] Discharge Date: [**2148-5-26**]
Date of Birth: [**2072-6-27**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Shellfish Derived / Ace Inhibitors / Levaquin /
mirtazapine / ceftriaxone
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Fevers, Altered mental status, ? Seizures
Major Surgical or Invasive Procedure:
Intubation [**2148-5-8**], [**2148-5-13**]
Extubation [**2148-5-11**], [**2148-5-13**], [**2148-5-20**]
Direct laryngoscopy, bronchoscopy, left substernal thyroidectomy
through cervical approach, with right subtotal thyroidectomy
History of Present Illness:
Ms. [**Known lastname 51035**] is a 75 year old female with a history of seizure
disorder who presented from her rehab facility with questionable
seizures and fevers. Per report, the patient was found yesterday
evening by workers at the facility to be aphasic, not responding
to commands or questions. At that time the workers thought she
was just tired and left her alone. In the morning at change of
shift, care takers who were more familiar with the patient's
clinical status were concerned she was having a seizure.
Additionally, at that time temperatures were reocrded at 101.4
at rehab.
.
In the ED, initial VS were T:100.2/repeat 101.3 and with rectal
temp of 104, BP 138/72, HR: 96, RR 20, Satting 100% on RA.
Initally, patient presented not following commands and
lethargic. Labs were significant for creatinine of 2.0 (baseline
1.5-2.0), glucose to 266, WBC count of 18.3 with 94% PMN's,
elevated K+ although labs were hemolysed. Phenytoin levels were
12.3. Lactate was 3.2 and she received 3 liters of NS, with
followup lactate of 2.6. Urinalysis was positive for large
amounts of WBC's, bacteria, and some RBC's. Given her fevers and
altered mental status, an LP was performed, and she was
empirically provided with vancomycin, ceftraixone, ampicillin,
and acyclovir. LP results were was grossly negative for
infectious etiologies. CXR did not show gross evidence of
pneumonia, and CT head was negative for ICH. She had a stat EEG
which was nonspecific, and neurology was consulted and will
eventually perform a full video EEG. The patient was given 2 mg
of IV lorazepam for suspceted fevers. Shortly after, oxygen
saturations dropped to the low 80's and the patient was
intubated for hypoxic respiratory distress. Per report, patient
was a difficult intubation requring use of a bougie. Propofol
was used for induction, and after her propofol bolus her blood
pressures dropped to the low 80's systolic, but responded with
decreases in propofol infusion.
Upon transfer to the floor, vitals were BP 102/47 HR74 and
T101.3 after rectal APAP.
.
On arrival to the MICU,patient is intubated and sedated on the
vent unresponsive.
.
Review of systems:
Unable to obtain.
Past Medical History:
Psychiatric illness
Paranoid delusions
Seizure disorder
Vascular dementia
Hypertension
Hyperlipidemia
Depression
Chronic kidney disease
Multinodular goiter
History of angioedema
GERD
Hyperthyroidism
Social History:
Patient is originally from [**University/College **], no tobacco, no alcohol. She
lives in [**Hospital3 **]
Family History:
Unable to obtain
Physical Exam:
ON ADMISSION TO ICU:
General: Intubated and sedated on the vent. Not responding to
verbal commands.
HEENT: Sclera anicteric, MMM, poor dentition.
Neck: supple, JVP not appreciated, no LAD
CV: Distant HS. Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Coarse breath sounds auscultated anteriorly, but
otherwise clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Protuberant. Soft, non-tender, hypoactive bowel sounds
present, no organomegaly
GU: foley in place with no urine (recently drained)
Ext: Cool hands and feet with poor peripheral lower extremity
pulses and 1+ radial pulses bilaterally. No edema appreciated.
No clubbing.
Neuro: Cannot complete full exam given sedation on vent. Laying
supine without evidence of decerabrate posturing. Pupils are
pinpoint and poorly reactive. No blink to corneal irritation.
Unable to appreciate DTR's in upper extremities or lower
extremities. Upgoing Babinski's bilaterally.
.
ON ADMISSION TO INPATIENT MEDICINE:
General: Alert, disoriented, tangential, speaking Spanish, no
acute distress
HEENT: PERRL 4->3mm bilat, sclera anicteric, MMM, oropharynx
clear
Neck: supple, JVP not elevated, surgical incision intact without
erythema, swelling, drainage. JP drain in place with
serosanguinous fluid.
Lungs: Clear bilaterally to anterior auscultation, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Midline scar below umbilicus, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: Foley in place with clear yellow urine
Ext: Cool, brisk cap refill, left upper extremity edema, bilat
LE edema, no clubbing, cyanosis
.
DICHARGE PHYSICAL EXAM:
General: AAOx3, speaking in English, no acute distress
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, surgical incision intact without
erythema, swelling, drainage.
Lungs: Clear bilaterally to anterior and posterior auscultation,
no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Midline scar below umbilicus, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: WWP, brisk cap refill, bilat UE edema L>R, trace bilat LE
edema, no clubbing, cyanosis
Pertinent Results:
ADMISSION LABS:
[**2148-5-8**] 02:15PM BLOOD WBC-18.3*# RBC-3.99* Hgb-11.6* Hct-38.0
MCV-95 MCH-29.0 MCHC-30.4* RDW-13.1 Plt Ct-221
[**2148-5-8**] 02:15PM BLOOD Neuts-93.8* Lymphs-3.1* Monos-1.9*
Eos-0.9 Baso-0.1
[**2148-5-8**] 02:15PM BLOOD PT-11.7 PTT-26.6 INR(PT)-1.1
[**2148-5-8**] 02:15PM BLOOD Glucose-266* UreaN-27* Creat-2.0* Na-133
K-8.4* Cl-99 HCO3-25 AnGap-17
[**2148-5-8**] 08:58PM BLOOD ALT-32 AST-33 AlkPhos-76 TotBili-0.3
[**2148-5-8**] 02:15PM BLOOD cTropnT-<0.01
[**2148-5-8**] 02:15PM BLOOD Albumin-4.0
[**2148-5-8**] 08:58PM BLOOD Albumin-3.3* Calcium-9.6 Phos-1.1*#
Mg-1.6
[**2148-5-9**] 05:29AM BLOOD TSH-0.62
[**2148-5-9**] 05:29AM BLOOD T4-5.4
[**2148-5-10**] 03:52AM BLOOD Free T4-1.1
[**2148-5-14**] 03:50AM BLOOD C4-27
[**2148-5-8**] 02:15PM BLOOD Phenyto-12.3
[**2148-5-8**] 04:21PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-439* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 AADO2-243
REQ O2-48 -ASSIST/CON
[**2148-5-8**] 02:31PM BLOOD Lactate-3.2* K-5.7*
[**2148-5-8**] 04:21PM BLOOD O2 Sat-97
[**2148-5-9**] 02:09PM BLOOD freeCa-1.32
.
MICROBIOLOGY DATA:
[**2148-5-8**] Urine Culture:
KLEBSIELLA PNEUMONIAE
. |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2148-5-8**] 4:55 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final [**2148-5-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2148-5-11**]): NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED
.
[**2148-5-8**] 8:59 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2148-5-11**]**
MRSA SCREEN (Final [**2148-5-11**]): No MRSA isolated.
.
[**2148-5-18**] 12:05 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2148-5-20**]**
GRAM STAIN (Final [**2148-5-18**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2148-5-20**]):
RARE GROWTH Commensal Respiratory Flora.
YEAST. RARE GROWTH.
.
[**2148-5-21**] 1:56 am BLOOD CULTURE FROM CVL LINE.
Blood Culture, Routine (Pending):
.
[**2148-5-21**] 9:55 am BLOOD CULTURE Source: Line-RIJ SET#2.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2148-5-23**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2148-5-23**] AT
0105.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2148-5-21**]:
URINE CULTURE (Final [**2148-5-22**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
.
RADIOLOGICAL STUDIES:
CT HEAD - [**2148-5-8**]
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect, shift
of normally midline structures, or vascular territorial infarct.
Ventricles
and sulci are mildly prominent consistent with age-related
atrophy.
Calcifications of the carotid siphons are again noted. No
fractures or soft
tissue abnormalities are seen. Imaged portions of the mastoid
air cells and
paranasal sinuses appear unremarkable.
IMPRESSION: No evidence of intracranial hemorrhage.
.
CHEST XRAY - [**2148-5-8**]
FINDINGS: Supine AP portable view of the chest was obtained.
There has been
interval placement of endotracheal tube, terminating
approximately 3 cm below
the carina. Nasogastric tube is seen coursing below the level
of the
diaphragm and terminating in the expected location of the distal
stomach. The
aorta is calcified and tortuous. The cardiac silhouette is not
enlarged.
Paratracheal opacity is again seen as also seen on the prior
study. Subtle
medial right base patchy opacity could relate to aspiration. No
pleural
effusion or pneumothorax is seen.
IMPRESSION:
1. Endotracheal and nasogastric tubes in appropriate position.
2. Subtle streaky medial right base opacity could relate to
aspiration
depending on the clinical situation.
.
RIGHT UPPER EXTREMITY ULTRASOUND
The left and right subclavian venous waveforms show normal and
symmetric
tracings with respiratory variability normally noted. The right
internal
jugular is patent and easily compressible. The axillary and
both brachial
veins are also easily compressible and fully patent. The
basilic vein is
patent but the cephalic vein is thrombosed. Extensive
subcutaneous edema is
noted in the arm.
CONCLUSION: 1. No evidence of DVT in the right upper
extremity. Superficial
cephalic venous thrombus is noted.
.
BILATERAL UPPER EXTREMITY ULTRASOUND
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 867**] was performed of
the bilateral
internal jugular, subclavian, axillary, paired brachial,
basilic, and cephalic
veins. A known superficial venous thrombus in the right
cephalic vein is
unchanged from [**2148-5-14**] with minimal flow demonstrated on power
Doppler
analysis. The right internal jugular vein contains a small
nonocclusive
thrombus. A right-sided PICC is in position within one of the
paired right
brachial veins extending into the right subclavian vein, which
demonstrates
normal compressibility, augmentation and flow. All remaining
visualized
venous structures in the right upper extremity show normal
compressibility,
augmentation, and flow. In the left upper extremity, the left
internal
jugular vein contains a small non-occlusive thrombosis with
preserved flow.
The remaining visualized venous structures in the left upper
extremity show
normal compressibility, augmentation and flow.
IMPRESSION:
1. Small non-occlusive thrombi in the right internal jugular
vein and left
internal jugular vein.
2. Stable nearly occlusive superficial venous thrombosis of the
right
cephalic vein from [**2148-5-14**].
.
DISCHARGE LABS:
[**2148-5-26**] 05:30AM BLOOD WBC-8.8 RBC-2.86* Hgb-8.2* Hct-27.4*
MCV-96 MCH-28.8 MCHC-30.1* RDW-15.2 Plt Ct-247
[**2148-5-24**] 04:40AM BLOOD Neuts-67.4 Lymphs-21.8 Monos-4.7 Eos-5.9*
Baso-0.1
[**2148-5-26**] 05:30AM BLOOD Glucose-116* UreaN-16 Creat-1.5* Na-144
K-4.0 Cl-105 HCO3-29 AnGap-14
[**2148-5-26**] 05:30AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0
[**2148-5-9**] 05:29AM BLOOD TSH-0.62
[**2148-5-10**] 03:52AM BLOOD Free T4-1.1
[**2148-5-9**] 05:29AM BLOOD T4-5.4
[**2148-5-23**] 05:59AM BLOOD Cortsol-18.9
[**2148-5-14**] 03:50AM BLOOD C4-27
[**2148-5-26**] 05:30AM BLOOD Phenyto-11.3
.
PENDING LABS:
Blood Cultures from [**2148-5-21**]
Brief Hospital Course:
Ms. [**Known lastname 51035**] is a 75 year old female with a history of seizure
disorder who presented from her rehab facility with questionable
seizures and fevers.
.
# Altered mental status/encephalopathy: Pt was initially
admitted with unresponsiveness with concern for seizure given
her seizure disorder. Neurology was consulted and EEG was
performed that did not show seizure activity. She was found to
have a UTI, urine culture grew klebsiella. She was treated with
ceftriaxone that was later changed to meropenem given concern
for possible angioedema (see below). She was then found to have
fungal UTI and was started on fluconazole (see below). Mental
status returned to baseline. She was continued on her home dose
of phenytoin then uptitrated as she was subtherapeutic (see
below).
.
# Seizure disorder: Patient initially presented with concern for
seizures. Neurology was consulted and EEG did not show seizure
activity. Patient continued on her home dilantin dose. On [**5-21**]
patient had seizure x3. Dilantin level was checked and was
undectable. Patient was reloaded with IV fosphenytoin.
Patient's home dilantin dose was increased to 125 mg [**Hospital1 **].
Dilantin level at time of discharge was 14.9 when corrected for
hypoalbuminemia. Please recheck patient's dilantin dose in
three days and adjust dilantin dosing; target dilantin level is
16.
.
# UTI, bacterial, and UTI, candidal: Pt initially had klebsiella
UTI treated with meropenem. She had repeat UA after seizure with
150 WBCs. Urine culture grew yeast x3. Discussed with ID,
started fluconazole for 10 days. Last dose for fluconazole is
[**2148-5-31**]. Please follow up with a repeat UA at the end of
fluconazole course.
.
# Respiratory distress: Upon presentation to ED, concern was
high for seizure and pt received benzodiazepines. In this
setting, she developed hypoxia and required intubation. She
required minimal ventilatory support and was able to follow
commands without need for much sedation. Extubation was
attempted on [**2148-5-11**] but she required re-intubation within 3
hours due to respiratory distress. She had a large amount of
laryngeal edema that was felt to be responsible for her failed
extubation and she was placed on IV steroids to reduce swelling.
She had several allergies to antibiotics with adverse reaction
being angioedema. Given concern that her ceftriaxone may be
causing angioedema, she was switched to meropenem. Extubation
was attempted again on [**2148-5-13**]; she once again developed
respiratory distress and hypoxia within 6 hours and required
re-intubation. A large amount of edema was again noted. ENT
was consulted regarding tracheostomy. They recommended CT neck
to evaluate size of her large multinodular goiter. They brought
her to the OR on [**2148-5-17**] for subtotal thyroidectomy and
extubation was again performed on [**2148-5-20**]. While in the ICU,
patient's total body balance was positive 14 liters and crackles
were appreciated on lung exam and she had edema of her limbs.
Patient was given lasix and her edema improved along with her
lung exam. Please monitor patient's fluid status and
respiratory status and give diuretics as needed. Extra fluid in
her body should mobilize and be excreted in urine.
.
# s/p Subtotal thyroidectomy: Pt was noted to have large
multinodular goiter. TFTs were within normal limits. She had
been on methimazole as outpatient; this was not continued in
house. CT neck showed large goiter and pt was seen by ENT who
recommended thyroidectomy as the goiter was compressing her
trachea and may have been the reason for her failed extubations.
Thoracic surgery was also called regarding possible
tracheomalacia seen on CT scan. Thoracic surgery felt that this
was not tracheomalacia but rather compression of trachea from
thyroid mass. She underwent thyroidectomy on [**2148-5-17**]. Right
thyroid lobe was left; parathyroids were left in place. Calcium
was monitored carefully postoperatively. She had JP drain in
place after surgery which was removed. She should follow up with
her endocrinologist 3 weeks after discharge and Dr. [**Last Name (STitle) 51039**] to
follow up with outcome of surgery.
.
# Volume overload / upper extremity edema: Patient's total body
fluid balance during her ICU stay was positive 14 liters. She
required several doses of IV lasix as she developed pulmonary
edema. Her upper extremities were noted to be swollen (L>R).
Bilateral upper extremity ultrasound was obtained and showed
no-occlussive thrombi in right and left IJ. No anti-coagulation
was initated as there is no clear evidence of benefit in
non-occlussive thrombi. Please continue to monitor patient's
upper extremities and reevaluate as needed.
.
# Transitional issues:
1) Follow up with ENT in 2 weeks; must call to schedule
appointment
2) Follow up with endocrinology in 3 weeks; must call to
schedule appointment
3) Follow up with PCP regarding this hospitalization
4) Recheck dilantin level in 3 days (must correct for
hypoalbuminemia) and consider readjusting dosing; target level
is 16.
5) Notable labs on last check here: Hct 27.4, Cr 1.5, ALT 47,
AST 31, phenytoin (Dilantin) level 11.3. These can be
followed-up after discharge.
Medications on Admission:
Medications (from Rehab)
Dilantin 100 mg PO qhs
Fluticasone nasal spray 50mcg 1 spray each nostril [**Hospital1 **]
Mucinex 600 mg 1 tab po BID
Calcium carbonate 600 mg give 1 tab po BID
Docusate 100 mg PO BID
metorpolol tartrate 75 mg [**Hospital1 **]
Artificial tears 1 drop both eyes TID
Donepezil 5 mg qhs
Combivent nebs 5 times a day prn
Vitamin D2 [**Numeric Identifier 1871**] units po qweek until [**2148-7-2**]
Vitamin D by mouth 1000 U qday [**2148-7-2**] and on
Trazodone 25 mg PO qhs
Bisacodyl 10 mg po PRN
Robitussin 10 cc's po q4hrs prn cough
APAP 500 mg PO q6hrs prn
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain or fever
max 4g/day
2. Albuterol-Ipratropium [**1-8**] PUFF IH Q4H:PRN wheezing, shortness
of breath
3. Calcium Carbonate 600 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Donepezil 5 mg PO HS
6. Metoprolol Tartrate 75 mg PO BID
7. Phenytoin Infatab 125 mg PO BID
8. Bacitracin Ointment 1 Appl TP QID
9. Fluconazole 100 mg PO Q24H Duration: 10 Days
Last Day [**5-31**]
10. Multivitamins 1 TAB PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Artificial Tears 1-2 DROP BOTH EYES TID
13. Bisacodyl 10 mg PO DAILY:PRN constipation
14. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]
1 spray each nostril
15. Guaifenesin [**5-16**] mL PO Q4H:PRN cough
16. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
until [**2148-7-2**]
17. Vitamin D 1000 UNIT PO DAILY
until [**2148-7-2**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1) Seizure disorder
2) Klebsiella urinary tract infection
3) Yeast urinary tract infection
4) Non-occlusive thombi in right and left internal jugular veins
5) Goiter s/p subtotal thyroidectomy
6) Volume overload secondary to aggressive fluid resuscitation
.
SECONDARY DIAGNOSES:
1) Hypertension
2) Hyperlipidemia
3) Chronic kidney disease
4) GERD
Discharge Condition:
Alert and oriented to time, place, and person.
Non-ambulatory.
Clinically stable and improved.
Discharge Instructions:
You were admitted to the medicine service for workup and
management of your confusion. Your confusion was likely
multifactorial as outlined below.
.
You were given lorazepam because there were concerns of
seizures, but EEG monitoring did not reveal any evidence of
seizure. As a consequence, your breathing was suppressed and had
to be sedated and intubated to help you breath better. After
successful removal of your breathing tube, you had a seizure and
was found that your dilantin level was subtherapeutic secondary
to propofol withdrawal and malabsorption of dilantin due to the
tube feed you were receiving while intubated. You received
loading doses of dilantin and your maintenance dose was
increased to 125mg twice daily from 100mg twice daily. On the
day of discharge, your dilantin level adjusted for
hypoalbuminemia was 14.9. Please have your doctor [**First Name (Titles) **] [**Last Name (Titles) 2449**] at
[**Hospital3 2558**] check your dilantin level (must correct for
albumin level to get effective dilantin level) in three days and
consider adjusting your dilantin dose. The goal dilantin level
is 16.
.
You were found to have a bacterial urinary tract infection.
This may have been a large contributor of your confusion. Your
urine culture grew Klebsiella that was resistant to
ampicillin/sulbactam, ciprofloxacin, and nitrofurantoin, but
sensitive to cefazolin, cefepime, ceftriaxone, and meropenem.
You were initially treated with ceftriazone, but showed signs of
allergic response and was treated with meropenem. At the end of
the course of meropenem, your urine culture grew yeast.
Therefore, you were started on fluconazole on [**5-22**], which is an
anti-fungal antibiotic. The last dose of fluconazole will be on
[**5-31**].
.
You were noted to have increased swelling of your extremities
and crackles in your lungs as a result of aggressive fluid
resuscitation in the intensive care unit. You received
diuretics to take off fluids until no more crackles were heard
in your lungs. After this, your body should be able to mobilize
the extra fluid in your body and put out in your urine. You
also received ultrasound examination of your upper extremities
as there were concerns for blood clots. Ultrasound imaging
showed non-occlussive blood clots in your right and left
internal jugular veins. There is no clear evidence for benefit
in treating non-occlussive blood clots. Therefore, we did not
start anti-coagulation. Please follow up with your primary care
physician to monitor swelling in your arms and your body's fluid
status.
.
While you were intubated in the medical intensive care unit,
there were difficulties removing the breathing tube. This was
thought to be secondary to your enlarged thyroid. Therefore, a
surgery was done to remove part of your thyroid by the ear,
nose, and throat surgeons. Please continue to use the
anti-bacterial ointment until you see the surgeons for followup
in two weeks. Please call to schedule the followup appointment
as described below.
Followup Instructions:
1) Please call [**Telephone/Fax (1) 41**] to schedule a followup appointment
in two weeks with Dr. [**Last Name (STitle) **] [**Name (STitle) **], MD regarding your thyroid
surgery.
2) Please set up a follow up appointment with your
endocrinologist in about 3 weeks.
3) Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2148-6-18**] 9:00
4) Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2148-6-18**] 9:00
5) Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2148-6-18**]
11:45
ICD9 Codes: 5990, 5849, 2760, 5859, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5696
} | Medical Text: Admission Date: [**2177-4-28**] Discharge Date: [**2177-5-2**]
Date of Birth: [**2104-8-19**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Percocet / Motrin / Tagamet
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
headache x 1wk
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72-year-old right-handed woman with PMH atrial fibrillation on
coumadin, HTN who presents with 1 wk of right frontal headache
after hitting her head. She was seen by PCP today and noted to
be unsteady with walking and not looking to her left. History
obtained from friends [**Name (NI) 3551**] and [**Name (NI) 553**].
<br>
Pt was pushed while in line resulting in her banging her head
against the wall about 1 week ago. Since then, she's had a
headache. Yesterday, around 1:30pm, pt had worsening of her
right frontal headache upon returning from brunch. She then
went to BINGO last night and a friend had to help her walk back.
<br>
By this morning, patient was vomiting x2 and needed help getting
down the stairs. She was evaluated by her PCP who was concerned
b/c the pt was not looking to the left and sent her to OSH for a
head CT where they found a right parieto-occipital ICH with
intraventricular spread on the right.
<br>
She was subsequently transferred to [**Hospital1 18**] ED, where she was
discovered to have a supratherapeutic INR 3.9 and was given 4
vials of profiline, 2U FFP and 10mg vitamin K for reversal.
Repeat NCHCT (~5hrs after initial OSH HCT) showed that
hemorrhage was relatively stable (reviewed with radiologist in
ED). She
also rec'd Dilantin 1g IV and 2mg IV morphine just prior to this
evaluation.
Past Medical History:
- ? afib on coumadin - when asked why she is on coumadin, pt
responds "i think i have a beating [**Last Name **] problem".
- h/o TIAs(?) - described by friends as episodes of
unresponsiveness, inability to speak and staring straight ahead
with return back to baseline.
- urinary incontinence at nighttime (has been seeing a
urologist)
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @[**Location (un) **] [**Location (un) 1459**]
Social History:
quit smoking in [**1-24**] but has had cig/day for the past 5 days.
ETOH 1-2 drinks/wk. Retired office clerk. Lives in [**Name (NI) 3786**]
friend [**Name (NI) 3551**].
Family History:
NC
Physical Exam:
T- 97.9 BP- 144/75 HR- 86 RR- 16 100 O2Sat RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination: Limited by IV morphine administered.
MS: not alert but arousable. oriented to person, place, date,
situation. inattentive but able to followed simple commands.
no
alien hand. fluent w/comprehension intact. alexic. registers
[**12-19**] despite clues at 30 seconds.
CN:
I: not tested
II,III: right gaze preference, decr'd blink to threat from the
left, when asked how many people in the room did not see people
standing to left of bed until instructed to look further to the
left. PERRL 4mm to 2mm
III,IV,V: EOMI intact to OCM, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-21**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; +Asterixis. No pronator drift.
Some
motor impersistence on the left.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5- 5 5 5 4+ 5 5
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 2 Extensor
R 2 2 2 2 2 Flexor
Sensation: Intact to light touch and w/d's to noxious stim b/l.
Coordination: finger-nose-finger normal on the right, too
distracted to perform using left hand.
Gait/Romberg: deferred due to severe oversedation from IV pain
meds.
Pertinent Results:
EKG:
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 192 100 400/449 75 -8 41
Labs:
143 106 15
----+----+---<111
3.4 30 0.9
estGFR: 62/74 (click for details)
Ca: 9.3 Mg: 1.9 P: 3.4
ALT: 17 AP: 74 Tbili: 0.3 Alb:
AST: 23 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 15
MCV 95
8.9 > 11.5 < 345
34.8
N:81.4 L:13.3 M:4.7 E:0.3 Bas:0.2
PT: 36.3 PTT: 31.1 INR: 3.9
CXR [**2177-4-28**] The hemidiaphragms are in normal position. There is
no evidence of pleural effusion. The size of the cardiac
silhouette is at the upper range of normal. There is slight
tortuosity of the thoracic aorta. There is no evidence of
hyperhydration, no evidence is seen of parenchymal opacity
suggestive of pneumonia. No pathologic mediastinal widening, the
hilar contours are normal.
NCHCT [**2177-4-28**] 3.5 cm intraparenchymal hemorrhage with
surrounding vasogenic edema. A small amount of subarachnoid
hemorrhage is noted along the right superior convexity.
Appearance of organized hematoma within the right lateral
ventricular body, suggesting subacute nature. Mass effect on the
occipital [**Doctor Last Name 534**] of the right lateral ventricle, and mild leftward
shift of the normally midline structures. Intraventricular
extension. Overall, the findings are not changed from the study
performed at outside hospital roughly three hours prior.
Repeat NCHCT [**2177-4-29**] Unchanged right parietooccipital hemorrhage
with intraventricular extension. No change in mass effect.
MRI/MRA on [**2177-5-2**] showed severe intracranial atherosclerotic
disease diffusely (both posterior and anterior circulation),
with surprisingly intact extracranial anatomy. The MRI showed
extensive white matter disease with multiple infarctions,
periventricular and the tip of the L temporal lobe. The GRE did
not reveal any microhemorrhages.
Brief Hospital Course:
BRIEF ICU COURSE:
Admitted initially to the Neuro ICU for close monitoring of her
clinical status and blood pressure. Her clinical exam and a
repeat non-contrast head CT were unchanged on the second day of
hospitalization. Her BP was well controlled (100-110 systolic)
on her home medications. Therefore, she was transferred to the
floor with telemetry.
She did not require additional Vitamin K or FFP to maintain her
INR at goal of 1.5 or lower. Her coags were checked q4h
initially and then spaced to q8h once stable.
Her TSH was found to be low at 0.24. T3 low at 64 (nl > 80), and
T4 1.5 (normal 0.9 - 1.7) - her levothyroxine was slightly
increased.
She was treated with phenytoin to prevent seizures, with a goal
level of > 10, especially because of her subarachnoid blood.
This should be discontinued in time, especially when it
potentially interferes with other medications. She is to take it
until follow-up.
BRIEF FLOOR COURSE:
She continued to show a stable neurological examination with a
field cut, neglect and mild disorientation. She was treated with
standard analgesics for continued headache, but eventually
needed stronger medication (IV Dilaudid low dose), leading to
excessive sedation. It was discontinued in the AM of [**2177-5-1**].
MRI/MRA showed severe intracranial atherosclerotic disease
diffusely (both posterior and anterior circulation), with
surprisingly intact extracranial anatomy. The MRI showed
extensive white matter disease with multiple infarctions,
periventricular and the tip of the L temporal lobe. The GRE did
not reveal any microhemorrhages - so even though technically she
could restart Coumadin (no microbleeds), there is no data to
support that with extensive intracranial atherosclerosis
Coumadin is superior to Aspirin.
She was discharged in stable condition and will follow up with
Dr [**Last Name (STitle) **] (Stroke Service) as outlined her discharge orders.
NOTE PLEASE BE AWARE OF POTENTIAL MEDICATION INTERACTIONS -
Calcium Carbonate and phenytoin, levothyroxine and others.
Medications on Admission:
fosamax 70mg qSun
diovan 320mg QD
triamterene/HCTZ 37.5mg-25mg QD
warfarin 5mg qSuTWFSa and 7.5mg qMTh
synthroid 100mcg QD
simvastatin 20mg QD
sanctura 20mg [**Hospital1 **]
aggrenox 25/200mg [**Hospital1 **]
protonix 40mg QD
citalopram 30mg QD
MVI
os-cal 500mg [**Hospital1 **]
chantix 2mg [**Hospital1 **]
ALL: PCN, percocet, percodan, motrin, tagamet, raw mushrooms
Discharge Medications:
1. Citalopram 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY (Daily).
2. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Valsartan 160 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule [**Hospital1 **]: One
(1) Cap PO DAILY (Daily).
6. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Phenytoin Sodium Extended 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule
PO TID (3 times a day).
9. Levothyroxine 112 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet [**Telephone/Fax (3) **]: One (1) Powder in Packet PO BID (2 times a day) for
1 days.
11. Senna 8.6 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO BID (2 times a
day) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (3) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Docusate Sodium 100 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO BID (2
times a day).
14. Sodium Phosphates Solution [**Telephone/Fax (3) **]: Forty Five (45) ML PO
ONCE (Once) as needed for PRN severe constipation for 1 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right parieto-occpital intraparenchymal hemorrhage and small
frontal traumatic subarachnoid hemorrhage.
Discharge Condition:
Stable
Discharge Instructions:
You have been admitted with a brain hemorrhage in the R parietal
and occipital area (right side of back of head) - you also had a
small R frontal (right side of forehead) bleed, as a consequence
of the trauma about a week earlier. We think both bleeds are
directly or indirectly related to your fall and Coumadin use.
We've spoken to your PCP about the recurrent strokes leading to
the use of Coumadin. For now, we do NOT want you to take
Coumadin.
Please take all your medications excactly as directed and please
attend all your follow-up appointments.
Please report to the nearest ER or call 911 or your PCP
immediately when you experience recurrence of weakness,
numbness, tingling, problems with speech, vision, language,
walking, thinking, headache, or difficulties arousing, or any
other signs or symptoms of concern.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2177-7-8**] 1:30
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2177-5-2**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5697
} | Medical Text: Admission Date: [**2144-1-16**] Discharge Date: [**2144-3-3**]
Date of Birth: [**2081-1-11**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever/chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 63 yo male with a h/o Type II DM, CAD s/p 4v CABG [**2129**]
and Ulcerative Colitis who p/w fever/chills/NS/weight loss and
enlarging peri-portal lymph nodes on abdominal CT concerning for
a new diagnosis of lymphoma.
.
Pt was recently admitted [**Date range (1) 19970**]/07 for abdominal pain, fevers,
and weight loss of 20 pounds in the last year, and in the
work-up was found to have multiple enlarging lymph nodes on
abdominal CT, the largest being a 1.6cm peri-portal LN. Pt was
discharged [**1-11**] and saw Dr. [**First Name (STitle) 572**] in GI on [**1-13**], who felt the LAD
was less likely infection, and more likely lymphoma, especially
if the fever persisted on antibiotics. The pt was supposed to
have an appointment with Dr. [**Last Name (STitle) **] this AM, but came to the ED
because he was feeling weak, tired and febrile at home. Now
admitted to the BMT service to expedite work-up for lymphoma.
.
Of note, pt was also admitted from [**Date range (1) 19971**] for
hyperglycemia to 900s, thought to be [**2-7**] non-compliance with
insulin [**2-7**] low PO intake [**2-7**] N/V thought to be [**2-7**] diabetic
gastroparesis.
.
Currently pt has no pain at rest. He notes that he has had chest
"discomfort" for weeks, which correlates to when he gets his
fevers. The pain is non-radiating, feels like a pressure and is
worse with inspiration. Pain/fever gets better with tylenol. No
positional/food relationship to pain, but when he coughs, he
gets the pain. His cough is non-productive and has been
relatively stable over the last few weeks. The pain and coughing
was very intense overnight, which brought him into the ED this
AM.
.
He also notes occasional epigastric discomfort that is also not
related to food/position/chest pain/fevers that he has also had
for weeks but goes away on its own.
Past Medical History:
1. Hypertension.
2. Type 2 diabetes (HgbA1c 8.2 in [**2142-8-6**]) complicated by
-retinopathy
-neuropathy.
-autonomic dysfunction, followed by Dr. [**First Name (STitle) **]. Previously on
fludrocortisone and midodrine
3. History of Nissen fundoplication for hiatal hernia [**2136**].
4. Gastroesophageal reflux disease symptoms: Remains on PPI
5. Coronary artery disease, status post 4 vessel CABG [**2129**];
-last stress (pyrimadole-MIBI) in [**2139**] with no anginal symptoms
or EKG changes, no reversible defects
-Echo in Sepetmber [**2143**] revealed LVEF>55%
-Cardiac cath in [**2137-12-6**] revealed native 3-vessel disease,
patent saphenous vein graft to third obtuse marginal, first
diagonal, and right posterior descending artery, a patent left
internal mammary artery with a distal left anterior descending
artery occlusion.
6. Ulcerative colitis times 15 years; recent endoscopy showed
gastritis in prepyloric region, colonoscopy was normal to the
cecum.
7. Gastroparesis
8. Cataract status post left phacoemulsification with posterior
chamber lens implant.
9. Squamous cell carcinoma
Social History:
Recently retired from work running autobody shop, following
multiple knee surgeries. Lives in [**Location (un) **] with his wife.
Adult son lives on [**Name (NI) 1456**]. Approximate 30 pack year smoking
history, but quit in [**2121**]. Denies current alcohol or IVDU.
Monogomous with wife of 37 years. No known blood transfusions.
Family History:
Notable for diabetes. [**Name (NI) **] mother had coronary artery
disease and sister has [**Name (NI) 4522**] disease.
Physical Exam:
PE: 112/58, 98.3, 70, 18, 97% O2 Sats RA, weight 195.7 lbs
Gen: obese male laying in bed in NAD
HEENT: posterior oropharyngeal erythema, no exudates, MMM
NECK: Supple, No LAD, No JVD
LAD: ?Left axillary LN vs fat pad; no cervical or inguinal LAD.
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: +bibasilar crackles, BS BL, No W/R/C
ABD: Soft, +epigastric tenderness, ND. NL BS. +RUQ pain worse
with inspiration. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Initial labs:
[**2144-1-16**] 01:51PM LACTATE-1.5
[**2144-1-16**] 12:10PM GLUCOSE-57* UREA N-11 CREAT-1.1 SODIUM-133
POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-30 ANION GAP-15
[**2144-1-16**] 12:10PM CK(CPK)-32*
[**2144-1-16**] 12:10PM cTropnT-<0.01
[**2144-1-16**] 12:10PM WBC-12.8* RBC-3.23* HGB-10.7* HCT-31.9*
MCV-99* MCH-33.2* MCHC-33.6 RDW-13.0
[**2144-1-16**] 12:10PM NEUTS-86.6* LYMPHS-8.2* MONOS-4.8 EOS-0.2
BASOS-0.3
[**2144-1-16**] 12:10PM PLT COUNT-329
[**2144-1-16**] 12:10PM PT-14.6* PTT-29.5 INR(PT)-1.3*
CT chest [**2144-1-16**]:
IMPRESSION: The lung findings primarily in the right lung may
have an infectious etiology given the recent cough and fever and
may represent atypical pneumonia such as mycoplasma or viral
pneumonia. Pulmonary lymphoma is less likely given the rapid
development of these findings. Lymphadenopathy may be reactive,
however, lymphoma cannot be excluded and a followup chest CT
eight weeks after antibiotic therapy is recommended.
.
Bm Bx [**1-20**]:
Morphologic features of a lymphoma, infectious process, or a
myelodysplastic syndrome are not seen. A lymph node biopsy,
however, demonstrated focal infiltration by ALK-1 POSITIVE
ANAPLASTIC LARGE T CELL (CD30+, CD4+, CD3+/-) LYMPHOMA.
Immunostains in the bone marrow to rule out minimal involvement
by lymphoma are in progress and will be reported in an
addendum.In summary the morphologic and immunophenotypic
findings combined, are consistent with focal nodal infiltration
by an anaplastic large cell lymphoma. Although the differential
diagnosis includes Hodgkin lymphoma, the lack of
classic/diagnostic [**Doctor Last Name **]-Sternberg cells, the presence of rather
cohesive aggregates of large cells, the presence of CD45, ALK-1
and CD4 immunoreactivity and lack of CD15 expression, all
strongly argue against Hodgkin lymphoma.
Lymph node bx:
In summary the morphologic and immunophenotypic findings
combined, are consistent with focal nodal infiltration by an
anaplastic large cell lymphoma. Although the differential
diagnosis includes Hodgkin lymphoma, the lack of
classic/diagnostic [**Doctor Last Name **]-Sternberg cells, the presence of rather
cohesive aggregates of large cells, the presence of CD45, ALK-1
and CD4 immunoreactivity and lack of CD15 expression, all
strongly argue against Hodgkin lymphoma.
CTA chest [**2144-1-22**]:
IMPRESSION:
1. No pulmonary embolism.
2. Unchanged abnormally enlarged mediastinal and hilar lymph
nodes, probably reactive to the consolidative changes in the
lungs. However, followup chest CT after eight weeks of therapy
is recommended to assess the improvement.
3. Previously seen ground-glass opacities in the upper lobes as
well as in the left lower lobe have evolved to form areas of
consolidation. Small bilateral pleural effusions, left greater
than right. \
.
CXR [**1-22**]:
FINDINGS: Compared with [**2144-1-19**], there is now diffuse increase
in pulmonary vascular and interstitial markings bilaterally,
consistent with moderate pulmonary edema.
A superimposed small area of consolidation in the right mid lung
field as well as in the retrocardiac left lower lobe could
represent superimposed pneumonia.
ECHO [**1-22**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with focal hypokinesis of the basal half of the
inferior and
inferolateral walls and of the distal septum. The remaining
segments contract
well. Right ventricular chamber size and free wall motion are
normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2144-1-9**],
regional left
ventricular systolic dysfunction is now identified c/w ischemia.
CT Torso [**1-26**]:
. Interval increase in moderate bilateral layering pleural
effusions, and interval worsening of patchy consolidation and
ground-glass opacity in the left upper lobe.
2. Stable chest and abdominal lymph nodes
Ct chest [**2-3**]:
Extensive coalescing peribronchial infiltration succeeding
ground glass abnormality over six days might represent
organizing viral pneumonia, perhaps fibrotic. The rare
diagnosis, acute interstitial pneumonitis is less likely because
of rapid improvement.
Mediastinal lymph nodes are most likely reactive to the ongoing
lung pathology, decreased since [**1-22**], now stable.
Stable intra-abdominal lymph nodes might be also reactive.
Interval decrease in moderate bilateral layering pleural
effusions.
[**2-9**] head CT:
No evidence of acute intracranial hemorrhage. Moderate left
frontal subgaleal hematoma
[**2-27**] pelvic MRI
IMPRESSION:
1. Bilateral retroperitoneal hematomas seen tracking within
bilateral psoas and iliacus (left greater than right) muscles.
Large approximately 10-cm left lateral coronal fascia layering
hemorrhage.
2. No acute fracture or evidence for AVN within the hips.
Discharge labs:
Brief Hospital Course:
ASSESSMENT: The patient is a 63 yo male with a h/o Type II DM,
CAD s/p 4v CABG [**2129**] and Ulcerative Colitis who p/w
fever/chills/NS/weight loss and enlarging peri-portal lymph
nodes on abdominal CT found to be positive for anaplastic T cell
lymphoma hospital course c/b NSTEMI and heart failure as well as
pneumonia.
.
PLAN:
# Lymphadenopathy/fevers: Mr. [**Known lastname **] was admitted for
accelerated workup of lymphoma given his history of fevers,
night sweats, and increasing lymphadenopathy. The differential
on admission included infectious vs neoplastic vs. inflammatory
- constitutional symptoms and length of fevers point toward
neoplastic, but admitted with evidence of PNA and gallstones,
which are potential etiologies of infection. The patient was
recently admitted to the [**Hospital Ward Name **] where he had a negative HIV
test, negative PPD, and negative hepatitis panel. A TEE was
also done to rule out endocarditis which showed no evidence of
vegetations. In addition, blood cultures have all remained
negative. On [**1-17**] a bone marrow biopsy was done given anemia
and lymphopenia. The bone marrow bx was negative. Surgery was
consulted on admission as a 1.6cm peri-portal LN was noted on CT
and was the largest available for biopsy. He had no palpable
lymph nodes on exam. The bx showed anaplastic T cell lymphoma.
A pulmonary consult was also obtained for possible
transbronchial biopsy of lymph nodes on CT, but this was not
done since the bx was revealing. SPEP was also sent and was
within normal limits. He was started on cipro and flagyl given
PNA on chest CT and was shortly switched to Ceftriaxone and
azithromycin given persistent fevers. Overnight on [**1-22**], he
desatted to 70s on 2L and required a nonrebreather. CTA was
negative for PE, but showed a multilobar PNA. Patient was 90%
on NRB, with one set of cardiac enzymes negative, EKG with
baseline ventricular ectopy. He continued to have SOB and no
improvement in his sats the following morning and was
transferred to [**Hospital Unit Name 153**] for hypoxemic respiratory insufficiency.
Second set of cardiac enzymes was positive for NSTEMI and he was
started on heparin gtt. While in the [**Hospital Unit Name 153**] several services were
consulted including ID, rheumatology, and cardiology. He was
also diuresed aggressively. He remained persistently febrile.
In the [**Hospital Unit Name 153**], his oxygenation improved rapidly with supplemental
O2. However, he continued to spike fevers despite adequate
antibiotic coverage for CAP. He was placed in respiratory
isolation and a TB rule out was started. He continued to spike
temperatures during this antibiotic course as well. The last Ct
chest looked better and antbiotics were stopped.
As the patient was ready to be transferred out of the [**Hospital Unit Name 153**], the
final pathology returned from pathology and showed anaplastic
lymphoma. He was transferred back to the BMT service for
management. The patient was initially treated with oral
prednisone and his fevers resolved. He was then tapered down on
the steroids and the fevers returned. This prompted starting
treatment for the lymphoma with CVP. Adriamycin was not given
because of the patient's heart failure. The patient did not have
any fever after starting treatment making it very clear that his
fevers were [**2-7**] lymphoma.
.
# NSTEMI: H/o CABG in [**2129**] however recent negative stress test.
Upon transfer to the [**Hospital Unit Name 153**], in the setting of SOB, cardiac
enzymes were drawn and patient ruled in for an NSTEMI. An ECHO
was performed which showed worsened wall motion abnormalities
and overall worsened pump function. Cardiology was consulted
who recommended aspirin, heparin drip, increased beta blocker
for tight HR control, 80 mg of QD statin, and diuresis as
patient had been fluid positive. He was also transfused 2
units of PRBCs to obtain a Hct>30. Patient's symptoms improved.
Cardiology did not feel any need for intervention beyond
medical management unless patient were to have recurrent
symptoms and evidence of further ischemic evolution. Once the
patient was transferred back to the BMT service, cardiology was
recalled to help [**Hospital Unit Name 4656**] the etiology of his heart failure.
They recommended a cardiac MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] for an infiltrative
process in addition to continuing aggressive medical management.
A follow-up echocardiogram revealed improvement in EF back up
from 40% to 50%. During this stay, the patient had a fall and
developed a retroperitoneal bleed. ASA, plavix and sulfasalazine
were stopped and the patient was given at least 12 units of
PRBCs and 2 units of platelets. The patient remained
hemodynamically stable and was chest pain free. He will need to
follow-up with cardiology and eventually will at least need to
restart ASA after the bleed is resolved. The patient's liver
function tests were also elevated and lipitor was held. He is
currently on losartan and metoprolol. Spirinolactone was started
and stopped after 1 week as patient was hyponatremic.
.
# Hypoxia: Covered appropriately for CAP, atypical PNA and
healthcare-associated PNA. He was continued on vancomycin,
ceftriaxone, azithromycin. Blood cultures were negative
throughout. Once back on the BMT service, a CXR was done which
showed a worsening infection despite antibiotic treatment. Out
of concern that he was being inadequately treated Pulmonary was
recalled for evaluation of hypoxia and worsening infiltrate.
They felt that his hypoxia was due to decompensated CHF and that
the radiology would likely lag behind the treatment of
infection. As the patient was improving clinically with
decreasing O2 sat requirement, they recommended completing the
course of antibiotics and continuing to diurese the patient. A
bronchoscopy was considered to obtain more tissue, however, as
the patient had a recent NSTEMI, they felt that bronchoscopy
would be a high risk procedure and would be of low yield. In
addition, the sleep medicine team came to [**Last Name (Titles) 4656**] the patient.
They did not feel that he was a candidate for a sleep study in
his present condition, however they recommended placing him on
2L O2 at night for presumptive sleep apnea. On transfer to
BMT, his antibiotic regimen was Cefepime and Flagyl. On [**1-30**]
the patient developed a rash which was likely related to
Cefepime. His antibiotics were changed on [**1-31**] to levo/flagyl.
Flagyl was d/c'd after one week since no aspiration on video
swallow and levaquin was continued for another week. Patient did
not have an O2 requirement upon leaving the hospital. He was
several liters negative on 20mg IV lasix daily. The patient
continued to have lower extremity edema and likely needs further
diuresis. He was sent home on 40mg PO lasix daily with
instructions to monitor I/O's and daily weights. This dose may
need to be adjusted to optimize volume status.
.
# DM: Severe and uncontrolled at home, associated with
retinopathy, neuropathy, gastroparesis. Takes NPH in home
regimen (75 QAM, 30 QPM) but is not compliant with recent
admission for BG 900s. Last A1c 8.2 in [**8-9**]. He was continued on
NPH x qam, x qhs, and ISS with titration as needed to optimize
BG control.
.
# Ulcerative colitis: He was asymptomatic for GI complaints
throughout admission. Thought unlikely to be causing fevers as
high as 103. Sulfasalazine was discontinued when pt had RP
bleed. Should be restarted as outpt.
.
# Gastroparesis: The patient suffered from frequent bouts of
retching for which he was taking reglan and a PPI. Ativan
seemed to work the best for the patient.
.
# GERD: s/p Nissen fundoplication. He was continued on
pantoprazole 40mg q24h
.
# Hyponatremia- patient persistently hyponatremic. This was
initially thought to be due to intravascular depletion and NS
was given. Patient was diuresed for volume overload and was
euvolemic. Urine lytes difficult to interpret given heavy lasix
doses. In the end it was thought that pt had SIADH given the
fact that his urine osm was 600-800. His thyroid and cortisol
levels were normal. He was put on fluid restriction, given lasix
to poison the tubule and demeclocycline and Na stabilized. It
was also thought that effexor was possibly causing hyponatremia,
so this was tapered off. The effexor can likely be restarted as
this does not seem to be causing the hyponatremia. We also
discontinued spirinolactone as this can cause hyponatremia.
.
Medications on Admission:
1. Ciprofloxacin 500 mg PO Q12H day [**6-16**].
2. Metronidazole 500 mg PO TID day [**6-16**]
3. Aspirin 81 mg Tablet PO once a day.
4. Atorvastatin 10 mg PO DAILY
5. Venlafaxine 150 mg PO DAILY (Daily).
6. Sulfasalazine 500 mg PO BID
7. Folic Acid 1 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. NPH 70U at breakfast and 30U at dinner
10. Lisinopril 30 mg PO DAILY
11. Senna 8.6 mg PO BID prn
12. Docusate Sodium 50 mg/5 mL PO BID
13. Tylenol#3 300-30 mg PO every 4-6 hours as needed for pain.
14. Metoclopramide 10 mg PO QIDACHS
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
1. Anaplastic lymphoma
2. Pneumonia
3. NSTEMI
4. Heart failure
5. Hyponatremia
6. T2DM
7. HTN
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted for a work-up of your chronic fevers and were
found to have anaplastic lymphoma and a pneumonia. You were
treated with antibiotics for the pneumonia and chemotherapy for
the lymphoma. In addition, you experienced a heart attack while
you were in the hospital. Cardiology was consulted and you were
started on medical management. You should follow-up with
cardiology as an outpatient and you will need a cardiac MRI as
well.
.
You must have your blood drawn within 1 week for monitoring of
your hematocrit, sodium, liver enzymes and bilirubin.
.
Please take all medications as directed. For now you should not
take aspirin, plavix, spironolactone or atorvastatin until you
speak with your cardiologist and are told to do so. Your effexor
was also discontinued and you can discuss this further with Dr.
[**Last Name (STitle) 12375**] at your next appointment.
.
Please follow-up with all outpatient appointments.
.
Please return to the hospital or call your doctor if you
experience chest pain, dizziness, shortness of breath, abdominal
pain, fever > 101.4 or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]), your
oncologist, on [**2144-3-10**] at 3:00PM.
.
Please follow-up with Dr. [**Last Name (STitle) 1016**], a cardiologist, on [**2144-3-26**] 9:00AM. In addition to discussion of you cardiac
medications and your recent heart attack, please also discuss
obtaining a cardiac MRI.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-4-7**]
2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Date/Time:[**2144-4-17**] 8:15
ICD9 Codes: 486, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5698
} | Medical Text: Admission Date: [**2130-12-28**] Discharge Date: [**2131-1-2**]
Date of Birth: [**2055-5-11**] Sex: M
Service: MEDICINE
Allergies:
Tetanus
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Upper Endoscopy
History of Present Illness:
The patient is a 75 year old male with a history of CAD s/p
CABG, hypertension, type II diabetes who presented to an OSH
with chills and altered mental status on [**2130-12-22**]. Per the
patient he was in his usual state of health prior to the day of
presenation. On the day of presentation he felt lightheaded,
weak and had chills. His "feet felt like rubber." He called one
of his friends who thought that he appeared confused an called
an ambulance. Per the patient he was not experiencing any chest
pain, shortness of breath, cough, congestion, nausea, vomiting,
abdominal pain, dysuria, hematuria, leg pain or swelling at that
time. Per the ER note at [**Hospital3 417**] he did endorse chest
pain on the day of presentation.
.
At Good Sumaritan there was intial concern for a urinary tract
infection and he was started on levoquin. He had an EKG which
showed normal sinus rhythm, normal axis, normal intervals, no
acute ST segment changes, small Q waves in II, III, aVF. He had
a CXR which showed no acute process. He had an echocardiogram
which showed moderate aortic stenosis with an ejection fraction
of 55-60%. Per reports he had had a nuclear stress test which
revealed an inferior perfusion defect. During his admission he
was found to have a phlebitis in his left lower leg and was
started on vancomycin and levoquin. He was transferred here for
cardiac catheterization.
.
In the catheterization lab he was found to have severe LAD and
diffuse PDA disease. A patent SVG to LAD and LIMA to diag.
There was no change in his anatomy since his prior
catheterization in [**2128**]. No interventions were performed.
.
On review of systems he currently denies lightheadedness,
dizziness, chest pain, shortness of breath, nausea, vomiting,
diarrhea, constipation, abdominal pain, orthopnea, PND. He does
endorse nocturia with weak urinary stream. He endorses lower
extremity edema at baseline (but current left leg swelling is
much different). He denies leg pain.
Past Medical History:
Diabetes
Hypertension
Hyperlipidemia
CAD s/p MI and s/p CABG in [**2115**] (LIMA-Diag, SVG-LAD, SVG-RPL),
s/p velocity stent to the OM in [**3-/2125**]
Osteoporosis
Diabetic Neuropathy
Osteoarthritis
Social History:
Lives with his wife who has alzheimer's disease. He denies a
history of smoking or alcohol use. He denies illicit drug use.
Family History:
He has two sons who are alive and healthy. He has 4
grandchildren. He has 2 brothers who have valvular disease.
His mother had diabetes and died at age 75. His father died of
"hardening of the arteries" and died at age 65.
Physical Exam:
Vitals: T: 98.1 BP: 140/65 HR: 111 RR: 18 O2: 97% on RA
General: elderly male, no acute distress
HEENT: PERRL, EOMI, sclera anicteric, MMM
Neck: JVP not elevated, no LAD
CV: RRR, S1 + S2, II/VI SEM at RUSB
Resp: clear to auscultation bilaterally, no wheezes, rales,
ronchi
GI: soft, non-tender, non-distended, +BS
Ext: WWP, 2+ pulses, left leg with erythema, mild warmth,
swelling, right leg with trace edema to shins
Neurologic: grossly intact
Pertinent Results:
Labs from OSH:
WBC on admission 15.1
.
On transfer:
WBC: 4.9 Hct: 34.2 Plts: 174
.
UA: negative
.
Na: 139 K: 4.3 Cl: 106 HCO3: 28 BUN: 17 Cre: 1.1 Glu: 183
.
Echo from OSH:
The ejection fraction is estimated at 55-60%. There is moderate
aortic stenosis.
.
CXR from OSH:
Post-operative changes, no acute disease.
.
Admission Laboratories from [**Hospital1 18**]:
[**2130-12-29**] 05:45AM BLOOD WBC-6.8 RBC-3.19* Hgb-9.2* Hct-26.9*
MCV-84 MCH-28.9 MCHC-34.3 RDW-14.5 Plt Ct-201
[**2130-12-29**] 05:45AM BLOOD Glucose-262* UreaN-57* Creat-1.2 Na-136
K-4.1 Cl-99 HCO3-29 AnGap-12
[**2130-12-29**] 05:45AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2130-12-29**] 05:45AM BLOOD CK(CPK)-32*
.
Discharge Laboratories from [**Hospital1 18**]:
[**2131-1-2**] 06:10AM BLOOD WBC-6.4 RBC-3.37* Hgb-9.9* Hct-28.6*
MCV-85 MCH-29.2 MCHC-34.5 RDW-15.7* Plt Ct-225
[**2131-1-2**] 06:10AM BLOOD Glucose-174* UreaN-13 Creat-1.2 Na-136
K-4.5 Cl-103 HCO3-23 AnGap-15
.
EKG from [**Hospital1 18**]: normal sinus rhythm, rate 87, normal axis,
normal intervals, small q waves in II, III, avF, no acute ST
segment changes.
.
Cardiac Catheterization [**2130-12-28**]:
1. Selective coronary angiography in this right dominant system
revealed diffuse, three vessel, coronary artery disease.
Overall,
findings were unchanged from prior catheterization. The LMCA
was
diffuse diseased to 40%. The LAD was occluded in the mid
vessel. The
LCx was without critical stenoses and the previously placed
stent was
widely patent. The RCA had a hazy 60% lesion proximally. The
lPDA was
diffusedly diseased to 90%. The SVG-LAD was widely patent. The
LIMA-D
was widely patent. The SVG-lPL was occluded.
2. Limited hemodynamics demonstrated a LVEDP of 10 mmHg.
Central
aortic pressure was 166/66 (systolic/diastolic in mmHg). There
was a 20
mmHg peak to peak gradient across the aortic valve on pullback.
3. Left ventriculography was not performed.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
.
Left Lower Extremity Ultrasound [**2130-12-29**]:
IMPRESSION:
No evidence of deep venous thrombosis involving the lower
extremities.
.
CT Abdomen and Pelvis [**2130-12-29**]:
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Relative increased attenuation of the right renal cortex,
which could represent acute tubular necrosis given recent
cardiac catheterization.
3. Two 2-mm nodules, requiring no followup in a patient without
malignancy or lung cancer risk factors. Otherwise, a 12-month
followup chest CT is recommended.
.
Upper Endoscopy [**2130-12-29**]:
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Excavated Lesions A single cratered spurting ulcer
was found in the duodenal bulb. 10 cc.Epinephrine 1/[**Numeric Identifier 961**]
hemostasis with partial success. [**Hospital1 **]-CAP Electrocautery was
applied for hemostasis successfully.
Impression: Ulcer in the duodenal bulb (injection, thermal
therapy)
Brief Hospital Course:
The patient is a 75 year old male with a history of CAD s/p
CABG, hypertension, type II diabetes who presented to an OSH
with chills and altered mental status on [**2130-12-22**] found to have
a left lower extremity phlebitis and positive stress test.
.
Coronary Artery Disease: The patient is s/p CABG. Per the
emergency department notes the patient endorsed chest pain on
arrival to the emergency room. The patient does not recall
experiencing any chest pain or dyspnea. He reportedly underwent
nuclear stress test at the OSH which showed a new perfusion
defect and was transferred here for catheterization. He was
started on plavix prior to transfer but was not started on IV
heparin. Catheterization revealed patent vein grafts and no
change in anatomy from prior procedure in [**2128**]. No
interventions were taken. His post-procedure course was
complicated by gastrointestinal bleeding as described below. In
this setting his aspirin was held with plans to restart in one
month. He otherwise was continued on his outpatient cardiac
regimen of lopressor, zocor and zestril. He will follow up with
his outpatient cardiologist and primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) **].
.
Upper GI Bleed: Mr. [**Known lastname 986**] was noted on [**2130-12-29**] to have to
have a hematocrit of 26.9, down from 37 at the outside hospital.
Additionally, he was noted to have tachycardia up to 140s and
hypotension to the 80s systolic. He also developed melena which
was grossly guaiac positive. He was transferred to the
intensive care unit for urgent upper endoscopy. Endoscopy
revealed a single cratered spurting ulcer in the duodenal bulb.
Epinephrine 1/[**Numeric Identifier 961**] hemostasis was partial successful.
Electrocautery was applied for hemostasis successfully. He
required transfusion of three units of packed red blood cells.
He received IV protonix infusion for 72 hours. He was
transferred back to the general medical floor after 48 hours.
For the remainder of his hospitalization he was hemodynamically
stable and his hematocrit was stable between 28-30. H. Pylori
antibody was found to be positive. He was started on
amoxicillin and clarithromycin for h. pylori infection with
plans to complete a 14 day course of antibiotics. He was also
started on protonix 40 mg [**Hospital1 **] for one month with plans to then
transition to 40 mg daily. He was instructed to hold his
aspirin for one month. He will follow up with his primary care
physician for repeat hematocrit check on [**2131-1-5**].
.
Left Leg Cellulitis: On presentation to the OSH the patient was
noted to have pain and swelling of his left leg with confusion,
an elevated white blood cell count and a left shift in his
differential. He was originally transferred on vancomycin and
levofloxacin. He had a lower extremity ultrasound on hospital
day one which was negative for DVT. On transfer his antibiotics
were switched to bactrim and keflex. He received 6 days of this
regimen. He was discharged with plans to complete a 14 day
course of bactrim for presumed cellulitis. On discharge his
swelling and erythema had completely resolved.
.
Hypertension: On hospital day two the patient suffered a
hemodynamically significant gastrointestinal bleed. His
antihypertensive agents were held in this setting. His
outpatient antihypertensive regimen was restarted on discharge
which includes lopressor, norvasc and zestril.
.
Hyperlipidemia: He was continued on his outpatient regimen of
zocor 40 mg daily.
.
Diabetes: The patient was continued on his outpatient regimen of
glyburide. He was also covered with an insulin sliding scale.
.
Code: Full Code
Medications on Admission:
Medications at transfer:
Plavix 75 mg daily
Norvasc 5 mg daily
Aspirin 325 mg daily
Zocor 40 daily
KCl 10 mEQ
Lopressor 25 mg [**Hospital1 **]
Zestril 10 mg daily
Vancomycin 1250 mg IV bid
Levofloxacin 500 mg daily
Glyburide--held this am
.
Home medications:
Fosamax 70 mg weekly
Zocor
Lopressor 25 mg [**Hospital1 **]
Glyburide 5 mg [**Hospital1 **]
Norvasc 5 mg daily
Accupril
ECASA 325 mg daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a
day for 13 days.
Disp:*26 Capsule(s)* Refills:*0*
9. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 13 days.
Disp:*52 Tablet(s)* Refills:*0*
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Primary:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Type II Diabetes
Duodenal Ulcer
H. Pylori infection
Lower extremity Cellulitis
Discharge Condition:
Stable. Chest pain free. Breathing comfortably on room air.
Ambulating without assistance.
Discharge Instructions:
You were seen and evaluated for your chest pain. You had a
cardiac catheterization which revealed stable heart disease from
your last study. At Good [**Hospital 39887**] hospital you were diagnosed
with a skin infection on your left leg for which you were
started on antibiotics. After your catheterization you had
bleeding from an ulcer and in your small intestines which
required endoscopy and treatment. You were diagnosed with h.
pylori which is an infection of the intestines often associated
with ulcers.
.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take Bactrim two times a day for six more days for
your leg infection
2. Please take Amoxicillin 1000 mg two times a day and
Clarithromycin 500 mg two times a day for 13 more days for your
h. pylori infection
3. Please take Pantoprazole 40 mg two times a day for one month.
After one month you can decrease your dose to one time per day.
4. Please hold your aspirin for one month. Please do not forget
to start taking it again after the new year.
.
Please keep all your follow up appointments.
.
Please seek immediate medical attention if you experience any
lightheadedness, dizziness, chest pain, difficulty breathing,
blood in your stool or worsening black stools, worsening
swelling or pain in your legs or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
as scheduled for this Friday, [**1-5**]. You will need to
have your blood counts checked. His office phone number is
[**Telephone/Fax (1) 3183**].
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5699
} | Medical Text: Admission Date: [**2179-3-22**] Discharge Date: [**2179-4-3**]
Date of Birth: [**2132-1-23**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine / Morphine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hepatic encephalopathy
Major Surgical or Invasive Procedure:
Central venous line placement
CVVH
Paracentesis
History of Present Illness:
This is a 47yoF with HCV Cirrhosis and hypertension who was
transferred from an OSH for further evaluation of hepatic
encephalopathy.
At the OSH([**Date range (1) 71225**]), she was admitted for hepatic
encephalopathy and hypovolemia was treated w/IVF initially then
w/lactulose and rifaximin and had [**2-27**] BMs per day w/o
improvement in her MS per report. She was afebrile, guiac
negative but found to be anemic(HCT 25) upon admission and was
transfused 2 units PRBCs. The following studies and treatments
were performed:
[**3-15**] EGD: portal gastropathy, no varices
[**3-18**] CT head negative;
[**3-17**] CT abdomen/pelvis: large ascites w/o significant change
from [**10-1**], punctate nonobstructive calculous in lower pole of
left kidney
She was found to have a dirty u/a and was treated w/levofloxacin
from [**Date range (1) 11505**] for UTI though Urine and blood cx were negative;
She had a therapeutic and diagnostic paracentesis performed on
[**3-13**] which was negative for SBP.
Because of her acute on chronic renal failure as well as
hypercalcemia she was worked up for multiple myeloma as well as
other etiologies of hypercalcemia including: PTH normal, kappa
light chain and bence [**Doctor Last Name 49**] proteins negative, whole body bone
scan negative. Improved w/IVF hydration and was normalizing on
transfer.
.
Upon arrival to the floor, she is responsive to verbal stimuli
but lethargic. She is unable to give hx or answer questions for
ROS.
Past Medical History:
Hepatitis C/Cirrhosis
-treated in [**2166**] for a year with interferon and Ribavirin
-retreated three years later with pegylated interferon and
Ribavirin for six months stopped due to intolerance which
included mental status changes and passing out.
- developed ascites in [**2176**] and had some encephalopathy at that
time although she also started her psychiatric medications then,
(which she continues on now with less mental status changes).
-She was initially referred to [**Hospital3 2358**] for transplantation,
but was denied this secondary to high body mass index and low
MELD score.
.
PMH:
HTN
Asthma
Depression
Social History:
Lives in [**Hospital1 189**] by herself but her daughter and husband visit
often.
Smoked 2.5-3 packs per day x 25yrs but quit one week ago by
tapering down.
No current EtOH (social drinker until 2yrs ago)
Family History:
Father and uncle with cirrhosis. Also cirrhosis and thyroid
disease.
Physical Exam:
Vitals: T 99.1 BP 100/60 HR 76 RR 18 Sat 93% RA
Gen: lethargic, NAD
HEENT: PERRL, o/p clear
Chest: clear bl no rrw
CV: RRR +murmur, no rubs gallops
Abd: NABS, distended, no rigidity, rebound, guarding
Extrem: no CCE
Neuro: moving all 4 extremities, responsive to verbal stimuli,
but not conversational, + asterixis
Pertinent Results:
Admission labs:
[**2179-3-22**] 10:07PM WBC-10.2# RBC-3.19* HGB-10.1* HCT-28.8*
MCV-90# MCH-31.7 MCHC-35.2*# RDW-19.8*
[**2179-3-22**] 10:07PM NEUTS-83.1* BANDS-0 LYMPHS-4.7* MONOS-11.8*
EOS-0.4 BASOS-0.1
[**2179-3-22**] 10:07PM PLT COUNT-111*
[**2179-3-22**] 10:07PM GLUCOSE-116* UREA N-24* CREAT-2.0* SODIUM-140
POTASSIUM-3.6 CHLORIDE-116* TOTAL CO2-16* ANION GAP-12
[**2179-3-22**] 10:07PM ALBUMIN-2.3* CALCIUM-10.1 PHOSPHATE-2.3*
MAGNESIUM-1.6
[**2179-3-22**] 10:07PM ALT(SGPT)-40 AST(SGOT)-63* LD(LDH)-171 ALK
PHOS-96 TOT BILI-2.5*
[**2179-3-22**] 10:07PM PT-24.1* PTT-46.1* INR(PT)-2.3*
.
Studies:
CHEST (PORTABLE AP) [**2179-3-22**]
New consolidation in the infrahilar right lung is suspicious for
pneumonia. A similar abnormality on the left was present earlier
in the day and could be pneumonia or atelectasis. There is no
pleural effusion. Heart size top normal, has increased
suggesting volume overload though there is no pulmonary edema.
.
CT HEAD W/O CONTRAST [**2179-3-22**]
IMPRESSION:
1. No intracranial hemorrhage.
2. Unchanged age-inappropriate global atrophy, likely related to
underlying liver disease.
3. Complete opacification of the left maxillary sinus, worsened
since previous exam.
.
DUPLEX DOPP ABD/PEL [**2179-3-22**]
IMPRESSION:
1. Cirrhotic-appearing liver with no focal masses.
2. Patent hepatic vasculature.
3. Massive ascites. The left lower quadrant was marked for
paracentesis to be performed by the clinical staff.
4. Splenomegaly.
.
CT ABDOMEN W/O CONTRAST [**2179-3-23**]
IMPRESSION:
1. Though somewhat limited, there is no evidence of
intra-abdominal infection.
2. Significant ascites seen within the peritoneal cavity.
3. Shrunken, cirrhotic-appearing liver.
4. Patchy airspace opacities identified at the lung bases
bilaterally. This may represent pneumonia and clinical
correlation is recommended.
.
RENAL U.S. [**2179-3-23**]
IMPRESSION:
1. Normal kidneys.
2. Large amount of intra-abdominal ascites.
.
CHEST (PORTABLE AP) [**2179-3-31**]
IMPRESSION:
1. Worsening pulmonary edema secondary to volume overload.
2. New right IJ and an advanced feeding tube are in satisfactory
location.
3. The heart size is top normal.
Brief Hospital Course:
Patient was a 47yo F with HCV Cirrhosis and hypertension who was
transferred from an OSH for further evaluation of hepatic
encephalopathy. She was admited to the Hepatorenal service.
She underwent a paracentesis and was found to have SBP.
Peritoneal fluid grew ESBL E. coli, and she was started on
meropenam. Her urine cx also grew ESBL E. coli. She was also
thought to have pneumonia and was started on vancomycin. For
her diarrhea and concern of C. diff, she was started on
metronidazole.
.
In addition, her creatinine began to trend up and she was
started on octreotide and midodrine. She then became ogliuric.
On [**3-27**], her respiratory status acutely worsened; this was felt
to be due to pulmonary edema and she did not respond to Lasix.
She was transferred to the MICU.
.
In the MICU, she was intubated and placed on mechanical
ventilation. She met criteria for ARDS and was ventilated per
ARDS net protocol. She was also started on levophed and
vasopressin for shock, which was likely multifactorial,
including sepsis initially and then cardiogenic during runs of
atrial fibrilation with RVR. For her acute renal
failure/anuria, octreotide and midodrine were discontinued and
she was initiated on CVVH for purposes of volume removal.
However, it was difficult to balance fluid removal with
worsening hypotension. Given the severity of the liver disease
and other comorbidities, CVVH was felt to be a means to no end
and was discontinued. Given the extremely poor prognosis of the
patient, there were multiple family discussions. Social work
was also involved. Pt was first made DNR on [**3-30**] and then no
escalation of care on [**3-31**]. She went into ventricular
tachycardia on [**4-3**] followed by asystole. She expired on [**4-3**].
HCP was notified. Autopsy was declined.
Medications on Admission:
Medications(from prior admission, unclear what meds she was on
upon transfer as documentation from OSH is poor):
Lactulose 30 ML PO TID
Nadolol 20 mg PO DAILY
Prilosec 20 mg daily
spironolactone 6.25mg daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Cardiogenic shock
Severe septic shock
Hypoxemic respiratory failure
Acute respiratory distress syndrome
Spontaneous bacterial peritonitis
Hepatorenal syndrome
End stage liver disease from Hepatitis C
Hepatic encephalopathy
Anemia
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 5070, 5715, 2859, 4019 |
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