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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5800 }	Medical Text: Admission Date: [2103-10-12] Discharge Date: [2103-10-21] Date of Birth: [2028-4-2] Sex: M Service: [Doctor Last Name 1181] HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old Chinese male with a history of left MCA cerebrovascular accident with resulting right hemiparesis on [2103-8-14], who was transferred to [Hospital1 69] from rehabilitation facility for treatment of recurrent aspiration pneumonia and possible tracheostomy placement for pulmonary toilet. The patient had been discharged from [Hospital1 346] to [Hospital1 2670] skilled nursing facility and then transferred to [Hospital3 ] facility. The patient continued to have aspiration and slight fevers despite the fact that he was treated with ceftazidime and vancomycin at [Hospital1 ]. The patient was unable to clear his secretions on his own, and suctioning seemed to exacerbate his regurgitation and aspiration per transfer notes. The patient also reports a significant weight loss over the past several months. The patient had been guaiac positive last [Hospital1 69] admission but, given the acuity of his stroke, did not undergo further workup for that at this time. Family was interested in colonoscopy and further workup of the patient's weight loss. PAST MEDICAL HISTORY: Significant for stroke as per history of present illness, chronic obstructive pulmonary disease, gout, hypothyroidism, asthma, hyperlipidemia. MEDICATIONS ON TRANSFER: Ceftazidime 1 gram every eight hours started [2103-10-3], vancomycin 1 gram every 12 hours started [2103-10-3], Protonix 40 mg by mouth twice a day, Ritalin 100 mg by mouth twice a day, Reglan 5 mg by mouth every six hours, and heparin 5000 units subcutaneously every 12 hours. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On presentation, the patient was febrile, with a temperature of 101.2, pulse 100, blood pressure 106/68, breathing 22 times a minute, oxygen saturation 93% on room air, 95% on 3 liters. Generally, he is a cachectic male, nonverbal. Head, eyes, ears, nose and throat: Remarkable for dry oral mucosa. Neck: The patient has flat neck veins and marked supraclavicular wasting. Cardiovascular examination reveals a regular rate, normal S1 and S2, no murmurs appreciated. The patient had shallow respirations with coarse rales bilaterally at the bases. Abdominal examination revealed a clean percutaneous endoscopic gastrostomy site with soft bowel sounds. Extremities: There was no edema. Feet were in waffle boots bilaterally. Neurologic examination was remarkable for a left fixed pupil, patient unable to follow commands secondary to language barrier, marked right hemiparesis with contracture and cogwheeling of the patient's left upper extremity. LABORATORY DATA: On admission, white count was 26.8, hematocrit 36.3 which is stable, platelets 507. Coags were all within normal limits. Electrolytes: Sodium 131, potassium 4.3, chloride 93, bicarbonate 28, BUN 11, creatinine 0.4, glucose 93. Chest x-ray revealed right middle lobe and left lower lobe opacities, consistent with pneumonia, and small bilateral pleural effusions. HOSPITAL COURSE: This is a 75-year-old male with a right hemiparesis secondary to left MCA infarct and recurrent aspiration pneumonia secondary to aspiration of food from gastrostomy tube. The patient is evaluated for further treatment of aspiration pneumonia and question of tracheostomy for pulmonary protection. 1. Pulmonary: The patient had adequate oxygen saturation on room air upon transfer, but still with marked secretions that were difficult to suction and evidence of pneumonia on chest x-ray. The patient was treated with ceftazidime and clindamycin. Vancomycin was stopped. The patient had some improvement over the next couple of days, however, on the morning of [10-14], the patient was found to be breathing at 40 to 45 times a minute. Arterial blood gas at that time was most consistent with respiratory alkalosis. The patient's chest x-ray revealed increased pleural effusions, particularly on the left side, and the patient was sent for a pulmonary embolus protocol scan to rule out pulmonary embolus, which was negative. However, the scan did reveal an increased size of the patient's left pleural effusion with question of loculation. This effusion was tapped, and about 500 cc of turbid fluid was removed. This effusion proved to be consistent with a parapneumonic effusion, simple, uncomplicated. No further treatment was needed, and cytology was negative for malignant cells. Cultures of this fluid remained negative. The patient's acute shortness of breath was treated with 20 mg of intravenous lasix, to which the patient had 1400 cc of urine output over four hours, with marked improvement in respiratory rate, down to the low 30s to high 20s. Diuresis combined with tap of the parapneumonic effusion resulted in a much improved pulmonary status, and the patient was breathing comfortably in the 20s for the rest of his hospital stay, and had oxygen saturations of 95% on 3 to 4 liters nasal cannula. While in-house, the patient also was evaluated by Interventional Pulmonary for placement of a tracheostomy tube for more aggressive pulmonary toilet. The patient underwent this procedure on [2103-10-18], tolerated the procedure well, and was able to be better suctioned once his tracheostomy tube was placed. 2. Infectious Disease: The patient had a white count of 26.8 on admission. The patient was switched from ceftazidime and vancomycin to ceftazidime and clindamycin. The patient was low-grade febrile for the first couple of days that he was in-house, however, after his left pleural effusion was tapped, the patient was afebrile for the rest of his stay. The patient's white count continued to decrease and was 9.6 on the day prior to discharge. The patient's ceftazidime was stopped on [2103-10-20]. The patient should continue to receive clindamycin for two more days to complete a ten day course. The patient's cultures remained negative throughout the course of his stay. 3. Weight loss: The patient came with a history of profound weight loss over the last several months. The patient had chest and abdominal CT to assess for occult malignancy. These fortunately revealed no masses. Thus the patient's weight loss is still somewhat of a mystery. 4. Gastrointestinal: The patient came with a history of recurrent aspiration pneumonia secondary to vomiting tube feeds. The patient underwent gastrostomy tube advancement into his jejunum while in-house. The procedure was done by Interventional Radiology, tolerated well by the patient. The patient was restarted on his tube feeds on [2103-10-20], and was tolerating them well and almost at goal at this time of this dictation. 5. Hematology: The patient came with a history of being guaiac positive previously. The patient's hematocrit remained stable while he was in-house. Given the patient's fluctuating respiratory status, we elected not to consult Gastroenterology and have the patient undergo colonoscopy at this time, however, in the future the patient should probably have a colonoscopy. 6. Endocrine: The patient had a history of being hypothyroid and was not on levothyroxine when he came in. His TSH was checked and found to be 4.2, within normal limits. Thus he was not started on any thyroid hormone replacement at this time. The patient was discharged to [Hospital6 23127] on [2103-10-21] in stable condition. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia 2. Left parapneumonic effusion 3. Chronic obstructive pulmonary disease 4. History of gout 5. History of hypothyroidism 6. Status post left MCA cerebrovascular accident 7. History of asthma DISCHARGE MEDICATIONS: 1. Lansoprazole oral solution 30 mg per gastrostomy tube once daily 2. Clindamycin 600 mg intravenously every eight hours for two more days 3. Heparin 5000 units subcutaneously every 12 hours 4. Methylphenidate hydrochloride 10 mg by mouth twice a day 5. Reglan 5 mg by mouth every six hours while the patient is taking tube feeds 6. Albuterol nebulizers every six hours as needed 7. Morphine sulfate .5 to 1 mg every four to six hours as needed for air hunger 8. Tylenol 325 to 650 mg by mouth every four to six hours as needed for pain or fever The patient should follow up with Dr. [Last Name (STitle) 17399], his primary care physician, [Name10 (NameIs) ] also with Dr. [Last Name (STitle) 10030] in Neurology. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Doctor First Name 102593] MEDQUIST36 D: [2103-10-21] 01:22 T: [2103-10-21] 01:58 JOB#: [Job Number 37930] ICD9 Codes: 5070, 5119, 496, 2749, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5801 }	Medical Text: Admission Date: [2118-9-29] Discharge Date: [2118-10-6] Date of Birth: [2055-1-4] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 6180] Chief Complaint: Fever and Hypotension Major Surgical or Invasive Procedure: 1. None History of Present Illness: Oncology History: Patient was originally diagnosed with Breast cancer in [2113]. At time of diagnosis she had a T1N0M0, ER+, PR-, her-2/NEU- lesion treated with lumpectomy and XRT. The patient had received Tamoxifen since [2113-12-25] without additional adjuvant chemotherapy and without known progression of disease to date as per patient's report. The patient's Tamoxifen was discontinued upon diagnosis of second primary malignancy. In late [2117-11-24], the patient presented with abdominal pain. A CT at that time revealed a mass in the pancreas w/extension to the Left adrenal and kidney with biopsy revealing mucinous adenocarcinoma. The patient is now s/p distal pancreatectomy, splenectomy, L adrenalectomy, L nephrectomy, and omentectomy for this lesion. She began treatment with XRT/xeloda and was then discovered to have metastatic disease for which gemcitabine/cisplatin were initiated. Most recently the patient has been receiving irinotecan and xeloda in [2118-8-25] in the setting of rising CA19-9 which has been followed by good response with a drop in her CA19-9 from 1549 to 439. Her last dose of Irinotecan was [9-14]. The patient was nearing completion of her second cycle of xeloda with her last dose taken on Tuesday [9-27]. She was to complete her cycle Wednesday night but was told to hold further doses given her symptoms for which she presented. Her next scheduled cycle was to begin Wednesday, [2118-10-5], but may be postponed given current symptoms. . The patient was reported to be in her USOH until Sunday afternoon when she developed onset of diarrhea. She was visiting friends in [Name (NI) ] at the time and previously reported she felt well. She reports small hiking but denies insect bites, tick bites, rashes, drinking stream or [Doctor Last Name ] water. The patient continued to have diarrhea and called her Oncologist on Tuesday for her ongoing symptoms. She was instructed at this time to hold her xeloda. The patient reported additionally decreased p.o. intake over the prior 48h. On the evening of presentation, the patient went to a hotel room to lie down. The patient was found by her partner to be somnolent. She was arousable but reported to be sleepy and unable to verbalize response. The patient was taken to [Hospital1 18] by taxi, with assistance. On the way to the hospital, she reports one episode of non-bloody, non-bilous vomiting. She denied on admission any ongoing fevers/chills, rashes, headaches, visual changes, chest pain, sob, cough, or abdominal pain. She denied any sick contacts. . In ED her vitals were as follows: 102.1, 105, 79/52, 18, 96% RA. Patient was noted to have altered MS, was confused and somnolent. She received cefepime 2g, vancomycin 1g, hydrocortisone 100mg, and levofloxacin 500mg iv x1. The patient's elevated INR was reversed w/ 1 U FFP for possible LP. However, the patient's MS improved w/3L NS with improvement in her blood pressure and an LP was not performed. . Interval History: Since admission to the MICU, the patient was noted to have episode of hypotension with SBP's in the 60's to 70's for which she received 2 500cc NS boluses. Patient continued to be hypotensive overnight and was additionally bolused another 500CC NS as well as 500CC LR. Patient was noted to have ongoing diarrhea and one episode of non-bilious, non-bloody vomiting overnight as well with dinner. She tolerated breakfast on the am of trasnfer to floor, but reports ongoing fatigue. She additionally reports some F/C this am but denies any additional N/V, abdominal pain. She denies any HA, neck stiffness, photophobia. She reports her mental clarity to be much improved since admission. . Allergies: Sulfas - patient reports adverse reaction to sulfa containing eye drops previously Past Medical History: PMHx: - Breast Ca, T1N0M0, ER+, PR-, her-2/NEU-, s/p lumpectomy and XRT, on Tamoxifen since [12-25], which was stopped with initiation of chemotherapy - Pancreatic Ca, as above - HTN - DVT - [7-29] - diagnosed asymptomatically by abd CT - Migraines Social History: Patient is currently retired. Previously employed as a superintendent for school district in [State 4565]. Patient denies etoh/tobacco/ivdu. Patient with male partner of 25 years, previously married with 2 children from previous marriage. Travel history as above to NH recently. Previously received her care with [Doctor Last Name 21721] in CA, referred to Dr. [First Name (STitle) ] for 2nd opinion, the reason for which she is currently in [Location (un) 86]. Family History: Mother deceased brain tumor age 54 Father deceased [Name2 (NI) 499] ca age 64 Physical Exam: Physical Exam Vitals: Tc:97.7___ Tmx:101 ([2118-9-28] 21:00)____ BP:120/59___ HR:94_____ RR:15____ O2 Sat: 99% on RA Rectal Tube: 2835cc over last 24 hours . Gen: Patient is a middle aged female, appears chronically ill but not greatly malnourished, in NAD HEENT: NCAT, EOMI, PERRL. OP: MMM, no lesions Neck: No LAD, No JVD. Supple Chest: Mildy decreased BS at left base, otherwise CTA A+P Cor: mildly tachycardic, no M/R/G Abd: firm but not rigid, mild/mod tenderness diffusely but greater in LLQ without rebound or guarding. +NABS with occasional borborygymi Extrem: No C/C/E Access: left chest port, + Foley, + rectal tube Pertinent Results: Admission Labs: [2118-9-29]: . [2118-9-29] 01:25AM PLT COUNT-271 [2118-9-29] 01:25AM PT-21.8* PTT-27.6 INR(PT)-3.4 [2118-9-29] 01:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL TEARDROP-OCCASIONAL HOW-JOL-OCCASIONAL [2118-9-29] 01:25AM NEUTS-33* BANDS-8* LYMPHS-28 MONOS-24* EOS-2 BASOS-0 ATYPS-1* METAS-2* MYELOS-0 NUC RBCS-2* OTHER-2* [2118-9-29] 01:25AM WBC-1.7* RBC-3.37* HGB-11.5* HCT-33.8* MCV-100* MCH-34.0* MCHC-33.9 RDW-20.1* [2118-9-29] 01:25AM ALBUMIN-3.8 CALCIUM-8.5 PHOSPHATE-1.4* MAGNESIUM-1.4* [2118-9-29] 01:25AM LIPASE-9 [2118-9-29] 01:25AM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-68 AMYLASE-15 TOT BILI-1.7* [2118-9-29] 01:25AM GLUCOSE-155* UREA N-19 CREAT-1.3* SODIUM-130* POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-20* ANION GAP-15 [2118-9-29] 01:43AM LACTATE-1.8 [2118-9-29] 02:20AM URINE GRANULAR-[6-3]* HYALINE-[2-26]* [2118-9-29] 02:20AM URINE RBC-[2-26]* WBC-[2-26] BACTERIA-FEW YEAST-NONE EPI-[2-26] [2118-9-29] 02:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG [2118-9-29] 02:20AM URINE TYPE-RANDOM COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.026 [2118-9-29] 08:14AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [2118-9-29] 08:14AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2118-9-29] 08:14AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2118-9-29] 08:14AM PT-24.6* PTT-29.1 INR(PT)-4.4 [2118-9-29] 08:14AM PLT SMR-NORMAL PLT COUNT-241 [2118-9-29] 08:14AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL SCHISTOCY-1+ BURR-OCCASIONAL HOW-JOL-1+ [2118-9-29] 08:14AM NEUTS-39* BANDS-14* LYMPHS-25 MONOS-17* EOS-0 BASOS-0 ATYPS-3* METAS-2* MYELOS-0 NUC RBCS-2* [2118-9-29] 08:14AM WBC-1.9* RBC-2.90* HGB-9.5* HCT-28.8* MCV-100* MCH-32.7* MCHC-32.8 RDW-19.7* [2118-9-29] 08:14AM CALCIUM-7.6* PHOSPHATE-1.8* MAGNESIUM-1.9 [2118-9-29] 08:14AM GLUCOSE-169* UREA N-16 CREAT-0.8 SODIUM-135 POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-16* ANION GAP-13 Additional Pertinent Labs/Studies: . [2118-10-4] ABG - pO2-92 pCO2-22* pH-7.40 calHCO3-14* Base XS--8 [2118-9-29] Venous Lactate-1.8 [2118-10-2] Venous Lactate-1.2 [2118-10-4] Venous Lactate-1.4 . Trends: WBC: 8.9 <- 5.1 <- 4.9 <- 3.2 <- 1.5 <- 2.4 <- 1.9 <- 1.7 ANC: 2950 ([2118-10-4]) <- 1369 <- 1290 <- 590 ([2118-10-1]) HCT: 26.2 <- 27.4 <- 29.6 <- 31.0 <- 25.8 <- 26.2 <- 28.8 <- 33.8 INR: 6.3 <- 4.8 <- 4.2 <- 6.0 <- 3.1 <- 4.2 <- 4.4 <- 3.4 . Microbiology: [2118-9-29] Blood cx - No growth [2118-10-1] Blood cx - No growth [2118-10-2] Blood cx - No growth [2118-10-3] Blood cx - No growth . [2118-9-29] Stool cx - No salmonella, shigella, or campylobacter found. FEW CHARCOT-[Location (un) ] CRYSTALS PRESENT. FEW POLYMORPHONUCLEAR LEUKOCYTES. NO OVA AND PARASITES SEEN. C. Diff negative [2118-9-30] Stool cx - MODERATE POLYMORPHONUCLEAR LEUKOCYTES. NO OVA AND PARASITES SEEN. [2118-10-1]: Stool: Negative for C. Diff [2118-10-2]: Stool: Negative for C. Diff [2118-10-4]: Stool cxs - No growth to date [2118-10-5]: Stool cxs - No groeth to date . [2118-9-29]: Urine cx - No growth [2118-10-3]: urine cx - No growth . Radiology: [2118-9-29]: Chest Pa/Lat: CHEST AP: Surgical clips are visualized over the right lateral upper chest. The right costophrenic angle has been excluded from the study. A left-sided Port-A-Cath is visualized with its tip in the proximal SVC. The heart size, mediastinal and hilar contours are unremarkable. The lungs are clear. There are no pleural effusions. The pulmonary vasculature is normal. IMPRESSION: No acute cardiopulmonary process. . [2118-9-29]: CT Head: FINDINGS: There is no intracranial mass effect, hydrocephalus, shift of normally midline structures or major vascular territorial infarction. The density values of the brain parenchyma are within normal limits. Surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: No mass effect or hemorrhage. . [2118-9-30]: Port-a-cath Flow Study: 1. Flow study through the port was suggestive of either a fibrin sheath, or less likely, a small catheter leak. 2. Good flow was obtained on aspiration of the port at the end of the examination. . [2118-10-4]: CT Abdomen + Pelvis: The lung bases are clear. Patient has prior distal pancreatectomy, splenectomy and radical left nephrectomy. In the left upper quadrant posteriorly, there is ill-defined area of soft tissue density located just posterior to the surgical clips to the left and slightly inferior to the celiac artery axis origin. This area of tissue density measures up to 2.8 cm AP x 1.6 cm transverse. This could represent postoperative thickening but correlation with any prior imaging is advised to exclude the possibility of local recurrence. The remaining portion of the proximal pancreatic body, neck and head appear normal. No intra or extrahepatic biliary dilatation. The liver is normal in size. Multiple sub cm ovoid hypoattenuating areas mainly in the left lobe ,these may represent small cysts but are too small to characterise on CT and should be correlated with prior imaging or interval follow up as small hypovascular metastases cannot be excluded. The gallbladder and right adrenal gland are normal. The remaining right kidney is normal in size, 1.5 cm fluid attenuating cyst in the upper pole cortex. The abdominal aorta is normal in caliber. No intra-abdominal ascites. In the lateral mid abdominal mesentry, there is a 9 mm area of nodularity just anterior to and separate from the descending [Month/Day/Year 499] (series 3 image 48) and a 5 mm area of nodularity more superiorly (series 3, image 43). There is no abnormal large or small bowel loop dilatation. Many of the small bowel loops are mildly prominent, measuring up to 3 cm in diameter and the [Month/Day/Year 499] is fluid filled throughout which may be due to a current episode of enteritis. . Pelvis: A small 2 cm fluid attenuating locule in the posterior inferior pelvis. The uterus is normal in size. No pelvic mass lesions or lymphadenopathy. No concerning bone lesions demonstrated on bone window setting. . CONCLUSION: 1)Fluid filled non-thickened non-distended [Month/Day/Year 499] .This may be related to current episode of enteritis depending on current clinical correlation. 2) No definite evidence of metastatic disease. There are a number of findings which require correlation with prior postoperative imaging if available or otherwise interval follow.These include an ill- defined area of thickening of the posterior operative site in the left upper quadrant, two sub cm areas of nodularity in the left abdominal mesentery and sub cm hypodensities mainly in the left lobe of the liver. Discharge Labs: . [2118-10-6] 07:25AM BLOOD WBC-5.8 RBC-2.90* Hgb-9.5* Hct-28.9* MCV-100* MCH-32.6* MCHC-32.7 RDW-20.8* Plt Ct-458* [2118-10-6] 07:25AM BLOOD Neuts-46* Bands-6* Lymphs-16* Monos-23* Eos-2 Baso-0 Atyps-0 Metas-5* Myelos-2* NRBC-41* [2118-10-6] 07:25AM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Target-OCCASIONAL Schisto-1+ How-Jol-OCCASIONAL Acantho-2+ [2118-10-6] 07:25AM BLOOD Fibrinogen - Pending [2118-10-6] 07:25AM BLOOD Glucose-98 UreaN-3* Creat-0.7 Na-134 K-3.8 Cl-108 HCO3-15* AnGap-15 [2118-10-6] 07:25AM BLOOD Calcium-7.5* Phos-2.0* Mg-2.0 Brief Hospital Course: Patient is a 63 year old female with pancreatic Cancer, recently receiving treatment with her 2nd cycle of xeloda and irinotecan who presents to hospital with fever, hypotension, and altered mental status. . #. Hypotension/Diarrhea - On presentation, the patient's presentation was assessed to meet criteria for SIRS with a septic like picture on presentation. The patient was febrile, hypotensive with altered mental status in the setting of an ANC of 590. While in the ED, the patient had cultures drawn, and was initially treated with Cefepime, Vancomycin, Levofloxacin, and Hydrocortisone. Upon transfer to the MICU, the patient was maintained on therapy with cefepime and vancomycin for treatment of febrile neutropenia. The patient had received 3L NS hydration initially and was given FFP with intention to reverse the patient's elevated INR (patient on coumadin for DVT) for possible LP. However, after hydration the patient's mental status was noted to significantly improve and an LP was not attempted at this time. The patient had a lactate of 1.8 with good response in blood pressure with hydration. Overnight in the ICU on the day of admission the patient had two episodes of hypotension, with systolics in the 60's to 70's range necessitating 2NS and 2LR boluses, again with good response. It was the impression of the treating attending oncologist that the patient's presentation and diarrhea was consistent with chemotherapy induced diarrhea rather than an infectious diarrhea. For this reason, the patient was started on anti-motility agents including lomotil and questran. However, these agents had little effect initially as the patient continued to have high volume diarrhea. In the 24 hours after admission, the patient was assessed to have a GI output of about 2800cc. The patient upon transfer to the floor had a rectal tube and foley in place. However, given that the patient had an ANC < 1000 at that time, the decision was made that invasive catheters should likely be removed. As the patient has been largely incontinent of stool, it has been difficult objectively to quantify exact GI output. The patient reported that over the course of her hospital stay, she has not felt that there has been great improvement to date in the quantity of stool produced ,although she has reported increased continence. However, the day prior to discharge to receiving hospital, the patient endorses two to three liquid green bowel movements that she reports she was not even aware of until they had passed. The patient has not required fluid bolusing since trasnfer to the floor, but has been receiving constant IV hydration with NS with 20mEq KCl requiring electrolyte repletion q12hr. The patient continues to have a significant non-gap acidosis secondary to diarrhea with serum bicarbonate levels of 11 to 14 over the last three days prior to discharge. However, an ABG performed on [2118-10-4] as follows: pO2-92 pCO2-22* pH-7.40 calHCO3-14* Base XS--8 revealed that the patient is not acidemic and adequately compensating for her bicarbonate loss. As the patient has had a normal serum pH she has not been receiving oral or IV bicarbonate but continues to receive hydration and volume repletion with NS at 125 to 175 cc/hr. As the patient continues to have significant GI output, she will require ongoing hydration and additionally should receive electrolyte panels with repletion q12hrs until no longer needed. In an attempt to decrease the patient's GI output, in addition to lomotil and questran which were initiated on admission, the patient has serially been given Kaopectate and the day prior to discharge was started on Octreotide and Metamucil to help bulk her very liquidy green stool. The patient has now been afebrile > 48 hours, and is currently receiving still cefepime 2gm IV q8hr, now Day 8 (started [2118-9-29]) and Flagyl which was initiated in place of Vancomycin (now Day 4, initiated [2118-10-3]). As the patient has been afebrile for > 48 hours consideration may be made towards discontinuing these medications but will be left to the discretion of the receiving hospital. The patient has had multiple stool and blood cultures sent during this admission (see pertinent results) which have demonstrated mild to moderate Leukocytes in the stool but cultures, O+P and C. Diff have been negative multiple times. As the patient reported some mild LLQ tenderness a CT of the abdomen was obtained to detect any occult abscess or other infectious process. CT results demonstrated soft tissue density a the site of the patient's known prior pancreatic mass but revealed no abnormal large or small bowel loop dilatation. CT demonstrated many of the small bowel loops to be mildly prominent, measuring up to 3 cm in diameter and revealed the [Month/Day/Year 499] to be fluid filled throughout, thought to be related to the patient's ongoing enteritis. In the pelvis CT additionally revealed a small 2 cm fluid attenuating locule in the posterior inferior pelvis. The patient is now being transferred to receiving hospital for ongoing management of patient's diarrhea and electroylte abnormalities. . #. DVT - The patient on admission was being treated with 2.5mg po qhs of coumadin qhs for known DVT diagnosed in 08-[2117]. The patient's INR on presentation was 3.4 which was partially reversed with 1U FFP in anticipation of possible LP. However, as above, given reversal of somnolence with volume rescucitation alone, an LP was not performed. The patient's coumadin was held throughout her stay as she continued to have a supratherapeutic INR without coumadin, thought likely to be secondary to her poor PO intake as well as extinguishing gut flora with antibiotics. The patient's INR was 6.0 on [2118-10-2] for which she received 2.5mg PO Vitamin K with good effect, and reduction of her INR to 4.2 the next day. The patient in error however was given a dose of 2.5mg coumadin x1 despite a holding order the following day. Her INR was again elevated to 6.3 the day prior to discharge. As the patient's INR was greater than 5, but without any evidence of any ongoing bleeding, the patient's coumadin continues to be held and an addiitional 2.5mg PO Vitamin K was administered. The patient's INR the am of discharge was found to be 7.0. The patient was given 5mg Vitamin K SC this am with concern that previous PO doses are not being well absorbed given the patients rapid GI transit time. Of additional note, the patient has been noted previously and again this am to have occasional schistocytes on peripheral blood smear. A fibrinogen level checked previously was 543 on [2118-10-3] and repeat fibrinogen am of discharge, [2118-10-6] was 418, not consistent with DIC. The patient should continue to have her INR carefully monitored at the receiving hospital with consideration towards additional Vitamin K SC/IV for reversal of INR > 5.0 or FFP with any signs of bleeding. . #. Access - In the ICU on admission, the patient's port was noted to be not functioning properly. A flow study was performed which demonstrated fluid flow proximal to the catheter tip suggestive likely of a fibrin sheath vs. a possible catheter leak. The port was used once on the floor prior to the results of the flow study being revealed and the patient reported some burning at the port entry site with the infusion of some fluids with potassium. Therefore, the port has not been used again during this hospital course and the port should not be used any longer. The patient's port likely will have to be removed given it is not functional. Plans were to be made to have the port removed now that the patient has been afebrile > 48hours and hemodynamically stable. Upon transfer to the receiving hospital, plans will need to continue to be initiated towards port removal or alternatively attempts could be made to have an attempted snare by interventional radiology for removal of a fibrin sheath if present. The patient is aware the port is not functional and aware it will likely need to be removed. . #. Pancreatic Ca: As discussed in H+P, the patient is currently s/p distal pancreatectomy, left adrenal/nephrectomy, ometectomy treated additionally with XRT and Xeloda, follwed by gemcitabine/cisplatin, and most recently treated with xeloda/irinotecan s/p two 3-week cycles. The patient was travelling to [Location (un) 86] for second opinion regarding treatment options when she developed severe diarrhea and hypotension. Given the patient's apparent chemo toxicity, chemo was held currently until patient is medically stable to continue. Impression of Oncologist seeing patient at [Hospital1 18] is that of the two agents, the Xeloda may be more responsible for the treatment response to date and the irinotecan her current GI toxicity. Given this, considerations towards additional chemo included Xeloda alone, possibly with the addition of low dose irinotecan if tumor markers began to rise again. Alternatively, patient could additioanlly receive FOLFOX or taxotere as well. The patient is being discharged to receiving hospital currently with plans towards continuing management of diarrhea, electrolyte abnormalities as outlined above and will continue treatment planning with regards to her pancreatic Ca with her oncologist. . #. HTN - Given patient's admission for hypotension, her outpatient regimen of propranolol was held during her hospital course. Upon resolution of large GI output and decreased need for IV volume sresuscitation, consideration could be made towards reinitiating patient's antihypertesnive regimen. . #. FEN- patient was kept on a low fat, lactose free BRAT diet with supplemental pancrease given. Patient's PO intake was not optimal during hospital course, but continues to improve with resolution of her symptoms. . #. Communication: Patient's significant other, [Name (NI) ] may be reached at [Telephone/Fax (1) 62493].; He is very supportive and intimately involved in the patient's care. Medications on Admission: Medications - outpatient: pancrease 1 capsule orally before meals coumadin 5 mg po qd xanax 0.25 mg [12-26] tab po qid prn anxiety propranolol 40 mg po bid prochlorperazine 10 mg po qid prn nausea capecitabine (xeloda) 500 mg 4 tabs qam, 3 tabs qpm x 14 days. loperamide 2 mg po prn diarrhea tylenol prn erythropoetin 20,000u sq qwk. . Meds on transfer to floor from MICU: RISS Lorazepam 0.5-1 mg IV Q4H:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN Pangestyme-EC 2 CAP PO TID W/MEALS Cefepime 2 gm IV Q12H, Day 2 Cholestyramine 4 gm PO BID Vancomycin HCl 1000 mg IV Q 12H D 2 Epoetin Alfa 8000 UNIT SC Discharge Medications: 1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) unit Injection QMOWEFR (Monday -Wednesday-Friday). 4. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 5. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: Two (2) Packet PO BID (2 times a day). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q6 (). 7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for diarrhea. 9. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day). 10. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every 4 hours) as needed. 11. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H (every 8 hours). 12. Octreotide Acetate 50 mcg/mL Solution Sig: Fifty (50) mcg Injection Q8H (every 8 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Primary: SIRS Hypotension Chemotherapy related diarrhea Pancreatic Cancer . Secondary: Breast Cancer Hypertension DVT - [7-/2118] Migraines Discharge Condition: 1. Fair. Patient is being transferred to receiving hospital in [State 4565] for ongoing management. Patient is currently afebrile, normotensive, with ongoing large liquid bowel movements and requiring frequent electrolyte repletion. Discharge Instructions: 1. Please take all medications as prescribed unless instructed otherwise by receiving hospital . 2. Please continue outpatient follow up with your oncologist in [State 4565] and continue to contact Dr. [First Name (STitle) ] at [Hospital1 18] as desired for ongoing treatment options. . 3. Upon discharge from receiving hosptial, please return to hospital for any signs or symptoms of increasing diarrhea, dizziness, fever, intractable nausea/vomiting, bleeding or any other concerning symptoms. Followup Instructions: 1. Please continue treatment under the supervision and care of receiving hospital in [State 4565] . 2. Please call your oncologist upon discharge for ongoing care and treatment plans ICD9 Codes: 0389, 2762, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5802 }	Medical Text: Admission Date: [2138-1-29] Discharge Date: [2138-2-5] Date of Birth: [2094-8-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization x 3 cardiac resuscitation History of Present Illness: 43 yo female w/ a h/o htn, tobacco abuse, and famhx of CAD who p/w 1 week of intermittent chest pain. Patient notes centrally located chest pressure associated w/ bilateral arm heaviness starting 1 week ago. The episodes were intermittent, lasting for hours at a time, and occurred at rest and with activity. Patient thought it was heartburn and treated w/ tums w/o improvement. Yesterday, the pain became more severe, [8-29], and did not remit. The pain yesterday was associated w/ SOB and nausea. She presented to [Hospital3 ] where ECG showed 0.5-[Street Address(2) 77963] elevations w/ QWs and symmetric TWIs in III, aVF c/w missed event. Cardiac enzymes were elevated w/ tropI of 3.4. She received asa 325 mg, plavix 600 mg, and was started on a heparin bolus and gtt. She was also hypertensive to 204/137 and received 20 mg of IV labetolol x2. She received multiple SLNTGs w/o improvement of symptoms as well as IV fentanyl and was started on a NTG gtt. She was transferred to [Hospital1 18] for catheterization. . In the cath lab, she was found to have a diffusely diseased RCA totally occluded with thrombus. She received thrombus could not be suctioned out, and multiple angioplasties were performed with residual thrombus at the end of the procedure. Currently she is chest pain free. Past Medical History: # htn # s/p c-section x2 Social History: Lives in [Location 55051] with husband. [Name (NI) ] 5 children. 1 ppd smoking hx x 25 yrs. Family History: Brother had an MI @ age 53. Father had an MI in late 50s. Physical Exam: VS: T: AF, BP: 123/65, HR: 61, RR: 15, O2: 100% on RA Gen: WDWN middle aged female in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP low sitting upright. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. No organomegaly. Groin: 2+ femoral pulses. Cath site w/o hematoma or bruit. Ext: WWP. No c/c/e. 2+ DP pulses. Skin: No stasis dermatitis, ulcers, scars Pertinent Results: [2138-1-30] 09:00AM BLOOD WBC-10.2 RBC-4.25 Hgb-13.3 Hct-38.2 MCV-90 MCH-31.3 MCHC-34.8 RDW-13.1 Plt Ct-249 [2138-1-30] 01:45AM BLOOD Plt Ct-224 [2138-1-30] 07:45AM BLOOD K-3.8 [2138-1-30] 09:00AM BLOOD Glucose-95 UreaN-7 Creat-0.7 Na-138 K-4.0 Cl-102 HCO3-29 AnGap-11 [2138-1-30] 07:45AM BLOOD CK(CPK)-605* [2138-1-30] 07:45AM BLOOD CK-MB-88* MB Indx-14.5* [2138-1-30] 09:00AM BLOOD Mg-1.8 Cholest-201* [2138-1-31] 07:30AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9 [2138-2-3] 05:40PM BLOOD calTIBC-283 Hapto-149 Ferritn-127 TRF-218 [2138-1-30] 09:00AM BLOOD Triglyc-222* HDL-45 CHOL/HD-4.5 LDLcalc-112 LDLmeas-134* [2138-1-31] 08:22PM BLOOD Type-ART pO2-356* pCO2-35 pH-7.18* calTCO2-13* Base XS--14 [2138-1-31] 08:22PM BLOOD Glucose-245* Lactate-8.2* Na-137 K-4.5 Cl-117* [2138-2-5] 06:00AM BLOOD WBC-7.7 RBC-3.19* Hgb-10.0* Hct-28.5* MCV-89 MCH-31.2 MCHC-35.0 RDW-15.2 Plt Ct-135* [2138-2-4] 08:05AM BLOOD PT-12.9 PTT-29.7 INR(PT)-1.1 [2138-2-5] 06:00AM BLOOD Glucose-85 UreaN-8 Creat-0.5 Na-142 K-3.4 Cl-108 HCO3-24 AnGap-13 [2138-2-1] 02:40PM BLOOD CK(CPK)-3135* [2138-2-1] 06:10AM BLOOD ALT-620* AST-686* LD(LDH)-1415* CK(CPK)-2762* AlkPhos-65 TotBili-0.5 [2138-2-3] 05:40PM BLOOD LD(LDH)-703* CK(CPK)-1722* [2138-1-30] 07:45AM BLOOD CK-MB-88* MB Indx-14.5* [2138-1-30] 09:00AM BLOOD CK-MB-98* MB Indx-15.1* cTropnT-0.61* [2138-1-31] 07:30AM BLOOD CK-MB-34* MB Indx-9.2* cTropnT-0.79* [2138-1-31] 11:50PM BLOOD CK-MB-148* cTropnT-3.87* [2138-2-1] 06:10AM BLOOD CK-MB-161* MB Indx-5.8 cTropnT-3.89* [2138-2-1] 02:40PM BLOOD CK-MB-142* MB Indx-4.5 [2138-2-2] 04:54AM BLOOD CK-MB-68* MB Indx-2.3 [2138-2-3] 06:25AM BLOOD CK-MB-18* MB Indx-0.9 cTropnT-2.33* [2138-2-3] 05:40PM BLOOD CK-MB-13* MB Indx-0.8 cTropnT-1.98* [2138-2-5] 06:00AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8 [2138-1-31] 08:39PM BLOOD Glucose-316* Lactate-13.6* Na-142 K-2.4* Cl-108 [2138-2-1] 12:02AM BLOOD Lactate-3.9* . Reports: C.CATH Study Date of [2138-1-29] PTCA COMMENTS: Initial angiography revealed a total occlusion of the RCA proximally with an aneurysmal area at the occlusion. There were left to right collaterals filling PDA but no right to right collaterals. We planned to treat lesion with export and balloon angioplasty. Heparin and integrelin were added to asa and plavix. A JR 4 guide was used initially which did not provide adequate support. We could not cross with a Prowater wire and were directed into a thrombotic marginal branch. A PT [Name (NI) 9165] intermediate wire did cross with moderate difficulty. Flow was restored by dottering which revealed a large diffusely diseased aneurysmal vessel with very large thrombus burden. We were unable to advance Export catheter and had to pull wire and exchange for a AR 2 guide which provided better support. We recrossed with a PT [Name (NI) 9165] intermediate wire and exchanged for a Stabilizer Supersoft. We were then able to do 2 passess with export but could not reach all the way to distal RCA due to support issues. No visible thrombus was retrieved. There were 2 areas of 90% stenosis, one proximally and the other in mid-distal RCA. We dilated with a 2.5x15mm Voyager balloon at distal lesion for 6-12atm x4 and the proximal lesion at 10atm x2. This improved flow to TIMI 3 but large thrombus burden remained. At this time further intervention was aborted and plan is to continue heparin and integrelin for 36 hours. Patient will be brought back to lab after that period for stenting of the two lesions with BMS if thrombus resolves. Of note patient was hemodynamically stable with BP 140 on TNG drip througout the case and there were no tachy or brady arrhythmias. COMMENTS: 1. Coronary angiography of this right dominant system revealed 2 vessel CAD. The LMCA and LAD were without angiographically evident flow limiting epicardial stenosis. The LCX had a 60-70% proximal stenosis. The RCA was totally occluded proximally with aneurysmal dilatation at the area of occlusion. 2. Resting hemodynamics revealed normal systemic arterial pressures with aortic systolic pressure of 127 mm Hg and mean arterial pressure of 88 mm Hg. 3. Left ventriculography was not performed. 4. POBA of proximal and mid-distal RCA lesions with 2.5mm balloon restoring flow in setting of sub-acute inferior STEMI. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Subacute inferior STEMI. 3. Angioplasty of RCA. . C.CATH Study Date of [2138-1-31] PTCA COMMENTS: Initial angiography revealed tandem lesions in the RCA. There was a 60% lesion proximally (free of thrombus) and an 80% lesion distally with large thrombus burden at this site. We planned to perform PTCA to the distal lesion with a view to stenting if this produced an unsatisfactory result. Heparin and Integrilin was commenced prophylactically. An AR2 guide engaged the RCA providing adequate support. The RCA was wired with some minor difficulty with a Prowater wire. The distal RCA lesion was then predilated with a 3.0x20mm Voyager balloon inflated to 10atms with improvement of the distal lesion to 50%. We then opted for distal distal protection (with Spider 7.0mm filter) and Angiojet thrombectomy. Initially no change but after removal of filter, thrombus not noted and PDA occluded mid. PDA was wired and IC nitroprusside was given. Flow in PDA did not return. Decision made to proceed to stenting of distal and proximal RCA lesion. We attempted to deliver a 4.5x28mm Ultra stent which failed with loss of wire position. The RCA was then engaged with an AL1 guide and attempted to re-wire with a Prowater wire leading to proximal large dissection. The dissected segment was eventually crossed with a CPT XS wire with some difficulty and exchanged for a Pilot 50 wire to cross distally. The distal lesion was stented with a 4.5 x 24 Liberte stent at 13 ATM. The proximal lesion and dissected segment was then stented with a 4.5x24mm Liberte stent deployed at 24atms. Final angiography showed no thrombus. TIMI 3 flow and no dissection. PDA slow flow. Patient left cathlab with continuing chest pain and inferior ST elevation. COMMENTS: 1. Hemodynamics: BP 147/88/113 2. Proximal 60% RCA lesion. Distal 80% RCA lesion with significant thrombus burden 3. Distal embolic protection with Angiojet thrombectomy of distal RCA. 4. Thrombotic emboli with slow flow down PDA. 5. Successful PTCA/stenting to distal RCA with a 4.5x24mm Liberte stent deployed at 13atms. Successful PTCA/stent to proximal RCA lesion and dissected segment with a 4.5x24mm Liberte stent deployed at 24atm. No apparent thrombus or dissection at end of procedure with TIMI 3 flow down vessel however slow flow down PDA. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe thombotic lesion in distal RCA with further lesion in proximal RCA (thrombus free). 3. PTCA/stenting to distal RCA with bare metal stent following Angiojet thrombectomy with compromise of PDA. 4. Successful PTCA/stenting of proximal RCA with bare metal stent. . C.CATH Study Date of [2138-1-31] BRIEF HISTORY: 43 yo female with a history of coronary disease status post STEMI [2138-1-29] with POBA of the RCA on [1-29] and stenting [2138-1-31] with ventriuclar fibrillation and cardiac arrest the evening of [2138-1-31] with successful rescuscitation for emergent cath. Intubated. PTCA COMMENTS: The initial angiography revealed a totally occluded thrombosed RCA at the proximal stent. Heparin and integrilin were being administered for anticoagulation. The strategy was to dotter the vessel, perform thrombectomy and administer intracoronary 2b3a to reestablish flow and subsequently perform the mid-RCA stenting. JR4 Guide provided good support. Choice PT XS wire crossed into the distal vessel with some manipulation. Some flow was restored by dottering the vessel with a 3.0 X 12 mm Voyager balloon. Subsequent angioplasty was performed of the vessel with a 3.0 X 12 mm Voyager balloon at 14 atms distally. Intracoronary Reopro was administered and the remaining thrombus was thrombectomized with multiple runs of the Export catheter with improvement in flow. 5.0 X 20 mm Quantum Maverick balloon was used to further predicate the vessel at 14 atms. 4.0 X 23 mm Vision stent was deployed at the distal RCA at 18 atms. The mid RCA was stented with a 5.0 X 28 mm Ultra stent deployed at 18 atms. Proximal RCA was stented with a 5.0 X 18 mm Ultra stent in an overlapping fashion. 5.0 X 20 mm Quantum Maverick balloon was used for postdilation at 16-18 atms. There was less than 20% residual stenosis in the proximal stent and no residual stenosis in the mid to distal vessel. Flow was TIMI III.The patient was hemodynamically stable and following commands at the end of the procedure. COMMENTS: 1. Coronary angiography of this right dominant system revealed acute stent thrombosis of the proximal RCA. There was mild disease in the LMCA, LAD, and LCX vessels. The RCA had an acute thrombotic lesion causing a 100% occlusion of the proximal RCA with some left to right collaterals. 2. Resting hemodynamics after successful CPR in the CCU revealed mildly elevated systemic arterial pressure with an SBP of 142 mm Hg. 3. Successful thrombectomy and stenting of the RCA with 4.0 X 23 mm Vision bare metal stent distally and 5.0 X 28 mm and 5.0 X 18 mm Ultra stents proximally in an overlappig fashion (see PTCA comments for detail). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Acute inferior myocardial infarction, managed by thrombectomy, PTCA of the proximal RCA vessel. 3. Successful stenting of the RCA with bare metal stents. . C.CATH Study Date of [2138-2-1] BRIEF HISTORY: Ms. [Known firstname 1258] [Known lastname ] is referred for repeat catheterization after acute chest pain and ST elevations in V1, III, and aVF. COMMENTS: 1. Selective coronary angiography of this right dominant system revealed widely patent RCA stents with distal RCA thrombus unchanged from the last catheterization. There was no angiographically evident stent thrombosis. The left coronary system was not injected. 2. Resting hemodynamics revealed elevated right and left sided filling pressures with RVEDP of 21 mm Hg and mean PCWP of 22 mmHg. Pulmonary arterial pressures were moderately elevated at 43 mm Hg. Systemic arterial pressures were normal with aortic sytolic pressure of 112 mm Hg and mean arterial pressure of 78 mm Hg. Cardiac index was preserved at 3.56 l/min/m2. 3. Left ventriculography was not performed. FINAL DIAGNOSIS: 1. One vessel coronary artery disease with unchanged RCA disease. 2. No evidence of stent thrombosis. 3. Elevated right and left sided filling pressures with preserved cardiac index. . ECHO [2138-1-30]: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the midventricular segment of the inferior and posterior walls. There is no ventricular septal defect. 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. Mild to moderate ([11-20]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: inferior posterior infarct with preserved ejection fraction . ECHO [2138-2-3] Conclusions 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 inferior and inferolateral hypokinesis. The remaining segments contract normally (LVEF = 50%). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2138-1-30], inferior/inferolateral left ventricular hypokinesis is new. The right ventricle is now mildly dilated, and the severity of mitral regurgitation and tricuspid regurgitation have increased. . ECG Study Date of [2138-1-29] 11:46:22 PM Sinus bradycardia. Possible prior inferior myocardial infarction. No previous tracing available for comparison. . ECG Study Date of [2138-1-31] 7:42:50 AM Sinus rhythm. There are Q waves in the inferior leads with associated ST-T wave changes consistent with prior inferior myocardial infarction. Compared to the previous tracing there is no significant change. . ECG Study Date of [2138-1-31] 11:58:36 AM Sinus rhythm. Inferior myocardial infarction of indeterminate age. There are non-specific T wave changes compared to the previous tracing of [2138-1-31]. TRACING #1 . ECG Study Date of [2138-1-31] 1:49:28 PM Sinus rhythm. Inferior myocardial infarction, could be recent. Non-specific anterior ST-T wave changes. Compared to the previous tracing of [2138-1-31] there is now inferior ST segment elevation and ST segment elevation in leads V3-V6. TRACING #2 . ECG Study Date of [2138-1-31] 2:59:56 PM Sinus rhythm. Inferior ST segment elevation could be acute/recent myocardial infarction. Anterior and lateral ST segment depression could be reciprocal. Compared to the previous tracing of [2138-1-31] there is evolution of the ST-T wave changes. TRACING #3 . ECG Study Date of [2138-1-31] 10:16:50 PM Sinus rhythm. Inferior myocardial infarction, probably recent. Non-specific anterolateral ST-T wave changes. Compared to the previous tracing of [2138-1-31] the inferior ST segment elevation is resolved and the Q waves are more prominent. TRACING #4 . ECG Study Date of [2138-2-1] 7:46:56 AM Sinus rhythm. Inferior myocardial infarction of indeterminate age. Early R wave transition. Non-specific anterolateral T wave flattening. Compared to the previous tracing of [2138-1-21] no significant change. TRACING #5 . ECG Study Date of [2138-2-1] 4:04:44 PM Sinus rhythm. There are Q waves in the inferior leads consistent with prior myocardial infarction. Non-specific lateral and anterolateral ST-T wave changes. Compared to the previous tracing there is no significant change. . CHEST (PORTABLE AP) [2138-2-1] 4:12 AM IMPRESSION: Endotracheal tube has been placed into the right main stem bronchus and needs to be pulled back 3 cm. Otherwise, no active disease in the chest. Discussed with house officer at the time of dictation. . CHEST (PORTABLE AP) [2138-2-2] 8:02 AM IMPRESSION: 1. Status post extubation. 2. Mild atelectasis right lung base, otherwise clear. . CHEST (PORTABLE AP) [2138-2-3] 10:49 AM IMPRESSION: Right linear basilar atelectasis. No evidence of pulmonary edema or consolidations. . SHOULDER [12-22] VIEWS NON TRAUMA LEFT [2138-2-2] 10:15 AM IMPRESSION: Questionable lucency through the distal acromion adjacent to the acromioclavicular joint. Degenerative changes versus possible fracture. Correlate with point tenderness. Brief Hospital Course: A/P: 43 y.o.f. w/ HTN, smoking history, and FH CAD s/p inferior STEMI s/p initial catheterization [1-29] w/ POBA and incomplete resolution of thrombus, then second cath with stent to RCA complicated by dissection and 35 minute vfib arrest associated with in-stent thrombosis, documented by later cath to be clear. . # CAD/Ischemia: She presented to [Hospital3 ] where ECG showed 0.5-[Street Address(2) 44678] elevations w/ QWs and symmetric TWIs in III, aVF. Cardiac enzymes were elevated w/ tropI of 3.4. She received asa 325 mg, plavix 600 mg, and was started on a heparin bolus and gtt. She was also hypertensive to 204/137 and received 20 mg of IV labetolol x2. She received multiple SLNTGs w/o improvement of symptoms as well as IV fentanyl and was started on a NTG gtt. She was transferred to [Hospital1 18] for cath on [1-29] which revealed a diffusely diseased proximal RCA, totally occluded with thrombus with aneurysmal dilation. The thrombus could not be sucked out, and POBA of proximal and mid-distal RCA lesions with 2.5mm balloon was performed, restoring flow in setting of sub-acute inferior STEMI. Due to the residual thrombus, no stent was placed due to concern for distal emboli of thrombus. The LCX had a 60-70% proximal stenosis. . She was transferred back to [Hospital Ward Name 121] 3 on [1-29] and did well with plan for repeat catheterization on [1-31] (hoping for resolution of thrombus by that time). Had some mild NSVT. On [1-31] the patient was taken to the cath lab where there remained a large amount of thrombus burden. A distal filter was placed and attempts at suctioning out clot and using angioget failed. Filter was pulled out and subsequent films showed dislodgement of the clot into the PDA. Patient developed pain and nitroprusside boluses/nitro gtt given for vasodilatation, as well as versed/fentanyl for pain. Was bradycardic transiently and per nursing report received atropine, but no atropine recorded in med log. Attention was then moved to stenting the RCA, c/b dissection in the proximal RCA with a transient period of no flow in the RCA. Both a proximal and distal stent were placed to the RCA with restoration of flow to RCA but minimal restoration of flow in the PDA. Patient was transferred to the holding area where she reported [4-29] chest discomfort, and was therefore transferred to the CCU for further monitoring. She then experienced a vfib arrest, requiring a 35 minute successful code, [12-21] instent thrombosis. She was taken back to the cath lab, where instent thrombosis in the proximal RCA was noted. She received successful thrombectomy and stenting of the RCA with 4.0 X 23 mm vision bare metal stent distally and 5.0 X 28 mm and 5.0 X 18 mm Ultra stents proximally in an overlappig fashion. A subsequent cath done for shoulder pain showed clean coronary arteries and stents. . She was then transferred back to [Wardname 13764], where she had no further chest pain and no apparent neurologic sequela of the arrest. She was maintained on plavix 150mg with plans to decrease to 75mg after one month as per discharge instructions, asa 325, enoxaparin 80 [Hospital1 ] x 1 month, lipitor 80, lopressor 25 [Hospital1 ], lisinopril 5. Her CK peaked at 3135. She was counseled on smoking cessation and given a nicotine patch. . # Rhythm: NSR with bradycardia intracath. s/p vib arrest in setting in-stent thrombosis. She was monitored on telemetry on the floor with no further events. Her BB was continued as above. . # Pump: ECHO on [1-30] with EF 50% and hypokinesis of the midventricular segment of the inferior and posterior walls. Clinically appeared euvolemic. Lopressor and lisonpril as above. She should have repeat ECHO as an outpatient. . # Anemia: per CCU team, stools have been guaiac negative. She continues to drift down despite two units of pRBCs on [2-1] without appropriate bump. Some might be from fluids and reequilibration, but also question hemolysis, iron deficiency, and/or bone marrow suppression given acute illness. She required a total of three units of pRBCs. Iron studies were wnl and her HCT was stable upon discharge. . # Shoulder pain: likely refered pain from diaphragm (inferior MI) vs. MSK pain since increased with movement s/p long code. AP film showed possible fracture near AC joint. [Month/Year (2) ] saw pt., recommend supportive tx, outpatient f/u in [Month/Year (2) ] clinic. . # Neuro: pt. with remarkably intact MS s/p prolonged arrest, appears neurologically intact . # HTN: Had HTN 11 yrs ago, but all antihypertensives stopped with pregnancy. - regimen as above . # Prophylaxis: PPI, bowels, AC, RISS . # Code: Full Medications on Admission: HOME MEDICATIONS: none . MEDICATIONS ON TRANSFER: aspirin plavix metoprolol heparin gtt NTG gtt Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous [Hospital1 ] (2 times a day). Disp:60 syringe Refills:1 2. Outpatient Lab Work sodium, potassium, chloride, bicarb, BUN, creatinine, glucose, calcium, magnesium, phosphate on [2138-2-7]. Please give result to Dr. [First Name (STitle) 39190] or covering physician. 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 months. Disp:60 Tablet(s) Refills:0 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: to be started after one month of plavix 150mg daily. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: inferior ST elevation MI ventricular fibrillation cardiac arrest acute systolic ventricular dysfunction coronary artery disease hypertension . Secondary: s/p c-section x2 Discharge Condition: good, stable, cardiac chest pain free Discharge Instructions: You were seen at [Hospital1 18] for chest pain and found to have a heart attack, for which you received stents and angioplasty. You had a cardiac event which required you to stay in the cardiac care unit for a couple days. Your medication regimen has changed, including new medications called Toprol XL, atorvastatin, lovenox, aspirin, and lisinopril. You will need to stay on the lovenox injections for at least one month. Your plavix should continue at the current dose for 1 month, and then you will be on 75mg daily. Please take your medications as prescribed. . You have been set up with Dr.[Name (NI) 39204] cardiology office because he referred you to [Hospital1 18]. His office will call you for an appointment time. We also gave you numbers of a couple other cardiologists if you choose to follow up with them instead of with Dr. [Last Name (STitle) 8098]. . You should stay out of work for two weeks, and then only go back part time (5 half days, not 3 full days) for the next 2 weeks. You may then need cardiac rehab after those 4 weeks. Please discuss cardiac rehab with your cardiologist. . The orthopedists saw you because of your shoulder pain. You may have a small fracture in your shoulder. You have follow-up as below for repeat xray of your shoulder. . Your potassium was also low. We have set you up with a lab draw appointment at your primary care physician's office as below to make sure your potassium is ok. . Please follow-up as below. . You should call your primary care provider or your cardiologist, or return to the emergency department if you experience chest/arm/jaw pain, shortness of breath, palpitations, lightheadedness/dizziness, loss of consciousness, nausea/vomiting, or any other symptoms that concern you. Followup Instructions: Please go to [First Name8 (NamePattern2) 6647] [Last Name (NamePattern1) 77964] office to have your blood drawn on [2138-2-7] at 8:30am. They are expecting you. We have given you a prescription for this blood draw. . Provider: [First Name8 (NamePattern2) 6647] [Name11 (NameIs) 77964] office, with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 20083], PA. [2138-2-11] at 2:20pm. . Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2138-2-25] 4:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD, orthopedics Phone:[Telephone/Fax (1) 1228] Date/Time:[2138-2-25] 4:20 . Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 8098], cardiology. Their office will call you for an appointment. His office number is [Telephone/Fax (1) ]. . Other cardiologists in your area: Cliff [Doctor Last Name ] [Telephone/Fax (1) 52395] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] [Telephone/Fax (1) 8725] . Please call if you need to reschedule. ICD9 Codes: 2768, 4275, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5803 }	Medical Text: Admission Date: [2100-11-18] Discharge Date: [2100-11-30] Date of Birth: [2026-12-26] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [2100-11-22] - Off pump CABG X 2 History of Present Illness: Mr. [Known lastname 4318] is a 73-year-old male with worsening anginal symptoms who underwent cardiac catheterization that showed severe left anterior descending and circumflex ostial disease. He was noted to have calcium in his ascending aorta by cath. A CT scan confirmed a porcelain ascending aorta. He also has baseline chronic renal insufficiency. Due to the severity of his disease, he was transferred to the [Hospital1 18] for surgical revascularization. He is presenting for high-risk coronary artery surgery. Past Medical History: HTN Hypercholesterolemia Renal insufficiency PVD AAA GERD Chronic Renal Insufficiency S/P left carotid endarterectomy Social History: Lives with wife in [Name (NI) 62675], [Name (NI) ] Family History: Cousin w/ CABG at age 50. Physical Exam: GEN: WDWN in NAD. A+Ox3 NECK: Left CEA scar well healed, no JVD HEART: RRR, no murmur LUNGS: Clear ABD: Obese, benign EXT: No varicosities, no edema. 2+ Pulses distally. NEURO: Normal gait, strength 5/5. Nonfocal. Pertinent Results: [2100-11-18] 09:50PM PLT COUNT-197 [2100-11-18] 09:50PM PT-13.4* PTT-26.5 INR(PT)-1.2 [2100-11-18] 09:50PM WBC-9.8 RBC-3.90* HGB-12.5* HCT-34.5* MCV-89 MCH-32.0 MCHC-36.1* RDW-13.4 [2100-11-18] 09:50PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [2100-11-18] 09:50PM ALT(SGPT)-26 AST(SGOT)-20 LD(LDH)-163 ALK PHOS-32* AMYLASE-64 TOT BILI-0.4 [2100-11-18] 10:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2100-11-18] 09:50PM GLUCOSE-118* UREA N-18 CREAT-1.3* SODIUM-141 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15 [2100-11-18] 10:41PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2100-11-30] 06:58AM BLOOD WBC-10.8 RBC-3.40* Hgb-11.2* Hct-31.6* MCV-93 MCH-32.8* MCHC-35.3* RDW-14.3 Plt Ct-316 [2100-11-30] 06:58AM BLOOD Plt Ct-316 [2100-11-30] 06:58AM BLOOD UreaN-18 Creat-1.2 K-4.1 [2100-11-29] 06:25AM BLOOD Calcium-8.2* Phos-3.6# Mg-2.2 [2100-11-19] Carotid Endarterectomy 1. No evidence of hemodynamically significant stenosis in the internal carotid arteries bilaterally. 2. Less than 40% stenosis of the distal right common carotid artery and 40%-59% stenosis of the distal left common carotid artery. [2100-11-19] CTA 1. Extensive calcific atheromatous disease of the entire aorta. 2. 9 mm probable left adrenal adenoma. 3. Calcified pleural plaque suggests prior asbestos exposure. 2 tiny nodules within the right middle lobe are noted. If there is no prior history of malignancy, 1-year CT follow-up is recommended. If there is a prior history of malignancy, this may be followed in 3 months with CT. [2100-11-29] CT Chest 1. Extensive calcific atheromatous disease of the entire aorta. 2. 9 mm probable left adrenal adenoma. 3. Calcified pleural plaque suggests prior asbestos exposure. 2 tiny nodules within the right middle lobe are noted. If there is no prior history of malignancy, 1-year CT follow-up is recommended. If there is a prior history of malignancy, this may be followed in 3 months with CT. [2100-11-25] CXR 1. Extensive calcific atheromatous disease of the entire aorta. 2. 9 mm probable left adrenal adenoma. 3. Calcified pleural plaque suggests prior asbestos exposure. 2 tiny nodules within the right middle lobe are noted. If there is no prior history of malignancy, 1-year CT follow-up is recommended. If there is a prior history of malignancy, this may be followed in 3 months with CT. Brief Hospital Course: Mr. [Known lastname 4318] was admitted to the [Hospital1 18] on [2100-11-18] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner by the cardiac surgical service including a carotid duplex ultrasound which showed no evidence of hemodynamically significant stenosis in the internal carotid arteries bilaterally. A chest xray showed pleural plaques as well as a heavily calcified aorta and a CT scan was obtained in follow-up. This revealed extensive calcific atheromatous disease of the entire aorta, a 9 mm probable left adrenal adenoma, calcified pleural plaque suggesting prior asbestos exposure and 2 tiny nodules within the right middle lobe. A 1-year CT follow-up was recommended. An echocardiogram was performed which revealed mild mitral regurgitation, a mildly dilated aorta and no aortic insufficiency. On [2100-11-22], Mr. [Known lastname 4318] was taken to the operating room where he underwent off-pump coronary artery bypass grafting to two vessels. An amiodarone drip was started intraoperatively for ectopy. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname 4318] [Last Name (Titles) 5058] neurologically intact and was extubated. Beta blockade and aspirin were resumed. On postoperative day two, Mr. [Known lastname 4318] was transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted to assist with his postoperative strength and mobility. Mr. [Known lastname 4318] was noted to cough with thin liquids and a speech and swallow consult was obtained. No evidence of aspiration was found and he was allowed to resume a regular diet. Mr. [Known lastname 4318] had some mild sternal drainage vancomycin was started prophylactically. A CT scan was performed which showed no evidence of dehiscence or infection. He was transfused for postoperative anemia. Vancomycin was switched to levofloxacin. Mr. [Known lastname 4318] continued to make steady progress and was discharged home on postoperative day eight. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: On transfer: Toprol 50mg Daily Folate 1mg daily Lipitor 10mg daily Aspirin 81mg daily Lasix 40mg daily Zestril 20mg twice daily Digoxin 0.125mg Daily Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: CAD PVD HTN CRI Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or ointments to any incisions no lifting > 10 # or driving for 1 month Followup Instructions: with NP or PA on [Hospital Ward Name 7717] within 1 week to evaluate wound with Dr. [Last Name (STitle) 62676] in [2-25] weeks with Dr. [Last Name (STitle) ] in 4 weeks Completed by:[2100-12-1] ICD9 Codes: 4111, 2851, 4240, 4439, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5804 }	Medical Text: Admission Date: [2131-5-31] Discharge Date: [2131-6-7] Date of Birth: [2074-12-8] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10223] Chief Complaint: Abdominal pain and emesis x 2days Major Surgical or Invasive Procedure: History of Present Illness: Pt awoke 2 days PTA w/ abdominal pain (epigastric, sharp, non-radiating, not associateed with food intake). He had a bowel movement (non-bloody, non-mucoid) that did not relieve his pain. He then ate a boiled egg and had a cup of coffee. Within a half-hour he vomited the food contents (non-bloody, non-bilious). His emesis was proceded and followed by nausea. He denies F/C/SOB/palpitations/urinary sx(frequency, urgency, dysuria) or changes in bowel movements (frequency, consistency, color). Past Medical History: --pancreatitis (secondary to ETOH) --HTN --cirrhosis (h/o ascites, h/o encephalopathy, esophageal varicies, spenomegaly) --ETOH abuse --left foot injury - pins placed Social History: ETOH abuse [12-1] gallon of vodka/day, stopped one year ago. 1 [12-1] ppd cigarette smoker x 40 yrs, down to 2-3 cigarettes/day over last year. Physical Exam: T96, BP150/80, HR68, R18, O297% HEENT: no lymphadenopathy, no JVD, no elevated JVP, MMM, EOMI, PERRL, NCAT CHEST: CTAB CV: RRR, NL s1/s2 ABD: soft, BS+, epigastric tenderness, ND, no guarding, no rebound EXT: warm, no C/C/E, venous stasis changes in left leg, scars from old trauma to left lower leg/foot NEURO: AxOx3 Pertinent Results: [2131-5-31] 06:45AM PLT COUNT-88* [2131-5-31] 06:45AM NEUTS-64.7 LYMPHS-20.3 MONOS-8.3 EOS-6.3* BASOS-0.3 [2131-5-31] 06:45AM WBC-6.7 RBC-4.12* HGB-13.2* HCT-39.4* MCV-96 MCH-32.1* MCHC-33.6 RDW-15.5 [2131-5-31] 06:45AM ALBUMIN-3.3* CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.6 [2131-5-31] 06:45AM LIPASE-105* [2131-5-31] 06:45AM ALT(SGPT)-33 AST(SGOT)-57* ALK PHOS-144* AMYLASE-96 TOT BILI-1.8* [2131-5-31] 06:45AM GLUCOSE-98 UREA N-16 CREAT-1.0 SODIUM-138 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13 [2131-5-31] CT ABD:No evidence of acute pancreatitis or any sequela of pancreatitis. Cirrhosis and evidence of portal hypertension. Stable appearance of enlarged lesser curvature iliac and portal lymph nodes. [2131-6-3] RENAL U/S:No evidence of stones, masses or hydronephrosis. [2131-6-3] CXR:There are increased interstitial markings which suggest some mild failure.07/04&[4-3] BLOOD CULTURE: negative [2131-6-4] FECES NEGATIVE FOR C. DIFFICILE TOXIN [2131-6-5] FECAL CULTURE: NO CAMPYLOBACTER FOUND [2131-6-6] FECAL CULTURE: NO SALMONELLA OR SHIGELLA FOUND. Brief Hospital Course: Pt was made NPO, given IVF, analgesics and antiemetics. His symptoms resolved overnight and was feeling much better the following day. He was caught smoking a cigarette in the hospital and was then allowed to continue to smoke outside. He returned and stated that his abdominal pain, N/V had returned. Pt was continued one NPO, IVF, analgesics and antiemetics. On the third day of hospitalization he had diarrhea w/ frank blood and an episode of dizziness w/ orthostatic changes. He was ruled-out for MI. GI consulted, colonoscopy was deferred. He continued to have diarrhea and abdominal pain. On the next day he experienced a marked drop in O2 sat into 80's while sleeping, was hypotensive, tachycardic, somnolent, positive asterixis. An ABG showed 7.22/47/96. His BP improved with a fluid bolus and his O2sat went into the 90's while he was awake. Narcotics were held, Pt was given Narcan with good response in mental status and lactulose was contniued for possible encephalopathy. This episode was also accompanied by an elevation in his WBCs, renal failure, positive U/A. Pt was transferred to [Hospital Unit Name 153]. Renal consulted, and agressive IVF for pre-renal ARF, and ciprofloxacin added for possible UTI. Pt improved in [Hospital Unit Name 153] secondary to hydration and narcotic wean. His amylase and lipase levels rose to 157 and 211 respectively, consistent with an acute on chronic pancreatitis. He spent two more days on the medicine floor, his O2 sat on RA, BP, and creatinine levels returned to his baseline levels, abdominal pain had resolved, mental status improved, and he was tolerating PO intake. Medications on Admission: oxycodone spironolactone folate multivitamins Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 2. Nadolol 80 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:qs 1 month Refills:2 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:qs 1 month Refills:0 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 6. Pantoprazole Sodium 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 7. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:21 Tablet(s) Refills:0 8. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HRS ON 12 HRS OFF (). Disp:60 Adhesive Patch, Medicated(s) Refills:2 9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Acute on Chronic Pancreatitis HCV and EtOH Cirrhosis w/encephalopathy Discharge Condition: stable Discharge Instructions: Please notify your doctors [First Name (Titles) ] [Last Name (Titles) 2449] of shortness of breath, pain, palpitations, nausea, vomiting, weight loss, inability to eat or drink or any other symptoms of concern. We recommend that you have a cardiac stress test within 1 week of leaving the hospital. DO NOT TAKE NARCOTICS OTHER THAN THE ONES PRESCRIBED TO YOU. Followup Instructions: 1) Please call to schedule an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 250] within 2 weeks of leaving the hospital. At this time you should have your bloodwork (electrolytes) checked. 2)Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD Where: LM [Hospital Unit Name 7129] CENTER Phone:[Telephone/Fax (1) 2422] Date/Time:[2131-11-14] 11:00 ICD9 Codes: 5715, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5805 }	Medical Text: Admission Date: [2190-8-29] Discharge Date: [2190-9-4] Date of Birth: [2108-1-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization Fistulogram and failed thrombectomy IJ dialysis catheter Tunnelled dialysis catheter History of Present Illness: 82 yo M with history of CAD s/p NSTEMI, ESRD on HD, DM2, HTN, HL, Hep C, presents with sudden onset of shortness of breath. In the ED, he received lasix 40 mg IV, morphine, and was placed on a nitro drip with improvement of his symptoms. He put out small amounts of urine to the lasix. At home he is able to produce some urine. Patient was also noted to be hypertensive and was given metoprolol 25 mg PO and 5 mg IV, but without much response from his blood pressure. . Initial EKG in the ED showed ST elevations and there was concern for STEMI. Cardiology reviewed his EKG and read them as J point elevations, which were similar to his previous EKGs. On transfer to the CCU, patient's vitals were T 75, BP 166/81, RR 16, O2sat 97% on 4L. . Past Medical History: - Hypertension. - NSTEMI in [2183]. - Hypercholesterolemia. - Hepatitis C virus - Glaucoma - Type 2 diabetes mellitus, diet-controlled. - Chronic renal insufficiency, now on hemodialysis; stage IV CKD secondary to hypertension and FSGS - Status post nephrectomy right-sided for suspected cancer, pathology benign. - Status post appendectomy. - Status post hernia repair. - Status post rotator cuff surgery in [2182]. Social History: Mr. [Known lastname ] lives in [Location 2268] with his son and grandson. [Name (NI) ] is a retired court officer. Admits to distant history of tobacco use while he was in the service; about 1PPW x 5 years. Prior marijuana use admitted to other OMR providers. Denies other illicit drug use. No alcohol use. The patient is separated from his wife, has 2 sons and one is deceased. Family History: Father with cancer of unknown origin per patient. Brother with cirrhosis, another brother who recently had a massive CVA. Sister w/[Name2 (NI) 499] cancer in her 70s. Physical Exam: Discharge physical exam Temp current: 98.8 HR: 69-85 RR: 18 BP: 100-143/58-88 O2 Sat:98% RA Physical Exam: Gen: alert, oriented, NAD. Lying in bed during dialysis HEENT: supple, no JVD at 20 degrees. CV: RRR, II/VI holosystolic murmur, no thrills. No S3-4 RESP: CTAB, no audible wheezes. ABD: flat, NT, hypoactive BS, no tenderness. EXTR: tunneled line c/d/i, papule in sacral area, no erythema, no open wound, no drainage noted. Feet warm with barely palp pulses DP/PT. No penile lesions noted. NEURO: A/O, speech clear, seems to have good recall of meds and hospital course Pertinent Results: [2190-8-29] 03:40AM BLOOD WBC-14.5* RBC-3.42* Hgb-11.6* Hct-35.3* MCV-103* MCH-33.9* MCHC-32.8 RDW-15.5 Plt Ct-207 [2190-8-30] 05:59AM BLOOD WBC-9.4 RBC-3.00* Hgb-9.8* Hct-30.8* MCV-103* MCH-32.8* MCHC-31.9 RDW-15.2 Plt Ct-208 [2190-8-31] 05:24AM BLOOD WBC-8.1 RBC-3.23* Hgb-10.4* Hct-33.0* MCV-102* MCH-32.3* MCHC-31.6 RDW-15.0 Plt Ct-212 [2190-9-2] 05:10AM BLOOD WBC-8.6 RBC-3.22* Hgb-10.6* Hct-32.9* MCV-102* MCH-33.0* MCHC-32.3 RDW-14.8 Plt Ct-222 [2190-9-3] 06:35AM BLOOD WBC-9.1 RBC-3.02* Hgb-9.8* Hct-30.7* MCV-102* MCH-32.6* MCHC-32.1 RDW-14.9 Plt Ct-303 [2190-9-4] 06:00AM BLOOD WBC-8.7 RBC-2.83* Hgb-9.2* Hct-28.9* MCV-102* MCH-32.4* MCHC-31.7 RDW-15.2 Plt Ct-296 [2190-8-29] 03:40AM BLOOD PT-15.1* PTT-31.0 INR(PT)-1.3* [2190-8-30] 05:59AM BLOOD PT-15.3* PTT-38.4* INR(PT)-1.3* [2190-9-2] 05:10AM BLOOD PT-14.2* PTT-78.2* INR(PT)-1.2* [2190-9-3] 06:35AM BLOOD PT-14.0* PTT-33.4 INR(PT)-1.2* [2190-8-29] 03:40AM BLOOD Glucose-241* UreaN-42* Creat-9.0* Na-142 K-5.4* Cl-98 HCO3-27 AnGap-22* [2190-8-30] 05:59AM BLOOD Glucose-110* UreaN-64* Creat-12.1# Na-139 K-5.8 Cl-97 HCO3-29 AnGap-19 [2190-8-31] 05:24AM BLOOD Glucose-102* UreaN-31* Creat-7.4# Na-140 K-4.7 Cl-96 HCO3-33 AnGap-16 [2190-9-2] 05:10AM BLOOD Glucose-83 UreaN-33* Creat-7.8# Na-141 K-4.5 Cl-98 HCO3-31 AnGap-17 [2190-9-3] 06:35AM BLOOD Glucose-110 UreaN-52* Creat-10.2# Na-138 K-4.7 Cl-94 HCO3-32 AnGap-17 [2190-9-4] 06:00AM BLOOD Glucose-116* UreaN-23* Creat-6.7# Na-140 K-4.2 Cl-95 HCO3-35* AnGap-14 [2190-9-1] 06:05AM BLOOD CK(CPK)-240 [2190-9-1] 03:00PM BLOOD CK(CPK)-202 [2190-9-1] 09:35PM BLOOD CK(CPK)-198 [2190-9-2] 05:10AM BLOOD CK(CPK)-159 [2190-9-2] 09:21PM BLOOD CK(CPK)-140 [2190-8-29] 03:40AM BLOOD cTropnT-0.06* [2190-9-1] 06:05AM BLOOD CK-MB-4 cTropnT-10.13* [2190-9-1] 03:00PM BLOOD CK-MB-3 cTropnT-10.81* [2190-9-1] 09:35PM BLOOD CK-MB-3 cTropnT-12.09* [2190-9-2] 05:10AM BLOOD cTropnT-11.88* [2190-9-2] 09:21PM BLOOD CK-MB-3 [2190-8-29] 03:40AM BLOOD Calcium-9.2 Phos-7.3* Mg-2.0 [2190-8-30] 05:59AM BLOOD Calcium-9.0 Phos-7.1* Mg-2.0 [2190-8-31] 05:24AM BLOOD Calcium-8.7 Phos-6.3* Mg-2.0 [2190-9-2] 05:10AM BLOOD Calcium-9.3 Phos-6.2* Mg-2.1 [2190-9-3] 06:35AM BLOOD Calcium-9.3 Phos-7.5* Mg-2.3 [2190-9-4] 06:00AM BLOOD Phos-5.4# Mg-2.0 [2190-9-3] 09:55PM URINE Color-Red Appear-Cloudy Sp [Last Name (un) ]-1.015 [2190-9-3] 09:55PM URINE Blood-LG Nitrite-NEG Protein-300 Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.5 Leuks-MOD [2190-9-3] 09:55PM URINE RBC->1000* WBC->1000* Bacteri-FEW Yeast-NONE Epi-0 [2190-9-3] 9:55 pm URINE Source: CVS. URINE CULTURE (Pending): [8-29]: Baseline artifact. Borderline resting sinus tachycardia at a rate of about 100 beats per minute. Left ventricular hypertrophy. Left atrial abnormality. Non-specific ST-T wave changes. Slow R wave progression with possible underlying anteroseptal myocardial infarction. Compared to the previous tracing of [2190-7-21] heart rate is faster. ST-T wave changes are more apparent. Clinical correlation is suggested. CXR [8-29]: PORTABLE AP CHEST RADIOGRAPH: There are bibasilar hazy opacities, compatible with increased interstitial edema, atelectasis and pleural effusions. There is minimal pulmonary vascular prominence. The cardiomediastinal silhouette is within normal limits. There is no pneumothorax. A left cervical rib is incidentally noted. IMPRESSION: Mild-to-moderate congestive failure. Re-evaluate after diuresis can be helpful to exclude superimposed infectious process. Echo [9-1]: The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The aortic valve leaflets (3) are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Minimal aortic valve stenosis. Small circumferential pericardial effusion without evidence of hemodynamic compromise. Increased PCWP. Compared with the prior study (images reviewed) of [2189-4-27], minimal aortic valve stenosis is now present. Biventricular systolic function remains preserved. The estimated PA systolic pressure is now lower (but was overestimated on the prior study). IR thrombectomy: IMPRESSION: Thrombosis of a left upper extremity AV graft with recurrent stenosis at the venous anastomosis of the graft. Flow could be restored temporarily, but rethrombosis occured twice, despite mechanical thrombectomy, chemical thrombolysis, balloon angioplasty, [Doctor Last Name ] embolectomy and stenting of the venous anastomosis. Left IJ access was obtained for dialysis. Cardiac Cath [9-2]: COMMENTS: 1) Selective coronary angiography in this right dominant system demonstrates three vessel coronary artery disease. The right coronary artery is a heavily calcified vessel with serial 50-60% stenoses. The posterior left ventricular branch is involved in a 60% stenosis. The left main coronary artery has a 20% lesion. The LAD isheavity calicified. The previously placed stent was patent. The first diagonal had diffuse 50-60% disease. The circumflex artery had a 70% ostial lesion. The midvessel had a 60% focal stenosis. The first obtuse marginal bifurcated, and one of these branches was totally occluded with a lesion believed to be the culprit lesion. 2) Hemodynamics measurements demonstrate normal cardiac output, and biventricular filling pressures. 3) lesion. Unsuccessful vascular closure with Mynx device. Recommend secondary prevention of CAD including plavix 75mg daily for 6 months, and medical management of the patient's ACS. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Unsuccessful PCI to Cx/OM lesion 3. Unsuccessful vascular closure with Mynx Tunneled Cath pending Brief Hospital Course: 82 yo M with history of CAD s/p NSTEMI, ESRD on HD, DM2, HTN, HL, presents with shortness of breath due to volume overload #Shortness of breath/volume overload: Likely due to ESRD with insufficient volume removal on HD. TTE in [2189-4-27] shows normal systolic function with LVEF of 55%. Symptoms improved once given lasix and placed on nitro drip in the ED; nitro drip was gradually weaned off. He was continued on metoprolol 25 mg PO BID and lisinopril 40 mg PO daily. He was given lasix 120 mg IV but did not make significant urine so lasix was discontinued. His fistula for dialysis was found to be clotted so an IR fistulogram and thromectomy was attempted but failed with immediate reclotting so an IJ temporary dialysis catheter was placed with plan for tunneled catheter in 2 days. Dialysis was done twice in the CCU with 1.8 L removed each time. The patient had a tunneled HD catheter placed in IR. . # CAD: patient has history of CAD with NSTEMI in [2183] requiring DES to mid LAD. He is not on aspirin or plavix at home. Patient reports that he was on aspirin previously but was told to stop it approximately 5 months ago. Troponin on admission was slightly elevated at 0.06 but in setting of chronic renal insufficiency. Ekg from [2190-8-31] 0800 showed marked T wave inversions in precordial leads, concerning for anteroseptal MI, different from prior EKGs. Repeat EKG on [2190-9-1] showed consistent changes. CE's were trended. Troponin was 10.13, up from 0.06 on admission, however both CK and MB were flat. Patient remained CP/SOB-free, however reported some dizziness/lightheadedness upon standing. Cards was consulted and a heparin gtt was started. ECHO was completed showing no wall motion abnormality and preserved LVEF. The patient had a cardiac catheterization which showed a distal lesion in his OM that was unable to be intervened upon due to the vessel being too small. He was medically managed for his NSTEMI with carvedilol, aspirin, plavix. . # DM2 - diet controlled at home. Managed with ISS. . # HTN - elevated BP on admission, was given metoprolol in the ED without much effect, but also in setting of volume overload. Continued on metoprolol and higher dose of lisinopril; HD x 2 in CCU. He was started on carvedilol and lisinopril 40mg with good control of his BP. . # ESRD - history of right nephrectomy for suspected malignancy, but found to be benign pathology. ESRD thought to be secondary to HTN and FSGS, is currently on HD qMWF at home. Baseline creatinine ranging from [5-21], creatinine of 9 on admission. Renal consulted and found fistula to be clotted. IR attempted thrombectomt but failed due to reclotting so a temporary IJ catheter was placed for dialysis. This was replaced by a tunneled HD cath placed in IR. His phosphorous was climbing so the patient was started on sevelamer. . #UTI: was on cipro on admission, started [8-26]. continue for total 10 day course. The cipro was stopped by the medical team on the floor after 1 week of therapy. He developed hematuria the day before discharge. This was monitored, the patient was able to urinate without difficulty and did not pass any clots. His hematocrit was stable and the patient was discharged with instructions to follow-up with Urology as an outpatient. . # Herpes - The patient had a lesion on his buttocks that was felt to be a herpes lesion. He was started on valtrex which gave relief to his discomfort. Medications on Admission: Simvastatin 20 mg daily Metoprolol Tartrate 25 mg [Hospital1 ] B Complex-Vitamin C-Folic Acid 1 mg 1 capsule daily Docusate Sodium 100 mg [Hospital1 ] Senna 2 tablets qhs Lisinopril 10 mg daily Brimonidine 0.1% 1 drop OU Ciprofloxacin 500 mg [Hospital1 ] x 10 days - prescribed [2190-8-26] Discharge Medications: 1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal DAILY (Daily). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 11. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: Acute Pumonary Edema, NSTEMI Secondary Diagnosis: CAD with NSTEMI in [2183] requiring DES to mid LAD End Stage Renal disease Hypertension Hyperlipidemia Diabetes Mellitus Type 2 Urinary Tract Infection 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 taking care of you during your hospitalization. You were admitted with shortness of breath. You were found to be volume overloaded and you were treated with diuretics and dialysis. Your dialysis fistula was not working properly. The IR doctors tried to restore the blood flow, but were unable to, so you received a temporary catheter through a vein in your neck and a more permanant tunnelled catheter that was placed on [9-3]. There were some EKG changes seen that were concerning for a blockage in one of your heart arteries. You had a cardiac catheterization which showed a small blockage in one of the arteries that supply the heart. This was too small to be intervened on so you were treated medically. An echocardiogram showed no changes in your heart function. Your blood pressures were running high and we adjusted your medicines. We started the following medications: START Aspirin 325 mg daily START taking labetalol 200mg twice daily to lower your blood pressure and heart rate (this medication will be instead of metoprolol) START taking calcium and Sevelamer with meals to lower your phosphate level We increased the following medication: INCREASE Lisinopril to 40 mg daily INCREASE Simvastatin to 40 mg daily We stopped the following medication: STOP taking Metoprolol STOP taking ciprofloxacin as you have finished the course of the antibiotic. You may take one more day of pyridium to treat burning in your bladder and penis. Because you had blood in your urine, you will need to follow-up with the Urologists to find out where this is coming from. Please call their office at ([Telephone/Fax (1) 772] to schedule an appointment. Followup Instructions: Please call the Urology department at ([Telephone/Fax (1) 772] on Monday to schedule an appointment to evaluate the blood in your urine. You should try to schedule an appointment to be seen as soon as possible. Department: CARDIAC SERVICES When: MONDAY [2190-10-11] at 4:00 PM With: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 2761], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: FRIDAY [2190-9-10] at 2:35 PM With: [First Name8 (NamePattern2) 5478] [Name8 (MD) 5479], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This is a follow up of your hospitalization. You will be reconnected with your primary care physician after this visit. Department: COGNITIVE NEUROLOGY UNIT When: TUESDAY [2190-10-19] at 1 PM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 18365], PHD [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 Department: PODIATRY When: TUESDAY [2190-11-23] at 10:20 AM With: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], 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 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] Completed by:[2190-9-10] ICD9 Codes: 5856, 5990, 2720, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5806 }	Medical Text: Admission Date: [2111-1-28] Discharge Date: [2111-2-7] Date of Birth: [2028-10-29] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Headache Major Surgical or Invasive Procedure: Bilateral Bur Holes for Subdural Hematoma History of Present Illness: This is an 82 year old right handed male who presented to an outside hospital with dizziness and headache. He was found to have bilateral subdural hematomas. The patient reprted having headahces for 2-3 days prior to admission. It started out as a dull ache that was holocephalic. The morning prior to admit the quality became for sharp. He also felt lightheaded and almost fell. Past Medical History: colon cancer s/p colectomy sick sinus syndrome s/p pacemaker atrial fibrillation (not on Coumadin) hypothyroidism hernia repair GERD esophageal rupture s/p repair R knee replacement hernia repair x2 Social History: Lives with three daughters. Non-[Name2 (NI) 1818]. [2-4] drinks/week. Family History: non-contributory Physical Exam: On admission: Vitals: T 98.4; BP 138/78; P 75; RR 18; O2 sat 99% General: lying in bed NAD Neck: supple Extremities: no c/c/e. Neurological Exam: Mental status: A & O x3. Fluent speech with no paraphasic or phonemic errors. Adequate comprehension. Follows simple and multi-step commands. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation intact, facial strength IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: SCM [5-6] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. No pronator drift. Full strength. Sensation: intact light touch. Reflexes: 1+ symmetric Toes downgoing bilaterally. Coordination: FNF intact. On discharge: Pt expired Pertinent Results: CTA Head [2111-1-28]: 1. No significant interval change in appearance of the moderately sized subdural collections which are isoattenuating and exert moderate mass effect with diffuse sulcal effacement, ventricular distortion and tight basilar cisterns. 2. Lobulated enhancing extra-axial mass overlying the left frontal lobe most likely represents a meningioma with less likely consideration to include dural-based metastasis. It is unclear what roll this mass may have played in the subdural collections. MRI can help for further assessment. 3. Chronic left maxillary sinusitis. CT Head [2111-1-29]: IMPRESSION: 1. Status post bilateral craniotomy and right frontal burr hole, with partial drainage of bilateral subdural hematomas. 2. Postoperative pneumocephalus resulting in slightly increased leftward shift. 3. Known left frontal extra-axial mass is not well characterized on this exam. 4. Chronic left maxillary sinusitis. IMPRESSION: 1. Increase in bilateral subdural hematomas, with moderate mass effect. 2. Progressive edema and effacement of bilateral inferior occipital lobes. This finding is nonspecific and may be seen with PRES, although the patient does not have a known history of uncontrolled hypertension, immunosuppression, or other inciting factors. Other considerations include mass effect from SDH, bilateral PCA infarcts, and various other infectious/inflammatory/neoplastic etiologies. Given the patient's pacemaker contraindication to MRI, a contrast-enhanced CT examination could be ordered for further evaluation. 3. Chronic left maxillary sinusitis. 4. Left frontal meningioma. Brief Hospital Course: Mr. [Name13 (STitle) 1549] was admitted to [Hospital1 ] ICU under the care of Dr. [Last Name (STitle) ]. He had Bilateral SDH's on imaging. There was suspicion of an underlying lesion. MRI was not able to be performed as the patient has a pacemake. CTA imaging showed 2.1 x 1.8 cm irregular lobulated mass which appears to be extra-axial overlying the left frontal lobe. The patient was lethagic and disoriented on [2111-1-29]. Repeat CT imaging was performed and he was taken to the OR. He had an evacuation of bilateral SDH with Dr. [Last Name (STitle) ]. He was trasnfered to the TSICU intubated. Post-op CT showed significant pneumocephalus. It was recommended that he remain intubated overnight. On [2111-1-30] he was being weaned toward extubation. His neuro status improved. He was following commands with all 4 extremities. He reported that his vision was impaired. He could not see colors. He could only see moving shapes. Opthomology was consulted. They felt that he had an occipital lobe infarct with a right heminoposia. Neurosurgically he was doing well and was transfered to the floor on [2-1]. Neuro/Stroke service was consulted. They recommended a follow up CT head wich showed no change from previous scan. Their final recommendations were obtain a TTE, HBA1C, and fasting lipid profile. They also recommended a repeat head and neck CTA. On [2-4], patient's neurologic exam began to decline, he was more lethargic with a R pronator drift and RLE weakness. Patient's family and health care proxy determined that the patient should be DNI/DNR. In the morning, patient's exam continued to rapidly decline, dilated and fixed L pupil and extensor posturing of BUE with no movement of the LE to noxious stimuli. The family was made aware that surgery would not be benefical at this time. They made the decision to make the patient CMO. He then passed at [2040] on [2-7]. Medications on Admission: Colchicine, 0.6 mg daily Digoxin daily Omeprazole daily Aspirin 81 mg daily Colace daily Discharge Disposition: Expired Discharge Diagnosis: Bilateral Subdural Hematoma Left Frontal Brain Mass Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2111-2-7] ICD9 Codes: 2449, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5807 }	Medical Text: Admission Date: [2133-10-30] Discharge Date: [2133-11-11] Service: MEDICINE Allergies: Streptokinase / Avandia / Amiodarone / Phenergan / Morphine / Percocet Attending:[Last Name (NamePattern1) 1167] Chief Complaint: CC: left lower extremity pain Major Surgical or Invasive Procedure: PICC placed on RUE Swan-ganz catheterization History of Present Illness: Mr. [Known lastname ] is an 87yo male with past medical history significant for diabetes, severe PVD, ischemic CMY (EF 25%), stage III CKD, CAD, hypothyroidism, and chronic atrial fibrillation who presents now complaining of LLE pain which was fairly abrupt in onset over last 24 hours, erythema and warmth all concerning for cellulitis vs. additional vascular compromise. He was seen by nurse practitioner [First Name (Titles) ] [Last Name (Titles) 191] earlier this afternoon and sent to ED for additional workup. He denies any numbness or tingling in foot. Denies fevers or chills. Small superficial left tibal area lesion but no other open wounds over LE. . Of significance, he states that he was seen at [Hospital3 2358] about 2 weeks ago for similar LE erythema and treated with oral antibiotics that he completed last week. He also had a recent visit with Dr. [Last Name (STitle) ] on [10-12] and severe right sided SFA stenosis discussed regarding need for future angioplasty/stenting but he was noted to have less severe left sided disease per OMR notes. . In the ED, initial vs were: T 97.5F,P 71, BP 127/53, RR 18 and O2 saturation 99% RA. Patient was given IV vancomycin and IV Unasyn antiobiotics follwed by Tramadol and Tylenol for pain with good relief. Two sets of blood cultures sent off. Labs were notable for a wbc count of 30 with 91% neutrophils. Urinalysis negative for infection and CXR with no infiltrates just minimal bilateral effusions. Fully dopplerable pulses in the ED. CT scan of LLE showed superficial soft tissue edema noted throughout the left calf, without focal fluid collection to suggest abscess and without soft tissue air. No concerning bony lesions to imply oseomyelitis. Also had LE US which was negative for any overt DVTs. . Orthopedic team and vascular surgery both consulted in ED due to concern for possible compartment syndrome and patient had Striker intracompartmental pressure monitor measured with posterior compartment of leg 10 cm H2O while diastolic BP was 52mmHg which ruled against any compartment syndrome. . On arrival to the medical floor he appeared to be in no acute distress. Vital signs were: T 96.9F, HR 69, BP 104/54, O2 sat 99% on 3L NC. States his LLE pain is minimal and denies feeling chills or feverish. . Review of systems: (+) Per HPI (-) Denies fever, chills, URI sx, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Medical History: - PVD - Diabetes - Dyslipidemia - CAD, s/p two vessel CABG - Pacemaker/[Month/Day (4) 3941], in [2125]: Biventricular PCM/[Year (4 digits) 3941], s/p ablation - Diverticulosis - s/p lower GI bleed - Ischemic cardiomyopathy, NYHA Class III - Chronic systolic congestive heart failure with severely depressed ventricular function, last LVEF 25% - Chronic a-fib - s/p MVA [6-15] injuring back, chest & hit head - Chronic renal insufficiency, stage 3 - Cholelithiasis s/p cholecystectomy - Pancreatic cysts - Gunshot wounds to left lower extremity with decreased sensation - Low back pain - Cataracts Social History: No alcohol drug or tobacco use. Pt lives at home in [Location (un) 6798] w/ his wife, daughter is near by and involved in care. Patient is decorated war hero, WWII veteran from the 1st marine corps, 2nd battalion, H company (Pacific theater). States he has a walker at home but does not use it. Daughter [Name (NI) ] very involved with his care as well. Family History: Non-contributory Physical Exam: Physical Exam: Vitals: T 96.9F, HR 69, BP 104/54, O2 sat 99% on 3L NC. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased lung sounds at bases but clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm noted, loud S2 and [2-14] apical holosystolic murmur with radiation to axilla. No rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Skin/Ext: Warm, well perfused, 1+ DP pulses bilaterally and difficult to palpate either PT pulse (dopplerable however). Left tibial area superficial skin ulcer (non bloody, no discharge) with surrounding bed of erythema that expands several cm, also erythema over lower shin and ankle area with no clear margins. No palpable underlying fluctuant areas and 1+ edema over LLE with minimal warmth compared to RLE. Pertinent Results: Admission labs: [2133-10-30] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2133-10-30] 04:50PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2133-10-30] 04:50PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2133-10-30] 05:45PM GLUCOSE-109* UREA N-35* CREAT-1.2 SODIUM-138 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13 [2133-10-30] 05:45PM WBC-30.2# RBC-4.34 HGB-11.5* HCT-34.9* MCV-80* MCH-26.4* MCHC-32.8 RDW-17.1* [2133-10-30] 05:45PM NEUTS-91* BANDS-0 LYMPHS-1* MONOS-7 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 Imaging/procdures: Catheterization COMMENTS: 1. Resting hemodynamics revealed elevated right and left sided filling pressures with RVEDP of 18 mm Hg and mean PCWP of 22 mm Hg. There was moderate pulmonary hypertension with PASP of 63 mm Hg. The cardiac index was depressed at 2 l/min/m2. The arterial oxygen saturation was taken from finger oximetry. 2. Milrinone infusion and repeat hemodynamic measurements to be completed in the CCU per the CHF team. FINAL DIAGNOSIS: 1. Left ventricular diastolic dysfunction. 2. Pulmonary hypertension. 3. Depressed cardiac index. Lower extremity Dopplers [11-3]: IMPRESSION: Deep venous thrombosis in the left peroneal vein. Brief Hospital Course: Mr. [Known lastname ] is an 87yo male with PMH significant for severe PVD s/p stenting, CAD, CHF/CMY, atrial fibrillation, diabetes, and chronic kidney disease who presents with leukocytosis, left LE pain and erythema most consistent with cellulitis. . # LLE DVT/cellulitis and E. coli bacteremia: Presented with LLE pain, swelling, and erythema. Prior to presentation, had recent history of LLE cellulitis with outpatient PO antibiotics which he states he completed about 1.5 weeks ago. He was treated 2 weeks ago with antibiotics at [Hospital3 2358] ([Location (un) 1456]) for LLE cellulitis in same distribution of his LLE. Unfortunately, no culture data or specific antibiotics details were available for review at time of admission. He presented with a WBC elevation to 30, with >90% PMNs. Also had local pain, erythema, warmth and imaging that shows soft tissue edema c/w cellulitis. No underlying abscesses or early signs of osteomyelitis per preliminary imaging which is reassuring. Cause may be related to open stasis wound over left tibia. The patient's Doppler studies demonstrated a DVT of his left peroneal vein. The patient was then bridged via heparin to Coumadin to achieve a therapeutic INR. The patient's blood culture from the Emergency Department also was positive for E. coli, susceptible to ceftriaxone, which the patient was started on ([11-2]) after two days on cefepime (started on [10-31]). The patient should complete a 14-day course of antibiotics. . # STAGE IV HEART FAILURE: Patient had been medically managed with ASA, atorvastatin, digoxin, eplerenone, hydrochlorothiazide, torsemide, and metoprolol. However, he continued to decline, so there was consideration of benefit from positive inotrope therapy with home milrinone. Swan-Ganz catheterization and study with milrinone suggested the patient would indeed respond to milrinone. Milrinone dose was titrated to 0.375mcg/kg/min. The patient was kept on ASA, atorvastatin, eplerenone, and his torsemide was increased to 100mg daily. Patient is NOT on an ACE-I because it causes severe hypotension. . #Severe PVD : He is followed by Dr. [Last Name (STitle) ] here in vascular clinic. Recent noninvasive arterial studies showed incalculable ABIs due to calcified vessels but his pulse volume amplitudes were dampened at the calf, right ankle, and forefoot per notes. He has venous stasis ulcers and skin changes over both LEs. Wound care was consulted and gave the following recommendations: 1. Cleanse LLE shin with normal saline. Pat dry. 2. Apply Adaptic dressing over site, 4x4 and wrap with Kerlix. 3. Secure with paper tape. No tape on skin. 4. Apply Aquaphor ointment to dry intact skin (pharmacy) daily. 5. PT consult for evaluation of safety and recommendations for ambulation. . #CKD: The patient presented with creatinine in the 1.6-2.0 range, with his baseline typically 1.2-1.4. Likely due to diabetes and blood pressure issues in the past. The patient's medications were renally dosed and inpouts/outputs tracked. His creatinine returned to the 1.2 area. . #CAD: As above, severe multi vessel native CAD and history of several prior PCIs and CABG x2. No current complaints of any chest pain, chest pressure, palpitations or shortness of breath. EKG with no new ischemic changes. Continued daily ASA, statin, beta blocker therapies . #Atrial fibrillation: Longstanding history but now has regular rate on his EKG and telemetry with Biv PCM and HR @70. INR is subtherapeutic now which may be due to recent adjustments with antibiotics at outside hospital. The patient had a subtherapeutic INR and was bridged with heparin while his coumadin was adjusted. His beta blockade was also adjusted to 150mg metoprolol succinate daily with an eventual goal dose of 200mg daily. His INR on day of discharge was 1.6. He should have his INR checked daily until he is therapeutic. His Heparin drip should be maintained for 48 hours once his INR is therapeutic. . #Diabetes: The patient had a longstanding history of type II diabetes and was on insulin at home. The patient was given 30 units glargine in the am and a Humalog sliding scale with qachs fingersticks relfecting his home dose. . #Hypothyroidism: Continued on usual home dose levothyroxine. . #GERD: Continued on home dose of Protonix 40mg daily. . Also, the patient has an eye appointment at the VA next week that has to be rescheduled. Medications on Admission: HOME MEDICATIONS: confirmed with pharmacy ASPIRIN - 81MG Tablet - ONE EVERY DAY ATORVASTATIN - 40 mg Tablet once a day CARVEDILOL [COREG] - 6.25 mg by mouth twice a day DIGOXIN - 125 mcg Tablet by mouth daily except Mon-Wed-Fri take TWO tablets daily EPLERENONE - 25 mg Tablet - one Tablet(s) by mouth once daily HYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet by mouth 30 minutes before Torsemide not more than 3 times per week INSULIN GLARGINE [LANTUS] - 30 units in am, can take up to 45 units daily INSULIN LISPRO [HUMALOG] SSI LEVOTHYROXINE - 150 mcg Tablet-daily NITROSTAT - 0.4MG Tablet, SL PRN PANTOPRAZOLE - 40 mg Tablet daily POLYETHYLENE GLYCOL 3350 [MIRALAX] - 100 % Powder - 1 tbsp [Hospital1 ] PRN POTASSIUM CHLORIDE - 20 mEq Tab daily TORSEMIDE - 40 mg twice daily WARFARIN - 3.75mg on Mon/Thurs, 2.5 mg other five days ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime DOCUSATE SODIUM - 100 mg Capsule [Hospital1 ] PYRIDOXINE [VITAMIN B-6] -Dosage uncertain Discharge Medications: 1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 2. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) bag Intravenous Q24H (every 24 hours): last dose Saturday [11-14]. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet 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. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO twice a day. 11. Milrinone 0.38 mcg/kg/min IV INFUSION 12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 13. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID (4 times a day) as needed for pain. 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 17. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 18. sodium chloride 0.65 % Aerosol, Spray Sig: [1-10] Sprays Nasal QID (4 times a day) as needed for irritation. 19. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 22. insulin glargine 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous once a day. 23. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: as per sliding scale units Intravenous continuous: Please overlap INR > 2.0 with heparin drip for 48 hours, thanks. 24. insulin lispro 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day. 25. torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Acute on chronic Systolic congestive Heart Failure Deep Vein Thrombosis Chronic Kidney disease Diabetes Mellitus Delerium Peripheral Vascular Disease Atrial fibrillation Internal cardiac Defibrillator Hypothyroidism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had a blood clot in your leg and have been started on intravenous heparin and continued on coumadin to treat the clot. You have had pain with the clot and have been taking tramadol to treat the pain. An infection was found in your blood and you will need intravenous antibiotics until [11-14] to treat this. In addition, we found that you had an acute exacerbation of your congestive heart failure and started you on a milrinone drip to help your heart pump better. You will need rehabilitation before you go home to get stronger. Medication changes: 1. Stop taking digoxin, carvedilol, HCTZ, potassium, and Ambien 2. Start taking Ceftriaxone IV to treat the bacteria in your blood 3. Start taking Mirtazipine to help you sleep and increase your appetite 4. Start taking Metoprolol to slow your heart rate 5. Start taking Tylenol every 8 hours and Tramadol every 4 hours to treat the pain from the blood clots in your leg. 6. Start taking a multivitamin and iron to help your anemia 7. Increase the lantus to 32 unit daily 8. Increase torsemide to 100 mg daily 9. Increase the warfarin to 4 mg daily . Weigh yourself every morning, call Dr. [First Name (STitle) 437] if weight goes up more than 3 lbs iin 1 day or 6 pounds in 3 days. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2133-11-18] at 9:30 AM With: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: WEDNESDAY [2133-12-23] at 11:40 AM With: [Name6 (MD) 251] [Last Name (NamePattern4) 1114], M.D. [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2133-12-29] at 2:00 PM With: DEVICE CLINIC [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: 7907, 4280, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5808 }	Medical Text: Admission Date: [2124-6-21] Discharge Date: [2124-6-30] Date of Birth: [2052-2-14] Sex: F Service: MEDICINE Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending:[First Name3 (LF) 710] Chief Complaint: hypotension and fever Major Surgical or Invasive Procedure: PICC placement [2124-6-29] History of Present Illness: 72 F resident of [Location 105502] with multiple medical problems including DM type II, dCHF, PVD, a.fib (on coumadin), and ICU admissions for sepsis in past who was noted to be lethargic on AM of [6-21]. There, pt's blood pressure was 80's systolic, rectal temp 103 F, HR in 100s. [Name6 (MD) ] [Name8 (MD) ] MD there was no obvious source of infection and sent to ED. Pt does not recall transfer to ED. In ED, she was noted to have SBP in 90's, HR in 100's in A fib, and CXR with chronic RLL opacity. She had a temp of 103.4. She was given 4 L of fluids with heart rate in 80's and improvement in her SBP to 120's. Femerol line attempted without success in ED. UA was positive but not a clean sample. CXR showed diffuse right sided infiltrates consistent with history of fibrosis. She was given Levofloxacin 500mg IV, Vancomycin 1gram IV, Flagyl 500mg IV. She had urine output of 1 L and resolution of delta MS. Of note, pt was admitted to ICU on [10-10] from HebReb with similar symptoms and treated for sepsis [3-9] nosocomial pneumonia. She was treated with 2 weeks of vancomycin/imipenem. Currently she is complaining of right leg pain which is old, starting in stump but then radiating to phantom leg, [7-15] from [2128-4-10] baseline. She denies diarrhea, chest pain, SOB, cough, dysuria. She complains of abdominal pain worst in RUQ but only with exam. No rash. Past Medical History: PMH: 1. CHF with diastolic dysfunction- Last LVEF was 65% with a normal MIBI in 01/[2123]. 2. Type 2 diabetes mellitus 3. Atrial fibrillation 4. Anemia 5. CAD s/p PTCA x3- Pt had a stent to her RCA in [2109], LCx in [2110], and RCA in [2113]. 6. Pulmonary HTN 7. COPD/[Name (NI) 105500] Pt is on intermittent oxygen at home. 8. Thyroid CA s/p resection- Pt is now hypothyroid. 9. Myoclonic tremors 10. H/O PE 11. OSA on CPAP 12. Depression 13. Anxiety 14. H/O MRSA and [Name (NI) 105501] Pt has two past ICU admissions for MRSA aortic valve endocarditis and pseudomonal sepsis. She has had two intubations. 15. S/P laproscopic cholecystectomy [34]. S/P right throcoscopy and decortication 17. S/P right lung biopsy 18. S/P right hip ORIF 19. S/P right ankle ORIF 20. s/p right AKA Social History: Social: Pt lives at [Hospital1 100] Senior Life. Divorced and has three children. She quit smoking in [2104] but has a history of 1 PPD for 15 years. No ETOH or drugs. . Family History: FHx: F: died at 47 of MI; M: died colon ca; B: DM Physical Exam: PE: Tm ED 103.4 Tc 100 P80 BP 128/89 R12 95% 3L NC Gen: NAD, converstaional, A+Ox3 HEENT: PERRLA, MM very dry Neck: LVP 8 cm above LA Resp: crackles [2-8] way up from bases bilaterally, with wheezes left side CV: irreg, tachy, normal S1s2 no MGR Abd: TTP RUQ > LUQ, no remound or guarding. hypoactive bowel sounds Ext: cool hands and leg. left leg with venous stasis changes, 2+ DP pulse Neuro: alert, oriented. Moving extremities to command. Pertinent Results: [2124-6-21] CT abd/pelvis: CT OF THE ABDOMEN WITH IV CONTRAST: The visualized portions of the lung bases demonstrate small bilateral pleural effusions and interstitial opacities consistent with CHF. There is a 9-mm vague hypodensity of the left hepatic lobe, which has not significantly changed compared to [2123-8-6] and is too small to definitively characterize. Otherwise, the liver is unremarkable. The patient is status post cholecystectomy. The pancreas is atrophic. There is a 1.5-cm hypodense lesion at the anterior margin of the spleen which is unchanged. There is cortical thinning of the left kidney which is chronic. The right kidney and adrenal glands are unremarkable. Again seen is diastasis of the anterior abdominal wall with protrusion of transverse colon. Otherwise, the bowels are unremarkable and there is no evidence of obstruction or free intra-abdominal air. There are extensive abdominal aortic calcifications. No intra-abdominal fluid collection or abscess is identified. There is no pathologic mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within the urinary bladder which is decompressed. The rectum, uterus, adnexa, and intrapelvic loops of bowel are unremarkable. There is no free pelvic fluid or lymphadenopathy. BONE WINDOWS: The patient is status post right hip arthroplasty. No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. Small bilateral pleural effusions and interstitial opacity of the lung bases consistent with CHF. 2. Vague 9-mm hypodensity of the left hepatic lobe is too small to be definitively characterized but unchanged from [2123-8-6]. 3. Atrophic pancreas. 4. Chronic left renal cortical thinning. 5. Diastasis of the abdominal wall with protrusion of transverse colon but no evidence of obstruction. 6. Extensive abdominal arterial calcifications. 7. No change in 1.5-cm hypodensity of the spleen. . [2124-6-21] ECG: Atrial fibrillation Modest nonspecific ST-T wave changes Since previous tracing of [2123-10-8], no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 92 0 70 [Telephone/Fax (2) 105503]2 -5 . [2124-6-22] CXR Pa/La: FINDINGS: There is worsening congestive failure, with increased pulmonary [Month/Day/Year 1106] congestion and a left pleural effusion. Right lower lobe opacity also appears somewhat more dense. Lung volumes are reduced. Osseous structures are diffusely demineralized with degenerative changes in the thoracic spine. IMPRESSION: Worsening congestive failure. Right lower lobe pneumonia. Tiny left pleural effusion. . CT chest: FINDINGS: Diffuse bilateral hazy ground-glass opacity is seen within both lungs, new since the most recent examination. Interlobular septal thickening is also present. There are new bilateral pleural effusions. Also new is a patchy opacity in the right middle lobe. Findings of traction bronchiectasis at the bases, and central and peripheral fibrosis with architectural distortion are unchanged. There are dependent secretions in the trachea. The bronchi are patent to the segmental level. Right paratracheal lymphadenopathy measuring up to 1.5 cm in short axis and other smaller mediastinal lymph nodes are unchanged. There is no pericardial effusion. Coronary calcifications are present. The heart and pericardium are otherwise stable in appearance. Patient is post-cholecystectomy. Dense arteriosclerotic calcifications are seen within the aorta and splenic artery in the upper abdomen. Density of the liver appears decreased compared to the prior study from [2123-4-5], and is now within normal limits. Small hiatal hernia. Degenerative changes are seen throughout the thoracic spine. IMPRESSION: 1. New bilateral effusions and diffuse ground-glass opacification with septal thickening most likely indicates congestive failure. 2. Patchy opacity in the right middle lobe probably represents a superimposed infectious process. 3. Largely unchanged appearance of architectural distortion and fibrosis in the middle and lower lobes and traction bronchiectasis most predominantly in the lower lobes. Unchanged lymphadenopathy. 4. Coronary calcifications. . CT head: FINDINGS: There is no acute intracranial hemorrhage, shift of normally midline structures, or hydrocephalus. Age-related brain atrophy is seen. Hypodensity is seen in the cerebral periventricular white matter, consistent with chronic small vessel infarction, unchanged from the prior exam. [Doctor Last Name ]- white matter differentiation is preserved. The mastoid air cells are clear. Minimal mucosal thickening is seen within the left ethmoid air cells and the sphenoid sinus, which has developed since the prior study. Also, the nasopharyngeal soft tissues are mildly thickened, also a new finding- this requires clinical correlation. There is no sinusitis. Osseous structures and soft tissues are unremarkable. IMPRESSION: No acute intracranial hemorrhage. See above report re: nasopharyngeal finding- clinical correlation required. . [2124-6-29] 04:50AM BLOOD WBC-8.2 RBC-3.80* Hgb-10.3* Hct-32.2* MCV-85 MCH-27.1 MCHC-32.0 RDW-14.7 Plt Ct-233 [2124-6-21] 07:10AM BLOOD PT-15.0* PTT-36.6* INR(PT)-1.3* [2124-6-29] 11:16PM BLOOD PT-36.5* PTT-53.3* INR(PT)-4.0* [2124-6-21] 06:15AM BLOOD Glucose-89 UreaN-16 Creat-1.0 Na-139 K-3.5 Cl-102 HCO3-28 AnGap-13 [2124-6-29] 11:16PM BLOOD Glucose-112* UreaN-20 Creat-0.8 Na-135 K-3.8 Cl-95* HCO3-33* AnGap-11 [2124-6-21] 06:15AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 [2124-6-29] 11:16PM BLOOD Calcium-8.6 Phos-2.2* Mg-2.4 [2124-6-23] 06:58AM BLOOD TSH-0.14* [2124-6-23] 06:58AM BLOOD Free T4-1.2 [2124-6-29] 04:50AM BLOOD Digoxin-0.5* [2124-6-26] 12:43AM BLOOD Type-ART pO2-158* pCO2-38 pH-7.38 calHCO3-23 Base XS--1 [2124-6-24] 06:35PM BLOOD Type-ART pO2-288* pCO2-40 pH-7.40 calHCO3-26 Base XS-0 Intubat-NOT INTUBA Comment-NC . [2124-6-27] TTE MEASUREMENTS: Left Atrium - Long Axis Dimension: 5.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 6.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 6.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.8 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.1 cm Left Ventricle - Fractional Shortening: 0.45 (nl >= 0.29) Left Ventricle - Ejection Fraction: 70% to 80% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aorta - Arch: 3.2 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.7 m/sec TR Gradient (+ RA = PASP): 35 to 50 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Hyperdynamic LVEF. No resting LVOT gradient. No LV mass/thrombus. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Mildly dilated aortic arch. Focal calcifications in aortic arch. AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. Moderate to severe [3+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 70-80%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Assesment: 72F with fever, hypotension consistent with severe sepsis and found to have RML pneumonia. . #) Sepsis/right middle lobe pneumonia: Admitted for hypotension/fever/sepsis and found to have RML pneumonia. CT abdomen was negative for intra-abdominal processes. The patient was initially empirically placed on levo/vanco, but the patient continued to have fevers. The patient blood pressure stabilized with IVF without requiring pressors and was observed in MICU overnight and transferred to the floor once hemodynamically stable. ID was [Month/Day/Year 4221] and the patient was switched from levo to meropenem to cover more broadly. The patient was unable to produce any adequate sputum. UA at admission was dirty, and Ucx x 2 revealed no growth. Blood cultures grew nothing to date. On meropenem, the patient defervesced and continued to stay hemodynamically stable. After 7 days of vancomycin, it was discontinued as no apparent source of gram positives. The patient is to finish 14 day course of meropenem. . #. Mental status change: Two days after transferred to the floor, the patient was transferred back to the unit for lethargy and mental status change. CT head was negative. It was thought to be secondary to oversedation from Oxycontin/oxycodone/fentanyl/neurontin. All narcotics were initially held and her mental status returned to baseline. For chronic neuropathic pain control, restarted fentanyl 25mcg and decreased neurontin dose. . #) Afibrillation- Was difficult to control due to sepsis. Metoprolol was titrated up to 50mg TID and the patient received diltiazem drip as well with HR still hovering in the 100-120s. On diltiazem gtt, the patient became hypotensive to 80s although asymptomatic. The team did not want to start amiodarone as there was a questionable amiodarone toxicity causing pulmonary fibrosis. EP was [Month/Day/Year 4221] and recommended stopping diltiazem gtt and titrating up metoprolol and/or starting digoxin if hypotensive. Digoxin was started on [6-28] with a loading dose 0.25mg followed by 0.125mg then daily dig 0.125mg qday. Dig level the day after loading dose was 0.5 and ECG had no signs of toxicity. The patient is to take digoxin 0.125mg daily and have dig level checked on [7-2] (therapeutic range is 0.8-2 ng/mL). Because coumadin and digoxin may interact to increase INR, INR needs to be checked and adjust coumadin dose as needed to establish a goal INR [3-10]. Coumadin was decreased from 2 to 1mg qday on [6-29]. The patient had a TTE, and result is as above. . #) Pulmonary fibrosis - restrictive lung disease by previous CT scan and PFT's. Also with history of [Month/Year (2) 105496] and COPD. Continued nebs and fluticasone. The patient was started on po steroids for wheezes and to finish 10 day taper. . #) History of dCHF - After receiving IVF for hypotension, the patient was volume overloaded. The patient was diuresed with IV lasix and restarted her 80mg maintenance dose. Because pt was -1.5 to 2L on maintenace lasix 80mg and was thought to be mildly dry, decreased maintenance lasix to 40mg qday on the day of discharge. . #) Neuropathic pain in RLE - Discontinued Osycontin/oxycodone and decreased neurontin and fentanyl for mental status changes. Pt did not complain more pain than usual. . #) Hypothyroidism - Due to low TSH and tachycardia, lowered levothroxine to 175mcg from 200mcg. . #) DM- continued lantus and RISS. . #) FEN: CHF/DM diet. Follow lytes. . #) proph - SQH, bowel regimen, protonix . #) access - L PICC placed on [2124-6-29]. . #) code - DNR, maybe DNI per daughter Medications on Admission: 1. oxycodone 10mg PO Q4 prn, oxycodone 10mg PO Q9pm 2. Combivent nebs Q4 prn 3. mom prn 4. Tylenol 975 mg PO Q4 prn 5. Topamax 25 mg [Hospital1 ] 6. Coumadin 1mg PO Qday 7. Artificial tears 1 drop OU [Hospital1 ] 8. Protonix 40 Qday 9. prednisilone 1% drops to R eye Qday 10.Zocor 20mg QHS 11.Lopressor 25mg PO BID 12.MVI Qday 13.Lasix 80mg PO Qday 14. Neurontin 600mg PO BID, 900mg QHS 15. celexa 60mg Qday 16. fentyl patch 75mcg Q72 hours 17. fluticasone 110mcg 2 puffs [Hospital1 ] 18. combivent MDI 2 puffs [Hospital1 ] 19. asa 325 Qday 20. Ketoralc 0.5% OD [Hospital1 ] 21. Levothroxine 200 mcg Qday 22. Ritalin 10mg QAM 23. Lantus 16 units QHS 24. RISS Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: Three (3) mL Inhalation every four (4) hours as needed for shortness of [Hospital1 1440] or wheezing. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every twelve (12) hours. 11. Lantus 100 unit/mL Cartridge Sig: Sixteen (16) units Subcutaneous at [Hospital1 21013]. 12. Insulin Regular Human 100 unit/mL Cartridge Sig: see sliding scale instruction Injection see sliding scale instruction: 151-200 0 units 201-250 2 units 251-300 4 units 301-350 6 units 361-400 8 >400 [Name8 (MD) ] MD . 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 14. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a day. 15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 22. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic [Hospital1 ] (2 times a day) as needed. 23. Prednisone 20 mg Tablet Sig: see other instructions Tablet PO once a day for 5 days: Take 2 tablet on [7-1], then 1 tablet on [4-25], then [2-7] tablet on [4-27], then off. . 24. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for see other instructions days: until [7-7]. 25. PICC PICC care per CCS protocol Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Sepsis Congestive heart failure Atrial fibrillation Discharge Condition: Good, afebrile Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Return to emergency deparement or call your doctor if you develop fevers, chills, shortness of [Name8 (MD) 1440], chest pain, or any other worrisome symtoms. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2124-8-15*] 1:00 ICD9 Codes: 486, 4280, 496, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5809 }	Medical Text: Admission Date: [2199-5-3] Discharge Date: [2199-5-8] Date of Birth: [2133-6-2] Sex: M Service: CARDIOTHORACIC Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 1283] Chief Complaint: Increase fatigue/Chest tightness w/ activity Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x 5 on [2199-5-3] History of Present Illness: 65 y/o active male with h/o HTN and DM c/o increase fatigue and chest tightness w/ activity. Had +ETT followed by cath which revealed severe 3 vessel disease. Past Medical History: Hypertension Diabetes Mellitus s/p Back surgery [2174] s/p L Hand tendon repair s/p R. Thunb repair s/p Cervical Laminectomy s/p Varicocele repair Social History: Lives with wife. [Name (NI) ]. Quit smoking 25 yrs ago. Doesn't drink. Family History: Non-contributory Physical Exam: Vitals: 80 20 160/80 6'1" 270 General: Well-appearing 65 y/o male in NAD Skin: Unremarkable, -lesions HEENT: EOMI, PERRLA, NC/AT Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/NT +BS Ext: Warm, well-perfused, trace edema, -varicosities Neuro: A&Ox3, CN2-12 intact, non-focal Pertinent Results: Pre-op CXR: No radiographic evidence of acute cardiopulmonary process. [2199-5-3] 12:12PM BLOOD WBC-14.0* RBC-3.40# Hgb-10.2# Hct-30.3# MCV-89 MCH-30.0 MCHC-33.6 RDW-12.5 Plt Ct-167 [2199-5-7] 05:55AM BLOOD WBC-9.5 RBC-3.93 Hgb-11.4* Hct-35.2* MCV-90 MCH-29.1 MCHC-32.5 RDW-12.5 Plt Ct-246 [2199-5-3] 12:12PM BLOOD PT-14.6* PTT-25.5 INR(PT)-1.4 [2199-5-3] 12:24PM BLOOD UreaN-22* Creat-1.0 Cl-111* HCO3-24 [2199-5-7] 05:55AM BLOOD Glucose-158* UreaN-20 Creat-0.9 Na-138 K-4.8 Cl-101 HCO3-27 AnGap-15 [2199-5-3] 02:16PM BLOOD Mg-2.5 [2199-5-5] 04:14AM BLOOD Mg-1.9 [2199-5-3] 07:18AM BLOOD freeCa-1.20 [2199-5-4] 03:26AM BLOOD freeCa-1.24 Brief Hospital Course: Pt. was a same day admit on [2199-5-3] and was brought to the OR and after general anesthesia he underwent a CABG x 5. Pt. tolerated the procedure well and had total bypass time of 96 minutes and cross-clamp time of 69 minutes. Please see op note for full surgical report. Following the procedure he was transferred to CSRU in stable condition with a HR of 96 a-paced, MAP 82, CVP 14, PAD 18, [Doctor First Name 1052] 24 and being titrated on Nitro and Propofol. He remained extubated through the next and early morning on POD #1 he was weaned from propofol and mechanical ventilation and extubated. He was awake, alert, MAE, and following commands. His Swan Ganz catheter and Chest tubes were removed pre protocol. Diuretic and B-blocker were started today. CXR on POD #2 revealed a small left apical PTX. On POD #3 Repeat CXR showed a regression in the PTX. He appeared to be doing well. Exam was unremarkable. His epicardial pacing wires and Foley were removed. He was transferred to telemetry floor. On POD #5, he cleared physical therapy and was discharged to home. Medications on Admission: 1. Atenolol 25mg [Hospital1 ] 2. Accupril 20mg qd 3. Zantazc 150mg qd 4. Metformin 1000mg [Hospital1 ] 5. Diltiazem 240mg qd 6. Glipizide 10mg [Hospital1 ] 7. ASA 325mg qd 8. Humulin NPH 60 units at hs 9. MVI 10 Ibuprofen prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:1 6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Quinapril HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:14 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 1 weeks. Disp:14 Packet(s) Refills:0 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:1 11. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 12. Insulin Regular Human 100 unit/mL Solution Sig: as directed units Injection as directed. Disp:1000 units Refills:2 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty (60) units Subcutaneous dinner. Disp:100 cc Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Arterty Disease s/p Coronary Artery Bypass Graft x 5 Hypertension Diabetes Mellitus s/p Back surgery [2174] s/p L Hand tendon repair s/p R. Thunb repair s/p Cervical Laminectomy s/p Varicocele repair Discharge Condition: Good Discharge Instructions: Can take shower. Wash incisions with warm water and mild soap. Gently pat dry. Do not bath or swim. Do not apply lotion, creams, or ointments to incisions. Do not lift greater than 10 pounds for 2 month. Do not drive for 1 month. Make/keep all follow-up appointments. [Last Name (NamePattern4) 2138]p Instructions: Follow-up with Dr. [Last Name (Prefixes) ] in 4 weeks. Follow-up with Dr. [Last Name (STitle) 3659] in [1-17] weeks. Follow-up with Dr. [First Name (STitle) ] in [12-16] weeks. ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5810 }	Medical Text: Admission Date: [2162-11-18] Discharge Date: [2162-12-29] Date of Birth: [2113-5-30] Sex: M Service: MEDICINE Allergies: Penicillins / Dicloxacillin Attending:[First Name3 (LF) 678] Chief Complaint: Pt unable to give [12-25] to history of MR. [Name13 (STitle) ] was sent here for eval after group home felt that his behavior was off. Major Surgical or Invasive Procedure: Endotracheal Intubation PICC line placement History of Present Illness: [Known firstname ] [Known lastname 106770] is a 49-year-old gentleman with severe mental retardation (non-verbal at baseline, deaf/blind since birth), epilepsy, bilateral anopthalmia, initially admitted for subdural hematoma (stable, no intervention performed) who was transferred from the floor with sudden onset of respiratory distress, desaturation to mid 80s on 6L NC. He had recently been noted to have a LUE DVT on [2162-11-27] associated with a PICC line which was subsequently pulled. No anticoaggulation given for this given the recent subdural hematoma for which he was admitted and the relatively low risk of PE with upper ext DVTs. The team was concerned for possible PE vs a new aspiration pneumonitis or pneumonia. Of note, he completed a 10 day course of levo/flagyl for aspiration pna on [2162-11-29] and had a G tube placed for TFs on [2162-11-25] given his chronic aspiration. Blood cultures positive for coag neg staph on [2162-11-18] and [2162-11-23] were felt likely to be contaminants given the fact that they were different species. . He had initially presented to the Emergency Department on [2162-11-18] s/p unwitnessed fall at Group Home. He was found to have acute right-sided subdural hematoma with minimal mass effect, and unchanged ventriculomegaly. He was given 1g Dilantin load and admitted to the Neurosurgical ICU. Repeat Head CT 5-hours later showed no change, and no intervention was planned. Patient was transferred to the MICU initially for hypernatremia up to 174 and ARF which resolved with IVFs and free H20. His WBC started to rise and he was started on Vancomycin for L knee cellulitis. Arthrocentesis of the knee was neg for septic joint. He had a PICC line placed and was transferred to the floor. . Past Medical History: 1. Severe mental retardation 2. Epilepsy 3. Hx DVT s/p IVC filter placement 4. Porcelain gallbladder 5. Bowel/bladder incontinence 6. Nephrogenic DI 7. History of GI bleeding 8. Hx Decubitus ulcers Social History: Parents both deceased, siblings uninvolved; lives in a group home, current guardian is at [Telephone/Fax (1) 106771], or [Telephone/Fax (1) ]. Family History: mother- DM, ALS father- mental health issues developmental delay in several family members Charcot [Name2 (NI) 106772] Tooth in several family members Physical Exam: PHYSICAL EXAM ON ADMISSION O: T:97 BP: 100/60 HR:70 R 18 O2Sats 93% ra Gen: Moans, uncooperative, with contracted all four extremities HEENT: anophthalmia Extrem: Warm. Neuro: Mental status: Arousable, moans, uncooperative with exam. VIII: Hearing appears intact, moves to voice Motor: Moves all four extremities, appears to have full strength, emaciated Sensation: unable to assess, moves extremities to light touch Reflexes: not detectable Toes downgoing bilaterally . PHYSICAL EXAM ON TRANSFER TO MICU VS: T 97.9; BP 125/104; HR 103; RR 24; O2 85% NRB, up to 98% NRB GEN: Chronically ill-appearing, grunting intermittently, aggitated, moving all extremities SKIN: Multiple ecchymoses over face, bilateral knees, R shoulder, R arm, L elbow HEENT: Anopthalmic on R. Edentulous. MM dry. No JVD. No carotid bruits. LUNGS: decr bs b/l, but otherwise clear CV: S1S2 RRR. No appreciable MRG ABD: + BS, soft, NT/ND. EXT: no peripheral edema. Palpable DP pulses NEU: Extremely limited exam due to mental state. Anophthalmic. Does not respond to voice. Does not follow commands. Moves limbs spontaneously. Pertinent Results: PICC LINE PLACMENT SCH [2162-12-14]: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the right basilic venous approach. Final internal length is 37 cm, with the tip positioned in SVC. The line is ready to use . CXR [2162-12-3]: Bibasilar improvement of atelectasis . US EXTREMITY NONVASCULAR LEFT [2162-11-29]: Status post removal of venous catheter with persistent echogenic thrombus which is not propagated on limited examination . UNILAT UP EXT VEINS US [2162-11-26]: Acute thrombus in the left subclavian, axillary and brachial veins surrounding the patient's PICC line. . CT torso [2162-11-25]: 1. Gastrostomy tube within the body of the stomach, which is not in an intrathoracic position. 2. Bilateral lower lobe airspace opacity most suggestive of aspiration although pneumonia cannot be excluded. 3. Porcelain gallbladder. This is a risk factor for gallbladder carcinoma. 4. Shriveled, malpositioned, calcified, and scarred right kidney consistent with chronic process. 5. Stool-filled distended rectum without evidence of proximal bowel dilation. . Head CT [11-19]: Acute or subacute right-sided subdural hemorrhage, measuring 1.1 cm in greatest diameter, with minimal mass effect and no evidence of midline shift. Unchanged ventriculomegaly. Again normal pressure hydrocephalus is a consideration in the proper clinical setting. . CT C-Spine: No definite evidence of fracture or malalignment. Ossific fragments associated with the C5 spinous processes are likely chronic/degenerative, however, correlation with detailed physical examination is recommended. . R SHOULDER AND L ELBOW XR: Extremely limited views of the right shoulder and left elbow. No gross evidence of fracture or dislocation. . L Knee XR: No evidence of acute fracture or dislocation. No joint effusion. . Pelvis AP: IMPRESSION: No evidence of fracture. . Repeat Head CT: Moderate-sized acute/subacute right subdural hemorrhage, unchanged compared to five hours prior. Brief Hospital Course: 49M h/o severe mental retardation, epilepsy, anophthalmia, and nephrogenic DI presenting following a fall found to have a right sided subdural hematoma, profound hypernatremia, and knee cellulitis. . SUBDURAL HEMATOMA: The patient had an unwitnessed fall at his group home. He was found to have an acute right subdural hematoma without evidence of midline shift. He was loaded with dilantin. He was evaluted by the neurosurgical service who recommended serial head CT which showed no change in the hematoma. Surgical intervention was deferred unless acute worsening with herniation was found. The patient will follow-up with the neurosurgeons with a repeat head CT in 2 weeks of discharge. . HYPERNATREMIA: This was felt most likely relate to significant dehydration worsened by his history of nephrogenic DI. He was able to concentrate his urine to Uosm>600. His serum sodium was corrected with initially isotonic fluids then with free water via his NG tube. The follow-up head CT did not show significant cerebral edema after sodium correction. He will need to continue to have appropriate amounts of free water per PEG to keep an appropriate Sodium. . Knee cellulitis: This was felt to be likely related to a prior fall that was secondarily infected. Orthopedics was consulted for evaluation of a potentially septic joint however a joint aspirate showed minimal fluid w/o evidence of infection. He was treated with vancomycin for 14 days. This problem was fully resolved at time of discharge. . ACUTE on Chronic RENAL FAILURE (stage 3, GFR 40): This was felt to be pre-renal in nature. He was volume expanded as above and his urine output improved appropriately. His Cr had returned to baseline at time of discharge. . Hypoxia: The patient had two events of significant hypoxia during his hospital stay. Upon arrival to MICU on [2162-11-30], the patient was aggitated and a good O2 sat could not be obtained b/c a good pleth was not seen. He was given haldol 3mg IV, became less aggitated, and his O2 sat came up to 98% on NRB. CXR revealed low lung volumes and evidence of large amount of stool in intestines. CT torso from [11-25] reviewed revealing collapse of lower lung lobes b/l as well as distended rectum. There was concern that his distended abdomen was making his respiratory status worse and he was disimpacted (large amount of stool removed). His resp status stabilized 98-100% on NRB. . On [12-3], the patient acutely decompensated, with PO2 on ABG at 49. He was intubated after discussion with pcp/guardian and brought to the MICU for aggressive suctioning. After a short intubated course he was extubated. Repeated discussions with his PCP led to [Name Initial (PRE) ] decision to make him truly DNI/DNR. He was extubated uneventfully and discharged to the floor. By the time of discharge he was saturating 94% on 1L NC. . MRSA/PROTEUS MIRABILIS PNEUMONIA: Upon transfer to the floor, Mr. [Known lastname 106770] had a bump in his WBC. Blood, urine, and sputum cultures were sent. Respiratory cultures were positive for MRSA and Proteus mirabilis. The patient was started on vancomycin and aztreonam. A PICC line was placed. He finished a 14 day course of each prior to discharge. . EPILEPSY: The patient's home dose of depakote and phenytoin was increased given a subtherapeutic level. The patient had no notable seizure episodes while in-house. Levels should be followed weekly after discharge. . ELEVATED PTT and thrombocytopenia: The patient has had an elevated PTT in OMR dating back to [2161-2-21] of unclear etiology. Also his platelets were just below his prior low baseline. There was no evidence of active consumption. Factor VIII and IX levels were normal. The thrombocytopenia was likely a chronic process either from a primary marrow process or less likely a medication effect (such as depakote) as his platelets were near his baseline his medications were not changed. Thrombocytopenia resolved by the time of discharge. . C-SPINE Osseus changes: The patient was found to have ossific fragments near C5 without cord compromise. Ortho-spine was consulted and recommended a soft-collar for comfort. Fall: As the patient suffered a fall at his group home, his case managers and social workers from the group home and MA [Name (NI) 71399] were contact[Name (NI) ] and will investigate the events. PPX: Patient maintained on a regimen of Colace, Senna, Dulcolax with good results. PPI was used throughout hospitalization. Pneumoboots were used for DVT prophylaxis; holding heparin in setting of subdural hematoma and ? coagulopathy. Calcium Carbonate and Vitamin D for bone health. . FEN: the patient was admitted with a weight of ~95 lbs which was down from 133 in [2162-3-23]. PEG tube was placed and TF modified with input from the nutrition service. . Medications on Admission: MEDICATIONS AT GROUP HOME 1. Depakote 500mg PO BID 2. Calcium Carbinate 600mg PO qd 3. Colace 100mg PO BID 4. Saline eye wash 5. Lactulose 30mL qd 6. Ativan 0.6 mg PO q2h:PRN 7. Prilosec 20mg PO qd 8. Seroquel 100mg PO qd 9. Vitamin D 400mg PO qd 10. Dulcolax 10mg PR: PRN 11. Fosamax 1 tablet by mouth weekly . ALLERGIES: PCN, Dicloxacillin Discharge Medications: 1. Balanced Salt Soln Non-[Doctor First Name ] #3 Solution [Doctor First Name ]: One (1) ML Ophthalmic QID (4 times a day). 2. Insulin Regular Human 100 unit/mL Solution [Doctor First Name ]: One (1) Injection ASDIR (AS DIRECTED). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet [Doctor First Name ]: One (1) Tablet PO DAILY (Daily). 4. Therapeutic Multivitamin Liquid [Doctor First Name ]: One (1) Cap PO DAILY (Daily). 5. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [Doctor First Name ]: One (1) PO DAILY (Daily). 6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet [Doctor First Name ]: One (1) Powder in Packet PO DAILY (Daily). 7. Lactulose 10 gram/15 mL Syrup [Doctor First Name ]: Thirty (30) ML PO TID (3 times a day): hold for >2BM/day. 8. Haloperidol 1 mg Tablet [Doctor First Name ]: One (1) Tablet PO TID (3 times a day) as needed for aggitation. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Bisacodyl 10 mg Suppository [Last Name (STitle) ]: One (1) Suppository Rectal DAILY (Daily). 11. Quetiapine 25 mg Tablet [Last Name (STitle) ]: Six (6) Tablet PO QHS (once a day (at bedtime)). 12. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO QID (4 times a day) as needed. 13. Valproic Acid 250 mg Capsule [Last Name (STitle) ]: Two (2) Capsule PO Q8H (every 8 hours). 14. Phenytoin 50 mg Tablet, Chewable [Last Name (STitle) ]: Two (2) Tablet, Chewable PO BID (2 times a day). 15. Outpatient Lab Work Please check phenytoin and valproic acid levels 16. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 17. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [Last Name (STitle) ]: One (1) NEB Inhalation Q6H (every 6 hours). 18. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) NEB IH Inhalation Q6H (every 6 hours). 19. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet [Last Name (STitle) ]: One (1) Powder in Packet PO DAILY (Daily). 20. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Twenty (20) mL PO BID (2 times a day). 21. Diazepam 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4H (every 4 hours). 22. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) ]: One (1) gram Intravenous Q 24H (Every 24 Hours) for 9 days. 23. Aztreonam 1 gram Recon Soln [Last Name (STitle) ]: One (1) Recon Soln Injection Q12H (every 12 hours) for 12 days. 24. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO QID (4 times a day) as needed for 12 days: please give via oral swab. 25. Outpatient Lab Work Please obtain vancomycin trough level on [2161-12-19], goal [9-12] 26. Outpatient Lab Work Please check phenytoin (goal 10.0-20.0) and valproate (goal 50-100) levels weekly Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing and Rehab Discharge Diagnosis: PRIMARY: right subdural hematoma pneumonia left subclavian deep venous thrombus Hypoxia Cellulitis (resolved) Poor Nutrition SECONDARY: epilepsy severe mental retardation bowel/bladder incontinence anophthalmia/blindness congenital deafness Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered 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 ?????? Fever greater than or equal to 101?????? F . You had a pneumnia. You finished an antibiotics course for 2 weeks. . You also had a fungal infection inside your mouth and was treated for it. . Please take medications as directed. . Please keep your follow-up appointments. Followup Instructions: Patient will be discharged to [Hospital ] [Hospital ] Nursing and Rehab. . YOU HAVE AN APPOINTMENT WITH DR. [Last Name (STitle) ], [Telephone/Fax (1) ], ON [2163-1-13] 2:00 PM. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO THAT WHICH WAS SCHEDULED ON [2163-1-13] 1:30 PM, [Telephone/Fax (1) 327]. . Follow-up with your primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216], [Telephone/Fax (1) 250], as needed, after transfer back to group home. . [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684] Completed by:[2162-12-29**] ICD9 Codes: 5070, 5849, 2760, 5859, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5811 }	Medical Text: Admission Date: [2136-5-1] Discharge Date: [2136-5-15] Date of Birth: [2136-5-1] Sex: F Service: NB HISTORY: Baby Girl [Known lastname 51647] #1 is a 1690 g product born at 30- [1-23] week gestation to a 35-year-old prima parous woman whose pregnancy was complicated by cervical shortening and pre-term labor. She was admitted on [4-17] and treated with betamethasone, tocolodex, and bed rest. Tonight progression of labor prompted C-section on the night of [5-1]. No sepsis risk factors were noted. Prenatal screens were complete and unremarkable. At delivery she did well and was vigorous and active. She was given blow-by oxygen and stimulation. Her Apgars were 8 and 9. She was brought to the NICU after visiting with her parents. On admission physical examination she is pink, active, and non-dysmorphic. Her skin is without lesions. Her head and neck exam is within normal limits. Her cardiac exam reveals a normal S1 and S2, without murmurs. Her abdomen is benign. Her genitalia reveals a normal preemie female. Her hips are normal. Her spine is intact. Her anus is patent. Her neurologic examination is nonfocal and age appropriate. She is moving all 4 extremities. On admission to the NICU she developed mild respiratory distress manifested by grunting and was placed on CPAP. Her hospital course in the NICU to the date of the interim summary is as follows, by system: Respiratory: She was initially on CPAP for the 1st day and a half of life but then developed an increasing oxygen requirement and was intubated and received 3 doses of serfactin. She was extubated by day of life 3. Was on CPAP for the next 2 days and was weaned to room air by day of life 7. She was loaded with caffeine prior to extubation. She remains on caffeine and is stable on room air at the time of this dictation. She has anywhere from [1-26] mild, mostly bradycardia spells, in a 24-hour period. Cardiovascular: She developed a murmur on day of life 2 which persisted, and which was shown to be a patent ductus arteriosis on day of life 7. She was treated with 1 course of indomethacin, and follow-up echocardiogram on day of life 8 revealed her PBA had closed. She has been cardiovascularly stable over the past week, with normal blood pressures and perfusion. She does not have a murmur on physical examination. Fluids, electrolytes, nutrition: She was initially NPO on starter parenteral nutrition. Feedings were initiated on day of life 3 and advanced slowly until full feeds by 1 week of life. She was then made NPO, and her murmur was discovered, and PDA diagnosed by echo. She continued NPO throughout her course of indomethacin treatment and feedings were reestablished by day of life 9. On day of life 14 she reached full enteral volume feedings with breast milk 20 calorie, and her calories were increased on the [5-15] to 22 calorie per ounce. She will also be breast feeding with this week. She has had electrolytes within normal limits. On days of life [1-19] she did have CO2s in the 18-19 range. By day of life 18 her CO2 was stable at 19, and will be checked weekly with her nutrition labs. She has had normal urine output. Her most recent weight was 1625 g on the [5-15]. Hematology: Her admission hematocrit was 47.6%. She had a small amount of blood loss from an IV that leaked over the day of her 2nd day of life. Her hematocrit on day of life was 39.8%. GI: She was started on phototherapy on day of life 2 for a bilirubin of 6.5 with a direct component of 0.3. This peaked at 7.3 on day of life 3. Her phototherapy was discontinued on day of life 7 for a bilirubin the day prior that had been 4.8. She was found to have a rebound bilirubin of 4.3/0.2 on day of life 8. Infectious Disease: She was started on ampicillin and gentamicin shortly after birth. She completed a 48-hour rule out with antibiotics. Blood culture was negative at the time of discontinuation. She has had no further infectious issues. Neurology: She had a head ultrasound done day of life 7 that was normal. She has not yet had hearing screening, eye exam, or hepatitis B vaccination. DISCHARGE DIAGNOSES: 1. Prematurity at 30-6/7 weeks. 2. Presumed sepsis ruled out. 3. Hyperbilirubinemia. 4. Patent ductus arteriosis status post indomethacin. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2136-5-15] 12:59:40 T: [2136-5-15] 14:02:36 Job#: [Job Number 61712] ICD9 Codes: 769, 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5812 }	Medical Text: Admission Date: [2170-6-30] Discharge Date: [2170-7-12] Date of Birth: [2115-2-16] Sex: F Service: SURGERY Allergies: Tylenol Attending:[First Name3 (LF) 695] Chief Complaint: HCV cirrhosis Major Surgical or Invasive Procedure: [2170-7-1] liver transplant [2170-7-6] ERCP with placement of PD & CBD stent [2170-7-12] Pancreatic stent removal Past Medical History: 1. HCV cirrhosis. 2. Portal hypertension. 3. Ascites. 4. Hepatopulmonary syndrome. Pertinent Results: [2170-6-30] 02:10PM WBC-5.4 RBC-2.96* HGB-10.8* HCT-32.5* MCV-110* MCH-36.6* MCHC-33.2 RDW-15.9* [2170-6-30] 02:10PM GLUCOSE-75 UREA N-13 CREAT-0.8 SODIUM-134 POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-18* ANION GAP-12 [2170-7-12] 05:00AM BLOOD WBC-12.0* RBC-3.44* Hgb-10.6* Hct-32.4* MCV-94 MCH-30.8 MCHC-32.7 RDW-16.9* Plt Ct-167 [2170-7-11] 04:55AM BLOOD WBC-13.9* RBC-3.42* Hgb-10.4* Hct-31.3* MCV-91 MCH-30.3 MCHC-33.2 RDW-17.2* Plt Ct-140* [2170-7-12] 08:35AM BLOOD PT-12.3 PTT-22.0 INR(PT)-1.0 [2170-7-12] 05:00AM BLOOD Glucose-95 UreaN-29* Creat-1.2* Na-138 K-3.6 Cl-102 HCO3-27 AnGap-13 [2170-7-11] 04:55AM BLOOD Glucose-74 UreaN-26* Creat-1.0 Na-137 K-3.7 Cl-103 HCO3-26 AnGap-12 [2170-7-12] 05:00AM BLOOD ALT-35 AST-14 AlkPhos-66 TotBili-0.4 [2170-7-12] 05:00AM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.4 Mg-1.6 [2170-7-11] 04:55AM BLOOD tacroFK-12.9 Brief Hospital Course: On [2170-7-1] she underwent Orthotopic deceased donor liver transplant (piggyback) with portal vein-portal vein anastomosis, common bile duct to common bile duct anastomosis without a T tube and celiac axis patch (donor) to branch patch (recipient). Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. Please refer to operative note for complete details. Two JPs were placed. She received standard induction immunosuppresion consisting of solumedrol and cellcept. Postop, she went directly to the SICU intubated where she did well. LFTS trended down and an u/s of the liver was performed on pod 1 showing patent hepatic vasculature with appropriate waveforms and no biliary dilatation or collection seen. A cxr was also done showing a small right pneumothorax. A chest CT confirmed this. Subsequently a chest tube was placed. She was extubated on pod1. PRBC and plt were given to keep hct greater than 30. An insulin drip was used for hyperglycemia. She continued to do well, but required O2 3-4 liters to keep sats in the 90-95 range. Standing IV lasix was started. She was transfered to the medical surgical floor where her diet was advanced and tolerated. PT followed, but activity was limited given O2 needs (please see PT notes)given hepatopulmonary syndrome. She was able to transfer to the commode with assist of one, wearing O2 continuous. The Chest tube remained in placed until [6-10] when non-bilious output decreased to less than 200ml. Post removal, his O2 desat'd to 79% when attempting to ambulate. Breath sounds remained clear with faint decrease in the right LLL. A cxr showed a tiny right apical pneumothorax. A repeat CXR was done on [6-11] showing near resolution of the pneumothorax. JP output was noted to be bilious therefore on [7-6] an ERCP was performed demonstrating a biliary leak at the anastomosis. Extravasation was noted at the middle third of the common bile duct. A sphincterotomy was performed and a stent was placed successfully after a pancreatic duct stent was placed. She tolerated the procedure well. Amylase and lipase remained normal. The JP drainage became non-bilious. LFTs continued to be normal. Unasyn was given for 6 days following the ERCP. On [6-12], the pancreatic duct stent was removed without incident. Post, procedure she was stable and diet was resumed. On [6-12], the remaining JP was removed and the site sutured. Oxycodone was given for incisional pain with good relief. Immunosuppression: Solumedrol was tapered per protocol down to 20mg qd starting on [7-7]. Cellcept 1 gram [Hospital1 ] continued and prograf was started on pod 1. Daily dosing occurred based on daily trough levels. Dose was decreased to 1mg [Hospital1 ] on [7-12] for a level of 15.2. Social work followed for emotional support. PT evaluated and recommended rehab given significant hepatopulmonary syndrome. She was only partially able to participate in PT eval given decreased O2 with exertion. O2 sat decreases into the mid 80's off O2. She continued to require 3liter of O2. IV lasix 40mg had been given [Hospital1 ] until day of discharge when this was stopped when her weight decreased to her admission weight. Incision appeared clean, dry and intact with staples. She was accepted by [Hospital ] Rehab Hospital and transferred there via ambulance on [6-12] in stable condition. Medications on Admission: Spironolactone 50 qd, Clotrimazole 10 5x a day, Boniva, Calcium Carbonate-Vit D3-Min, B12, Folic Acid Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Q12H (every 12 hours). 2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection ASDIR (AS DIRECTED): see printed scale. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 10. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 12. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: HCV cirrhosis hepatopulmonary syndrome right pneumothorax, resolved s/p liver transplant bile leak, s/p biliary stent placement Discharge Condition: good Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if fever, chills, shortness of breath, chest pain, nausea, vomoiting, jaundice, abdominal pain, incision redness/bleeding/drainage. Labs every Monday and Thursday for cbc, chem10, LFTs, and trough prograf level. Results need to be fax'd to the Transplant office [Telephone/Fax (1) 697] [Name8 (MD) 5035] RN coordinator Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2170-7-19] 9:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2170-7-26] 9:40 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] TRANSPLANT SOCIAL WORK Date/Time:[2170-8-1] 9:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2170-7-12] ICD9 Codes: 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5813 }	Medical Text: Admission Date: [2185-1-10] Discharge Date: [2185-2-17] Date of Birth: [2118-9-2] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: L facial swelling/abscess Major Surgical or Invasive Procedure: Debridement of necrotizing fascitis I&D of facial abscesses Intubation Tracheostomy PEG tube placement Chest tube placement Pigtail insertion into chest History of Present Illness: Ms. [Known lastname ] is a 66yo female with PMH significant for ETOH abuse who presents with left facial swelling. History is obtained from medical chart. She initially presented to [Hospital1 3325] this morning with swelling and redness of the left side of her face and the tissue around both of her eyes. Per son, she had been complaining of pain of one of her L wisdom tooth and had seen a dentist 1 month ago. She was apparently scheduled to have some further work-up. At OSH she underwent a CT head and neck which were without evidence of orbital cellulitis. There was also a report of a fall 1 day prior to admission but no additional information was available. She received Vancomycin 1gm, Zosyn 3.375gm, and Clindamycin 900mg IV. She was then transferred to [Hospital1 18] for further work-up. . Initial vitals in the ED were T 99.8 BP 72/46 AR 126 RR 18 O2 sat 86% on 2L NC. Given her hypoxia and trismus on exam, she underwent an elective fiberoptic intubated by anesthesia. A R femoral line was placed and she was started on a dopamine and levophed gtt. She also received Solumedrol 125mg IV. She also received 5.5L of NS. She underwent repeat imaging and CT neck showed venous thromboses involving the superior sagittal sinus, right transverse sinus and right sigmoid sinus. She was then started on a heparin gtt prior to transfer to the MICU. Past Medical History: -ETOH abuse -H/o PTX -Borderline HTN (diet controlled-last outpt BP=120/70 per PCP) -borderline DM (diet controlled, last HbA1C=5.9) -Rosacea -High Chol. (~300s) -s/p hysterectomy -liver bx -foot [Doctor First Name ] Social History: Patient lives alone. History of tobacco and alcohol use, quantity unknown. Unclear about IVDA. Family History: NC Physical Exam: vitals T 97.8 BP 149/104 AR 101 RR 20 vent settings: AC/0.50/400/5 Gen: Patient sedated, not responsive to commands HEENT: ETT in place, eyes closed and difficult to open on exam, increased thick discharge, sclera erythematous Heart: Sinus tachycardia, no m,r,g Lungs: Course breath sounds anteriorly Abdomen: soft, NT/ND, +BS Extremities: No LE edema, 2+ DP/PT pulses bilaterally; R femoral line in place; L face with significant edema and erythema, bilateral periorbital edema Pertinent Results: [2185-1-10] 10:07PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]->1.035 [2185-1-10] 10:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-15 BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG [2185-1-10] 08:30PM GLUCOSE-386* UREA N-16 CREAT-0.4 SODIUM-140 POTASSIUM-2.9* CHLORIDE-108 TOTAL CO2-23 ANION GAP-12 [2185-1-10] 08:30PM ALT(SGPT)-13 AST(SGOT)-19 LD(LDH)-221 ALK PHOS-96 AMYLASE-21 TOT BILI-1.9* [2185-1-10] 08:30PM ALBUMIN-1.8* CALCIUM-7.1* PHOSPHATE-2.8 MAGNESIUM-2.4 [2185-1-10] 08:30PM WBC-17.6# RBC-3.71 HGB-11.3* HCT-34.2* MCV-92 MCH-30.4 MCHC-33.0 RDW-13.2 [2185-1-10] 08:30PM PLT COUNT-132* [2185-1-10] 08:30PM PT-15.8* PTT-150* INR(PT)-1.4* [2185-1-10] 03:31PM LACTATE-2.0 [2185-1-10] 03:29PM GLUCOSE-158* UREA N-20 CREAT-0.3* SODIUM-137 POTASSIUM-2.4* CHLORIDE-96 TOTAL CO2-29 ANION GAP-14 [2185-1-10] 03:29PM estGFR-Using this [2185-1-10] 03:29PM ALT(SGPT)-12 AST(SGOT)-20 CK(CPK)-23* ALK PHOS-109 AMYLASE-37 TOT BILI-2.1* [2185-1-10] 03:29PM LIPASE-28 [2185-1-10] 03:29PM cTropnT-<0.01 [2185-1-10] 03:29PM CK-MB-NotDone [2185-1-10] 03:29PM ALBUMIN-1.9* [2185-1-10] 03:29PM ALBUMIN-1.9* [2185-1-10] 03:29PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2185-1-10] 03:29PM URINE HOURS-RANDOM [2185-1-10] 03:29PM URINE HOURS-RANDOM [2185-1-10] 03:29PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2185-1-10] 03:29PM WBC-11.4* RBC-4.17* HGB-12.5 HCT-36.7 MCV-88 MCH-30.1 MCHC-34.2 RDW-13.2 [2185-1-10] 03:29PM NEUTS-93.3* BANDS-0 LYMPHS-3.1* MONOS-3.2 EOS-0.1 BASOS-0.2 [2185-1-10] 03:29PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 RENAL EPI-[1-26] [2185-1-10] 03:29PM URINE COLOR-Amber APPEAR-SlHazy SP [Last Name (un) 155]->1.035 [2185-1-10] 03:29PM PT-13.5* PTT-29.8 INR(PT)-1.2* [2185-1-10] 03:29PM PLT SMR-LOW PLT COUNT-113* [2185-1-10] 03:29PM NEUTS-93.3* BANDS-0 LYMPHS-3.1* MONOS-3.2 EOS-0.1 BASOS-0.2 [2185-1-10] 03:29PM WBC-11.4* RBC-4.17* HGB-12.5 HCT-36.7 MCV-88 MCH-30.1 MCHC-34.2 RDW-13.2 [2185-1-10] 03:29PM URINE GR HOLD-HOLD [2185-1-10] 03:29PM URINE HOURS-RANDOM [2185-1-10] 03:29PM URINE HOURS-RANDOM [2185-1-10] 03:29PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: Ms. [Known lastname ] is a 66 year old female with PMH EtOH, borderline diabetes who presents in septic shock in the setting of a facial abcess/necrotizing faciitis. . # Odontogenic infection/facial abcess/necrotizing faciitis/septic shock: Patient presented to OSH with increased edema and erythema of her face and tissue surrounding her eye suggestive of an underlying infection. She underwent a CT neck here which confirmed the presence of a large, deep abcess involving the muscles of mastication. Patient underwent surgical abscess drainage on [1-11] by ENT and found to have necrotizing faciitis with extensive debridement performed. Cultures from the wound are demonstrating likely polymicrobial infection. Blood cultures initially drawn at the OSH prior to transfer were preliminarily growing actinomyces, with plans to transfer those cultures to [Hospital1 18] lab for further evaluation. Ultimately, the only positive culture data was for Bacteroides sp and Peptostreptococcus in the blood from the OSH. Extensive further culturing was unrevealing. . The source of infection was felt to be her wisdom teeth on her left side, given the CT scan findings. Therefore oral surgery was consulted and proceeded to bring patient to the OR for teeth removal, and continued to follow along during her hospital course. The patient developed a new left mandibular and bilateral pre-septal abscesses several weeks after the initial debridement. OMFS took the patient back to the OR for I/D of the left mandibular abscess and further tooth extraction. . Given the extent of the infection and involvement of orbital area, opthalmology was following along throughout hospital course. Although the infection involved the pre-septal area, it did not extend into the orbit/globe of eye, and intraocular pressures remained normal. She developed bilateral pre-septal abscesses and she had bedside I/D of these lesions with improvement. She had a persistent fluid collection behind the eye on the right side that was monitored by imaging, but not aggressively intervened on given the extent of the procedure she would require and the low likelihood that it was clinically significant. . Infectious disease also followed along during hospital course given extent of infection. The patient was maintained on vancomycin, zosyn, and clindamycin initially, until an MRI scan to evaluation for dural thromboses (see below) demonstrated meningeal enhancement, therefore the zosyn was changed to meropenem for better CNS coverage. She developed an extensive drug rash, likely from meropenem, and she was changed to levofloxacin, vancomycin and flagyl at ID recommendation. Ultimately, clindamycin was re-added after the patient developed recurrent abscesses (as above), without recurrence of her rash. She was ultimately weaned down to PO levo and clinda for a 6 week course since last debridment, last day will be [2-24]. Plastics was consulted for wound closure and was going to take the patient to OR for wound flap, however she developed a new R hemiparesis (see below) and neurology did not want patient to be taken off anticoagulation for the procedure given risk of new infarcts. She will need to follow up with plastics one week following discharge. Her wound was dressed with xeroform dressing tid to prevent scalp dessication. She will also need to follow up with ENT 2 weeks following discharge. . As stated above, the patient presented in septic shock, with hypotension initially requiring dual pressor therapy. She was given numerous IVF boluses to maintain her urine output and CVP of [7-3], and had pressors slowly weaned off. During this period, the patient responded well to blood transfusions, therefore, her hematocrit goal was 25. Once her hemodynamics stabilized, her transfusion threshold was lowered to 21. . # Dural venous thromboses/septic thrombophlebitis: Patient was found to have venous thromboses involving the superior sagittal sinus, right transverse sinus, and right sigmoid sinus on head CT. Neurology was consulted and recommended initiating the patient on heparin drip, and obtaining an MRV for further evaluation, which confirmed thrombosis of posterior superior sagital sinus, torcula, right transverse sinus, sigmoid/upper internal jugular veins bilaterally. It also demonstrated meningeal enhancement concerning for meningitis (see above). The patient remained on heparin drip with monitoring from neurology. Following the MRV, an ultrasound of her internal jugular veins and subclavian veins showed that these were patent. She underwent angiography, and was found to have nonocclusive thrombi, thus was kept on heparin. She was briefly transitioned to Lovenox, but when her abscesses recurred and her need for procedures restarted, she was kept on heparin only. Prior to scalp wound closure by plastics, as above, the patient was evaluated by neurology and she was found to have a new right sided hemiparesis. An MRI/V/A of the patient's head was performed. The stroke service reviewed the imaging and saw persistent venous thrombosis and concern venous infarct on the left. Prior to discharge her heparin gtt was stopped and she was transitioned to coumadin/lovenox bridge with goal INR of [12-26]. . # Respiratory failure: Patient was noted to be hypoxic on initial presentation to [Hospital1 18] ED. Also found to have significant trismus on exam. Underlying facial edema likely contributing to hypoxia. She underwent a fiberoptic intubation in the ED via her nose. She initially was maintained on steady minimal ventilator support without attempt to wean given frequent OR visits for debridement/ENT procedures as above. On [1-15] she was noted to have LUL airway collapse, at which time sputum culture demonstrated pan-sensitive Klebsiella. This was felt to be a colonizer versus an infection, as she was on antibiotics that covered this organism and her respiratory status stayed stable with just clearing of secretions allowing for opening of the atalectasis of her LUL. On [1-17] she had placement of tracheostomy and PEG tube. She was intermittently on the ventilator in relation to procedures and dressing changes. On [2-3] the patient underwent CT scan to evaluate for a loculated effusion for persistent low grade fevers. This study demonstrated a hydropneumothorax and a fluid-filled left lung bleb. She underwent chest tube placement with resolution of the hydropneumothorax which drained serosanguinous fluid with a HCT of <2, but exudate. She also underwent pig-tail catheter placement into the bleb space which drained thick serosanguinous fluid with a HCT of 3, also exudate. The patient's chest tube was pulled on the day prior to discharge as it no longer had drainage. At the time of discharge the patient was no longer requiring ventilatory support, though continued to require frequent suctioning. . # Thrombocytopenia: Patient was noted to have decreasing platelets on 1st week after admission, initially concerning for DIC or HIT. DIC labs were sent and were negative. HIT Antibody was sent, and returned negative. Her thrombocytopenia resolved spontaneously. . # History of borderline Diabetes: Per the patient's PCP, [Name10 (NameIs) ] last HgA1c was 5.9%. Her blood sugars were initially quite elevated in the setting of acute infection, requiring placement on insulin drip. Once blood sugars stabilized, she was transitioned to insulin sliding scale. . # History of EtOH: Per patient's son, she has a history of active drinking, but unknown quantities. She was maintained on thiamine and folate, did not require CIWA scale as was intubated and sedated (with versed initially) during what would have been her withdrawl period. . # FEN: Patient was initially on tube feeds via NGT, then converted to tube feed via PEG tube after this was placed on [1-17]. . # Prophylaxis: Patient anti-coagulated with heparin gtt, PPI, bowel regimen. . # Code: Full Medications on Admission: None Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Necrotizing fascitis of face Septic thrombophlebitis L hydropneumothorax Discharge Condition: The patient's respiratory status is stable with her tracheotomy. She is able to get out of bed with assistance. Discharge Instructions: The patient should take all medications as prescribed. The patient should make all appointments as indicated below. The patient's PCP should be [Name (NI) 653] or the patient should return to the Emergency room if she develops: --fever or chills --shortness of breath --chest pain --red, painful, or warm skin at her surgery sites --weakness or loss of sensation --confusion --any other symptom that concerns the patient or her health care providers Followup Instructions: Please follow up with ENT surgeon Dr. [First Name (STitle) ] on [3-7] at 10am. His office is located in [Location (un) 55], [Location (un) ]. Please call [Telephone/Fax (1) 2349]. . Please follow up with Infectious Disease, Dr. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2185-3-21] 10:30am. . Please follow up with Neurologist Dr. [Last Name (STitle) ] on [3-22] at 4pm. His office is located on the [Location (un) ] of the [Hospital Ward Name 23] building. Please call [Telephone/Fax (1) 657] prior to your appointment to update your registration information. The patient should follow up with the out-patient plastic surgery department within 1 week from discharge. The phone number is [Telephone/Fax (1) 4652]. The patient should follow-up with the out-patient ophthalmology department at [Telephone/Fax (1) 78009] within 1 week from discharge. The patient should follow-up with the out-patient interventional pulmonology department at [Telephone/Fax (1) 3020] within 1 week from discharge. ICD9 Codes: 0389, 2875, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5814 }	Medical Text: Admission Date: [2159-2-1] Discharge Date: [2159-2-5] Date of Birth: [2092-8-28] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Percocet Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [2159-2-1] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending artery with vein grafts to diagonal, obtuse marginal and posterior descending artery. History of Present Illness: This is a 66 year old female with known coronary artery disease. Over the last several months, she has been experiencing exertional angina and shortness of breath. She describes the pain as substernal which occasionally radiates to her shoulders and left arm. Stress testing on [2159-1-11] was positive for ischemia. Subsequent cardiac catheterization on [2159-1-25] revealed severe three vessel disease and normal left ventricular function. Based upon the above results, she was referred for surgical revascularization. Past Medical History: Coronary artery disease, Prior PTCA in [2149], Hypertensios, Hyperlipidemia, Type II Diabetes Mellitus, Peripheral Vascular Disease - prior Left Fem-[Doctor Last Name ] Bypass, Anemia, GERD, Arthritis, Prior Appendectomy Social History: 30 pack year history of tobacco, quit approximately 2 years ago. Admits to 2 glasses of wine per week. She is a semi-retired registered nurse. She is married and lives with her husband. Family History: Father MI at age 52. Mother and two brothers died of sudden cardiac arrest. Two brothers had CABG in their 60's. Physical Exam: Vitals: BP 130/58, HR 63, RR 14, SAT 98% on room air General: well developed female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, right carotid bruit noted Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [2159-2-5] 07:40AM BLOOD WBC-9.7 RBC-2.67* Hgb-8.4* Hct-24.7* MCV-93 MCH-31.7 MCHC-34.2 RDW-15.1 Plt Ct-301# [2159-2-5] 07:40AM BLOOD Glucose-153* UreaN-19 Creat-0.8 Na-143 K-4.0 Cl-104 HCO3-28 AnGap-15 Brief Hospital Course: Mrs. [Known lastname 71082] was admitted and brought to the operating room where Dr. [Last Name (STitle) ] performed coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and weaned from pressor support without difficulty. She did well and transferred to the SDU for further care and recovery. Over several days, medical therapy was optimized and she continue to make clinical improvements with diuresis. She remained in a normal sinus rhythm without atrial or ventricular arrhythmias. The rest of her postoperative course was uneventful and she was cleared for discharge on postoperative day four. Medications on Admission: Plavix 75 qd, Atenolol 50 am and 25 pm, Lisinopril 10 qd, Imdur 90 qd, Lopid 600 [Hospital1 ], Lipitor 80 qd, Metformin 500 [Hospital1 ], Glipizide 10 qd, Fosamax Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:0 8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:50 Tablet(s) Refills:0 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: Coronary artery disease - s/p CABG, Prior PTCA in [2149], Hypertension, Hyperlipidemia, Type II Diabetes Mellitus, Peripheral Vascular Disease - prior Left Fem-[Doctor Last Name ] Bypass, Anemia 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. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) ] in [3-29] weeks. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [1-27] weeks. Local cardiologist, Dr. [Last Name (STitle) ] in [1-27] weeks. Completed by:[2159-2-5] ICD9 Codes: 2724, 4019, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5815 }	Medical Text: Admission Date: [2126-12-4] Discharge Date: [2126-12-10] Date of Birth: [2067-1-2] Sex: F Service: MEDICINE Allergies: Morphine Sulfate / Codeine Sulfate Attending:[First Name3 (LF) 2074] Chief Complaint: R total knee arthoplasty Major Surgical or Invasive Procedure: 1. Primary right total knee arthroplasty. History of Present Illness: 59 year old female with breast cancer status-post bilateral mastectomies in [2120], complicated by subsequent non-ischemic dilated cardiomyopathy related to adriamycin toxicity, admitted for elective R TKA. She was initially admitted on [2126-12-4] for elective TKA. She was admitted to ICU post operatively and did well. She was called out to the general orthopedics floor on POD #2. At that point, she developed onset of SOB and lightheaded, without chest pain. Pulsus was paradoxical to 20, but otherwise hemodynamically stable. Stat transthoracic echocardiogram showed no pericardial effusion, 2+ mitral regurgitation and tricuspid regurgitation, mild pulmonary hypertension, global hypokinesis, and EF 30-35%. Review of systems negative for PND, orthopnea, or DOE (activity limited by knee). Past Medical History: History of breast cancer - b/l mastectomy; tx with adriomycin, taxol, XRT Congestive heart failure/CM- EF 25%; [12-26] adriomycin Gastric ulcers. Cecal ulcer. Gastrointestinal bleed [2123] Cervical spondylosis. History of gram-negative sepsis. History of nonsustained ventricular tachycardia - tx with amioderone. Hypertension. Vein stripping. Left knee arthroplasty. Right parotid tumor. Chronic renal failure. Hyponatremia Thyroid cyst Social History: Pt lives in [Location 47] with husband and son. Non [Name2 (NI) 1818] Family History: n/c Physical Exam: Vital signs: T 97.9, BP 115/58, HR 89, RR 20, O2 sat 100% 3.5L; pulsus to 15 on transfer to [Hospital Unit Name 196] service HEENT: PERRL, EOMI, oropharynx clear CV: Regular rate and rhythm, S1, S2, II/VI systolic murmur at apex Chest: Scattered wheezes on right, otherwise clear BS bilaterally Abdomen: Soft, NT, +BS Extr: Mild edema on right, right knee dressing clean, dry, intact Neuro: Alert and oriented x 3, non-focal Pertinent Results: TTE ([2126-12-6]): The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [2126-3-19], global left ventricular ssytolic function is slightly improved and the left ventricular cavity is smaller, the severity of mitral regurgitation is slightly worse, and the estimated pulmonary artery systolic pressure is lower. R KNEE FILMS: Right knee: Two views show new total knee arthroplasty without complication. Small amount of cement is seen adjacent to the medial tibial tray. Skin staples are in place. There is post-surgical soft tissue swelling with joint effusion. Brief Hospital Course: Initial impression: Patient underwent total right knee arthroplasty, which she tolerated well. She was admitted to the ICU post-operatively for monitoring of fluid status by right heart catheterization. She did well and was called out to the floor on POD #2. On POD #3, she developed onset of shortness of breath and lightheadedness, but denied chest pain. A pulsus pardoxus of 20 was documented. She was otherwise hemodynamically stable. A stat echocardiogram was signficant for no pericardial effusion (results detailed above). Her elevated pulsus was presumed to have been exagerated by her subjective dyspnea. She was transferred to the cardiology service for monitoring. She was transfused 2 units of pRBCs with lasix, and noted improvement in her dyspnea and LH. She was continued on her outpatient CHF medication regimen and remained clinically euvolemic. Her oxygen saturations remained > 93% on room air. Her echocardiogram was otherwise significant for improvement in her EF, as well as improvement in her known pulmonary artery hypertension. She was also continued on her outpatient regimen of Aromasin while hospitalized. She received standard post-TKA care with physical therapy and Lovenox DVT prophylaxis. She was discharged to rehab in stable condition. Medications on Admission: amiodarone 200 qd carvedilol 25 [Hospital1 ] dig 0.125 qod anzemet 12.5 iv q8 prn colace 100 [Hospital1 ] lovenox 30 sq [Hospital1 ] analapril 20 qd lasix 20 qd imdur 30 qd synthroid 112 mcg qd demerol 25-50 po q6 prn protonix 40 qd aldactone 25 qd Discharge Medications: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Exemestane 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 15. Meperidine 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 16. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection once a week. 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: 1. Right Knee Osteoarthritis 2. Congestive Heart Failure 3. Anemia Discharge Condition: good. short term rehab needs. Discharge Instructions: Please report chest pains, shortness of breath, palpitations or other medical concerns to your primary physician. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2126-12-19] 1:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2038], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2127-2-26] 11:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2038], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2127-5-14] 11:30 Provider: [Name10 (NameIs) ],[First Name4 (NamePattern1) 24276] [Last Name (NamePattern1) 102829] [Telephone/Fax (1) 71474] Appointment should be in [6-2] days . Call Dr[Name (NI) 3536] office at [Telephone/Fax (1) 4451] to schedule a follow up appointment. Completed by:[2126-12-18] ICD9 Codes: 4254, 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5816 }	Medical Text: Admission Date: [2176-11-16] Discharge Date: [2176-11-22] Date of Birth: [2136-4-11] Sex: M Service: MEDICINE Allergies: Keflex Attending:[First Name3 (LF) 30] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: none History of Present Illness: This is a 40 year old man with a history of depression who is transferred from the [Hospital3 ] ED with hemoptysis. He was involved in an altercation on [2176-11-8] during which he was punched in the head and fell down 4 stairs. He fell onto the right side of his chest against a stone landing. Since that time he has had severe pain on his right side, particularly with movement or respirations. He has also had hemoptysis since that time. He has had persistent pinkish sputum. He also had two episodes of bright red blood, the first was the day after the altercations (about 1 tablespoon) and the second on the morning of admission (about 1 teaspoon). He has also had subjective F/C, diaphoresis, and decreased PO intake. He denies N/V, abd pain, diarrhea, constipation, and dysuria. He has tried tylenol, motrin, Aleve, and percocet (belonging to a friend) for the pain, but nothing has worked. . He initially presented to the [Hospital1 2436] ED where CXR showed dense RLL and RML consolidation and patchy RUL infiltrate. Chest CT was read as RML and RLL dense consolidations, patchy infiltrate RUL, plugged RLL bronchus. By verbal report from the ED, this was felt to be likely hemorrhagic consolidation of R lung and possible RLL bronchus clot. Prelim read of CT abdomen/pelvis was negative. Hct was found to be 31 and differential was notable for 15 bands. He was transferred to [Hospital1 18] for further care of pulmonary hemorrhage. . In the ED here, VS: 97.2, 88, 122/69, RR 14, 96% on 2L nc. CXR revealed RLL and RUL opacities, and he was given doses of levofloxacin and flagyl. He also received tylenol and morphine for pain. His OSH CT was reviewed by radiology here and was read as intraparenchymal hemorrhage on the R, but no RLL bronchus clot. IP was [Name (NI) 653], and they recommended admission to the ICU for bronchoscopy. Past Medical History: depression knee surgery . valium 10mg [Hospital1 ] prozac 60mg daily albuterol MDI motrin, tylenol, aleve prn as above . Social History: Lives alone. Works in sales for a paving company (recently sold his own paving/masonry business). Smokes 1.5-2ppd x20 years. Former heavy alcohol history, but quit 2y ago. Occasional marijuana use. No IVDU. Family History: FH: Father had a valve replacement. Mother is healthy. 1 sister is healthy as far as he knows. Physical Exam: VS: 95.6, 106, 146/73, 23, 95% on 2L nc Gen: Appears uncomfortable, but able to speak in full sentences. HEENT: PERRL, MM dry, OP clear, poor dentition Neck: supple, no JVD Lungs: CTA on the left. Markedly decreased breath sounds and dullness to percussion [12-25] way up on the R. No wheezes or rales. Heart: RRR, no m/r/g Abd: +BS, soft, mild TTP in the RUQ which is mainly over the lower ribs. Extrem: no c/c/e Pertinent Results: Admission . CXR: Consolidation of right lower lobe. Opacities in right upper lobe also seen; which may reflect multifocal pneumonia or developing contusions. Please correlate clinically. . EKG: Sinus rhythm at 80bpm. nl axis, nl intervals. J-point elevation in V2-V3. No change from prior from OSH (no prior here for comparison). . WBC-32.6* RBC-2.86* HGB-8.5* HCT-26.0* MCV-91 MCH-29.7 MCHC-32.5 RDW-13.9 LACTATE-1.0 GLUCOSE-92 UREA N-16 CREAT-0.7 SODIUM-135 POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15 Brief Hospital Course: Mr. [Known lastname 70747] is a 40 year old man with a history of depression who presents with hemoptysis and dense RML and RLL consolidations in the setting of chest wall trauma. . 1) Pulmonary hemorrhage: Pt with history of chest wall trauma, imaging concerning for pulmonary hemorrhage. Also with possible RLL bronchus clot on CT read at OSH, radiology here does not agree. Differential diagnosis of consolidations also includes infection. However, hematocrit continued dropping at outside hospital following admission, concerning for continued bleeding. In the ICU at [Hospital1 18], his hematocrit was stable and Interventional Pulmonary opted to defer bronchoscopy. The patient had an elevated white count and was treated for possible pneumonia (given fever, WBC) with levo/flagyl x 7 day course. Pain controlled initially with dilaudid pca, changed to MScontin with MSIR for breakthrough pain. Given his ongoing therapy for narcotics abuse, he was discharged with a Rx for Oxycodone 5 mg #15, NRF. . 2) Anemia: Hct around 30, but baseline unknown. Likely blood loss anemia secondary to pulmonary hemorrhage based on imaging, history of trauma. Hemodynamically stable. Recommend iron studies at outpatient follow-up. . 3) Fever/Leukocytosis: Here, WBC 32 with left shift but no bands. (At OSH, differential notable for 15 bands.) Treating possible pneumonia as above with levofloxacin/flagyl. Patient was afebrile with downward trending WBC at time of discharge. . 4) Thrombocytosis: Marked thromocytosis both at OSH and here, with unknown baseline. Most likely this is reactive thromocytosis in the setting of hemorrhage/infection. Would recommend follow-up as an outpatient. . 5) RUQ tenderness: Mainly tender over the lower ribs (likely either secondary to bruising from the fall vs. muscular strain from coughing). CT abd/pelvis at OSH was reportedly negative for evidence of subacute GI bleed. . 6) Tobacco use: Pt recently was prescribed albuterol MDI. Significant smoking history; was treated with nicotine transdermal during until discharge. . 7) Depression/anxiety: Continued valium and prozac per home regimen. Mr. [Known lastname 70747] was seen by Psychiatry consult service following an attempt to leave AMA from the ICU. At that time, he was deemed to lack capacity for his own medical decision-making as he was experiencing some delirium and risk of medical sequelae was considered to be high. On transfer to the floor, he was reevaluated by Psychiatry who felt his cognitive status to be significantly improved. His outpatient psychiatrist, Dr. [Last Name (STitle) 59975], was [Name (NI) 653], and follow-up appointment was arranged for the day following discharge. Patient has no further episodes of self-injurious behavior and Psychiatry consultant felt there was no contraindication to discharge home. Medications on Admission: valium 10mg [Hospital1 ] prozac 60mg daily albuterol MDI motrin, tylenol, aleve prn as above Suboxone - off at time of admission Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 2. Diazepam 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:20 Tablet(s) Refills:0 3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:90 Capsule(s) Refills:0 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:0 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Pulmonary hemorrhage 2. Pulmonary contusion 3. Thrombocytosis 4. Pneumonia 5. Depression 6. Anemia Discharge Condition: Stable Discharge Instructions: You were found to have bleeding in your right lung after a traumatic injury you sustained. Your bleeding has been well-controlled over the past few days. You were also treated for pneumonia during this hospitalization. You still have some evidence of healing injury in the right lung, but your oxygen levels are adequate to go home. . You were seen by psychiatry during this hospitalization. You should continue your previous regimen of Valium and Fluoxetine and follow-up with Dr. [Last Name (STitle) 59975]. . You should continue to take around-the-clock ibuprofen for pain control and for relief of the inflammation in your chest. In addition, you are being discharged with a prescription for Oxycodone which you should use for breakthrough pain. You will need to follow-up with Dr. [Last Name (STitle) 59975] or your PCP regarding your continued use of this medication. . You should return to the Emergency Room if you experience any further episodes of coughing up blood. Followup Instructions: You should call your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 70748], to schedule a follow-up appointment for next week. You should have a CBC performed at this visit. [Telephone/Fax (1) 35502]. . You should follow-up with your psychiatrist Dr. [First Name8 (NamePattern2) ] [Name (STitle) 59975]. You are scheduled to see him at 1 p.m. on [2176-11-23]. ICD9 Codes: 486, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5817 }	Medical Text: Admission Date: [2115-8-17] Discharge Date: [2115-8-21] Service: HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old male with a history of pulmonary tuberculosis as a teenager, and more recent history of vertebral Pott's disease treated with 18 months of anti-tuberculous therapy as well as vertebral stabilization, off TB therapy for the past 6 months, who presented to the Emergency Room at [Hospital1 346] on [2115-8-16] after a day of malaise and fever. The patient reported a day of feeling unwell; he had been taking Tylenol at home for this for at least one day. On the morning of the 26th, he fell at home after getting out of bed. Subsequently, the patient's wife noted a fever to 100.6 and he received Tylenol. Later that day, he was lethargic so his family brought him to the Emergency Room. In the Emergency Room a chest x-ray was performed, which showed changes in his right lung consistent with his prior tuberculosis. A head CT and an LP were performed which were both unremarkable. Prior to the head CT and LP, the patient received empiric Vancomycin and Ceftriaxone for possible meningitis. An erythematous rash was noted at the time of presentation to the Emergency Room. The patient was then admitted to the general medicine service for further evaluation. PAST MEDICAL HISTORY: 1) Pulmonary TB as a teenager in [Country 651]. 2) Pott's disease status post stabilization and debridement and 18 months of anti-TB therapy. 3) Chronic renal failure - creatinine 1.6 - thought secondary to Rifampin induced nephritis. Was on hemodialysis for a year but this was stopped as his renal function improved. 4) Hypertension. 5) Hypothyroidism. 6) Prostate cancer status post XRT. 7) Recurrent UTI's. MEDICATIONS: Tylenol, Synthroid 50 mcg per day, Prilosec 20 mg per day, Nephrocaps one per day. ALLERGIES: Vancomycin (red man's syndrome), Fluoroquinolones (erythroderma), Unasyn (?), Benadryl (urinary retention), Rifampin (nephritis), Pyrazinamide. SOCIAL HISTORY: Former [University/College ] professor of engineering. Quit smoking many years in the past. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Rash for approximately one day. PHYSICAL EXAMINATION: Temperature 100.6, heart rate 90's, blood pressure 130's/80's, O2 sat 100% on room air. General: The patient was alert but noted to be lethargic. HEENT: Anicteric sclera. Oropharynx unremarkable. No JVD. Thorax, lungs clear to auscultation bilaterally. Cardiac, regular pulse, first and second heart sounds, regular rate and rhythm, no murmurs. Abdomen, bowel sounds positive, soft, nontender, nondistended. Extremities, no edema. Skin, diffuse erythema over the back and portions of the lower extremities. LABORATORY DATA: On admission, white blood cell count 15.6, hematocrit 40.2, platelet count 224,000, sodium 143, potassium 4.5, chloride 103, CO2 22, BUN 31, creatinine 1.8, glucose 120. Differential on the patient's CBC was 89% neutrophils, 8% bands, 2% lymphocytes. Lumbar puncture revealed one white blood cell and 89 red blood cells. The protein was 29 and glucose 69. Gram stain was negative. Chest x-ray, right lower lobe nodules and right upper lobe calcified granulomas, unchanged in appearance. Head CT, no acute process. HOSPITAL COURSE: 1. Dermatologic: Over the first 36 hours of his hospital course, the patient's initial erythematous rash progressed to bullous changes with desquamation. The area most severely involved initially was the patient's back. On the third hospital day, the patient was transferred to the ICU for better monitoring, wound care and management of his diffuse erythroderma. The dermatology and plastic surgery services were consulted. Aggressive fluid replacement for the patient's insensible losses was provided. As there was initial concern for a staph scalded skin syndrome, anti-staphylococcal coverage was provided with Linezolid and Clindamycin. The differential diagnosis for the patient's skin condition was staph scalded skin syndrome vs toxic epidermal necrolysis. Biopsies were performed of the involved skin. An initial biopsy showed full thickness necrosis consistent with toxic epidermal necrolysis; a subsequent biopsy was more suggestive of bullous erythema multiforme; however, the patient's clinical progression was felt most consistent with TEN. Exposed areas of skin were covered with Silver Sulfadiazine and Xeroderm dressings. IVIG was initiated on [2115-8-20] when biopsy results were obtained. The patient received two doses of 25 gm of IVIG. Morphine was provided for pain control. The patient's skin involvement progressed to involve approximately 70-80% of his body surface area, including the back, abdomen, and all extremities. The etiology of the TEN was unclear; his only new preadmission medication was Tylenol; the TEN may have represented a reaction to Tylenol. He did also receive Vancomycin and Ceftriaxone in the Emergency Room empirically; however, he clearly had a rash and developing illness prior to admission. 2. Fluids, Electrolytes & Nutrition: Aggressive hydration was provided due to the patient's large insensible losses. Initially this was done with D5 .9 normal saline; this was subsequently changed to .9 normal saline. The patient's sodium remained stable in the 130 to 135 range. Electrolytes were checked q 8 hours with frequent repletion necessary. The patient's albumin declined to 2.4 by the fourth hospital day. The patient continued to take an oral diet, but tube feeds were to be initiated due to the patient's large nutritional needs. 3. ID: All blood and tissue cultures were negative for organisms. CSF culture was also negative. The Clindamycin was discontinued after preliminary result suggested TEN. The Linezolid was continued on the advice of the ID service. Contact precautions were undertaken and Silver Sulfadiazine was used to prophylax against skin infections. On the last hospital day the patient spiked a fever to 101.5 and repeat cultures were performed. 4. Renal: The patient has chronic renal failure. During the second hospital day the patient's creatinine rose to 2.4, but this acute renal failure resolved with aggressive fluid repletion. A Foley catheter was placed on the last hospital day after much discussion with his family, who is reluctant to allow this in light of past problems with catheter associated urinary tract infections. 5. Cardiovascular: The patient remained hemodynamically stable throughout his ICU course. 6. Access: The patient had a left internal jugular catheter placed on [2115-8-19]. 7. Hematology: The patient's hematocrit dropped from an initial level of 40 to a level of 30 following hydration. On the last hospital day, the hematocrit fell to 27. White blood cell count also fell to 3.8 from 8.2. The fall in counts on the last hospital day raised the concern of an affect of the Silver Sulfadiazine vs developing superinfection. DISPOSITION: In light of the patient's extensive skin losses, a burn unit was felt to be the best location for patient's further management. After contacting the local burn units, the patient was accepted for transfer to [Hospital6 99434]. The patient was transferred to [Hospital6 99434] Burn Unit on [2115-8-21]. TRANSFER MEDICATIONS: Linezolid 600 mg po bid, Protonix 40 mg per day, Synthroid 50 mcg per day, Morphine prn, .9 normal saline, IVIG status post two doses of 25 gm out of a planned five day course, Silver Sulfadiazine to exposed areas. DISCHARGE DIAGNOSIS: 1. Toxic epidermal necrolysis. 2. Acute renal failure. 3. Chronic renal failure. 4. Hypertension. 5. Hypothyroidism. DISCHARGE STATUS: Stable. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ], M.D. [MD Number(1) 292] Dictated By:[Last Name (NamePattern1) 99435] MEDQUIST36 D: [2115-8-27] 18:18 T: [2115-9-3] 17:52 JOB#: [Job Number 36802] ICD9 Codes: 5849, 2765, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5818 }	Medical Text: Admission Date: [2179-3-4] Discharge Date: [2179-3-6] Date of Birth: [2179-3-4] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [Known lastname ] was a former 24 0/7 week gestation male, born to a 25-year-old GII (TAB at 14 weeks gestation) P0 mother. [Name (NI) 37516] [2179-6-24]. This pregnancy was uncomplicated until the mother was admitted on [2179-2-26] due to premature cervical dilatation associated with vaginal bleeding. Ultrasound demonstrated a footling breech with estimated fetal weight of 594 grams, in the 42nd percentile. Mother's cervical dilatation continued to progress. She received Pitocin following progressive dilatation, and declined cesarean section due to increased risk with classical incision, including infertility. Membranes were ruptured at about 7:30 P.M. Delivery was at 7:50 P.M. Mother did receive antibiotics greater than four hours prior to delivery, and other than premature delivery, the infant did not have any other sepsis risk factors. No maternal fever, no fetal tachycardia. PRENATAL SCREENS: O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, unknown GBS, rubella immune. Prior to delivery, several attending neonatologists spoke with the mother regarding viability issues at this gestational age and the potential for severe long-term neurological sequelae. The infant was born at 7:50 pm by vaginal delivery. At the time of delivery, the baby's umbilical cord emerged first, i.e. prolapsed, followed by infant's legs. The rest of the infant's body emerged soon after but, due to severe clamping of cervix, head delivery was delayed. During this time, the infant's body was external with minimal movement noted. The infant emerged without activity, received positive pressure ventilation by mask. Heart rate initially low but responded quickly to positive pressure ventilation. Heart rate was greater than 100 at 1.5 minutes of life, with pink color. Infant was intubated without difficulty at about two minutes of age. He had first signs of respiration with gasps at about five minutes of age. The infant was without evidence of spontaneous activity, and continued with gasping intermittently. The baby was brought to the [Name (NI) ] Intensive Care Unit for further evaluation. Apgars of 1 at one minute, 4 at five minutes, 5 at ten minutes, and 5 at 20 minutes. SOCIAL HISTORY: Father of the infant was in [Location (un) 11177] at the time of delivery, with a plan to fly to [Location (un) 86] once he heard of the circumstances. In the [Location (un) ] Intensive Care Unit, the infant received surfactant. UA and UV lines were placed. The baby was placed on high-frequency ventilation with a MAP of 8, frequency of 15, and oxygen weaned to 31% FIO2. PHYSICAL EXAMINATION: On admission, ill-appearing infant, weight 725 grams (just below the 50th percentile), head circumference 21 cm (25th percentile), length 34.5 cm (greater than 50th percentile). Temperature 91.4, heart rate 180s, initial blood pressure with a mean of less than 20, oxygen saturation initially 99% on 100% FIO2, weaned quickly to 31% with oxygen saturations of 95%. Color pink, eyelids fused, immature skin. Significant bruising, especially the left leg, left hand and slightly over the right leg. Normal S1, S2, no murmur. Breath sounds slightly coarse bilaterally, equal. Gasps noted intermittently. Abdomen soft, nontender, nondistended, no hepatosplenomegaly. Testes not palpable. Patent anus, patent spine. Hypotonia noted diffusely. No spontaneous activity noted except for the right arm jerks, which was not consistent with seizure activity since it was able to be stopped when held, and no association with vital sign changes. LABORATORY DATA: CBC: White count 15.7, hematocrit 42%, platelets 216,000. Arterial blood gas: 7.11/48/84/base excess -11. The baby was given two normal saline boluses and one bicarbonate bolus. Blood culture was sent. Chest x-ray initially showed a high endotracheal tube that was advanced, bilaterally well-expanded lungs, evidence of reticulogranular pattern, diffuse, consistent with hyaline membrane disease. Umbilical lines in good position, and no pneumothorax. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The baby was placed on high-frequency ventilator as described above. He received a total of 12 mEq/kg of bicarbonate for metabolic acidosis. Baby was transitioned to the conventional ventilator due to difficulty oxygenating on HFOV, with ventilator settings of 20/5 and a rate of 30, and about 60 to 70% oxygen. He received three doses of surfactant, and managed to wean down to ventilator settings of 19/5 and a rate of 22. His blood gases normalized, with pH of 7.31 to 7.42, CO2 in the high 30s to 50s, and was requiring 27 to 36% oxygen. As stated previously, chest x-ray was consistent with hyaline membrane disease. 2. Cardiovascular: The baby initially received three normal saline boluses and was started on dopamine and required 20 mg/kg/hour of dopamine. Hydrocortisone for replacement on day of life one for blood pressure instability was added. His dopamine ultimately weaned down to 13 mcg/kg/hour. He did not have any signs of patent ductus arteriosis. 3. Fluids, electrolytes and nutrition: The baby was nothing by mouth. As stated previously, had a UAC and a double-lumen UVC line in. Was receiving initially maintenance intravenous fluids, and then was started on hyperalimentation and interlipids for nutritional support. Total fluids started at 140 cc/kg and were advanced based on electrolytes to 180 cc/kg. Dextrose sticks were greater than 60. He did not show any evidence of hyperglycemia or hypoglycemia. Initial electrolytes: 148/5.5/116/16, ionized calcium .96. Maximum sodium on day of life one was 158, and on [3-6] he had electrolytes of 147, hemolyzed potassium of 6.2, chloride of 111, CO2 of 23. Dextrose sticks remained within normal range. 4. Gastrointestinal: Baby did exhibit extreme bruising. Several bilirubins were done. He was under single phototherapy. His maximum bilirubin was 4.5/.4. 5. Hematology: Baby's blood type was B positive, Coombs negative. He did receive one blood transfusion of 15 cc/kg initially after birth because of his hypotension. His subsequent hematocrit was 47.7, and repeat after that was 40.8. 6. Infectious Disease: Initially had CBC done with a white count of 10.8, 23 polys, 4 bands, 59 lymphs, platelets of 216,000. A blood culture was sent, and he was started on ampicillin and gentamicin. His gentamicin levels were a peak of 2 and a trough of 2.2. Blood cultures remained negative. 7. Neurology: Because of his initial perinatal depression and clinical examination and gestational age, head ultrasound was done on day of life one. This was very concerning, and showed diffuse parenchymal echogenic areas bilaterally. On day of life one, baby exhibited seizure-like activity, was loaded with phenobarbital, received 5 mg/kg x 3, and then an additional 10 mg/kg. Neurological examination was abnormal, with little spontaneous movements, no spontaneous respirations, and flaccid tone. After the phenobarbital, the baby still exhibited some intermittent seizure activity. The baby also received fentanyl from his time of birth as needed for pain control. 8. Dermatology: Skin was extremely bruised, with necrotic-looking areas on the right lower leg, and also had abdomen breakdown. Aquaphor was applied. There was extreme bruising diffusely noted in various areas of the body. 9. Family: From prior to delivery through delivery and after delivery, the medical team was very concerned about [Known lastname 4946] long-term prognosis. The team met numerous times with the mother. The father unfortunately was out of town working in [Location (un) 11177]. The family was followed by [First Name4 (NamePattern1) 4457] [Last Name (NamePattern1) 36244], our social worker, while here in the hospital. The couple has been married since [Month (only) 1096]. She had been working in the [Month (only) ] as a project engineer in [Location (un) 11177]. Her husband is presently stationed in [Location (un) 11177], and returned to [Location 86] upon notification of the delivery. The mother no longer works for the [Name (NI) ]. She is originally from [State 2690], but has been living in [State 350] for the past month. Her family lives here as well. The mother also has some friends here, and they have all been in to see her. As stated above, the mother met with Neonatology and felt that she had been well informed, but was very overwhelmed with the events around delivery and making such decisions alone. The father arrived on [3-6] in the morning, and was updated in several meetings on [Known lastname 4946] progress, with the long-term prognosis and serious concerns for devastating sequelae given early manifestations including significant perinatal depression, persistent abnormal neurological examination, diffuse posterior sagittal echodensities on head ultrasound, and seizure activity. The medical team recommended to the family redirection of continuing support. The parents appeared to understand the concerns, and spent the day discussing options with each other, and other family members. Pastoral services were also offered. Over the course of [3-6], the infant remained critically ill. The team continued management, as the family and medical team continued to discuss appropriate levels of intervention. After several meetings with [Known lastname 4946] family, the parents decided to redirect support to comfort measures only with full agreement of the medical team. The family was able to stay with [Known lastname ]. He was extubated at 16:10. The time of death was 17:47. Bereavement and social work information and support has been offered. The parents have declined autopsy. Mother's name is [Name (NI) 13544], father's name is [Name (NI) ] [Last Name (NamePattern1) ], [Name (NI) ]., and the baby's name is [Name (NI) ] [First Name5 (NamePattern1) ] [Name (NI) 1105]. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 36144] MEDQUIST36 D: [2179-3-7] 00:56 T: [2179-3-7] 00:59 JOB#: [Job Number 38691] ICD9 Codes: 769, 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5819 }	Medical Text: Admission Date: [2128-12-30] Discharge Date: [2129-1-12] Service: MEDICINE Allergies: Sulfur / Loperamide Attending:[First Name3 (LF) 710] Chief Complaint: CHF, COPD, NSTEMI, GI Bleed while anti-coagulated for NSTEMI Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a [Age over 90 ] yo F w/ COPD, CRI, hypothyroidism, and hyperlipidemia who initially presented to [Hospital1 18] on [2128-12-30] with COPD exacerbation; her hospital course was complicated by an NSTEMI on [1-2] which was treated medically with heparin gtt, ASA and plavix - she now has had BRBPR, melenotic stool and report of black vomit for several hours. . The patient initially presented with SOB and LE edema similar to two other COPD flares she has had over the last two months. During both admissions she was found to have EKG changes but negative cardiac enzymes. Recent clinic notes document increaing dyspnea despite diuresis, and increased use of supplemental O2 (at first only used intermittently, then usuing it all day) with persistent SOB despite O2 sats in the upper 90's. She was sent to ED by her PCP. . In the [Last Name (LF) ], [First Name3 (LF) ] EKG showed TWI in avl, V5, V6 and slight STE in V1-V3, all stable from previous. Overall stable EKG from [11-29]. BNP was > 15,000 (12,000 in [10-30],000 in [11-30]). She was admitted for COPD exacerbation and being treated with nebs, diuresis, O2. She initially had elevated troponin with flat CK and CKMB; the troponin (0.09-0.2) was thought to be [12-25] renal failure. . On [1-2] patient triggered with episode of chest pain, found to have elevated CK (peak 86), MBIndex (16) and Troponin (2.08) but no new changes on EKG. She was seen by cardiology and placed on heparin gtt, ASA 325, plavix 600mg as well as beta blocker, continued on lipitor 80mg for medical treatment of NSTEMI. TTE ([1-3], full report below) showed EF >60%, mod LVH, Increased PCWP, 1+MR, 1+TR, mod APH, sma pericardial effusion. . On [1-4] patient's heparin was discontinued for PTT 149, she was also orthostatic so lasix, imdur, b-blocker were also held. In the afternoon/evening she had three episodes of BRPBR as well as large melanic stool. Later on the patient's daughter reported an episode of black colored emesis, she later vomited food material. VS were: SBPs in the low 100's, HR in 80's (beta blocked) with O2 sat low 90's on 3-4L nc. Her HCT dropped from 28 on am labs -> 24; received 1L fluids on floor. Multiple attempts at NGT and OGT were unsuccessful, and IV access was tenuous, prompting admission to ICU. . GI fellow was consulted - Patient received 2 units of PRBCs and 1 unit of FFP. Her HCT has been stable in MICU. Her vitals were stable as well. Received lasix IV volume overload after PRBCs. CT abdomen was suspicous for ischemic colitis in [Female First Name (un) 899] region, and tagged red cell scan was negative. Patient and family has refused surgery. Empirically started treating with vanc/levo/flagyl. She was started on Clear diet and is tolerating it. . On transfer to the floor patient denies chestpain, abdominal pain, nausea, vomitting, dizziness, headache, change in vision/hearing, weakness. States that she felt slight SOB during trasportation. Otherwise feels 'fine'. Past Medical History: COPD Hypercholesterolemia depression Right breast cancer s/p R mastectomy 40 y ago Orthostatic hypotension Hypothyroidism Arthritis Age-related hearing loss Urethral stricture Internal and external hemorrhoids GERD s/p hysterectomy s/p appendectomy s/p R carotid endarterectomy Social History: She was a long time smoker with approximately a 40-pack-year history; however, she quit about 20 years ago. There is no alcohol, drug or herbs usage. She lives with her daughter and son in law who help her with medications. She is able to walk on her own and walks to the end of block and back before she gets tired normally. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: Temp: 96.6 BP: 150/70 HR: 85 RR: 24 O2sat 93% on 2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, OP clear NECK: JVP not elevated, carotid pulses [12-26] RESP: [Hospital1 ]-basilar crackles. no wheezes CV: RRR, S1 and S2 wnl, 2/6 systolic murmur heard best a LUSB. ABD: positive BS, soft, tender to palpate in LLQ, no masses or hepatosplenomegaly EXT: warm, DP 2+, trace edema SKIN: multiple echymosis NEURO: Alert and awake. Able to say name, date. Unable to recall the hospital's name. Able to say the city. Able to name president. DF/PF [3-28]. Spontaneously moves BUE. sensation intact. muscle tone wnl. Pertinent Results: Admit Labs: [2128-12-30] 04:05PM BLOOD WBC-9.2 RBC-3.38* Hgb-11.2* Hct-32.8* MCV-97 MCH-33.3* MCHC-34.3 RDW-15.5 Plt Ct-303 [2128-12-30] 04:05PM BLOOD Neuts-79.5* Lymphs-13.1* Monos-5.3 Eos-1.8 Baso-0.3 [2128-12-30] 04:05PM BLOOD Glucose-103 UreaN-35* Creat-2.0* Na-138 K-4.0 Cl-98 HCO3-28 AnGap-16 [2128-12-30] 04:05PM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.6 Mg-2.002/07/08 04:20PM BLOOD TSH-3.3 Cardiac enzymes: [2128-12-30] 04:05PM BLOOD CK-MB-NotDone cTropnT-0.21* proBNP-[Numeric Identifier 58855]* [2128-12-30] 04:20PM BLOOD CK-MB-NotDone cTropnT-0.20* proBNP-[Numeric Identifier 58856]* [2128-12-30] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.14* [2128-12-31] 06:35AM BLOOD CK-MB-NotDone cTropnT-0.14* [2129-1-2] 10:24AM BLOOD CK-MB-NotDone cTropnT-0.09* proBNP-6439* [2129-1-2] 04:45PM BLOOD CK-MB-27* MB Indx-16.0* cTropnT-0.25* [2129-1-3] 02:00AM BLOOD CK-MB-86* MB Indx-15.8* cTropnT-0.76* [2129-1-3] 06:50AM BLOOD CK-MB-80* MB Indx-15.6* cTropnT-1.08* proBNP-6600* [2129-1-3] 04:00PM BLOOD CK-MB-52* MB Indx-13.2* cTropnT-1.90* [2129-1-3] 11:15PM BLOOD CK-MB-29* MB Indx-10.6* cTropnT-2.08* [2129-1-4] 06:58AM BLOOD CK-MB-20* MB Indx-9.7* cTropnT-1.89* [2129-1-5] 06:30AM BLOOD Lactate-1.4 [2129-1-6] 09:14AM BLOOD Lactate-0.8 . ECHO ([1-3]): The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is borderline low (2.4 L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. 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. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. In the absence of a prominent history of systemic hypertension, an infiltrative process (e.g., amyloid, etc.) should be considered. . CXR ([1-2]): Mild cardiomegaly is unchanged. Small bilateral pleural effusions greater on the left have mildly increased. There has been also mild interval increase in left lower retrocardiac opacity, likely atelectasis. There is no overt CHF or pneumothorax. Surgical clips are noted in the neck. Patient post right mastectomy. . GI BLEEDING STUDY [2129-1-5]: No evidence of active GI bleeding. . CT ABD/PELVIS W/O CONTRAST [2129-1-5]: 1. Circumferential thickening of the descending colon extending from the splenic flexure to the descending/sigmoid colon junction, indicating colitis. The differential diagnosis includes ischemia, especially given the degree of calcified atherosclerotic plaque in the abdominal aorta, as well as infectious and other inflammatory causes. The mesenteric vasculature cannot be assessed on this non-contrast exam. There are small amounts of fluid in the left paracolic gutter, but no pneumatosis or free air at this time. 2. Moderate bilateral pleural effusions and small-to-moderate pericardial effusion are not significantly changed since [Month (only) 404] [2128]. 3. Ground-glass opacity in the periphery of the right lower lobe, for which interval CT followup is recommended. 4. Evidence of prior granulomatous infection. 5. Mildly dilated CBD. 6. Left internal iliac artery aneurysm measuring 11 mm. Brief Hospital Course: [Age over 90 ] yoF w/COPD, CRI and cardiac risk factors who initially presented with CHF/COPD exacerbation; she was admitted to MICU with GI Bleed in the setting of anticoagulation for treatment of NSTEMI. ?Ischemic colitis but patient and family does not want surgery. Transfered to floor as her HCT has stabilized. . # GI Bleed: unclear source - patient with BRBPR, melanic stools and report of black emesis; black vomit and melanic stools support an upper GI source whereas bright red blood, history of diverticulosis seen on last colonscopy ([8-30]) as well as internal and external hemorrhoids point towards a lower GI source. CT ABD showed likely ischemic colitis in [Female First Name (un) 899] distribution with fluid in pelvis, negative tagged red cell scan. Ischemic colitis could be [12-25] vascular disease. Unlikely embolic given anticoagulation for NSTEMI. Perhaps also a bleeding diverticula. She has received 1L fluids, 2 BRBC, 1 unit FFP; HCT now stable around 30. Lacate is 0.8. Patient and family agree that she does not want surgery. Appreciated surgery recs. Patient was intially treated with PPI [Hospital1 ]. Held all anticoagulants and antiplatellets. Antibiotics, ampicillin, levofloxacin and flagyl were administered for 2 days. Diet advanced to regular prior to discharge. She does not have active bleeding at the time of discharge. She is hemodynamically stable with benign abdominal exam at the time of discharge. Follow up appointment with primary care doctor [First Name (Titles) ] [Last Name (Titles) 19379]d in one week prior to discharge. Geriatric team, Dr.[Last Name (STitle) ] to follow the patient at [Hospital1 ]. . # NSTEMI: Ruled in by CEs, MB trended down prior to discharge. HCP has preferred medical management to cath. No motion abnormality by ECHO, though marked hypertrophy and likely diastolic dysfunction. Heparin, ASA, and plavix held for GIB as mentioned above. Patient was tolerating metoprolol prior to discharge. . # SOB: patient with recent worsening of dyspnea prior to this admission, in the setting of progressive decline since at least [Month (only) 1096]. Likely component of diastolic dysfunction and COPD exacerbation. Currently saturating well in 2L NC. Restarted on diuretics and tolerated it well. Continued Ipratropium Bromide Neb. Systemic steroids started for COPD flare to be weaned off as out patient. Started on Vantin for possible bronchitis. . # Leukocytosis: Started after receiving systemic steroids. No signs of infection. UA not suspicous for UTI. Urine culture showed no growth. Will start on Vantin for possible bronchitis. Geriatric team, Dr.[Last Name (STitle) ] to follow the patient at [Hospital1 ]. . # Orthostasis: noted on floor [1-4], managed with midodrine chronically. Midodrine discontinued per cardiology recs. . # CRI: baseline Cr of 1.5. At baseline prior to discharge. . # Chronic diarrhea: Resolved prior to discharge. C diff negative. On entecort at home. Started on low dose cholestyramine, to be adjusted according to Geriatrics team as out patient. . # Depression: Continued on out patient celexa. . # Hyperlipidemia: Lipitor uptitrated in the setting of NSTEMI. . # Hypothyroidism: Continued levoxyl . # Code Status: DNR/DNI but otherwise aggressive intervention (central access, pressors ok). . # Communication: with patient and daughter, [Name (NI) ] [Last Name (NamePattern1) ], who is HCP. Phone [Telephone/Fax (1) 58854]. Medications on Admission: Medications at Home: Celexa 10mg qday entocort EC 9 mg q am lasix 20mg qday ipratropium bromide tid levoxyl 88mcg qday lipitor 10 qday midodrine 2.5 mg [Hospital1 ] omeprazole 20 mg qday Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO once a day. 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:40 Tablet(s) Refills:2 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): Hold for SBP < 100 or HR < 60. 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP < 100. 10. Ondansetron 4 mg IV Q8H:PRN 11. Cholestyramine-Sucrose 4 gram Packet Sig: 0.5 Packet PO DAILY (Daily): Please DO NOT admininster this medications with other medications. Packet(s) 12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal bloating. 14. Prednisone 5 mg Tablet Sig: as directed below Tablet PO once a day for 10 days: Please administer prednisone 40 mg daily for 2 days ([1-13] to [1-14]) followed by 30 mg for two days ([1-15] to [1-16]) followed by 20 mg daily for two days ([Date range (1) 58857]) followed by 10 mg ([1-19] to [1-20]) followed by 5 mg ([12/2049] to [1-22]) and then stop. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day: hold for SBP < 100 and HR < 60. 16. Vantin 200 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: Non ST elevation Myocardial Infarction Gastrointestinal bleed Congestive Heart Failure Chronic Obstructive Lung Disease Chronic Renal Insufficiency Discharge Condition: Stable to be discharged to [Hospital1 ] Discharge Instructions: You were admitted with mild volume overload and congestive heart failure. You had a heart attack during this hospital stay. You were started on blood thinners to treat this heart attack. You had gastrointestinal bleeding while on blood thinners. Please continue to follow up with Dr. [Last Name (STitle) 36656] after discharge as below. . Please take medications as instructed below. . If you develop worsening chest pain, shortness of breath, lower extremity swelling, weight gain >2 lbs, bleeding or any other concerning symptoms, please call Dr. [Last Name (STitle) ] or report to the nearest ER. Followup Instructions: You have a follow up appointment made with your primary care doctor, DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 719], on [1-20], [2128] at 4.30 pm. . PREVIOUSLY SCHEDULED APPOINTMENTS: Provider: [Name10 (NameIs) 161] [Name8 (MD) 6476], MD Phone:[Telephone/Fax (1) 2998] Date/Time:[2129-2-3] 11:45 . Please call if you need to reschedule. Completed by:[2129-1-12] ICD9 Codes: 5789, 4280, 5859, 2449, 2720, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5820 }	Medical Text: Admission Date: [2118-9-4] Discharge Date: [2118-9-7] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7333] Chief Complaint: shortness of breath for 1 night, productive cough Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 28030] is an 86 year-old man with a history of non-ischemic CM (EF 30-35%), hx PAF on coumadin and s/p recent successful cardioversion [8-28] followed by initiation of amiodarone, and a history of difficult to control volume status secondary to dietary indiscretion. He is now presenting with respiratory distress for one day and found to be in atrial fibrillation. . Over the past few days he has had increased productive cough of brownish sputum, however, he does mention having this productive cough at baseline. He has not noticed any fevers or chills at home. Last night was particularly difficult for him to sleep because he could not lie flat in bed without feeling short of breath. He denies ever having to sleep in a chair and says the he usually lies on 2 pillows. He feels like he has gained some weight over the past week or so. Otherwise he denies any chest pain or palpitations. He can not feel when he goes into atrial fibrillation unless his rate is really quick. . In the ED, initial VS T 98, BP 126/72, HR 114, RR 20, O2 91% on RA. Exam was notable for bibasilar crackles and irregularly irregular HR. EKG showed atrial fibrillation without ischemic changes. CXR showed evidence of pulmonary vascular congestion and ? RLL pneumonia. O2 Sat fell to 85% on RA and he was placed on high-flow facemask. He received ASA 325 mg, 750 mg IV levofloxacin, and 1 g IV vancomycin and was admitted to the CCU for further managment. . On review of systems, he does have a history of pulmonary embolism and is currently anticoagulated. He denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, 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. He does have dyspnea on exertion. No palpitations, syncope or presyncope. . Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: cath [2109] showing 1. Mild two vessel coronary artery disease. 2. Mild left ventricular diastolic and focal systolic dysfunction. 3. JNC VI Stage 2 hypertension -PACING/ICD: none - chronic systolic CHF - EF 30-35% on [2118-6-27] echo -mild diastolic HF per [2109] cath - paroxysmal atrial fibrillation, s/p cardioversion [2118-8-27] followed by initiation of amiodarone . OTHER PAST MEDICAL HISTORY: - Rheumatoid Arthritis - HTN - ? COPD - HL - DM2 - PE [6-28] found to have multiple sub-segmental PEs, anticoagulated since Social History: Jehovah's witness. Lives alone in [Location (un) 538], widowed. Former smoker (80 pack-year history), quit 50yrs ago, former etoh, no illicit drug use. He worked full time until he was 80 in the truck sales industry. Mr. [Known lastname 28030] is a very meticulous man who keeps lists and charts of his medications and physician [Name Initial (PRE) 10700]. Family History: Noncontributory Physical Exam: T 96, HR 101, BP 100/77, RR 15, 93% on 5L GENERAL: Pleasant, well appearing male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. NECK: JVP visible at jaw CARDIAC: irregularly irregular, tachycardic LUNGS: Crackles [1-21] way up lung fields ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: 1+ edema of ankles and shins, 1+ distal pulses, no calf tenderness. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation and full strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: . CXR [9-4]: UPRIGHT AP RADIOGRAPH OF THE CHEST: There is increased opacity in the right lower lobe. There is cephalization of the pulmonary vasculature. The left lung is relatively well aerated. There is moderate cardiomegaly, stable. Backrgound prominence of interstitial markings, consistent with known interstial disease seen on prior CT is noted, ([2118-7-17]). Aortic arch calcifications are noted. Hilar contours are unremarkable. There is no pneumothorax or appreciable pleural effusion. IMPRESSION: Mild pulmonary edema with more confluent right lower lung opacity, concomitant infection in this region cannot be excluded. . CXR [9-5]: FINDINGS: Since [2118-9-4], increased opacification of the anterior segment of the right upper lobe and of the right lower lobe, consistent with pneumonia or less likely asymmetric pulmonary edema. Unchanged cardiomegaly and cephalization of the pulmonary vasculature. There is no pleural effusion, and there is no pneumothorax. IMPRESSION: Increasing lung opacity consistent with pneumonia, less likely asymmetric pulmonary edema. Unchanged cardiomegaly and pulmonary venous hypertension. . EKG [9-4]: Atrial fibrillation with rapid ventricular response. Delayed precordial R wave transition. Non-specific inferolateral ST-T wave changes. Compared to the previous tracing of [2118-8-23] the ventricular response is faster. . [2118-9-7] 05:55AM BLOOD WBC-7.3 RBC-3.91* Hgb-10.6* Hct-32.7* MCV-83 MCH-27.1 MCHC-32.5 RDW-14.6 Plt Ct-326 [2118-9-7] 05:55AM BLOOD Plt Ct-326 [2118-9-7] 05:55AM BLOOD PT-24.1* PTT-29.2 INR(PT)-2.3* [2118-9-7] 05:55AM BLOOD Glucose-223* UreaN-25* Creat-1.2 Na-136 K-4.2 Cl-99 HCO3-25 AnGap-16 [2118-9-4] 08:12PM BLOOD CK(CPK)-118 [2118-9-4] 07:50AM BLOOD ALT-15 AST-20 LD(LDH)-223 CK(CPK)-132 AlkPhos-53 TotBili-0.4 [2118-9-6] 06:00AM BLOOD proBNP-1850* [2118-9-4] 07:50AM BLOOD CK-MB-3 proBNP-[2040]* [2118-9-4] 08:12PM BLOOD CK-MB-3 cTropnT-<0.01 [2118-9-4] 07:50AM BLOOD cTropnT-<0.01 [2118-9-4] 08:12PM BLOOD %HbA1c-8.2* [2118-9-6] 8:31 am SPUTUM Source: Expectorated. GRAM STAIN (Final [2118-9-6]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. *Blood cultures x2 drawn on [2118-9-4] are pending at the time of this discharge. Brief Hospital Course: This is an 86 yo man with a history of non-ischemic cardiomyopathy and paroxysmal atrial fibrillation s/p successful cardioversion [8-28] presenting with an acute exacerbation of chronic systolic and diastolic congestive heart failure and found to again be in atrial fibrillation. . # Acute on chronic systolic and diastolic congestive heart failure: EF 30-35% on echo [6-28]. Given exam, elevated BNP, CXR, most likely etiology of hypoxia is volume overload. Precipitant seems to be a combination of dietary indiscretion, failure to adjust his home furosemide dosing based on his daily weights, and poorly tolerating atrial fibrillation. No clear evidence of infection. No evidence of ischemia on EKG. - He responded well to diuresis with Lasix 40mg IV and PO. times two doses. He lost about 3 kg from his admission weight and his dry weight seems to be 95 kg. His home dose of Lasix was switched to 40mg once daily from 20mg twice daily. He was also advised to follow a low salt diet and give himself an extra dose of Lasix 40mg if his weight increases 5 pounds above his baseline dry weight. - He will also be discharged on his home dose of olmesartan 40mg, spironolactone 25mg daily was started, digoxin 125mcg every other day was continued. His home amlodipine was discontinued. Referral to the Heart Failure Clinic at [Hospital1 18] was done, he will follow-up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP. . # Atrial Fibrillation: He is currently back in atrial fibrillation, s/p recent cardioversion [2118-8-23]. It is unclear whether reversion to atrial fibrillation may have contributed to volume overload. His INR remained therapeutic on his home Coumadin dosing. His initial rate in atrial fibrillation was up to the 120s so his metoprolol dosing was increased to 50mg twice daily and his home digoxin was continued. His rate then improved to the 70s, but it is unclear whether his rate would have improved with diuresis alone. - He will continue his anticoagulation with alternating coumadin 2 mg and 2.5 mg daily with a goal INR [2-22]. - His digoxin will continue at 125mcg every other day and he will be put on metoprolol succinate 100mg daily for rate control. - He will continue his amiodarone per the loading dose schedule that was given to him by his outpatient cardiologist Dr. [Last Name (STitle) ]. - He will undergo a repeat cardioversion in [3-23] weeks after amiodarone has reached steady state wit Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. . # CAD: 2VD on cath [2109]. Currently, no evidence of active ischemia. - CEs were negative times 2. - His simvastatin dosing was decreased to 20mg given the interaction with amiodarone. - ASA at 81 mg daily should be considered after warfarin dose is stable on full load of amiodarone. . # ARF: His creatinine bumped to 1.3 from his baseline of 1.0. This is probably secondary to poor forward flow from being fluid overloaded. The creatinine trended down to 1.2 prior to discharge. His [Last Name (un) ] was initially held, but was restarted prior to discharge. Spironolactone 25mg daily was newly started in house and he will continue as an outpatient. Labs to check Chem-7, Dig level and INR will be done in 1 week. . # HTN: He remained normotensive throughout his hospital course. He will be discharged on metoprolol succinate 100mg daily, olmesartan 40mg daily, spironolactone 25mg daily. His home amlodipine will not be continued as an outpatient. . # Lactic acidosis: Initial lactate 3.9 with anion gap 15. Likely secondary to hypoxia vs cardiac hepatopathy. The lactate was followed and resolved with diuresis. . # ? RLL consolidation: Most likely represents assymetric volume overload as it improved dramtically on follow-up CXR after diuresis. He did not appear to be infected clinically. He received 1 dose of vancomycin and levaquin in the ED, but his antibiotics were not continued in the CCU. . # DM2: On metformin and glyburide at home. Sugar 300s on admission chemistry panel and A1C=8.2. Metformin was held in the setting of ARF and lactic acidosis, glyburide was also held. He had QID FS and his sugars were covered with ISS. Pt understands that his diabetic control is suboptimal and states he will avoid concentrated sweets at home and will speak to Dr. [Last Name (STitle) ] who manages his diabetes as an outpt. . # hx PE: given subsegemental nature, plan was to continue anticoagulation for 3 months, but he will benefit from long term anticoagulation for his PAF anyway and has tolerated the medication well. Currently therapeutically anticoagulated and he will continue his coumadin at home dose. . # Lung nodules/possible ILD/possible COPD: Had small amounts of reddish brown sputum production consistent with hemoptysis. Multiple pulmonary nodules and mediastinal LAD on CT [7-17] concerning for infection vs neoplasm. Plan was for outpatient follow up for PET CT and possible bronchoscopy with biopsy vs mediastinoscopy for tissue diagnosis. Interlobular thickening seen on CT [7-17] concerning for ILD (has risk factors including RA, hx coal dust and possible asbestos exposure, tobacco). Had an outpatient appointment with Dr. [Last Name (STitle) 1632], but was in house. This was rescheduled to mid-[Month (only) ] but office will call pt at home with an earlier appt. . Dispo: Pt has been a full code here. He is a Jehovah's witness and will not accept blood products. VNA was refused at discharge but as pt is independent, is able to care for himself at home. Medications on Admission: humira 40 mg twice monthly digoxin 125mcg 3x/wk amlodipine-olmesartan 5 mg-40 mg daily vitamin D 50 0000 units 3 times per month finasteride 5 mg daily folate 1 mg daily furosemide 20 mg [Hospital1 ] glyburide 5 mg-500 mg 2 tabs [Hospital1 *] metoprolol tartrate 100 mg daily oxycodone-acetaminophen prn simvastatin 40 mg daily warfarin 2 mg alternating with 2.5 mg QOD omeprazole 20mg daily Vitamin C, beta carotene, calcium, garlic, ginkgo, colon herbal cleanser, Lutein vision formula Discharge Medications: 1. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s)* Refills:2 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Super Calcium-Vitamin D 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): change to 600 mg daily on [2118-9-7] and follow taper as before. 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QOD (). 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QOD (). 13. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO once a day. 14. Glyburide Micronized-Metformin 5-500 mg Tablet Sig: Two (2) Tablet PO twice a day. 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 16. Beta Carotene 30 mg Capsule Sig: 0.5 Capsule PO once a day. 17. Garlic Oil 500 mg Capsule Sig: Two (2) Capsule PO once a day. 18. Ginkgo Biloba 120 mg Tablet Sig: One (1) Tablet PO once a day. 19. Humira 40 mg/0.8 mL Kit Sig: One (1) injection Subcutaneous twice per month. 20. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO three times per month. 21. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: Take additional 40 mg daily if your weight increases 5 pounds . Disp:90 Tablet(s) Refills:2 22. Outpatient Lab Work Please check chem-7, Digoxin level and INR on [2118-9-13] and call results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 7728] Discharge Disposition: Home Discharge Diagnosis: Acute on Chronic Systolic Congestive Heart Failure Atrial fibrillation with rapid ventricular response Hemoptysis Dyslipidemia Acute Renal Failure Diabetes Mellitus Type 2 Discharge Condition: stable Discharge Instructions: You were admitted with congestive heart failure that we think was due to your high sodium diet and your rapid heart rate. You will need to follow a low sodium diet as discussed with you and weigh yourself daily. . You will need to return for a cardioversion in about 3-4 weeks on a Monday or Tuesday. Please call the cardiology intake nurses at [Telephone/Fax (1) 15452] to schedule this when you get home. You will see Dr. [Last Name (STitle) ] at that time. . Medication changes: 1. discontinue your [Last Name (un) 28031] 2. Start spironolactone 25 mg daily 3. Start taking Olmesartan 40 mg daily 5. Continue your amiodarone taper as before 6. Increase your lasix to 40 mg daily. Please take an additional 40 mg if your weight increases 5 pounds from your baseline weight until your weight is back down to 208 pounds. 7. Decrease your Simvastatin to 20 mg daily. 8. Increase your Digoxin to every other day. 9. Your metoprolol was changed to a long acting pill. 10. Stop taking herbal colon cleanse and Vitamin E. . Weigh yourself every morning. If weight >5 lb up, please take an additional 40 mg of your Lasix. . Call [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] or Dr. [Last Name (STitle) ] if you have any trouble breathing, increasing cough, swelling in the legs or trouble lying flat to sleep. Also call for fevers, chest pain, vomiting or any other unusual symptoms. Followup Instructions: Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 7728] Date/time: [9-12] at 3:00pm. . Pulmonology: Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2118-10-5] 10:30 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2118-10-5] 10:10 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4507], MD Phone: ([Telephone/Fax (1) 513] Date/Time: [10-5] at 10:00am. [Hospital Ward Name 23] Clinical Center, [Location (un) 436], [Hospital Ward Name 516], [Location (un) ], [Location (un) 86]. . Heart Failure: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [MD Number(3) 1240]: [Telephone/Fax (1) 13133] Date/Time: Wednesday [9-14] at 10:00am. [Hospital Ward Name 23] Clinical Center, [Location (un) 436]. Completed by:[2118-9-7] ICD9 Codes: 5849, 4254, 2762, 4280, 2724, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5821 }	Medical Text: Admission Date: [2178-3-9] Discharge Date: [2178-3-13] Date of Birth: [2110-6-6] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Admitted for IL-2 treatment Major Surgical or Invasive Procedure: [2178-3-10] Pericardial window via mini L thoractomy History of Present Illness: Mr. [Known lastname 68742] is a 67 yo with metastatic RCCA admitted to begin IL-2 therapy. CSR to confirm central line placement showed enlarged cardiac silhouette, echocardiogram was done and confirmed moderate pericardial effusion and RV diastolic collapse consistent with tamponade physiology. Past Medical History: RCC to lungs on IL-2 cycle 2, HTN, Stress with reversible inf hypokinesis, S/p L adrenalectomy and splenectomy for L adrenal mass, OA Social History: retired professor 3 etoh/day remote pipe smoking Family History: NC Physical Exam: 97.6 81 144/62 28 NAD crackles L base Preop exam otherwise unremarkable. Pertinent Results: [2178-3-12] 01:58AM BLOOD WBC-13.7* RBC-4.11* Hgb-12.6* Hct-38.5* MCV-94 MCH-30.6 MCHC-32.6 RDW-14.0 Plt Ct-695* [2178-3-12] 01:58AM BLOOD Plt Ct-695* [2178-3-11] 03:00AM BLOOD PT-13.4* PTT-24.1 INR(PT)-1.2* [2178-3-12] 01:58AM BLOOD Glucose-114* UreaN-12 Creat-1.1 Na-136 K-4.4 Cl-104 HCO3-24 AnGap-12 Brief Hospital Course: He was taken emergently to teh operating room on [2178-3-10] where he underwent a pericardial window via a left mini thoracotomy. He was transferred to the SICU in critical buit stable condition. He was extubated on POD #1. His neo was weaned to off and he was transferred to the floor on POD #2. He was ready for d/c to home on POD #3 with cardiology and oncology follow up locally. Medications on Admission: lipitor, toprol, asa, glucosamine, chondroitin Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:50 Tablet(s) Refills:0 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 5 days. Disp:10 Packet(s) Refills:0 9. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 weeks. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Tamponade RCC to lungs on IL-2 cycle 2, HTN, Stress with reversible inf hypokinesis, S/p L adrenalectomy and splenectomy for L adrenal mass, OA Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower,no baths, no lotions, creams or powders to incisions. No driving for 2 weeks of while taking narcotic pain medicine. Followup Instructions: Dr. [First Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 68744] 2 weeks Dr. [Last Name (STitle) 665](Oncologist) @ [Hospital 1727] Medical after discharge Dr. [Last Name (STitle) 11907](cardiologist) @ [State 1727] Cardiology after discharge for [State 113] within one month Already scheduled appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2178-4-21] 2:00 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2178-4-13] 3:00 Provider: [Name10 (NameIs) ] LAB TESTING Phone:[Telephone/Fax (1) 128] Date/Time:[2178-3-16] 10:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2178-3-13] ICD9 Codes: 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5822 }	Medical Text: Admission Date: [2179-11-25] Discharge Date: [2179-12-2] Service: Coronary Care Unit CHIEF COMPLAINT: Status post fall. HISTORY OF THE PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old male with history of CA quadriplegia secondary to motor vehicle accident in [2155], but without significant cardiac history, presents status post fall while ambulating in the EMERGENCY DEPARTMENT of [Hospital 21807] [Hospital ] Hospital. He is being transferred from the Emergency Department to the CCU Service for suspected hemodynamically significant chronotropic insufficiency. The patient has been well until the date of admission, when he presented to the [Location 21807] VA Emergency Department with upper respiratory infection symptoms and subjective fevers. As he was being evaluated by the Triage Staff, he reportedly fell forward any unidentified precipitant. He suffered multiple facial lacerations. Responders at the scene noted that he was lethargic, but arousable, with a blood pressure of 63/36, heart rate 55, temperature 97, and normal oxygen saturation. He denied loss of consciousness, light headedness, headache, palpitations, chest discomfort, nausea, vomiting, or shortness of breath. He states that he has fallen a couple of times in the past, but these were attributed by the patient to loss of balance. When asked if the loss of balanced played a part in this fall, he was unable to say yes or no. The patient was placed on dopamine drip and stabilized his blood pressure. Initial evaluation included blood, urine cultures. Skull films were negative. Heard CT did not show evidence of hemorrhage. Cardiac enzymes and EKG were negative for evident signs of ischemia. Neck CT, however, did show evidence of a new C4 to C6 cord compression in the setting of an old disk herniation. He was transferred to the [Hospital1 69] emergency department on the dopamine drip for a MRI of the neck. Heart rate was reportedly stable in the 50s to 60s throughout his [Location 37286] VA stay. In the [Hospital1 69] Emergency Department, the staff attempted to wean the patient from the dopamine. However, he was noted to be become hypotensive to the 60 to 80 systolic range and bradycardiac in the 30s. The EKG tracings during this episode revealed sinus bradycardia with numerous pauses, some as long as two seconds. For this reason, it was suspected that the patient was having chronotropic insufficiency and he was thus referred to the Coronary Care Unit Team for evaluation. Neck MRI, although limited by the patient noncompliance, showed possible evidence of central cord compression. The patient also reported decreased numbness and weakness in his upper extremities; however, he denied any bowel or bladder incontinence, loss of consciousness, palpitations, light headedness, shortness of breath, fever, nausea, vomiting, diarrhea, or dysuria. PAST MEDICAL HISTORY: The patient is status post motor vehicle accident in [2155], complicated by a CA fracture and subsequent quadriplegia. The patient is presently able to walk with a walker; hypertension; cholelithiasis status post appendectomy; ventral hernia, status post transurethral resection of the prostate; osteoarthritis. MEDICATIONS: Aspirin. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives alone. There is no current tobacco or alcohol use. FAMILY HISTORY: History is noncontributory. PHYSICAL EXAMINATION: Examination on admission revealed the following: GENERAL: [Age over 90 ]-year-old male in no acute distress with racoon eyes and new sutured laceration over the right eyebrow. VITAL SIGNS: 97.5; heart rate 75; blood pressure 150/85 on a 7.5 mcg/kg per minute drip of dopamine. Regular rate and rhythm 16; 96% on two liters. Urine output 1500 cc over 8 hours in the ED. HEENT: Bilateral racoon eyes, PERRLA, EOMI, multiple abrasions/lacerations on the forehead. Oropharynx clear. NECK: Neck in collar, no posterior tenderness. CHEST: Chest was clear to auscultation anterolaterally. CARDIOVASCULAR: Normal S1 and S2, bradycardia, no murmurs, rubs, or gallops, diminished heart tones. ABDOMEN: Soft, nontender, positive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGICAL: Oriented to name, place and time. Decreased motor strength in the right upper extremity, [3-11] wrist extension. Left upper extremity: [3-11] tricep extension, hand grip [2-8] in wrist flexion and extension [2-8]. Right lower extremity [4-10]; left lower extremity [4-10]. Toes downgoing on the right, upgoing on the left. Gait not tested. LABORATORY DATA: Studies revealed the white count of 6.4, hematocrit 36.2, platelet count 226,000. Sodium 137, potassium 3.8, chloride 107, bicarbonate 21, BUN 19, creatinine .9; CK of 452, index 1%, troponin .04. EKG from 8 am that morning revealed sinus bradycardia of 56, PR interval 240, QRS 76, and QT corrected 413 with possible P-pulmonale. Rhythm strip in the ED showed sinus bradycardia with numerous sinus pauses, but no evidence of Wenckebach; longest pause two seconds. Neck MRI was inconclusive on admission secondary to patient's claustrophobia and inability to remain in the proper position during the scan. HOSPITAL COURSE: The patient was placed on decadron IV, which was subsequently tapered over a one week period for the question of cord compression. Neurosurgery evaluated the patient and did not feel that he required surgery at that time. They suggested a three to ten week period with a cervical neck collar in place and followup with Dr. [Last Name (STitle) 1327] in three weeks and to continue on the Decadron taper. The MRI was read to show some degenerative changes at the C3 to C6 with resultant spinal canal stenosis with history of prior cervical spinal injury. There was evidence of cord compression at the C3 to C6 levels. CARDIOVASCULAR: The patient presented with bradycardia and hypotension requiring dopamine drip. It is unclear what precipitated this event, but most likely the hypotension and bradycardia counted for the patient fall as opposed to being secondary to fall. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit and maintained on his dopamine drip. .................... were placed at the bedside and the patient was taken off beta blockers and negative chronotropics. He was placed on telemetry overnight. Echocardiogram was done, which showed a mildly dilated left atrium. The left ventricle was normal. There was hyperdynamic left ventricle with an EF greater than 75%, normal RV, moderately thickened and reduced systolic excursion of the aortic leaflets, mild aortic stenosis, no aortic insufficiency, one to two plus mitral regurgitation, 2+ tricuspid regurgitation, mild pulmonary artery systolic hypertension, no effusion. The patient's maximum CK values peaked at 1143, although the MB portion had always remained negative. Therefore, the CK was probably secondary to crush injury versus rhabdomyolysis. Due to negative CKMB and lack of ischemic EKG changes, there was no reason to believe that an ischemic event had occurred. The EKG did show sinus node dysfunction and sinus pause; also a first degree A-V block. The patient was brought to the EP Laboratory for a pacemaker insertion. A DDD pacemaker was placed. No A-V testing or pacing was done or right atrial catheter secondary to patient's delirium and agitation. The patient remained on four microgram of dopamine in the peripheral IV after the pacer insertion. The patient became delirious and agitated in the EP laboratory and immediately upon return to the CCU he was given Haldol for control. The patient had one episode of sustained narrow complex tachycardia up to a rate of 150 with no decrease in the blood pressure or change in mental status. He was given a 2.5 mg IV Lopressor push, which reverted him back to his paced rhythm. The patient was ultimately weaned off dopamine and maintained his pressures after completion of the weaning. The patient was then started on low dose beta blocker when his blood pressure could allow. After being stabilized, the patient, on [2179-11-28] was transferred to the floor. Pacer was functioning well and no cardiac issues were evident following the pacer placement and weaning of pressors. Although, the patient did have two to three episodes of PVC triplets, but a very small amount of ectopy, otherwise he remained asymptomatic. PULMONARY: The patient presented to the [Hospital ] Hospital with the complaints of cough and question of bronchitis. He also displaced increased pulmonary vascular congestion on chest x-ray. The patient was started on Levofloxacin and Flagyl secondary to patient's high risk of aspiration. Sputum gram stain showed greater than 25 PMNs, greater than 10 epithelium, 4+ oropharyngeal flora and 2+ gram-negative rods. Chest x-ray showed no effusion, mild increase in the right lower lobe opacity. No air bronchogram. Questionable loss of partial left diaphragmatic line and question of pneumonia. The patient was maintained on Levofloxacin and Flagyl and had rhonchi and slight wheezing on examination. Therefore, the patient was also placed on Atrovent nebulizers p.r.n. HEMATOLOGY: The patient was transfused one unit of packed red blood cells for hematocrit less than 30. The patient's hematocrit remained stable after this transfusion in the low 30s at the time of discharge. INFECTIOUS DISEASE: The patient presented to [Location 37287] VA secondary to URI symptoms. Urine culture and sputum culture were negative at [Hospital1 188]. HOSPITAL COURSE: He remained during the stay and the white count never went above 9.8, although he did display a bandemia on admission of 8%. The patient had also been on corticosteroids since admission, which may have caused demargination. The patient displaced no signs of systemic infection, except for possible localized bronchitis or pneumonia, which was treated with Levofloxacin and Flagyl. At the time of discharge, the patient was without any cardiac complaints. His DDD pacer had been placed without problems. Neurologically, he had been placed in a hard cervical collar for at least three to ten weeks. He is on a Decadron taper, and he will require neurological rehabilitation as an outpatient. The patient has question of pneumonia versus bronchitis, which is actively being treated with Levaquin and Flagyl and Combivent nebulizers, p.r.n. DISCHARGE DIAGNOSES: 1. Status post DDD pacemaker insertion. 2. Status post cervical spine injury with cord compression. 3. Status post bradyrhythmia. 4. Status post motor vehicle accident in [2155] with C8 fracture and quadriplegia, hypertension, cholelithiasis, status post appendectomy, status post transurethral resection of the prostate, osteoarthritis, ventral hernia. DISCHARGE MEDICATIONS: 1. Lopressor 12.5 mg p.o.b.i.d. 2. Decadron 4 mg p.o.q.12h. times one day, then 3 mg p.o. q.12h. times one days, then 2 mg p.o.q.12h. times one day, then 1 mg p.o. q.12h. times one day and 1 mg p.o.q.d.times one day. 3. Flagyl 500 mg p.o.t.i.d. until [2179-12-4]. 4. Levofloxacin 250 mg p.o.q.d. until [2179-12-4]. 5. Protonix 40 mg p.o.q.d. 6. Heparin 5000 units subcutaneously b.i.d. until the patient is out of bed and mobile. 7. Colace 100 mg p.o.b.i.d.. 8. Enteric coated aspirin 81 mg p.o.q.d. 9. Regular insulin sliding scale. The patient should take a cardiac low-salt, low cholesterol diet. The patient will be discharged to rehabilitation with plans to followup with the Neurosurgery physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 1327] in three weeks. The patient should continue C-collar use for at least three weeks until followup and possibly for a ten-week course in total. [First Name8 (NamePattern2) 2053] [Last Name (NamePattern1) 2052], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 15885] MEDQUIST36 D: [2179-12-1] 15:53 T: [2179-12-1] 16:05 JOB#: [Job Number ] ICD9 Codes: 5070, 2930, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5823 }	Medical Text: Admission Date: [2195-3-7] Discharge Date: [2195-3-11] Date of Birth: [2148-5-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4028] Chief Complaint: Abdominal pain, hypothermia Major Surgical or Invasive Procedure: 1) Arterial line 2) Central venous line /femoral line 3) Patient continued his usual peritoneal dialysis sessions History of Present Illness: Mr. [Known lastname 122] is a 46 year-old male with HIV, Hepatitis B/C, ESRD on peritoneal dialysis who presented to the ED with abdominal pain, constipation and also feeling dizzy with lightheadedness. Called the ambulance for these symptoms. Initial VS 91.1F orally, HR 72, BP initially unmeasurable, RR 20 and 100% oxygen saturation on room air. Exam with clear lungs, RRR, distended abdomen which was soft and full. He refused a rectal exam. CT was obtained given abdominal pain and preliminary read was negative for any acute intrabdominal processes. Right femoral line was placed with some difficulty due to scar tissue. BP remained difficult to assess given severe vascular disease. Repeat VS soon after presentation revealed temperature 96.1F, 75HR, BPs of 59/25-105/47, RR 12, and oxygen saturation was 100% room air. Fingerstick glucose was 123. Patient had potassium repleted with 40 mEq K in 1L NS, with 3 additional L NS. His peritoneal dialysate was sampled and did not reveal evidence of infection. Denies ever having abdominal pain, but more a sense of constipation and "fullness". Systolic blood pressures in ED ranged 74--> 68 --> 90 --> 105. By time of transfer from ED to inpatient setting he was saturating well on RA, eating and requesting more food. Given patient's initial presentation of appearing very unwell, was sent to the ICU for closer monitoring. Upon arrival in the ICU, denied any complaints except a sense of constipation in his abdomen. Upon ROS, patient denied associated nausea, vomiting, fevers, chills, dizziness,dysuria, rash, dyspnea. Confirms he had decreased oral intake for 4 days in the setting of his constipation and has taken an unknown medication for his constipation in the past. Also with partial blindness which is his baseline. States he had one episode of chest pain on day before admission but this improved with sugar as provided in the ED. Denies any exertional component or pain radiation. Past Medical History: HIV Hepatitis B Venous capillary sepsis Venous thromboembolism Depressive disorder & nervousness CMV infection History of tuberculosis ESRD [1-12] HIV - on peritoneal dialysis, followed at [Last Name (un) 4029] in [Location (un) ] on [State ] St. Chronic constipation - on senna PRN h/o XRT at MEEI for SCC in his left ear Hypertension Syphilis in [Month (only) ] l993. CSF showed lymphocytosis. The patient was treated with intravenous penicillin for ten days. Hepatitis C antibody positive SURGICAL HISTORY: PD catheter placement [2190], numerous HD catheters and AV fistulas; all failed Social History: Tobacco [12-12] PPDx 20 years, no ETOH, unemployed and lives alone in an apartment and he has CMA nursing help at home. Family History: Noncontributory Physical Exam: T: unable to obtain initially, BP: 89/64, PR: 67, RR: 13, O2: 100/RA General: Alert, oriented, no acute distress; able to relay history in a coherent fashion HEENT: Sclera anicteric, MM mildly dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, distant heart sounds but no appreciable murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding; bandaged PD wound in LLQ Ext: Warm, nonpalpable distal pulses, no edema; R femoral groin wound noted Neuro: CN II-XII grossly intact; A&O x 3 Skin: Multiple excoriated lesions over entire body, slight crusting; including arms, back Pertinent Results: ADMISSION LABS [2195-3-7] 07:15PM LACTATE-0.9 K+-3.0* [2195-3-7] 03:45PM ASCITES WBC-2* RBC-0 POLYS-8* LYMPHS-17* MONOS-72* MESOTHELI-4* [2195-3-7] 01:42PM LACTATE-3.0* K+-2.4* [2195-3-7] 01:30PM GLUCOSE-93 UREA N-28* CREAT-10.0* SODIUM-137 POTASSIUM-2.3* CHLORIDE-94* TOTAL CO2-27 ANION GAP-18 [2195-3-7] 01:30PM estGFR-Using this [2195-3-7] 01:30PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-1.9 [2195-3-7] 01:30PM WBC-2.3* RBC-4.44* HGB-13.3* HCT-40.0 MCV-90 MCH-30.1 MCHC-33.3 RDW-17.8* [2195-3-7] 01:30PM NEUTS-65 BANDS-0 LYMPHS-29 MONOS-3 EOS-2 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2195-3-7] 01:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2195-3-7] 01:30PM PLT SMR-LOW PLT COUNT-92* [2195-3-7] 01:30PM PT-13.2 PTT-31.1 INR(PT)-1.1 [2195-3-9] BLOOD LABS /HIV CD COUNTS: -WBC: 3.0 Lymph: 26 Abs-[Last Name (un) ]: 780 CD3%: 78 Abs-CD3: 612 CD4%: 35 Abs-CD4: 273 CD8%: 42 Abs-CD8: 328 CD4/CD8: 0.8 ENDOCRINE STUDIES: [2195-3-8] 06:04PM BLOOD Free T4-1.3 [2195-3-9] 04:32AM BLOOD TSH-3.6 [2195-3-8] 06:04PM BLOOD Cortsol-19.2 [2195-3-11] 05:29AM BLOOD Cortsol-17.5 . IMAGING: [3-8] CXR: IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: The patient has had resection of the medial left clavicle, and a vascular graft follows the course of the left subclavian and brachiocephalic veins to the SVC. Mediastinal widening extends to the apices of the chest with thickening of the pleura and may represent treated adenopathy. Heart is mildly enlarged. Lower lungs clear. No pleural effusion. . CT ABDOMEN /PELVIS: IMPRESSION: 1. Cirrhosis with ascites. 2. Atrophic native kidneys wuth hyperdense cystic lesions in the left kidney which do not qualify as simple cysts. These lesions should be watched closly on follow-up exams. 3. PD catheter in place. 4. Probable emphysema at the lung bases. [3-11] -CT HEAD WITHOUT CONTRAST: 1. No definite acute intracranial process. 2. Relatively symmetric, confluent low-attenuation in bihemispheric periventricular white matter, most likely representing chronic microvascular infarction, in a patient with these predisposing conditions; there is no evidence of acute vascular territorial infarction. 3. Extensive fluid-opacification involving the left mastoid air cells, of uncertain duration and clinical significance; this should be closely correlated clinically. 4. Prosthetic right globe with abnormal appearance to the left globe, as detailed above. EKG: Sinus rhythm. P-R interval prolongation. Lateral ST-T wave changes. Modest QTc interval prolongation. MICROBIOLOGY: Blood Cultures 3/28, [3-8] and [3-9], [3-10] all negative to date at time of discharge Peritoneal Fluid: [2195-3-7] 3:45 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [2195-3-7]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2195-3-10]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . DISCHARGE LABS: [2195-3-11] 05:29AM BLOOD WBC-3.5* RBC-3.17* Hgb-9.7* Hct-28.9* MCV-91 MCH-30.6 MCHC-33.6 RDW-18.8* Plt Ct-85* [2195-3-11] 05:29AM BLOOD Neuts-68.3 Bands-0 Lymphs-25.6 Monos-3.6 Eos-2.2 Baso-0.4 [2195-3-11] 05:29AM BLOOD Plt Ct-85* [2195-3-11] 05:29AM BLOOD Glucose-65* UreaN-29* Creat-9.5* Na-142 K-3.0* Cl-104 HCO3-28 AnGap-13 [2195-3-11] 05:29AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.8 Brief Hospital Course: Mr. [Known lastname 122] is a 46 year-old male with HIV, Hep B/C, ESRD on peritoneal dialysis who presented with abdominal pain x 1 day, hypothermia, and hypotension which resolved status-post IVFs. Brief MICU Course: The patient was admitted to the MICU for close observation, although his symptoms of abdominal pain had resolved. His blood pressure did drop to as low as 60s systolic, and he received 2 L NS, and was started on Levophed. He was cultured and covered empirically with Vanco/Zosyn given the hypotension and this was later narrowed to Zosyn alone. He was hypothermic to 92 degrees rectally, and a Bair Hugger was applied. Peritoneal Dialysis was attempted but terminated early given the hypotension. Blood pressure readings were inconsistent so an a-line was placed. Over the course of hospital day 1, the patient's hemodynamics improved and the Levophed was weaned off. TSH and cortisol levels were normal. Throughout this, the patient mentated well and was A&Ox3. On Hospital Day 2 he was called out to the regular medical floor from the ICU for ongoing monitoring. Please see below for problem based summary after transfer to general medical wards. Continued course after transfer out of ICU to medical floor: # Abdominal Discomfort: Continued to deny any active abdominal pain after hospital day 2. Bloated from constipation on admission but he had multiple bowel movements with relief of his sense of "fullness" soon after admission. Oral intake improved daily. Exam revealed a soft, NT abdomen. No noted organisms in peritoneal culture; all cultures NTD thus far, finals pending. Initially had elevated lactate, but this resolved. CT abdomen essentially clear with exception of cirrhosis and ascites and some kidney findings as [Known lastname 4030] below. Probably dehydration from admitted poor PO intake promoted constipation. He was monitored with serial abdominal exams. Aggressive bowel regimen with Senna and lactulose given for regularity of bowel movements. . # Hypothermia / Hypotension: Low blood pressures have stabilized. Still unclear etiology, although likely from his poor PO intake and some mild dehydration. Changes in body temperature unlikely endocrinologic in nature as initial cortisol and TSH were within normal limits, repeat a.m. cortisol added on [3-11] and was also WNL. Some of his borderline low blood pressure shifts may be due to small amount of volume changes with dialysis treatments as well (although PD not HD). Initial infectious workup labs/studies for concerns over looming SIRS/sepsis picture have all been unremarkable to date. History of HIV, HepC, HepB. Latest CD-4 count=273. Leukopenias initially concerning for an acute infection but as he appeared markedly more stable after IVFs and all culture data was unrevealing it was felt hat his low blood cell counts were more likely due to his HIV. Anuric so no urine studies collected. Trended temperatures, improved after he was transferred to the medical floor from the ICU. However, he is still having some more intermittent low temperatures in the 93F range with oral measures. He had a CT head without contrast on the morning of [3-11] to rule out of any hypothamalmic masses/CVAs that may have impacted his ability to self regulate body temperature. Head CT showed no definite acute intracranial process, and relatively symmetric, confluent low-attenuation in bihemispheric periventricular white matter, most likely representing chronic microvascular infarction. Otherwise, it is quite possible that his body temperature is having fluctuations in the setting of his 2L exchanges during peritoneal dialysis with resultant cooling of underlying mesenteric venous bed. Patient's rectal temperature taken on [2195-3-11] but was too low to register on rectal thermometer which had a cut-off of 96F. Vitals today at time of discharge included BPs 98-110/60-80s range, HR 70-100, RR 18 and oxygen saturations at 100% room air. CXR unremarkable for any acute new infiltrates or PNAs although some subtle perihilar area changes should be followed up on a repeat CT/CXR over the next 1-2 weeks time. At time of discharge several cultures were also pending, will plan to follow-up final reports and notify [Hospital1 ] staff of any organisms/infections identified. . # Leukopenia: Likely from his HIV history, appears to be a chronic issue. Initial WBC with slight drop from baseline however to 2.3; PMN 65%, now WBCs up to 3 range. Not neutropenic currently. CD4 is 273. Trended daily CBC with differential/ANC levels, remained stable. Continue Zosyn for now; will complete 7 day course on [2195-3-14]. # ESRD: Continued peritoneal dialysate regimen with daily exchanges. Euvolemic on exam now. Renal team followed while inpatient. Anuric with his ESRD. Continued on Calcitriol 0.25mcg daily, Sensipar 90mg daily, PhosLo TID, and Epogen. He will resume his ongoing PD sessions on transfer. Last BUN/Cr was 29/9.5 respectively at time of discharge. . #Labile affect: Please note that Mr. [Known lastname 122] was refusing multiple medications during his stay and missed a few doses of his antibiotics and a few of his usual daily medications on [3-10]. Also refused a P.M. peritoneal dialysis session on night of [3-10] as well. Patient is alert and oriented x3 and seems to have capacity so team felt he had right to refuse treatment but made repeated efforts to discourage this behavior by reviewing risks/benefits. Team was considering a psychiatry consult near time of discharge as patient's refusal to collect vitals and accept medications was counter to his effective management. He has a noted PMH of depression and anxiety per records. He seemed to perseverate on going back to [Hospital1 ] and expressed that he feels less anxious at [Hospital1 ] as he has been cared for there in past. He may benefit from formal psychiatric evaluation upon return to [Hospital1 ] if this behavior continues. . # Kidney cysts/masses: Please note that routine CT abdomen for workup of abdominal pain showed atrophic native kidneys wuth hyperdense cystic lesions in the left kidney which do not qualify as simple cysts. These lesions should be watched closly on follow-up exams and repeat CT recommended in 2 months. . # HIV: CD4 in [2192-3-10] was 27, now current CD4 count is up to 273. He was continued on outpatient Tenofovir 300mg once weekly. Bactrim DS 1 tab MWF continued. As above, no new acute infections identified. Will plan to follow-up on outstanding final blood culture reports. . # Fluids, Electrolytes & Nutrition: Continued on his peritoneal dialysis; hypokalemia trend noted so he was repleted as needed. Given some magnesium repletion as well prior to discharge. Renal diet provided, good appetite. #Access: Femoral line was placed. Patient with very difficult upper extremity access so team left access with femoral line in place so that he could complete the additional 3 days of his antibiotics. Line appears clean /dry/ intact. Also has left abdominal catheter/peritoneal port for his ongoing peritoneal dialysis sessions. #Prophylaxis: He was continued on a PPI / Pneumoboots / bowel regimen PRN . #Code Status: DNR/DNI confirmed on admission with patient. . . Medications on Admission: (per CMA service 1-[Telephone/Fax (1) 4031]) Bactrim DS 1 tab MWF Epivir 25mg daily Phoslo 667mg 3 tabs TID with meals Tenofovir 300mg (qWeek per CMA service) Zerit 15mg daily Zyprexa 5mg QHS Epogen 10000u SC Qweek Omeprazole 20mg Qday Calcitriol 0.25mcg daily Sensipar 90mg daily Senna 2 tabs QHS Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 2. Lamivudine 100 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily). 3. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 3 days: please complete on [2195-3-14] . 5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO 1X/WEEK ([Doctor First Name ]). 6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once a week. 12. Stavudine 15 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 13. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day: with meals. 14. peritoneal dialysis instructions Peritoneal Dialysis Orders: 4 exchanges/24hrs; 2.5% solution; 2L volume; 4 hr dwell time. Please record daily weights, I/Os, effluent appearance daily. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Primary: Hypotension Hypothermia Constipation . Secondary: HIV Hepatitis B/C End Stage Renal Disease Discharge Condition: Good. At time of discharge the patient had stable blood pressures, and he had no residual complaints of abdominal pain. Constipation had resolved and he was having regular bowel movements. Discharge Instructions: It was a pleasure taking care of you here at [Hospital1 771]. You were admitted with complaints of lightheadedness, low blood pressures, low body temperatures (hypothermia)and abdominal pains. A CT scan imaging study of your abdomen showed no acute new abdominal issues to explain this abdominal pain and your symptoms were likely due to your constipation as you had not had a bowel movement in several days. Once you had medication to help you have a bowel movement you felt better. Multiple lab studies were done and there were no infections found to explain your symptoms. The renal team was called and helped to continue your usual peritoneal dialysis sessions while you were here in the hospital. . Please follow-up with your primary doctor [First Name (Titles) 3] [Last Name (Titles) 4030] below. If you have any additional abdominal pains, fevers, low blood pressures, feelings of dizziness, diarrhea, more constipation, or any additional health concerns please call your primary doctor or notify your covering medical staff at the [Hospital ] Hospital. . Medication Instructions: Antibiotics for broad coverage were added to your daily regimen for a planned 7 days of therapy. Please continue daily Zosyn as prescribed up until [2195-3-14]. -Otherwise you can continue taking all of your usual medications as previously prescribed. - Additional Notes/Instructions: Please follow-up with your doctor for a repeat CT abdomen in 2 months to assess a left sided kidney cystic region that was found on CT. This should be evaluated for any increase in size or signs or concerning features with repeat imaging. Followup Instructions: Please call the infectious disease clinic and your primary care doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], at [Telephone/Fax (1) 4032] to make a follow-up appointment over the next 1-2 weeks time. Completed by:[2195-3-11] ICD9 Codes: 5856, 5715, 4589, 2768, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5824 }	Medical Text: Admission Date: [2160-6-13] Discharge Date: [2160-7-4] Date of Birth: [2080-8-19] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1666] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Percutaneous Nephrostomy Tube Percutaneous Coronary Catheterization History of Present Illness: 79yoF with hx of CABG ([2153]), EF 65%, prior MI, PAF of Coumadin, DM, sinus node dysfunction with hospitalization in [2158], that on [2160-6-12] experienced [9-26] mid sternal chest pain, radiating to her back. Pt reports that the pain felt steady. No SOB, palpitations or diaphoresis. No nausea or vomitting. The patient was subsequently brought to [Hospital6 17032] were she ruled in for a NSTEMI with a peak troponin of 2.14 from 0.05. She is on Coumadin for PAF, her last dose was [6-11] in the PM. Upon arrival to [Location (un) ] the patient received Morphine and Nitro which releived her pain. She was kept there overnight and subsequently transfered to [Hospital1 18] for cardiac catheterization. Cardiac cath was delayed due an increased INR. . Pt also admitted to abdominal pain without dysuria at OSH, +UA and started on Levaquin for UTI. Abdominal U/S revealed L Hydrophrosis. Increased WBC without fevers or CVAT. Past Medical History: #Sinus node dysfunction, #Paroxysmal atrial fibrillation, history of #coronary artery disease, S/P CABG in [2153], #peripheral vascular disease, #status post left AKA in [2153], #status post right TMA, history of #hypertension #diet controlled diabetes #Renal US - Left hydronephrosis #known history of gallstone #CRI #UTI Social History: Pt lives in an [Hospital3 ] facility. She is a widow. She has one son who lives in [Name (NI) ] and one daughter who lives in [Name (NI) 4310]. She denies having a drink in the past 15 years, before that she was a social drinker. She is a former smoker, quit 15 years ago. Physical Exam: VS 98.2F 119/61 18 65 95%RA Gen: Middle aged female lying in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 8 cm. CV: PMI could not be appreciated, RR normal S1, S2. Grade II/VI systolic ejection murmur at the left sternal border. No rubs or gallops. No thrills, lifts. No S3 or S4. Chest: Well healed thoroctomy scar with keloid, no scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Resp: Mild inspiratory crackles [12-20] bilaterally otherwise CTAB, no wheezes or rhonchi. Abd: Soft, morbidly obese, NT/ND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits apprecaited. Ext: No c/c/e. Hyperdactyly of left hand. No femoral bruits appreciated. AKA of left, TMA on right. Tenderness to palpation on dorsal aspect of right foot. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Back: No CVA. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 1+ Left: Carotid 2+ Pertinent Results: Pertinent Labs from OSH: Troponin 2.14->1.62 WBC 16.0 -> 12.1 Cr 2.2. -> 2.1 INR 1.9 Amylase 109, Lipase 26 UA +Leuk Est, +Nitrites BCx ([6-12]) - [1-19] E.coli, pansensitive . CT abd/pelvis [6-14] - 1. Moderate left-sided hydronephrosis with an obstructive stone at the left ureteropelvic junction measuring 13 x 8 mm. Smaller stone in the left lower renal pelvis measuring 7 mm. 2. Nonobstructive stone on the right measuring 4 mm. . Renal U/S: [6-15] FINDINGS: The right kidney is normal measuring 8.9 cm. There is no right hydronephrosis. The left kidney measures 8.5 cm with mild hydronephrosis with the renal pelvis measuring approximately 1.7 cm. The bladder is collapsed with a Foley catheter. There are no obstructive stones noted on US. IMPRESSION: Both kidneys are relatively small in size, with mild left hydronephrosis. . [2160-6-18] Pmibi stress test - - No anginal symptoms or ischemic ST segment changes. Transient drop in heart rate noted post-infusion (? related to medication or SA Node dysfunction or ?combination of both). Nuclear report sent separately. - Moderate fixed perfusion defects involving the inferior wall and inferolateral base. No reversible ischemia. EF preserved, 51%. . Ct abd/pelvis: [6-21] There is bibasilar atelectasis, more extensive on the right than left, with a small right pleural effusion. Marked coronary artery calcifications are present. Within the limitations of a non-contrast study, the liver is unremarkable. The pancreas is atrophic. The adrenal glands and spleen are within normal limits. The left kidney is again larger than the right and again shows a persistent nephrogram. Medial to the left kidney are foci of air and hemorrhage, similar in extent. However, although there is fat stranding about the left kidney and proximal course of the ureter, there is no fluid collection or ascites. Although retention of contrast is noted in the cortex of the right kidney, a much denser persistent nephrogram on the left is present, as before. There is a stone in the left renal collecting system of 7 mm in diameter and another of 7 mm at the left ureteropelvic junction. A nephrostomy tube is in an unchanged position, terminating immediately above the ureteropelvic junction. The stomach, small and large bowel are within normal limits. There is no lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is within a collapsed bladder. There a few uterine calcifications attributable to fibroids. The rectum and sigmoid are unremarkable. There is no lymphadenopathy. Stranding is again present along the course of the left ureter up to the pelvic brim. BONE WINDOWS: There are no suspicious lytic or blastic lesions. Degenerative changes are noted in the lumbar spine with large osteophytes. IMPRESSION: 1. Pigtail catheter terminating shortly above the ureteropelvic junction, above the site of a known UPJ stone. 2. Persistent asymmetric nephrogram, with a greater degree of cortical contrast retention on the left than right, as before. . CXR [6-23]: In comparison with study of [6-20], there is progressive clearing of the lower lung zone with some residual atelectatic change. The possibility of some pleural fluid at the right base cannot be excluded. No focal pneumonia. . Microbiology: multiple negative blood cultures UA: positive with large leuk, nitrite positive, moderate bacteria, WBC 34, RBC 6 Ucx: - neg on [6-13] - proteus 10,000- 100,000 URINE CULTURE (Final [2160-6-25]): PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2160-6-26] 08:49AM 15.5* 3.37* 9.2* 28.7* 85 27.4 32.1 14.8 333 Source: Line-central [2160-6-25] 05:45AM 27.5* 3.59* 9.9* 31.3* 87 27.6 31.7 15.0 378 Source: Line-Left IJ [2160-6-24] 05:28AM 22.7* 3.95* 10.8* 33.5* 85 27.4 32.3 15.1 396 Source: Line-LIJ [2160-6-23] 07:44AM 22.1* 4.10* 11.7* 35.1* 86 28.5 33.3 15.4 394 Source: Line-unh30JLC [2160-6-22] 06:30AM 20.6* 3.90* 10.9* 32.9* 84 27.9 33.1 15.7* 444* [2160-6-21] 05:39AM 25.0* 4.00* 11.1* 33.4* 84 27.8 33.2 15.5 474* Source: Line-left tcl [2160-6-20] 03:00AM 21.2* 3.78* 10.6* 32.0* 85 28.1 33.2 15.5 365 Source: Line-central [2160-6-19] 09:03PM 23.1# 3.79 10.6* 31.7* 84 27.9 33.3 15.5 372 Source: Line-central [2160-6-19] 08:15AM 14.9* 3.66* 10.4* 31.4# 86 28.4 33.1 15.1 306 Source: Line-left IJ [2160-6-18] 10:25PM 22.0 Source: Line-left IJ [2160-6-18] 09:40PM 21.8* Source: Line-left IJ [2160-6-18] 07:37AM 21.1* 3.23* 8.6* 27.2* 84 26.8* 31.8 15.4 417 Source: Line-LIJ [2160-6-17] 07:00AM 19.6* 3.65* 9.8* 31.0* 85 26.7* 31.4 14.2 432 [2160-6-16] 07:35PM 31.2* Source: Line-left CVL [2160-6-16] 02:32PM 13.9* 3.45* 9.6* 28.9* 84 27.8 33.1 14.7 392 Source: Line-central [2160-6-16] 03:41AM 15.0* 3.55* 9.6* 29.6* 83 27.2 32.6 14.1 357 Source: Line-central [2160-6-15] 05:56AM 13.2* 3.71* 10.1* 30.8* 83 27.1 32.7 14.7 370 Source: Line-left TCL [2160-6-14] 07:37AM 12.5* 3.74* 10.2* 31.7* 85 27.3 32.3 14.2 341 . Glucose UreaN Creat Na K Cl HCO3 AnGap [2160-6-26] 01:00PM 108* 34* 2.0* 139 3.4 105 24 13 Source: Line-IJ [2160-6-26] 08:49AM 191* 37* 2.1* 137 3.4 105 23 12 Source: Line-central [2160-6-25] 05:45AM 96 45* 2.5* 146* 4.2 112* 23 15 Source: Line-Left IJ [2160-6-24] 02:08PM 106* 43* 1.8* 145 4.0 111* 25 13 Source: Line-Central [2160-6-24] 05:28AM 98 42* 1.8* 145 3.6 111* 24 14 Source: Line-LIJ [2160-6-23] 01:56PM 156* 50* 2.1* 147* 3.8 111* 25 15 Source: Line-Central [2160-6-23] 07:44AM 108* 50* 2.2* 147* 4.4 111* 24 16 Source: Line-unh30JLC [2160-6-22] 05:39PM 365* 65* 3.2* 143 3.0* 106 24 16 Source: Line-LIJ triple lumen [2160-6-22] 02:49PM 413* 66* 3.2* 144 3.0* 107 25 15 Source: Line-IJ [2160-6-22] 11:16AM 284* 69* 3.4* 149* 3.1* 113* 26 13 Source: Line-IJ [2160-6-22] 06:30AM 130* 73* 4.1#1 1542 3.3 115* 26 16 [2160-6-21] 05:39AM 126* 76* 5.5* 147* 3.5 108 23 20 Source: Line-left tcl [2160-6-20] 03:54PM 278* 76* 5.8* 145 3.7 110* 19* 20 Source: Line-central [2160-6-20] 03:00AM 134* 72* 5.4* 147* 4.2 110* 21* 20 Source: Line-central [2160-6-19] 09:03PM 150* 69* 5.4* 145 4.5 110* 18* 22* Source: Line-central [2160-6-19] 08:15AM 108* 63* 4.8* 143 5.3* 111* 18* 19 Source: Line-left IJ [2160-6-18] 07:37AM 86 59* 4.2# 142 4.8 109 21* 17 Source: Line-LIJ [2160-6-17] 07:00AM 100 52* 3.1* 143 5.1 109* 22 17 [2160-6-16] 02:32PM 45* 2.2* Source: Line-central [2160-6-16] 03:41AM 96 46* 2.3* 140 4.4 107 24 13 Source: Line-central [2160-6-15] 05:56AM 92 38* 2.1* 142 4.5 108 24 15 Source: Line-left TCL [2160-6-14] 07:37AM 80 40* 2.1* 143 4.4 108 25 14 . [2160-6-22] 06:30AM ALT 15 AST18 LD220 AlkP 138* Tbili 0.5 Lipase 26 Trop 0.14 Brief Hospital Course: 79yo female with hx of CABG ([2153]), EF 65%, PAF on Coumadin, and DM who was transferred from an OSH with a NSTEMI, found to have bacteremia and Lt hydronephrosis secondary to an impacted stone complicated by acute on chronic renal failure now s/p ureteral stent placement. . #. CAD - Patient with known CAD, S/P CABG [2151]. + Troponins at OSH. Patient has not had chest pain since admitted. The initial plan was for her to go to cath, however as she was bacteremic we decided to treat her medically with heparin, ASA, Beta blocker, statin, and ACEi. On [6-18] she underwent a P-Mibi stress test which showed no reversible ischemia. As she developed acute on chronic renal failure, we held her acei which was restarted prior to discharge. . #. Pump - PMIBI in [1-25] EF 65%. Initially she was euvolemic on exam with no signs of increased JVD, trace crackles [12-20], and no edema. Pt was normotensive. On Wednesday night ([6-18]) she received 2 units FFP, 2 units PRBC in conjuction with decreased UOP and acute renal failure and started looking volume overloaded with crackles b/l on exam and new O2 requirement, and requried 5 L to maintain sats in the low 90's. In the setting of increased O2 requirement, decreased BP, and her retroperitoneal bleed, the patient's amlodipine, isosorbide mononitrate, and metoprolol were held on the morning on [2160-6-19]. She was transferred to the MICU as it was thought she would need dialysis and renal wanted to use CVVHD, however once at the MICU her urine output picked up and she was able to maintain her oxygen sats on oxygen. Once back on the floor, she was weaned off the oxygen and sating in the high 90's on room air. . #. Rhythm - Pt with hx of PAF and sinus node dysfunction, admitted in NSR. We initially continued the patient on her beta blocker and calcium channel blocker. As she developed acute on chronic renal failure the disopyramide was at first renally dosed, and then dc'ed on [6-17] (but she got some at her PMibi on [6-18]). On the morning of [6-19] she was found to have a junctional rhythm with HRs in the high 40's maintaining her BP. We held her B-blocker and CCB at this time. She was restarted on the B-blocker on [6-21]. Since this time she has remained in NSR with HR 60's, except for occasional regular irregularity which was likely caused by runs of premature atrial contractions. She was restarted on her norpace ([7-2]) when her ARF had resolved. Coumadin was held for procedures and she was intermittently on a heparin drip. Heparin drip was also held after retroperitoneal bleed but then restarted when her HCT stabalized. After ureteral stent placement, she was restarted on heparin for bridge to coumadin. On [7-4] her INR reached 2.0 and her heparin drip was stopped. She will need her INR checked frequently until it stablely ranges between 2.0-3.0. . # Bacteremia/ Pyelonephritis - The patient was found to grow pansensitive E. coli [1-19] from [6-12] BCx(OSH). Pt had + UTI with WBC of 16 which decreased to 12. New L hydronephrosis confirmed on U/S and 1.3 x 0.8 stone seen obstructing the Lt ureter. We think her bacteremia was secondary to her hydronephrosis in the setting of obstructive nephrolithiasis. She was treated with levaquin q48h and switched to ciprofloxacin and then back to levaquin. BCx from [6-14], [6-16], [6-18], [6-19], and [6-23] are no growth/ NGTD. The patient has remained afebrile. Her WBC remained elevated in the low to mid 20's throughout most of her stay. She had the inital perc nephrostomy attempt on [6-16] which may have drained some of the pus. A second attempt took place on [6-18] which resulted in a small retroperitoneal bleed with HCT drop. She was transfused 2 units, heparin drip was held and her HCT were followed closely. HCT remained stable. On [6-19] IR placed a nephrostomy tube using CT-guidance. However the tube did not drain well and was removed on [6-24]. On [6-25] the patient went for stone removal and stent placement by urology. Urology was unable to remove the stone via laser and placed a stent. Repeat Ucx revealed proteus resistant to floroquinolones; she was switched to ceftriaxone. She had a PICC placed to receive 14 days of ceftriaxone. After antibiotics and resolution of acute pyelonephritis/bacteremia, she should be seen in urology for repeat attempt at stone removal vs lithotripsy. An appointment has been made for her with Dr. [Last Name (STitle) ] [Last Name (STitle) ] follow up. Her WBC dropped from 27 to 15 after stent placement and continued to trend down to 12. . # Acute on chronic renal failure: The patient has a baseline Cr of appromiately 2. Once the stone was visialized, urology was consulted, however they did not feel comfortable with surgical stone removal due to the risk of sepsis as she was already bacteremic, they recommended IR doing a percutaneous nephrostomy. After the first perc nephrostomy attempt on [6-16](during which she had an episode of hypotension) her Cr began rising and she developed acute renal failure likely due to ATN versus obstructive uropathy. On Wednesday we reultrasounded her left kidney and saw reaccumulation of the fluid, so a second perc nephrostomy was attempted, however they were unable to place a tube. We followed her electrolytes and volume status and on [6-19] consulted nephrology as we anticipated that she might need dialysis. As her Cr rose to from 3.1 to 3.4 to 4.8 and her urine output droped from 800 to 400 to very little. The patient was given in succession 60mg lasix iv, 100mg lasix iv, then 200mg lasix iv with no significant urine output following the blood cell transfusions on [6-19]. She was transferred to the MICU as it was thought she would need dialysis and renal wanted to use CVVHD, however once at the MICU her urine output picked up and her Cr peaked around 5. From [6-20] to [6-24] her Cr continued to decrease to 1.8, but then rose to 2.5 on [6-25]. Urology place a ureteral stent. Her cr trended down to her baseline of 1.4-1.6. . # Anemia - The patient has chronic anemia, likely secondary to CKD with a baseline Hct of approximately 31. After the second percutaneous nephrostomy attempt, the patient developed a retroperitoneal bleed on [2160-6-18] with a HCT drop from 31 to 21.9. The patient was also noted to be hypotensive with SBPs 90s and HR 40s-50s. A noncontrast CT showed a bleed along her iliopsoas. Patient was given 3 units of packed red blood cells [6-19], and vitamin K 10mg [5-19], and 5mg [5-20]. The patient's hematocrit responded well and her HCT was 31.4. Over [6-26] to [6-28] her Hct slowly declined from to 26.1 and in the setting of chest pain overnight on [6-27] she was transfused 2 units PRBC on [6-28] and a noncon CT of her abd/pelvis was completed to look for intrabdominal bleeding. Her heparin gtt and coumadin were also stopped. Once her Hct stabilized again her heparin gtt and coumadin were restarted until her INR was therapeutic at 2.0 and then only coumadin was continued. . # Hypernatremia: Peak sodium 154 w/o mental status changes. Given poor PO intake and mild post-ATN diuresis, this was thought to be due to free water deficit. Her sodium improved with repletion of free water deficit. Free water intake needs to be encouraged. . # Leukocytosis: [1-19] to pyelonephritis. CXR showed no PNA. Blood Cultures after the initial E.coli from the OSH were all negative. C.diff x1 negative but no diarrhea. LFT's normal. Peaked at 27 and then trended down after ureteral stent placement. . # Right upper extremity DVT - patient developed swelling in her RUE on [6-29] and was found on US to have a nonocclusive thrombus at her PICC site. The PICC was pulled and she was restarted on her heparin drip. . # DM: The patient's glucose has been well-controlled on SSI. . # Access: It was extremely difficult to establish access. She had a left internal jugular central line placed and in anticipation of dialysis a right non-tunneled HD catheter. Dialysis line and IJ were pulled prior to discharge. PICC line was placed for IV antibiotics for on the right side, now on the left as she developed a right DVT. Medications on Admission: OUTPATIENT MEDICATIONS: Norpace CR 100-mg [Hospital1 ], Imdur 90-mg/day, Norvasc 5-mg [Hospital1 ], Lisinopril at an unknown dose, Simvastatin at an unknown MEDICATIONS ON TRANSFER: EC ASA 325mg PO Daily RISS LEVAQUIN 250mg IV Q24 (Day 1) PRILOSEC 20mg PO BID CARAFATE 1gm PO QID NORVASC 5mg PO BID NORPACE CR 100mg PO BID ISOSORBIDE 90mg PO QAM LISINOPRIL 10mg PO QAM SIMVASTIN 80mg PO QPM COUMADIN (Held since 6/25pm) NITROPASTE 1 inch q6 HR Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Phenergan 25 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. 11. Insulin give insulin as per attached sliding scale 12. Outpatient Lab Work Monitor INR every other day and adjust coumadin as needed to keep INR 2.0-3.0 13. PICC line care PICC line care as per protocol. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: adjust dose to maintain INR 2.0-3.0. 15. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 5 days: day 1 is [2160-6-25], will need a total 14 day course to end on [2160-7-8]. 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:0 18. Disopyramide 100 mg Capsule Sig: One (1) Capsule PO Q 12H (Every 12 Hours). 19. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 20. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 21. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) Units Injection QMOWEFR (Monday -Wednesday-Friday). Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: Primary- NSTEMI Urinary Obstruction/ Hydronephrosis Pyelonephritis Bacteremia Acute renal failure Junctional Bradycardia due to Norpace toxicity (in the setting of renal failure) Retroperitoneal Bleed Right upper extremity deep venous thrombosis Secondary - Diabetes Mellitis, type II Hypertension Discharge Condition: improved Discharge Instructions: You were admitted for a heart attack for which you received medications. You were also found to have a kidney stone that was blocking your kidneys leading to acute renal failure and kidney infection. A stent was placed in your urinary tract system to drain the kidney. You were also given antibiotics. . Because of your impaired renal function, your medications lisinopril and norpace were held. You will need to restart these medications in the future. . If you have fever, chills, rising WBC count or chest pain, you should return to the emergency room. Followup Instructions: You will need to have your renal function, white blood cell count and INR monitored. . Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 1911] (cardiology) [Telephone/Fax (1) 62] [2160-9-4] 2:40 pm Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] (urology) [Telephone/Fax (1) 921] [2160-7-9] 3:30am Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 12982] (primary care) [Telephone/Fax (1) 62842] [2160-7-17] 11:15am. Fax number: [Telephone/Fax (1) 15181] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673] Completed by:[2160-7-4] ICD9 Codes: 5849, 2851, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5825 }	Medical Text: Admission Date: [2185-4-28] Discharge Date: [2185-5-5] Date of Birth: [2110-7-2] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 3298] Chief Complaint: Recurrent gastrointestinal bleeding. Major Surgical or Invasive Procedure: EGD/Colonoscopy Interventional radiology duodenal artery embolization History of Present Illness: Mr. [Known lastname 58316] is a 74M with hx of COPD, dCHF, HTN, recent admission to [Hospital3 3583] for GI bleed, transfered from [Hospital3 3583] after being admitted [2185-4-25] again for rectal bleeding. Patient reported episodes of loose bowel movements mixed with blood around 2pm on [2185-4-25]. He reports a toilet bowl full of bright red blood that day, then two large melenotic stools the following day, [2185-4-26]. He denied any chest pain, shortness of breath, DOE, symptoms of orthostasis or presyncope. At OSH, he was started on protonix drip and seen by Gastroenterology. His Hct dropped to 26 (from 31), so he was transfused 1u pRBCs, after which his Hct bumped appropriatedly to 29. EGD both last month showed a visible pulsatile vessel in duodenum with no ulcer, which underwent successful epinephrine injection and Endo clip, and appeared to be at high risk for rebleed. During this hospitalization, patient underwent repeat EGD on [2185-4-26] which again showed pulsatile vessel with small clot on it, felt to be arterial, no evidence of active bleeding, and it again responded to epinephrine injection and was clipped with no further bleeding. There was discussion with gastroenterology about potential surgical treatment. When he was admitted last month, he did admit to some lightheadedness and had noted both melena and hematochezia. Currently, patient feels well without complaints. He has not had a bowel movement in 2 days. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: COPD, continued tobacco use Chronic dCHF Hypertension Hyperlipidemia GERD, doudenitis, gastritis - H. Pylori s/p treatment - Hx Schatzki Ring - Hx of recent hospitalization for GI bleeding [2185-3-28] Osteoarthritis Prostate cancer s/p prostatectomy Social History: Married. Retired. Tobacco: smokes a few cigarettes/day. Denies hx of ETOH abuse. Family History: Father died in 90s. Mother died at age 74 due to aneurysm rupture Physical Exam: ON ADMISSION: Vitals - 98.2 157/80 66 18 99%RA GENERAL: alert, oriented x3, pleasant, no acute distress, well appearing HEENT: dry mucus membranes, pink conjunctivae (just mildly pale), no scleral icterus CARDIAC: reg rhythm, normal rate but muffled heart sounds LUNG: clear to auscultation bilaterally ABDOMEN: soft, mildly distended, nontender EXT: no peripheral edema NEURO: CN III-[Last Name (LF) ], [First Name3 (LF) 81]-XII intact (cannot hear finger rub on either side) PSYCH: Listens and responds to questions appropriately, pleasant On Discharge: Exam is stable and unchanged from discharge. Pertinent Results: LABS ON ADMISSION: [2185-4-28] 10:40PM BLOOD WBC-9.5 RBC-3.62* Hgb-10.6* Hct-32.4* MCV-90 MCH-29.2 MCHC-32.6 RDW-15.0 Plt Ct-237 [2185-4-28] 10:40PM BLOOD PT-11.7 PTT-29.2 INR(PT)-1.1 [2185-4-28] 10:40PM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-140 K-3.8 Cl-105 HCO3-24 AnGap-15 [2185-4-28] 10:40PM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8 IMAGING & STUDIES: EGD [2185-5-2]: Impression: Schatzki's ring Nodularity and congestion in the stomach compatible with gastritis A 2-3mm visible vessel was seen in the duodenal bulb. Gold probe was applied for thermal therapy. The lesion then began to bleed in a pulsatile manner. The lesion was injected with 8ccs of epinephrine. An endoclip was applied in an attempt to achieve hemostasis. There was residual oozing of bright red blood around the area of the clip with poor visualization. With 2 additional ccs of epinephrine the bleeding subsided. There was no clear location in which to place an additional clip. Angioectasias in the duodenal bulb Otherwise normal EGD to third part of the duodenum [2185-5-2] IR embolization imaging: 1. No evidence of active arterial extravasation from the gastroduodenal artery or its branches on DSA arteriogram of the gastroduodenal artery. 2. Successful retrograde coil embolization of the gastroduodenal artery, resulting in occlusion/flow stasis. [2185-5-2] Post line placement: R PICC in mid-SVC LABS ON DISCHARGE: [2185-5-5] 05:46AM BLOOD Hct-28.3* Brief Hospital Course: This is the brief hospital course of a 74 year-old male with chronic obstructive pulmonary disease, chronic diastolic heart failure, hypertension, and recurrent GI bleeds who was admitted this hospitalization from [Hospital3 3583] following a GI bleed. Over the course of the first two hospital days at [Hospital1 18], the patient did not have any bowel movements. On HD #3, he was noted to have 2 frankly melanotic bowel movements. GI was consulted and a plan was established to perform an EGD and colonoscopy the following day, [2185-5-2]. During the procedure, the patient began to demonstrate pulsatile bleeding from his presumed duodenal artery that was not responsive to cauterization, epinephrine injection, or clipping. The patient was transferred to the MICU on HD #4 ([2185-5-2]) for closer monitoring with plans to undergo IR embolization of the bleeding artery at the next possible time. PICC line was placed for better IV access. He successfully underwent IR-guided retrograde coil embolization of the greater duodenal artery on HD #5 ([2185-5-3]). After this his HCT remained stable around 28-29, and he remained hemodynamically stable with no further episodes of bleeding until his transfer back to the floor on [2185-5-4], HD #6. He was kept overnight (to abide by 72 hour inpatient regulations following active GI bleed) until [2185-5-5], HD #7, when he was discharged home in good condition, with no evidence of active bleeding. The patient's home PPI dose was increased to 40mg twice daily. He was given stool softeners to be taken at home as needed. He will follow up with his primary gastroenterologist, who was informed of this course by the inpatient GI team. Additionally, IVs placed at [Hospital3 3583] in the patient's RIGHT arm as well as one on the LEFT arm were infiltrated on his arrival to [Hospital1 18]. Hot packs were used to alleviate pain and sweliing. On the day of discharge, these were resolved. INACTIVE ISSUES THIS ADMISSION: # COPD - duonebulizers were given prn # Hypertension - home amlodipine and atenolol were held as patient was normotensive while in house, did not discharge on either medication, will follow-up with PCP for restart # Hyperlipidemia - continued home simvastatin 20mg Qday # Tobacco Use - encouraged smoking cessation and offered nicotine patch prescription The patient was informed that he should still have a screening colonoscopy performed as part of his regular health maintenance in the near future as the studies done this admission were not adequate for this screening. Transitional Issues: -Amlodipine and Atenolol were held at discharge. -Patient will need screening colonoscopy in the future as he has not had this. Medications on Admission: Multivitamin Simvastatin 20mg omeprazole 20mg atenolol 50mg daily norvasc 10mg daily Discharge Medications: 1. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day. Disp:120 Tablet, Delayed Release (E.C.)(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: upper gastrointestinal bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred from another hospital because of a repeat upper gastrointestinal bleed. Here, you were observed and underwent an endoscopy where you were found to have a visible vessel that bled, so you were transferred to the medical ICU and underwent interventional radiology-guided embolization of a blood vessel to stop the bleeding. Now you have been stable for 3 days without any further episodes so you are being discharged home with plans to follow up with your Gastroenterologist and your Primary Care doctor. We made the following changes to your medications: -INCREASED Omeprazole to 40mg twice a day -STARTED Colace and Senna for constipation prevention -HOLD Norvasc and Atenolol as blood pressure has been controlled in the hospital, your PCP may restart these medication at your follow-up appointment on [2185-5-9]. Followup Instructions: PRIMARY CARE Name: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 73838], NP (works with Dr [Last Name (STitle) 42306]) Location: [Location (un) ]-[Location (un) ] PRIMARY CARE Address: [Apartment Address(1) 112058], [Location (un) ],[Numeric Identifier 40624] Phone: [Telephone/Fax (1) 13266] Appt: [5-9] at 3pm *Note: we asked your to HOLD Norvasc and Atenolol as your blood pressure has been controlled in the hospital, but please discuss this at your PCP visit because your PCP may restart these medication at your follow-up appointment on [2185-5-9].* GASTROENTEROLOGY Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: DIGESTIVE DISEASE ASSOCIATES Address: [Last Name (un) 91681], [Location (un) ],[Numeric Identifier ] Phone: [Telephone/Fax (1) 85660] Appt: Pending, if you do not hear about appt by Friday @ noon, call. *Please note that you should have a colonoscopy for routine colon cancer screening.* Completed by:[2185-5-5] ICD9 Codes: 5789, 4280, 496, 2851, 4019, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5826 }	Medical Text: Admission Date: [2133-4-30] Discharge Date: [2133-5-1] Date of Birth: [2133-4-30] Sex: F Service: NB IDENTIFICATION: Baby Girl [Known lastname 2433] is a 1 day old former 31 [3-21] week infant with recurrent Atrial Flutter and Hydrops who is being transferred from [Hospital1 18] NICU to [Hospital3 1810] Cardiac Intensive Care Unit. HISTORY: Baby girl [Known lastname 2433] is a 31-4/7 week gestation female infant admitted to the newborn intensive care unit because of prematurity and a prenatal diagnosis of fetal tachycardia and hydrops. This mother is a 35-year-old gravida 2 para 0 now 1 mother. Prenatal screens: Blood type A positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group beta strep status unknown. Chlamydia, HIV and GC cultures negative. This pregnancy was complicated by the development of maternal hypertension noted 3 days prior to delivery when she was admitted to [Hospital ] Hospital. Fetal assessment revealed fetal tachycardia and hydrops and the mother was transferred to [Hospital1 346] for further care. A fetal echo done after admission to [Hospital1 69] revealed intermittent fetal tachycardia sometimes with rates into the 270 range. Also noted was moderately severe ascites, mild pleural effusions and scalp edema and polyhydramnios. The mother was evaluated by Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] of the cardiology electrophysiology team at [Hospital3 1810] and maternal treatment with digoxin was initiated. The mother was also treated with flecainide. Because of worsening pregnancy induced hypertension and concern for persistent fetal tachycardia, the baby was delivered by cesarean section. The infant emerged with cry and some good respiratory effort. She was bulb suctioned and intubated orally and was noted to have equal breath sounds. Apgar scores were 7 at one minute and 8 at 5 minutes of age. EXAM: Initial exam notable for an LGA infant with moderate edema and significant ascites. Wt was 2765 gm, length was 41.5 cm, and HC was 33.5 cm, all greater than the 90th%ile. Infant was tachycardic with a systolic murmur. Lungs were coarse and moderately aerated. Abdomen was distended. Tone and activity were grossly normal. Infant was non-dysmorphic. HOSPITAL COURSE: CARDIOVASCULAR: Upon admission to the NICU, the baby was noted to have a heart rate in the 230s. An EKG at that time revealed a diagnosis of atrial flutter with 2:1 conduction. After placement of umbilical venous and umbilical arterial lines, as well as treatment with surfactant, an attempt to cardiovert the infant with transesophageal pacing was attempted but was unsuccessful. The infant was then treated with 2 joules of synchronized cardioversion with immediate conversion to normal sinus rhythm. The baby was also treated with 1 dose of procainamide IV infusion over 1 hour around that time. Overnight, during placement of umbilical venous catheter, the infant converted back into atrial flutter. There was a subsequent successful conversion back to normal sinus rhythm with a procainamide bolus at that time. The infant once again returned to atrial flutter this morning with EKG revealing aberrant conduction. Attempts were made to convert back to sinus rhythm with adenosine boluses which were unsuccessful but with subsequent successful conversion to normal sinus rhythm this morning with esophageal pacing. The infant remained in normal sinus rhythm for the majority of the day of [5-1] from about 8 a.m. in the morning until 5 p.m. at night but with physical stimulation during chest x-ray, the infant was noted to convert back into atrial flutter. At that time, she received a 5 per kilo bolus of procainamide, without effect. Esophageal pacing was attempted, also without effect. Sinus rhythm was eventually obtained with direct cardioversion. Of note, infant was maintained on procainamide infusion of 30 mcg/kg/min throughout. Procainamide level this morning was 9.1 with a NAPA level of 2.3. Blood pressures have remained borderline, with MAPs 25-30 by A-line and 30-35 by cuff. The infant has received 1 normal saline bolus for low blood pressures this morning, has not received any further boluses today. An echocardiogram was performed earlier in the day of [5-1]. The results of that echocardiogram are pending. Preliminary findings showed a moderately depressed ventricular function, AV regurgitation and a patent ductus arteriosus. Respiratory: Upon admission to the newborn intensive care unit, the infant was placed on a conventional ventilator and has received a total of 2 doses of surfactant. Blood gases have been stable. The last blood gas showed a pH of 7.36 with a PCO2 of 43. She is currently on settings of 24/6 with a rate of 26 and an FIO2 of 31-50%. Chest x-ray was notable for mild RDS. FEN: Upon admission to the NICU, the infant was started on IV fluids of D10W at 60 cc per kilogram per day. Initial D stick was 22 for which she received a 2 per kilo D10W bolus. Subsequent D stick was 36. She received another 2 per kilo D10W bolus with subsequent blood sugars in the 70 to 90 range. Electrolytes at 2 p.m. this afternoon showed a sodium of 134, potassium 5.2, chloride 105, bicarb 22, BUN 14, creatinine 1. Albumin level 1.9. Bilirubin 4.5 with a direct bilirubin of 0.3. Ionized calcium this morning was 1.15. Urine output has been minimal throughout the day. Foley placement would likely be beneficial. ID: Upon admission to the NICU, a CBC and blood culture were drawn. White blood cell count was 5500, hematocrit 46.1, platelet count 230 with 40% polys and 1% bands. A blood culture that was drawn at that time has no growth so far. The infant was started on Ampicillin and cefotaxime and she continues to be on those antibiotics. GI: Infant has been maintained NPO. Moderate ascites is notable on exam, and an abominal ultrasound can be considered in the future. LFTs this afternoon revealed AST 4, ALT 32, Bili 4.5/0.3, and albumin 1.9. NEUROLOGY: The infant is currently receiving fentanyl 2 mcg per kilogram q.4 hours for sedation. A head ultrasound has not been performed, but likely should be considered within first week of life. The infant is currently n.p.o., receiving IV fluids of D10W with 2 mEq of sodium per 100 cc via the umbilical venous catheter. The infant has [12-16] normal saline with 1/2 unit of heparin per ml running through the umbilical artery catheter. The infant is n.p.o. Total fluids are 60 cc/kg/day. State newborn screen was sent just prior to discharge. The infant has not received any immunizations. DISPOSITION: Due to recurrent atrial flutter thus far not amenable to medical therapy, infant was transferred to [Hospital3 18242] Cardiac Intensive Care Unit. Transfer was discussed with parents, who agree. DISCHARGE DIAGNOSES: 1. Prematurity at 31-4/7 weeks. 2. Respiratory distress syndrome. 3. Rule out sepsis. 4. Atrial flutter, status post cardioversion. 5. Hydrops. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2133-5-1] 18:29:17 T: [2133-5-2] 10:46:38 Job#: [Job Number 72666] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5827 }	Medical Text: Admission Date: [2162-6-9] Discharge Date: [2162-6-29] Date of Birth: [2109-9-4] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Ethylsuccinate Attending:[Last Name (NamePattern1) 1561] Chief Complaint: 52 yr old male w/ tracheobronchial malacia w/ stent placement in [2162-5-24]. Now admitted on [2162-6-9] for tracheobronchoplasty and right upper lobe wedge volume reduction. Major Surgical or Invasive Procedure: Awake bronchcoscopy, right thoracotomy tracheobronchoplasty and right upper lobe wedge resection for volume reduction. History of Present Illness: 52 yr old male w/ PMHX significant for COPD, tobacco history with tracheobronchomalacia. Admitted for tracheoplasty w/ marlex mesh. Past Medical History: Chronic Obstructive Pulmonary Disease, recurrent bronchitis infections, Gastric Esophogeal reflux disease, Hypercholesterolemia, s/p Left arm levator repair, trachealbronchomalacia. Social History: LIves on [Location (un) ] w/ his wife. [Name (NI) 1403] in a hotel and part-time as actor. + smoker 30 years 1ppd, quit [2156]. Family History: Uncle- emphysema [Name2 (NI) ] history of lung cancer Physical Exam: Well appearing slightly obses male in NAD HEENT: PERRL, EOMI, No cervical or supraclavicular lymphadenopathy. Resp: CTA bilat, equal but diminished. Chest: symmnetrical Heart: RRR S1, S2, no murmur ABD: soft, NT, ND, +BS Extrem: no C/C/E Neuro: Alert and oriented x 3. no focal neurologic deficits. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2162-6-27] 04:33AM 10.9 4.27* 12.2* 36.4* 85 28.7 33.6 13.4 310 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2162-6-27] 04:33AM 310 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2162-6-27] 04:33AM 94 16 0.9 137 3.9 97 30* 14 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2162-6-27] 04:33AM 9.2 5.1* 2.1 RADIOLOGY Preliminary Report CHEST (PA & LAT) [2162-6-28] 10:02 PM CHEST (PA & LAT) Reason: ?PTX [Hospital 93] MEDICAL CONDITION: 52 year old man with s/p trachoplasty and right lung bleb resection NOW WITH H-VALVE REASON FOR THIS EXAMINATION: ?PTX HISTORY: Post-tracheoplasty and right bleb resection. ? PTX. PA AND LATERAL CHEST (THREE RADIOGRAPHS): This examination is essentially unchanged from study done 11 hours earlier on same day. Right chest tube, a portion of which may lie within the minor fissure. Small right apical PTX and possible _____small basal PTX. Extensive right subcutaneous emphysema. Bilateral upper lobe emphysema with associated vascular attenuation. Heart normal size without vascular congestion and I doubt the presence of consolidation. There are minor pleural changes and probable atelectasis in the right lung. IMPRESSION: No short interval change. Small right PTX. Severe upper lobe emphysema. DR. [First Name (STitle) ] M. [Doctor Last Name ] Brief Hospital Course: Pt was admitted on [2162-6-9] for tracheoplasty and right lung volume reduction. Operative course was uneventful. Pain was managed by epidural. Placed on imperic levoflox. POD#[1-24]: Bronch post op w/o evidence of malacia. Chest tubes w/ persistant air leak on SXN. POD#3: pt developed increasing SQ air in chest, face, neck. Persistant large air leak from chest tube -kept to SXN. Diet and activity progressed, cont'd encouragement for pul hygiene. POD#[4-27]: cont'd air leak but resolving SQ air. Epidural d/c'd and started on PCA. POD#6: pleuradesis w/ doxycycline. POD#[7-31]: peristant but diminished air leak. started on benzodiazepines for anxiety r/t prolonged hospital stay d/t persistant air leak. Chest tube remains to SXN. Progressing w/ ambulation and pul hygiene. POD#10; Chest tube placed to water seal w/o adverse effects but w/ small intermittant air leak. POD#11: worsening SQ air with chest tube on water seal-placed back to SXN. POD#[1-4] no change in air leak. Moderate bilateral LE edema d/t dependent positioning of lower extremities. Started on aldactone (already on lasix) and [Male First Name (un) ] stockings. Repeat doxycycline pleuradesis by interventional pulmonology w/ conscious sedation d/t pain. and Bronchcoscopy d/t tenacious green secretions- sputum C+S sent. Chest tube back to water seal w/ small intermittant persistant air leak. POD14-18-Chest tube in place to water seal w/intermittent air leak, afebrile, ambulation ad lib. POD#19- Pleurovac replaced w/ Heimlick valve w/ sputum trap connected for small amount of drainage. CXRY post Heimlick valve placement showed unchanged/slight improvement. POD#20- Pt discharged to home in stable condition w/ chest tube and Heimlick valve in placed to be managed by [Location 22108] and wife. [Name (NI) 22109] provided to patient for self and VNA. VNA referral for pulmonary rehab. Appt w/ [Last Name (NamePattern4) 22110], MD; [7-6]/at 12 noon. Medications on Admission: Flovent 110", protonix 40', speriva', albuterol prn Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 1 Refills:1 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 1 Refills:0 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:1 1 Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Pantoprazole Sodium 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:1 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 11. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO bid () as needed for abundant secretions. Disp:60 Tablet Sustained Release(s) Refills:1 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). Disp:120 Tablet(s) Refills:0 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day for 10 days. Disp:10 10 Refills:0 15. Hydromorphone HCl 2 mg Tablet Sig: [1-24] Tablet PO every four (4) hours as needed for pain: take 30 minutes prior to percocet for pain . Disp:60 Tablet(s) Refills:0 16. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Disp:60 Tablet(s) Refills:0 17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: tracheoplasty, right lung volume reduction, doxycycline pleuradesis x2 Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office for: fever, redness or drainage at incision site, chest pain, shortness of breath. Resume medications as taken prior to hospitalization except for strovent and spiriva- Call Dr.[Name (NI) 6005] office on instructions for these inhalers. Resume inhalers on medication list. Take new pain medication as directed. Dilaudid 1mg 30 minutes before taking percocet. YOu may shower by covering chest tube and valve area w/ saran/cling wrap around abdomen. No tub baths. Refer to Heimlick Valve instruction sheet for care of Heimlick valve Empty collection cup at Heimlick valve as needed. Speak to [Location 22108] for Pulmonary REhab resources and phone numbers. Followup Instructions: Call Dr.[Name (NI) 1816] office for appointment in 1 week. [Telephone/Fax (1) 170].[7-6] at 12noon. Call Dr.[Name (NI) 6005] office for when your next appointment with him should be. Completed by:[2162-6-29] ICD9 Codes: 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5828 }	Medical Text: Admission Date: [2151-5-10] Discharge Date: [2151-5-15] Date of Birth: [2093-7-2] Sex: F Service: NEUROLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a 57-year-old left-handed woman with a history of uncontrolled hypertension, never previously on any antihypertensive medications and taking several herbal medications that possibly contribute a bleeding diathesis, who was admitted on [2151-5-10] after presenting to an outside hospital with headache as well as some dizziness and complaints of left arm and leg clumsiness and inability to move them where she wanted to. The patient initially went to [Hospital3 ] where a head CT showed a right thalamic hemorrhage. Her blood pressure at that time was 240/140. She was started on a Nipride drip and transferred to the [Hospital6 256]. At [Hospital3 ], she had a repeat head CT which showed stable size of her right thalamocapsular hemorrhage. She was transferred to the ICU for blood pressure management which was initially very difficult to control requiring a Nipride drip for the first four days after admission. PAST MEDICAL HISTORY: 1. Uncontrolled hypertension. 2. Raynaud's phenomenon. MEDICATIONS ON ADMISSION: 1. Multivitamin. 2. Multiple herbal medications including Coenzyme Q, [Location (un) ], and horse chestnut. 3. Claritin. 4. Aspirin. ALLERGIES: She has a possible allergy to morphine. She also reports multiple sensitivities to multiple chemicals and medications which she cannot clarify further. SOCIAL HISTORY: She lives alone. She denied tobacco or alcohol use. She works for an insurance company. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON TRANSFER TO THE NEUROLOGY FLOOR: Vital signs: Temperature 98.4, blood pressure 146/80, pulse 67, respirations 20, saturating 94% on room air. General: She was awake and alert, in no acute distress. Neck: Supple with no carotid bruits. Lungs: Clear to auscultation bilaterally. Cardiac: Regular. Abdomen: Benign. Mental status: She was awake, oriented times three with normal language, naming, repetition, comprehension. She has no neglect. Cranial nerves: The pupils were 4 mm to 2 mm, round, and reactive to light. The extraocular movements were full. The visual fields were full to confrontation. Facial sensation was equal. Her face was symmetric. Her palate was upgoing and symmetric. The tongue was midline. Motor examination revealed mild upper motor neuron pattern weakness in her left deltoid, triceps, wrist extensors, and finger extensors. She also has mild to moderate weakness in her left iliopsoas, hamstrings, and toe extensors. She has slightly increased tone on the left. Reflexes: 2+ in the right upper extremity, 3+ in the left upper extremity. They were also 3+ at the left patella, 2+ at the right patella, absent at the ankles with an extensor plantar response on the left. Sensation: She had slightly decreased joint position sense in the left upper extremity and left lower extremity, graphesthesia and double-simultaneous stimulation were intact. She was intact to light touch and pinprick throughout. Coordination revealed slow random alternating movements on the left with mild dysmetria on finger-nose-finger, not out of proportion to weakness. LABORATORY DATA ON ADMISSION: White count 10.3, hematocrit 32, platelets 208,000. INR 1.2, PTT 26.3. Sodium 139, potassium 3.7, BUN 22, creatinine 0.7, glucose 105. Her liver function tests were within normal limits. She had a urinalysis which was also within normal limits. The urine culture revealed no growth. She ruled out for a myocardial infarction with serial CKs of 127, 84, and 54. Her troponins were less than 0.3. Hemoglobin A1C was 5.4, total cholesterol 157, triglycerides 49, HDL 59, LDL 88. She had an EKG which showed sinus rhythm at 90 beats per minute with a right bundle branch block. Head CT was done on [2151-5-10] and [2151-5-11] which showed stable size of a 1.5 by 1.7 cm right thalamocapsular hemorrhage with slight surrounding edema with some extension into the right lateral ventricle but no evidence of hydrocephalus. HOSPITAL COURSE: The patient is a 57-year-old left-handed woman with uncontrolled hypertension who presents with left-sided weakness and sensory loss in the setting of excessively elevated blood pressure, most likely hemorrhage is due to uncontrolled hypertension. She had a transthoracic echocardiogram during admission which showed an ejection fraction of greater than 60% with no focal wall motion abnormalities. However, she had evidence of severe left ventricular hypertrophy which was symmetric. She remained in the ICU on Nipride drip for the first four days of admission as her oral blood pressure medications were tapered up. She was discharged to the floor in stable condition on metoprolol, captopril, and hydralazine with her blood pressure of 146/80. She had slight improvement in her left-sided weakness and sensory loss during admission and she is to be transferred to a rehabilitation hospital upon discharge. DISCHARGE DIAGNOSIS: 1. Right thalamocapsular hemorrhage with residual mild left hemiparesis and left-sided sensory loss. 2. Uncontrolled hypertension. DISCHARGE MEDICATIONS: 1. Metoprolol 100 mg p.o. b.i.d. 2. Captopril 50 mg p.o. t.i.d. 3. Hydralazine 25 mg p.o. q.i.d. 4. Colace 100 mg p.o. b.i.d. 5. Saline nasal spray to each nostril t.i.d. p.r.n. 6. Tylenol 325-650 mg p.o. q. 4-6 hours p.r.n. DR.[Last Name (STitle) ],[First Name3 (LF) ] 13-279 Dictated By:[Last Name (NamePattern1) 1203] MEDQUIST36 D: [2151-5-14] 04:01 T: [2151-5-14] 18:24 JOB#: [Job Number 98287] ICD9 Codes: 431, 4271, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5829 }	Medical Text: Admission Date: [2114-12-18] Discharge Date: [2115-1-2] Date of Birth: [2045-12-15] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 4282] Chief Complaint: fatigue Major Surgical or Invasive Procedure: none History of Present Illness: HPI: The patient is a 69 yo woman with h/o recently diagnosed MDS ([4-9]), azacytodine chemotherapy, day 15 presently cycle 5. Presented to clinic for scheduled NP follow up visit s/p C5 Azacitidine; arrived feeling extremely weak, quite pale, shivering; describes 4 days of these sx, including diarrhea; no n/v, states taking large amounts of po fluids, non productive cough with fever to 102. She had received 3U PRBC prior to a 3 week trip in mediterranean. Presented to clinic fatigued, with non-productive cough, but has been afebrile, without evidence of respiratory distress. . Past Medical History: PAST ONCOLOGIC HISTORY: --Presented to ER in [2114-1-1] with shortness of breath and fever secondary to pneumonia. Hemoglobin and hematocrit levels were 4.9 mg/dl and 14.2%, respectively, with MCV = 122 at the time. Required several red cell transfusions between [1-8] and [4-9]. --Bone marrow biopsy on [2114-4-26] showed "hypercellular erythroid dominant bone marrow with dyserythropoiesis and ringed sideroblast consistent with myelodysplastic syndrome best classified as RARS. Cytogenetics revealed trisomy 8. IPSS intermediate-1 risk score. --Began Procrit 40,000 units weekly [2114-5-1] with increase of dose to 60,000 units weekly with no improvement in her red cell transfusion requirement. --Received Cycle 1 azacitidine chemotherapy [2114-7-9] through [2114-7-13]. Cycle 2 administered [Date range (1) 97986]; delayed by one week due to neutropenia. Cycle 3 administered [Date range (1) 97987]; again delayed by one week due to neutropenia. Cycle 4 administered . PAST MEDICAL HISTORY: s/p pericarditis 4 years ago Bilateral [Hospital1 15309] neuroma h/o migraines that resolved 2 years ago s/p plantar fasciitis L foot s/p shingles s/p multiple skin cancers removed by either dermatologists, Dr. [Last Name (STitle) ], or Dr. [Last Name (STitle) 22342] s/p tonsillectomy. Pericarditis Social History: Lives alone by herself in Collidge Corner in a condominium. No known family members. [Name (NI) ] lots of friends who live nearby. 1 pack cig per day active smoker for approx 50 years. Family History: Father passed away of PNA. Physical Exam: PHYSICAL EXAM: Vs: Tc: 98.7 hr: 100 BP: 106/51 . General: comfortable. Skin: very pale, warm, dry, without ecchymosis, erythema, petechiae or rash. HEENT: sclera anicteric, conjunctiva very pale. Oropharynx pale pink, moist, without mucositis, erythema or thrush. Lungs: breathing easily with occasional dry cough, able to talk in full sentences; dullness to percussion at L base; diminished coarse breath sounds at R base with inspiratory and expiratory crackles. Remainder of lung fields clear. Cardiac: heart rate regular in rate and rhythm, without murmur, rub or gallop. Extremities: symmetrical, trace edema bilaterally from feet to mid-calf bilaterally. No erythema or tenderness. Pertinent Results: [2114-12-18] 09:00PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM HAV-NEGATIVE [2114-12-18] 09:00PM Smooth-NEGATIVE [2114-12-18] 09:00PM [Doctor First Name ]-POSITIVE * [2114-12-18] 09:00PM HCV Ab-NEGATIVE [2114-12-18] 08:50AM UREA N-22* CREAT-1.1 SODIUM-130* POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-21* ANION GAP-16 [2114-12-18] 08:50AM ALT(SGPT)-191* AST(SGOT)-230* LD(LDH)-343* ALK PHOS-89 TOT BILI-0.7 [2114-12-18] 08:50AM HAPTOGLOB-176 [2114-12-18] 08:50AM WBC-0.8# RBC-1.53# HGB-4.5# HCT-13.6# MCV-89 MCH-29.4 MCHC-33.1 RDW-21.4* [2114-12-18] 08:50AM NEUTS-42.8* LYMPHS-53.5* MONOS-1.5* EOS-0.9 BASOS-1.3 [2114-12-18] 08:50AM PLT SMR-VERY LOW PLT COUNT-74# [2114-12-18] 08:50AM RET AUT-2.5 . Micro: DIRECT INFLUENZA A ANTIGEN TEST (Final [2114-12-19]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [2114-12-19]): Negative for Influenza B. [2114-12-19]: Liver US. . IMPRESSION: 1. No intra- or extra-hepatic biliary duct dilatation. 2. Small amount of free perihepatic fluid. 3. Collapsed gallbladder with wall edema and small amount of pericholecystic fluid. These findings could be due to a variery of chronic conditions including hypoalbuminemia, chf, or can be seen in hepatitis. There is no evidence to suggest acute inflammation. . CXR: [2114-12-18] Very severe heterogeneous opacification has developed in the left upper lobe. Left lower lobe was collapsed in [Month (only) 1096], now reexpanded and densely consolidated. There may be left hilar adenopathy and small left pleural effusion. Overall, findings are consistent with extensive pneumonia though under the appropriate clinical circumstances, this could be infiltrated malignancy. Small region of ground-glass opacity in the right apex persists since the chest CT done on [2114-1-13]. Mild-to-moderate cardiomegaly is longstanding and right lung shows some mild vascular redistribution but I do not believe pulmonary edema is playing any role. . -[2114-12-21] TTE: The left atrium is mildly dilated. Left ventricular wall thicknessis is normal. There is normal cavity size and regional/global systolic function (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is mildly dilated with normal free wall contractility. 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 no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. -[2114-12-24] CT chest: 1. Multifocal pneumonia, comparable in extent to the appearance on the chest radiograph, [12-23], which has progressed since [12-18]. Small bilateral pleural effusions are also comparable and not of sufficient size to suggest empyema. There are no characteristics of the widespread pulmonary infection, to permit discriminating among possible causes: virus, bacteria, or fungus. 2. Minimal increase in size and number of mediastinal lymph nodes, presumably reactive. More substantial left hilar adenopathy cannot be excluded, but if present, is not obstructive, and is equally likely to be reactive. 3. New tiny right middle lobe lung nodule. 4. Small pleural and pericardial effusions could be sympathetic to infection, or residual from prior cardiogenic edema -[2114-12-27] CT head No acute intracranial hemorrhage. No acute intracranial process -[2114-12-30] MRI/MRA Multiple areas of restricted diffusion are seen in both cerebral hemispheres involving frontal, parietal and occipital lobes. No focal acute infarcts are seen within the posterior fossa. The distribution is in the watershed region in the left frontal lobe, but otherwise, it is in the cortical and subcortical region of both cerebral hemispheres. There is no acute hemorrhage identified. There is no mass effect, midline shift or hydrocephalus. Mild-to-moderate brain atrophy is seen. IMPRESSION: 1. Multiple small acute cortical and subcortical infarcts including infarct in the left frontal watershed distribution as described above. Mild diffuse decreased signal within the bony structures of the head could be due to marrow hyperplasia or infiltration and clinical correlation recommended. MRA OF THE NECK: Neck MRA shows normal flow in carotid and vertebral arteries without stenosis or occlusion. IMPRESSION: Normal MRA of the neck. MRA HEAD: Head MRA demonstrates normal flow in the arteries of anterior and posterior circulation. IMPRESSION: Normal MRA of the head -[2115-1-1] TTE Bubble Study: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers -[2115-1-1] CSF: WBC: 2 (x2 tubes) TP 28 Gluc 51 LDH 31 -[2115-1-2] EEG: Pending at time of discharge Labs on day of discharge: WBC 4.4 Hct 21.9 Plt 221 Na 138 K 4.3 Cl 109 HCO3 26 BUN 16 Creat 0.7 Gluc 73 ALT 37 AST 81 AP 158 TBil 0.2 Alb 2.0 Brief Hospital Course: 69 yo with myelodysplastic syndrome (RARS), presently D15C5 azacitidine presenting with fever, neutropenia, profound anemia, diarrhea and cough with fever, lung exam concerning for PNA. . Respiratory Distress: Patient presented with profound anemia likely secondary to her MDS. She received 5 UPRBC with improvement of her HCT from 13.6 on admission to 23.2. She developed respitratory distress likely secondary to combined insult of her pneumonia and volume overload for which she triggered. She was found to be in flash pulmonary edema. She received supportive therapy. Her respiratory status improved and she was transferred to the floor. She was started on albuterol nebulizer treatement for possible bronchospasm, but this may not need to be continued at the rehabilitation facility. . PNA/recurrent fevers: She had presented to clinic where she was found to be febrile to 102 and neutropenic. a CXR showed a Left lower lobe pneumonia. She was started on vancomycin and cefepime. A DFA was negative. Blood cultures were negative. In the interim, the patient was managed with meropenem, voriconazole, azithromycin, and vancomcyin in the setting of recurrent fevers and night sweats. She was discharged after being afebrile for 1-2 days, with a short course of meropenem to be completed. . MDS/Anemia: She has a history of sideroblastic anemia for which she is on azacitidine. She received 5 units of pRBC over the first 2 days of her hospitalization. There was a consideration, given the recurrent fevers and night sweats, that the patient had a hematologic etiology, perhaps transformation to AML. A smear was obtained and was unremarkable, so bone marrow biopsy was deferred. She received a unit of pRBC on the day of discharge, which she completed prior to transfer to rehabilitation. . Altered mental status/right hand-wrist weakness: The patient developed right hand/wrist weakness on [12-26]. The patient also developed attention/cognitive deficits. An MR head was obtained which showed a likely watershed infarct in the left frontal cortex, with multiple focal lesions in both hemispheres. LP was negative for meningitis. TTE bubble study was negative for PFO or ASD. EEG was performed with results pending at time of discharge. Her mental status improved considerably and she had a clear thought process, and was consistently oriented to her name, the name of her hospital, and the month/year. . LFT elevation: Hepatitis serologies were negative, as were smooth Antibodies. She did have a positive [Doctor First Name ] with titer pending. Hepatic US showed Small amount of free perihepatic fluid, collapsed gallbladder with wall edema, and small amount of pericholecystic fluid. LFTs were improved by day of discharge. . Neutropenic Fever: Her neutropenia was likely secondary to her chemotherapy. She was placed on neutropenic precautions and her ANC was trended. Her neutropenia resolved with periodic dosing of neupogen. She had had no fevers for 1-2 days prior to discharge. Per ID recommendations, she was discharged on meropenem, to be continued for six days following discharge. . Prophylaxis: She did not receive heparin SQ prophylactically given the contraindication posed by her azacitidine therapy. As her platelet count remained normal, and there was no evidence of intracranial hemorrhage on imaging, SC heparin was given for DVT prophylaxis. Medications on Admission: PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea ZOLMITRIPTAN [ZOMIG] - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ASPIRIN [ASPIRIN [Hospital1 ]] - (Prescribed by Other Provider; OTC) - 81 mg Tablet, Chewable - one Tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1cap Capsule(s) by mouth once daily OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain VITAMIN E - (Prescribed by Other Provider) - Dosage uncertain . ALLERGIES: Codeine Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nAUSEA . 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 5. Meropenem 500 mg Recon Soln Sig: One (1) dose Intravenous every six (6) hours for 6 days: Last doses on [2115-1-8]. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Treatment Inhalation every four (4) hours as needed for sob/wheeze. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for PRN FEVER. 8. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1) Capsule PO once a day. 10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Multifocal Pneumonia Febrile neutropenia Left frontal watershed cerebral infarct Myelodysplastic syndrome Secondary s/p pericarditis 4 years ago Bilateral [Hospital1 15309] neuroma h/o migraines that resolved 2 years ago s/p plantar fasciitis L foot s/p shingles s/p multiple skin cancers removed by either dermatologists, Dr. [Last Name (STitle) ], or Dr. [Last Name (STitle) 22342] s/p tonsillectomy. Pericarditis Discharge Condition: Medically stable for discharge to rehabilitation facility. Discharge Instructions: You were admitted to the hospital because you were fatigued and having fevers. You were found to have a pneumonia treated with antibiotics. You also received blood transfusions. Your breathing initially improved, however your lungs became overloaded with fluid and you went to the intensive care unit. Your breathing improved and you came back to the regular floor. . You coninued to have difficulty with your breathing and continued to have fevers so procedures were done to sample your lung fluid to culture and remove some of the fluid, which did not show obvious infection. Your pnuemonia was treated with antibiotics. You also developed some mild confusion and right hand weakness, due to a stroke, which was seen on MRI. A lumbar puncture did not show any infection of your cerebrospinal fluid. You had an EEG exam to look for seizure activity, the final results of which were pending at the time of discharge. . The following changes were made to your medications: -You were started on MEROPENEM, an intravenous antibiotic. You will have an IV line placed at the rehabilitation facility to receive this medication. You will continue to take this for six days post-discharge, with your last doses on [2115-1-8]. -Added Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. -Added Benzonatate 100 mg Capsule, One Capsule by mouth 3 times a day -Added Acetaminophen 325-650 mg by mouth every eight hours as needed for fever; PLEASE DO NOT EXCEED 2000MG/ DAY -Added Albuterol 0.083% Nebulizer to be inhaled every four hours, as needed for shortness of breath or wheeze . Please return to the hospital or call your doctor if you feel faint, light headed, experience nausea, vomiting, constipation, headache, blurry vision, weight loss, night sweats, chest pain, abdominal pain, shortness of breath, muscle aches, joint aches, fever, blood in your stool or urine, or any other symptoms that are concerning to you. Followup Instructions: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3014], RN & [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2115-1-10*] 1:30 ICD9 Codes: 486, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5830 }	Medical Text: Unit No: [Numeric Identifier 74991] Admission Date: [2105-9-10] Discharge Date: [2105-9-18] Date of Birth: [2105-9-10] Sex: M Service: NB HISTORY: This is a preterm infant born at 34 3/7 weeks gestation to a 34-year-old, gravida 2, para 1->2, B+, antibody negative, hepatitis B surface antigen negative, RPR nonreactive woman. Her past medical history is unremarkable. This pregnancy is remarkable for IVF surrogate gestation with donor egg from cousin and sperm from cousin's husband. Antepartum course was complicated by recent onset of hypertension prompting admission on day prior to delivery. Because of nonreassuring fetal heart tracing with bradycardia to 60, stat C-section under general anesthesia was done. After delivery, the baby required resuscitation with positive pressure ventilation for 20-30 sec and first spontaneous cry at about 1 min. Apgars were 5, 7 and 8 at one, five and ten minutes. The baby was transferred to the NICU for further care. Physical exam at discharge: Weight 2200 grams. Pulmonary: clear bilaterally. Cardiovascular: regular rate and rhythm with no murmur. Abdomen: soft, nontender, no organomegaly, umbilical stump is detaching cleanly Neuro: Normal activity and tone. Hospital Course by systems: 1. Respiratory: Because of increasing oxygen requirement and decreased breath sounds, [Known lastname ] was intubated and given a dose of surfactant. The baby was weaned from mechanical ventilation after one day of SIMV and he was extubated to room air. He has been stable in room air since that time. He has never had any apnea/brady or desaturation spells. 2. Cardiovascular: [Known lastname ] has been hemodynamically stable throughout her stay with no murmur. 3. Fluids/electrolytes/nutrition: [Known lastname ] was initially NPO on IVF, but began PO feeds on day of life #1 after extubation. He was weaned from IVF by day of life #2 and has been feeding PO well since day of life #4. His calories were advanced to Enfamil 24 on day of life #6. At discharge he is feeding Enfamil 20. His weight was stable overnight but he has not yet returned to birthweight. His d-sticks remained stable throughout his hospitalization. 4. GI: [Known lastname ] had some physiologic hyperbilirubinemia. Maximal bilirubin was 7.4 on day of life #4. This clinically resolved, so further levels were not checked. 5. Heme: Initial Hct was 55 with plts 218K. He has not required any transfusions during his stay. 6. Infectious disease: Due to his respiratory distress after birth, there was concern for sepsis risk. [Known lastname ] was empirically treated with Ampicillin and Gentamicin for 48 hrs. Antibiotics were discontinued when blood cultures remained negative. 7. Neurology: Exam has remained normal. His gestational age did not qualify him to need screening cranial US. 8. Sensory: Hearing screening was performed with automated auditory brainstem responses and was passed on [9-17]. 9. Psychosocial: [Known lastname ] will be going home with his biologic parents, Mr. and Mrs. [First Name (STitle) 8096] and [First Name5 (NamePattern1) 13762] [Last Name (NamePattern1) 74992]. His name after discharge will be [Known lastname ] [Last Name (NamePattern1) 74992]. Condition at discharge: good. Discharge disposition: to home with parents in a car bed. His family will ultimately return to [Location (un) 4551], but today they will fly to [Location (un) 2848] to reside there for several months. They have arranged a nanny to accompany them and will have a pediatrician there. Primary Pediatrician: Dr. [Last Name (STitle) 74993] [Name (STitle) 74994] in [Last Name (LF) 2848], [First Name3 (LF) 108]. Phone [Telephone/Fax (1) 74995]. Fax [Telephone/Fax (1) 74996]. Care/recommendations: a. Feeds are Enfamil 20 ad lib. b. Medications: none. [Initials (NamePattern4) ] [Known lastname ] mother prefers for him to travel in a car bed, so he did not receive car seat postion screening. d. State newborn screening sent and pending. [Initials (NamePattern4) ] [Known lastname ] received Hepatitis B vaccination on [9-16]. f. Immunizations recommended: i. 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 <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-age siblings; 3)chronic lung disease; or 4)hemodynamically significant congenital heart disease. ii. 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 a child's life), immunization against influenza is recommended for household contacts and out-of-home caregivers. [Name (NI) ]. This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends that 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. g. Follow-up is to be with Dr. [Last Name (STitle) 74994] in [12-16] days after discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 34 weeks and 3 days. 2. Respiratory distress syndrome - resolved. 3. Risk for sepsis - resolved. 4. Hyperbilirubinemia - resolved. [Doctor First Name ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD [MD Number(2) 72747] Dictated By:[Last Name (NamePattern4) 74947] MEDQUIST36 D: [2105-9-17] 20:43:17 T: [2105-9-18] 08:40:15 Job#: [Job Number 74997] ICD9 Codes: 769, 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5831 }	Medical Text: Admission Date: [2126-3-31] Discharge Date: [2126-4-5] Date of Birth: [2126-3-31] Sex: M Service: NB IDENTIFICATION: Baby [Name (NI) ] [Known lastname ] (twin #2) is a 9 day old former 33 [12-2] week premature infant being transferred from [Hospital1 18] NICU to [Hospital 1474] Hospital SCN. HISTORY OF PRESENT ILLNESS: [First Name8 (NamePattern2) ] [Known lastname ] is the former 1.695- kilogram product of a 33-1/7-weeks gestation pregnancy born to a 23-year-old G1, P0 woman. Prenatal screens: Blood type B- positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group B strep status unknown, HIV negative, chlamydia negative, cystic fibrosis negative. Pregnancy was notable for dichorionic-diamniotic spontaneous twins. EDC was [2126-5-18]. The mother developed severe preeclampsia, treated with magnesium and betamethasone. She was transferred from [Hospital 1474] Hospital to [Hospital1 69] where she was managed expectantly. She was taken to cesarean section for worsening pregnancy-induced hypertension. This twin #2 emerged vigorous with Apgars of 8 at 1 minute and 8 at 5 minutes. He was admitted to the neonatal intensive care unit for treatment of prematurity. Of note, amniotic fluid of twin #1 was meconium-stained at delivery. Birth parameters: Birth weight 1.695 kilograms, length 42 cm, head circumference 30 cm, all 25th-50th percentile. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: [Doctor First Name ] has been in room air since admission to the neonatal intensive care unit. He maintains oxygen saturations greater than 95%. He has occasional episodes of apnea and bradycardia, not needing treatment with caffeine. 2. Cardiovascular: [Doctor First Name ] has maintained normal heart rates and blood pressures. No murmurs have been noted. 3. Fluid, electrolytes, and nutrition: [Doctor First Name ] was initially on intravenous fluids. Enteral feeds were started on day of life 1 and gradually advanced to full volume. At the time of discharge, he is taking 150 mL per kilogram per day of breast milk or Special Care formula 24 calorie per ounce. Serum electrolytes were normal at 24 hours of age. He is feeding PO/PG, with modest PO intake. 4. Infectious disease: Due to his prematurity, [Doctor First Name ] was evaluated for sepsis upon admission to the neonatal intensive care unit. A complete blood count was within normal limits. A blood culture grew gram-positive cocci identified as Streptococcus viridans. He was recultured on day of life 1 and started on ampicillin and gentamicin. The 2nd culture prior to starting antibiotics was no growth, but it was decided to administer a 7-day course of ampicillin. The course was completed on [2126-4-7]. A lumbar puncture was performed on [4-4], [2125], with results 1 red blood cell, 1 white blood cell per high power field. Differential was 1% polys, 67% lymphocytes, 31% monocytes, protein of 79, glucose of 54, and negative Gram stain. Culture was negative. Initial Strep viridans culture was penicillin-sensitive. 5. Hematological: Hematocrit at birth was 54.7%. [Doctor First Name ] did not receive any transfusions of blood products. He was begun on iron supplementation, and is receiving ferinsol 0.3 mL daily (4 mg/kg/day). 6. Gastrointestinal: [Doctor First Name ] required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life 2, total of 8.8 mg per deciliter. He received 2 days of phototherapy. 7. Neurology: [Doctor First Name ] has maintained a normal neurological exam, and there are no neurological concerns at the time of discharge. 8. Sensory: Audiology: Hearing screening is recommended prior to discharge. CONDITION AT DISCHARGE: Good. PHYSICAL EXAM AT DISCHARGE: General: Nondysmorphic preterm infant in no acute distress. Skin: Warm and dry. Color pink. Head, eyes, ears, nose, throat: Anterior fontanel soft and flat. Sutures opposed. Normal facies. Chest: Breath sounds clear and equal, breathing in room air. Cardiovascular: Regular rate and rhythm, no murmur. Normal pulses. Abdomen: Soft, nontender, no masses, active bowel sounds. GU: Normal preterm male. Extremities: Moving all well, symmetric tone. Neuro: Appropriate reflexes. DISCHARGE DISPOSITION: Transferred to [Hospital 1474] Hospital for continuing level II care. The primary pediatrician is Dr. [Last Name (STitle) ] [Name (STitle) 72355], [Street Address(2) ], [Hospital1 1474], [Numeric Identifier ], phone number ([Telephone/Fax (1) 73339]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: 150 mL per kilogram per day of breast milk or Similac Special Care 24 calorie per ounce formula. 2. Ferinsol 0.3 mL po daily (4 mg/kg/day). 3. Iron supplementation is recommended for preterm and low birth weight infants until 12 months of corrected age. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units daily. This may be provided as multivitamin preparation and continued until 12 months corrected age. 4. Car seat position screening has not yet been performed, but is recommended prior to discharge. 5. State newborn screen was sent on [2126-4-3]. No notification of abnormal results to date. 6. No immunizations have been administered. DISCHARGE DIAGNOSES: 1. Prematurity 33-1/7-weeks gestation. 2. Twin #2 of a twin gestation. 3. Streptococcus viridans bacteremia. 4. Unconjugated hyperbilirubinemia. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2126-4-5] 02:57:00 T: [2126-4-5] 06:59:38 Job#: [Job Number 73341] ICD9 Codes: 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5832 }	Medical Text: Admission Date: [2139-9-29] Discharge Date: [2139-10-5] Date of Birth: [2071-6-29] Sex: F Service: CARDIOTHORACIC Allergies: Naproxen / Iodine; Iodine Containing / Rofecoxib / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1505] Chief Complaint: increased DOE Major Surgical or Invasive Procedure: s/p OPCABx1(LIMA->LAD) [2139-9-30] History of Present Illness: 68 yo F with exertional chest pressure and DOE, diagnosed with CAD one year prior. ETT + for ischemia, referred for surgical revascularization. Past Medical History: CAD HTN hypercholesterolemia PVD COPD TIA Aorto-Bifem BPG right CEA laminectomy bilat iliac stents appy pilonidal cyst right cataract Social History: retired quit tobacco [2120], 20 pack year history [12-8] glasses wine/day Family History: sister with CABG in mid [2082]'s Physical Exam: WDWN F in NAD, mildly overweight Skin well healed abdominal and groin incisions. HEENT unremarkable Neck supple bilat carotid bruits L>R Lungs CTAB Heart RRR Abd + bruit L side extrem warm, no edema superficial varicosities r thigh Neuro alert and oriented, 5/5 strength t/o, MAE, normal gait Pertinent Results: [2139-10-5] 06:51AM BLOOD WBC-9.0 RBC-3.39* Hgb-10.8* Hct-30.2* MCV-89 MCH-31.8 MCHC-35.6* RDW-15.9* Plt Ct-265# [2139-10-5] 06:51AM BLOOD Plt Ct-265# [2139-10-5] 06:51AM BLOOD Glucose-102 UreaN-12 Creat-0.6 Na-133 K-4.1 Cl-98 HCO3-25 AnGap-14 Brief Hospital Course: Ms. [Known lastname ] was scheduled for surgery on [9-29], carotid u/s on [9-28] showed 100% [Doctor First Name 3098] stenosis & occluded L vertebral. Her surgery was cancelled and she was admitted to F2 for further work up. She was seen by vascular surgery who cleared her for surgery. MRIshowed occluded [Doctor First Name 3098], patent L vert and moderate to severe [Country ] stenosis. On 10.25 she underwent an off-pump CABG x 1. She awoke neurologically intake and was extubated that same day. She was weaned from her vasoactive drips and transferred to the floor on POD #1. She developed a small left apical pneumothorax following chest tube removal whoch resolved spontaneously. She was ready for discharge to home on POD #5. Medications on Admission: [Doctor First Name 130] crestor diovan advair spiriva low dose aspirin calcium CoQ Flaxseed Fish oil MVI albuterol fiber caps Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:1 Cap(s) Refills:0 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:60 Tablet, Chewable(s) Refills:0 6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 7 days. Disp:40 Capsule, Sustained Release(s) Refills:0 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:qs Refills:0 Discharge Disposition: Home With Service Facility: VNA of Greater [Location (un) 5871]/[Location (un) 6159] Discharge Diagnosis: CAD Bilat. severe carotid stenoses Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 68568] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 6254] for 3-4 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Completed by:[2139-10-6] ICD9 Codes: 496, 4439, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5833 }	Medical Text: Admission Date: [2102-4-6] Discharge Date: [2102-4-14] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Endotracheal intubation Flexible bronchoscopy [2102-4-8] History of Present Illness: Ms. [Known firstname 79145] is a [Age over 90 ] year-old female with a history of HTN, DM, ?chronic aspiration, and Alzheimer's dementia who was transferred from the ED intubated after presenting with hypoxia and tachypnea. She was in her usual state of health until two days ago when she began experiencing a nonproductive cough and dyspnea. Her symptoms worsened and her [Age over 90 ] and son-in-law, whom she lives with, brought her to the ED. On presentation, her VS were 98.1 74 154/82 18 79%RA. She appeared to be in acute respiratory distress, with increased work of breathing. She was placed on a NRB and was satting in the 80-85% range, and a CXR demonstrated left sided consolidation. She was started on levofloxacin and ceftriaxone and intubated because of worsening tachypnea and hypoxia and then transferred to the [Hospital Unit Name 153]. . Per discussion with her [Hospital Unit Name ], the patient has not received a flu shot this year but did receive the pneumovax about five years ago. She has no sick contacts and has no recent hospital or nursing home exposure. She last had pneumonia one year ago and was treated as an outpatient. Review of systems is otherwise negative for fevers, chills, arthralgias, nausea, vomiting, diarrhea, and chest pain. Ms. [Known lastname 22114] has chronic constipation at baseline. Past Medical History: HTN DM2 (diet controlled) ?Chronic aspiration Alzheimer's dementia Breast cancer (diagnosed seven years ago) Lower back pressure ulcer Social History: Ms. [Known lastname 22114] is Russian speaking and wheelchair bound at baseline. She lives with her [Known lastname ] and son-in-law in [Location (un) 14307] and moved to the United States from [Country 532] five years ago. She does not smoke or drink alcohol. She has VNA services for dressing changes for her lower back pressure ulcer. She has only seen her PCP once and most of her medical history is part of the [Hospital6 ] system. Family History: No heart disease or diabetes. Otherwise non-contributory. Physical Exam: On discharge satting 100% on 4L NC, HR 59, BP 161/58. PHYSICAL EXAM GENERAL: NAD, opens eyes to voice, but does not interact HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: Decreased lung sounds on Right, crackles on left ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Muscle wasting, no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: moves all extremities, downgoing toes, responds to noxious stimuli. Pertinent Results: [2102-4-14] 04:13AM BLOOD WBC-10.9 RBC-4.05* Hgb-12.3 Hct-37.3 MCV-92 MCH-30.4 MCHC-33.0 RDW-14.5 Plt Ct-384 [2102-4-6] 04:15PM BLOOD WBC-15.7# RBC-4.37 Hgb-13.5 Hct-40.0 MCV-92 MCH-30.9 MCHC-33.8 RDW-15.1 Plt Ct-351 [2102-4-10] 03:38AM BLOOD Neuts-72.0 Lymphs-21.0 Monos-4.8 Eos-1.9 Baso-0.3 [2102-4-11] 03:39AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2* [2102-4-14] 04:13AM BLOOD Glucose-123* UreaN-25* Creat-1.1 Na-141 K-4.2 Cl-97 HCO3-36* AnGap-12 [2102-4-8] 04:44AM BLOOD ALT-38 AST-30 LD(LDH)-159 AlkPhos-134* TotBili-0.3 [2102-4-6] 04:15PM BLOOD cTropnT-<0.01 [2102-4-6] 04:15PM BLOOD CK-MB-NotDone proBNP-5423* [2102-4-13] 04:48AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2 [2102-4-12] 03:12PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.010 [2102-4-12] 03:12PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2102-4-12] 03:12PM URINE RBC-92* WBC-14* Bacteri-FEW Yeast-NONE Epi-0 Urine, Blood and sputum cultures negative Studies: ECHO: EF 70-75%, Preserved regional and global biventricular systolic function. Severe pulmonary hypertension. Moderate mitral regurgitation. Mild to moderate functional mitral stenosis from mitral annular calcification. Mild to moderate tricuspid regurgitation. RUQ US: 1. Limited evaluation of gallbladder without evidence of cholelithiasis. 2. Very limited evaluation of the liver. Mass and hepatic calcifications are better evaluated on concurrent CT abdomen. 3. Splenic calcifications suggest prior granulomatous disease. CTA CHEST: 1. Negative examination for pulmonary embolism. 2. Large to moderate amount of bilateral pleural effusion associated with adjacent atelectasis. 3. Multifocal areas of consolidation of right upper lobe, right middle lobe, and both lower lobes are probably related to pneumonia. 4. Known mass in left axilla that seems to be invading the left breast. 5. Multiple calcified nodules in the liver and spleen suggest prior granulomatous exposure. 6. Hypodense mass in right hepatic lobe. Dedicated abdominal evaluation is suggested. CXR [2102-4-13]: There is interval development of new whiteout of right hemithorax with right mediastinal shift, finding consistent with a complete atelectasis of the right lung. Given the rapid development it is consistent with a mucus plug aspiration. The left lung aeration is preserved and demonstrates the presence of a mild to moderate pulmonary edema. A left pleural effusion is present. The NG tube tip is in the stomach. Brief Hospital Course: Ms. [Known lastname 22114] is a [Age over 90 ] year-old female with a history of HTN, DM, ?chronic aspiration, and Alzheimer's dementia who was transferred from the ED intubated after presenting with hypoxia and tachypnea. #. Respiratory failure/Pneumonia: Patient presented with hypoxia and tachypnea and chest radiograph c/w a LUL consolidation pneumonia. She was started on ceftriazone/azithromycin for community acquired pneumonia on presentation. On her second hospital day her chest radiograph changed significantly with the consolidation in her left upper lobe generally resolving suggesting this was more consistent with mucous plugging and volume loss. She went on to have a CT scan that showed multifocal pneumonia as well as probable pulmonary edema with large bilateral pleural effusions. She was transiently intubated with reexpansion of a previously collapsed upper lobe. Given that her pulmonary edema and large pleural effusions were likely contributing to her volume loss and respiratory compromise an attempt was made to diurese with furosemide boluses, to which she responded well with decreasing oxygen requirements, down to 4L NC at dischage. Pt also had intermittent lobar collapse, thought to be due to mucous plugging and aspirating of secretions. She generally responded to deep suctioning but was unable to effectively cough to clear her own secretions. #. Hypertension: The patient has severe and labile hypertension and was continued on an aggressive anti-hypertensive regimen at home including beta [Last Name (LF) 7005], [First Name3 (LF) 14595]-1 [First Name3 (LF) 7005], CCB, and ACE inhibitor. In the setting of diuresis, pt was intermittently hypotensive requiring fluid boluses. She also at times was hypertensive, requiring prn doses of hydralazine. #. Alzheimer's dementia: The patient has severe dementia at baseline, but is on no treatment for this at home. As of extubation her mental status was at baseline (opens eyes to voice but does not interact or follow commands). #. Breast cancer: The patient has a necrotic mass in her left axilla of locally advanced breast cancer. No aggressive therapies are being pursued. # Lower back pressure ulcer: Care per wound nurse recommendaitons #. DM2: Finger sticks were monitored QID and treated with ISS. #. Nutrition: Given pt's repeated aspiration, pt was fed via NGT. Contacts: [Name2 (NI) 2957] makes health decisions, [First Name8 (NamePattern2) 7346] [Last Name (NamePattern1) 79146] [Telephone/Fax (1) 79147] (c). Granddaughter, [Name (NI) 1457] [Name (NI) 79146], was pharmacist in [Country 532] and can be reached at [Telephone/Fax (1) 79148] (c). Code: CPR not indicated but intubation allowed - confirmed with daughter and granddaughter. . Medications on Admission: Diltiazem 180 [Hospital1 ] Doxazosin 2 qd Enalapril 20 [Hospital1 ] Furosemide 20 qd Toprol 100 [Hospital1 ] Potassium 8 meq qd Arimidex Simvastatin 20 qd Catapres 2( Clonidine patch 0.2 mg/24 hours) Clonidine 0.2 po tid Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Per NGT. 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Per NGT. 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Per NGT. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: [2-10] PO BID (2 times a day) as needed for constipation: Per NGT. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: Per NGT. 6. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Per NGT. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours). 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Per NGT. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Digoxin 0.125 mg IV EVERY OTHER DAY 12. Arimidex 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Pneumonia Secondary: Hypertension Discharge Condition: Stable, breathing comfortably on 4L NC. Discharge Instructions: Ms [Known lastname 22114]: You were admitted with shortness of breath and low blood oxygen levels and you were intubated (a breathing tube was placed) in the emergency room because of your shortness of breath. You were found to have a pneumonia and you were treated with antibiotics. Your pneumonia improved, but you continued to be short of breath due to aspiration of your saliva and heart failure. For your heart failure your medications were changed to control your blood pressure and remove fluid as it was collecting in your lung. Because your cough is very weak you continued to have difficulties during this admission with secretions, and several times your secretions would fill your airway and cause collapse of the lung which we would then see on xray. Sometimes it would help to do deep suction to remove the secretions, but sometimes this did not help. . . The following medication changes were made during this admission: . Diltiazem was STOPPED. Doxazosin was STOPPED. Enalapril was CHANGED to captopril. Furosemide was INCREASED. Toprol was CHANGED to metoprolol. Potassium was STOPPED. Catapres was CHANGED to oral clonidine pill. Clonidine 0.2mg was CHANGED to a different dose of clonidine. . The following medications were started: Digoxin, famotidine, senna, colace, albuterol, ipratropium. . All of your other home medications remain the same. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L. If you develop shortness of breath, chest pain, or any other concerning symptom please call your primary care doctor or return to the hospital. Followup Instructions: [Hospital 100] Rehab: Please make an appointment for the pt to see the primary care doctor (Dr. [Last Name (STitle) 8682] [Telephone/Fax (1) 133]) when she leaves rehab. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 486, 5119, 5180, 4019, 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5834 }	Medical Text: Admission Date: [2115-6-29] Discharge Date: [2115-7-3] Date of Birth: [2059-10-9] Sex: M Service: MEDICINE Allergies: Penicillins / Doxycycline / Codeine Attending:[First Name3 (LF) 2297] Chief Complaint: right lower leg cellulitis, CO2 retaining Major Surgical or Invasive Procedure: [2115-6-29] Right below knee guillotine amputation History of Present Illness: This is a 55M with COPD/CO2 retainer, VTE, bilateral chronic lymphedema and multiple ulcers who was admited for LE cellulitis/sepsis and who underwent [Month/Day/Year 6024] three days ago is transfered to MICU for medical management. He has a history of LE ulcers that have been treated with skin grafts by Dr. [Last Name (STitle) 3649] at [Hospital6 ]. Over the last two weeks he developed worsening erythema, swelling, and pain in his right lower extremity. He initially presented with these symptoms at OSH and then transfered to [Hospital1 ] after developing hypotension. He was initially treated with IVF followed by phenylephrine (discontinued this morning, [2115-7-1]), vancomycin, cefepime and flagyl for cellulitis of his RLE and sepsis. On intial presentation he was also noted to have hyperkalemia of 5.9, treated with 30mg PO kayexelate and supratherapeutic INR (on outpatient warfarin) treated with 2 units FFP and subcutaneous vit K. Three days ago he underwent right [Month/Day/Year 6024] and tolerated the procedure well. Given his body habitous his stomp was closed by secondary infection with wound vac. He was extubated this morning and his respiratory status is at baseline. He is still sleepy and history was obtained from chart. On transfer his vs were: T 99 P 98 BP 92/49 R18 O2 sat 90%. Past Medical History: IDDM Morbid obesity OSA DVT PE COPD on home O2 CAD s/p MI congestive heart failure PSH: multiple skin grafts, back surgery Social History: He lives home alone, was walking with walker pre [Name (NI) 6024], sister is caregiver, smoked 1.5 ppd x 20 years, down to 3 cigarretes per day currently Family History: NC Physical Exam: Vitals: T 99 P 98 BP 92/49 R18 O2 sat 90% General: Alert, oriented self, place but not date, sleepy HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Coarse breath sounds, poor effort, cannot rotate to listen to his back CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft non tender GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; [Name (NI) 6024] LLE, no strikethrough, drain in place: ss d/c Neuro: responds to commands, symmetric facial mm, perrla, symetric squize hand Pertinent Results: ADMISSION LABS: . [2115-6-29] 02:00AM BLOOD WBC-26.0* RBC-3.58* Hgb-10.5* Hct-31.8* MCV-89 MCH-29.4 MCHC-33.1 RDW-17.1* Plt Ct-216 [2115-6-29] 02:00AM BLOOD Neuts-89.2* Lymphs-8.0* Monos-2.4 Eos-0.2 Baso-0.2 [2115-6-29] 02:00AM BLOOD PT-93.5* PTT-57.9* INR(PT)-11.5* [2115-6-29] 02:00AM BLOOD Plt Ct-216 [2115-6-29] 02:00AM BLOOD Glucose-99 UreaN-82* Creat-2.5* Na-125* K-7.3* Cl-91* HCO3-26 AnGap-15 [2115-6-29] 10:34AM BLOOD ALT-18 AST-24 AlkPhos-141* TotBili-0.9 [2115-6-29] 10:34AM BLOOD Albumin-2.4* Calcium-7.1* Phos-5.7* Mg-2.3 [2115-6-29] 10:48AM BLOOD Type-ART pO2-211* pCO2-74* pH-7.21* calTCO2-31* Base XS-0 [2115-6-29] 03:43AM BLOOD Lactate-1.5 [2115-6-29] 11:55AM BLOOD freeCa-1.03* PERTINENT LABS/STUDIES: . Hct: 31.8 -> 28.9 -> 26.0 -> 25.6 INR: 11.5 -> 6.4 -> 4.4 -> 2.6 ([7-2]) FDP: 10-40 ([7-1]) Fibrinogen: 430 D-Dimer: 1236 Blood culture: Negative x2 TTE ([7-2]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably normal (LVEF~55%). Right ventricular free wall motion is probably well visualized although not well visualized. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly to moderately thickened with probably no significant aortic stenosis (aortic velocity measurements were technically limited). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is at least moderate pulmonary artery systolic hypertension. CXR ([7-2]): In comparison with the study of [6-30], there is substantial increased engorgement of pulmonary vessels consistent with overhydration. Enlargement of the cardiac silhouette persists and there are atelectasis or even consolidative changes at the bases DISCHARGE LABS: . [2115-7-3] 03:55AM BLOOD WBC-8.7 RBC-2.76* Hgb-7.8* Hct-25.6* MCV-93 MCH-28.2 MCHC-30.4* RDW-17.4* Plt Ct-182 . [2115-7-3] 03:55AM BLOOD Glucose-104 UreaN-22* Creat-1.1 Na-140 K-4.4 Cl-103 HCO3-34* AnGap-7* . [2115-7-3] 03:55AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0 Brief Hospital Course: The patient presented on [2115-6-29] in sepsis due to severe right foot cellulitis and gangrene. He was coagulopathic with an INR of 11. He was actively reversed with FFP and vitamin K and started on broad spectrum antibiotics. He was taken emergently to the operating room for a right foot guillotine amputation to control his infectious source. He was transferred to the CVICU for post-operative monitoring and resuscitation. His WBC normalized on POD1 and he was able to be weaned off of pressors and extubated. Due to his body size and poor pulmonary function, it was decided that the best approach to his stump would be to place a wound vac to faciliate closure rather than risk general anesthesia for a second time. On POD2 he did have quite a bit of bloody oozing from his stump that required the placement of [2-24] sutures to control bleeding. The vac was applied later that day to ensure that the bleeding had stopped. Due to he many medical comorbidities he was transferred to the care of the MICU team. The vac lost suction overnight due to increased bloody drainage. The stump was then monitored overnight and the bleeding stopped. He is now ready for discharge with wound vac placement to occur when he gets to rehab. Assessment and Plan: This is a 55M with COPD/CO2 retainer, VTE, bilateral chronic lymphedema and multiple ulcers who was admited for LE cellulitis/sepsis and who underwent [Month/Day (1) 6024] three days ago is transfered to MICU for medical management # Cellulitis c/b sepsis s/p [Month/Day (1) 6024]: Improving hemodynamics and leukocytosis resolved. Continuing ABX (vanc and cefephime, both started on [2115-6-29]). Hypotension improved with IVF and now s/p phenylephrine over several hours. Blood and urine cx negative. Treated with Cefepime and Vancomycin with planned duration of 14 days. # Hypotension: Component of sepsis and surgical blood loss. Stable MAP after discontinuation of phenylephrine. Resolved rapidly and was normotensive for 48 hours prior to discharge. # Coagulopathy: intially thought to be related to warfarin use. Imrpoved with FFP and vit K, pre procedure but now PTT and INR rising again. One concernign possibility is DIC. Dilutional effects are possible but only 2 pRBC and 9 PLT. Alternatively acquired inhibitor. AST/ALT within normal limits and bili fine, but low albumin so synthetic funtion impairment. Finally on heparin QS tid. No evidence of DIC. Decreased heparin dosing and trended INR. Once INR returned to 2.6, warfarin was restarted. # Hypercarbia/Hypoxia with underlying COPD: h/o CO2 retainer. Post extubation [Last Name (un) ] with stable Co2. Goal O2 sat high 80s to mantain respiratory drive. Continued CPAP at night and O2 via nasal cannula during the day with usual requirement of 1-3L/min. # Sleepiness: Possibilities include recent use of propofol during intubation and obesity. Also COPD with h/o CO2 retain. Improved with good suctioning, supplemental oxygen and avoidance of sedating medication. # [Last Name (un) 6024] with wound vac in place: Clearly absent of signs of infection. Followed by Vascular and will see them post discharge. # Methadone dependence: Dose confirmed, continued on 100mg daily. # Diabetes mellitus: On insulin sliding scale while inpatient. Restarted Metformin on discharge. # History of DVT: Anticoagulation as above. # Coronary artery disease with history of myocardial infarction: Continue on low dose beta blocker after resolution of his hypotension. Not on statin medication. Daily Aspirin therapy. Bowel regimen and home proton-pump inhibitor. Patient was full code while inpatient. Medications on Admission: Coumadin unknown dose bactrim ds 2 tabs [Hospital1 ] unknown reason percocet prn miralax prn colace prn bumex 2mg daily cardizem cd 180mg dailys lopressor 25mg tid spironolactone 50mg [Hospital1 ] prilosec 20mg prn nortriptyline 20mg qHS prn metformin 1000mg [Hospital1 ] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Do not exceed 4 gm Acetaminophen daily. 5. Methadone 10 mg Tablet Sig: Ten (10) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing or SOB: New medication for COPD. 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily): New medication for COPD. 8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Previously on 11.5 mg daily but supratherapeutic; will need INR monitoring and titration. 12. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nortriptyline 10 mg Capsule Sig: [11-23] Capsules PO QHS (once a day (at bedtime)) as needed for insomnia. 15. Outpatient Lab Work INR monitoring. Please check [2115-7-5] AM and adjust coumadin dosing as appropriate. Coumadin restarted [2115-7-3] with INR 2.6. 16. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 17. Vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous twice a day for 12 days: For 2 weeks total. Started [2115-7-1]. On [2115-7-3] dose was decreased from 1500 mg [Hospital1 ] to 1250 mg [Hospital1 ] given trough of 22. 18. Cefepime 2 gram Recon Soln Sig: Two (2) gm Intravenous twice a day for 12 days: Two weeks duration, started [2115-7-1]. 19. Foley care Patient is being transported with Foley in place as he is too weak to participate in regular urinal use. Will need voiding trials as he improves with goal to discontinue Foley as soon as possible. Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital Discharge Diagnosis: Primary: Acute cellulitis, Peripheral vascular disease, right below knee amputation Secondary: Diabetes, obstructive sleep apnea, morbid obesity, coronary artery disease with history of myocardial infarction, congestive heart failure, tobacco use Discharge Condition: Hemodynamically stable, afebrile. Discharge Instructions: You were admitted with infection in your lower legs. You were treated with IV antibiotics and fluid. Your right leg was amputated because the infection was so severe that it would not heal and would put your at great risk. You did well with the operation. Once improved, you were discharged to rehab for further care including antibiotics, physical therapy and occupational therapy. Please take all medications as prescribed. Your rehab will be giving you your medications. Please keep all outpatient appointments. Seek medical advice immediately if you develop chest pain, difficulty breathing, fever, chills, diarrhea, pain with urination, severe pain in your leg or stump, uncontrolled bleeding or any other symptom that is concerning to you. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2115-7-23] 1:15PM Completed by:[2115-7-3] ICD9 Codes: 0389, 5849, 2761, 2851, 412, 4280, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5835 }	Medical Text: Admission Date: [2162-5-2] Discharge Date: [2162-5-11] Date of Birth: [2105-11-8] Sex: F Service: NEUROLOGY Allergies: Taxol Attending:[First Name3 (LF) 8850] Chief Complaint: Peripheral Edema. Major Surgical or Invasive Procedure: Thoracentesis. History of Present Illness: Ms. [Known firstname 1439] [Known lastname ] is a 56-year-old woman with history of metastatic breast cancer affecting brain and lungs, sarcoidosis, coagulopathy, presenting with lower extremity edema for the last 3 weeks. Patient reports that she has noticed the lower extremity edema since starting dexamethasone as part of her chemotherapy, as was noted in her neuro-oncology visit note. Patient reports she began having pain in her right leg that was worse with walking. She also reports having "cold like symptoms" with a [Known lastname ] and some runny nose, denies any fevers or chills. Patient decided to come into the ED after her symptoms were not improved with Tylenol. In the emergency department patient vitals were T: 97 HR: 114 BP: 127/103 O2 Sat:93% on 4L. Lower extremity ultrasound was obtained to evaluate for DVT, CTA of the chest ordered to rule out PE. Patient received vancomycin and levofloxacin for suspected post obstructive pneumonia. Patient also given 500 ml of saline bolus. Patient noted to have transient desaturations to mid 80's with movement. Given tenuous stauts, patient admitted to [Hospital Unit Name 153] for close monitoring. Past Medical History: ONCOLOGICAL HISTORY: Breast cancer with metastases to cerebellum -completed whole brain cranial irradiation on [2160-8-6], -s/p a third ventriculostomy by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. on [2161-4-22], -s/p Cyberknife radiosurgery on [2161-4-30] to a left cerebellar metastasis to 1,800 cGy at 82% isodose line and to a right cerebellar metastasis to 1,600 cGy at 73% isodose line on [2161-4-30], and -has been getting lapatinib and carboplatin every 3 weeks since [2161-9-11] for her progressive disease; delayed because of her surgeries. -s/p second third ventriculostomy procedure by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. on [2162-1-14]. -she was scheduled to receive Doxil on [2162-2-24] but did not go. OTHER PAST MEDICAL HISTORY: h/o Factor VIII deficiency Hypertension Sarcoidosis s/p Right lumpectomy [2146], L lumpectomy [2149] s/p Lung biopsy [2156] Social History: She does not smoke cigarettes, drink alcohol or use illicit drugs. She lives alone but her father has been staying with her and helping to take care of her. Family History: Her mother died of breast cancer. An aunt from the maternal side has breast cancer. She has 2 uncles, one died of smoking-related lung cancer while another is alive with non-smoking-related cancer. There are other members of her family with diabetes. Physical Exam: VITAL SIGNS: Tmax: 35.6 ??????C (96.1 ??????F) Tcurrent: 35.6 ??????C (96.1 ??????F) HR: 118 (118 - 118) bpm BP: 142/88(101) {142/88(101) - 142/88(101)} mmHg RR: 7 (7 - 7) insp/min SpO2: 90% Heart rhythm: ST (Sinus Tachycardia) PHYSICAL EXAMINATION GENERAL: Pleasant, well appearing woman with cushinoid features. SKIN: Rash along posterior surface of right leg. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. obese neck. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops LUNGS: Decreased breath sounds at right base, (+) Egophony. Anterior rhonchi on right. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Massive lower extremity edema to the thigh. NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 50. She is awake, alert, and able to follow commands. Her language is fluent with good comprehension. Her recent recall is fair. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [6-15] at all muscle groups, except for 2/5 strength in proximal lower extremities and triceps. She has 3/5 strength in foot dorsiflexors. Her muscle tone is normal. Her reflexes are 0 and symmetric bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. She cannot walk. Pertinent Results: ADMISSION LABS: CBC: [2162-5-1] 09:50PM BLOOD WBC-8.7 RBC-3.15# Hgb-11.0 Hct-33.6* MCV-107* MCH-35.1* MCHC-32.9 RDW-20.6* Plt Ct-134* [2162-5-2] 09:41AM BLOOD Neuts-86* Bands-6* Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-2* [2162-5-2] 09:41AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-2+ Microcy-1+ Polychr-1+ Tear Dr[Last Name (STitle) 833] LACTATE: [2162-5-1] 09:50PM BLOOD Lactate-3.5* [2162-5-2] 12:02PM BLOOD Lactate-2.6* CHEMISTRIES: [2162-5-1] 09:50PM BLOOD Glucose-133* UreaN-21* Creat-0.7 Na-140 K-3.2* Cl-105 HCO3-22 AnGap-16 PLEURAL FLUID: [2162-5-2] 01:31PM PLEURAL WBC-225* RBC-315* Polys-7* Lymphs-37* Monos-7* Meso-2* Macro-43* Other-4* [2162-5-2] 01:31PM PLEURAL TotProt-2.4 Glucose-105 Creat-0.4 LD(LDH)-428 Albumin-1.7 URINE ANALYSIS: [2162-5-2] 12:50AM URINE Color-Amber Appear-Hazy Sp [Last Name (un) ]->=1.035 [2162-5-2] 12:50AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.5 Leuks-MOD [2162-5-2] 12:50AM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-NONE Epi-1 ======= DISCHARGE LABS: [2162-5-7] 06:40AM BLOOD WBC-9.5 RBC-2.84* Hgb-9.6* Hct-30.9* MCV-109* MCH-33.7* MCHC-31.0 RDW-20.8* Plt Ct-118* [2162-5-7] 06:40AM BLOOD Glucose-106* UreaN-18 Creat-0.4 Na-141 K-4.1 Cl-107 HCO3-28 AnGap-10 [2162-5-7] 06:40AM BLOOD ALT-136* AST-144* AlkPhos-245* TotBili-1.2 ======= MICROBIOLOGY: Time Taken Not Noted Log-In Date/Time: [2162-5-2] 11:46 am URINE Site: CLEAN CATCH ADDED TO 0052J. FINAL REPORT [2162-5-4] URINE CULTURE (Final [2162-5-4]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S ------------ ================== IMAGING STUDIES: [2162-5-1] LENIs: No DVT [2162-5-1] CTA chest: 1. No definite evidence of pulmonary emboli. 2. Extensive lung masses and nodules involving both lungs, which appears to have increased when compared to prior exam. Some of these masses appear to encase the distal segmental pulmonary arteries. 3. Extensive ground-glass opacity and septal thickening. This could represent lymphangitic spread or edema. 4. Hypodense lesions in the liver concerning for metastasis and fluid within the perihepatic space. 5. Sclerotic lesions in the lower thoracic vertebral bodies with compression deformities. 6. Large left pleural effusion and small right pleural effusion. [2162-5-1] CT head: 1. Unchanged small hyperdense foci in the right cerebellar hemisphere within a known metastasis. Otherwise, no acute hemorrhage. 2. The extent of metastatic disease is better assessed on the [2162-4-26] MRI. [2162-5-4] CT Abd/Pelv (to r/o IVC obstruction) IMPRESSION: 1. Attenuation of the intrahepatic IVC due to extensive hepatic metastatic disease, without evidence of severe stenosis or thrombus. The infrahepatic IVC and iliac veins remain patent. 2. Known pulmonary metastases. Worsened ground-glass opacity within the right middle and lower lobes which may represent edema or tumor spread. 3. Decreased size of right pleural effusion which is now moderate. Unchanged small left pleural effusion. 4. Pelvic free fluid. 5. Osseous metastatic disease with T9 vertebral body compression fracture. Brief Hospital Course: This is a 56-year-old woman with metastatic breast cancer to bone, lung and brain, presenting with worsening lower extremity edema, found to be hypoxic and with new large right pleural effusion. (1) RESPIRATORY DISTRESS: On admission the pt required 4L O2, while her baseline is 100%on RA. The patient did not have a fever, had minimal [Last Name (LF) ], [First Name3 (LF) ] pneumonia seemed less likely, and CTA was negative for PE. Since the patient did have significantly increased size of her pulmonary metastases it seemed the most likely cause of the pt's hypoxia was the metastasis combined with the large right pleural effusion. On [2162-5-2] the pt had a therapeutic thoracentesis which per the patient provided an improvement in symptoms. Despite therapeutic thoracentesis patient has continued to have a [5-16] liter oxygen requirement. CXR on [2162-5-5] demonstrated some re-accumulation of the right sided pleural effusion and interval increase in the left sided pleural effusion. Interventional radiology was consulted for possible repeat thoracentesis or pleurX catheter placement but did not feel there was enough fluid on ultrasound to safely attempt thoracentesis. Patient has remained comfortable with her breathing despite her oxygen requirement. (2) LOWER EXTREMITY EDEMA: On admission the patient had bilateral pitting edema to the thighs, with petechiae on the right side that appeared to be dependent petechiae. Admission lower extremity dopplers were negative for DVT, so the patient's extremities were kept elevated. Given history of liver mets near the IVC there was concern for obstruction of venous return, though abdominal imaging did not demonstrate any IVC obstruction though the read did comment on intra-hepatic attenuation of the IVC likelyy due to extensive liver metastases. The patient also had an X-ray of the right ankle as it was quite tender on admission, and the X-ray was negative for fracture and foreign body. (3) METASTATIC BREAST CANCER: OMED team in contact with primary oncologist Dr. [Known lastname ] [Last Name (NamePattern1) 15759] who did not support further chemotherapy given patient's poor prognosis. A family meeting was held which also included the palliative care team and patient and family felt comfortable with discharge to hospice. (4) URINARY TRACT INFECTION: On admission on [2162-5-2] the patient was started on Levaquin for a three-day course of antibiotic treatment for UTI. However, urine grew enterococcus so patient started on vancomycin which was changed to amoxicillin to complete a 7 day course. Patient was DNR/DNI during this admission. Medications on Admission: Iron Diovan Dexamathasone 4gm [Hospital1 ] Vitamin D Vitamin B6 Nexium Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 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. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO twice a day. 9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 3005] Hospice Discharge Diagnosis: Primary: Metastatic Pleural Effusions, Urinary Tract Infection Secondary: Metastatic Breast Cancer, Hypertension, Sarcoidosis, Factor VIII Deficiency Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for work up of your low blood oxygen level and lower extremity swelling. We determined that you had fluid around your lungs and some of this fluid was drained. You continue to require oxygen because some of this fluid has reaccumulated. We are not exactly sure what is causing your lower leg swelling but feel that it is likely related to your cancer. During your admission we also found that you had a urinary tract infection which was treated. Please take all medications as directed. You are going home with hospice care. Followup Instructions: Please follow up with your oncologist as below: RADIOLOGY MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2162-6-21] 11:15 [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2162-6-21] 1:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2503], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2162-7-2] 11:00 Completed by:[2162-5-13] ICD9 Codes: 5990, 5789, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5836 }	Medical Text: Admission Date: [2184-2-9] Discharge Date: [2184-2-18] Service: SURGERY Allergies: Aspirin Attending:[First Name3 (LF) 4691] Chief Complaint: R chest wall pain Major Surgical or Invasive Procedure: [2184-2-9] exploratory laparotomy, right thoracotomy with packing [2184-2-11] 1. Unpack packed abdomen with abdominal washout and closure. 2. [Doctor Last Name ] gastropexy with feeding gastrostomy. 3. Unpack packed right hemithorax. 4. Internal fixation of multiple (#4) ribs. History of Present Illness: 86F transferred from referring institution after falling down 10 stairs onto her right side. Now with rib fractures along her entire right side. Past Medical History: alzheimer's dementia, HTN, OP, Gerd, ^chol Social History: nc Family History: nc Physical Exam: deceased Pertinent Results: [2184-2-9] 02:45AM PT-12.7 PTT-23.3 INR(PT)-1.1 [2184-2-9] 02:45AM WBC-8.4 RBC-3.53* HGB-10.7* HCT-31.0* MCV-88 MCH-30.2 MCHC-34.4 RDW-13.6 [2184-2-9] 02:45AM cTropnT-<0.01 [2184-2-9] 02:45AM CK(CPK)-73 [2184-2-9] 02:45AM GLUCOSE-182* UREA N-34* CREAT-1.3* SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13 CXR [2184-2-9] 8:19 AM Increased right pleural effusion (likely hemothorax) with increasing right basilar opacity, which likely reflects atelectasis. No evidence of pneumothorax. KUB [2184-2-9] 2:06 AM No radiographic evidence of intraperitoneal air. Large hiatal hernia. Right rib [6-27] fractures Brief Hospital Course: Briefly, Mrs. [Known lastname ] was transferred to [Hospital1 18] from a referring institution on [2184-2-9] after she fell down 10 steps onto her R side with no LOC sustaining severe R 8-10th rib fractures. Per referring institution reports, her head CT and spine CT were negative. CT here showed no active bleeding into any cavity but there was concern for liver herniation through a diphragmatic injury versus an eventrated diaphragm on the right. While in the ED on the early AM of [2-9] the patient became hypotensive. Surgery was called. Fluids were begun and the patient was moved the patient to the TSICU. Shortly thereafter she coded with PEA arrest x25 min. During the code a chest tube was placed with no air gush but 700cc blood emptied immediate into the pleurovac. This bleeding persisted. A TEE during the code showed a type B thoracic aortic dissection, probably due to CPR and previously undiagnosed critical aortic stenosis (valve 0.8 cm) which likely cause the PEA arrest. She was resuscitated regaining normal pulses and relatively normotension on pressors. Since she was continuing to bleed from the chest she was taken to OR. Initially an exploratory laparotomy was performed but the liver and diaphragm were uninjured. A thoracotomy was then done showing massive hemorrhage into the chest from multiple broken ribs - probably related to the CPR. Multiple belledrs were ligated, packing was placed, and she received 12 units RBC, 4 units FFP, 2 units PLT, 1 unit cryoprecipitate and 25 mcg/Kg Factor 7a before being controlled. She was closely monitored in the TSICU post-operatively. On [2-11] pt returned to OR for unpacking, washout and wound closure of the chest and abdomen. All sites were dry. 2 chest tubes remained in place. She was followed by APS for analgesia, nephrology for ischemic ATN and oliguria in the setting of hemorrhagic PEA arrest, neurology was asked to evaluate for possible anoxic brain injury. Neurologic eval was remarkable for minimal cortical function on EEG, c/w anoxic brain injury. On [2-13] the palliative care team met with patient's family. Another family meeting was held on [2184-2-16], and it was decided that she would be extubated and made CMO with her family present on [2184-2-17]. She expired peacefully at 4:45am this morning with her family present at the bedside. Medications on Admission: aripirazole 20'', amlodipine 5', Aricept 10', Lisinoril 10', Lipitor 20', Mirtazapine 15', colace, vit d, MVI Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: multiple right rib fractures s/p fall Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: n/a ICD9 Codes: 5119, 2762, 5845, 4019, 4275, 4241, 4589, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5837 }	Medical Text: Admission Date: [2166-9-4] Discharge Date: [2166-9-8] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: right upper lobe lung cancer Major Surgical or Invasive Procedure: bronchoscopy, needle aspiration History of Present Illness: This is an 85 year old female who presented to [Hospital1 18] after a CXR at [Hospital 46] rehab demonstrated a RUL mass. A CT scan confirmed a mass as well as pericardial adenopathy and an sooiciated RLL nodule. A bone scan showed increased uptake in her left hip. She was admitted to the thoracic surgery service for work up of her nodules. Past Medical History: A-fib, COPD, HTN, CHF, neuropathy, asthma, OA, depression Social History: 45 pack year smoker Family History: brother- breast CA, brother- brain CA, mother- cervical CA, brother- stomach CA Physical Exam: VS- 98.1, 51, 142/58, 18, 94% 3L Gen- NAD CV: S1S2, irregular Resp: coarse rales b/l Abd: soft, NT/ND Ext: no c/c/e Pertinent Results: [2166-9-4] 07:40PM BLOOD WBC-14.8* RBC-4.18* Hgb-10.7* Hct-32.8* MCV-79* MCH-25.7* MCHC-32.7 RDW-16.7* Plt Ct-219 [2166-9-6] 03:17AM BLOOD WBC-19.7# RBC-3.92 Hgb-10.1* Hct-30.8* MCV-79* MCH-25.8* MCHC-32.8 RDW-16.5* Plt Ct-186 [2166-9-4] 07:40PM BLOOD PT-15.8* PTT-25.1 INR(PT)-1.4* [2166-9-4] 07:40PM BLOOD Glucose-99 UreaN-21* Creat-0.6 Na-139 K-4.0 Cl-105 HCO3-25 AnGap-13 Brief Hospital Course: This is an 85 year old female who was admitted on [2166-9-4] for workup of a right sided lung nodule. A CT scan demonstrated extensive mediastinal and bilateral hilar lymphadenopathy with the cavitary spiculated lesion in the right upper lobe and a second spiculated lesion in the right middle lobe. There was also a right pleural effusion and a small pericardial effusion. Geriatrics was consulted. Orthopedics was consulted for a left minimally displaced femoral greater trochanter fracture, possibly due to metastatic disease. A bronchoscopy was done HD 2, as well as needle aspiration. NSCLC was suspected. She desaturated later that night, but she is DNR/DNI. After extensive discussion with her family, the desicion was made to refrain from further intervention and control her pain only. On HD 4, a morphine dripe oversedated her. MS contin was started with some success. On HD 5, she was discharged to hospice. Medications on Admission: duonebs, advair, ventolin, xalatan, coumadin, diovan, HCTZ, colace, pravachol, singulair, vicodin, xanax Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q 2hrs PRN as needed for pain: disp 30 ml. Disp:30 ml Refills:2 2. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO Q 4 hrs PRN. Disp:12 Tablet(s) Refills:2 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:2 4. Ipratropium Bromide 0.02 % Solution Sig: [12-23] Inhalation Q6H (every 6 hours). Disp:1 inhaler Refills:2 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: [12-23] Disk with Devices Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 6. Morphine 2 mg/mL Syringe Sig: [12-23] Injection Q2H (every 2 hours) as needed: breakthrough pain. Disp:30 ml Refills:2 Discharge Disposition: Extended Care Facility: [Last Name (un) 14710] House (Hospice Home) - [Location (un) 620] Discharge Diagnosis: right sided lung cancer Discharge Condition: terminal Discharge Instructions: Please discharge patient to Hospice Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2038], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2167-3-18] 11:00 Completed by:[2166-9-8] ICD9 Codes: 496, 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5838 }	Medical Text: Admission Date: [2112-8-5] Discharge Date: [2112-8-16] Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: This is an 84-year-old woman who was admitted to [Hospital3 417] Hospital on [2112-8-4], and ruled in for a non-Q-wave myocardial infarction by enzymes and electrocardiogram criteria. She subsequently developed postinfarction angina and was referred to the [Hospital6 1760] for cardiac catheterization on [2112-8-5]. Cardiac catheterization at that time demonstrated that she had a left dominant system. There was an 80% stenosis of the left main coronary artery, severe obstructions of the left anterior descending, first diagonal, distal circumflex, and left posterior descending coronary arteries. The right coronary artery was occluded and diminutive. An echocardiogram revealed an ejection fraction of 40%. On [8-7], Cardiothoracic Surgery was consulted and evaluated the patient. At that time it was recommended that the patient undergo coronary artery bypass grafting. MEDICATIONS ON ADMISSION: Diltiazem ER 240 mg p.o. q.d., Isosorbide 90 mg p.o. q.d., Accupril 40 mg p.o. q.d., Atenolol 100 mg p.o. q.d., ASA 81 mg p.o. q.d., Gabapentin 300 mg p.o. q.h.s. PHYSICAL EXAMINATION: Vital signs: Temperature 98.2??????, pulse 52, blood pressure 120/60, respirations 18. General: She was awake and comfortable and was pleasant. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Neck: Supple. No jugular venous distention. Heart: Regular, rate and rhythm. No murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Protuberant, but soft, nontender, and nondistended. Normoactive bowel sounds. Extremities: Warm and well perfused without edema. PAST MEDICAL HISTORY: Chronic renal insufficiency with a creatinine of 2.0. Coronary artery disease. Hypertension. Gout. Arthritis. HOSPITAL COURSE: The patient was initially admitted to the Medicine Service where she underwent the aforementioned studies. Her surgery was delayed because of a bump in her creatinine to a peak of 3.0, thought to be secondary to acute tubular necrosis from the cardiac catheterization. On [8-8], the patient underwent a vein mapping which revealed that the right greater saphenous and bilateral lesser saphenous veins were all patent. This study failed to identify a left greater saphenous vein. Over the days leading up to her surgery, her creatinine began to drop indicative of resolution of her acute tubular necrosis. She had isolated episodes of anginal pain treated with Lopressor. On [2112-8-10], the patient underwent and uncomplicated aorto-coronary bypass graft times three with a left internal mammary to the left anterior descending, reversed autogenous saphenous vein to the first diagonal and circumflex marginal coronary arteries. The patient tolerated the procedure well and was transported to the Cardiothoracic Surgery Intensive Care Unit, intubated, stable, and in good condition. The patient remained intubated over night. She was found to have a lactic acidosis and was receiving bicarb. She had a low urine output and a low cardiac index; she was given Hespan and started on a Dobutamine and Neo-Synephrine drip. She underwent a transesophageal echocardiogram which was significant for a hypokinetic inferior wall with good left ventricular function and mild mitral regurgitation and trace tricuspid regurgitation. The heart was noted to be underfilled. The patient was being AV paced, and no ectopy was noted. Her creatinine had declined to baseline levels, and she was making 30-45 cc/hr of urine. By the morning of postoperative day #2, the patient's Neo-Synephrine drips had been weaned. She was placed on CPAP and was continuing to be paced. Her urine output remained adequate, and her lactate level declined to 2.8. The patient tolerated CPAP and was extubated. Her chest tube was removed. The patient was weaned from the ventilator and was extubated. On postoperative day #3, the patient had been noted to have a few episodes of premature atrial contractions after her Neo-Synephrine drip was discontinued. Her pacemaker was turned off, and the patient was in normal sinus rhythm at a rate of 86-88. She was noted to be in first degree AV block without ectopy. By postoperative day #4, her Dobutamine drip had been discontinued, and her cardiac index was above 2.0. She continued to undergo her Lasix diuresis putting out greater than 400 cc/hr. As the patient was deemed stable and in good condition, her Swan-Ganz catheter was removed, and she was transferred to the floor. On postoperative day #5, the patient was in stable cardiopulmonary condition. She was making good urine. Her pressures and heart rate were stable. Her Foley was discontinued, and she was ready for rehabilitation placement. On postoperative day #6, the patient obtained a bed and was subsequently discharged to rehabilitation in stable condition. DISCHARGE MEDICATIONS: Lopressor 12.5 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d., Potassium Chloride 20 mEq p.r.n., Colace 100 mg p.o. b.i.d., Aspirin 81 mg p.o. q.d., Percocet [12-1] tab p.o. q.3-4 hours p.r.n. pain, Protonix 40 mg p.o. q.d., Combivent MDI 2 puffs inhaled q.4 hours p.r.n., Gabapentin 300 mg q.h.s. DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature 97.4??????, heart rate 79, blood pressure 126/64, respirations 18, oxygen saturation 89-91% on room air. Neck: Supple. Lungs: Clear with slightly coarse breath sounds bilaterally. Her sternum was stable, clean, dry and intact. Heart: Regular, rate and rhythm. No murmurs, rubs or gallops. Abdomen: Her belly was soft, nontender, nondistended. Extremities: Warm and well perfused. Her incision was clean, dry and intact. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting. 2. Acute on chronic renal insufficiency. DISPOSITION: The patient is discharged to rehabilitation in stable condition. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 13625] Dictated By:[Last Name (NamePattern1) 3801] MEDQUIST36 D: [2112-8-16] 13:42 T: [2112-8-16] 13:44 JOB#: [Job Number 36811] ICD9 Codes: 5845, 2762, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5839 }	Medical Text: Admission Date: [2143-3-2] Discharge Date: [2143-3-5] Date of Birth: [2069-1-30] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5569] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 74 yoF with vascular dementia and history of cadaveric kidney transplant at [Hospital1 112] ten years ago, comes form [Hospital3 12272] center where she had been complaining of persistent non productive cough and dysuria for one week. This morning she complained of worsening LLQ abdominal pain. She was brought to ED where a CT scan of her abdomen revealed a large 6.6 (TRV) x 4.5 (AP) x 21.6 (CC) cm rectus sheath hematoma. She is pleasantly demented, and complains only of some mild Left sided abdominal pain. Her daughter, who is with her, reports that she has been experiencing a peristent non productive cough and dysuria. ROS: she denies any chest pain, SOB, headache, vision changes, musculoskeletal pain, nausea, vomiting or diarrhea. Past Medical History: history of DVT bilateral legs [2131] - told by PCP she CANNOT go off anticoagulation. Anxiety, frequent UTI, hypercholesterolemia, CRF s/p CRT in [2132](?), HTN, vascular dementia. PSgH: CRTx in [2132] at [Hospital1 112]. Social History: Lives at [Location (un) ] Alzheimer Unit ([Location (un) 538]) Physical Exam: AAO x 1, pleasantly demented RRR no MRG appreciated on auscultation CTA B/L no RRW Soft, minimally tender in Left side, palpable mass c/w rectus sheath hemoatoma on left side, scars c/w prior surgery as above. + edema B/L Brief Hospital Course: 74 yo F h/o Vascular Dementia, Renal transplant, DVTs on coumadin admitted with recuts sheath hematoma on supratherapeutic Coumadin. She was admitted and started on Vitamin K and give FFP given in ED. Coumadin was held. FFP 4 units and a total of 3 units of PRBC and 2 units of platelets were administered. Serial HCT checks and coags were done until stable. Serial abdominal exams were done noting increased bruising along left flank and abdomen. Discomfort abated. Bruising stopped. Vital signs remained stable. She did not requird embolizaton. Initially, she was kept NPO, but once stable, diet was resumed and tolerated. PT was consulted and noted that patient was at baseline. Recommendations were to return to chronic placement at alzheimer unit at [Location (un) ] in [Location (un) 538]. The decision was made to stop the coumadin given hematoma and h/o falls. Information communicated to Dr.[Name (NI) 90239] (PCP)nurse ([Telephone/Fax (1) 3530]). She was discharged in stable condition back to [Location (un) ] off Coumadin. Medications on Admission: [Last Name (un) 1724]: ativan 0.5 q6 PRN, tylenol, benzonatate 100 TID prn cough, robitussin prn cough, namenda 10 q am and 5 q pm, pravastatin 40 qhs, prednisone 10 q am, citalopram 10 q am, lisinopril 20 q am, mycophenolate 1500 [Hospital1 ], donepezil 10 q am, CaCO3 600 [Hospital1 ], MVI, Coumadin 2.5 M,F and 3.5 T,W,Th,Sa,[Doctor First Name ]. ALL: nkda Discharge Medications: 1. Discontinued Meds Coumadin 2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. memantine 5 mg Tablet Sig: Two (2) Tablet PO q am (). 5. memantine 5 mg Tablet Sig: One (1) Tablet PO q pm (). 6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. mycophenolate mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) ] Discharge Diagnosis: Left rectus sheath hematoma supra therapeutic inr h/o dvts h/o renal transplant Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). See PT notes Discharge Instructions: You will transfer back to [Location (un) ] in [Location (un) 538] with [Location (un) 86] VNA Followup Instructions: follow up with Dr. [Last Name (STitle) ] in 1 week Completed by:[2143-3-5] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5840 }	Medical Text: Admission Date: [2138-7-26] Discharge Date: [2138-8-12] Date of Birth: [2065-4-11] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 73-year-old female with a history of type 1 diabetes mellitus, hypertension, coronary artery disease, atrial fibrillation, who presented after approximately four hours of pain, numbness and cold sensation of her left arm. She was awakened by this pain and this precipitated her to seek attention at [Hospital1 346]. PAST MEDICAL HISTORY: Significant for known coronary artery disease, hypertension, diabetes mellitus, atrial fibrillation, patient was discharged from the hospital two weeks prior to admission with acute onset of atrial flutter which was treated at the time with anticoagulation. She presented with an acute embolic event to her left arm. PAST SURGICAL HISTORY: Significant for excision of a cyst on her left axilla and some skin graft procedure. MEDICATIONS: Preoperative medications included insulin, Atenolol, Coumadin, Lipitor, Zestril and Zantac. PHYSICAL EXAMINATION: Vital signs on admission to the hospital were as follows. The patient was afebrile, blood pressure 220/110, heart rate 144, atrial flutter, respiratory rate 16 and oxygen saturation of 100%. She was neurologically alert and oriented. She had 5/5 strength on the right upper extremity and 1-2/5 on the left and also decreased sensation of the left arm. She was in atrial fibrillation by cardiac exam. Her respiratory exam was unremarkable. Her lungs were clear to auscultation bilaterally. Abdomen was soft, non distended, nontender. The patient had a left doppler signal in the axillary area and no arterial flow documented in the brachial, ulnar or radial arteries. On the right side the patient had palpable pulses throughout her right arm. On her legs, the left femoral pulse was obtainable by doppler and her right was palpable and she had doppler signals bilaterally in her popliteal arteries as well as her feet. LABORATORY DATA: Patient's admitting PT was 14, admitting INR was 1.3. Other laboratory values on admission were unremarkable. HOSPITAL COURSE: The patient was admitted to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] service and was taken to the operating room the day of admission, [2138-7-26] where she underwent a left upper extremity embolectomy. The patient also had a right IJ triple lumen catheter placed for IV access. Postoperatively the patient was stable hemodynamically, was heparinized, had a therapeutic PTT and was noted to have a large hematoma in the left incision site. The patient was also placed on a Diltiazem IV drip due to atrial flutter with rapid ventricular response. Cardiology consultation was obtained later on the day of admission, [2138-7-26]. It was their recommendation to decrease the Diltiazem drip, to place her on oral Lopressor and to follow-up with transesophageal echocardiogram. The patient remained stable from a hemodynamic standpoint. Her hematoma showed no signs of increasing or enlarging and was felt to be stable and not require any intervention from a vascular surgery standpoint. Electrophysiology service was consulted regarding the persistent atrial dysrhythmia. On postoperative day #2 the patient was transferred to the cardiology medicine service since she had no active vascular surgical issues at this time. Her history of coronary artery disease and atrial dysrhythmias were felt to be the predominant problems at this time. The patient underwent echocardiogram on [2138-7-30] which revealed a moderate to severe spontaneous echo contrast seen in the body of the left atrium, no mass or thrombus was seen in the left atrium or left atrial appendage. The patient also underwent cardiac catheterization on [2138-7-30] which revealed a left ventricular ejection fraction of 40%, a significant three vessel coronary artery disease including a left main osteal lesion of 80% and also pulmonary hypertension. The patient was followed on the medicine service over the next few days. Cardiac surgery consult was obtained and the patient was taken to the operating room on [2138-8-4] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] where she underwent a coronary artery bypass graft times three with a LIMA to the LAD, a vein to the ramus and a vein to the distal circumflex artery. Postoperatively she was on Norepinephrine, Epinephrine and Milrinone IV drip and she was transported from the operating room to the cardiothoracic Intensive Care Unit in stable condition. Postoperatively the Norepinephrine was weaned off the night of surgery. She was maintained on low dose Epinephrine drip and the Milrinone was discontinued. On postoperative day #1 the patient had improved hemodynamically, she was weaned down from mechanical ventilator and extubated on postoperative day #1. On postoperative day #2 the patient remained in atrial fibrillation with a ventricular rate of 70-90/minute. Her blood pressure stabilized with time. She was treated with IV Amiodarone and an attempt at elective synchronous cardioversion was undertaken and unsuccessful. The patient remained in atrial fibrillation over the next couple of days. In the cardiothoracic Intensive Care Unit on [2138-8-8], postoperative day #4, another attempt at cardioversion was made after an additional IV Amiodarone bolus. There were three attempts made at that time using 300 followed by 360 joules and these attempts were also unsuccessful. The patient had been anticoagulated throughout her postoperative course on IV Heparin drip and Coumadin had been started on postoperative day #2. The patient was transferred out of the Cardiothoracic Intensive Care Unit on postoperative day #4, [2138-8-8] to the telemetry floor where she was begun with ambulation and cardiac rehabilitation. The patient initially had significant difficulty ambulating. She had significant weakness in her right leg with attempts to ambulate. It was questioned whether the patient possibly had cerebrovascular accident, however, she was alert and oriented, she had clear speech, she had equal hand grasps bilaterally and the weaker leg which was the right, was her saphenous vein harvest site leg. Attempts at ambulation did improve significantly over the next 48 hours although she still complained of a heavy feeling in her right foot and right leg. Today, postoperative day #7, [2138-8-11], the patient is hemodynamically stable and ready to be discharged to a rehabilitation facility. Her exam is as follows: She is alert and oriented, her pupils are equal and react to light and accommodation. Her speech is clear. She still has some right lower extremity weakness, it is unclear as to the etiology of this. She has bilateral equal hand grasps which are significantly strong and does not appear to have any other neurologic deficits. Her lungs are clear to auscultation with few bibasilar crackles, left greater than right. The patient has a smoking history. She has some sputum production which is clear and scant amount. Her heart sounds are irregular with no murmur noted. Her sternum is stable. Her Steri-Strips are clean, dry and intact to her sternal incision. Her Steri-Strips to her right leg incisions are also clean, dry and intact. Patient's most recent INR values are as follows. On [8-9] her INR was 1.6. On [8-10] her INR is 1.8. On [8-11] her INR was 3.1. It was today, on [8-11], that her Heparin was discontinued. The patient has received 2.5 mg of Coumadin on [8-25], [8-9] and [8-10]. She is to receive 1 mg of Coumadin today, [8-11] and her INR should be checked daily until she is on a stable dose of Coumadin with her target INR being 2.5 to 3.0 for her atrial fibrillation and history of embolic events. DISCHARGE MEDICATIONS: Lasix 20 mg po bid times one week, potassium chloride 20 mEq po q d times one week, Zantac 150 mg po bid, Amiodarone 400 mg po q d, Captopril 50 mg po tid, Lipitor 20 mg po q h.s., Lopressor 25 mg po bid, Dulcolax tablets 100 mg po bid prn, Coumadin 1 mg today, [8-11], follow prothrombin time and INR for target INR of 2.5 to 3.0 as previously discussed. NPH insulin 12 units subcu q a.m., 5 units subcu q p.m., Percocet 1-2 tablets q 4 hours prn pain, sliding scale regular insulin before meals and at bedtime as follows: Blood sugar 150-200 = 3 units regular insulin subcutaneously, blood sugar 201-250 = 6 units and 251-299 equals 9 units, blood sugar of 300-350 = 12 units. The patient is being discharged to a rehabilitation facility in stable condition. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post coronary artery bypass graft. 2. Left arm arterial embolus status post left arm embolectomy. 3. Atrial fibrillation. 4. Insulin dependent diabetes mellitus. 5. Hypertension. FOLLOW-UP: The patient is to follow-up with Dr. [Last Name (STitle) 70] in [2-16] weeks and the patient is to follow-up with her primary care physician who is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2961], [Telephone/Fax (1) 99394] upon discharge from the rehabilitation facility. It was felt to be left up to the discretion of Dr. [Last Name (STitle) 2961] whether she felt it was imperative to work up the patient for possibility of a CVA. It was felt appropriate for the patient to be discharged at this time to rehabilitation facility to work on cardiac rehabilitation and physical therapy and if the right leg weakness did not resolve, that would be left up to the discretion of Dr. [Last Name (STitle) 2961] to work that up for definitive diagnosis in the right leg weakness. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2138-8-11] 14:24 T: [2138-8-11] 17:35 JOB#: [Job Number ] ICD9 Codes: 4240, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5841 }	Medical Text: Admission Date: [2185-11-7] Discharge Date: [2185-11-13] Date of Birth: [2109-9-30] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[First Name3 (LF) 1505] Chief Complaint: abnormal stress test Major Surgical or Invasive Procedure: Coronary artery bypass grafting (left anterior mammary artery to left anterior descending, saphenous vein graft to obtuse marginal and diagonal) [2185-11-9] History of Present Illness: Mr. [Known lastname ] is a 76 year old man with a history of non obstructive coronary artery disease and hypertension who was admitted after a cardiac catheterization showed three vessel disease not ammenable to intervention. Past Medical History: Coronary artery disease, noncritical Hypertension Left ear basal cell cancer s/p surgery in [State 108] [2183] Gastro-intestinal reflux disease Asbestosis Erectile dysfunction Benign prostatic hypertrophy Social History: Mr. [Known lastname ] lives with his wife and has five adult children, 12 grandchildren, and 5 great-grandchildren. He is very active he walks three times weekly. He quit smoking in [2153] and has a 30 year history. He denies alcohol and illicit drug use. Family History: His son had a coronary artery bypass graftin at age 48. Physical Exam: ADMISSION EXAM: GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, oropharynx clear with no erythema or exudates, upper dentures. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: RRR, normal S1, S2, +S4. No m/r/g. LUNGS: clear to ausculation anteriorly given that pt is on bedrest from cath, no crackles, wheezes or rhonchi. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. No HSM or tenderness. EXTREMITIES: warm and well perfused. No femoral bruits, cath site wtih dressing in place, no hematoma or ecchymosis, minimally tender to palpation, 2+ DP pulses SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 30998] (Complete) Done [2185-11-9] at 12:41:53 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2109-9-30] Age (years): 76 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG ICD-9 Codes: 424.0 Test Information Date/Time: [2185-11-9] at 12:41 Interpret MD: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Name Initial (MD) ] [Name8 (MD) 4901], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW2-: Machine: U/S 3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.9 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - MVA (P [2-6] T): 4.7 cm2 Findings LEFT ATRIUM: No mass/thrombus in the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Mild spontaneous echo contrast in the LAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal regional LV systolic function. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple 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. Mild (1+) mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST-BYPASS Normal biventricular systolic function. Left ventricular ejection fraction now 55-60%. No changes in valvular function. The thoracic aorta is intact after decannulation. Radiology Report CHEST (PA & LAT) Study Date of [2185-11-12] 1:08 PM CHEST (PA & LAT) Clip # [Clip Number (Radiology) 30999] Reason: eval for effusion Final Report AP PORTABLE CHEST HISTORY: Post-CABG. COMPARISON: [2185-11-11]. Right jugular catheter has been removed. There is no evidence of pneumothorax or vascular congestion. No significant infiltrate is seen. Heart is slightly enlarged. Pleural plaquing is again noted. IMPRESSION: No pneumothorax post-central venous line removal. [2185-11-7] 12:45PM BLOOD WBC-5.1 RBC-4.31 Hgb-13.5* Hct-39.4* MCV-91 MCH-31.4 MCHC-34.4 RDW-13.1 Plt Ct-173 [2185-11-8] 07:35AM BLOOD WBC-5.7 RBC-4.39* Hgb-14.0 Hct-40.9 MCV-93 MCH-31.8 MCHC-34.1 RDW-13.2 Plt Ct-184 [2185-11-9] 11:46AM BLOOD WBC-8.4 RBC-3.34* Hgb-10.5# Hct-31.0 MCV-93 MCH-31.4 MCHC-34.0 RDW-13.3 Plt Ct-113* [2185-11-10] 02:04AM BLOOD WBC-9.2 RBC-3.02* Hgb-9.6* Hct-27.0* MCV-89 MCH-31.9 MCHC-35.7* RDW-13.0 Plt Ct-128* [2185-11-11] 03:51AM BLOOD WBC-11.7* RBC-3.16* Hgb-10.0* Hct-29.4* MCV-93 MCH-31.5 MCHC-34.0 RDW-13.4 Plt Ct-132* [2185-11-12] 07:05AM BLOOD WBC-9.5 RBC-3.28* Hgb-10.3* Hct-30.2* MCV-92 MCH-31.4 MCHC-34.2 RDW-12.6 Plt Ct-139* [2185-11-7] 12:45PM BLOOD PT-13.2 INR(PT)-1.1 [2185-11-7] 12:45PM BLOOD Plt Ct-173 [2185-11-12] 07:05AM BLOOD Plt Ct-139* [2185-11-7] 12:45PM BLOOD Glucose-102* UreaN-12 Creat-0.8 Na-141 K-4.2 Cl-104 HCO3-28 AnGap-13 [2185-11-8] 07:35AM BLOOD Glucose-185* UreaN-13 Creat-0.8 Na-139 K-4.1 Cl-99 HCO3-31 AnGap-13 [2185-11-9] 11:46AM BLOOD UreaN-11 Creat-0.7 Na-145 K-4.0 Cl-110* HCO3-25 AnGap-14 [2185-11-10] 02:04AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-136 K-4.3 Cl-102 HCO3-28 AnGap-10 [2185-11-11] 03:51AM BLOOD Glucose-147* UreaN-12 Creat-0.7 Na-130* K-4.0 Cl-93* HCO3-31 AnGap-10 [2185-11-12] 07:05AM BLOOD Glucose-123* UreaN-17 Creat-0.8 Na-129* K-4.4 Cl-90* HCO3-34* AnGap-9 [2185-11-13] 07:05AM BLOOD UreaN-16 Creat-0.8 Na-137 K-4.5 Cl-97 [2185-11-7] 12:45PM BLOOD %HbA1c-6.2* eAG-131* Brief Hospital Course: Mr. [Known lastname ] is a 76 year old male with history of hypertension who was admitted with one year of progressive chest pressure, found to have diffuse three vessel disease requiring coronary artery bypass grafting. He was managed medically on the floor while undergoing a pre-operative work-up. On [11-9] he underwent a coronary artery bypass grafting (left anterior mammary artery to left anterior descending, saphenous vein graft to obtuse marginal and diagonal) performed by Dr. [Last Name (STitle) ]. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He extubated without incident on the same day. On POD #1 he was transferred to the septdown unit. His chest tubes and temporary pacing wires were removed per protocol. He was started on statin, betablockers, and gently diuresed toward his pre-op weight. He developed a brief episode of post-op afib whcih was treated with IV and po amiodarone and he converted back to sinus rhythm. Postoperative CXR showed a stable left apical pneumothorax. He was evaluated by physical therapy and discharge to home with VNA services was recommended. On POD# 4 he was cleared for discharge to home in stable condition. Medications on Admission: atenolol 25 mg daily tamsulosin 0.4mg daily aspirin 81 mg daily multivitamin Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:3 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Do not drive, drink alcohol, or operate machinery while taking this medication. Disp:50 Tablet(s) Refills:0 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever/pain. 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Start after finishing 400mg once daily for 7 days. Continue this dose until follow up with cardiologist. Disp:30 Tablet(s) Refills:2 12. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 13. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 7 days. Disp:7 Capsule, Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: coronary artery bypass grafting CAD 3 vessel disease noncritical, Hypertension, Left ear basal cell CA s/p surgery in FLA [2183], GERD, Asbestosis, Erectile dysfunction, BPH Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 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 Surgeon Dr. [First Name (STitle) ] [Name (STitle) ] [Telephone/Fax (1) 170] on [12-14] at 1:30pm in the [Hospital ] medical office building [Hospital Unit Name ], [Last Name (NamePattern1) ], [Location (un) 86] Cardiologist: [Last Name (LF) ], [First Name3 (LF) ] on [11-18] at 8:15am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] L. [Telephone/Fax (1) 10381] in [5-10] 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 Completed by:[2185-11-13] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5842 }	Medical Text: Admission Date: [2103-10-13] Discharge Date: [2103-10-19] Date of Birth: [2028-4-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 29767] Chief Complaint: nausea, weakness Major Surgical or Invasive Procedure: None History of Present Illness: 75 yo with h/o severe HTN, DMII, CRI, h/o prostate cancer s/p chemo/XRT, left [First Name3 (LF) 6024], presents from home with nausea and weakness since morning of admission and constant emesis on DOA. Patient was unable to tolerate po and did not take any of his medications including anti-hypertensives or insulin on DOA. In the ED: SBP 220's, tachy at 100-125, given hydralazine. The patient was actively vomiting. LBBB demonstrated on EKG old, but patient had a troponin of 0.1 (CK/MB flat). Blood sugars elevated in 400's with anion gap 27, ketones/glucose in urine, lactate 4.4. Insulin gtt started and femoral line placed as unable to get other access. He was given empiric Vanco and ceftriaxone and transferred to the MICU for further management. In the MICU, insulin gtt was weaned when AG closed and BG < 250. IV hydration was continued. Troponin trended down. ASA and metoprolol were given, but no heparin b/c suspicion of thromboembolic event was low. HTN was treated with home doses. Lactate improved and there was NGTD on cultures. ARF resolved. . ROS: No fevers, chills, (+) cough, abdominal pain. No CP, SOB. Past Medical History: -DMII -Prostate CA, s/p chemo/radiation -s/p Left [Name (NI) 6024], pt sustained injury wading through water while living in [Location (un) 5770] during Hurricane [Doctor First Name 3064], was admitted to hospital in [Location (un) 36413], as well as to hospitals in [Name (NI) 86] (pt does not recall which) -Hypothyroidism -HTN -Depression, coping after Hurricane and [Name (NI) 6024] -Iron deficiency anemia -H/o aspiration pna, with h/o MRSA in sputum?? [Hospital 65041] medical records, as pt recently moved to [Location (un) 86] area Social History: Lives at home with wife. Quit tobacco but smoked 1.5 ppd x many years. Originally from [Country 3594] but moved to U.S. at age 6. Used to live in [Location (un) 5770], but left after Hurricane [Name (NI) 3064], wife is here in [Name (NI) 86] with him. Previously a cook, however no longer working. Twin brother recently died. No EtoH or IDU. Family History: Wife had nausea/vomiting/diarrhea a week prior to the patient's admission. Physical Exam: ADMISSION TO MICU: PHYSICAL EXAM: 95.6 120 205/82 23 97% RA awake, alert to self, "hospital", "Saturday", could not state month MM dry JVP flat RR, tachycardic, nl S1, S2 Abd s/nt/nd, no rebound/guarding L [Name (NI) 6024], RLE thin, no edema . TRANSFER TO FLOOR: Vitals: T afeb HR 76 BP 184/63 RR 14 97%RA Gen: awake, alert, oriented to self, "hospital" and date; slurred speech HEENT: PERRL, EOMI, anicteric, OP clear, MMM Neck: JVP flat CV: RR, tachy, nl S1/S2, early systolic murmur LLSB; late non-radiating crescendo systolic murmur at apex Pulm: CTAB although exam limited by poor compliance Abd: (+) BS, soft, ND/NT, no rebound or guarding Ext: L [Name (NI) 6024], RLE thin, warm, no edema; 2+ distal pulses Pertinent Results: [2103-10-13] EKG: Sinus rhythm Possible left atrial abnormality Left anterior fascicular block Intraventricular conduction defect LVH with secondary ST-T changes Since previous tracing, no significant change . [2103-10-15] Renal U/S: 1. No downstream evidence of renal artery stenosis. 2. Bilateral renal cysts. No hydronephrosis or solid mass. 3. Bilateral pleural effusions. . [2103-10-17] LUE U/S: No evidence of DVT. . [2103-10-17] HEAD CT: IMPRESSION: No acute intracranial process . [2103-10-18] HEAD MRI/MRA: No stroke. Evidence of small vessel disease. . [2103-10-13] 11:48PM GLUCOSE-231* UREA N-23* CREAT-1.6* SODIUM-150* POTASSIUM-3.4 CHLORIDE-116* TOTAL CO2-22 ANION GAP-15 [2103-10-13] 11:48PM CK(CPK)-165 [2103-10-13] 11:48PM CK-MB-7 cTropnT-0.12* [2103-10-13] 11:48PM CALCIUM-8.3* PHOSPHATE-0.8# MAGNESIUM-1.8 [2103-10-13] 09:45PM GLUCOSE-394 UREA N-23* CREAT-1.6* SODIUM-147* POTASSIUM-3.1* CHLORIDE-112* TOTAL CO2-18* ANION GAP-20 [2103-10-13] 08:29PM ACETONE-LARGE [2103-10-13] 08:28PM GLUCOSE-426* LACTATE-4.4* [2103-10-13] 07:00PM GLUCOSE-459* UREA N-25* CREAT-1.9* SODIUM-146* POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-17* ANION GAP-31* [2103-10-13] 07:00PM ALT(SGPT)-9 AST(SGOT)-16 CK(CPK)-127 ALK PHOS-78 AMYLASE-131* TOT BILI-0.4 [2103-10-13] 07:00PM CK-MB-6 cTropnT-0.10* [2103-10-13] 07:00PM NEUTS-92.9* LYMPHS-5.7* MONOS-1.3* EOS-0.1 BASOS-0.1 [2103-10-13] 07:00PM WBC-20.2# RBC-4.39 HGB-12.1* HCT-34.9* MCV-79* MCH-27.5 MCHC-34.7 RDW-15.3 Brief Hospital Course: Mr. [Known lastname 52213] was found to be in DKA on admission which may have been secondary to gasteroenteritis and subsequent decreased insulin use. In the MICU, an insulin drip was initiated and was weaned when his anion gap closed and blood glucose was < 250. His blood glucose was in the 100-200 range when he was transferred to the floor. He was started on an insulin regimen consisting of 6 NPH [Hospital1 ] and 3 Humalog with meals. Humalog sliding scale was provided for additional coverage QID. The patient's NPH was converted to Lantus upon discharge to the nursing home. . The patient had an elevated blood pressure on admission and remained difficult to control. Renal ultrasound/doppler did not reveal renal artery stenosis. He was transitioned to Labetolol. Metoprolol and amlodipine were discontinued. TSH was also within normal limits. . The patient also appeared to have left-sided facial weakness and dysarthria when he arrived on the floor. It was unclear when this started, but his wife reported that he did have some trouble speaking at home during the week prior to admission. Given the pooling of secretions and dysphagia, head CT was done to rule out a stroke. CT of the head was negative as well as subsequent brain MRI/MRA. Speech and swallow consultation was also obtained. His facial weakness and dysphagia improved to his reported baseline within 24 hours after initiating levaquin for a presumed UTI. . As above, Mr. [Known lastname 52213] was started on Levaquin for a presumed UTI because he was having intermittent fevers. His blood cultures showed no growth to date on discharge. His chest xray also demonstrated [Hospital1 ]-basilar opacities that possibly represented aspiration pneumonia or pneumonitis. Aside from [Hospital1 ], he was otherwise assymptomatic. . The patient had a troponin leak on admission. This was likely related to cardiac strain. ASA and metoprolol were given per his home regimen, but heparin was not started given low suspicion of thromboembolic event. He was also found to have ARF on admission, but creatinine had returned to baseline on discharge. . The patient experienced a mechanical fall on the day prior to discharge after trying to ambulate from the bathroom to bed without any assistance. He slipped on the floor and hit his head on a plastic sharps container mounted on the wall. There were no external signs of trauma on exam and his neurologic exam was at baseline. . The patient was discharged to [Hospital ] [Hospital ] Rehabilitation facility where Dr. [Last Name (STitle) 1699] will follow-up with him. Medications on Admission: MEDICATIONS ON ADMISSION: ?insulin 70/30 lisionopril 40mg qd lantus ?15U qday toprol 300mg qday flomax 0.4mg qday hydralazine 60mg [Hospital1 ] norvasc 5mg po qd dulcolax ?simvastatin 10mg qd . MEDICATIONS ON TRANSFER FROM MICU -Insulin SS -Acetaminophen 325-650 PO q4-6h PRN pain -Amlodipine 5mg PO BID -ASA 325 PO qD -Anzemet 12.5-25mg IV q8h PRN nausea -Heparin 5000U SC TID -Hydralazine 50mg PO QID -Lisinopril 40mg PO qD -Metoprolol 100mg PO TID -Pantoprazole 40mg IV qD -Prochlorperazine 10mg IV q6h PRN nausea Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). Tablet(s) 6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Lantus 100 unit/mL Solution Sig: 0.12 mL Subcutaneous qam: Please start in the morning on [2103-10-20]. Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: DKA Hypertension Discharge Condition: Stable. Nausea resolved. Afebrile. Walks with assistance. Discharge Instructions: Please return to ED or call your doctor [First Name (Titles) ] [Last Name (Titles) ] > 101.5, severe nausea/vomiting, intractable headache or pain or any other concerning symptoms. . Please take all medications as prescribed. . Please follow-up with all appointments as scheduled. Followup Instructions: Dr. [Last Name (STitle) 1699] will see you next week at [Hospital ] [Hospital ] Rehabilitation. ICD9 Codes: 5856, 5849, 5119, 2449, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5843 }	Medical Text: Admission Date: [2152-2-22] Discharge Date: [2152-3-2] Service: CARDIOTHORACIC Allergies: doxycycline Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2152-2-25] - 1. Mitral valve replacement 27-mm Biocor tissue heart valve. 2. Coronary artery bypass grafting x3 with reverse saphenous vein graft to the marginal branch, diagonal branch, left anterior descending. History of Present Illness: This 88 year old male with known mitral regurgitation recently developed new onset of exertional chest discomfort. He underwent elective catheterization at [Hospital1 ] which revealed severe coronary disease. He is transferred for surgical evaluation. He is without pain on transfer. Past Medical History: Mitral Regurgitation Hypertension Peripheral Vascular Disease Pancytopenia Blepharitis Left rib resection Social History: Occupation: retired fire-fighter Cigarettes: Smoked no [] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [] [1-4] drinks/week [] >8 drinks/week [] Illicit drug use Family History: No premature heart disease Physical Exam: Pulse:79 Resp:18 O2 sat: 98% B/P Right: Left: Height: 5ft 3" Weight: 150lb Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade _3/6_____ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left:+2 DP Right: +1 Left:+1 PT [Name (NI) 167]: +1 Left:+1 Radial Right: +2 Left:+2 Carotid Bruit Right: +2 Left:+2 Pertinent Results: [2152-2-23] Carotid U/S: Right ICA <40% stenosis. Left ICA 60-69% stenosis. . [2152-2-25] Echo: PRE BYPASS The left atrium is 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. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the distal anterior, anterolateral, and apical walls. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is partial mitral leaflet flail involving the P1 and P2 scallop interface. There is also a very small area of A! that prolapses. There is also centrally directed mitral regurgitation. There is moderate to severe mitral annular calcification. An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. 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 AV paced. There is normal right ventricular systolic function. There is some suggestion of left ventricular septal dyskinesis/dyssynchrony that may be reated to ventricular pacing. The apical and distal anterior, anterolateral hypokinesis noted in the prebypass study remains. Overall ejection fraction is about 45 to 50%. There is a bioprosthesis located in the mitral position. It appears well seated and the leaflets appear to be moving normally. There is a trace perivalvular jet of mitral regurgitation on the anterior side of the prosthesis and a trace jet of valvular regurgitation. The maximum gradient across the valve was 16 mmHg with a mean of 7 mmHg at a cardiac output of about 4.5 liters/minute. This may indicate some element of functional mitral stenosis. The rest of valvualr function is unchanged from the prebypass period. The thoracic aorta is intact after decannulation. . [2152-3-2] 05:34AM BLOOD WBC-7.5 RBC-3.46* Hgb-10.5* Hct-33.8* MCV-98 MCH-30.5 MCHC-31.2 RDW-15.2 Plt Ct-164 [2152-3-2] 05:34AM BLOOD PT-15.3* INR(PT)-1.4* [2152-3-1] 02:00AM BLOOD PT-13.4* PTT-25.0 INR(PT)-1.2* [2152-2-25] 06:53PM BLOOD PT-13.6* PTT-35.5 INR(PT)-1.3* [2152-3-2] 05:34AM BLOOD Glucose-114* UreaN-42* Creat-1.5* Na-143 K-3.8 Cl-102 HCO3-33* AnGap-12 [2152-3-1] 02:00AM BLOOD Glucose-136* UreaN-44* Creat-1.6* Na-138 K-3.8 Cl-100 HCO3-32 AnGap-10 [2152-2-29] 02:02AM BLOOD Glucose-156* UreaN-41* Creat-1.8* Na-137 K-4.1 Cl-99 HCO3-33* AnGap-9 [2152-2-28] 03:13AM BLOOD Glucose-135* UreaN-32* Creat-1.9* Na-136 K-4.0 Cl-98 HCO3-28 AnGap-14 [2152-2-26] 03:03AM BLOOD Glucose-92 UreaN-20 Creat-1.2 Na-139 K-4.7 Cl-108 HCO3-26 AnGap-10 Brief Hospital Course: Mr. [Known lastname 90075] was transferred from an outside hospital after catheterization and echo showed severe coronary artery disease and mitral regurgitation. Upon admission he underwent the usual surgical work-up and was medically managed. He remained stable and on [2-25] was brought to the Operating Room where he underwent mitral valve replacement and coronary artery bypass graft x 3. He suffered a ventricular fibrillatory arrest in the holding area preoperatively. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition on Milrinone and NeoSynephrine.. He awoke intact, weaned from all vasoactive medications and was weaned from the ventilator and extubated. He developed an ileus that resolved over a couple of days and he was then able to eat, although a modified soft solids and nectar thick liquids. He had urinary retention and the Foley was replaced on two occassions and was therefor, left in at discharge. Coumadin was started for persisitent atrial dysrhythmia and Amiodarone was given with rate control. On POD 6 he was intact and ready for discharge. Rehab was recommended and he consented. He was transferred to [Hospital1 ] reahb in [Location (un) 1110]. Medications on Admission: Lisinopril 40mg daily Toprol xl 25mg daily Amlodipine 2.5mg daily Aspirin 81mg daily Avodart 0.5mg daily Tamsulosin 0.4mg daily Sertraline 50mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 4. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: as ordered for goal INR 2-2.5 for atrial fibrillation. 9. Outpatient Lab Work INR on *** 10. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg (two tablets) twicew daily for two weeks, then 200mg (one tablet) twice daily for two weeks, then 200mg (one tablet) daily until instructed to stop. 11. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing for 2 weeks. 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Mitral Regurgitation and coronary artery disease s/p mitral valve replacement and coronary artery bypass graft x 3 Hypertension Peripheral Vascular Disease Pancytopenia h/o Blepharitis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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 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 Surgeon: Dr. [Last Name (STitle) ]([Telephone/Fax (1) 170]) on [2152-4-5] at 3:15 PM Cardiologist: Dr. [First Name (STitle) 437] on [2152-3-8] at 11:20am in [Hospital Ward Name 23] 7 Wound check in [Last Name (un) 6752] 2A on [2152-3-14] at 10:15 am Please call to schedule appointments with your Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]([Telephone/Fax (1) 3658]) in [3-2] 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 Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2-2.5 First draw [3-3] Will need Coumadin follow up arranged after rehab discharge Completed by:[2152-3-2] ICD9 Codes: 4275, 9971, 4240, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5844 }	Medical Text: Admission Date: [2114-11-26] Discharge Date: [2114-11-29] Date of Birth: [2046-9-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 45] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 68y/o F w/ CCU admit for tailored medical management of CP attributed to thoracic aneurysm w/clot . CAD, MI, PCI and stent [64], dyslipidemia, PVD s/p AAA repair '[11] c/b hemiplegia, CVAs x 2 c/b hemiparesis '[99], cerebral aneurysms s/p clips '[11], awoke this AM w/L breast pain, took SL NTG with no relief, took all AM meds, called EMS, recieved NTG spray en rounte w/benefit. Upon arrival in ED was pain free w/BP 92/41 HR 73. CT performed with concern for new thoracic dissection, compressing the L PA, LLL collapse, b/l effusions, pt referred to [Hospital1 18] ED. . Upon arrival, pt was seen by CT [Doctor First Name ], review of CT by [Hospital1 18] radiology attending revealed no dissection but intramural thrombus in the descending aorta with aneurysmal dilatation. Pt declined surgical intervention. ED stay complicated by BP elevations to 140s/80s w/sinus tachycardia and SOB/chest pressure, no sig ECG changes, this resolved with IV NTG, morphine, lasix 40mg IV, and approx 1L urine output. . ROS: no PND/orthopnea, no edema, palpitations, syncope or presyncope, denies sick contacts, felt [Name2 (NI) ] prior to this AM, no f/c/n/v/anorexia until ED arrival, no abd pain, mild constipation, incontinent of stool and urine. Past Medical History: CAD, recent pneumonia admission [11-14], h/o MI, PCI [11-14] for NSTEMI and LCX stent placed, PCI [Hospital1 2025] '[06], dyslipidemia, h/o tobacco, PVD s/p thoracoabdominal aneurysm repair at [Hospital1 2025] Dr. [Last Name (STitle) 62999] c/b CVA and b/l LE paralysis, known new thoracoabdominal aneurysm, cerebral aneurysms LUE paresis s/p clips, HTN, anemia, DVT, established preference for comfort care and DNR/DNI status Social History: no tobacco, quit 3y ago, 40PY, no etoh or illicits, lives w/husband, w/c bound, son and dtr in law live in same building Family History: noncontributory Physical Exam: Vitals:97. BP: 96/42 HR:86 RR:16 O2sat:99% 5L NC GEN:thin, frail, fatigued appearing woman HEENT: NC, nl lids, conjunctiva pink, injected, anicteric, PEERL, 3mm->2mm, dry mucosa, poor dentition, op clear, mmm, thyroid nl, nt, no masses appreciated, trach scar CV: carotids w/nl upstroke and amplitude, no bruits, no JVP elevation, PMI diffuse, quiet s1/s2, 2/6 systolic m, no r, +S3, ?pleural rub, no abdominal bruits, palpable pulsation, radial and dp pulses 1+ b/l, cool hands, clammy, thigh edema b/l, +varicosities, cap refill <3 sec RESP: no accessory mm use, I:E = 1:2, crackles [2-4] way up, no wheezes ABD: scaphoid, s/nt/nd/nabs, no organomegaly appreciated MUSC: gait not assesed, no clubbing or cyanosis, poor mm tone NEURO: CN 2-12 grossly intact PSYCH: nl affect, no anxiety or agitation, good judgement and insight, A&Ox3, recent and remote memory grossly intact Pertinent Results: ECG: 15:45 sinus 80s, reg, LAD, QII, III, F, TWI in III, V1, biphasic in V2, compared to early in day at OSH Ts are less biphasic across precordium, 22:19 w/sinus tach at 120s, LAD, no sig ST/TW changes . CXR: LLL opacification, cephalization Admission Labs: CK 64, trop 0.57 at 3pm, CK 69 and trop 0.70 at 2330, WBC 16.8, nl diff, hct 34.6, plt 471, Na 140, K 5.3, CL 109, bicarb 17, BUN 27, Cr 1.0, gluc 111 [2114-11-26] 11:30PM ALT(SGPT)-7 AST(SGOT)-14 LD(LDH)-253* CK(CPK)-69 ALK PHOS-116 TOT BILI-0.4 [2114-11-26] 11:30PM LIPASE-28 [2114-11-26] 11:30PM CK-MB-NotDone cTropnT-0.70* [2114-11-26] 11:30PM ALBUMIN-3.7 [2114-11-26] 03:05PM GLUCOSE-111* UREA N-27* CREAT-1.0 SODIUM-140 POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-17* ANION GAP-19 [2114-11-26] 03:05PM CK(CPK)-64 [2114-11-26] 03:05PM CK-MB-NotDone cTropnT-0.57* [2114-11-26] 03:05PM WBC-16.8* RBC-3.55* HGB-11.5* HCT-34.6* MCV-98 MCH-32.3* MCHC-33.1 RDW-13.6 [2114-11-26] 03:05PM NEUTS-86.8* LYMPHS-9.0* MONOS-2.5 EOS-1.3 BASOS-0.4 [2114-11-26] 03:05PM HYPOCHROM-1+ MACROCYT-1+ [2114-11-26] 03:05PM PLT COUNT-471* [2114-11-26] 03:05PM PT-14.6* PTT-29.8 INR(PT)-1.4 [2114-11-28] 06:50AM BLOOD WBC-21.3* RBC-3.32* Hgb-10.7* Hct-32.5* MCV-98 MCH-32.4* MCHC-33.1 RDW-14.1 Plt Ct-486* [2114-11-26] 03:05PM BLOOD Neuts-86.8* Lymphs-9.0* Monos-2.5 Eos-1.3 Baso-0.4 [2114-11-28] 06:50AM BLOOD Plt Ct-486* [2114-11-28] 06:50AM BLOOD Glucose-147* UreaN-40* Creat-1.9* Na-145 K-5.4* Cl-112* HCO3-16* AnGap-22* [2114-11-27] 08:11PM BLOOD CK(CPK)-48 [2114-11-27] 08:11PM BLOOD CK-MB-NotDone cTropnT-1.16* [2114-11-27] 01:00PM BLOOD CK-MB-NotDone cTropnT-0.96* [2114-11-27] 05:00AM BLOOD CK-MB-7 cTropnT-0.84* [2114-11-28] 06:50AM BLOOD Calcium-8.5 Phos-5.2* Mg-2.0 [2114-11-27] 05:00AM BLOOD Triglyc-139 HDL-39 CHOL/HD-4.4 LDLcalc-104 [2114-11-27] 08:11PM BLOOD Cortsol-48.5* Brief Hospital Course: The presenting complaint of chest pain/SOB was thought to be presumably due to demand ischemia +/- aortic dilation and clot formation, however her symptoms improved upon admission, but continued to occur intermittently. Patient was continued on her aspirin and plavix, but demonstrated labile blood pressure and heart rate variation. Her blood pressure was initially elevated in ED, then trended down and patient became hypotensive, particularly after narcotic administration for pain relief. In regards to her elevated troponin, it was thought to be secondary to her recent MI and stent placement. Patient made it clear that she did not want any further intervention, including further studies or imaging. Given her chronic renal insufficiency, it was also a concern that catheterization would further damage her kidneys, resulting in hemodialysis, which the patient refused as well. A palliative care consult was obtained and it was determined, after extensive discussion with the patient and all involved physicians, that the patient wished to be DNR/DNI with comfort measures only. The patient and her family expressed wishes to be discharged home with hospice care/VNA. The patient was continued on all of her medications, continued on oxygen, and given morphine for pain control, with Anzemet to help control nausea. In addition, the patient was prescribed a seven day course of levofloxacin for infiltrates seen on CXR, thought to be likely partially treated pneumonia, which may also be contributing to the patient's dyspnea. The patient was arranged to receive home nursing assistance, home oxygen, and all necessary medications. In addition, her primary care physician was [Name (NI) 653] to be informed of the plan, and of note, she stated that the aneurysm found on CT was known, not new, and that discussions had already been initiated with the patient regarding comfort care/end of life issues. The patient was kept comfortable until discharge. Medications on Admission: Meds: asa 325, lisinopril 20, zoloft 50, prevacid 30, neurontin 100mg [Hospital1 ], labetolol 100mg [Hospital1 ], levofloxacin 500mg since [11-14] . NKDA Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. 11. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 5 days. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Morphine Concentrate 20 mg/mL Solution Sig: 5-10mg mg/ml PO Q1-2H () as needed for air hunger, pain. 14. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch Transdermal ONCE (once): to dry/lessen secretions . 15. Senna 8.6 mg Capsule Sig: Two (2) Tablet PO HS (at bedtime). 16. Hyoscyamine 0.15 mg Tablet Sig: One (1) Tablet PO every [5-9] hours as needed for cough: please give to lessen secretions if pt does not want scopalamine patch. 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety: please give PO or IV. 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 19. Dolasetron Mesylate 12.5-50 mg IV Q8H:PRN nausea 20. Ceftriaxone 1 gm IV Q24H Duration: 5 Days 21. Azithromycin 500 mg IV ONCE Duration: 1 Doses Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: thoracoabdominal aneurysm with clot chest pain acute renal failure chronic renal insufficiency hypoxia anemia hypotension bradycardia CAD myocardial infarction dyslipidemia lower extremity paralysis Discharge Condition: BP low but stable, on oxygen tent for hypoxia, comfort measures enacted Discharge Instructions: Please take all medications as advised. Call your primary care physician with any questions or for any need needs. Followup Instructions: See you PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] as needed [Telephone/Fax (1) 12597] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [Doctor First Name 63] ICD9 Codes: 486, 5849, 5859, 2762, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5845 }	Medical Text: Admission Date: [2157-11-17] Discharge Date: [2157-11-25] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: 89F with h/o HTN, bilat cerebellar strokes, frontal stoke, sciatica, dementia, who presented with a "head cold" x few days. She developed a low grade temperature, nonproductive cough most of the day today, and reported sob overnight. In the am, her caregiver noticed she was breathing rapidly and called EMS. The patient presented to the ED with a 100 % O2 saturation on NRB and no room air saturation was recorded. She had a temperature of 104 and bp of 207/97. She was initially placed on a ntg gtt with minimal response in BP. She was also started on labetalol. Her chest XR was without infiltrate but severely rotated. Given her fever and bandemia she was treated for pneumonia with ceftriaxone and clindamycin (suspected aspiration). She was briefly started on bipap and then switched to NRB but continued to be tachypneic in the ED to 40's although satting well and MICU evaluation was called. At baseline the patient walks with ta walker, is incontinent. Rec'd flu shot per home health aid. ROS: no ns/chills/cp/appetite or dietary changes / abdominal pain /nausea /diarhea/hematuria/dysuria Past Medical History: B cerebellar strokes, frontal stoke hypertension sciatica IBS dementia hyperactive bladder Social History: Lives at home with 24 hour caregiver. [Name (NI) ] who lives in [Hospital1 ] is healthcare proxy & very supportive. EtOH socially in the past, none since strokes, smoked most of her life but quit many years ago. Family History: noncontributory Physical Exam: (at admission) VS: 97.0 axil, 85/37, 175, 32, 99% on NRB Gen: thin elderly female in no apparent distress HEENT: nc/at, perrl, eomi, mmd, poor oral hygeine CV: rrr, no murmurs/r/g Lungs: diffuse ronchi, inspiratory wheezes, left>right, good air movement Abd: s, nt, nd, active bs Ext: no c/c/e Skin: mottled diffusely . (at discharge) VS: T97.3, BP 140/80, HR 68, O2Sat 95-6% on 4.5L NC Lungs: course breath sounds throughout but good air movement Pertinent Results: Trop T peaked at 0.04, CK peaked at 143 (MB was 3) WBC was 11.7 at admission CT angio of chest without evidence of pulm embolism CXR with basilar opacities c/w pneumonia ECG: (during 2nd [Hospital Unit Name 153] stay) was atrial fibrillation Brief Hospital Course: 88F with h/o HTN, bilat cerebellar strokes, frontal strokes, sciatica, IBS, dementia, bladder incont who initially p/w a low grade F, nonprod cough, tachypnea on [11-17]. In ED, temp 104; SBP 200s, placed on ntg gtt & labetalol. Tx for PNA w/ceftriaxone and clindamycin. Pt was watched o/n in [Hospital Unit Name 153] due to tachypnea then called out to medicine floor [11-18]. On [11-19], shortly after trying some nectar-thickened POs, pt developed resp distress thought to be fr aspiration & sent back to [Hospital Unit Name 153] where her resp status stabilized with conservative management. Blood Cx fr [11-17] grew gram-positive cocci in prs & clusters on [11-19]. Pt also developed new atrial fibrillation in [Hospital Unit Name 153], controlled w/dilt drip which was transitioned to metop PO. Pt returned to [Location 213] sinus rhythm. Pt's O2 need decreased from facemask to nasal cannula with stable sats in the mid-90s. Pt also failed speech/swallow study in [Hospital Unit Name 153] so IR placed NGT which was kept in place for 2 days with tube feeding. # ID/Pulm: Pt likely had community-acquired pneumonia leading to bacteremia. Pt then with aspiration pneumonia prompting the 2nd transfer to ICU. CXR w/RLL retrocardiac opacity. Chest CT [11-20] neg for PE. BCx [12-19] bottle fr [11-17] grew coag-neg staph on [11-19]. Repeat CXR with bibasilar opacities. After initial treatment, pt remained afebrile & VS stable throughout remainder of hospital stay. Pt was initially on ceftriaxone/azithro but this was transitioned to levofloxacin/flagyl for aspiration PNA. Plan total 14 day course (5 additional days at discharge). Pt was on nonrebreather oxygen mask in [Hospital Unit Name 153] but was weaned to simple facemask then to nasal cannula with sats in the mid-90s. # Atrial fibrillation: Pt had 1st known episode while she was in [Hospital Unit Name 153] in the setting of hypoxia, infection, and respiratory distress. Pt was rate-controlled w/dilt drip which was transitioned to PO metoprolol. Pt converted back to NSR and remained with a regular rhythm throughout remainder of hospital stay. Pt's TSH was WNL. Pt discharged home on atenolol (see below). Recommend titrating up atenolol if pt returns to atrial fibrillation. # Hypertension: Given h/o multiple strokes, pt's BP was was to maintain SBP in 130-150 range. Pt was continued on metoptolol with good BP control and this was changed to daily atenolol at discharge. Recommend increasing atenolol dose if pt becomes hyertensive above goal BP after discharge. # Dementia/Psych/Neuro: chronic microvasc infarctions seen in past CTs; bilat cerebellar strokes in past; R-cerebellar & R-occipital strokes in [11-18]. Pt was continued on Plavix, Aggrenox, and Celexa. # Hypernatremia: developed during hospital stay while having limited POs but resolved w/IVF & tubefeeds. # FEN: Pt failed swallow study [11-21]. Post-pyloric NGT placed by IR [11-22] for temporary feeding. This was pulled out on [11-24]. Family has made it clear that they do NOT want PEG (with understanding that pt likely will not be able to meet her nutritional needs) and medical team agrees with this. After extensive discussion about aspiration risk of allowing pt to eat vs role of food for pt's comfort and quality of remaining life, family (including healthcare proxy) decided to allow pt to eat pureed and thickened foods (with full aspiration precautions such as having pt upright when taking POs). Family understands significant risk for another aspiraton event. Pt was on RISS for hyperglycemia during hospitalization but this was discontinued at discharge due to stable FS glucose. # Prophyl: pt was on PPI, SC heparin throughout hospital stay for GI & DVT prophylaxis. These were discontinued at discharge as pt will go home with hospice. # Communic: Medical team communicated regularly with pt's [Month (only) 802] who is healthcare proxy. [Telephone/Fax (1) 105160] (W) or [Telephone/Fax (1) 105161] (C). After multiple, extensive discussions with family, including HCP, pt was made DNR/DNI and then comfort measures only. The patient is being discharged home with hospice services. Family discussion also included that pt would not be transferred back to hospital for acute care as the primary goal is the patient's comfort. Medications on Admission: On admission: folate lipitor 10 mg daily plavix 75 mg daily celexa 20 mg daily aggrenox 25/20 [Hospital1 ] mvi On transfer to MICU [11-19]: folate, mvi lipitor 10 mg daily plavix 75 mg daily celexa 20 mg daily aggrenox 25/20 [Hospital1 ] levofloxacin 500 mg daily flagyl 500 mg tid captopril 25 mg tid metoprolol 25 mg [Hospital1 ] Discharge Medications: 1. Dipyridamole-Aspirin 200-25 mg Capsule, Multiphasic Release Sig: One (1) Cap PO BID (2 times a day). Disp:60 Cap(s) Refills:2 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:60 dose Refills:0 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:15 Tablet(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. Disp:90 Tablet(s) Refills:0 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for itching. Disp:1 tube Refills:0 9. Nebulizer with Adult Mask Device Sig: One (1) kit Miscell. as directed. Disp:1 kit Refills:0 10. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: One (1) dose Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:60 doses Refills:2 11. Oxygen-Air Delivery Systems Device Sig: One (1) device Miscell. as directed. Disp:1 kit Refills:0 12. oxygen 5L via NC continuous 13. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1-2h as needed for pain or dyspnea: sublingual. Disp:10 mL Refills:0 14. Levsin SL solution prn 15. Lorazepam SL solution prn Discharge Disposition: Home With Service Facility: Healthcare [Hospital 94111] Hospice Discharge Diagnosis: aspiration pneumonia hypertension dementia and h/o cerebrovascular accidents Discharge Condition: stable, tolerating thickened POs, minimal physical activity Discharge Instructions: contact primary care physician or hospice services with any questions Followup Instructions: follow-up with Dr. [Last Name (STitle) 1728] as needed [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2157-11-25] ICD9 Codes: 5070, 4019, 2720, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5846 }	Medical Text: Admission Date: [2174-11-29] Discharge Date: [2174-12-2] Date of Birth: [2098-2-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: 6yoM h/o DVT/PE, a fib, CRI, critical aortic stenosis was found down by neighbors on the floor after a friend, who recently became his HCP, called to check in and couldn't get ahold of him. He was alert but somnolent. Recent hospitalization for incarcerated ventral hernia and SBO, refused surgery. Seen by palliative care and plans were made to make patient comfort measures only, however paperwork not completed. Discharged home. In the emergency department vitals on arrival HR 160 (a fib), BP 102/54, RR 32, O2sat 92%. Found to have large PNA and aspirated in ED. Given Vanc/Zosyn/Flagyl. Intubated and had femoral line placed (pt arrived in spinal immobilization). Given 6L IVF but BP unresponsive to fluid. Started on levophed and with versed for sedation. Seen by surgery in ED who evaluated incisional hernia, which was noted to be reduced but found to have a new left inguinal hernia. CT with evidence of SBO. During last admission patient refused surgical intervention, recommended keep OG tube in place and will follow. Pt intubated on arrival to MICU and unable to obtain further history. Past Medical History: 1. Ventral Hernia with SBO ([11-4]) 2. DVT/PE ([2170]) 3. A fib 4. Hyperlipidemia 5. CRI (baseline creatinine 1.4-1.8) 6. CHF 7. severe AS(0.6 from ECHO [11-22]) 8. BPH 9. C diff colitis Social History: Veteran of the Korean retired due to back pain. He lives alone. 60 pack-year tobacco history but quit 20 years ago. Denies current ETOH use but up until [2172] had h/o ETOH abuse. Family History: Unavailable Physical Exam: VITAL SIGNS: T= 101.5 BP= 120/53 HR= 121 RR= 25 O2= 96% PHYSICAL EXAM GENERAL: Intubated, sedated HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. MMM. Neck collared. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Systolic ejection murmur, no rubs or [Last Name (un) 549]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. Soft hernia left of umbilicus EXTREMITIES: Cool, 2+ dorsalis pedis pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: Unable to assess Pertinent Results: LABS: (on admission) 7.3 > 43.5 < 185 N:66% Band:26% L:4% Atyps: 1% 140 \| 96 \| 38 -------------- < 102 3.8 \| 24 \| 2.2 Ca: 9.7 Mg: 1.8 P: 2.0 PT: 17.2 PTT: 26.9 INR: 1.5 ALT: 20 AST: 39 AP: 31 Tbili: 1.8 Lip: 22 Lactate 4.0 -> 2.1 CK: 105 CK-MB: 4 Trop: 0.09 ABG: 7.43 /37 / 174 / 25 UA: small bili, 500 protein, trace ketone, trace RBC STUDIES: CXR: Diffuse left lung opacities which are nonspecific, and differential considerations include infection, infarction, or hemorrhage. CT head: no acute intracranial process. CT C-spine: no fracture or traumatic malalignment. Degenerative changes are noted with mild ventral thecal sac effacement at C4/5. If concern exists for intrathecal abnormalities, these would be best evaluated with MRI. CT Chest/Abd/Pelvis: L renal cyst, large ventral hernia with dilated loops proximally unchanged from previou Brief Hospital Course: 76yoM with a history of CHF, atrial fibrillation on coumadin found down by neighbor at home who presented with pneumonia and sepsis to the medical ICU. He had a recent history of declining aggressive care for a hernia, but gave verbal consent to intubation in the emergency department. On arrival he had a left-shifted leukocytosis and hypotension thought to be due to pneumonia given the large inflitrate seen on CXR. His urine did not have evidence of infection. He had a recent history of incarcerated hernia without repair, but his CT did not have evidence of abscess or perforation. He was started on vancomycin, Zosyn and Flagyl on arrival and required Levophed to maintain his blood pressures. Over the next 24 hours his clinical situation deteriorated significantly. He had cool mottled extremities and required significant pressor support to maintain blood pressures. He had an elevated troponin and acute on chronic renal failure. He was seen by surgery because of his ventral and inguinal hernias. Neither appeared incarcerated and the patient had recently expressed his desire not to be operated upon. The patient required increasing pressor support through hospital day#2 and his health care proxy (HCP) [Name (NI) ] [Name (NI) 59353] expressed a desire to not escalate care. Pressors and mechanical ventilation were maintained while the HCP [Name (NI) 653] family members. WIth the family members it was decided to withdraw care. The patient was extubated and his pain controlled with fentanyl. He passed away peacefully. Medications on Admission: (per D/C plan [11-25]) Doxazosin 2mg PO HS Metoprolol Tartrate 50mg PO BID Lisinopril 5 mg PO DAILY Simvastatin 10mg PO DAILY Folic Acid 1 mg PO DAILY Coumadin 2mg PO once a day: One tablet by mouth Monday-Saturday. Two tablets by mouth on Sundays. Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Primary diagnosis: Severe Pneumonia complicated by sepsis Secondary diagnoses: Ventral and inguinal hernias Cardiopulmonary arrest Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2174-12-11] ICD9 Codes: 486, 5849, 4241, 5859, 4280, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5847 }	Medical Text: Admission Date: [2187-3-14] Discharge Date: [2187-3-26] Date of Birth: [2130-12-8] Sex: M Service: CARDIOTHORACIC Allergies: Sulfonamides / Warfarin Sodium / Triamterene/Hctz / Spironolactone / Amoxicillin Attending:[First Name3 (LF) 1267] Chief Complaint: Congestive heart failure Major Surgical or Invasive Procedure: [2187-3-15] - Mitral Valve Replacement (31mm Mosaic Porcine Heart Valve) History of Present Illness: The patient is a 56-year-old man with long term cardiac cirrhosis who presents with increasing congestive heart failure. He was found to have severe mitral regurgitation and moderate to severe tricuspid regurgitation. He has been offered surgery on numerous occasions but has always declined. He presents with an INR of 1.5 after 2 units of fresh frozen plasma. The patient understands the risks of surgery and the risks of giving aprotinin. He consents and wishes to proceed. Past Medical History: 1. Congestive heart failure with 4+ mitral regurgitation and tricuspid regurgitation. This has been longstanding, and the patient has thus far refused surgery for valve replacement. 2. Atrial fibrillation. (past refusal of anticoagulation) 3. Gout. 4. Nephrolithiasis. 5. Prostatitis 6. hypercholesterolemia 7. hx hepatitis (unknown type)? CMV developed jaundice and RUQ pain but no diagnosis made. Never seen a liver specialist. 8. s/p tonsillectomy 9. s/p ankle fx 10. R inguinal hernia Social History: Lives with his mother. [Name (NI) 1403] for the Red Cross. Also plays the trumpet and tuba. Family History: No fam hx CAD, HTN, DM. Father had rheumatic heart disease and a valve replacement. Physical Exam: Vitals: BP 95/65, HR 75, RR 14, SAT 100% on room air General: well developed male in no acute distress lying in bed s/p cath HEENT: oropharynx benign, poor dental health Neck: supple, no JVD, transmitted murmur to carotid noted Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur Lungs: clear bilaterally Abdomen: very distended, nontender, normoactive bowel sounds. Scrotum distended. Ext: 1+ edema, chronic venous stasis changes Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2187-3-14] 05:20PM PT-17.0* PTT-31.5 INR(PT)-1.6* [2187-3-14] 05:20PM PLT COUNT-225 [2187-3-14] 05:20PM WBC-7.1 RBC-4.03* HGB-12.9* HCT-38.7* MCV-96 MCH-32.0 MCHC-33.3 RDW-15.0 [2187-3-14] 05:20PM ALT(SGPT)-8 AST(SGOT)-11 ALK PHOS-221* AMYLASE-35 TOT BILI-1.2 [2187-3-14] 05:20PM GLUCOSE-148* UREA N-20 CREAT-1.1 SODIUM-138 POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-27 ANION GAP-14 [2187-3-14] 06:58PM URINE RBC-[7-21]* WBC-[7-21]* BACTERIA-MOD YEAST-NONE EPI-0-2 TRANS EPI-[4-15] [2187-3-14] 06:58PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR [2187-3-14] 06:58PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.022 [2187-3-14] CXR There is stable marked cardiomegaly with particular enlargement of the left atrium. Mediastinal and hilar contours are unchanged. Pulmonary vasculature shows upper zone redistribution, but there is no overt pulmonary edema. The lungs are clear. Osseous and soft tissue structures are unremarkable. [2187-3-24] CXR Since the prior study of [2187-3-22], left chest tube has been removed. A tiny left apical pneumothorax is seen. The left lateral costophrenic sulcus is cut off from view. Some fluid and atelectasis are seen in this location. Less fluid visualized compared to prior study. The right lung remains clear. [2187-3-16] EKG Ectopic atrial rhythm. Non-specific ST-T wave changes. Low QRS voltage in the precordial leads. Compared to the previous tracing of [2187-3-16] non-captured pacemaker spikes are absent. Clinical correlation is suggested. Brief Hospital Course: Mr. [Known lastname 52477] was admitted to the [Hospital1 18] on [2187-3-14] for surgical management of his mitral valve disease. Fresh frozen plasma was given as his INR was slightly elevated due to his hepatic dysfunction. A foley catheter was placed with some difficulty preoperatively and thus a size 18 french was used. The On [2187-3-15], Mr. [Known lastname 52477] was taken to the operating room where he underwent a mitral valve replacement utilizing a 31mm mosaic porcine heart valve. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname 52477] [Last Name (Titles) 5058] neurologically intact and was extubated. He was transfused for postoperative anemia. Aspirin was started. Mr. [Known lastname 52477] developed atrial fibrillation which was treated with diltiazem and amiodarone. He was gently diuresed towards his preoperative weight. On postoperative day five, Mr. [Known lastname 52477] was transferred to the cardiac surgical step down unit for further recovery. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He was slow to ambulate as he had foot and joint pain. As he had extensive peripheral edema, his ethacrynic acid was resumed. His left pleural tube remained in place as he continued to have drainage. It was ultimately removed on [2187-3-24] without complication. He needed close monitoring and repletion of his electrolytes his diuresis on ethacrynic acid. His INR remained stable in the range of 1.5 off vitamin K. Mr. [Known lastname 52477] continued to make slow but steady progress and was discharged to the Life Care Center rehabilitation on postoperative day eleven. His amiodarone will be titrated appropriately. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist Dr. [Last Name (STitle) ] and his primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] as an outpatient. His electrolytes and INR will be monitored daily while at rehabilitation. Medications on Admission: Diltiazem 180mg QD Toprol XL 25mg QD Aspirin 81mg QD Ethacrynic acid 100mg QD KCL 20mEq QD Inspra 25mg QD Vitamin K 5mg QD Folic acid Vitamin D3 Eplerenone 50mg QD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): [Month (only) 116] stop when off pain medication. 2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. Ethacrynic Acid 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: Take 400 mg (two tablets) once daily for 1 week, then starting [2187-4-2] take 200mg (one tablet) once daily. 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 9. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day). 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: Life care of [Location (un) 5165] Discharge Diagnosis: Hypercholesterolemia CHF Atrial Fibrillation Mitral Regurgitation Gout Nephrolithiasis Past Hepatitis Prostatitis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of greater then 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lifting greater then 10 pounds for 10 weeks. 5) No driviing for 1 month. 6) Take amiodarone 400mg once daily for 1 week then starting [2187-4-2], take 200mg once daily thereafter. 7) Please monitor electrolytes and replete as needed. Please check potassium on [2187-3-27]. Please check INR while at rehab. Patient was on Vitamin K 5mg daily preop. INR has been stable at 1.5. 8) Please remove staples on postoperative day 14 ([2187-3-28]). 9) Please call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in 4 weeks. ([Telephone/Fax (1) 1504] Follow-up with your cardiologist Dr. [Last Name (STitle) ] in [2-12] weeks. Follow-up with Dr. [Last Name (STitle) ] in [2-12] weeks. Call all providers for appointments. Completed by:[2187-3-26] ICD9 Codes: 4240, 4280, 2851, 5715, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5848 }	Medical Text: Admission Date: [2192-8-19] Discharge Date: [2192-9-4] Date of Birth: [2111-4-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1042] Chief Complaint: coffee-ground emesis Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: HPI: The patient is an 81 year old female who presented from a nursing home with coffee ground emesis on [2192-8-19]. The patient was unable to provide a history due to dementia but the MICU admitting team was able to speak to her nursing home who provided the following history. Per her nurse she had several episodes of dark, coffee-ground emesis on the day prior to admission. She did not complain of abdominal pain. Per report from her nursing home she also fell two days prior to admission and hit her forehead (no further history on her fall available). Per the patient's daughter at baseline, pt is minimally verbal, able to answer simple questions and interject into conversation but does not speak spontaneously and has significant word finding difficulties. She adds that the pt has been less active in the few days preceeding admission. . In ED her vitals were BP 132/50, HR 76, O2 sat 95% on RA. She was found to have a hematocrit of 37. She received 1L of NS and IV protonix. An NG lavage per report was not performed because there was no evidence of active vomiting. CT of the head revealed no evidence of acute bleed. . While in the MICU her vital signs have been stable. Her hematocrit on admission to the ER was 37 on [8-19] at 12 AM. This decreased to 29.8 at 6 AM, 27.6 at 12 PM and 30.8 at 12 AM on [8-20]. At no time did she require transfusion. Bilateral lower extremity ultrasounds were performed given assymetric lower extremity edema which were negative for clots. She was started on high dose IV PPI for her presumed GI bleed. She underwent CT of the abdomen which showed a large hiatal hernia with a thoracic stomach and no evidence of pancreatitis despite incidentally noted elevated pancreatic enzymes. She was evaluated by gastroenterology who plan for her to under upper endoscopy tomorrow AM. . Past Medical History: # [First Name8 (NamePattern2) ] [Male First Name (un) 923] aortic valve, not currently anticoagulated at rehab/nursing home # Atrial Fibrillation # hiatal hernia with esophagitis # hypoxic brain injury # Dementia # breast ca s/p lumpectomy # osteoporosis # CHF, EF unknown # CAD s/p CABG Social History: Has been living at [Hospital 19453] Nursing Home & Rehab for past month. Family History: Noncontributory Physical Exam: Vitals: 95.5 133/56 72 19 99% 3L NC GEN: lying in bed, oriented to person, "hospital," and "Saturday in [Month (only) 205]." HEENT: ecchymosis over L lower eyelid, PERRL, EOMI, OP clear NECK: jugular veins difficult to assess [2-24] body habitus CV: mechanical valve sounds CHEST: cta ant and lateral fields ABD: soft, nontender, NABS EXT: no c/c/e SKIN: no rashes Pertinent Results: Admission Labs [2192-8-19]: Hematology: CBC: WBC-13.0# RBC-4.38 HGB-12.5 HCT-37.2 MCV-85 MCH-28.4 MCHC-33.5 RDW-21.9 PLT COUNT-421# Differential: NEUTS-80.7* LYMPHS-14.7* MONOS-3.4 EOS-0.9 BASOS-0.2 PT-11.6 PTT-21.6* INR(PT)-1.0 Chemistries: Glucose-146* UreaN-30* Creat-0.9 Na-145 K-3.9 Cl-99 HCO3-37* AnGap-13 Calcium-8.9 Phos-3.5 Mg-2.1 ALT-27 AST-37 AlkPhos-174* Amylase-326* TotBili-0.4 Lipase-276* Albumin-4.1 . Others [2192-8-21]: ALT-17 AST-23 LD(LDH)-279* AlkPhos-149* Amylase-62 TotBili-1.0 Lipase-22 GGT-25 Triglyc-70 HDL-51 CHOL/HD-3.9 LDLcalc-133* B12: 631 Folate: 9.0 TSH: 0.66 . Discharge Laboratories: [2192-8-31] CBC: WBC: 9.4 Hgb: 10.6* Hct: 31.6* Plts: 400 [2192-9-3] [Name (NI) 2591] PT: 21.2* PTT: 28.2 INR: 2.1* . Imaging: . CT Head [2192-8-19]: Despite repetition, some of the posterior fossa scans are degraded by patient motion. Within this limitation, there is no significant interval change seen compared to the prior examination. Specifically, there has been no interval development of an intracranial hemorrhage or overt area of acute brain ischemia. However, if the latter diagnostic consideration is a possibility, an MRI scan would be a more sensitive means for detecting an area of acute infarction. The multiple areas of chronic small-vessel infarctions previously described are re-demonstrated. No other new extracranial abnormalities are discerned, either. . CT Abd [2192-8-19]: 1. Intrathoracic stomach which may represent gastric volvulus. If the patient is not symptomatic these findings may be related to chronic volvulus. 2. No CT evidence of pancreatitis . Bilateral LE US [2192-8-19]: Grayscale and Doppler examination of bilateral common femoral, superficial femoral, and popliteal veins were performed. Normal compressibility, augmentation, waveforms, and Doppler flow is demonstrated. There is no evidence of intraluminal clot. . Upper Endoscopy [2192-8-21]: Findings: Normal esophagus, large hiatal hernia with [Location (un) 3825] lesions, normal duodenum. . Upper GI with Small Bowel Follow Through [2192-8-21]: 1. Intrathoracic stomach with the pyloric at the level of the diaphragmatic hiatus. No evidence of gastric outlet obstruction or volvulus. 2. Small amount of barium aspiration noted in the central airways. Followup chest x- ray is recommended if there is concern for development of pneumonia. . Echocardiogram [2192-8-22]: Conclusions: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. . CT Head [2192-8-24]: 1. No significant interval change to brain parenchyma without acute hemorrhage identified. 2. Slight decrease to predominantly left supraorbital subgaleal hematoma. Brief Hospital Course: Mrs. [Known lastname 24831] is an 81 year old female with a history of CAD, atrial fibrillation, aortic valve replacement and dementia who presents with evidence of an upper gastrointestinal bleed. . # Upper GI bleed: On presentation the patient had experienced two episodes of coffee ground emesis at her nursing home. She has a history of esophagitis but otherwise no history of gastrointestinal disorders or bleeding events. In the emergency room two large bore IVs were placed and she received IV fluids. Her hematocrit on admission was 37.2. This fell over the course of the following day decreased to 27.1 but the patient did not require transfusion. She was hemodynamically stable and asymptomatic throughout. She was started on high dose intravenous PPI therapy. A CT scan of the abdomen was performed in the emergency room which revealed the presence of a large hiatal hernia with a complete intrathoracic stomach. The patient underwent upper endoscopy on [2192-8-21] which revealed no obvious bleeding sources but confirmed the presence of the large hiatal hernia with the presence of [Location (un) 3825] lesions. Given that her hematocrit had stabilized and there was no obvious bleeding source on endoscopy no further workup was initiated. She was discharged on an oral proton pump inhibitor. No further episodes of bleeding were observed throughout this hospitalization. . # Hiatal Hernia: The patient was noted to have a large hiatal hernia on CT scan. The presence of an intrathoracic stomach was confirmed on upper endoscopy. An upper GI with small bowel follow through was obtained to further clarify her anatomy. This again showed the hiatal hernia, but showed no evidence of volvulus or gastric outlet obstruction. The possibility of surgical intervention to prevent strangulation was discussed with the patient's daughter. [Name (NI) 227] the patient's age and comorbities and relatively low lifetime risk of adverse events secondary to her hernia, surgical correction was not pursued further. She should continue to take a proton pump inhibitor to protect against future bleeding events. . # Dementia: The patient has a history of traumatic brain injury as well as senile dementia. On admission she was taking aricept, seroquel and namenda. While in house she was observed to have reversal of her sleep/wake cycles with frequent episodes of calling out at night. Psychiatry was consulted to assist with her medication regimen. Her aricept and standing seroquel were discontinued. She was started on Haldol 0.25 mg PO TID with good effect. Behavioral interventions particularly effective included allowing patient to sit in public areas where she was able to interact with other people. . # Mechanical Aortic Valve: The patient has a St. [Male First Name (un) 1525] mechanical aortic valve. She was not on anticoagulation on admission. Her primary care physician was [Name (NI) 653] who confirmed that anticoagulation was appropriate. She was started on a heparin drip for anticoagulation which was quickly switched to lovenox. She was also started on coumadin. Her lovenox was discontinued when her INR was within therapeutic range. Over the remainder of her hospitalization her coumadin was titrated to a goal INR between 2.5 to 3.5 for patients with a mechanical valve and atrial fibrillation. She was discharged on coumadin 1.5 mg T,Th,[Last Name (LF) ],[First Name3 (LF) ] and 2 mg M,W,F. She will need to have her INR monitored every other day at her nursing home until her INR is stable. . # Atrial Fibrillation: Currently well-rate controlled with metoprolol. She was started on anticoaglation with coumadin as described above. . # CHF: Patient has a past medical history of CHF but the details of this diagnosis are unclear. As an outpatient she takes Toprol XL and lasix. On admission her antihypertensive medications were held in the setting of acute bleeding but were restarted once serial hematocrits were stable. An echocardiogram was performed during this admission which revealed mild symmetric LVH, no regional wall motion abnormalities, LVEF of > 55%, and a well-seated aortic valve prosthesis with normal disc motion and transvalvular gradients. She was started on lisinopril 5 mg daily during this admission and this can further managed in the outpatient setting. . # CAD - The patient has an unclear cardiac history but on CT scan she has evidence of CABG and takes a beta blocker as an outpatient. A lipid profile was obtained to further assess her cardiac risk. Her LDL was elevated at 133 and given her history of CAD she was started on simvastatin 10 mg daily. She was also started on lisinopril 5 mg daily. She was continued on her beta blocker. She was not started on an aspirin on this admission given her presentation with a GI bleed but this can be considered as an outpatient. . # HTN: The patient has a history of hypertension treated with metoprolol as an outpatient. On admission her antihypertensive medications were held in the setting of acute bleeding but were promptly restarted. Given that her blood pressures continued to be elevated in the 140s on her outpatient regimen she was started on lisinopril 5 mg daily during this admission with good blood pressure control. . # Paget's Disease: Patient was incidentally noted to have evidence of paget's disease in the right hemipelvis and L1 vertebral body on CT. She also has a mildly elevated alkaline phosphatase and normal GGT consistent with this disorder. This issue may be followed as an outpatient. . # Urinary Tract Infection: Patient was noted to have Klebsiella UTI during this admission. She was asymptomatic but we opted to treat with a three day course of ciprofloxacin given her waxing and [Doctor Last Name 688] mental status. . # Osteoporosis: Patient has a history of osteoporosis. She takes vitamin D and Calcium as an outpatient and these were continued during this admission. . # Anemia: Patient has a history of iron deficiency anemia. Baseline hematocrit is unknown. Further workup was not pursued during this admission given her acute bleeding episode. She was continued on her home iron supplementation. . # Prophylaxis: She was treated with subcutaneous heparin for DVT prophylaxis. . # Code Status: DNR/DNI Medications on Admission: Namenda 10mg [Hospital1 ] Seroquel 12.5mg [Hospital1 ] trazodone 50mg prn Aricept 10mg daily Calcium with D 600/200 [Hospital1 ] Iron 325mg daily Vit C 500mg daily MVI Lasix 40mg daily KCl 20mEq [Hospital1 ] Toprol XL 25mg Discharge Medications: 1. Namenda 10 mg Tablet [Hospital1 ]: One (1) Tablet PO twice a day. 2. Ferrous Sulfate 325 (65) mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Ascorbic Acid 500 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Furosemide 40 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Melatonin 3 mg Tablet [Hospital1 ]: One (1) Tablet PO at bedtime. 9. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 10. Warfarin 1 mg Tablet [Hospital1 ]: 1.5 Tablets PO HS (at bedtime): Please take Tuesday, Thursday, Saturday and Sunday. 11. Warfarin 1 mg Tablet [Hospital1 ]: Two (2) Tablet PO at bedtime: Please take Monday, Wednesday and Friday. 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 13. Haloperidol 0.5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO TID (3 times a day). 14. Haloperidol 0.5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO every eight (8) hours as needed for aggitation . 15. Calcium 600 with Vitamin D3 Oral 16. Toprol XL 25 mg Tablet Sustained Release 24 hr [Last Name (STitle) ]: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: Armenian Nursing & Rehabilitation Center - [Location (un) 538] Discharge Diagnosis: Primary: Upper GI bleed Dementia Urinary Tract Infection . Secondary Atrial Fibrillation Mechanical Aortic Valve Hypertension CHF CAD Discharge Condition: Stable Discharge Instructions: You were seen and evaluated because you were vomiting blood. You were given intravenous fluids and medication to decrease the acid in your stomach. You underwent upper endoscopy which did not identify a clear source of bleeding. You had a CT scan of your head which showed no evidence of bleeding in the brain You had a CT of your chest which showed that your stomach is located above your diaphragm. You also had an upper GI study. You were found to have a urinary tract infection which was treated with antibiotics. You were started on coumadin for your mechanical heart valve. . Please take all your medications as prescribed. The following changes were made to your medications. 1. Your seroquel was discontinued 2 Your aricept was discontinued 3 Your trazadone was discontinued 4. You were started on Haldol 0.25 mg by mouth three times a day 5. You were started on lisinopril 5 mg daily 6. You were started on lansoprazole 30 mg daily 7. You were started on coumadin for your mechanical aortic valve. You will have to have your INR checked daily until your levels have stabilized. 8. You were started on simvastatin for your cholesterol 9. You were started on melatonin . You should been seen by your new primary doctor at your new facility within one week . Please seek immediate medical attention if you experience any chest pain, shortness of breath, vomiting blood, blood in your stool or darkness of your stool, fevers, numbness, inability to move your arms or legs, or any other concerning symptoms. Followup Instructions: You should seen by your new primary care physician at your new nursing home within one week. ICD9 Codes: 4280, 5990, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5849 }	Medical Text: Admission Date: [2180-10-15] Discharge Date: [2180-11-10] Date of Birth: [2145-7-4] Sex: F Service: MEDICINE Allergies: Compazine / Zosyn Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Nausea, labored breathing Major Surgical or Invasive Procedure: cardiac catheterization endocardial biopsy History of Present Illness: 35yF with multiple medical problems (including SLE, restrictive lung disease, global cardiomyopathy with severely depressed systolic function, nephrotic syndrome), with recent admission [Date range (1) 68983] for nausea, vomiting, and diarrhea, re-admitted with shortness of breath, tachycardia, and persistent nausea. Her symptoms began in [Month (only) ] (after a recent hospitalization), when she developed diarrhea (which she relates to her metoprolol). The diarrhea (multiple times daily, non-bloody, brown in color) initially improved but then worsened again. She then developed nausea, vomiting, and dry heaves, without abdominal pain, and was admitted on [10-10]. She also reported worsening shortness of breath, 3 pillow orthopnea, and episodes of paroxysmal nocturnal dyspnea. She was felt to be intravascularly dry, so she was given IV fluids. She had a thorough workup for causes of her diarrhea (infectious, structural, medication related etc.) and was scheduled for GI follow up on [10-16]. During the admission, an echocardiogram was performed, demonstrating worsening systolic function (EF 15-20%), but she was felt to be intravascularly dry, so her Lasix was held. Given the patient's concern that her diarrhea started at the same time as metoprolol (75mg daily), this medication was also stopped (and switched to carvedilol 3.125mg [Hospital1 ]). She was to have close follow up with her cardiologist. She had acute on chronic renal failure which returned to close to baseline (1.5) with IV fluids; she had a renal biopsy during that admission, the results of which are still pending. Her Imuran was initially held during the last hospitalization but was restarted after a conversation with her [Hospital1 112] rheumatologist. During that hospitalization, her nausea was not fully explained, but there was a possibility that restarting her Imuran may have contributed. Her presentation today is similar. She has nausea and dry heaves (non-bloody, non-bilious), along with worsening shortness of breath/PND/orthopnea. Her husband (who follows her vitals closely) has noted increased blood pressures and heart rates since she was discharged from the hospital. Given her worsened nausea and tachycardia to the 120's, he brought her to the hospital. She denies any history of blood clot (but had IUFD at 21wks recently). In the ED, triage vitals were T97.6F, HR 124, BP 126/109, RR 18, Sat 100%. She was given 4mg IV ondansteron x 2, in addition to ceftriaxone and azithromycin given an equivocal chest x-ray. She was transferred to the floor for further evaluation. Her respiratory rate was noted to be as high as 33. On review of systems, she reports nausea and vomiting, as well as shortness for breath and orthopnea as above. Diarrhea is unchanged. She denies fevers, chills, chest pain (but perhaps some chest "heaviness"), palpitations, pleuritic chest pain, cough, weakness, numbness, tingling, abdominal pain, constipation, hematemesis, hematochezia, urinary symptoms. Past Medical History: - SLE: diagnosed in [2168], manifested by kidney disease (membranous nephropathy by report of biopsy), facial rash, Sjogren's syndrome, Raynaud's phenomenon, and pleuritis - Gastritis - Restrictive lung disease: followed by Dr. [Last Name (STitle) ], noted to be moderate to severe on PFTs completed 5/[2179]. - History of pancytopenia associated with varicella zoster infection - History of persistent thrombocytopenia - Baseline proteinuria (Cr 0.8-0.9 pre-pregnancy) - Intrauterine fetal demise [7-/2180] (at gestational age ~21wks) - Right- and left-sided cardiomyopathy (EF estimated 15-20% in [9-/2180]) Social History: Patient is a computer programer in [Location (un) 745] and married. She was accompanied at presentation by her husband [Name (NI) ] and sister. She denies tobacco or EtOH. Family History: Adopted Physical Exam: Vitals: T94.5F (oral, repeat axillary temp was 95.4F), BP 120/94, HR 120, RR 40, Sat 95%RA General: Moon facies, chronically ill-appearing, tachypneic, in mild respiratory distress; malar rash present HEENT: EOMI, PERRL, anicteric, OP clear Heart: Tachycardic without murmurs Lungs: Clear to auscultation bilaterally, no crackles appreciated Back: No CVA tenderness, no spinal tenderness Abd: Soft, non-tender, non-distended, + bowel sounds, no hepatosplenomegaly Extremities: No clubbing, cyanosis; 1+ DP pulses bilaterally; 2+ pitting edema in feet to mid-shin bilaterally (L>R) Neuro: A&O x 3 Pertinent Results: Urine: Yellow, Hazy, SpecGr 1.022, pH 6.0, Sm leuk, Sm blood, 500 prot, [1-20] RBC, few bacteria, 0-2 epi Na 133 K 4.3 Cl 101 HCO3 18 BUN 33 Creat 1.4 Gluc 100 CK: 13 MB: Notdone Trop-T: 0.04 ALT: 29 AST: 34 AP: 121 Tbili: 0.3 Lip: 64 proBNP: [Numeric Identifier 68984] WBC 5.6 N:81.3 L:12.8 M:5.3 E:0.4 Bas:0.2 Hgb 12.1 Hct 37.5 Plt 137 MCV 96 PT: 11.7 PTT: 24.4 INR: 1.0 CXR [10-15] PA/Lat (prelim): Retrocardiac opacification which may represent atelectasis vs. pneumonia; bibasilar effusions and increased hilar infiltrates suggestive of volume overload; stable moderate cardiomegaly. ECG [10-15]: Sinus tachycardia. Leftward axis, normal intervals. TWF in I, II, V5-V6 (interpreted as pseudonormalization in ED, but unimpressive). [Month/Year (2) ] [10-11]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. RV with severe global free wall hypokinesis. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2180-7-24], the LV cavity size has increased and the LVEF is slightly lower (LVEF OVERestimated on prior study). RV dysfunction is now more prominent. . The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis. Quantitative (biplane) LVEF = 33 %. Right ventricular chamber size is normal with borderline normal free wall systolic function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [Year (4 digits) ] [2180-11-6] Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Right ventricular chamber size is normal. with borderline normal free wall function. 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. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. [Month/Day/Year ] [2180-11-9] Compared with the prior study (images reviewed) of [2180-11-6], left ventricular cavity size is smaller, global systolic function is improved (quantitative biplane LVEF 30% on review of prior study), and the severity of mitral regurgitation and estimated pulmonary artery systolic pressure are reduced. Brief Hospital Course: 35yF with multiple medical problems (including SLE, restrictive lung disease, global cardiomyopathy with severely depressed systolic function, nephrotic syndrome), with recent admission [Date range (1) 68983] for nausea, vomiting, and diarrhea, admitted with shortness of breath, tachycardia, and persistent nausea. . #) Cardiomyopathy: Pt was initially admitted to the hospitalist service but transferred for cath and endocardial biopsy in the setting of worsening EF. Her cardiomyopathy was thought to be due to lupus. Peripartum cardiomyopathy was also considered however given the timing of onset and biopsy showing immune complexes seen on endocardial biopsy, lupus cardiomyopathy was thought to be more likely. She was treated with steroids, cytoxan, plasmaphoresis, IVIG and supportive care, and improved from an EF of 15 to 33%. It is unclear which therapy led to improvement. She did require temporary CCU transfer for milrinone given worsening EF, however was weaned after a few days and transferred back to the floor in stable condition. Her mitral regurgitation and hypertension also contributed to her poor forward flow, and htn improved with diuresis, hydralazine, lisinopril and amlodipine. . #) sCHF, volume overload: On admission, pt was clearly tachypneic but satting well on room air. Reported 3 pillow orthopnea and paroxysmal noctural dyspnea, in the setting of recent d/c Lasix and IVF resuscitation, LE edema also suggested fluid overload. BNP extremely elevated at 65,187. She also had non-specific sxs concerning for HF including throat tightness and GI sxs. Her sxs improved with diuresis and symptomatic management and she was discharged on oral torsemide. She was also treated with BP control and bblocker therapy. Given her SOB and LE edema R>L, a LE US was performed and showed no LE clot, therefore PE was thought to be unlikely. . #) SLE. Pt diagnosed in [2168], manifested by kidney disease previously membranous nephropathy, facial rash, Sjogren's syndrome, Raynaud's phenomenon, and pleuritis. Previously followed by Dr. [Last Name (STitle) 68981] at B&W, however has requested to transfer her care to [Hospital1 18] after this admission. Initially contined on Plaquenil and Imuran, as well as prednisone. Plaquenil dc'd per rheumatology recs. Cardiomyopathy and renal failure on current admission were felt to be manifestation of underlying lupus. Rheumatology was consulted and recommended aggressive therapy with steriods, cytoxan and plasmapheresis. Received solumedrol 1g daily x 3 followed by solumedrol 30mg IV q12hrs, which was uptitrated to 60 q 12 hrs and subseuquently tapered and she was ultimately discharged on prednisone 60mg orally daily. She was also placed on atovaquone PCP prophylaxis in the setting of immunosuppression. She recieved 1 dose of cytoxan 750mg on [10-20] with mesna, cell counts with nadir on [11-5]. Prior to cytoxan, she received 7.5mg Lupron for ovarian protection with plans to pursue egg harvesting for fertility as an outpatient. Received 5 cycles of plasmapheresis. 3 doses of IVIG was also administered given that pts HF continued to worsen during the hospital stay. Additional plasmaphoreis was considered but held due to her continued improvement. . #) Nausea/diarrhea. Initially thought secondary to restarting Imuran, however pt and husband attributed to bblocker therapy. Most likely due to gut edema in the setting of right HF. GI was consulted and agreed however recommended ruling out infectious etiology given her immunosuppression; w/u was negative. She improved with symptomatic tx and treatment of her HH. . #) thrombocytopenia: Pt bleeding from HD site [10-21], improved with Cryo, Platelets, and Surgicel. Patient developed thrombocytopenia with nadir of 68, likely multifactorial related to dilution, imunnosupression, and possibly pheresis. Heme consulted and recommended removing ASA, NSAIDs, all heparin products, f/u LFTs, fibrinogen. Platelet drop was too quick to be related to Cytoxan and likelihood of developping 4T score is 3. HIT ab negative. Fibrinogen nomralized. Thrombocytopenia quickly improved, however then fluctuated in the setting of cytoxan use. IgG and IgM ACA negative, so unlikely to have prothrombotic state. . #) Acute on chronic RF: Pt with h/o SLE Nephritis. Pt previously with membranous nephropathy on prior biopsy. She had repeat biopsy showing type 3,4,5 lupus nephritis. Worsening renal failure with creatinine increased to 3.7 up from 1.4 on admission. Urine lytes indicative of prerenal ischemia (FeUrea < 0.02%) +/- evolving ATN likely from poor cardiac output/ cardiorenal syndrome. renal U/S show's no obstruction. While her renal function showed some initial worsening with diuresis, diuresis was continued due to continued volume overload, and creatinine remained stable. . # HTN: BPs improved with uptitration of hydralazine and addition of lisinopril. Pt concerned that hydralazine may be causing joint pain. Given this and her improved renal function, lisinopril was uptitrated and hydralazine discontinued. Blood pressures stable . # Anemia: Likely due to acute renal disease, cytoxan therapy. Pt was given one unit of PRBCs while in patient and started on epo with good improvement in her crit. . # Joint pain: ? medication side effect (IVIG, hydralazine) vs lupus flare, however pt has never had joint pain with lupus flares in the past. Hydralazine was discontinued, symptomatic relief with tylenol, PT. Medications on Admission: Pantoprazole 40 mg po BID Prednisone 15 mg qam and 5 mg qpm Vitamin D 400 units daily Calcium 500 mg twice daily Ferrous sulfate 325 mg once daily (not continued last admission) Multivitamin one tablet once daily (not continued last admission) Cyanocobalamin 1000 mcg injection once a month (not listed at last admission) Folic acid 1mg daily Furosemide 40 mg by mouth once daily (held after admission) Plaquenil 200 mg by mouth once daily Metoprolol 75 mg XL by mouth daily at bedtime (changed to carvedilol) Carvedilol 3.125mg [Hospital1 ] Imuran 50 mg daily Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: please do not exceed 3000mg/day. 5. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) 5ml teaspoons PO DAILY (Daily). Disp:300 ml Refills:2 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR ([Hospital1 766] -Wednesday-Friday). Disp:12 injections Refills:2 8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID (2 times a day). Disp:300 ML(s) Refills:2 10. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 13. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal Q DAY (). Disp:1 tube Refills:2 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 15. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Systemic Lupus Erythematosus Associated Cardiomyopathy. . Secondary Systemic Lupus Erythematosus Hypertension Persistent Thrombocytopenia Discharge Condition: stable, good, baseline ambulatory and mental status Discharge Instructions: You were admitted to the hospital because you were having nausea shortness of breath. You were found to have a lupus induced cardiomyopathy causing heart failure. You received immunosuppressive medications to control your immune system and your heart function improved as shown on serial echos. You received diuretics to remove the fluid that accumulated due to the heart failure, and medications to control your blood pressure. . The following changes were made to your medications. We STOPPED: plaquenil . We changed to: carvedilol 25mg twice a day vitamin D 1000mg daily . We added: lisinopril 20mg daily torsemide 20mg twice a day hydrocortisone 2.5% rectal cream 1 application per rectum daily with rectal pain spironolactone 25mg daily amlodipine 10mg daily ferrous sulphate 325mg daily erythropoeitin Alfa 4000 unit SC injection MWF atovaquone suspension 1500mg daily while on prednisone nyastatin 5ml p.o [Hospital1 ] as needed for oral thrush . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: 1.Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4900], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2180-11-13] 8:00 . 2.MD: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5700] Specialty: PCP [Name Initial (PRE) 2897]/ Time: Thursday, [11-24] at 3:15pm Location: [Apartment Address(1) 68985], [Location (un) 583], MA Phone number: [Telephone/Fax (1) 31923] . 3.Cardiology [Telephone/Fax (1) ] Lab Specialty: Cardiology Date/ Time: [Last Name (LF) 766], [11-21] at 3:00pm Location: [Location (un) ], [Hospital Ward Name 23] Bldg [Location (un) ], [Location (un) 86], MA Phone number: [Telephone/Fax (1) 62] . 4.MD: Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] Specialty: Cardiology Date/ Time: [Last Name (LF) 766], [11-21] at 4:00pm Location: [Location (un) ], [Hospital Ward Name 23] Bldg [Location (un) ], [Location (un) 86], MA Phone number: [Telephone/Fax (1) 62] ICD9 Codes: 5849, 4254, 4280, 2859, 5859, 4240, 2767, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5850 }	Medical Text: Admission Date: [2140-8-21] Discharge Date: [2140-8-31] Date of Birth: [2086-8-29] Sex: F Service: NEUROLOGY Allergies: Lamictal / Keflex / Navane / Inderal / Depakote Attending:[First Name3 (LF) 5167] Chief Complaint: transfer from OSH, seizure Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: Ms. [Known lastname ] is a 53yo woman with PMH significant for seizure disorder, brain injury, and ?atypical multiple sclerosis who presents with right face twitch and right arm shaking. History is obtained from her sister, [Name (NI) 49852] from [Name (NI) ], and from her primary neurologist, Dr. [First Name (STitle) ]. She lives in an [Hospital3 ], and was noted yesterday to have generalized tonic-clonic activity beginning on the right side and lasting 90 minutes. EMS gave her valium 5mg pr at the facility and brought her to [Hospital3 1196]. She persisted with right sided seizure activity there and was given valium 10mg and ativan 1mg, as well as loaded with dilantin 1000mg. She was transferred to the [Hospital1 18] MICU. Here she was given an additional valium 5mg x 2 and ativan 1mg x 3 for persistent twitching in her face and right hand. Since the ativan, her facial twitching has apparently improved, but she continues to have hand twitches. She also had an EEG, which showed left sided slowing on preliminary read. Apparently she has a long history of seizure disorder, possibly from a history of traumatic brain injury (though per Dr. [First Name (STitle) ], records from that hospitalization indicate she may have only had a very mild injury) and has been managed on dilantin and keppra. Since she has seen Dr. [First Name (STitle) ], she has had at least two episodes of status epilepticus and one generalized seizure, as well as some less significant seizures which are characterized by left gaze preference and left sided tonic-clonic activity. Her dilantin levels had been somewhat difficult to control. He tried adding lamictal, but this caused a rash. At the time of her last visit ([2140-2-17]) Dr. [First Name (STitle) ] had discussed the addition of a third [Doctor Last Name 360], possibly zonegran (less likely topamax), to the dilantin 200mg [Hospital1 ] and keppra 1500mg [Hospital1 ]. Her sister had wanted to keep the current course because she felt she was doing well where she was living and did not want to upset that. However, she had several dilantin levels drawn since her last visit, with 15.4 in [4-23].5 in [Month (only) ], and 3.[8-19]. Her sister reports that the medication dose had been changed to 200mg qam and 100mg qpm in [Month (only) ], and a review of her [Hospital1 ] records indicates that this may have occurred in an urgent care appointment secondary to slurred speech and a recent fall and a non-trough level of 15.9. According to her sister, the patient has no short-term memory. She has been living in an [Hospital3 ] facility and frequently calls her even right after she has left without remembering her visit. The patient walks with a walker at baseline and goes out for dinner and shopping with her sister. Ms. [Known lastname ] also carries a diagnosis of "atypical MS", which she brought with her to Dr. [First Name (STitle) ]. According to Dr. [First Name (STitle) ], she has had stable deficits for many years without any flare-like episodes. She had an MRI in [2139] that showed multiple plaque-like lesions, but these were entirely stable since [2135]. She is not undergoing any treatment. Reportedly she has been evaluated at [Hospital1 1774], [Hospital1 ], and possibly [Hospital1 112]. She has not had an LP as far as Dr. [First Name (STitle) ] knows. Past Medical History: h/o head trauma atypical MS seizures depression hypercholesterolemia Social History: lives in [Hospital3 ]. Sister [Name (NI) 717] is HCP Family History: not elicited Physical Exam: ICU exam: VS: T99.5, BP 126/72, HR 99, RR 15, SaO2 99%/RA Genl: lying in bed, right hand moving rhythmically, NGT in place MS: not following commands, withdraws to noxious stimuli, making incomprehensible vocalizations CN: PERRL, corneal reflex intact, nasal tickle intact, face symmetric. Motor: moving right hand rhythmically with occasional right face twitching as well. Moves all extremities to stimuli, L > R Sensation: intact to noxious stimuli in all four extremities Reflexes: 3+ throughout, both toes upgoing Recent exam: Afebrile, VSS Following commands, oriented to name, place. Able to carry on simple conversation. No dysarthria, speech fluent. CN: PEERL, EOM full, tongue midline Motor: moves all extremities with some strength, improved bilaterally Reflexes: as above Pertinent Results: Admission labs: [2140-8-21] 03:54AM BLOOD WBC-11.4# RBC-3.96 Hgb-12.1 Hct-35.1* MCV-88 MCH-30.6 MCHC-34.6 RDW-13.1 Plt Ct-152 [2140-8-29] 07:50AM BLOOD Neuts-83.3* Lymphs-10.1* Monos-5.3 Eos-1.1 Baso-0.2 [2140-8-21] 03:54AM BLOOD PT-12.3 PTT-26.7 INR(PT)-1.1 [2140-8-21] 03:54AM BLOOD Glucose-97 UreaN-12 Creat-0.4 Na-137 K-3.8 Cl-101 HCO3-26 AnGap-14 [2140-8-21] 03:54AM BLOOD Albumin-4.0 Calcium-8.0* Phos-2.9 Mg-2.0 [2140-8-21] 03:54AM BLOOD ALT-14 AST-18 AlkPhos-92 TotBili-0.3 [2140-8-21] 03:54AM BLOOD Phenyto-18.4 Discharge labs: [2140-8-30] 07:25AM BLOOD Phenyto-5.1* U/A: [2140-8-23] 03:04PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.010 [2140-8-23] 03:04PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2140-8-23] 03:04PM URINE RBC-6* WBC-29* Bacteri-OCC Yeast-NONE Epi-<1 [2140-8-29] 03:04PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2140-8-29] 03:04PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.5 Leuks-NEG [2140-8-29] 03:04PM URINE RBC-[12-5]* WBC-[3-20] Bacteri-FEW Yeast-NONE Epi-0-2 CSF: [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-2* Polys-0 Lymphs-92 Monos-8 [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-0 Polys-0 Lymphs-95 Monos-5 [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) TotProt-56* Glucose-77 [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-PND [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) VDRL-PND [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) [Male First Name (un) 2326] VIRUS (JCV) DNA DETECTION BY POLYMERASE CHAIN REACTION (PCR)-PND [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA (PCR)-PND [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-PND [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) EBV-PCR-PND [2140-8-26] 02:20PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS - PCR-negative Other: cryptococcus: negative CSF negative blood cx NGTD urine cx lactobacillus CSF cytology: NEGATIVE FOR MALIGNANT CELLS. Reactive lymphoid cells. immunotyping negative. CXR [8-29]: No evidence for pneumonia. No change since prior study of [2140-8-25]. CT HEAD FINDINGS: There is moderately severe, confluent periventricular white matter hypodensity surrounding the frontal horns, posterior horns, and more superiorly, involving the centra semiovale. These findings are unchanged from prior studies, and may relate to the "atypical" demyelinating process, suggested in the indication on the prior MRI; however, they are non-specific. There is no evidence of acute intra- or extra- axial hemorrhage. There is no shift of normally midline structures. The ventricles are mildly prominent, but are unchanged from the prior study. There is no interval loss of focal [Doctor Last Name 352]-white matter differentiation to suggest acute infarction, though CT is not sensitive in the early stages. No focal masses is seen. IMPRESSION: 1) No intracranial hemorrhage or mass effect; no significant interval change from CT of [2140-6-20]. 2) Diffuse, confluent periventricular white matter hypodensity, which may relate to an underlying demyelinating process (as suggested in the indication provided for the prior MRI). The markedly low-attenation (14-15 [Doctor Last Name ]) centered within this process suggests either irreversible demyelination with cavitation ("black hole"), or lacunar infarction on a vascular basis. Generalized and marked callosal atrophy (on the MR) also suggest advanced, irreversible disease. 3) No mass is appreciated on this limited non-contrast study; if clinically concerned, an MRI with gadolinium is recommended. MRI: There is a similar configuration of increased T2 signal in the periventricular white matter of both cerebral hemispheres, suggesting demyelinating disease. As previously noted, there is associated volume loss, thinning of the corpus callosum, and slight widening of the ventricles. On post-contrast images, there is a probably stable appearance of a 5mm linear, focal area of enhancement in the left centrum semiovale, of uncertain etiology. Also ehancing is 3mm linear lesion in the left hippocampal cortex anteriorly, not seen on the [7-21] MR, but that study was very motion- degraded. The hippocampus would be a most unusual site for involvement by multiple sclerosis. There is no apparent mass lesion or mass effect. No changes in the overall morphology of the brain are identified. The surrounding osseous and soft tissue structures are unremarkable. The major vascular flow patterns are normal. IMPRESSION: 1. Stable appearance of confluent areas of increased T2 signal in the periventricular white matter, consistent with severe demyelinating disease. 2. Enhancing lesions in the left centrum semiovale and also left hippocampal cortex. This former lesion was evident on MR dating back to [2139-7-17], though is more prominent at this time, likely due to less motion degradation of the current scan. Etiology of these enhancing lesions is uncertain, but could be atypical manifestations of demyelination. EEG: ABNORMALITY #1: Throughout the recording there were frequent bursts of generalized theta and delta slowing. Facial twitching was described by the technologist and seen on the video. This is primarily right-sided, facial movement clinically and did not appear to involve the forehead or eye. There were no clear EEG correlate. ABNORMALITY #2: The background voltages were occasionally lower on the left side, and there were additional bursts of delta slowing seen broadly on the left side alone. ABNORMALITY #3: The background rhythms were dominated by much faster beta rhythm. They appeared to reach an 8 Hz frequency on the right at times, though the background was disorganized and slow on both sides for much of the recording. It was of much lower voltage on the left. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal portable EEG due to the bursts of generalized slowing and additional left-sided slowing and voltage dimunition, along with some slowing of the background. The generalized and background features indicate a wide-spread encephalopathy. The left sided slowing and voltage reduction surpassed an additional dysfunction on the left side, possibly wide-spread cortical dysfunction. There is a possibility of a structural lesion on the left, but the encephalopathy dominated the overall picture. There were no clear epileptiform discharges. No EEG correlate was established for the facial twitching. The lack of EEG correlate to the facial twitching does not exclude a central cause (and, indeed, this appeared most likely based on the clinical and video observations). Brief Hospital Course: 53yo woman with h/o seizure disorder, demyelinating disease, and brain injury, presents with prolonged seizure, now unresponsive with persistent twitching of right arm and face. This is most consistent with complex partial seizures with a focus in the left hemisphere, most likely the motor strip. In the past, her seizures were on the left side, which implies that she now has a new focus. It is possible that this is secondary to her underlying demyelinating disease, but per report this has not been very active. Other possibilities include infection, including her UTI. It is likely that these seizures began due to subtherapeutic dilantin levels on her new dose of 200mg/100mg. Her seizure management is difficult, given the higher doses were causing her to fall and slur her speech. Discussed with Dr. [First Name (STitle) ] the addition of an alternate [Doctor Last Name 360] with the possibility of tapering down the dilantin in the future, and he agreed that she may benefit from zonegran. Cannot use lamictal or depakote due to reactions. Topamax is another possibility, but not ideal in a patient with preexisting cognitive deficits. She was started on zonegran at 50mg daily with plans to increase by 50mg every other week to a goal dose of 200mg/day; she was on 100mg daily at discharge and should have her dose increased on [9-12] and again on [9-26]. She was continued on keppra and dilantin with trough checked frequently and adjustment as needed. Ativan was used for breakthrough seizures (facial twitching). MRI/MRA showed new temporal lesions, but it is unclear if these are the cause or effect of her seizures. She will need to have a repeat MRI in several months for further evaluation. LP was done and had no changes to suggest a different etiology (ie negative cytology and negative immunophenotyping). Oligoclonal bands were not assessed as there was not enough CSF per the laboratory. She will need repeated dilantin troughs with one time dose when trough is subtherapeutic. Pending tests: ANGIOTENSIN 1 CONVERTING ENZYME EBV-PCR HERPES SIMPLEX VIRUS PCR [Male First Name (un) 2326] VIRUS (JCV) DNA PCR LYME, TOTAL EIA WITH REFLEX TO CSF RATIO VARICELLA DNA (PCR) VDRL 2. atypical MS: discussed with her outpt neurologist (Dr. [Last Name (STitle) 13039] in [Hospital1 1559]); no current role for MS medications. MRI was performed and showed new lesions vs sz effects in the left temporal lobe. She also had a new lesion on her last MRI in the centrum semiovale. LP was done to evaluate for malignancy, and no malignant cells were seen. Immunotyping was negative as well (per verbal report). Unfortunately, oligoclonal bands could not be sent from the CSF (lab sent CSF for other studies and there was not enough left over for OCBs). This was relayed to the family ([Doctor First Name 717]). Given that she does have new lesions on MRI, if OCBs were sent this would have weighed in in her dx of MS, and it's possible she could benefit from MS therapy. This was relayed to the family, and they will readdress this with Dr. [Last Name (STitle) 13039] (MS doctor). The family is confident in any decision Dr. [Last Name (STitle) 13039] would make re: therapy for her MS. 3. fevers on admission: Pt w/ positive U/A, treated with bactrim x 3 days with defervescence. 4. depression: continue escitalopram; assess need to change medication as an outpatient. 5. FEN: NGT was placed given her altered mental status, and she has been unable to pass a swallow evaluation, but has improved. This should be repeated in several days as her mental status continues to clear. Commun: Sister [Name (NI) 717] is HCP. [Telephone/Fax (1) 49853] Dispo: PT/OT worked with patient during admission Medications on Admission: Dilantin 200/100 Keppra 1500 mg [Hospital1 ] Lexapro 20 mg q day Folate 1 mg q day Calcium 1 tab [Hospital1 ] Discharge Medications: 1. Zonisamide 100 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily): Increase by 50mg every other week (next increase [2140-9-12]). 2. Phenytoin 50 mg Tablet, Chewable [Month/Day/Year ]: Four (4) Tablet, Chewable PO QAM (once a day (in the morning)). 3. Phenytoin 50 mg Tablet, Chewable [Month/Day/Year ]: Three (3) Tablet, Chewable PO QPM (once a day (in the evening)). 4. Phenytoin 50 mg Tablet, Chewable [Month/Day/Year ]: One (1) Tablet, Chewable PO EVERY OTHER DAY (Every Other Day). 5. Levetiracetam 500 mg Tablet [Month/Day/Year ]: Four (4) Tablet PO BID (2 times a day). 6. Escitalopram 10 mg Tablet [Month/Day/Year ]: Two (2) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY (Daily). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Docusate Sodium 150 mg/15 mL Liquid [Last Name (STitle) ]: One Hundred (100) mg PO BID (2 times a day). 10. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 11. Bisacodyl 10 mg Suppository [Last Name (STitle) ]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: 5000 (5000) units Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Seizure History of atypical multiple sclerosis Memory loss Status post brain injury Urinary tract infection Discharge Condition: Stable, much improved from admission, and almost at baseline. Discharge Instructions: Take all medications as prescribed. Please increase zonegran dose by 50 every other week until it reaches 200mg daily, with first dose change [9-12] to 150mg daily and second dose change [9-26] to 200mg daily. Follow up with Dr. [Last Name (STitle) ], Dr. [First Name (STitle) ], and Dr. [Last Name (STitle) 49854] upon discharge. Call the doctor or go to the emergency room with increased seizure frequency, unresponsiveness, new weakness or numbness, or any other concerning symptoms. Followup Instructions: Please follow up with a repeat MRI in several months to evaluate new lesions in the brain. Follow up with: Dr. [Last Name (STitle) 49854] ([Telephone/Fax (1) 49855]) on [2140-9-5] at 915am. Dr. [First Name (STitle) ] ([Telephone/Fax (1) 19791]) on [2140-9-20] at 145pm. Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 250]) on [2140-9-26] at 10am. ICD9 Codes: 5990, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5851 }	Medical Text: Admission Date: [2102-10-14] Discharge Date: [2102-10-15] Date of Birth: [2054-6-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8487] Chief Complaint: Food bolus impaction in esophagus Major Surgical or Invasive Procedure: Upper endoscopy 2x Elective tracheal intubation History of Present Illness: Pt is a 48y/[Initials (NamePattern4) ] [Last Name (NamePattern4) 4746] w/ a PMH significant for HTN who presents tonight w/ the acute onset of dysphagia and throat pain during a meal. The patient was in his USOH until dinner tonight when he noted the above symptoms directly after swallowing. He was unable to clear his throat at home and reports being unable to clear oral secretions. He reports a past history of 2 prior esophageal food boluses ~20yrs ago that have required EGD disimpaction but denies any CP, SOB, fever, abdominal pain, N/V, or diarrhea today. He denies any history of GERD symptoms and does not have any other significant GI history. He has not had any recent dyspagia or odynophagia. He denies any recent travel and has had no sick contacts. [Name (NI) ] has not had any caustic ingestions. He denies a history of rheumatologic conditions or skin changes. His past EGDs have not shown any evidence of stricture or ring and he claims to have had an esophageal motility study in the past that showed a sluggish (though non-pathologic) esophagus. . In the ED, the patient was given glucagon x1 for presumed esophageal impaction w/out resolution of his symptoms and was admitted to the ICU for EGD managment of an impacted esophageal food bolus. Past Medical History: 1. HTN 2. Food bolus x2 Social History: Single gay male. Works as a CPA. Drinks socially but denies tobacco or drug use. Lives in [Location 1468]. Family History: Father w/ pancreatic cancer. Grandparents w/ CAD. Physical Exam: 100.1, 140/67, 109, 19, 97% 2L HEENT: EOMI, MMM, O/P clear Neck: Mild tenderness to palpation at site of bolus CV: Tachycardic, no murmurs Lungs: CTA bilaterally Abd: S/NT/ND, +BS Ext: No C/C/E Neuro: Appropriate in conversation, moving all extremities spontaneously Skin: No obvious rashes Pertinent Results: [2102-10-14] 02:13AM PT-12.6 PTT-22.9 INR(PT)-1.1 [2102-10-14] 02:13AM PLT COUNT-204 [2102-10-14] 02:13AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+ OVALOCYT-1+ [2102-10-14] 02:13AM NEUTS-90.8* BANDS-0 LYMPHS-5.2* MONOS-3.7 EOS-0.2 BASOS-0.1 [2102-10-14] 02:13AM WBC-14.8* RBC-5.11 HGB-16.3 HCT-45.0 MCV-88 MCH-32.0 MCHC-36.3* RDW-12.6 [2102-10-14] 02:13AM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.1 [2102-10-14] 02:13AM GLUCOSE-119* UREA N-19 CREAT-1.1 SODIUM-140 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 Brief Hospital Course: 48y/[Initials (NamePattern4) ] [Last Name (NamePattern4) 4746] w/ a PMH of HTN and GERD who presented with an esophageal impacted foreign body. . Esophageal impaction: No relief with glucagon in the ED. EGD was done and showed a tight impaction with food (pot roast) was found in the middle third of the esophagus at 30cm from the incisors. No ulceration were noted. The scope was removed and an overtube was passed to protect the airway while meat impaction was removed. The distal esophagus could not be seen despite multiple attempts to go around the bolus. The large biopsy forceps and [Doctor Last Name ] net and colonoscopy snare were used to remove the meat. However after 90 mins, there was still a wedged piece of meat in the distal esophagus which could not be removed due to the patient becoming restless and concern about leaving the overtube in for a prolonged period of time. The pt was electively intubated for airway protection and sedation for a second attempt to remove the foreign body. During the second EGD a food bolus was again seen in the middle third of the esophagus. It was pushed into the stomach with the endoscope, and the obstruction was completely removed. There were some erosions seen on the site of the bolus. In a patient with prior food impaction 20 yrs back, a motility disorder and/or a Schatzki's ring was suspected. A mild Schatzki's ring was found in the lower third of the esophagus, probably not accounting for the impaction. A small size hiatal hernia was seen. The pt was extubated and his pt's diet was subsequently advanced slowly. Repeat EGD in a few weeks to f/u on the ring and biopsy to r/o eosinophilic esophagitis was recommended. The pt was empricially treated with Ceftriaxone for presumed aspiration for 2 days. A repeat CXR showed no evidence of aspiration and the patient was asymptomatic, there antibiotic coverage was stopped. . HTN: Atenolol on hold. Pt normotensive. . PPX: Protonix . Code: full Medications on Admission: Atenolol 50 Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:0 Capsule, Delayed Release(E.C.)(s) Refills:0 2. Atenolol 50mg QD Discharge Disposition: Home Discharge Diagnosis: Food impaction in the esophagus Discharge Condition: good Discharge Instructions: Please come back to the hospital immediately if you experience any chest pain, fevers, problems swallowing or if you have any other concerns. . Continue to take Omeprazole 20mg [Hospital1 ]. . Please continue to take a soft diet for two more days, then advance to a regular diet. Followup Instructions: Please follow up with your primary care doctor within the next week. . It is recommended that you have a repeat EGD in four weeks to follow on the schatzki's ring and to have a biopsy to rule out eosinophilic esophagitis. Please call the GI department on Monday to arrange for an appointment ([Telephone/Fax (1) 8892]. ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5852 }	Medical Text: Admission Date: [2103-4-27] Discharge Date: [2103-5-1] Date of Birth: [2041-11-30] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2103-4-27] Redo Coronary Artery Bypass Grafting utilizing vein grafts to ramus and posterior descending artery History of Present Illness: Mr. [Known lastname ] is a 61 year old male who underwent CABG at the [Hospital1 3343] in [2088]. Since that time, he has undergone multiple percutaneous interventions and stent placements to both vein grafts back in [2096] and [2101]. Over the past several months, he has complained of exertional chest pain and decreased exercise tolerance. He underwent nuclear stress testing in [2103-3-17] which was signifcanct for ischemic EKG changes and angina. Imaging showed severe, predominantly reversible myocardial perfusion defect involving lateral and inferolateral wall. There was global HK and the LVEF was estimated at 32%. Subsequent cardiac catheterization in [2103-4-16] revealed a patent LIMA to LAD, patent SVG to RCA, and occluded SVG to OM. Based upon the above results, he was referred for cardiac surgical intervention. Past Medical History: [2088] CABG at [Hospital1 1774]: LIMA to LAD, SVG to OM, SVG to RCA. [2096] [Hospital1 1774]: three 4.0 stents to SVG to OM [2102-7-3] cath d/t moderate reversible inferior and inferolateral wall defect: S/P 2.5 x 18mm Cypher to SVG to OM, s/p 3.5 x 23mm Cypher to SVG to RCA. LIMA to LAD patent. [2102-7-25] cath d/t c/o recurrent exertional symptoms showed patent SVG-OM and SVG-RCA CHF- EF- 32% on CPAP at night Hyperlipidemia Excision of anal tag [1-19] NIDDM- BS typically 140s Back pain - tx'd with epidural steroid injections from the [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Clinic Hemorrhoids Cervical disc surgery [2089] Cholecystectomy [2089] Polyps removed 2 yrs ago Social History: He is married and works full-time as a computer programmer. Denies drug or tobacco use. Family History: Both his parents died in their mid 50's of MI's. Sister had a large CVA at age 64. Older brother died of an MI and a CVA at age 66, 2 months ago. Physical Exam: Vitals: BP 140/74, HR 63, RR 14, General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2103-5-1] 06:14AM BLOOD WBC-4.9# RBC-2.91* Hgb-9.0* Hct-26.1* MCV-89 MCH-31.0 MCHC-34.6 RDW-13.4 Plt Ct-160 [2103-5-1] 06:14AM BLOOD Glucose-133* UreaN-20 Creat-1.0 Na-140 K-4.6 Cl-103 HCO3-27 AnGap-15 [2103-5-1] 06:14AM BLOOD Mg-2.0 Brief Hospital Course: Mr. [Known lastname ] was admitted and underwent redo coronary revascularization surgery. For surgical details, please see seperate dictated operative note. Following the procedure, he was transferred to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics and weaned from inotropes without difficulty. His CSRU course was otherwise uneventful and he transferred to the SDU on postoperative day one. Most of his preoperative medications were resumed. Beta blockade was slowly advanced as tolerated. Over several days, he made clinical improvements with diuresis. He remained in a normal sinus rhythm. The rest of his postoperative course was uncomplicated and he was medically cleared for discharge to home on postoperative day four. Chest x-ray prior to discharge showed only bilateral atelectasis with no evidence for effusions or pneumonia. Medications on Admission: Atenolol 25 qd Allopurinol 300 qd Lisinopril 10 [Hospital1 ] Glyburide 2.5 [Hospital1 ] Aspirin 81 qd Plavix 75 qd Zoloft 100 qd Etodolac 400 [Hospital1 ] Norvasc 5 qd Mirapex Lipitor 20 qd Tricor Neurontin Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(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). Disp:30 Tablet(s) Refills:2 4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO q12 noon () as needed for restless leg syndrome. 8. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qPM () as needed for restless leg syndrome. 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 weeks. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: s/p redo CABG PMH:CAD/CABG '[88], HTN, ^chol, DM2, CCY, cervical disc [Doctor First Name ], hemorroids Discharge Condition: Good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Callfor any fever, redness or drainage from wounds Followup Instructions: Dr [Last Name (STitle) ] in [1-19] wks Dr [Last Name (STitle) ] in [1-19] weeks Dr [Last Name (STitle) 914] in 4 weeks Completed by:[2103-6-1] ICD9 Codes: 4019, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5853 }	Medical Text: Admission Date: [2125-11-24] Discharge Date: [2125-11-27] Date of Birth: [2087-8-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 9160] Chief Complaint: Agitation, disoriented Major Surgical or Invasive Procedure: Intubation History of Present Illness: 38 yo male with history of paranoid schizophrenia and ETOH dependance (1 pint vodka per day) brought from Bornewood on Section 12 for ETOH withdrawal and audiovisual hallucinations. Pt initially was brought to [Hospital6 41256] on [11-23] after being found on the street acting "oddly". He had a head CT that was negative and tox screen that was negative as well. He admitted to suicidal ideation at that time, received zyprexa 5mg, total of valium 15mg, and seroquel 100mg and was transfered to Bornewood yesterday evening. At Bornewood, he was reportedly in a catatonic state, disorganized, responding to internal stimuli with audiovisual hallucinations, picking at the walls and sucicidal ideation. He has been off his meds for an undetermined period of time. Pt began exhibiting signs of alcohol withdrawal this morning. He received 17.5 mg PO valium, 100MG thorazine and 4mg IV Ativan at Bornewood prior to transfer. On presentation to [Hospital1 18], initial Vitals were 97.8 116 126/86 20 96% RA. He was very anxious and having audiovisual halliciations, was paranoid and reportedly with suicidal ideation. He was initially placed in 4 point restraints and received 5mg IM haldol and 2mg IM ativan. However, he remained quite agitated and tachycardic, and received an additional IV ativan for seizure activity (total of 20mg). He was intubated for airway protection and was started on midazolam and propofol drip. Psych was consulted in the ED prior to transfer. Serum tox screen was negative, other labs unremarkable. . Review of systems: unable to obtain [2-28] AMS Past Medical History: Past Medical History: - schizophrenia - alcohol dependence Social History: Social History: may live at group home, possibly homeless - Tobacco: denies - Alcohol: 1 pint vodka/day - Illicits: remote h/o cocaine use Family History: none known Physical Exam: On Admission: General Appearance: Thin, sedated, does not respond to voice or touch, though does have posturing like movements, more frequently when being touched though noted to occur without touch as well Eyes / Conjunctiva: pupils constricted but symmetrical and reactive to light Head, Ears, Nose, Throat: Endotracheal tube Cardiovascular: normal S1 and S2 Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: Expansion: Symmetric, Breath Sounds: Clear : , No Crackles or wheezes Abdominal: Soft, Non-tender, Bowel sounds present, Not Distended, no hepatosplenomegaly Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm, Rash: excoriated rash on left calf, blood blister on left heel, right foot bandaged Neurologic: pt sedated, not following commands Pertinent Results: On Admission: [2125-11-24] 09:22AM BLOOD WBC-6.5 RBC-4.19* Hgb-13.9* Hct-40.6 MCV-97 MCH-33.1* MCHC-34.2 RDW-14.0 Plt Ct-243 [2125-11-24] 07:58PM BLOOD PT-20.3* INR(PT)-1.9* [2125-11-24] 09:22AM BLOOD Glucose-88 UreaN-9 Creat-0.8 Na-142 K-3.8 Cl-103 HCO3-29 AnGap-14 [2125-11-25] 03:02AM BLOOD ALT-44* AST-70* TotBili-0.7 [2125-11-25] 03:02AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 [2125-11-24] 09:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: ## Encephalopathy / Alcohol withdrawal: On transfer to [Hospital1 18], the patient was noted to be very anxious and having audiovisual halliciations. He admitted to suicidal ideation. Placed in 4 point restraints and received 5mg IM haldol and 2mg IM ativan. However, he remained quite agitated and tachycardic, and received an additional IV ativan for questionable seizure activity (total of 20mg). He was intubated for airway protection and was started on midazolam and propofol drip. Transferred to the ICU. A CT head was unremarkable. In the ICU, the patient was weaned off sedation and transitioned to ativan. He was extubated on [2125-11-25]. Psychiatry consulted who felt that patient's visual hallucinations were most consistent with an organic etiology such as EtOH withdrawal. He was started on standing diazepam 10mg q6hr with PRN CIWA protocol with Diazepam 5mg Q6H PRN. He will be discharged on this regimen. There were no other active issues during this admission. SW followed him throughout admission. He will be discharged to an inpatient Psychiatric facility. Medications on Admission: None 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). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): for alcohol withdrawal. 5. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for CIWA>10. Discharge Disposition: Extended Care Facility: [Hospital3 8063] - [Location (un) ] Discharge Diagnosis: Alcohol withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for severe alcohol withdrawal. You had to be intubated and placed on a ventilator to help you breathe. You were placed on medicine to treat and prevent withdrawal symptoms. You should avoid alcohol use as best as possible since both drinking alcohol and withdrawing from alcohol can be life-threatening. Followup Instructions: Should follow-up with PCP [Name Initial (PRE) 176] 2 weeks of discharge from Psychiatric facility. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 9162] Completed by:[2125-11-27] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5854 }	Medical Text: Admission Date: [2122-7-12] Discharge Date: [2122-8-7] Date of Birth: [2049-10-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1190] Chief Complaint: 72 year old male admitted on [2122-7-12] with right iliac stent artery aneurysm with a cheif complaint of back pain and mild shortness of breath. Major Surgical or Invasive Procedure: [2122-7-13]- Endovascular stent graft repair of right common iliac artery with extender stend into external iliac artery and hypogastric artery embolization. History of Present Illness: The pt is a 72 year old male s/p AAA orininally presented on [2122-5-19] for SOB, and a CTA of the A/P at that time demonstrated a RCI aneurysm. Pt was instructed to follow up at a later date, as this was not deemed an emergent issue. On [2122-6-11], he presented for a CAT and IV fluids for his RI. He was then discharged and told to follow up with Dr. [Last Name (STitle) ]. On [2122-7-12], the pt arrived to have his RCI aneurysm endvascularly repaired. Past Medical History: AAA repair COPD CAD anemia HTN CRI CHF chronic UTI dementia depression Social History: Spanish speaking, lives in a nursing home, ex-smoker and alcohol user. Family History: noncontributory Physical Exam: Gen: cachectic male HEENT: PERRLA, EOMI Lungs: rhonchi b/l bases Cardiac: RRR, no murmurs Abd: PEG tube site clean, slightly distended, soft, nontender Ext: No C/C/E Neuro: AxOx3 Palp PT bil Pertinent Results: [2122-8-6] WBC-13.4* RBC-3.59* Hgb-10.2* Hct-32.2* MCV-90 MCH-28.3 MCHC-31.6 RDW-17.1* Plt Ct-219 [2122-8-5] Neuts-75.9* Lymphs-16.6* Monos-5.0 Eos-2.2 Baso-0.3 [2122-7-31] PT-13.4* PTT-32.4 INR(PT)-1.2 [2122-8-6] Glucose-156* UreaN-48* Creat-1.2 Na-140 K-4.6 Cl-100 HCO3-30* AnGap-15 [2122-8-6] Calcium-10.3* Phos-4.3 Mg-2.1 [2122-7-13] CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVIC Reason: Locate central and r/o pneumo AP SUPINE CHEST: Comparison to AP upright chest of 8 hours prior. There has been interval intubation with the ETT tip 5 cm above the carina. Right IJ line seen with its tip distal SVC. No pneumothorax is identified, though limited assessment due to severe emphysema and overlying tubes. Severe upper lobe bullous emphysema. There remains bibasilar opacities, which may be secondary to chronic emphysema, however, it is difficult to exclude an element of mild CHF/volume overload superimposed on background emphysematous changes. No pneumonia is seen. There is a persisting left retrocardiac opacity, which is unchanged dating back to multiple prior chest x-rays. IMPRESSION: 1) ETT and right IJ in satisfactory position; no pneumothorax identified, though limited assessment due to emphysema and overlying tubes. 2) Equivocal mild CHF/volume overload superimposed on background emphysema. No new pneumonia. Unchanged appearance of left retrocardiac opacity. Follow-up again recommended to ensure resolution is recommended. ECHO MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.0 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% to 60% (nl >=55%) Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm) Aorta - Ascending: 3.5 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 0.50 Mitral Valve - E Wave Deceleration Time: 252 msec TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg) Findings: LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or vegetations on aortic valve. MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on mitral valve. Trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: Left ventricular wall thicknesses are normal. 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 probably 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. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (tape reviewed) of [2122-7-14], there is probably no change. IMPRESSION: No valvular vegetations seen. If clinically indicated, a TEE would better to exclude a small valve vegetation. [2122-8-5] CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: SOB PROCEDURE: CT of the chest. INDICATION: Tachycardic and tachypnic with shortness of breath. TECHNIQUE: Multidetector noncontrast low-dose images of the chest, and contrast-enhanced images of the chest following rapid bolus administration of 100 cc of IV Optiray were performed. Images are reformatted in the sagittal and coronal planes. IV CONTRAST: Nonionic IV Optiray contrast was used for rapid bolus administration. CT OF THE CHEST WITH AND WITHOUT CONTRAST: There is severe emphysematous change throughout the lungs, with marked bullous formation in the upper lobes as well as anteriorly towards the lung bases. No pulmonary embolism is identified. There are no areas of consolidation. There are no pleural effusions. There is a focal 1.2 cm opacity seen in the periphery of the lingula, not seen on prior study of [2122-5-11]. The aorta is markedly tortuous, and is seen to have mass effect on the left atrium as before, which might compromise venous return. There is mild dilatation of both main pulmonary arteries indicative of pulmonary hypertension. The right pulmonary artery measures 2.5 cm, and the left 2.2 cm. There is no pneumothorax. No pericardial effusion. Within the imaged portions of the upper abdomen, no abnormalities are identified. Bone windows show no suspicious lesions. Some secretions are noted within the trachea and right main stem bronchus. MULTIPLANAR REFORMATTED IMAGES: Images reformatted in the sagittal and coronal planes show no evidence of pulmonary embolism. No aortic aneurysm or dissection identified. IMPRESSION: 1. No pulmonary embolism identified. 2. Severe emphysema with marked bullous changes particularly at the upper lobes and in the lower thorax anteriorly. 3. Focal 1.2 cm opacity in the periphery of the left lingula, not seen previously. While this may represent atelectasis or an inflammatory opacity, short-term followup in one to two months is recommended to ensure stability or resolution. [2122-7-17] SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [2122-7-17]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2122-7-19]): MODERATE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S IMIPENEM-------------- 2 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S ACID FAST SMEAR (Final [2122-7-20]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. Brief Hospital Course: The patient was admitted on [2122-7-12] PCP followed patient while in hospital The patient is an elderly male who underwent treatment of a ruptured aortic aneurysm at an outside hospital. He recovered, but was left with a greater than 6 cm right common iliac artery aneurysm. Although the aneurysm was very large and the iliac artery proximal and distal was very tortuous, there appeared to be a suitable proximal and distal cuff zone for endovascular repair. Pt pre-op'd cleared for surgery. [2122-7-13] Pt underwent a endovascular stent graft repair of right common iliac artery aneurysm. extender stent graft into external iliac artery and embolization of right hypogastric artery.He tolerated the procedure well. There were no complications. He was transfered to the PACU in stable condition. [2122-7-14] Pt remained in PACU overnight. He was extubated this day. He was also diuresed post procedure. Pt had to reintubated for failed extubation. Pt has a history of 02 dependent COPD / aspiration pna. When extubated pt dropped his o2 sats and had labored breathing. [2122-7-15] - [2122-7-27] Pt transfered to SICU. Pt CRI/CHF remained stable. Pt on CPAP/PS. recieved inhalers. Tube feeds through PEG, foley remained, hct stable, SSI, lines remained in place. Pt experienced low grade temps. Yellow secretions. Required no BP control. Pt experienced low grade temps. Pt pan cx'd. Found to have increase WBC. Pt given zosyn for pna. Also pt started on Vancomycin for pos blood cx. Pt weaned to BIPAP. While in the SICU pt [Last Name ] problem was the inability extubate. He recieve Antibiotics for PNA. He experienced some minor dementia. This was thought to be due sun downing. Pt also reqiured a variety of IV medications for BP support Steroids were started for COPD flare. Pt extubated [2122-7-28] - [2122-7-30] Pt transfered to the VICU in stable condition. Zosyn was Dc'd / Vancomycin Dc'd. Steroids were tapered CVL dc'd. Pt still required some diuresis. [2122-7-31] -[2122-8-3] Foley [Name (NI) ] PT WBC remained elevated. A CT scan was obtained. This was negative. [2122-8-4] Pt transfered to Medicine for on going leukocytosis. Medications on Admission: FS Jevity Tylenol 325' Lipitor ASA Lopressor 6.25'' Protonix SQ heparin Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: Right common iliac artery aneurysm CRI CHF PNA Discharge Condition: Stable Discharge Instructions: Follow-up with Dr [Last Name (STitle) 3407] in two weeks. Please call [Telephone/Fax (1) 1241]. Completed by:[2122-8-7*] ICD9 Codes: 4280, 2859, 4019, 311, 2930, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5855 }	Medical Text: Admission Date: [2127-5-12] Discharge Date: [2127-6-5] Date of Birth: [2041-2-6] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Gantrisin / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1406] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [2127-5-13] elective intubation [2127-5-13] Pericardiocentesis with placement of drain [2127-5-22] Cardiac arrest, Intubated, Central line placement, bronchoscopy [2127-5-23] Transesophageal echocardiogram History of Present Illness: 86M s/p AVR, CABG [2127-4-23] with Dr. [Last Name (STitle) ]. Post-op course was relatively uncomplicated. He did revert to AFib and coumadin was resumed. He was started on Kefzol for a small amount of sternal drainage, which resolved. Beta blockade was held due to 2nd degree AV block. He was discharged to rehab on POD 5. He left on IV diuresis via his PICC. He developed a pneumonia last week and has been treated with antibioitcs and a steroid taper. Additionally, he has received multiple blood transfusions for anemia. Reportedly, diuresis was discontinued at rehab on [5-9]. The patient was seen at this cardiologist office today and was noted to be significantly SOB and appeared fluid overloaded. He was sent directly to the ER for evaluation and admission. He remained hemydynamically stable. Stat bedside echo showed moderate effusion. Creat elevated at 1.5. CXR clear. He was admitted to the CVICU for monitoring. Stat TTE was obatined which showed large pericardial effusion with RV collapse, no pulses paradoxes. Interventional cardiology was consulted and the decesion was to hold off on doing percutaneous drainge of effusion until AM. INR 2.0 coumadin held and FFP and vitamin K. Past Medical History: Aortic stenosis s/p AVR Coronary artery disease s/p CABG Chronic obstructive pulmonary disease Peripheral vascular disease. Status post abdominal aortic aneurysm repair (endovascular repair in [2120] at [Hospital1 2025]). Hypertension. Dyslipidemia Paroxysmal atrial fibrillation Probable ischemic cardiomyopathy with chronic systolic heart failure with left ventricular ejection fraction of 30%. Gout. Mild obesity. First and second degree Wenckebach. Nephrolithiasis. Vitiligo Tuberculosis (45 years ago treated with INH). Status post ventral hernia repair. Status post right inguinal hernia repair x2. Status post left wrist ganglion removal. Left antecubital nerve repair, right heel spur. Social History: non-smoker, 2-3oz wine per day, married, 3 daughters Family History: father MI age 52, brother MI age 58 Physical Exam: On Admission: Pulse:70 Resp: 36 O2 sat: 100 on 3L B/P Right:130/60 General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: limitied ROM Chest: Lungs clear bilaterally diminished in the bases Heart: RRR [x] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds[x] Extremities: cool mottled Varicosities: None [x] Neuro: Grossly intact [x] weak with upper ext tremors Pulses: Femoral Right: +1 Left:+1 DP Right: dopp Left:dopp PT [Name (NI) 167]: dopp Left:dopp Radial Right: +1 Left:Trace Carotid Bruit Right: None Left:None Pertinent Results: [2127-6-5] 01:05AM BLOOD WBC-8.0 RBC-2.69* Hgb-8.1* Hct-25.3* MCV-94 MCH-30.1 MCHC-32.0 RDW-18.1* Plt Ct-163 [2127-5-12] 11:05AM BLOOD WBC-12.0# RBC-3.17 Hgb-9.3* Hct-29.6* MCV-94 MCH-29.4 MCHC-31.4 RDW-17.2* Plt Ct-199# [2127-6-5] 01:05AM BLOOD PT-18.0* PTT-34.6 INR(PT)-1.7* [2127-5-12] 11:05AM BLOOD PT-21.2* PTT-31.1 INR(PT)-2.0* [2127-6-5] 01:05AM BLOOD Glucose-106* UreaN-119* Creat-1.8* Na-147* K-5.3* Cl-115* HCO3-23 AnGap-14 [2127-5-12] 11:05AM BLOOD Glucose-129* UreaN-69* Creat-1.5* Na-126* K-4.2 Cl-86* HCO3-28 AnGap-16 [2127-6-4] 03:34AM BLOOD ALT-25 AST-53* LD(LDH)-270* AlkPhos-96 Amylase-56 TotBili-0.4 [2127-5-12] 08:00PM BLOOD ALT-26 AST-34 LD(LDH)-410* AlkPhos-94 TotBili-0.6 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], I [Hospital1 18] [Numeric Identifier 83902]TTE (Complete) Done [2127-5-23] at 2:55:49 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 18] - Department of Cardiac S [Last Name (NamePattern1) 439], 2A [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2041-2-6] Age (years): 86 M Hgt (in): 70 BP (mm Hg): 121/59 Wgt (lb): 180 HR (bpm): 83 BSA (m2): 2.00 m2 Indication: Evaluate ejection fraction and Pericardial effusion. ICD-9 Codes: 785.0, 423.9, 424.1, 424.0, 424.2 Test Information Date/Time: [2127-5-23] at 14:55 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: TTE (Complete) Son[Name (NI) 930]: [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) ] Doppler: Limited Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Suboptimal Tape #: 2012W000-0:00 Machine: E9-1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 6.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: 6.4 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 60% >= 55% Left Ventricle - Stroke Volume: 69 ml/beat Left Ventricle - Cardiac Output: 5.74 L/min Left Ventricle - Cardiac Index: 2.87 >= 2.0 L/min/M2 Aortic Valve - Peak Velocity: 2.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 31 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 10 mm Hg Aortic Valve - LVOT pk vel: 1.70 m/sec Aortic Valve - LVOT VTI: 22 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Pressure Half Time: 411 ms Mitral Valve - E Wave: 0.8 m/sec TR Gradient (+ RA = PASP): 30 to 36 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [2127-5-15]. LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). Trabeculated LV apex. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Dilated RV cavity. RV function depressed. Abnormal septal motion/position. AORTIC VALVE: Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Mild (1+) MR. PERICARDIUM: Very small pericardial effusion. Effusion echo dense, c/w blood, inflammation or other cellular elements. No echocardiographic signs of tamponade. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is elongated. The right 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 size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded (basal to mid infero-lateral hypokinesis is suggested on some images.). Overall left ventricular systolic function is preserved (LVEF>50%). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a very small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2127-5-15], the pericardial effusion appears smaller. RV systolic function cannot be compared due to poor RV visualization on prior. LVEF is probably similar. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2127-5-23] 15:39 ?????? [2117] CareGroup IS. All rights reserved. [Known lastname ],[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Medical Record Number 83903] M 86 [2041-2-6] Neurophysiology Report EEG Study Date of [2127-6-2] OBJECT: NO IMPROVEMENT IN MENTAL STATUS POST-CARDIAC ARREST. ASSESS FOR EPILEPTIC ACTIVITY. REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] FINDINGS: ABNORMALITY #1: Frequent generalized bifrontally dominant broad-based sharp discharges. ABNORMALITY #2: The background was diffusely slow and discontinuous with admixed theta and delta activity reaching maximal for 5-5.5 Hz with no anterior-posterior gradient. BACKGROUND: The same as Abnormalities #2 and #1. HYPERVENTILATION: Is not performed as the patient is intubated. INTERMITTENT PHOTIC STIMULATION: Is not performed due to portable equipment. SLEEP: No normal sleep morphologies are present. CARDIAC MONITOR: A single EKG channel shows a generally regular rhythm with an average rate of 78 bpm. IMPRESSION: This is an abnormal awake and sleep EEG because of frequent generalized bifrontally dominant epileptic discharges indicative of areas of cortical irritability with potential epileptogenicity. In addition, background activity is diffusely slow and discontinuous suggestive of severe diffuse cerebral dysfunction in this case most likely related to hypoxic brain injury. Other potential causes include medication effect or toxic or metabolic disturbances. No electrographic seizures are present. INTERPRETED BY: [Last Name (LF) 96],[First Name3 (LF) 125] H. ([Numeric Identifier 83904]) [Known lastname ],[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Medical Record Number 83903] M 86 [2041-2-6] Radiology Report MR HEAD W/O CONTRAST Study Date of [2127-5-25] 10:16 PM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2127-5-25] 10:16 PM MR HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 83905] Reason: eval for embolic event/ ischemic regions [Hospital 93] MEDICAL CONDITION: 86 year old man unresponsive after code x 72 hours REASON FOR THIS EXAMINATION: eval for embolic event/ ischemic regions CONTRAINDICATIONS FOR IV CONTRAST: None. Final Addendum Degenerative changes are noted at C4/5 level. DR. [First Name (STitle) 10627] PERI Approved: MON [2127-5-26] 12:05 PM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2127-5-25] 10:16 PM MR HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 83905] Reason: eval for embolic event/ ischemic regions [Hospital 93] MEDICAL CONDITION: 86 year old man unresponsive after code x 72 hours REASON FOR THIS EXAMINATION: eval for embolic event/ ischemic regions CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Unresponsive, aftercode x 72 hours; to evaluate for embolic event/ischemic regions, 72 hours. COMPARISON: None. TECHNIQUE: MR of the head without contrast. FINDINGS: There is no obvious focus of slow diffusion to suggest an acute infarct. Evaluation for subacute infarcts can be limited on the DWI sequence given the long interval. There are extensive periventricular and subcortical FLAIR hyperintense foci, some of which are discrete and others are confluent in the frontal and the parietal lobes on both sides. There is moderate dilation of the lateral and the third ventricles including the temporal horns on both sides. The bifrontal diameter of the lateral ventricles at the level of foramen of [Last Name (un) 2044] measures 39.4 mm. The right temporal [Doctor Last Name 534] is larger than the left. A few small scattered foci of negative susceptibility in the brain parenchyma scattered in the cerebral hemispheres and a few faint foci in the right cerebellar hemisphere. The major intracranial arterial flow voids are noted. The right vertebral artery is dominant. The left vertebral artery is markedly diminutive in size. There is increased signal intensity in the mastoid air cells on both sides from fluid and mucosal thickening. Slightly increased signal intensity in the right transverse sinus, may relate to slow flow. There is diffuse increased signal intensity in the paranasal sinuses and the ethmoid and the maxillary sinuses, right more than left and the sphenoid sinus along with fluid in the nasal cavity and nasopharynx related to intubation. IMPRESSION: 1. No large area of obvious acute infarct. Evaluation for subacute infarcts can be limited on the present study. 2. FLAIR hyperintense areas in the cerebral white matter, non-specific in appearnace and a few scattered T2 susceptibility foci related to microhemorrhages as described above. 3. Diffuse paranasal sinus disease with fluid in the nasopharynx; fluid and mucosal thickening diffusely in the mastoid air cells. 4. Moderate dilation of the lateral and the third ventricles as described above-? related to parenchymal volume loss with or without a component of communicating hydrocephalus such as NPH. Correlate clinically. DR. [First Name (STitle) 10627] PERI Approved: MON [2127-5-26] 12:03 PM Imaging Lab There is no report history available for viewing. [Known lastname ],[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Medical Record Number 83903] M 86 [2041-2-6] Radiology Report CT CHEST W/O CONTRAST Study Date of [2127-5-20] 8:40 AM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2127-5-20] 8:40 AM CT CHEST W/O CONTRAST Clip # [Clip Number (Radiology) 83906] Reason: assess for dehisence of sternum [Hospital 93] MEDICAL CONDITION: 86 year old man s/p AVR CABG [4-23]- now w/unstable sternum REASON FOR THIS EXAMINATION: assess for dehisence of sternum CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: SJBj TUE [2127-5-20] 11:27 AM There is dehisence of the superior and inferior ends of the sternum. A 3.8 x 3.5cm dense collection at the sterno manubrial junction has characteristics of hematoma. The superior manubrial fragments are seperated by 7mm. The upper most 2 sternal wires do not encircle the right sternal fragment. There is 14mm of dehiscence of the inferior left sternum lateral to the sternotomy with a non-hemorrhagic collection between the seperated fragments. Moderate pericardial effusion with layering density suggestive of hematoma. Moderate right and small left pleural effusions. Mild pulmonary edema. Wet Read Audit # 1 Final Report INDICATION: 86-year-old man with post AVR and CABG on [4-23] with unstable sternum. COMPARISON: Chest radiographs [4-28] and [2127-5-18]. TECHNIQUE: MDCT data were acquired through the chest without intravenous contrast. Data were reconstructed using soft tissue and lung kernels. Images were displayed in multiple planes. FINDINGS: The initial CT tomogram confirms abnormal alignment of median sternotomy wires as identified on prior radiographs. There is a 3.5 x 3.9 cm dense fluid collection at the sternoclavicular articulation (2.9, 400B:36). Two surgical clips are seen adjacent to this area (2.7). The two halves of the manubrium are seperated by 7mm. The most superior two sternal wires wind around only the left sternal half (2:14). The third and fourth sternal wires surround both fragments of the sternum, which are in appropriate relationship. Although the fifth sternal wire appears to deviate towards the left, this wire appears to properly fixate both halves of the sternum. The most inferior three sternal wires are shifted to the right. There is approximately 2.7 cm of separation between the sternum and the left inferior costal cartiladge (2:38). Fluid with simple attenuation fills this space. The thyroid has normal attenuation. No mediastinal, hilar or axillary adenopathy is present. There is a moderate pericardial effusion. Dense material layers in the pericardial effusion likely representing blood products (2:46). Severe three-vessel coronary artery atherosclerosis is identified. The aorta and aortic valve prosthesis is in expected position. A left pleural effusion is moderate and right pleural effusion is small. Basilar dependent atelectasis is present. Lung volumes are low and severe respiratory motion hampers their assessment. Pulmonary edema is mild. No focal consolidation is identified. This exam is not tailored to evaluate subdiaphragmatic structures. No right adrenal nodule is identified. BONE WINDOWS: Compression deformities of T7 and T11 are noted. There is no lytic or sclerotic lesion concerning for malignancy. A left-sided SVC line terminates in the upper SVC. An enteric catheter extends into the stomach. IMPRESSION: 1. Manubrial and inferior left sternal dehisence 2. 3.8 x 3.5cm sterno manubrial hematoma. 3. 2.7cm left lateral inferior sternal non-hemorrhagic fluid collection 4. Moderate pericardial effusion with layering density suggestive of hematoma. 5. Moderate right and small left pleural effusions. 6. Mild pulmonary edema. Discussed with [First Name8 (NamePattern2) ] [Doctor Last Name ] via phone at [Pager number ]. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 819] [Last Name (NamePattern1) ] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: TUE [2127-5-20] 7:36 PM Imaging Lab There is no report history available for viewing. Brief Hospital Course: Mr [Known lastname 83900] was transferred from cardiologist office to emergency room for evaluation of dyspnea that was progressively worsening at rehab that was thought to be related to pneumonia and COPD exacerbation at rehab. He had echocardiogram that revealed large pericardial effusion and right ventricular compression. His creatinine was elevated due to cardiac compromise with acute kidney injury and elevated troponin due to demand ischemia from cardiac strain. He was on coumadin and received fresh frozen plasma and vitamin K for reversal. He was treated with IV fluids and levophed for hemodynamic management. He was taken to the cardiac cath lab [5-13] and underwent pericardiocentesis with placement of drain. Of note prior to procedure he was electively intubated for the procedure in the intensive care unit. He tolerated the procedure, he was started on diuretics for diuresis as he was significantly volume overloaded. On [5-14] he was extubated without any complications and was continued to be diuresed and creatinine continued to improve. On [5-15] he was note for diarrhea and stool was positive for Clostridium dificile, flagyl was started. He underwent echocardiogram as the drain had less than 50 ml, and based on echo finding the drain was removed, the remaining effusion was thought to be loculated. He was evaluated by speech and started a modified diet however his oral intake was not sufficient and dobhoff was placed for additional nutrition on [5-16]. He continued to be diuresed but there was noted to be paradoxical breathing at times that was thought to be related to his sternum. He continued to be monitored. On [5-18] EP was consulted due to arrythmia with concern for AV nodal block but was diagnosed with atypical atrial flutter. On [5-20] he underwent a CT scan due to ongoing paradoxical breathing, Plastic surgery was consulted in regards to potential sternal plating or flap coverage due to dehiscence of the sternum. Additionally due to worsening rashes on skin dermatology was consulted, the left lower extremity was felt to be hyperkeratosis and facial rash was vitiligo but felt to be chronic. He continued with diuresis, pulmonary exercises and non invasive ventilation at night. On the night of [5-22] he had difficulty breathing while completing respiratory treatment and then became bradycardic with PEA arrest. ACLS protocol was initiated see code sheet. He received chest compressions, defibrillation, medications, and intubation. After he was resuscitated he underwent bronchoscopy, echocardiogram, and central line placement. He was noted for significant secretions, was started on empiric antibiotics and BAL revealed pseudomonas. He required vasopressors and inotropic support. Infectious disease was consulted due to resistant pseudomonas and antibiotics were adjusted per their recommendation. He continued treatment for pneumonia, clostridium dificile, and urinary tract infection. He hemodynamically improved post cardiopulmonary arrest however was not waking up. Neurology was consulted he underwent MRI that did not reveal any acute findings and EEG that showed significant slowing which neurology felt he was unlikely to have a meaningful recovery. There was a family meeting on [5-28] and the family wanted to continue treatment with plan for repeat EEG in 1 week. Mr.[Known lastname 83900] remained unresponsive and without improvement. The EEG was repeated and showed slowing, likely from anoxic brain injury. The family discussed with Dr.[Last Name (STitle) ] and the cardiac surgery team making Mr.[Known lastname 83900] [Last Name (Titles) ] care measures only. On [2127-6-5] under the critical care guidelines, [Date Range ] measures were instituted. reporting protocol was followed. Medical Examiner denied case and the family denied autopsy. Please refer to death report for further information. ......stop [5-29] Medications on Admission: medications at rehab aspirin 81 mg daily tamsulosin 0.4 mg at bedtime finasteride 5 mg Daily probenecid 500 mg Daily atorvastatin 80 mg Daily allopurinol 300 mg daily prednisone 5 mg QAM prednisone 2.5 mg QPM ranitidine HCl 150 mg [Hospital1 ] albuterol sulfate 2.5 mg /3 mL Neb Q6H as needed for dyspnea. ipratropium bromide 0.02 % [Male First Name (un) ] Inhalation Q6H as needed for dyspnea. warfarin 1 mg daily Vancomycin Cefapime Discharge Disposition: Expired Discharge Diagnosis: Respiratory arrest leading to cardiac arrest Acute on chronic systolic heart failure Healthcare acquired pneumonia Clostridium dificile Anemia Pericardial effusion with tamponade Cardiogenic shock due to tamponade Demand ischemia due to tamponade Acute kidney injury Atypical atrial flutter Retention hyperkeratosis Sternal dehiscence Urinary tract infection Secondary: Aortic stenosis s/p AVR Coronary artery disease s/p CABG Chronic obstructive pulmonary disease Peripheral vascular disease. Status post abdominal aortic aneurysm repair (endovascular repair in [2120] at [Hospital1 2025]). Hypertension. Dyslipidemia Paroxysmal atrial fibrillation Probable ischemic cardiomyopathy with chronic systolic heart failure with left ventricular ejection fraction of 30%. Gout. Mild obesity. First and second degree Wenckebach. Nephrolithiasis. Vitiligo Tuberculosis (45 years ago treated with INH). Status post ventral hernia repair. Status post right inguinal hernia repair x2. Status post left wrist ganglion removal. Left antecubital nerve repair, right heel spur. Discharge Condition: expired Completed by:[2127-6-5*] ICD9 Codes: 9971, 5990, 4271, 4280, 2724, 2859, 4275
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5856 }	Medical Text: Admission Date: [2191-8-9] Discharge Date: [2191-8-17] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5827] Chief Complaint: CHF exacerbation Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo male with a PMHx of CHF, HTN, chronic lymphedema/venous stasis was admitted to [Hospital1 18] with worsening SOB "for a long time." Over the last day, his SOB at NH increased. A CXR had CHF findings and the patient got 140 po lasix (via 3 doses) with good urine output. Despite this, he continued to be SOB. O2 sat by ems was 74 on 4L; this increased to 96% on NRB. He was given 40 iv lasix and 3 sl nitro by ems with slight improvement and transferred to [Hospital1 18]. No cp/f/c/n/v. Per patient, + for orthopnea and increasing SOB Past Medical History: -CHF -multiple falls -HTN -BPH -Chronic Lymphedema -Venous stasis (w/ LLE stasis ulcer) -PEripheral Neuropathy Social History: Txferred from [Hospital3 2558]. Family History: NA Physical Exam: On admission: T:97.6 BP:113/82 P: 94 RR: 15 O2 sats:98% NRB Gen: Pleasant elderly gentleman slightly SOB with speaking HEENT: JVD not visible. CV: +s1+s2 +diastolic murmur along L sternal border Resp: Crackles at bases bilaterally. No wheezing Abd: +BS Soft NT ND Ext: L>R leg with lymphedema. Non pitting edema. Pertinent Results: Labs on Admission: [2191-8-9] 08:07PM BLOOD WBC-9.2 RBC-4.65 Hgb-15.0 Hct-43.5 MCV-94 MCH-32.2* MCHC-34.5 RDW-16.6* Plt Ct-237 [2191-8-9] 08:07PM BLOOD Neuts-77.4* Lymphs-16.6* Monos-4.3 Eos-1.5 Baso-0.2 [2191-8-9] 08:07PM BLOOD Plt Ct-237 [2191-8-9] 08:07PM BLOOD Glucose-154* UreaN-24* Creat-2.0* Na-139 K-6.4* Cl-102 HCO3-27 AnGap-16 [2191-8-9] 08:07PM BLOOD CK(CPK)-195* [2191-8-9] 08:07PM BLOOD CK-MB-2 [2191-8-9] 08:07PM BLOOD cTropnT-0.05* [2191-8-10] 04:06AM BLOOD CK(CPK)-140 [2191-8-10] 04:06AM BLOOD CK-MB-3 cTropnT-0.07* [2191-8-9] 08:07PM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3 [2191-8-10] 02:45AM BLOOD Type-ART pO2-82* pCO2-48* pH-7.40 calTCO2-31* Base XS-3 [2191-8-9] 10:26PM BLOOD Lactate-1.8 * Studies: CHEST (PORTABLE AP) [2191-8-9] 9:43 PM FRONTAL CHEST RADIOGRAPH: Study is slightly limited by motion artifact. Cardiac and mediastinal contours appear grossly unremarkable allowing for portable technique. Increased interstital opacities are noted, consistent with mild-to-moderate CHF. No focal consolidations are seen. No definite pleural effusions identified. IMPRESSION: Slightly limited by motion artifact. Mild-to-moderate CHF. * BILAT LOWER EXT VEINS [2191-8-10] 12:42 PM FINDINGS: Grayscale and color Doppler imaging of the common femoral, superficial femoral, and popliteal veins were performed bilaterally. The right common femoral vein only partially compresses and likely has non- occlusive thrombus within. The superficial femoral vein does not compress and no demonstrable flow is seen within. The right popliteal vein compresses and demonstrates normal flow. Likely non-occlusive thrombus is also identified within the left common femoral vein though normal compressibility and flow is seen within the left superficial femoral and popliteal veins. IMPRESSION: Non-occlusive thrombus within the common femoral vein bilaterally. Occlusive thrombus likely within the right superficial femoral vein. * ECHO [2191-8-10] Conclusions: The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. Interventricular septal motion is 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. Mild to moderate ([11-23]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal LVEF. Dilated RV with borderline normal systolic function. Moderate to severe pulmonary hypertension. These findings suggest chronic pulmonary hypertension. No findings of acute, massive pulmonary embolism are suggested. * Brief Hospital Course: * A/P: 89 yo male with hx of CHF, HTN and venous stasis/lymphedema with CHF exacerbation . # CHF Exacerbation/Hypoxia: now resolved thought to be due to CHF exacerbation. PT had CTA which was negative for PE. Pt started on Levofloxacin for question of pneumonia. Pt received Lasix daily with good result. . #. [Name (NI) 61151] Pt had bilateral superficial femoral thrombosis. Pt was started on a heparin gtt with bridge to coumadin with goal INR 2.5 - 3.0. Currently at goal on discharge. . # Fever: Pt had one upon admission, thought to be [12-24] pneumonia, treated with 5 day course of Levofloxacin. [8-9] blood culture pending, [8-9] urine culture contaminated but negative for Legionella Ag. [8-12]- sputum cultures 4+ GP cocci in pairs/chains, 2+ GN rods, 2+ GP rods . Medications on Admission: -lasix 80mg daily -prilosec 40mg daily -aspirin 325mg daily -diltiazem SA 120mg daily - fluticasone nasal spray 50mcg -KCl 40mEq daily -Therapeutic-N one tab daily -Spiriva 18mcg daily -colchicine 0.6mg daily -mirtazapine 15mg daily -acular ls 0.4% each eye [Hospital1 ] -labetalol 100mg [Hospital1 ] -artificial tears -tylenol PRN -MOM PRN -NTG PRN -duonebs PRN Discharge Medications: 1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal DAILY (Daily). 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 7. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ketorolac Tromethamine 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Outpatient Lab Work Please check INR [8-18], [8-22], [8-25] If INR>3.0 will need coumadin dose adjusted and pt should follow up with his PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 335] [Last Name (NamePattern1) 5351]. Pt will need help with administration of nebulizers and other medicaitons. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: CHF exacerbation Discharge Condition: Improved Discharge Instructions: You were admitted to the hospital for a CHF exacerbation. You were initially treated with some supplemental oxygen and Lasix to imrove your urine output. In addition, a study showed that you clots in your veins in the legs and you were started on heparin and than transitioned to Coumadin. You will need to get routine checks of your INR which will help monitor your coumadin level. You will need to be checked in 2 days and then every 3 days thereafter. If you are feeling short of breath or having any chest pain, please return to the ED for further management Followup Instructions: You will see Dr [First Name8 (NamePattern2) 335] [Last Name (NamePattern1) 5351] while at [Hospital3 2558] ICD9 Codes: 4280, 486, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5857 }	Medical Text: Admission Date: [2117-7-11] Discharge Date: [2117-7-27] Date of Birth: [2055-10-24] Sex: M Service: LIVER TRANSPLANT SURGERY SERVICE CHIEF COMPLAINT: End stage liver disease secondary to Laennec cirrhosis, ETOH. HISTORY OF PRESENT ILLNESS: Patient was a 61 year-old male with a history of alcohol related cirrhosis of the liver. Patient with long standing history of alcohol consumption to the point that where he would pass out presented for transplantation. He quit drinking 6 years ago. Starting in [2106] the patient had bleeding from esophageal varices for which he was status post banding multiple times most recently in [2116-11-25]. Patient also had a history of hepatic encephalopathy with the first episode in [2116-8-26]. The patient has had 6 or so events during which he became confused and near comatose was admitted to the hospital and later discharged with complete resolution of symptoms. Patient noted these episodes usually occurred after consuming high protein intake. Patient was also status post paracentesis x 3 in the past 6 months each one removing large volumes of 3 to 5 liters respectively with last tap earlier in the month. Patient denied recent hematemesis, variceal bleed, no blood in his stools, no abdominal pain, no shortness of breath, no chest pain, no nausea, vomiting, fever, chills, headache or dizziness. No blood or difficulty with urination. No history of bleeding problems or coagulopathy. Patient started the transplant with process back in [2116-8-26]. No history of hepatitis or IV drug use. Never experienced withdraw symptoms. PAST MEDICAL HISTORY: IDDM since [2101] status post cardiac stent placement approximately 6 months ago. PAST SURGICAL HISTORY: Cholecystectomy in [2086]. In the spring of [2115] he had an LIH repair, status post cardiac stent replacement. MEDICATIONS AT HOME: Lasix, insulin, Aldactone, Prilosec and Inderal. ALLERGIES: No known drug allergies. No environmental allergies noted. Patient became heparin induced antibodies. The patient is now allergic to heparin. SOCIAL HISTORY: Patient lives alone in [Initials (NamePattern4) ] [Last Name (NamePattern4) ] that has 1 set of stairs for him to climb. No alcohol in 6 years. One pack of cigarettes per week x 10 years. No IV drugs or recreational drugs. He has a helpful significant other. She was present postoperatively. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: On admission the patient was able to walk several blocks with some shortness of breath. Vital signs were 97.4, 63, 122/58, 16, 100% on room air. His weight was 77.4 kilos. He was a well developed, well nourished and in no acute distress, resting comfortably. HEENT pupils equal, round, reactive to light and accommodation. EOMs intact. MCAT. Lungs clear to auscultation. No wheezes, rhonchi appreciated. Cardiac regular rate and rhythm. Normal S1, S2. No murmurs, regurg or gallop. No JVD appreciated. Abdomen was soft, distended, tender to deep palpation right upper quadrant. Bowel sounds positive. No spider angiomatas. No caput medusae were noted on extremities. Pulses were 2+. No cyanosis, clubbing or edema. Capillary refill was approximately 2 seconds. No asterixis. LABORATORIES ON ADMISSION: He had white count of 2.6, crit of 28.4 and platelets of 30. Sodium 135, potassium 4.3, chloride 100, bicarb 28, BUN 34, creatinine 2 and glucose of 213. AST 33, ALT 201, alkaline phosphatase 178 and T bili 3.6. Coags 15.3, 34.4 and 1.5. An EKG was normal. Hemoglobin A1C was 5.5 back in [2117-6-17]. HOSPITAL COURSE: Patient was taken to the OR on [2117-7-11] for piggy back liver transplant. Surgeons were Drs. [Last Name (STitle) ] and [Name5 (PTitle) 816]. Assistants Dr. [Last Name (STitle) 33758] and [Doctor Last Name ]. Anesthesia was general anesthesia. EBL was 4 liters. Fluids in were 10 liters of crystalloid, 750 of albumin, 10 units of packed red blood cells, 6 units of platelets, 4 units of FFP and 1 unit of cryo. Urine output was 1450. There were no complications. Patient was transferred to the CICU and intubated, sedated. He had a JP, a Foley an NG tube. He was NPO. Immunosuppression was started intraop with Solu-Medrol and CellCept and he also had a Foley postoperatively. In the CICU he did well. Vital signs were stable. Hematocrit was initially 29.8. He did receive on postop day one 1 unit of packed red blood cells, 2 units of FFP and 6 units of platelets for platelets count of 68, white count of 5.2 and a crit of 28.1. creatinine increased to 2.1 on hospital day 1. JP medial put out 330 cc and lateral 1025 cc. LFTs trended down on postop day 1 with an AST of 167, an ALT of 179 and alk phos of 8.1 with a total bili of 1.2 down from 5.8. An ultrasound was done on postop day 1. Ultrasound of the liver on postop day 1 demonstrated abnormal weight form in the main and right hepatic artery with no diastolic flow to inverted diastolic flow. A single tracing of the left hepatic artery demonstrated normal flow within that vessel. The portal vein and branches as well as the hepatic veins demonstrated normal flow. Flow was also seen within the conduit. A duplex was again repeated on postop day 2 and again the conclusion was that the hepatic and portal veins were patent. The arterial assessment was suboptimal, but there was arterial flow in the main hepatic artery towards the bifurcation. The transplanted liver was normal in size. The left common, middle and right hepatic veins were patent with normal directional flow and spectral doppler wave form. Main portal vein right and left portal veins were patent. The arterial assessment was a bit more difficult. Arterial spectral signal demonstrated within the main hepatic artery with good systolic upstroke, arterial flow toward the origin of the right hepatic artery was demonstrable, but definite intrahepatic right or left segmental arterial flow was not demonstrated on that study. LFTs continued to trend down with a total bili of 0.6 on postop day 7 and an AST of 40, ALT of 115 and alk phos of 113. Creatinine preoperatively was 1.5. This slowly increased to a high of 3.5 on postop day 8. Nephrology was consulted. Medications were adjusted slightly to accommodate this. A renal ultrasound was done that demonstrated slightly echogenic appearing right kidney, which was smaller then the left kidney that likely represented renal parenchymal disease. The arterial and venous flow on both kidneys was present. There was a moderate amount of free fluid seen within the lower abdomen. The patient was in the CICU initially. He did well there. He was weaned from the ventilator. He continued on his immunosuppression of Solu-Medrol taper, CellCept 1 gram b.i.d. and he was started on Prograf on postop day 1. He was extubated on postop day 1. Vital signs were stable. He continued to be afebrile throughout this hospital course. On postop day 3 he underwent an angio in the cath lab. On postop day 3 he underwent placement of stents into stent the celiac stenosis. He did well throughout that procedure. Vital signs remained stable. Post crit was 28.6. It was recommended that he be maintained on Plavix 75 mg daily for 9 months. On postop day 3 his central line was down graded to a triple lumen central line. He did receive IV Lasix for diuresis as his weight was elevated. His NG tube was removed on postop day 3. He remained on an insulin drip per protocol as he was on Solu-Medrol for immunosuppression. On postop day 4 he was transferred to the medical surgical unit where he remains on his immunosuppression of CellCept, Prednisone and Prograf. Foley continued to drain urine in the range of 600 cc up to as high as 2600 with IV Lasix. He was again transfused with a 1 unit of packed red blood cells on postop day 6 for hematocrit of 26 as well as 1 bag of platelets for a platelet count of 35. Heparin induced thrombocytopenia antibody was checked and this was negative. A repeat duplex on the 21, there was interval development of mild diastolic flow in the right hepatic artery, resistive indicis in the main and right hepatic artery remained slightly elevated. There was equivocal appearance of wave forms and diastolic flow within the main and left hepatic arteries. All portal vessels and hepatic veins were patent with appropriate wave forms. This ultrasound was done postop angio with stent placement. Chest x-ray on [7-14] demonstrated no cardiopulmonary process. Patient was transferred to medical surgical unit on [2117-7-17] with blood pressure 150/68, heart rate of 60 and respiratory rate of 20, 96% on room air. He was alert and oriented. Breath sounds were decreased at the bases. He had a productive cough, raising some white secretions. He was encouraged to use his incentive spirometer. He was turned and encouraged to cough and deep breath. His abdomen appeared distended with positive bowel sounds. He was passing flatus. His abdominal dressing was intact. JP continued to drain serosanguineous fluid and he did have bilateral lower extremity edema. He did receive another unit of packed red blood cells followed by 48 mg of IV Lasix post transfusion for hematocrit of 26. Foley continued to drain clear yellow urine. He was insisted to get out of bed and he did quite well with that. Post transfusion hematocrit was 29.1. A renal consult was obtained was obtained for rise in creatinine post liver transplant with his baseline creatinine of 1.6 to 2.0. Renal recommendations were doing a renal ultrasound, sending urine for a sodium creatinine urea, nitrogen, protein, eosinophils and serum eosinophils. Recommendations were to avoid nephrotoxic medications and with the consideration to switch Prograf to rapamycin when appropriate. Possible etiologies for ATN were hypotension during surgery and nephrotoxic medications such as Prograf. Bactrim was maintained at every day. Valcyte was adjusted to be given 450 mg po every other day. Prograf levels reached a high of 13.2 on postop day 10. He was maintained on 3 mg twice a day of Prograf and the range for Prograf levels were 10.7 to a low of 7.5 on hospital day 15. He continued on 20 mg of Prednisone and CellCept 1 gram b.i.d. Physical therapy was consulted for weakness and decreased endurance. They recommended continued physical therapy for strengthening, safety and balance. A protein to creatinine ratio was done this revealed a value of 0.3. Urine eosinophils were negative and a FENA was 4 on Lasix, therefore not applicable. Patient continued to be maintained on Lasix 40 mg po b.i.d. for diuresis. His weight continued to be elevated. Preop weight was 80.3 and he went up as high as 82.6 on hospital day 4. This trended down to a low of 73.4 on postop day 14. He was seen by the [Last Name (un) ] physician for management of insulin and glucose as he had some blood sugars in the 200 range. His insulin was adjusted. Toward the end of his hospital course his blood sugars were actually lower and he actually experienced hypoglycemia on 2 successive afternoons. His glargine was decreased as well as his sliding scale Humalog insulin. Foley was removed. He initially was able to void, but then developed some problems with incomplete emptying with some post void residuals of 415 cc of urine. A Foley was replaced temporarily for half a day and then the Foley was removed again. He was able to void on his own independently. Again did demonstrate some post void residual in the 400 range. Again he was recatheterized on [7-23] for incomplete voiding. The Foley was removed the next day and he was able to urinate independently for the remainder of the hospital course. On hospital day 10 his incision continued to drain large amounts of ascitic fluid. Bulky dressing was applied. At that time he was receiving Percocet for pain medication and tolerating this. Due to a persistent leaking of ascitic fluid through the incision a wound VAC was placed with drainage by suction. The wound VAC drained a total of initially 325 cc for 1 day and then on the second day of placement it drained 70 cc. On hospital day 14 he complained of loose stool x 7. A C diff was sent off and at this time is pending. Due to persistent thrombocytopenia HIP antibody was sent off. This subsequently returned positive on the 22nd. The patient was not on heparin at that time and a sign was placed above the head for no heparin to be administered. His central line was changed over to a peripheral IV on postop day 11. He continued to diurese with significant decrease in edema in his extremities. On postop day 15 patient was stable, afebrile. Blood pressure controlled with a high of 142/71 and a low of 120/100. Po intake of 1660. Urine output of 1415 with a white blood cell count of 5.7, hematocrit of 30.3, platelet count of 75 with a creatinine of 2.7. AST was 16. ALT 30. Alk phos 134, total bili 0.3, albumin 3.3. He remained on CellCept 1 gram b.i.d., Prednisone 20 mg every day and Prograf 3 mg po b.i.d. Plan was to discharge patient on [2117-7-27] to skilled nursing facility for physical therapy to continue to work with the patient to increase endurance and balance. MEDICATIONS ON DISCHARGE: Albuterol nebs 0.83% neb 1 neb IH every 4 hours prn, Anzemet 12.5 mg IV prn every 8 hours, Colace 100 mg po b.i.d. to be held if stool output greater then 2 bowel movements per day, fluconazole 200 mg po every 24 hours, Lasix 40 mg po b.i.d., insulin sliding scale and fixed dose of insulin. Insulin 70/30 20 units in the morning, 12 units at lunch and 17 units at bedtime of 70/30. He also maintained insulin sliding scale of Humalog starting at 161 to 200 mg per dl 2 units to be administered at that time. Please see discharge medications. Metoprolol 12.5 mg po b.i.d., CellCept [Pager number ] mg po four times a day, Percocet 1 to 2 tabs po prn every 4 to 6, Protonix 40 mg po every 24 hours, prednisone 20 mg po every day, Phenergan 12.5 mg prn every 6 hours IV, Sevelamer 1200 mg po t.i.d., Bactrim single strength Monday, Wednesday and Friday, Tamsulosin 0.4 mg po at bedtime. Prograf 3 mg po b.i.d., Valcyte 450 mg po every other day. PLAN: Plan is for discharge [2117-7-27] to [Hospital3 7] and Rehab Center with physical therapy with follow up appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2117-8-4] at 10:20. DISCHARGE DIAGNOSES: Laennec cirrhosis status post piggy back liver transplant on [2117-7-11]. History of renal insufficiency. Heparin antibody positive. History of insulin dependent diabetes mellitus since [2101]. Cardiac stent placement approximately 6 months prior to admission. Past surgical history as previously stated. Patient in stable condition. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD, PHD[Numeric Identifier ] Dictated By:[Doctor Last Name 31787] MEDQUIST36 D: [2117-7-26] 22:07:10 T: [2117-7-27] 06:36:40 Job#: [Job Number 33759] ICD9 Codes: 5849, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5858 }	Medical Text: Admission Date: [2120-3-14] Discharge Date: [2120-3-26] Date of Birth: [2049-3-21] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: History of Present Illness: 70 yo man with reported history of COPD, EtOH abuse was found down, reportedly after a fall from standing. There was apparently seizure activity and EMS arrived to find the patient "post-ictal," incontinent of urine and stool, with some bruising over the right eye. He was brought to [Hospital1 29405] and was intubated there after reportedly receiving lidocaine, a paralytic, and etomidate. CT of the head showed a left frontal intraparenchymal hemorrhage with a component of SAH. There was also concern for a non-displaced frontal bone fracture. He apparently had [3-3] seizures prior to arrival, unclear timing and simeology. He received 2 mg ativan x 2 and was loaded with cerebyx before arrival at [Hospital1 18]. Here, he was given a dose a 2 mg versed in the trauma code prior to the neurosurgical evaluation. Past Medical History: Past Medical History: -COPD -Alcohol abuse Social History: Social History: Unknown, but reportedly a history of alcohol abuse as described above. Family History: unknown Physical Exam: Physical Exam Vitals: T 102.0 F BP 94/61 P 87 RR 18 SaO2 100% on vent General: NAD, well nourished HEENT: minimal bruising over the temporal aspect above the right eye, sclerae anicteric, orally intubated Neck: C-spine hard collar in place Lungs: coarse ventilated breath sounds CV: regular rate and rhythm, no MMRG Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: cool, no edema, pedal pulses appreciated, some dirt on legs Skin: no rashes Neurologic Examination: Mental Status: Lightly sedated, able to open eyes to voice and move extremities on command Cranial Nerves: Fundi poorly appreciated due to patient ability to cooperate with exam; blinks to threat bilaterally. Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Corneals intact bilaterally. Extraocular movements intact laterally, no nystagmus. Facial symmetry difficult to appreciate given instrumentation. Motor: Normal bulk throughout. No adventitious movements noted. Moving upper and lower extremities anti-gravity and symmetrically without obvious focal deficit. Sensation: Withdraws to noxious bilaterally in upper extremities, appears to triple flex in lower extremities. Reflexes: B T Br Pa Pl Right 2 1 2 1 0 Left 2 1 2 1 0 Toes were upgoing bilaterally. Coordination and gait: unable ON DISCHARGE PT WITHOUT NONFOCAL NEUROLOGICAL EXAM. Pertinent Results: Data: 12.2 15.9>---<165 34.4 PT: 12.2 PTT: 29.2 INR: 1.0 Fibrinogen: 274 Na:135 K:4.8 BUN 16 Cl:103 Cr 1.1 TCO2:20 Glu:111 freeCa:1.03 Lactate:4.4 pH:7.32 Hgb:12.8 CalcHCT:38 [Doctor First Name ]: 130 Phenytoin pending Serum and urine tox: negative UA: moderate blood, 50 ketones, [7-9] RBC, 0-2 WBC, [7-9] epi, many bacteria, [4-3] granular casts EKG: NSR, no noted ST-T changes Chest portable: Study is limited by underlying trauma board. Endotracheal tube seen with tip approximately 4 cm above the carina. Nasogastric tube is seen coiled with tip within the stomach. Cardiac and mediastinal contours appear unremarkable. Pulmonary vascularity appears within normal limits. There are no focal consolidations. There are no displaced rib fractures. IMPRESSION: Endotracheal tube seen with tip approximately 4 cm above the carina. Nasogastric tube is seen with tip coiled within the stomach. No evidence of displaced rib fracture. Non-contrast CT head: Reviewed with Dr. [Last Name (STitle) 548], a left frontal IPH, ~2.4 x 1.7 cm with subarachnoid component noted along convexity. There is a gap at the mid-frontal bone that was concerning for a fracture at the OSH. However, it appears somewhat distinct from the area of hemorrhage and there is no clinical correlate with trauma at that location on examination. Await official read. * Appears stable after review of CT head from OSH with radiology. We also reviewed CT C-spine that showed no apparent fracture or other pathology. [2120-3-15] MRI head - 1. No significant change in the acute intraparenchymal hematoma, with subarachnoid and subdural hemorrhage, as described above. Small amount of intraventricular hemorrhage in the occipital horns, better seen on MR. 2. No definite abnormal enhancement noted in the left frontal lobe at the site of the hematoma to suggest a vascular lesion. However, any underlying vascular lesions obscured by the hematoma cannot be evaluated. 3. Dedicated MR angiogram of the head was not performed on the present study. Hence, limited assessment for evaluation of aneurysms. 4. To consider repeating the study without and with IV contrast as well as MR angiogram, after resolution of the hematoma, for assessment for any vascular lesions. 6. Moderate sinusitis, as described above, with a few retention cysts/polyps in the maxillary sinuses. [2120-3-19] 05:55AM BLOOD WBC-4.9 RBC-3.26* Hgb-10.6* Hct-30.8* MCV-94 MCH-32.5* MCHC-34.4 RDW-13.6 Plt Ct-152 [2120-3-15] 05:01AM BLOOD PT-12.9 PTT-32.3 INR(PT)-1.1 [2120-3-19] 05:55AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-143 K-3.6 Cl-107 HCO3-25 AnGap-15 [2120-3-14] 04:15PM BLOOD ALT-64* AST-61* LD(LDH)-408* AlkPhos-79 TotBili-0.5 [2120-3-14] 04:15PM BLOOD Albumin-4.2 [2120-3-19] 05:55AM BLOOD Phenyto-8.8* SHOULDER XRAY: [2120-3-25] IMPRESSION: 1. No evidence of acute fracture. 2. Remodeling of distal end of the left clavicle suggests old fracture. 3. AC joint osteoarthritis. Brief Hospital Course: Pt was admitted to the TICU for close monitoring. His neuro exam remained stable with moving all 4 extremities and following commands while intubated. He was extubated on HD#2. His repeat head CT was stable and he was transferred to the floor. MRI showed no definitive underlying lesion. His diet and activity were advanced. Foley was removed. Was monitored with CIWA scale and given ativan occasionally for agitation. Dr. [First Name (STitle) ] assumed care of patient. He was seen by PT/OT who intially recommended rehab. Future visits found pt to be ambulatory with only observation needed. The patient had left shoulder discomfort limiting range of motion and an x-ray revealed osteoarthritis and an old healed fracture. No acute PT / OT needs. Pt wishes to be discharged to [Doctor Last Name ] [Doctor Last Name ] SHELTER INTAKE DEPARTMENT FOR [Location (un) ] SHELTER PLACEMENT IN [Hospital1 ]. Medications on Admission: Unknown Allergies: -Unknown Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Should take for 3 months. Disp:90 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Traumatic SAH Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit 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 He should have weekly Dilantin levels drawn and dilantin dose adjusted appropriately. Followup Instructions: Follow up with Dr. [First Name (STitle) ] in 4 weeks - call ([Telephone/Fax (1) 88] for appointment YOU WILL NEED A CAT SCAN OF THE BRAIN AT THAT TIME. ICD9 Codes: 496, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5859 }	Medical Text: Unit No: [Numeric Identifier 61858] Admission Date: [2168-6-18] Discharge Date: [2168-6-21] Date of Birth: [2168-6-17] Sex: F Service: NB HISTORY: Baby Girl [Known lastname 11923] [Known lastname 3647] delivered at 38 and 1/7 weeks gestation with a birth weight of 3200 grams and was admitted to the newborn intensive care unit from the newborn nursery around 30 hours of life for management of hyperbilirubinemia due to ABO incompatibility. The infant was born to a 38 year old gravida V, para II, now [Name (NI) 1105] mother. Prenatal screens included blood type O positive, antibody screen negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, and group B Strep status unknown. The pregnancy was reportedly uncomplicated. No perinatal sepsis risk factors. Delivery was by repeat cesarean section on [2168-6-17]. Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. The infant was initially in the newborn nursery breast feeding on day of birth with some formula supplement on day #1. When she had bottles, she was taking around [4-15] to 1.5 ounces per feeding and tolerating them well, normal voiding and stooling pattern. On her examination the day after delivery, day of life #1, she was noted to be jaundiced and a bilirubin was drawn and was noted to be a total bilirubin of 17. Phototherapy was started and 4 hours later the bilirubin was 18.7 with a reticulocyte count of 21% and a hematocrit of 38%. She was transferred to the newborn intensive care unit for continued medical care. PHYSICAL EXAMINATION: On admission, birth weight 3200 grams (75th percentile), length 48 centimeters (50th percentile), head circumference 34 centimeters (75th percentile). The infant is active, alert, no distress, under phototherapy with protective eye wear. Anterior fontanelle soft, flat. Good suck. Intact palate. Lungs clear to auscultation. Regular rate and rhythm, no murmur. Femoral pulses 2+. The abdomen was soft, no hepatosplenomegaly, bowel sounds present. Extremities well perfused, pink, jaundiced, appropriate tone and activity for gestational age. HOSPITAL COURSE: Respiratory: No issues. Is comfortable breathing 30s to 50s. Cardiovascular: No issues, no murmur. Heart rate was running in the 130s to 140s. Blood pressure today 77/42 with a mean of 55. Fluids, electrolytes and nutrition: Is breast feeding and taking supplemental formula feeds. Taking about 45 to 55 ml every 3-4 hours, is voiding and stooling appropriately. Weight today on [2168-6-21], is 3015 grams. GI: Was placed on triple phototherapy on admission with a follow-up bilirubin total 15.6, direct 0.3. Bilirubin today on [2168-6-21], was total 14.1, direct 0.3. She was changed to phototherapy with a follow-up bilirubin about 12 hours later that was decreased to a total of 13.4, direct 0.3. Hematology: The baby's blood type is A positive, direct Coombs positive. Her hematocrit on admission was 39% with a reticulocyte count of 21%. Her hematocrit today on [2168-6-21], was 36.3%. Infectious disease: No issues. Neurology: Examination is age appropriate. Sensory: Hearing screening has not been performed. Will need prior to discharge. CONDITION ON DISCHARGE: Stable. DISPOSITION: Transferred to newborn nursery for further monitoring and care of hyperbilirubinemia. PRIMARY PEDIATRICIAN: [Hospital ] Pediatrics. CARE AND RECOMMENDATIONS: 1. Ad lib breast or bottle feeding. 2. State newborn screen was drawn on [2168-6-20]. 3. Received hepatitis B immunization on [2168-6-21]. 4. Continue double phototherapy. 5. Bilirubin in a.m. of [2168-6-22]. DISCHARGE DIAGNOSES: Term appropriate for gestational age female infant. ABO hemolytic disease. Hyperbilirubinemia secondary to ABO hemolytic disease. Mild anemia secondary to ABO hemolytic disease. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Dictator Info ] MEDQUIST36 D: [2168-6-21] 19:34:16 T: [2168-6-21] 20:15:26 Job#: [Job Number 61859] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5860 }	Medical Text: Admission Date: [2101-11-6] Discharge Date: [2101-11-9] Date of Birth: [2101-11-6] Sex: M Service: Neonatology HISTORY: Baby [Name (NI) ] [Known lastname ] is a 3130 gram product of a full-term pregnancy born to a 32-year-old G1 P0 now 1 mom. Prenatal screens: Blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, GBS positive, but treated with antibiotics greater than four hours prior to delivery. Patient born by spontaneous vaginal delivery with Apgar scores of 9 and 9 at one and five minutes respectively. Baby taken to the Newborn Nursery and was noted to have some tachypnea. Was seen by the private pediatrician, and then the pediatric nurse practitioner. He remained comfortable in room air with oxygen saturations greater than 98%, respiratory rate of 70-90s. Was sent to the NICU for further evaluation. PHYSICAL EXAM ON ADMISSION: The baby was comfortable with tachypnea. Temperature 98 degrees, respiratory rate 50s-70s, sats 98-100% in room air. Blood pressure in his right arm is 76/36 with a mean of 52. Left arm 70/38 with a mean of 53. Right leg is 61/42 with a mean of 49. Left leg 56/37 with a mean of 44. Lungs are clear bilaterally. Heart was regular, rate, and rhythm, no murmur. Abdomen was soft with active bowel sounds. Extremities are warm and well perfused with brisk capillary refill. Hips stable. Spine midline. Anus patent. Mongolian spot present on buttocks. Femoral pulses are 2+ bilaterally, good tone. Chest x-ray performed which was normal. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Patient remained tachypneic through day of life one, comfortable throughout. Tachypnea gradually resolved. At time of discharge, the patient is breathing comfortably on room air with respiratory rates in the 50s. 2. Cardiac: Cardiovascularly stable throughout admission with normal blood pressures and no murmurs. 3. FEN: Patient initially breast feeding adlib on admission. Lactation support was consulted. On day of life two, the patient began supplementing breast feeding with bottle feeding. Patient with good intake with bottle feeds. Birth weight 3130 grams. Weight on discharge 3730 grams down 13% on birth weight. Glucoses were monitored and remained stable throughout admission. Patient with adequate urine output and good stool output. 4. GI: Patient had a small spit-up questionably bilious on the night of [11-7]. A KUB was performed which was normal. Additional small spit-up on [11-8], which was thought consistent with colostrum. Patient subsequently p.o. feeding well with no further spit-ups. Abdomen was benign throughout. 5. Hematology: Patient's hematocrit is 53.2 on admission. The patient required no blood products during this admission. 6. ID: CBC and blood cultures sent on admission. White count 15.6 with 50 polys and 9 bands. Patient was not started on antibiotics. Blood cultures with no growth at greater than 48 hours. 7. Sensory: Audiology hearing screen was performed with automated auditory brain stem responses. Baby passed bilaterally. 8. GU: Patient had circumcision on [9-9], tolerated well. 9. Immunizations: The patient received hepatitis B vaccine on [11-9]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Discharged to home with parents. NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 29768] [Hospital2 50536] [Hospital3 37830], phone number [Telephone/Fax (1) 37832]. CARE AND RECOMMENDATIONS: Feeds at discharge: P.o. adlib breast feeding and bottle feeding with Enfamil 20, with breast milk and Enfamil 20. MEDICATIONS: None. Newborn state screen sent. Results are pending. IMMUNIZATIONS RECEIVED: Hepatitis B. FOLLOW-UP APPOINTMENTS: Follow-up appointment scheduled with Dr. [Last Name (STitle) 29768] on [11-10]. [First Name11 (Name Pattern1) 37693] [Last Name (NamePattern4) 37927], M.D. [MD Number(1) 37928] Dictated By:[Last Name (NamePattern1) 50027] MEDQUIST36 D: [2101-11-10] 06:04 T: [2101-11-10] 06:13 JOB#: [Job Number 50537] ICD9 Codes: V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5861 }	Medical Text: Admission Date: [2192-6-9] Discharge Date: [2192-6-14] Date of Birth: [2128-1-21] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: Motor vehicle accident Major Surgical or Invasive Procedure: [2192-6-9]: L chest tube History of Present Illness: 64M s/p motorcycle crash, moderate speed, unhelmeted. Alert and following commands at scene, and taken to [Hospital 8641] Hospital. Reportedly became hypotensive and unresponsive in CT scan, and was intubated for airway protection. Transferred to [Hospital1 18] for trauma evaluation. Became hypotensive in trauma bay, transfused 2 units pRBCs and a left chest tube placed. A TEE was performed in the trauma bay, which showed hyperdynamic LV function and no aortic dissection. Past Medical History: CAD s/p stenting, HLD, HTN, recently passed kidney stone Past Surgical History: cardiac cath, otherwise unknown Social History: Denies tobacco, alcohol, and illicit durg use. Independent with ADLs. Family History: NC Physical Exam: Discharge physical; NAD, lying in bed. breathing unlabored. rrr ctab, but diminished at L lung base LUE with ecchymosis, no evidence of skin tenting or skin compromise. No deformity. 2+ L radial pulses. Arms and forearms are soft no LE edema Pertinent Results: [2192-6-9] 03:15PM BLOOD WBC-10.4 RBC-3.25* Hgb-9.5* Hct-29.1* MCV-89 MCH-29.3 MCHC-32.8 RDW-13.1 Plt Ct-96* [2192-6-9] 03:15PM BLOOD Glucose-181* UreaN-25* Creat-0.8 Na-141 K-3.7 Cl-116* HCO3-18* AnGap-11 [2192-6-9] 05:50PM BLOOD ALT-22 AST-27 AlkPhos-45 TotBili-0.5 CT abdomen/pelvis: 1. A displaced comminuted fracture of the distal left clavicle. No apparent associated major vascular injury is noted. 2. A displaced comminuted fracture of the scapula with associated hematoma. 3. Small left pneumothorax. 4. Small left hemorrhagic pleural effusion. 5. Small bilateral consolidations, may represent aspiration, infection or atelectasis. 6. Right upper lobe peripheral ground-glass opacity may reflect pulmonary contusion. 7. Hepatic hypodense lesion, incompletely characterized on today's exam. 8. Multiple left rib fractures. 9. Extensive calcified atherosclerotic disease of the aorta and its branches without aneurysmal changes. CT Cspine: 1. No evidence of acute fracture or malalignment. 2. Subcutaneous gas in the left cervical region. Left clavicular fracture on scout- see CT Torso for other fractures. Clavicle: Fracture involving the junction of the mid/distal third of the clavicle is noted with superior displacement of the distal fracture fragment by approximately one shaft width. Right knee: No acute fracture or dislocation is identified [2192-6-13] Post chest tube pull cxr: As compared to the previous radiograph, the left pneumothorax has decreased in extent, it is barely visible on today's image. Unchanged are the rib fractures, the scapular fractures and the areas of atelectasis at the left lung base as well as the moderate cardiomegaly without pulmonary edema. There is unchanged air content in the soft tissues of the left cervical region. No other changes. [2192-6-14] 09:00AM BLOOD WBC-7.4 RBC-3.47* Hgb-10.0* Hct-31.3* MCV-90 MCH-28.9 MCHC-32.0 RDW-13.6 Plt Ct-144* [2192-6-14] 09:00AM BLOOD Plt Ct-144* Brief Hospital Course: Mr. [Known lastname 81709] was admitted to the trauma ICU with the following injuries: - comminuted left distal clavicle fx - comminuted displaced left scapular fx - small left pneumothorax - small left pleural effusion - Left 1st rib fracture - Left temporal bone fracture On admission, he was noted to be hypotensive and required levophed for support. A bedside echo was performed and showed no evidence of wall motion abnormalities. He was fluid resusciated overnight and weaned off pressor. He was extubated without event. His pain was well controlled with a dilaudid PCA. He was hemodynamically stable with a GCS of 15 thereafter and was transferred to the floor on [2192-6-10]. On the pt's pain was aggressively controlled w/ tylenol/tramadol/and po dilaudid prn. IS was encouraged. On [2192-6-11] chest tube was placed to water seal with no leak. Tube subsequently removed on [2192-6-13], post pull cxr w/out evidence of ptx. ENT was consulted for L temporal bone fx. They recommended ciprodex drop to left ear [Hospital1 ] x 10 days as well as outpt audiogram. Ortho managed fractures non-operatively. Pt's left arm was in sling at all times while out of bed, and PT began pendulum exercises with patient. Medications on Admission: lipitor 20', toprol XL 50', folic acid, plavix 75', rosuvastatin 20', fluoxetine 10', valsartan 60', cholecalciferol, ASA 81' Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: Four (4) drops Otic twice a day for 9 days: to left ear. Disp:1 bottle Refills:0 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for pain. Disp:40 Tablet(s) Refills:0 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:50 Capsule(s) Refills:0 11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: 1. L claviclular fx 2. L scapular fx 3. L PTX 4. L 1-10th rib fx 5. L temporal bone fx 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: Admitted after Motor vehicle accident resulting in multiple fractures and short ICU stay. Please resume all of your home medications. Continue dry ear precautions for your left ear. No water may enter L ear until follow up with ENT at least. Use ear drops as prescribed for an additional 8 days. Tylenol, as well as narcotic pain medications for pain as needed. Stool softeneres may be necessary to prevent constipation. Left upper extremity/arm is non-weight bearing. Maintain in sling. Pendulum exercises w/ PT left chest tube incision should remain dressed w/ airtight dressing until the wound has completely closed. Followup Instructions: Follow-up in [Hospital 2536] clinic in 2 weeks. Telephone #[Telephone/Fax (1) 600] Follow in 3 weeks with Dr. [Last Name (STitle) 1005] of Orthopaedic Surgery. telephone #([Telephone/Fax (1) 2007] X-Rays of your L shoulder will be obtained at follow up. Please call ENT (#[Telephone/Fax (1) 41]) to schedule a follow up audiogram and an appointment with Dr. [Last Name (STitle) ] in about 2 weeks. Completed by:[2192-6-14] ICD9 Codes: 5119, 4589, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5862 }	Medical Text: Admission Date: [2148-9-19] Discharge Date: [2148-10-6] Date of Birth: [2097-5-15] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: RCC with new pancreatic head mass Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Gastroenterostomy (antecolic retrogastric isoperistaltic). 3. Open cholecystectomy. 4. Extended adhesiolysis. 5. Ileocolic bypass (by Dr. [Last Name (STitle) 1924]. 6. Appendectomy. History of Present Illness: 51M PMH of aggressive renal cell carcinoma s/p R nephrectomy. Metastatic disease to the lungs and s/p chemo with solid tumor recurrence. On recent imaging, the head of his pancreas was found to have a necrotic gas-filled appearance consistent with a metastatic lesion there which had necrosed. Past Medical History: Onc Hx: diagnosed with kidney cancer in [5-/2147] when he presented with hematuria and abdominal pain. The CT showed a large right renal mass and he underwent nephrectomy on [2147-6-6]. Nephrectomy showed an 11 cm tumor with invasion into the perinephric tissues and major veins, with clear cell histology, Furhman nuclear grade 2. His preoperative workup had revealed pulmonary emboli requiring anticoagulation. CT scans following nephrectomy showed recurrence in the nephrectomy bed site as well as increased mediastinal lymphadenopathy. He received HD IL-2 treatment in [2147-9-1] without response. He was enrolled in the phase I avastin/sorafenib trial initiating treatment in [11-5]. PAST MEDICAL HISTORY: 1. Status post partial colectomy after perforated bowel secondary to a motorcycle accident. 2. Status post right knee surgery. 3. Status post left knee arthroscopy. 4. History of pulmonary emboli on anticoagulation. Social History: Social History: He works in the telecommunication industry and often drives for hours at a time. Remote ETOH hx Tob: 1 ppd x 30 years Married and lives with wife and 7 yr old child Family History: Family History: Father and uncle with lung CA [Name (NI) ] with [Name2 (NI) 499] CA Sister with lung problems [Name (NI) ] family hx of kidney cancer Physical Exam: On discharge: AVSS Well-developed, thin 51yo male NCAT, NAD EOM full, anicteric, non-injected sclera Neck supple, no LAD Chest clear bilaterally Heart regular without murmurs Abdomen, soft, moderate incisional tenderness, midline incision has been opened in multiple areas and is packed with iodoform dressing, it is granulating well and does not have any surrounding erythema and minimal induration, normal bowel sounds, there are no drains in place LE warm, well perfused, no edema Pertinent Results: [2148-10-4] 04:51AM BLOOD WBC-9.5 RBC-2.42* Hgb-7.1* Hct-22.2* MCV-92 MCH-29.3 MCHC-32.0 RDW-17.8* Plt Ct-611* [2148-10-5] 07:09AM BLOOD PTT-51.4* [2148-9-27] 03:48PM BLOOD AT III-56* [2148-10-4] 04:51AM BLOOD Glucose-130* UreaN-24* Creat-0.8 Na-136 K-4.7 Cl-105 HCO3-23 AnGap-13 [2148-10-4] 04:51AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.5 [2148-9-23] 8:01 am SWAB Source: Abdomen. FINAL REPORT [2148-9-27] GRAM STAIN (Final [2148-9-23]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2148-9-25]): [Female First Name (un) ] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. ANAEROBIC CULTURE (Final [2148-9-27]): NO ANAEROBES ISOLATED. . SPECIMEN SUBMITTED: APPENDIX & GALLBLADDER. Procedure date Tissue received Report Date Diagnosed by [2148-9-19] [2148-9-19] [2148-9-25] DR. [Last Name (STitle) ]. BELSLEY/vf Previous biopsies: [-6/2171] 11 TH RT RIB, RT KIDNEY. DIAGNOSIS: I. Appendix: Appendix, no diagnostic abnormalities recognized. II. Gallbladder (C-D): Chronic cholecystitis. Cholelithiasis. Clinical: Recurrent kidney cancer. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [2148-9-22] 12:00 PM CTA CHEST W&W/O C&RECONS, NON- Reason: assess for PE IMPRESSION: 1. Segmental right middle lobe pulmonary artery pulmonary emboli. 2. Fluid-filled distal right lower lobe bronchus with associated atelectasis. 3. Focal ground-glass opacity within the right lower lobe which could represent either aspiration or early pneumonia. . CHEST (PORTABLE AP) [2148-9-24] 4:16 AM CHEST (PORTABLE AP) Reason: RML AND rll atelectasis s/p significant time on Bipap; any i The right internal jugular line tip is in low SVC. The NG tube tip is in the stomach. The IVC filter is in expected position. There is no interim change in the appearance of right middle and right lower lobe atelectasis. There is unchanged basal atelectasis in the left lower lobe. Small left pleural effusion cannot be excluded. The upper lungs are unremarkable. . CT ABDOMEN W/O CONTRAST [2148-9-26] 9:12 AM IMPRESSION: 1. Mild-to-moderate interval increase in amount of intra-abdominal free fluid. A few small pockets of hyperdense fluid along the anterior abdominal wall adjacent to incisional site are likely small postoperative hematomas. 2. Interval increase in size to a known invasive pancreatic head mass. No significant interval change to retroperitoneal/right nephrectomy mass. Please note, overall examination is limited due to lack of IV and oral contrast. 3. Interval placement of suprarenal IVC filter. 4. Probable bilateral, right greater than left, basilar atelectasis with areas of adjacent patchy ground-glass opacities. Superinfection/aspiration pneumonitis cannot be excluded. 5. Gastric tube with its tip in the fundus. Nonvisualization of GJ tube mentioned in history. . CHEST (PORTABLE AP) [2148-9-28] 4:26 AM IMPRESSION: Small bilateral pleural effusions and bibasilar atelectasis. Slight interval worsening in bilateral airspace opacities. Diagnostic considerations again include pneumonia. . Brief Hospital Course: Pain: Chronic opioid user for pain, post-operatively the pt had severe abdominal pain, out of proportion to his abdominal exam, which remained relatively soft, although distended, throughout his hospitalization. On POD8, APS was consulted after pain control could not be achieved using a fentanyl gtt at 300mcg/hour, dilaudid PCA@0.75mg/q6mins, clonidine patch in the ICU. APS transitioned the pt to a ketamine infusion at 10-15mg/h, with dilaudid PCA and clonidine patch. Before discharge the patient was transitioned to a PO regimen that included methadone 20mg tid, dilaudid 8-10mg q3h prn, and clonidine and fentanyl patches. On discharge the pain was well-controlled. PE: On POD3, the pt developed acute dyspnea with tachypnea, requiring non-rebreather and CPAP to maintain adequate oxygenation. He was transferred to the SICU, where his respiratory failure could be appropriately managed. Once stabilized, a PE protocol CTA was done and demonstrated a segmental right middle lobe pulmonary artery pulmonary embolus. The pt was started on a sub-therapeutic heparin drip (goal PTT 50-60) and vascular surgery was consulted to put in a supra-renal IVC filter, which they did on POD4. On POD5, PPD1, a flex bronch with therapeutic aspiration was done with much improvement in the pt's respiratory status. By POD8, the pt's respiratory status had improved and the pt was transferred to the floor. Supplemental oxygen was weaned, and on discharge the pt did not require any supplemental oxygen. The heparin drip was discontinued on POD15, and he was discharged without any anticoagulation due to the risk of bleeding from the pancreatic tumor. Elevated glucose: Throughout his hospitalization, the pt had elevated blood glucose measurements between 100-200mg/dl. The pt was discharged without insulin, but it was recommended that he follow up the week of discharge with his primary care physician for management of this issue. ID: Intraoperatively, there was some stool spillage into the abdomen so the pt was placed on broad spectrum antibiotics. After spiking a fever on POD___, antibiotics were changed to vancomycin and zosyn. The pt was pan-cultured, and blood and urine cultures were negative, as was the CXR. Cultures from the midline incision fluid were sent and grew back [Female First Name (un) ] albicans, but no organisms were found on gram stain. Throughout the remainder of the hospitalization, the pt remained afebrile on vanc/zosyn and this regimen was continued for the duration. On discharge, the pt were transitioned to augmentin for a 2 week course. GI: [Name (NI) ], pt had a prolonged ileus. He was receiving TPN. In the ICU, the pt passed one bowel movement, but upon transfer to the floor, he was not passing any flatus. By POD13, he began passing gas and his diet was advanced from sips to clears, which he tolerated well. His abdominal exam continued to improve with diminishing distention. He was transitioned to full liquids on POD14 after having a successful bowel movement, and on POD15 he did well with a regular diet and his TPn was weaned off. His was discharged on a diabetic diet on POD16, having regular bowel movements without nausea. Medications on Admission: zestril 2.5', norvasc 10', oxycontin 90bid, oxycodone 15q3-4prn, synthroid 100', ativan 1-2prn, ambien qhs, wellbutrin, zantac 150", miralax prn Discharge Medications: 1. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Disp:4 Patch Weekly(s) Refills:0 2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 8. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed. 10. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 11. Zestril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 12. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: VNA of [Location (un) 86] Discharge Diagnosis: metastatic RCC, pancreatic mass Discharge Condition: stable Discharge Instructions: Activity as tolerated Regular diet OK to shower Follow up with Dr. [Last Name (STitle) ] in 2 weeks. Call Dr.[Name (NI) 2829] office with any questions. You should call your PCP to arrange an appointment in [3-3] days. Your home blood pressure medication was not started because your blood pressure has not been elevated during this hospitalization. You should take 14 days of augmentin as directed. You should change your dressing twice daily, using iodoform packed within the wound. Followup Instructions: Make an appt with [Hospital 19083] Care Center Office Phone: ([Telephone/Fax (1) 19084] Office Fax: ([Telephone/Fax (1) 19085] and with Oncology/Hematology Office Phone: ([Telephone/Fax (1) 19086] Your PCP next week. Completed by:[2148-10-8] ICD9 Codes: 5185, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5863 }	Medical Text: Admission Date: [2155-4-22] Discharge Date: [2155-4-24] Date of Birth: [2120-11-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Mr. [Known lastname 4702] is a 34M with ESRD on HD and poorly controlled blood pressure who presents with increased SOB. Of note, he was recently admitted [Date range (1) 58652] with CP in the setting of HTN requiring ICU admission and a labetalol drip. . He reports that over the last weekend he had some nausea and non-bloody emesis. Last HD was [Last Name (LF) 766], [First Name3 (LF) ] his report was uneventful. Upon return from HD he noticed that he felt short of breath with activity. He felt discomfort in his chest "like he was being punched" associated with palpitations. This would go away over a few minutes if he rested. The pain was non-radiating, and not related to position, breathing, or PO intake. He had some associated nausea, without lightheadedness or diaphoresis. The CP felt similar to his prior CP, in fact less intense. Denies any fevers, chills, sweats, coughing, abdominal or back pains. Has had some pruritis, but denies any abnormal taste in his mouth. Had constipation over the weekend, no diarrhea or dysuria. Reports taking all his home antihypertensives and denies any substance use. . In the emergency department, initial vitals were 98.3 110 196/143 28 97% on RA -> NRB. On exam, tachypneic and wheezy. EKG showed SR with lateral STD. CXR showed mild pulmonary edema. He was given atrovent, aspirin 325mg, nitroglycerin, and lasix 200mg with little urine output. Started on a nitroglycerin drip. Renal evaluated him in the ER, felt he did not urgently need HD. 98 103 169/106 31 94 on 4L, still on nitroglycerin drip, SOB and CP improved. Access 22g PIVx1. . On evaluation in the MICU, he reported continued CP up to [6-6] as well as a headache that started after he got nitroglycerin in the ER. Past Medical History: - ESRD secondary to HTN - started on dialysis in [12/2152] - HTN - h/o medication non-compliance - h/o substance abuse - h/o right internal jugular vein thrombus associated with HD catheter - h/o pulmonary edema in the setting of hypertensive urgency - h/o intubation in the setting of hypertensive urgency/flash pulmonary edema - dyslipidemia on statin - s/p appendectomy - s/p ex-lap Social History: He used to work as a plasterer, but is now on disability. Mother died 4 months ago. Tobacco: 1PPD x 20 years, currently 3 cigarettes a day. EtOH/Drugs: Denies recent alcohol, cocaine and marijuana use. Family History: There is no family history of premature coronary artery disease or sudden death. Father - Died at age 36 from unknown cancer Mother - Died at age 58 of MI, had HTN Maternal grandmother - on hemodialysis for end-stage renal disease. Physical Exam: Vitals 97.9 88 139/90 27 92% on labetalol drip General Uncomfortable appearing young man, in moderate distress. Coughing occasionally. HEENT Sclera anicteric conjunctiva pink MMM Neck No JVD Pulm Lungs with diminished breath sounds a few rales at bases, no wheezing or rhonchi CV Regular S1 S2 no m/r Abd Mildly distender no rigitiy or guarding +bowel sounds nontender Extrem Warm palpable pulses, L AV fistula with palpable thrill Neuro CN 2-12 intact, full strength in bilateral extremities, normal sensation to light touch Pertinent Results: LABS: CBC 5.6>35.2<267 CK 351 MB 4 Tropn 0.20, was 0.10 on [4-6] Chem 140/4.8/96/25/69/10.9<85 INR 1.2 PTT 26.4 . ECG: SR @82 nl axis and intervals, poor R wave progression with deep S waves in precordial leads. <1mm STD with TWI in V6 and vF. TWI in III more prominent today. q's in vL and I. In comparison to [2155-4-1] EKG, the TWI in v6 is new (but seen previously [2155-3-19]) . STUDIES: . CXR UPRIGHT AP VIEW OF THE CHEST: Moderate cardiomegaly is stable from prior. The mediastinal and hilar contours are similar. Bilateral hazy air space opacities are present, with indistinctness of the pulmonary vascularity suggestive of mild pulmonary edema. No pleural effusions are seen. There is no pneumothorax. Rounded calcification within the right upper quadrant is unchanged from prior which was previously noted to be a calcified renal mass. IMPRESSION: 1. Mild pulmonary edema. 2. Unchanged cardiomegaly. 3. Unchanged calcified lesion in the right upper quadrant corresponding to a calcified renal mass seen on previous CT from [2155-3-18]. . CTA chest [4-1] IMPRESSION: 1. No pulmonary embolus. No aortic dissection. 2. Diffuse ground-glass opacity with air trapping at bases suggests small airways disease and/or poor respiratory effort. Mild pulmonary edema. 3. Right chest wall collaterals suggest stenosis, occlusion of the right subclavian vein. 4. Persistent coronary artery calcifications. 5. Stable appearance of calcified right renal mass. 6. Pulmonary hypertension given enlarged diameter of pulmonary artery. 7. Dilated ascending aorta, stable from prior. 8. Stable cardiomegaly. . Echo [11-4] EF 40-45%, Moderate LVH, moderate HK inferior septum and inferior wall, [11-29]+ AR, 2+ MR Brief Hospital Course: * Hypertensive urgency Chest pain in setting of marked hypertension with abnormal EKG consistent with hypertensive emergency. He has had multiple admissions for similar complaints. The reason for these repeated presentations is not certain but according to [Name (NI) ] pt has history of poor medication compliance. Given ESRD, volume is likely a contributor to his hypertension but renal team feels that HD not needed emergently. Patient was started on labetalol gtt then transitioned to PO meds with better BP control. * Chest discomfort [Month (only) 116] have cardiac ischemia in setting of marked hypertension. Think a primary plaque rupture event is less likely. Patient said he would not be able to take daily medication (including plavix) even knowing the risk of blood clot without it. So he was deemed not to be an appropriate candidate for stress test since, if positive, he would not comply with therapy that would be needed after therapeutic catheterization. Was continued on [Month (only) ], imdur, and statin. Also not a candidate for beta blocker given cocaine abuse. Cardiac enzymes were checked and trended down from 0.20->0.15 (baseline for him). He had a follow up appointment in cardiology on the day of discharge and was discharged in time to make it to that appointment for further discussion of the best management of his presumed coronary artery disease. * Nausea [Month (only) 116] have been from coronary ischemia in setting of HTN-emergency. Resolved with BP control and HD. KUB was WNL. * ESRD on HD. Received dialysis [2155-4-23]. Unclear how often he has been going to HD as outpatient although he reported going to HD on Friday prior to admission. He was continued on phos binders. FEN regular PPX PPI Code full Medications on Admission: (per [3-29] DC summary) sevelemer 1600mg TID phoslo 1334mg TID imdur 30mg daily lisinopril 40mg daily simvastatin 80mg qhs nifedipine 90mg daily terazosin 1mg qhs MVI [Month/Day (2) ] 325 daily ferrous sulfate 325mg daily percocet prn ibuprofen 800mg tid prn, colace, senna Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Hypertensive emergency Secondary ESRD on HD hx cocaine abuse Discharge Condition: Afebrile. Hemodynamically stable. Discharge Instructions: You were admitted to the hospital with chest pain and a high blood pressure. You received medications for this and your chest pain went away when your blood pressure came down. It is very important that you should continue taking your medications every day exactly as they are prescribed to keep your blood pressure under control. Medication Changes: None Please come back to the hospital or call your primary care doctor if you have fevers, chills, chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, or any other concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2155-4-24] 2:00 Please follow up with the nurse practitioner who works with your primary care provider, [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 3817] ([Telephone/Fax (1) 250]) on [2155-5-1] at 12:20. She is located in the Atrium Suite on the [Location (un) 448] of the [Hospital Ward Name 23] building on the [Hospital Ward Name 516] of [Hospital3 ] Medical Center. Please continue to keep your dialysis appointments at [Location (un) 76539] on Mondays, Wednesdays, and Fridays. Their phone number is ([Telephone/Fax (1) 76547]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2155-4-24] ICD9 Codes: 5856, 2724, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5864 }	Medical Text: Admission Date: [2129-6-28] Discharge Date: [2129-6-28] Date of Birth: [2069-6-26] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: 60F on coumadin; was found slightly drowsy tonight; then fell down stairs; paramedic found her unconscious and she was intubated w/o any medication; head CT shows multiple IPH; transferred to [Hospital1 18] for further eval Major Surgical or Invasive Procedure: None Past Medical History: Her medical history is significant for hypertension, osteoarthritis involving bilateral knee joints with a dependence on cane for ambulation, chronic back pain. She also has a history of a right lung cancer requiring right lobectomy in [2099]. No metastasis was known and she has since recovered well and is considered cured. Social History: Unknown Family History: NC Physical Exam: PHYSICAL EXAM: 124/82 108 20 100% Intubated, non sedated; received no paralytic medication; No eye opening; pupil: Rt: 5 mm, Lt: 4 mm, both non reactive; Corneal + bilat; Extends both UE to stim; min withdrawal/triple flexion both LE; Upgoing toes bilat; Brief Hospital Course: CT scan revealed very severe IPH. Given her poor prognosis with fixed pupils and posturing, patient was made CMO by family. She expired shortly after arrival to hospital. Medications on Admission: Unknown Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: IPH Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2129-9-18] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5865 }	Medical Text: Admission Date: [2178-10-20] Discharge Date: [2178-10-25] Date of Birth: [2114-8-15] Sex: F Service: MEDICINE Allergies: Celebrex / Adhesive Tape Attending:[First Name3 (LF) 1145] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cardiac Cath [10-20] with 2 BMS placed Cardiac Cath [10-21] History of Present Illness: This 64 year old woman with a prior history of breast cancer s/p XRT, hypertension and hyperlipidemia who has been experiencing chest discomfort with exertion for the past three years. She describes chest tightness with exertion while either walking quickly or starting up an incline. Over the past three months this exertional angina has wrosened. She has not had angina at rest. She denies shortness of breath, lightheadedness, dizziness, PND, Orthopnea, palpitations, snycope, edema, or claudication. She has been followed by Dr.[Name (NI) ] and had a stress MIBI done in [2175] which was remarkable for Moderate, partially reversible septal and apical wall perfusion defect. Global hypokinesis with EF of 48%. Since then, she has been medically managed, however more recently she was enrolled in a study looking at heart disease and lifestyle modification. As part of the study, she underwent a coronary CT which demonstrated significant calcium in the proximal part of the LAD. . She has also recently had an exercise stress test, done on [2178-6-26]. She exercised for 6 minutes on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol and was stopped for marked ST changes. Negative for symptoms. At peak exercise, the patient had 3.5 to 4mm St segment depression in the inferolateral leads as well as 1.5 -2mm St segment elevation in V1-V2. These changes are in the setting of baseline prominent voltage repolarization abnormalities. They resolve with rest by minute 8 of recovery. . Prior to admission to the CCU, she underwent an elective catheterization for CAD. She was given pre-hydragion and had 320 cc of contrast. During the procedure she had an estimated 100 cc blood loss, with no angiographic evidence of CAD in her LMCA. Her LAD had a diffuse proximal 90% and mid vessel calcific disease, origin D1 with 50% stenosis at origin. LCX: Mild luminal irregularities into OM1 with mild vessel 60% stenosis into OM2. RCA: Proximal 50% stenosis. She had chest pain during the procedure and was transfered to the CCU. . Upon arrival to the CCU the patient was chest pain free, although she complained of some nausea. She had been given 8 mg of Zofran, and was given a one time dose of 10 mg Compazine. Her vitals were: 76 123/72 11 and 100 RA. . Past Medical History: 1. CARDIAC RISK FACTORS: + Dyslipidemia +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -Breast cancer [2140] s/p left radical mastectomy, radiation therapy -Back surgery 2 yrs ago for spinal stenosis -GERD -Osteoporosis -Remote GIB -[2157] Social History: -Retired dental hygenist, and business manager for family practice -retired -non-smoker -no ETOH Family History: Paternal Grandfather with Stroke Father with MI Physical Exam: Exam on Discharge: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CARDIAC: Regular Rate Rhytm with normal S1, S2. No S3 or S4. II/VI Systolic crescendo decrescendo murmur at RSB radiating to carotids. LSB II/VI murmur radiating to the apex. LUNGS: Scar across R breast. No accessory muscle use, no labored breathing, CTA- anteriorly, no crackles, wheezes or rhonchi appreciated. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No LE edema Pertinent Results: STUDIES: Catherization [2178-10-20]: (prelim report) COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated one vessel coronary artery disease. The LMCA was free of angiographically apparent disease. The LAD had diffuse, calcific proximal and mid-vessel stenosis of 90%. The origin of the first diagonal branch had a 50% ostial stenosis. The LCx had mild luminal irregularities into OM1 with mid vessel 60% stenosis into OM2. The RCA had a proximal 50% stenosis. 2. Limited resting hemodynamics revealed normotension. 3. Successful cutting balloon/rotablation/PTCA/stenting of the mid LAD with a Taxus Liberte Atom 2.25x16 mm drug-eluting stent (DES) followed by a more proximal Taxus Liberte 2.5x12 mm [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5177] at 12 atm and 15 atm respectively. We then stented the more distal mid LAD disease with a Taxus Liberte 2.5x16 mm DES at 10 atm. Final angiography revealed normal flow, no angiographically apparent dissection and 0% residual stenosis in the stents with an ostial 60% DIAG branch vessel stenosis with TIMI 2 flow. (see PTCA comments) 4. R 6Fr radial artery sheath removed and Terumo TR band placed without complications. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful cutting balloon/rotablation/PTCA/stenting of the mid LAD with a Taxus Liberte Atom 2.25x16 mm drug-eluting stent (DES) and then a more proximal Taxus Liberte 2.5x12 mm [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5177] at 12 and 15 atm respectively. We then stented the more distal mid LAD disease with a Taxus LIberte 2.5x16 mm [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5177] at 10 atm. (see PTCA comments) 3. ASA indefinitely 4. Plavix (clopidogrel) 75 mg daily for at least 12 months 5. Integrilin (eptifibatide) gtt for 18 hours 6. Secondary prevention for coronary artery disease 7. R 6Fr radial artery Terumo TR band placed without complications. Catheterization [2178-10-21]: 1. Selective coronary angiography in this right dominant system demonstrated one vessel disease. The LMCA had no angiographtically apparent disease. The LAD had widely patent stents in the proximal and mid portion of the vessel. There was TIMI 2 flow in D1 that was of similar appearance/ unchanged from films taken on [2178-10-20]. The Cx had a 50% distal stenosis that was unchanged from films taken on [2178-10-20]. 2. Limited resting hemodynamics revealed a central aortic pressure of 118/66 mmHg. 3. The right femoral arteriotomy site was successfully closed with a 6 French angioseal device. 4. FINAL DIAGNOSIS: 1. One vessel coronary artery disease that is unchanged from [2178-10-20]. 2. Successful closure with angioseal device. ECHO [2178-10-21]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior wall, anterolateral wall, distal inferior wall and apex. The remaining segments contract normally (LVEF = 40-45 %). Right ventricular chamber size and free wall motion are normal. The study is inadequate to exclude significant aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Focused views. Focal left ventricular regional dysfunction c/w CAD. Mild aortic regurgitation. Probable mild aortic stenosis. Brief Hospital Course: 64 year old woman with a prior history of breast cancer s/p XRT, hypertension and hyperlipidemia who has been experiencing worsening exertional angina who presented for an elective cath procedure and had rotational atherectomy of the LAD, DES in the LAD who required a relook cath for chest pain. This second procedure was complicated by diagonal perforation. There was no clinical evidence of tamponade after this perforation and it was thought to be healed upon discharge. . # Decreased EF: Last ECHO in [2178-5-5] with normal EF of 55% without any changes in wall motion abnormalitiy. ECHO performed during this hospitalization after known ischemia showed EF 40-45%. Afterload reduction with Lisinopril was started. Of note, patient had known mild AS prior to admission, also seen on ECHO here with mild AR. . # CAD: Diffuse Coronary disease with intervention to proximal LAD with 3 DES. No interval change upon re-cath. The patient was maintained on medical management with the following agents: Prasugrel (out of concern for interaction w/ PPI), ASA, Metoprolol, Simvastatin, Lisinopril. ASA dose was increased and Imdur was held on discharge. . # Sinus Tachycardia: The patient developed tachycardia after the catheterization procedures that was thought to be likely due to decreased EF. HR was well controlled with increase in Metoprolol prior to discharge. Resting HR 80s, ambulatory HR 110. . # Apical hypokinesis: Seen on Echo (see Echo report.) Initiation of anticoagulation necessary to prevent accumulation of thrombus. Patient started bridge from heparin to coumadin in patient and was continued on Lovenox outpatient. . # Anemia: Stable throughout hospitalization. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day in the morning BUTALBITAL-ACETAMINOPHEN-CAFF - 50 mg-325 mg-40 mg Tablet - [1-3] Tablet(s) by mouth every 6 hr as needed for HA ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg Tablet Sustained Release 24 hr - 0.5 (One half) Tablet(s) by mouth once daily PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - Tablet(s) by mouth CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider; OTC) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 mL Subcutaneous Q12H (every 12 hours): Total dose 70mg or 0.7mL. Discard the remainder of the syringe. Disp:10 Syringes Refills:2 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: Take 1 every 5 minutes up to 3 tabs, then call your doctor/911. Disp:30 Tablet, Sublingual(s) Refills:5 6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not miss a dose. Disp:30 Tablet(s) Refills:2 11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Disp:240 Tablet(s) Refills:2 12. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: Dosage will change based on blood levels, to be directed by Dr.[Doctor Last Name 35583] office. Disp:90 Tablet(s) Refills:2 13. Outpatient Lab Work Please Draw INR on [10-25] and fax results to Dr.[Name (NI) 35583] office, attention [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 26695]. Office Phone:([Telephone/Fax (1) 2037] Office Fax:([Telephone/Fax (1) 35584] Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary Diagnoses: Coronary artery disease s/p cath x2 Heart failure ef 45% Secondary Diagnoses: Sinus Tachycardia Apical hypokinesis Anemia Aortic Stenosis Hypertension Dyslipidemia: As above GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have been admitted to the hospital after an elective catheterization procedure to look at the arteries in your heart. While you were here, you received 2 stents to help keep open your arteries. In addition, we have noted some decrease in your heart function. This puts you at risk for clots that could cause a stroke. As a result, we have started a medicine called Warfarin to keep your blood thin, and another called Lovenox (the injection) to protect you while Warfarin takes effect. There have been several changes to your medication: -Start Prasugrel 10mg once daily to protect your stents/arteries, it is important that you do not miss a dose of this medicine. -Start Warfarin 7.5mg (3 pills) once daily to thin your blood. There will be lab monitoring associated with this medicine. -Start Lovenox (injection) twice daily until told by your doctor to stop. This will thin your blood while the warfarin takes effect. -Increase your Aspirin to 325mg daily -Start lisinopril 2.5mg to help your heart/blood pressure -Stop Atenolol. Instead take Metoprolol as directed to control your heart rate. This dose will likely be decreased over time. -Stop Isosorbide (Imdur) and only take nitroglycerin as needed for chest pain and as directed. Followup Instructions: On Tuesday [10-27], please have your blood drawn at [Hospital1 ]-[Location (un) 1439]. The results should be communication to Dr.[Doctor Last Name 3733]. This is important as it affects your Coumadin(warfarin) dosing. Follow up: [Name6 (MD) ] [Last Name (NamePattern4) 6559], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2178-11-3] 10:20 ICD9 Codes: 4111, 9971, 4241, 4019, 2724, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5866 }	Medical Text: Admission Date: [2108-12-15] Discharge Date: [2108-12-19] Service: NEUROSURG FINAL DIAGNOSIS: Cardiorespiratory arrest following cerebrovascular accident. HISTORY OF PRESENT ILLNESS: This is a 77 year old lady who was transferred to [Hospital1 69] status post fall with change in mental status. CT scan showed evidence of subdural hemorrhage. PHYSICAL EXAMINATION: On exam she was initially arousable to name. Pupils were reactive. Air entry was bilaterally equal. She had a pacemaker in situ with regular rate and rhythm. There was no murmur. Abdomen was soft and nontender, bowel sounds heard. Left hand showed evidence of an old stroke with contracture and clonus and the same with the left lower extremity. Neuro exam was not possible because she was uncooperative. There was residual left hemiparesis. She was moving the right arm and leg well. LABORATORY DATA: CT scan was repeated on admission which showed extension of the subdural hematoma involving the sagittal, falx tentorium as well as the left convexity. There was also parenchymal hemorrhage involving the occipital and parietal lobes. There was substantial left to right subtentorial herniation. Admission labs were hematocrit of 37.1, white cell count 12.4, platelets 219. INR was 3.2, PT 21.3, PTT 40.7. Sodium was 143, potassium 3.9, chloride 107, bicarb 23, urea 28, creatinine 1. Blood sugar was 132. CK was elevated to 1365, troponin less than 0.3. HOSPITAL COURSE: The coagulopathy was corrected, but despite there was an extension of the subdural bleed. The neurosurgery team evaluated the possibility of evacuation of the subdural hematoma to relieve the pressure. The patient's general condition and very low ejection fraction put her at a very high anesthesia risk. The risk was discussed with the family and the family decided against any surgical intervention and opted for comfort measures only. The rest of the [Hospital 228] medical treatment was discontinued and she was given morphine and comfort measures were given. The patient eventually passed away on [2108-12-19], at 10:42 a.m. CONDITION ON DISCHARGE: The patient expired at 10:42 a.m. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 33505], M.D. [MD Number(1) 33506] Dictated By:[Doctor Last Name 22706] MEDQUIST36 D: [2108-12-19] 14:19 T: [2108-12-23] 09:53 JOB#: [Job Number 33507] ICD9 Codes: 4280, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5867 }	Medical Text: Admission Date: [2165-9-30] Discharge Date: [2165-10-15] Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2165-10-4] - s/p Coronary Artery Bypass Graft x4 (Left internal mammary artery -> Left anterior descending, Saphaneous Vein graft -> Obtuse marginal, Saphaneous Vein graft -> Diagonal, Saphaneous Vein graft -> Posterior descending Artery)and Left atrial appendage ligation [2165-10-1] - Cardiac Catheterization History of Present Illness: 82 y/o female who presented to an outside hospital with chest pain. She was transferred to the [Hospital1 18] and underwent cardiac catheterization. Past Medical History: Hypertension hypercholesterolemia Atrial Fibrillation Skin cancer carpal tunnel syndrome hypothyroid Social History: Retired. Former 1ppd smoker for 20 years. Quit 30 years ago. Lives alone. Rarely uses alcohol. Family History: Mother with heart disease Physical Exam: Admission HR 70 RR 18 B/P 144/85 151/75 64" weight 149 pounds GEN: NAD HEENT: Unremarkable NECK: Supple, FROM, No JVD, No carotid bruits HEART: RRR, no m/r/g LUNGS: Clear ABD: Benign EXT: Warm, well perfused , no edema, 2+ Pulses NEURO: Grossly intact Pertinent Results: [2165-10-1] 08:30AM BLOOD WBC-10.4 RBC-4.50 Hgb-13.9 Hct-40.3 MCV-90 MCH-30.8 MCHC-34.4 RDW-12.8 Plt Ct-271 [2165-9-30] 01:15PM BLOOD INR(PT)-1.6* [2165-10-1] 06:10AM BLOOD PT-15.5* PTT-70.2* INR(PT)-1.4* [2165-10-1] 08:30AM BLOOD Plt Ct-271 [2165-10-1] 06:10AM BLOOD Glucose-102 UreaN-12 Creat-0.7 Na-142 K-4.0 Cl-107 HCO3-28 AnGap-11 [2165-10-1] 12:00PM BLOOD ALT-25 AST-26 AlkPhos-81 Amylase-51 TotBili-0.7 [2165-10-1] 12:00PM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE [2165-10-1] 12:00PM BLOOD Triglyc-99 HDL-49 CHOL/HD-3.6 LDLcalc-109 [2165-10-8] 06:00AM BLOOD TSH-4.0 [2165-10-8] 06:00AM BLOOD T4-6.7 T3-65* GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The rhythm appears to be atrial fibrillation. Results were Conclusions: PRE-CPB The left atrium is markedly dilated. 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. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). The right atrium is elongated. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular cavity size is normal. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed. There is mild global right ventricular free wall hypokinesis. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. POST-CPB Normal right ventricular systolic function. Left ventricle initially with some mild septal hypokinesis which improved after 15 minutes. Overall EF about 50-55%. No other changes from pre-CPB. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD on [2165-10-4] 13:17. [Location (un) ] PHYSICIAN: Brief Hospital Course: Ms. [Known lastname 8026] was admitted to the [Hospital1 18] on [2165-9-30] for further management of her chest pain. She underwent a cardiac catheterization which revealed 95% mid LAD lesion, 80% LCX stenosis,and a 99% diffuse RCA lesion. An echo showed an EF of 60-70%. Given the nature and severity of her disease, the cardiac surgery service was consulted for surgical revascularization. She was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed minimal internal carotid artery disease bilaterally. Ciprofloxacin was started for a urinary tract infection. Heparin was continued for anticoagulation. On [2165-10-4], Ms. [Known lastname 8026] was taken to the operating room where she underwent coronary artery bypass grafting to four vessels and a left atrial appendage ligation. Postoperatively she was transferred to the cardiac surgical intensive care unit for monitoring. She developed some atrial fibrillation overnight that was self limited. On postoperative day one, Ms. [Known lastname 8026] [Last Name (Titles) 5058] neurologically intact and was extubated. She was transfused for postoperative anemia. Coumadin was resumed for her atrial fibrillation. On postoperative day three, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperativ strength and mobility. The geriatrics service was consulted for assistance with her memory loss. Multiple medications as well as a social work evaluation were recommended and implemented. It is recommended that she follow up with the neurobehaviorist after discharge (Dr. [First Name (STitle) 6817]. Ms. [Known lastname 8026] continued to make steady progress and was discharged to rehab on [2165-10-15] in stable condition. She will follow-up with Dr. [Last Name (STitle) 914], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Coumadin 2.5mg daily Univasc 15mg QD Diltiazem 240mg QD Synthroid 88mcg QD Zocor 20mg QD MVI Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Risperidone 0.25 mg Tablet Sig: Two (2) Tablet PO twice a day. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: then check INR on Wednesday, [10-17] and dose for INR 2.0-2.5. 12. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO four times a day for 5 days: for EVH site erythema. Discharge Disposition: Extended Care Facility: Life Care Center at [Location (un) 2199] Discharge Diagnosis: s/p Coronary Artery Bypass Graft x4 (Left internal mammary artery -> Left anterior descending, Saphaneous Vein graft -> Obtuse marginal, Saphaneous Vein graft -> Diagonal, Saphaneous Vein graft -> Posterior descending Artery)and Left atrial appendage ligation Primary medical history: Hypertension hypercholesterolemia Atrial Fibrillation Skin cancer carpal tunnel syndrome hypothyroid Discharge Condition: good Discharge Instructions: [Month (only) 116] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 4966] after discharge from rehab ([Telephone/Fax (1) 40969]) please call for appointment Dr [Last Name (STitle) ] after discharge from rehab ([Telephone/Fax (1) 285]) please call for appointment Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6817] (neuro behaviorist) [Telephone/Fax (1) 1690] Completed by:[2165-10-15] ICD9 Codes: 5990, 486, 2859, 4019, 2724, 2449, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5868 }	Medical Text: Admission Date: [2153-7-2] Discharge Date: [2153-7-6] Date of Birth: [2071-10-23] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2153-7-2] Aortic valve replacement History of Present Illness: [Known lastname ] is an 81yo female with now symptomatic aortic stenosis, hypertension, CVA, renal insufficiency, mild pulmonary hypertension deemed of acceptable risk for surgical AVR pending additional studies. In the interim, she was excepted for the [Last Name (un) ] valve in [Doctor Last Name ]however has elected to move forward with an open AVR with Dr. [Last Name (STitle) ] in early to mid [Month (only) ]. Past Medical History: Aortic stenosis s/p Aortic valve replacement Past medical history: - Coronary artery disease - Pulmonary hypertension (PA 48/19/27) - CVA/TIA (no residual) - hypertension - renal insufficiency (Cr 1.2) - GI bleed s/p AVM cauterization - childhood asthma - glaucoma - bilateral cataracts - lower extremity varicose veins - bilateral knee replacements - bilateral carpal tunnel surgeries - bilateral bunion surgery - anal fistula repair ([2121]'s) Social History: Recently relocated from [State 18250] to live with daughter. Basement room with chairlift for stairs. Enjoys piano playing. Family History: Father deceased age 62, emphysema. Mother deceased age 89, dementia. Two aunts with hx cancer. Brother with ICD/CHF, head and neck cancer. Daughter and three sons. Physical Exam: Pulse: Resp: 71 SR O2 sat:93% RA B/P 155/90 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 [x] Murmur IV/VI systolic radiating to carotids Abdomen: Soft [x]non-distended [x]non-tender [x]bowel sounds+ Extremities: Warm [x], well-perfused [x] Edema [x]1+ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: 2+ throughout Carotid Bruit: radiating from AS Pertinent Results: [2153-7-2] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is global left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area ,0.5 cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS: LV systolic function is slightly improved. LVEF ~45-50%. RV systolic function remians normal. There is a well seated, functioning bioprosthesis in the aortic position. There is mild peri-valvular AI. The remaining study is unchanged from prebypass. . [2153-7-6] 04:55AM BLOOD WBC-8.1 RBC-2.97* Hgb-10.0* Hct-29.5* MCV-99* MCH-33.6* MCHC-33.8 RDW-14.2 Plt Ct-160 [2153-7-5] 04:57AM BLOOD WBC-9.4 RBC-3.09* Hgb-9.9* Hct-30.6* MCV-99* MCH-32.1* MCHC-32.4 RDW-14.3 Plt Ct-138* [2153-7-6] 04:55AM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-27 AnGap-12 [2153-7-5] 04:57AM BLOOD Glucose-126* UreaN-18 Creat-0.9 Na-136 K-3.5 Cl-101 HCO3-31 AnGap-8 Brief Hospital Course: Mrs. [Known lastname ] was a same day admit and brought directly to the operating room where she underwent an aortic valve replacement. Please see operative note for surgical details. 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, lethargic but oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Lopressor was titrated up and additional antihypertensives were added for better blood pressure control. The patient was transferred to the telemetry floor for further recovery. All narcotics were stopped due to lethargy and she was on Tylenol only for pain at the time of discharge and oriented x 3. 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 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Mt. St. [Hospital ] rehab in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Lisinopril 5 mg PO DAILY 2. ALPRAZolam 0.5 mg PO TID:PRN anxiety 3. Metoprolol Tartrate 25 mg PO TID 4. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 5. Furosemide 20 mg PO DAILY 6. Spironolactone 12.5 mg PO DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 8. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 3. Lisinopril 10 mg PO DAILY hold for sbp<100 RX lisinopril 10 mg daily Disp #30 Tablet Refills:0 4. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 25 mg twice a day Disp #60 Tablet Refills:0 5. Acetaminophen 650 mg PO Q6H 6. Furosemide 20 mg PO DAILY 7. Spironolactone 12.5 mg PO DAILY 8. ALPRAZolam 0.5 mg PO TID:PRN anxiety RX alprazolam 0.5 mg tid, prn Disp #30 Tablet Refills:0 9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY Discharge Disposition: Extended Care Facility: mount st. [Doctor First Name ] Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement Past medical history: - Coronary artery disease - Pulmonary hypertension (PA 48/19/27) - CVA/TIA (no residual) - hypertension - renal insufficiency (Cr 1.2) - GI bleed s/p AVM cauterization - childhood asthma - glaucoma - bilateral cataracts - lower extremity varicose veins - bilateral knee replacements - bilateral carpal tunnel surgeries - bilateral bunion surgery - anal fistula repair ([2121]'s) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema: trace lower and upper extremity edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 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] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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 Surgeon: Dr. [Last Name (STitle) ] [2153-8-8] at 1:45p Cardiologist: Dr. [First Name4 (NamePattern1) 2048] [Last Name (NamePattern1) ] [2153-7-31] at 1:00p Please call to schedule appointments with your Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 110131] in [4-26] 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 Completed by:[2153-7-6] ICD9 Codes: 4241, 2875, 4168, 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5869 }	Medical Text: Admission Date: [2139-6-3] Discharge Date: [2139-6-13] Date of Birth: [2075-1-8] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 11291] Chief Complaint: seizures, concern for status epilepticus Major Surgical or Invasive Procedure: Intubation and subsequent extubation History of Present Illness: HPI: Ms [Known lastname ] is a 64 year old right handed woman with a history of seizures, leukodystrophy, dementia, feeding tube, presenting as a transfer from [Hospital6 ] for status epilepticus. This history was taken over the phone from her Daughter; [First Name5 (NamePattern1) 402] [Last Name (NamePattern1) 25807] [Telephone/Fax (1) 25808]. She lives at home with her and the patients husband who are her primary care givers. She is bedbound at baseline with quadraparesis with prominent rightsided weakness. This morning she was scheduled to see IR today to have G tube replace at 3 pm. This morning she had a questionable small seizure with non responsiveness and quivering of her lips but it was short lived. Daughter; felt she had a low grade temp and a mild cough, but no overt illness. On the way to [Hospital3 9717] she went into a generalized tonic clonic seizure at 2:30 pm with was refractory to 5 mg of ativan, she was intubated at 3:30 for airway protection and was given a paralytic so it was unclear if she was still seizing. They got a head ct and transferred her to [Hospital1 ] for further management. lidocaine 70 mg IV x 1 Fentanyl 120 mcg IV x 1 Rocuronium 36 mg IV x 1 Propofol gtt 10 mg / kg/ min Zosyn 3.375 g IV x 1 sq As far as her seizure history, they have been fairly well controlled on Dilantin, with her lat seizure being months ago. They are often generalized and recover her to come to the emergency room. Seizure began around the beginning of her mental decline and discovery of her leukodystrophy back in 99, she did have one seizure requiring intubation at that time. Regarding her Leukodystrophy, she had genetic testing at [Hospital1 2025] and [Last Name (un) 18355] School, she was tested for common for leukodystrophies and "they all came up negative." But cognitive decline started in 99 with slurred speech and weakness on one side, and wasn't sure if it was MS [First Name (Titles) ] [Last Name (Titles) 25809] and then had as seizure, has continued to decline and has been bedbound for about 6 years. Currently, her neurologic baseline is that she has some movement of limbs, weaker on right side; does move a little bit, but not much, she fidgets a lot with her hands, rips blankets off and tips. Her Primary Contacts: Lives Daughter: [First Name5 (NamePattern1) 402] [Last Name (NamePattern1) 25807] [Telephone/Fax (1) 25808] Husband: [Name (NI) ] [Name (NI) 25810] [Telephone/Fax (1) 25811] Past Medical History: 1. Cerebral leukodystrophy described above 2. Seizure disorder. 3. COPD, history of CO2 retention. 4. Depression. 5. Status post NCR. 6. Recurrent UTIs. 7. Chronic dysphagia and history of aspiration pneumonias PSH: Status post right hip fracture and status post ORIF, ORIF for right ankle fracture. Social History: SOCIAL HISTORY: Lives at home with family, no home Health Aide, former smoking quit in [Month (only) ] of 99, former drinker, but quit in 99. No former drug use. Family History: She is adopted, no family history is available Physical Exam: Physical Exam on Admission: Vitals: T: 98.1 P:72 R:12 BP:126/72 SaO2:100% General: intubated HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, Pulmonary: Lungs CTA Cardiac: RRR Abdomen: soft, NT/ND, Extremities:cold feet bilaterally Skin: no rashes or lesions noted. . Neurologic: -Mental Status: obtunded grimaces to noxious no eye opening. -Cranial Nerves: PERRL 3 to 2mm and brisk, + brisk corneals bilaterally, + gag, face symmetric -Motor: withdraws left side to noxious, intermittent rhytmic shaking of the left arm. -DTRs:[Name2 (NI) 20772] throughout Physical Exam on Transfer: General: awake and alert, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA Cardiac: RRR Abdomen: soft, NT/ND Extremities: no edema Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Awake and alert, able to state name and answer a few simple questions, follows basic commands. -Cranial Nerves: PERRL, EOMI with limited rightward gaze, ?partial INO, VFF, R facial droop. -Motor: Quadriparetic, weaker on R. Able to lift b/l arms anti-gravity and wiggles toes b/l. -DTRs: [Name2 (NI) ] throughout. L toe down, R toe up. Physical Exam on Discharge: ???????????? Pertinent Results: [2139-6-3] 06:45PM WBC-17.7* RBC-4.18* HGB-14.0 HCT-41.5 MCV-99* MCH-33.5* MCHC-33.7 RDW-12.3 [2139-6-3] 06:45PM NEUTS-91.6* LYMPHS-5.0* MONOS-3.0 EOS-0.2 BASOS-0.2 [2139-6-3] 06:45PM PLT COUNT-229 [2139-6-3] 06:45PM GLUCOSE-126* UREA N-17 CREAT-0.4 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17 [2139-6-3] 06:45PM estGFR-Using this [2139-6-3] 07:00PM LACTATE-2.7* [2139-6-3] 07:48PM O2 SAT-98 [2139-6-3] 07:48PM LACTATE-1.6 [2139-6-3] 07:48PM TYPE-ART RATES-16/ TIDAL VOL-450 PEEP-5 O2-100 O2 FLOW-7 PO2-366* PCO2-35 PH-7.50* TOTAL CO2-28 BASE XS-4 AADO2-314 REQ O2-58 -ASSIST/CON INTUBATED-INTUBATED [2139-6-3] 11:04PM URINE MUCOUS-RARE [2139-6-3] 11:04PM URINE RBC-103* WBC-7* BACTERIA-NONE YEAST-NONE EPI-1 [2139-6-3] 11:04PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [2139-6-3] 11:04PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.023 CT head [2139-6-3]: IMPRESSION: No acute intracranial process. Severe chronic small vessel disease and atrophy. CXR [2139-6-3]: FINDINGS: AP portable supine chest radiograph obtained. The endotracheal tube is seen with its tip residing approximately 3.4 cm above the carina. The NG tube courses into the left upper abdomen. Contrast is seen within large bowel loops in the right upper quadrant. Linear areas of plate-like atelectasis in the right and left lower lungs are noted. There is no large consolidation or signs of CHF. No definite pneumothorax is present. The heart and mediastinal contours appear grossly unremarkable aside from atherosclerotic calcifications of the aortic knob. No definite displaced rib fractures are seen. IMPRESSION: Appropriately positioned endotracheal and nasogastric tubes. CXR [2139-6-4]: FINDINGS: As compared to the previous radiograph, the endotracheal tube and the nasogastric tube are in unchanged position. There is unchanged mild elevation of the right hemidiaphragm. The pre-existing right basal atelectasis is improved. Retrocardiac atelectasis is unchanged. Unchanged size of the cardiac silhouette. No newly appeared focal parenchymal opacities. Brief Hospital Course: 64-year-old right handed woman with a history of seizures, leukodystrophy, dementia, and G tube placement who presented as a transfer from [Hospital6 ] for status epilepticus. She had a GTC yesterday afternoon which was refractory to 5mg of ativan and was subsequently intubated and paralyzed. Head CT showed severe chronic small vessel disease and atrophy but no acute intracranial process. Upon transfer she was continuing to have some intermittent rhythmic movements of the left hand. She was admitted to the neuro ICU for close monitoring. ICU and Hospital course: #Neuro: She was continued on her home Dilantin as well as a propofol drip overnight and had no further evidence of seizure activity. She was maintained on continuous EEG monitoring which showed L sided slowing with polymorphic delta compared with R sided theta but no epileptiform activity. She was extubated in the am of [6-4] and quickly returned to her baseline, able to answer simple questions appropriately and follow basic commands. Dilantin level was 15.4. She received an extra 200mg dilantin on [6-4] and her home dose was increased to 100mgQAM/200QPM 5x/wk rather than 4x/wk, with 100mg [Hospital1 ] 2x/wk. Etiology of her seizure is somewhat unclear at this point. Infectious w/u has been negative thus far; it is possible she could have had an underlying low grade viral URI given her recent hx of cough. Labs unremarkable except for leukocytosis which is now downtrending. The patient was transferred to the floor in good condition. The patient was extubated the day after admission and did well over the weekend, however on [6-8] the patient spiked a temp and was found to have a white count of 19 (see below). She began having more seizures that responded acutely to ativan. She was frequently somnolent following the seizures - which had a unique semiology, including rather purposeful picking at covers and items real and imagined on her bed, waving her hand in the air as if being attacked by flies, and looking off into the corner of the room, often up and to the left. She received several boluses of Dilantin and her dose was increased to 300 mg total daily. A steady level was difficult to obtain and she was switched to infatabs that could be crushed and administered via g-tube. The patient tolerated this transition well with improved level. Her medications and seizures were discussed with her daughter and husband who care for her, as well as her primary doctor who has been managing her dilantin. Plan was made to continue at 300 mg total daily with plans to recheck the level in the week following discharge. The patient did generally well through the rest of her hospitalization with a single seizure the day prior to discharge for which she received an extra dose of dilantin with a level up to 14.4 on discharge. # Infectious disease: She initially had some low grade fevers with a Tmax of 100.3. UA and CXR were unremarkable. Blood cultures were negative. She was continued on her home Bactrim for chronic UTI. On transfer to the floor she became more somnolent related in part to being post-ictal and also due to a new fever up to 103, as well as an elevated WBC count and inflammatory markers. A CXR revealed bilateral aspiration pneumonias, likely related to her seizures. These were treated with empiric antibiotics with significant clinical improvement withing 36 hours. A PICC line was placed and Cefepime and Vanco were coursed conitnued for 4 more days following discharge (~ 10 day course). # FEN/GI: She was maintained NPO as at baseline does not take anything by mouth. She received her medications and tube feeds via her PEG. Her temporary PEG tube was replaced by IR aas it had fallen out the week prior and was due to be replaced as an outpatient. A foley had been placed there temporarily. The patient tolerated the new tube well. # Cardiovascular: She was maintained on telemetry monitoring. She was continued on her home antihypertensives. # Pulmonary: She was successfully extubated on [6-4] and remained stable from a respiratory standpoint. CXR was clear. Subsequent aspiration PNA as above. #CODE: full confirmed with family Contact: Lives w/ Daughter: [First Name5 (NamePattern1) 402] [Last Name (NamePattern1) 25807] [Telephone/Fax (1) 25808] Husband: [Name (NI) ] [Name (NI) 25810] [Telephone/Fax (1) 25811] The patient was discharged home in improved condition with VNA and a plan to complete her antibiotic course, continue on dilantin and follow-up with her primary doctor. Medications on Admission: 1. metoprolol 25 mg twice daily 2. vitamin B12 tablet 1000 mcg daily 3. alendronate 70 mg every Friday 4. doxepin 25 mg q.p.m. 5. Advair Diskus one inhalation twice daily 6. Methenamine hippurate 500 mg twice daily 7. Paroxetine 10 mg every morning 8. Dilantin liquid 100 mg q am and MWF takes 100 mg in the evening, T,TH, F, Sat,Sun 200 in the evening. 9. Ranitidine 300 mg at bedtime 10. Spiriva one inhalation daily. levocarnitine, Discharge Medications: 1. Alendronate Sodium 70 mg PO QFRI 2. CefePIME 1 g IV Q12H RX cefepime 1 gram twice a day Disp #8 Each Refills:0 3. Phenytoin Infatab 100 mg PO QAM Start now, Crushed tabs. RX Dilantin Infatabs 50 mg twice a day Disp #180 Each Refills:4 4. Tiotropium Bromide 1 CAP IH DAILY 5. Vancomycin 1000 mg IV Q 12H Duration: 5 Days RX vancomycin 1 gram twice a day Disp #8 Each Refills:0 6. Docusate Sodium 100 mg PO BID 7. Doxepin HCl 25 mg PO HS 8. Paroxetine 10 mg PO DAILY 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [Hospital1 ] 10. Cyanocobalamin 1000 mcg PO DAILY 11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 12. Metoprolol Tartrate 25 mg PO BID hold for SBP < 100, HR < 60 13. Outpatient Lab Work Please draw Dilantin level prior to one of her scheduled doses to get a trough level (prior to pulling PICC line). Send results to PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 25812] [Last Name (NamePattern1) 25813], [Telephone/Fax (1) 25814], fax [Telephone/Fax (1) 25815]. 14. Lorazepam 1-2 mg PO Q4H:PRN seizures RX lorazepam 1 mg q1 hr as needed Disp #12 Each Refills:1 15. Phenytoin Infatab 200 mg PO QPM Crushed tabs via G-tube Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: 1. Status epilepticus, 2. Leukodystrophy Discharge Condition: Mental Status: Confused. Level of Consciousness: Alert and interactive, perseverative, intermittently follows commands. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: Mental status as above, intermixed appropriate and inappropriate responses to questions, pseudobulbar. CNs intact. Strength is at least antigravity and against some resistance in all extremities, left greater than right. Discharge Instructions: Ms. [Known lastname ] was admitted to [Hospital1 69] on [2139-6-3] after a prolonged seizure. She was initially admitted to the ICU,, requiring a mechanical respirations while her seizures came under control. She was transferred to the floor and had another seizure and subsequently developed bilateral aspiration pneumonias. She was treated with IV antibiotics and her Dilantin was increased. A large IV was placed for her to get medicine at home and her G-tube was replaced. Because we had trouble maintaining an accurate level with her Dilantin we switched to the infatabs and increased her dose to 100 mg in the morning and 200 mg in the evening every day. Her level the morning of discharge was 11.2 and she was given an extra 200 mg, which should bring her level up above 15. Next week she should follow up with her primary doctor and get a level drawn. The Visiting nurses who will remove her PICC line may be able to do this for you. Followup Instructions: With PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 25812] [Last Name (NamePattern1) 25813], [Telephone/Fax (1) 25814], fax [Telephone/Fax (1) 25815]. ICD9 Codes: 5070, 496, 311, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5870 }	Medical Text: Admission Date: [2193-4-10] Discharge Date: [2193-4-13] Date of Birth: [2124-4-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: back pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] is a 69 year old man who presents with sudden onset of nonradiating lower back pain while on a ladder. He has a past medical history of hypertension, well controlled per patient's wife. [Name (NI) ] was unable to describe the pain and states that it was not ripping or tearing. It was, however, painful enough that when EMTs arrived, the patient was doubled over in pain. Transferred from [Hospital1 ] and upon arrival, was noted to have BP 170/100. At this ED, he was started on an esmolol drip with nipride. He responded well and at admit, his BP was 136/72. ROS: + dyspnea, no fever, chills, Nausea, vomitting, diarrhea, weight loss, hematuria, diaphoresis, chest pain, presyncope, numbness, tingling, sciatica, trauma Past Medical History: hypertension leukemia, last chemo 2 years ago paroxysmal atrial fibrillation osteoarthritis of the knees Social History: lives with wife, nonsmoker, nondrinker, works as a machinist and enjoys scuba diving and skiing. Goes to his daughter's volleyball games. Family History: father died of leukemia Physical Exam: T: 97, BP 136/72, RR 14, O2 97% Gen: sleeping, hard of hearing HEENT: MMM, excess tissue around neck Pulm: CTAB anteriorly Cor: RRR no M/R/G Abd: soft, tender to deep palpaton periumbically that "comes and goes" Ext: WWP, 2+ DP bilaterally, no edema Pertinent Results: CT abdomen: evidence of thickening of the wall of the aorta at the level of the aortic hiatus felt to be the continuation of a sealed disection in the wall of the descending thoracic aorta. The branches of the aorta appear unremarkable. There is ectasia of both iliac vessels which are seen only without contrast. The bowel appears unremarkable except for diverticulosis of the sigmoid colon. Calculus lower pole of the right kidney. CXR: There is stable tortuosity and dilation of the thoracic aorta. The heart size is normal and stable. There is an area of discoid atelectasis in the left mid lung zone. The lungs otherwise appear clear. [2193-4-10] 11:45AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.025 [2193-4-10] 11:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2193-4-10] 11:45AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2193-4-10] 06:40AM GLUCOSE-128* UREA N-16 CREAT-0.7 SODIUM-142 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-33* ANION GAP-8 [2193-4-10] 06:40AM CK(CPK)-198* [2193-4-10] 06:40AM CK-MB-9 cTropnT-<0.01 [2193-4-10] 06:40AM WBC-5.1 RBC-3.60* HGB-12.2* HCT-35.9* MCV-100* MCH-34.0* MCHC-34.1 RDW-14.1 [2193-4-10] 06:40AM PLT COUNT-127* Brief Hospital Course: Mr. [Known firstname ] is a 69 year old with a type II aortic disection, not amenable to surgery. His UA was negative, indicating that his dissection did not affect the renal arteries. For his hypertension, he was started on a labetolol drip. Then he was transitioned to PO medications. An ACE inhibitor was added and titrated up to reach a goal SBP 100-110. His labetalol was titrated up and the drip was weaned as his PO meds took effect. He was back pain free during his hospitalization. During his course, Mr. [Name13 (STitle) 284] was noted to be in atrial fibrillation with ventricular rates in the 140's. He was symptomatic with chest pain a single time. He responded well to sub-lingual nitroglycerin and quickly became chest pain free. Diltiazem was pushed since it was thought that pushing metoprolol would not be effective as the beta receptors were already occupied by the labetolol. His rate slowed to the 60's with systolic BP 102 after administration of the diltiazem. He converted back to sinus rhythm a few hours later. At discharge, his blood pressure (110-120/60-70)and heart rate (50-60) were at goal. Mr. [Known lastname ] was found to have oxygen desaturations at night. His wife states that he wakes up a lot at night and that he often seems to have breathing difficulties. He was told to follow up with his primary care doctor. His O2 sats were in the mid 80s overnight. Medications on Admission: lopressor QD, unknown quantity. Alieve QD Discharge Medications: 1. Blood Pressure Cuff Misc Sig: One (1) Miscell. twice a day: please check blood pressure twice per day and record. Disp:1 Refills:2 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: type II aortic dissection atrial fibrillation hypertension obstructive sleep apnea Discharge Condition: good Discharge Instructions: Monitor your blood pressure every day and record it for your doctor. Take labetolol twice per day and lisinopril twice per day. Call your doctor for back pain, chest pain, shortness of breath, blood in the urine or perfuse sweating. If your blood pressure is higher than 140/80, call your doctor. Your goal blood pressure is 110-120/60-70. Avoid heavy exercise or excessive agitation for 2-3 weeks. Consider avoiding volleyball games for a few weeks. Ask your doctor when you should resume your exercise and use of viagra. You also need to be evaluated for obstructive sleep apnea. You should start a low salt diet (see patient information) and ask your doctor when to start a reasonable exercise program (swimming). Followup Instructions: Follow up within 2 weeks with [Last Name (LF) ],[First Name3 (LF) 20] L. [Telephone/Fax (1) 29252]. Please ask your doctor to work you up for obstructive sleep apnea. Your doctor should also be aware that you were in atrial fibrillation during your hospitalization. Please call the aorta clinic for a follow up appointment: Division of Cardiothoracic Surgery, [Hospital Unit Name 2231], [Location (un) 86], [Numeric Identifier 718], Phone: [Telephone/Fax (1) 170]. ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5871 }	Medical Text: Admission Date: [2194-5-15] Discharge Date: [2194-5-20] Date of Birth: [2123-6-22] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4891] Chief Complaint: cough Major Surgical or Invasive Procedure: [2194-5-15]: Rigid bronch, debridement, balloon dilation, bronchial washing, and #8 tracheostomy tube placement. History of Present Illness: 70M with O2-dependent COPD who was admitted to [Hospital ] Hospital in [Month (only) 404] of this year for COPD flare & pneumonia. He had a prolonged hospital course that included a month-long ICU stay requiring mechanical ventillation [1-4] and tracheostomy [1-22]. Eventually he was discharged to a vent rehab and was decannulated 3-4 weeks ago. His O2 requirement has diminished to only needing 2-3L at night. . For the past 5 days, however, he noted the development of difficulty clearing his secretions, which at times can be quite tenacious. He and his family report intermittent periods of what might be interpreted as stridor. He was seen at [Hospital ] Hospital where chest CT demonstrated a, "...4mm sub-glottic stenosis..." after which he was transferred to [Hospital1 18] for further management. . Patient has not had any fever, chills, night sweats. His cough is productive of a thick, non-purulent sputum. He recently finished a 3 day course of azithromycin for a question of bronchitis. . Past Medical History: # COPD on O2 x 6yr, underwent trach at [Hospital ] Hospital in [1-14] that was later decannulated [4-14]. # CAD s/p CABG x3/tissue AVR'[88] ([Hospital1 112]) # PAF s/p multiple DCCV on coumadin # HTN # back surgery '[61] # RLE osteo '[61] # spinal decompression '[86] # EtOH abuse (sober x 6 mos) Social History: Married, was living at home x 1 month with wife, prior to this was at [Hospital1 ] rehab. Cigarettes [x] ex-smoker Pack-yrs: 100+ quit: [2188] ETOH: [x] No (sober 6 months) previously 4 drinks/day Family History: Mother smoker died of lung cancer Father smoker died of lung cancer . Physical Exam: Exam on Transfer to Medicine Service: VS: 97.6 128/57 67 22 99TM 97.5kg GENERAL: NAD, trach mask in place,comfortable, appropriate. Mouthing words given failure to speak. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Trach. Supple, no JVD. HEART: distant, difficult to hear over breath sounds LUNGS: diffusely rhonchorous, but good airmovement. No appreciable rales. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: Chronic venous changes. Otherwise. WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact . Exam on discharge: AVSS, NAD, trach mask in place,comfortable, appropriate. Communicating by mouthing words. HEART: II/VI systolic ejection murmur, heard across precordium LUNGS: diffusely rhonchorous, but good airmovement, breathing unlabored. No appreciable rales or wheezes. Moderate secretions. Ext: trace pedal edema. Skin changes c/w chronic venous stasis, 1+ TP bilat Neuro- A and O x3, CN 2-12 grossly intact excepted for noted surgical pupil on L. transfers from bed to chair with some assistance. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2194-5-19] 13:00 8.1 3.59* 11.1* 32.1* 89 30.9 34.6 14.4 219 [2194-5-18] 06:10 7.9 3.61* 11.2* 32.9* 91 31.0 33.9 14.7 242 [2194-5-17] 06:30 7.7 3.34* 10.5* 30.6* 91 31.5 34.5 14.5 228 [2194-5-16] 07:00 8.4 3.15* 10.1* 28.2* 90 32.1* 35.9* 14.4 217 [2194-5-15] 21:46 8.2 3.14* 9.7* 28.0* 89 30.9 34.7 14.7 213 [2194-5-15] 15:05 11.6* 3.73* 11.3* 33.3* 89 30.4 34.1 14.8 274 . DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2194-5-15] 21:46 89.2* 9.8* 0.9* 0.1 0 [2194-5-15] 15:05 86.0* 9.5* 1.9* 2.5 0.2 . BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2194-5-19] 13:00 219 [2194-5-19] 13:00 16.1* 27.1 1.4* [2194-5-18] 09:00 15.9* 1.4* [2194-5-18] 06:10 242 [2194-5-17] 06:30 228 [2194-5-17] 06:30 17.9* 27.5 1.6* [2194-5-16] 07:00 217 [2194-5-16] 07:00 18.8* 1.7* [2194-5-15] 21:46 213 [2194-5-15] 21:46 19.5* 29.6 1.8* [2194-5-15] 15:05 274 [2194-5-15] 15:05 29.2* 30.1 2.8* . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2194-5-19] 13:00 1251 15 0.6 135 4.3 97 31 11 [2194-5-18] 06:10 1031 17 0.7 131* 3.8 95* 30 10 [2194-5-17] 06:30 981 16 0.7 133 3.8 97 30 10 [2194-5-16] 07:00 1351 13 0.7 128 4.9 88* 35* 10 [2194-5-15] 21:46 1711 11 0.6 128 4.4 89* 33* 10 [2194-5-15] 15:05 [Telephone/Fax (2) 109989]* 5.0 87* 32 11 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2194-5-17] 06:30 8.8 3.2 2.1 [2194-5-16] 07:00 8.8 3.7 2.2 [2194-5-15] 21:46 8.6 3.3 1.6 LAB USE ONLY LtGrnHD GreenHd [2194-5-15] 15:05 HOLD [2194-5-15] 15:05 HOLD1 . Urine Hematology GENERAL URINE INFORMATION Type Color Appear Sp [Last Name (un) ] [2194-5-15] 15:35 Straw Hazy 1.005 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln [2194-5-15] 15:35 TR POS NEG NEG NEG NEG NEG 5.0 LG MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp [2194-5-15] 15:35 2 >182* FEW NONE 0 Chemistry [2194-5-15] 09:45 RANDOM 65 25 83 OTHER URINE CHEMISTRY Osmolal [2194-5-15] 09:45 253 Admission Labs: [2194-5-15] 03:05PM WBC-11.6# RBC-3.73 HGB-11.3* HCT-33.3* MCV-89# MCH-30.4 MCHC-34.1 RDW-14.8 [2194-5-15] 03:05PM NEUTS-86.0* LYMPHS-9.5* MONOS-1.9* EOS-2.5 BASOS-0.2 [2194-5-15] 03:05PM PLT COUNT-274# [2194-5-15] 09:45AM URINE HOURS-RANDOM SODIUM-65 POTASSIUM-25 CHLORIDE-83 [2194-5-15] 09:45AM URINE HOURS-RANDOM SODIUM-65 POTASSIUM-25 CHLORIDE-83 . [2194-5-17] 10:20 am BLOOD CULTURE Blood Culture, Routine (Pending): . [2194-5-15] 7:30 pm BRONCHIAL WASHINGS RIGHT LOWER LOBE. GRAM STAIN (Final [2194-5-15]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2194-5-17]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 8 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [2194-5-16]): SPECIMEN NOT PROCESSED DUE TO: INAPPROPRIATE SAMPLE FOR ANAEROBIC CULTURE. TEST CANCELLED, PATIENT CREDITED. . [2194-5-15] 3:35 pm URINE Site: CLEAN CATCH URINE CULTURE (Final [2194-5-17]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R . Radiology Report PICC LINE PLACMENT SCH Study Date of [2194-5-19] 10:28 AM PICC LINE PLACED [2194-5-19] Official report pending, per written report PICC line OK to use. . CHEST XRAY [2194-5-16] COMPARISON: [2194-5-15]. BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: A tracheostomy tube is unchanged, ending 5.3 cm above the carina. Multiple median sternotomy wires are intact and note is again made of an aortic valve prosthesis. Enlargement of the cardiac silhouette is unchanged. Mediastinal and hilar contours are normal. Note is made of bibasilar opacities atelectasis. In addition, there are bilateral right greater than left pleural effusions which are unchanged. Finally, pulmonary edema appears unchanged. . CHEST XRAY [2194-5-15] SINGLE BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: A tracheostomy catheter is visualized terminating 4 cm above the carina. There is no pneumothorax. Though the right costophrenic angle is beyond the field of view, there are likely bilateral pleural effusions. Note is made of enlargement of the cardiac silhouette. Mediastinal and hilar contours are normal. There is a background of moderate pulmonary edema with more focal opacities at both lung bases which may be atelectatic. Multiple median sternotomy wires are intact and note is made of an aortic valve replacement. . Notably, review of an OSH Chest CT dated [0-0-0] for comparison purposes reveals extensive plugging of the bronchus intermedius of uncertain etiology. Would recommend comparison to bronchoscopy. . Brief Hospital Course: TSICU COURSE: Mr. [Known firstname ] [Known lastname 8389] is a 70 year old male admitted to Thoracic Surgery service on the evening of [2194-5-15] for cough. He was taken to the operating room with rigid bronchoscopy revealing well organized granulation tissue in the subglottic area with malacia, extending for 0.6 cm. A large amount of purulent secretions were suctioned and sent for micro. He underwent balloon dilatation to 18mm and stenosis recurred immediately. Size #8 [Last Name (un) 295] TTS fixed phalange tracheostomy tube was placed. The patient recovered in PACU where he was successfully extubated. Broad spectrum antibiotics started: [5-15]- vanc, cipro, cefepime. The patient underwent swallow eval on [5-16] which he passed. PT/OT consults were obtained for dispo planning to ([Hospital1 ]) rehab. [Known lastname 8389] was dc'd. IVFluids stopped. He received diamox 500mg IV once. He was stabilized on the surgical service and given multiple medical issues: PNA, PAF, hyponatremia, Thoracic surgery requested medicine transfer which occured on [5-19]. Coumadin 5mg resumed for Paroxysmal AF on [5-16] (lower dose due to antibiotics) MEDICINE SERVICE HOSPITAL COURSE: [5-19] - [5-20] 70M COPD, CAD s/p CABG x3 and Porcine AVR, PAF on coumadin, hospital day and POD #5 for trach recannulation that was transferred to the medicine service found to have [Hospital 89618] hospital-acquired pneumonia, E. Coli UTI and exacerbation of CHF (unclear is systolic of disastolic). # Pseudomonal HAP: Pt initially with leukocytosis. Following transfer the pt remained afebrile without leukocytosis. Breathing comfortably on 50% trach mask. Continues to have secretions, but now improving with addition of mucomyst. Pt was initially treated broadly with Vanc, Cefepime, and Cipro which was narrowed to Cefepime on [5-17] for a planned total 14 day course to end [2194-5-28]. A PICC Line was placed on [5-19] and the pt was dischared to rehab with 8 additional doses of Cefepime. # Subglottal Stensosis - now POD #5 from trach-recannulation with #8 trach. Thoracics/ IP following. Breathing comfotably. The pt will follow-up with both thoracics and IP on [6-10], these appointments have been made. Passy- Muir valve was fitted to help pt to cough up secretions prn just prior to transfer. # Acute CHF: Unclear if systolic vs diastolic. No evidence of S3 or S4 on exam. Pt initially had 2+ LE edema, whic has been decreasing, likely secondary to diuresis with lasix. Per records pt is on lasix 40mg PO and has been receiving 20 ml IV in hospital. Pt stated that his baseline weight is 215lbs. On [5-18] was 207.4lbs, 206.5 on [5-19], and 205.9 on [5-20]. Weight at transfer to LTACH was 205.9. He will continue on Lasix 20mg IV on transfer although on exam he seems to be approaching euvolemic. Please assess daily need for further diuresis. # E. Coli UTI: Clinically stable, patient asymptomatic. Cefepime should cover due to end [2194-5-28]. # Paroxysmal AFib: Pt remained rate controlled on medicine service without nodal agents. Coumadin was initially held but restarted [2194-5-16]. INR was found low [2194-5-19] at 1.4; increased coumadin to 6 mg (from 5mg) QD [5-19]. # Porcine AVR: Clinically stable. No additional reason to bridge with heparin. TRANSITIONAL ISSUES - Blood cultures drawn [5-17] still pending (no growth to date) - Wife and HCP: [Name (NI) ] @ [Telephone/Fax (1) 109990]; HCP paperwork in chart here -pt confirmed full code here Medications on Admission: mucinex 600mg po BID aldactone 50mg po BID lasix 40mg po daily coumadin 7-8mg po daily flomax 0.4mg po daily advair 1 puff inh [Hospital1 ] spiriva inh daily zpac [Date range (1) 109991] ativan 1mg prn po Discharge Medications: 1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for sob/wheeze. 3. acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscellaneous TID (3 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation QID (4 times a day): Please give 10 min prior to acetylcysteine administration. 5. CefePIME 2 g IV Q8H 6. furosemide Sig: Twenty (20) mg Intravenous once a day: titrate according to fluid status and Cr. 7. heparin Sig: 5000 (5000) units Subcutaneous three times a day: Until INR therapeutic. 8. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Subglottic stenosis. Pseudomonal Pneumonia. Urinary Tract Infection due to e coli. Anemia of chronic disease CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. **Activity Status: OOB to chair as tolerated. Pt needs full PT assessment on arrival to rehab Discharge Instructions: You were admitted for shortness of breath thought secondary to narrowing of your airway; you subsequently received a new tracheostomy tube. You were found to have pneumonia and a urinary tract infection and are currently receiving antibiotics. . Call Dr.[Name (NI) 5070] office at [Telephone/Fax (1) 2348] if you have fevers greater than 101.5, chills, shakes, increasingly productive cough, worsening shortness of breath. . Trach: suction as needed. Keep trach secured at all times. If this falls out patient will require emergent intubation. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[0-0-] Date/Time:[2194-6-10] 2:30pm on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) 24] (interventional pulmonology) . Provider: [Name10 (NameIs) 1532] [Name11 (NameIs) 1533], MD Phone:[0-0-] Date/Time:[2194-6-10] 3:00pm to follow. (thoracic surgery) . Please obtain CHEST XRAY on Clinical center [Location (un) 861] Radiology at 2pm on [2194-6-10] Completed by:[2194-5-20**] ICD9 Codes: 2761, 5990, 496, 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5872 }	Medical Text: Admission Date: [2163-2-5] Discharge Date: [2163-2-11] Date of Birth: [2105-12-16] Sex: M Service: NSU NARRATIVE SUMMARY: The patient is a 57-year-old gentleman with no significant past medical history who complained of four to five-day history of memory difficulty and decreased speech problems. The patient was taken to [Hospital6 ] where a CT scan showed a left hemispheric hemorrhage in the left sylvian fissure and the patient was admitted to the neurosurgical service. The patient was awake, alert and oriented times three. Speech was intact but had paraphrasic errors. Repetition was intact. The patient's three-object memory was impaired. He remembered zero out of three in five minutes. He was moving all extremities with full strength. He had no drift. His finger-to-nose was intact bilaterally. Pupils were equal, round and reactive to light. Extraocular movements full. Cranial nerves were intact He was admitted to the neurosurgical service and had a CT angiogram which was negative for an aneurysm. The patient was seen by Dr. [Last Name (STitle) 1132] who felt the patient required an angiogram. On [2163-2-6], the patient underwent an angiogram which showed no evidence of aneurysmal dilatation. The patient was, therefore, referred to Dr. [First Name (STitle) ]. The patient was seen by Dr. [First Name (STitle) ] who recommended getting a body CT scan to rule out primary neoplasm and to have stroke service see the patient. A CT scan of the chest, abdomen, and pelvis showed no primary malignancy identified although there were bilateral scattered pulmonary nodules measuring up to 6.0 mm which require three-month follow up. Neurology service recommended doing an electroencephalogram to rule out intermittent seizure activity due to the patient's continued problems with nonfluent aphasia. The electroencephalogram showed no evidence of epileptiform activity although did show some slowing in the central parietal area. Dr. [First Name (STitle) ] spoke with the patient and his wife at length, giving them the options for treatment. The patient and his family opted to have this thing followed by serial MRI scans. Therefore, the patient was discharged on [2163-2-11] in stable condition with follow up in the Brain [Hospital 341] Clinic in two weeks with a repeat MRI scan with and without contrast. DISCHARGE MEDICATIONS: 1. Dilantin 100 mg p.o. three times a day. 2. Decadron 4 mg p.o. twice a day for five days and then 2 mg p.o. twice a day. 3. Famotidine 20 mg p.o. once a day while on Decadron. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 8632] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2163-3-22] 11:20:24 T: [2163-3-22] 11:48:26 Job#: [Job Number 59020] ICD9 Codes: 431
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5873 }	Medical Text: Admission Date: [2167-3-17] Discharge Date: [2167-3-23] Date of Birth: [2108-1-11] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Recent MI without sympoms Major Surgical or Invasive Procedure: [2167-3-17] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to Diag, SVG to OM) History of Present Illness: 59 y/o male with known coronary artery disease with PCI 9 yrs ago. Was pain free until [2167-2-9] when he awoke with severe epigastric pain. Went to the ED where EKG revealed an acute MI. Underwent an emergent cardiac cath with PCI/BM stent placement of the RCA into the PDA. Now presents for surgical revascularization. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction w/ PCI [2167-2-9] , MI with PCI 9 years ago, Hypertension, Diabetes Mellitus, Dyslipidemia Social History: equipment operator quit smoking 2 months ago ( smoked 1 to 1 [2-10] ppd) lives with wife rare ETOH Family History: no premature CAD Physical Exam: VS: 76 20 150/84 6' 280# Gen: Well-appearing 59 y/o male in NAD Skin: Warm, Dry -lesions HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD, -Carotid Bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS+ Pertinent Results: [2167-3-21] 04:35AM BLOOD WBC-7.8 RBC-3.29* Hgb-9.2* Hct-27.1* MCV-82 MCH-28.1 MCHC-34.1 RDW-14.2 Plt Ct-157 [2167-3-22] 05:47AM BLOOD Hct-27.0* [2167-3-21] 04:35AM BLOOD Plt Ct-157 [2167-3-22] 05:47AM BLOOD Glucose-135* UreaN-21* Creat-1.0 Na-139 K-4.4 Cl-102 HCO3-26 AnGap-15 [3-13] HbA1C 13.1% pre-op Cardiology Report ECHO Study Date of [2167-3-17] Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. There is mild symmetric left ventricular hypertrophy. There is global moderate LV systolic dysfunction. There is mild global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Slight improvement of LV systolic fx. Anterior wall motion slightly improved. Other parameters as pre-bypass. [2167-3-23] 07:45AM BLOOD WBC-7.5 RBC-3.41* Hgb-9.7* Hct-29.0* MCV-85 MCH-28.5 MCHC-33.5 RDW-14.4 Plt Ct-246# [2167-3-23] 07:45AM BLOOD Plt Ct-246# [2167-3-22] 05:47AM BLOOD Glucose-135* UreaN-21* Creat-1.0 Na-139 K-4.4 Cl-102 HCO3-26 AnGap-15 Brief Hospital Course: Admitted [3-17] and underwent cabg x3 with Dr. [Last Name (STitle) 1290]. Transferred to the CSRu in stable condition on insulin, neosynephrine, and propofol drips. Extubated that evening and transferred to the floor on POD #1 to begin increasing his activity level. Over the next several days, the [Last Name (un) ] diabetes service was consulted for tighter glucose management as pre-op HbA1C was 13.1%. He made good progress and was cleared for discharge to home on POD #6. Pt. to make all follow-up appts. as per discharge instructions. Medications on Admission: toprol XL 50 mg daily lipitor 80 mg daily lisinopril 10 mg daily lantus insulin 68 units QHS ASA 325 mg daily plavix 75 mg daily ( stopped [3-10]) metformin ER 500 mg [Hospital1 ] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 10 days. Disp:40 Capsule, Sustained Release(s) Refills:0 8. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 9. Metformin 500 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO BID (2 times a day). Disp:120 Tablet Sustained Release 24HR(s) Refills:2 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous at bedtime. Disp:30 vials Refills:2 12. sliding scale humalog insulin [First Name8 (NamePattern2) ] [Last Name (un) ] recommendations Discharge Disposition: Home With Service Facility: [Hospital1 ] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: s/p Myocardial Infarction / Stent [2167-2-19]), MI 9 years ago with PCI, Hypertension, Diabetes Mellitus, Dyslipidemia 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. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 6254] in [3-14] weeks Dr. [Last Name (STitle) ] in [2-10] weeks Completed by:[2167-3-23] ICD9 Codes: 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5874 }	Medical Text: Admission Date: [2119-12-4] Discharge Date: [2119-12-10] Date of Birth: [2042-4-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9240] Chief Complaint: Sepsis and hypoxia- direct admit (intubated) from ED Major Surgical or Invasive Procedure: ORIF Left Femur History of Present Illness: 77 yo M w/ CAD, HTN, AFIB on coumadin presented to ED today from rehab when he was found roncherous in acute distress with O2 sats low 66% 2L NC and tachy to 120s. He had cough but no CP. In the [Name (NI) ], pt was doing well and ruled out for CTA when O2 sats fell to 70s and SBP was low in 30s. He was started on Levophed, intubated and started on Vanc/Flagyl/Zosyn for probable aspiration PNA. CXR revealed mild failure. He was subsequently transferred to the [Hospital Unit Name 153], intubated, for further workup. . Of note, he was discharged [12-3] after an admission for left Femur fracture/ 5th metatarsal fracture complicated by hypoxic respiratory failure and a MICU stay and intubation during that admission. He was found to have an aspiration PNA and discharged to rehab on Levoquin to complete a 10 day course Past Medical History: 1. Hypertension. 2. Peptic ulcer disease. 3. Gastroesophageal reflux disease. 4. Atrial fibrillation. 5. Coronary artery disease status post MI in [2113-1-31] with severely decreased left ventricular ejection fraction - 20% in 3/00,. 6. Hypercholesterolemia. 7. History of liver abscess. 8. Status post Meckel diverticulum in [2069]. 9. Status post Nissen fundoplication in [2112-2-1]. 10. Status post left inguinal hernia repair in [2112-12-31]. 11. Status post small bowel hernia/resection in [Month (only) 956] of [2112]. 12. Type 2 DM. 13. Dementia. 14. Right Inguinal Hernia Social History: He lives in [Hospital3 22534]. He never smoked. He drinks on M, W, Fs a few beers/wine. His last drink was Friday. He walks up and down 1 flight of stairs from his apartment to the dining room every day without shortness of breath. He rarely walks outside. Family History: Non-contributory Physical Exam: PE: 100.6 121/69 101 18 93% O2 Sats on AC 100% TV 600, PEEP 5, RR 14 Gen: Elderly man intubated resting in bed, responsive to stimuli, but sedate GENL: NAD HEENT: EOMI, PERRLA, sclera anicteric, sl dry MM, No OP lesions NECK: JVP - 7cm, supple PULM: Loud ronchi ant/lat CV: RRR, Nl S1, S2, No Murmurs, Rubs, or Gallops. ABD: soft, nontender, and nondistended, positive bowel sounds. Well healed midline scar, large right inguinal hernia EXT: L femoral scar, no c/c/e Pertinent Results: [2119-12-3] 06:38AM PT-26.4* PTT-38.5* INR(PT)-2.7* [2119-12-3] 06:38AM WBC-13.0* RBC-3.45* HGB-11.0* HCT-31.9* MCV-93 MCH-31.8 MCHC-34.4 RDW-14.6 [2119-12-3] 06:38AM CALCIUM-7.9* PHOSPHATE-3.0 MAGNESIUM-2.2 [2119-12-3] 06:38AM PLT COUNT-325 [2119-12-3] 06:38AM GLUCOSE-106* UREA N-26* CREAT-1.1 SODIUM-142 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14 [2119-12-4] 09:17AM PT-42.5* PTT-41.7* INR(PT)-4.8* [2119-12-4] 09:17AM PLT SMR-NORMAL PLT COUNT-331 [2119-12-4] 09:17AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-2+ [2119-12-4] 09:17AM NEUTS-86* BANDS-5 LYMPHS-5* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [2119-12-4] 09:17AM WBC-18.1* RBC-3.07* HGB-10.2* HCT-28.7* MCV-93 MCH-33.2* MCHC-35.6* RDW-14.7 [2119-12-4] 09:17AM CK-MB-9 cTropnT-0.05* [2119-12-4] 09:17AM LIPASE-90* [2119-12-4] 09:17AM ALT(SGPT)-41* AST(SGOT)-99* CK(CPK)-328* ALK PHOS-65 AMYLASE-53 TOT BILI-1.4 [2119-12-4] 09:17AM estGFR-Using this [2119-12-4] 09:17AM GLUCOSE-217* UREA N-33* CREAT-1.3* SODIUM-143 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-24 ANION GAP-19 [2119-12-4] 09:33AM LACTATE-2.7* [2119-12-4] 10:25AM URINE AMORPH-FEW [2119-12-4] 10:25AM URINE HYALINE-0-2 . CXR [12-4] IMPRESSION: Bibasilar patchy opacities may represent atelectasis or aspiration. Peripheral right lung opacity appears slightly improved, and may represent slowly resolving infectious pneumonia or, in the appropriate setting, chronic eosinophilic pneumonia. . CT Abd and CTA chest IMPRESSION: 1. New bilateral basilar airspace opacities and associated pleural effusions. Findings may represent multifocal pneumonia or aspiration. 2. Slight improvement in peripheral right upper lobe airspace opacity. As mentioned on plain radiograph examination, this could represent chronic eosinophilic pneumonia or resolving acute pneumonia. 3. Small amount of air seen in the peripheral left lobe of the liver of uncertain significance. There is no evidence of ischemic bowel. There is no history of biliary intervention. Close follow up examination is recommended. 4. Large right inguinal hernia containing nonobstructed ascending colon. 5. Moderate-to-large hiatal hernia. The NG tube terminates proximal to the GE junction and should be advanced. 6. Extensive soft tissue stranding as described above. These findings correlate to ecchymoses seen in the left subcutaneous tissues on clinical exam. [2119-12-4] 10:25AM URINE RBC-[11-20]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2119-12-4] 10:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2119-12-4] 10:25AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2119-12-4] 01:36PM LACTATE-2.2* [2119-12-4] 01:36PM TEMP-37.7 PO2-64* PCO2-47* PH-7.35 TOTAL CO2-27 BASE XS-0 COMMENTS-LINE [2119-12-4] 01:37PM HCT-30.9* [2119-12-4] 04:25PM PT-44.2* PTT-47.0* INR(PT)-5.1* [2119-12-4] 04:25PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ [2119-12-4] 04:25PM NEUTS-88.9* BANDS-0 LYMPHS-4.0* MONOS-4.0 EOS-1.0 BASOS-0 METAS-2.0* [2119-12-4] 04:25PM WBC-29.1# RBC-3.48 HGB-11.1* HCT-32.7* MCV-94 MCH-31.7 MCHC-33.8 RDW-15.2 [2119-12-4] 04:25PM ALBUMIN-2.6* CALCIUM-7.8* PHOSPHATE-3.7 MAGNESIUM-2.2 [2119-12-4] 04:25PM CK-MB-7 cTropnT-0.06* [2119-12-4] 04:25PM ALT(SGPT)-46* AST(SGOT)-99* LD(LDH)-465* CK(CPK)-353* ALK PHOS-76 AMYLASE-58 TOT BILI-1.7* [2119-12-4] 04:25PM GLUCOSE-152* UREA N-33* CREAT-1.2 SODIUM-142 POTASSIUM-4.2 TOTAL CO2-26 [2119-12-4] 04:34PM LACTATE-2.7* [2119-12-4] 04:34PM TYPE-ART PO2-58* PCO2-46* PH-7.39 TOTAL CO2-29 BASE XS-1 Brief Hospital Course: ASSESSMENT: The patient is a 77 yo M w/ CAD, HTN, AFIB on coumadin who presented today in respiratory distress and was intubated and found to have new bilateral basilar airspace opacities and associated pleural effusions in setting of hypotension. PLAN: . # Sepsis: Pts SBP was in the 30s in the ED. He was intubated with decreased O2 sats and sent to the [Hospital Unit Name 153]. He was discharged yesterday to complete a 10 day course of levaquin and flagyl for possible aspiration pneumonia. Started on vanco/zosyn for possible nosocomial PNA for a total of 2 weeks, has 8 more days at discharge. He was also evaluated by speech/swallow and felt to have aspiration. He was recommended to continue strict aspiration precautions, including chin tuck, crushing all large pills, swallowing twice, and taking a sip from a straw follow all swallows. To continue speech therapy after d/c. . #CAD: Hx of demand ischemia. Continue Atorvastatin and ASA but holding antihypertensives initially. Restarted when BP improved. On a lower dose of metoprolol, which may need to be titrated up at NH. He was noted to be fluid overloaded as well, and his lasix dose was increased to 40 mg daily for continued diuresis. . #Afib: He was restarted on coumadin after recent surgery. At discharge yesterday his INR was 2.7 and his discharge coumadin dose was 2.0. On admit INR was 5.1 so coumadin was held, but was then restarted after INR fell. Will need to have INR rechecked [12-11] for goal INR [2-3]. . #Left Femur Fracture/ 5th metatarsal fracture: S/p ORIF. He is scheduled to follow up with Dr. [Last Name (STitle) ] on [12-21]. Continue PT at [Hospital3 537]. . #DM II: RISS while in the hospital. Holding home glucophage. Restarted at d/c. . #Dementia: Aricept to be held while pt is intubated and restarted after extubation. . #GERD: Switched to lansoprazole to be easier to swallow. . # CODE: FULL . Medications on Admission: MEDS: 1. Donepezil 5 mg Tablet [Hospital3 ]: Two (2) Tablet PO HS (at bedtime). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Hospital3 ]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Atorvastatin 10 mg Tablet [Hospital3 ]: One (1) Tablet PO once a day. 4. Glucophage 500 mg Tablet [Hospital3 ]: One (1) Tablet PO twice a day. 5. Lisinopril 5 mg Tablet [Hospital3 ]: 0.5 Tablet PO DAILY (Daily). 6. Furosemide 20 mg Tablet [Hospital3 ]: One (1) Tablet PO DAILY (Daily). 7. Levofloxacin 500 mg Tablet [Hospital3 ]: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Last day [12-6]. 8. Metronidazole 500 mg Tablet [Month/Day (4) ]: One (1) Tablet PO TID (3 times a day) for 4 days: Last dose on [12-7]. 9. Coumadin 2 mg Tablet [Month/Day (4) ]: One (1) Tablet PO at bedtime. 10. Aspirin 325 mg Tablet [Month/Day (4) ]: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet [Month/Day (4) ]: One (1) Tablet PO TID (3 times a day). Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution [Month/Day (4) ]: sliding scale sliding scale Injection ASDIR (AS DIRECTED). 2. Metformin 500 mg Tablet [Month/Day (4) ]: One (1) Tablet PO twice a day: may need to be crushed to help swallow. 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO BID (2 times a day). 5. Albuterol Sulfate 0.083 % Solution [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours). 6. Acetylcysteine 10 % (100 mg/mL) Solution [Last Name (STitle) ]: One (1) neb Miscell. Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. Aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO DAILY (Daily). 9. Atorvastatin 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Donepezil 5 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime). 11. Furosemide 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 12. Warfarin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime): Have INR checked [2119-12-11] to adjust coumadin dose. 13. Piperacillin-Tazobactam 4.5 g Recon Soln [Month/Day/Year ]: 4.5 g Intravenous Q8H (every 8 hours) for 8 days. Disp:qs 8 days Refills:0 14. Vancomycin in Dextrose 1 g/200 mL Piggyback [Month/Day/Year ]: One (1) g Intravenous Q 12H (Every 12 Hours) for 8 days. Disp:qs 8 days Refills:0 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Month/Day/Year ]: Two (2) ML Intravenous DAILY (Daily) as needed. Disp:qs 2 weeks Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: Sepsis from Aspiration Pneumonia Systolic Congestive Heart Failure Left Femur Fracture s/p ORIF Diabetes Type 2 Atrial Fibrillation Coronary Artery Disease Discharge Condition: stable on 3L O2 Discharge Instructions: Please continue your medications as listed. Please follow up with Dr. [Last Name (STitle) ] and your PCP. [Name10 (NameIs) 357] call your doctor if you experience increased pain, shortness of breath or other concerning symptoms. Please continue strict aspiration precautions. Followup Instructions: 1. Provider: [Name10 (NameIs) 5865] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2119-12-21] 7:40 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1984], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2119-12-21] 8:00 3. Please have your coumadin level (INR) checked on [2119-12-11] to adjust your coumadin dose. 4. Please follow up with your PCP [Last Name (NamePattern4) ] [2-4] weeks. Call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 608] for an appointment. 5. Please have your PICC line removed when you have finished your course of vanco/zosyn ICD9 Codes: 0389, 5070, 4280, 2720, 412, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5875 }	Medical Text: Admission Date: [2107-2-24] Discharge Date: [2107-3-1] Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 106] Chief Complaint: Intraventricular hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 88 yo f with history of CVA x 3 (most recent last month) on coumadin was found down and brought to OSH where she was found to have a INR of 3.8 and an intraventricular hemorrhage on CT scan. Patient was then transferred to [Hospital1 18] SICU. Past Medical History: CVA x 3 with residual right sided weakness Thyroid disease Social History: Unable to attain secondary to mental status. Family History: Unable to attain secondary to mental status. Physical Exam: VS: T 97.6, BP 146/89, HR 75, RR 20, O2sat 98%4L Gen: Elderly female in NAD, sleeping but arousable. Not very cooperative but responds to questions appropriately. Mood, affect appropriate. HEENT: NCAT. Conjunctiva pink. No xanthalesma. Neck: Supple with JVD to angle of jaw, no carotid bruit. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Diffuse crackles b/l on auscultation of anterior lungs. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. Neuro: Oriented to name, "hospital" and "[Month (only) 956]." Not cooperative with most of exam but able to follow 1-step commands. PERRL, EOMI. Face appears symmmetric. Moves all extremities independently. Pertinent Results: [2-24]: Head CT: - intraventricular hemorrhage fills and expands 3rd ventricle, extends into right lateral ventricle, small amount of blood dependently within left occipital [Doctor Last Name 534]. ventricular enlargment concerning for hydrocephalus. 2.5cm left frontal calcified mass - ? meningioma. no surrounding edema prior CT from OSH not currently available . [2-24]: Neck CT: no fracture, malalignment or prevertebral swelling identified . [2-25] Head CT: No change in intraventricular hemorrhage or ventricular size. Unchanged calcified left frontal meningioma. . [2-25] Head MRI: Unchanged left frontal meningioma. Unchanged right intraventricular hemorrhage. Unchanged ventricular size. . [2-26] CT Head/Abd/Pelvis: Expected evolution of blood products within the ventricular system with no new regions of hemorrhage identified. no RP bleed. patchy RML, RLL, LLL opacities concerning for pna or pneumonitis . EKG demonstrated TWI in inferior leads and precordial leads with TWI in V5-V6 new since prior done 12 hours earlier. . TELEMETRY demonstrated:NSR . 2D-ECHOCARDIOGRAM performed on [2107-2-26] demonstrated: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with inferior akinesis and inferolateral hypokinesis. The remaining segments contract normally (LVEF = 40-45%). Right ventricular chamber size is normal with mild global free wall hypokinesis. The ascending aorta is mildly dilated. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly-directed jet of mild to moderate ([12-31]+) mitral regurgitation is seen. There is mild pulmonary artery systolic HTN. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild regional biventricular systolic dysfunction, c/w CAD (inferoposterior and ?right ventricular infarction). Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Brief Hospital Course: Imaging at the OSH revealed right intraventricular hemorrhage into the 3rd ventricle and expanding into the 4th ventricle. She also has a left superior frontal calcified meningioma. She was transferred to the SICU where she was managed conservatively in the SICU with serial neurologic exams and head CT which remained stable. . On [2107-2-25] she was noted to be hypotensive and bradycardic. EKG showed ST elevations in the inferior leads and a peak CK of 1063. Given her hemorrhage, patient was managed conservatively with aspirin 325mg, simvastatin 80 mg daily and low dose beta blocker (lopressor 2.5mg IV Q6H). TTE performed showed biventricular hypokinesis. On the day of transfer to the cardiology floor [2107-2-27] she had two bradycardic episodes associated with nausea and hypertension. . On the floor, patient remained somnolent but arousable, able to answer simple questions and would follow commands. She denied any chest pain or shortness of breath. Patient was monitored closely on telemetry. Asymptomatic pauses of 3 seconds were noted and beta blockers were discontinued. Patient remained hemodynamically stable without symptoms of chest pain, hypotension, shortness of breath, or further neurologic deterioration during the rest of her admission. Cardiology recommendation was to continue full strength aspirin and high dose statin with baseline LFTs obtained near normal (ast 74, alt 21). Risk of bradyarrhythmia outweighed the benefit of beta-blockade, and decision was made to hold this medication indefinitely. She will follow up with a cardiologist at [Hospital1 18] after she is discharged from rehab to further discuss medical managament of her coronary artery disease. At the time of discharge, there was no indication for a coronary intervention in the future, but this will continue to be discussed on follow up. . Her home thyroid regimen was confirmed prior to discharge. It is recommended that she continue on .... . Patient should continue current medical therapy with aspirin and simvastatin. Per neurology recommendations patient may restart her coumadin on [2107-3-12]. Coumadin should be started at a low dose (2.5 mg daily) given patient's supratherapeutic INR on presentation. Her INR should be closely monitored after restarting coumadin and her hematocrit should be monitored at the time of coumadin initation and 1 week later. She should have a repeat MRI performed to evaluate the status of her bleed and a follow up appointment with Neurology to review the imaging. These have been scheduled. Patient should also schedule a follow up appointment with Dr. [Last Name (STitle) ] in Cardiology clinic after her discharge from rehab. Medications on Admission: Coumadin 1.25mg/2.5mg alternating days Atenolol 25mg daily Levothyroxine 75mcg daily Discharge Medications: 1. Aspirin 325 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Please do not start this medication until [2107-3-12]. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Right Intraventricular Hemorrhage ST Elevation Myocardial Infarction Atrial Fibrillation Secondary: CVA x 3 with residual right sided weakness Hypothyroidism Discharge Condition: Stable Discharge Instructions: You were transferred to [Hospital1 18] after you were found to have had bleeding in your brain after a recent fall. You were admitted to the ICU where you were closely monitored. During this admission you had a heart attack. You were started on new medications for your heart and transferred to the cardiology floor. You tolerated the medication well without any further events. . The following changes were made to your medications: 1) STOP coumadin can restart [2107-3-12] at 2 mg daily 2) START aspirin 325 mg daily 3) START atorvastatin 80 mg daily 4) START pantoprazole 40 mg daily 5) START senna 8.6 mg by mouth twice a day as needed for constipation 6) START bisocodyl by mouth daily as needed for constipation 7) START docusate 100 mg by mouth twice a day 8) Continue levothyroxine 75mcg daily . Please continue all other home medications as previously directed. . Please notify your physician or return to the hospital if you experience fever, chills, chest pain, shortness of breath, new neurologic problems or any other symptom that is concerning to you. Followup Instructions: Please call the [Hospital1 18] Cardiology Clinic ([Telephone/Fax (1) 62]) after discharge from rehabilitation to arrange a follow up appointment with Dr. [Last Name (STitle) ]. . Please have a repeat MRI of your brain performed on [4-8] at 2:35pm on the fourth floor of the [Hospital Ward Name 23] building on the [Hospital1 18] [Hospital Ward Name 516]. Please call [Telephone/Fax (1) 327] if you need to reschedule. . Please call the [Hospital 18] [Hospital 878] Clinic ([Telephone/Fax (1) 2574]) to confirm your appointment with Dr. [Last Name (STitle) ] currently scheduled for [4-12]. . Please have your INR closely monitored after restarting your coumadin on [2107-3-12]. ICD9 Codes: 4271, 2449, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5876 }	Medical Text: Admission Date: [2158-10-6] Discharge Date: [2158-10-19] Date of Birth: [2089-11-8] Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3645] Chief Complaint: lower back pain and hip pain Major Surgical or Invasive Procedure: Posterior surgical fusion T9-L1 with anterior column reconstruction at T11 level History of Present Illness: A 68 year-old female with history of bilateral breast cancer and metastatic kidney cancer, with extensive osseous and pulmonary metastases presented with chronic and acute lower back pain and hip pain. She has chronic lower pain and b/l hip pain for 2 years. The pain has gotten worse over the past one month. The pain was constant and [10-23] in intensity. Any movement would aggravate the pain and only pain med would relieve the pain. Because of the pain, she underwent a CT of abd and pelvis on [2158-10-4], which found that dramatic increase in overall tumor burden and metastatic disease at T11/T12 results in focal spinal instability with a invasion of the spinal canal with nearly 50% canal narrowing and greater than 50% vertebral body involvement. She denied focalized weakness, numbness, fecal or urine incontinence, buttock area numbness, or urine retention. However, she has constipated over the past one week. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: ONCOLOGIC HISTORY: [2142-6-26]: left nephrectomy for 11 cm clear cell renal cell carcinoma [2155-3-15]: diagnosted with bilateral breast cancer (node-positive on left, ER/PR positive, HER-2 negative). Treated with neoadjuvant dose-dense AC and weekly taxol ending [2155-10-3], bilateral mastectomy [2155-12-25] (after lumpectomy with positive margins), radiation ending [3-22]. On arimidex since completion of chemotherapy. [2156-7-14]: CT torso (done because of elevated alk phos) showed 1.5 and 0.6 cm left upper lobe nodules. [2156-8-26]: Left upper lobectomy showed two foci of clear cell renal cell carcinoma. [2157-5-4]: MRI of T/L spine with disease at T10, T11 vertebral bodies, soft tissues T10-T12, and L3 body. CT-guided biopsy consistent with renal cell carcinoma. Bone scan [2157-4-18] also showed involvement of several left ribs. Subsequently received XRT to thoracic spine. [5-/2157]: Began sunitinib; dose reduced over time to 25 mg because of toxicities. Sutent ended in [2158-1-14] because of disease progression. [2158-2-7]: MRI L-spine with T11 disease with persistent mass effect on thecal sac but no significant cord compression, and T9 and T10 disease, all likely unchanged. New T12 compression fracture. Significant progression of L3 vertebral body lesion with pathologic fracture and retropulsion of posterior cortex. [2158-2-13]: CT torso with interval marked progression of innumerable pulmonary mets since [2157-8-2]. Destructive lytic lesion within left femoral head. [2158-2-14]: XRT to lumbar spine [2158-4-12]: signed consent for 08-184 trial of avastin and temsirolimus. CT torso showed osseous mets in spine and left ribs, with interva lincrease in size in soft tissue component at T11 encasing thecal sac, invading cord, and invading more than 50% of the spinal canal. At L3, compression fracture with soft tissue component extending into spinal canal. Increase in number and size of numerous pulmonary mets bilaterally. Destructive lytic lesion within left femoral head. [2158-4-19]: C1D1 08-184 (avastin/temsirolimus) [2158-6-7]: CT torso with significant decrease in size of bilateral pulmonary lesions and stable osseous disease with decrease in soft tissue mass at T11 - [Date range (3) 10263]: admitted for PNA, mental status changes, found to have frontal CVA, taken off study - [2158-8-9] CT TORSO: stable disease Other Past Med Hx: - Hypertension - Breast Cancer s/p resection - gout Social History: She lives with her 3 sons who assist with her medical care. She used to work at [Hospital3 2568] in the GI division. She is a non-smoker, no alcohol or other drugs. Family History: Father had esophageal cancer. Her maternal grandmother had breast cancer in her 70s. Physical Exam: Vitals: 98.2 99 132/73 18 97% General: AAOX3 NAD HEENT: NC/AT, EOMI, anicteric, slightly dry MM, chin-to-chest normal motion and not painful CV: RRR, nl s1/s2, no m/r/g Lungs: clear to auscultation bilaterally without rales or rhonchi Abdomen: + bowel sounds, nondistended, no tenderness to palpation, no organomegaly appreciated Extremities: no edema or rash Neurologic: A&OX3, CN II-XII grossly intact. However, due to the pain, other neurologic exam wa sunable to performed Psych: appropriate, pleasant, cooperative Pertinent Results: [2158-10-6] 09:29PM GLUCOSE-100 K+-3.9 [2158-10-6] 09:20PM GLUCOSE-105* UREA N-10 CREAT-1.0 SODIUM-134 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-15 [2158-10-6] 09:20PM estGFR-Using this [2158-10-6] 09:20PM WBC-5.6 RBC-3.99* HGB-11.6* HCT-34.0* MCV-85 MCH-29.0 MCHC-34.0 RDW-17.4* [2158-10-6] 09:20PM NEUTS-83.9* LYMPHS-8.4* MONOS-6.2 EOS-1.0 BASOS-0.5 Ct of the abd on [2158-10-4]: Dramatic increase in overall tumor burden, including increase in size and number of numerous pulmonary nodules, and increased size of destructive bony lesion and soft tissue metastases. Metastatic disease at T11/T12 results in focal spinal instability with a invasion of the spinal canal with nearly 50% canal narrowing and greater than 50% vertebral body involvement, placing the patient at high neurological and pathologic fracture risk. A large right femoral head mass is at increased risk for pathologic fracture as well. [2158-10-8] skeletal survey:[10-9]: MRI shows cord compression. ortho spine will pursue surgery on wednesday. pt states pain control improved but not optimal. pall care came by and meds adjusted. toradol stopped, deemed not safe for pt with one kidney. stopped ASA in prep for surgery. [10-10]: pall care came by again in AM and uptitrated pain meds. pt reports in PM it is better. surgery plan for tomorrow. Final MRI read in and shows cord compression. neuro exam stable. [2158-10-8] MRI T- and L-spine:1. Heterogenous expansile lesion invlolving T11 vertebral body and posterior elements. There is posterior epidural soft tissue noted at this level which along with retropulsion of vertebral body causes compression of the spinal cord at this level. There is increase in the amount of compression of the vertebra as compared to the prior study, with increased epidural soft tissue and increased spinal canal stenosis. 2. Hyperintense signal in the spinal cord extending from T3-T12, which likely represent syrinx and is unchanged since the prior study. 3. Heterogenous lesion in the posterior elements of T12 vertebra on the left side with associated periosseous soft tissue. Hypointense lesion in C6 vertebral body. These are new since the prior study. 4. Decreased height of L3 vertebral body with biconcave shape. There is retropulsion of the vertebral body causing moderate spinal canal stenosis and indentation of the ventral thecal sac. 5. Multiple nodules in bilateral lung fields suggestive of metastases. Brief Hospital Course: A 68 year-old female with history of bilateral breast cancer and metastatic kidney cancer, with extensive osseous and pulmonary metastases presented with chronic and acute lower back pain and hip pain found to have metastatic bone disease. # Bony Mets: pt was admitted for pain crisis and found to have extensive bony lesions in the spine and femur, likely secondary to known renal carcinoma. No focal neurologic deficits. MRI and skeletal survey were ordered and pt was found to have cord compression near T11-T12. Skeletal survey also showed metastatic disease in T11, T12, L3 and lungs bilaterally. Pt was started on dexamethasone for cord compression protocol. Sliding scale insulin and GI prophylaxis with raniditine were also started. Ortho spine and rad/onc were consulted consulted and decision was made to pursue surgery of spine for decompression. Ortho Spine team wanted embolization of tumor prior to procedure so pt underwent Angio on [2158-10-11]..... # Pain Crisis: palliative care was consulted to assist in pain control after several days of difficulty controlling pain. Pt was satisfied with regimen of neurontin and oxycontin standing, with oxycodone for breakthrough and dilaudid for refractory pain. # HTN: continued home valsartan # Anemia: likely secondary to underlying cancer. Hct was near baseline and remained stable. Medications on Admission: anastrozole 1 mg Tab 1 Tablet(s) by mouth once a day Diovan 160 mg Tab 1 Tablet(s) by mouth once a day hold for bp < 110 ondansetron 4 mg Tab, Rapid Dissolve 1 Tablet(s) by mouth every 8 hours as needed for nausea aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth daily acetaminophen 325 mg Tab 1 Tablet(s) by mouth every 6 hours Ativan 0.5 mg Tab [1-15] Tablet(s) by mouth three times a day as needed for anxiety do not drive while taking this medication simvastatin 10 mg Tab 1 Tablet(s) by mouth once a day prochlorperazine maleate 10 mg Tab 1 Tablet(s) by mouth every six (6) hours as needed for nausea/vomiting docusate sodium 100 mg Cap 1 Capsule(s) by mouth levothyroxine 50 mcg Tab 1 Tablet(s) by mouth once a day OxyContin 10 mg 12 hr Tab 2 Tablet(s) by mouth twice a day oxycodone 5 mg Tab 1 Tablet(s) by mouth every 4 hours as needed for pain Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare & Rehabilitation Center - [Location (un) ] Discharge Diagnosis: Unstable T11 Spinal metastasis 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: You have undergone the following operation: Thoracic/Lumbar Decompression With Fusion Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - 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. - Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - 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. Physical Therapy: Activity: Activity: Activity as tolerated tid Pneumatic boots per pt Treatments Frequency: dressing can be changed PRN when wet to dry sterile dressing Followup Instructions: Brain [Hospital 341] Clinic Date: [2158-10-30] Phone: ([Telephone/Fax (1) 6574] Please call the Spine Care Clinic and make a follow up appointment for two weeks at [Telephone/Fax (1) 3736] Completed by:[2158-10-19] ICD9 Codes: 2930, 4019, 2749, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5877 }	Medical Text: Admission Date: [2164-2-3] Discharge Date: [2164-2-8] Date of Birth: [2127-8-3] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Clozaril Overdose Major Surgical or Invasive Procedure: None History of Present Illness: Pt is 36F h/o "schizophrenia" admitted for clozapine overdose. Per report of her psychiatrist (per ED note) pt's mother was treating her daughter at home for schizophrenia. She kept her locked in the house during the days while she was at work believing that the pt may be denied a Green Card upon receiving the diagnosis of schizophrenia. Starting in [Name (NI) 1096], pt began to express her desire to end her life, so mother sought medical attention. On day of admission pt was found at home on the floor, unconscious in a pool of vomit, surrounded by 5 empty bottles of clozapine (100 25mg tabs per bottle). EMS was called, pt was thrashing, incoherent and agitated. Taken to [Hospital1 18] ED where she was intubated for airway protection. In ED received Ativan 2 mg IV, activated charcoal, succ/etomidate and 3L NS. Propofol gtt was ineffective in sedating her so pt was paralyzed with vecuronium, thinking that her lactate may improve if twitching stopped. Her lactate did not improve and vecuronium d/c'd. Past Medical History: "Schizophrenia" symptoms started 10 yrs ago, worse over past year, with SI since [Name (NI) 1096] Mother reports that patient had "unknown" brain surgery for her schizophrenia in [Country 651]. Social History: Pt is a Chinese citizen. She has an associate degree and speaks English. She lives with mother [Name (NI) 1255] [Name (NI) ] [Telephone/Fax (1) 60311] who is giving her psych meds from [Country 651] to prevent documentation of diagnosis. Pt's psychiatrist's pager is [Telephone/Fax (1) 60312]. Family History: no FH of psychiatric illness Physical Exam: 96.3 137 114/38 100% on 0.5 Fi02 Genl: Well developed young woman, with intermittent jerking HEENT: intubated CV: rr no m PULM: ctab ABD: s, nt ,nd EXT: no edema NEUR: sedated, moving all 4 in intermittent asymmetrical jerks, reflexes 2+ and symmetrical Pertinent Results: Labs on Admission: TYPE-ART PO2-533* PCO2-37 PH-7.28* TOTAL CO2-18* BASE XS--8 LACTATE-7.0* GLUCOSE-127* UREA N-11 CREAT-0.6 SODIUM-141 POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-17* ANION GAP-16 WBC-18.7* RBC-3.48* HGB-11.3* HCT-31.1* MCV-89 MCH-32.4* MCHC-36.3* RDW-12.2 NEUTS-93.4* BANDS-0 LYMPHS-3.5* MONOS-3.0 EOS-0 BASOS-0.1 HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL PLT SMR-NORMAL PLT COUNT-221 TYPE-ART PO2-298* PCO2-30* PH-7.33* TOTAL CO2-17* BASE XS--8 INTUBATED-INTUBATED LACTATE-8.3* URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.023 BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 TRANS EPI-[2-4] HYALINE-[5-11]* GLUCOSE-163* UREA N-16 CREAT-0.8 SODIUM-144 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-17* ANION GAP-30* ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-220 CK(CPK)-336* ALK PHOS-86 TOT BILI-0.5 LIPASE-21 CK-MB-7 cTropnT-<0.01 ALBUMIN-4.7 CALCIUM-9.6 PHOSPHATE-5.0* MAGNESIUM-1.5* LITHIUM-<0.2 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG WBC-27.0* RBC-4.11* HGB-13.1 HCT-37.3 MCV-91 MCH-31.8 MCHC-35.0 RDW-12.3 [2164-2-3] 07:20PM NEUTS-90.0* BANDS-0 LYMPHS-5.4* MONOS-4.4 EOS-0 BASOS-0.2 HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL PLT SMR-NORMAL PLT COUNT-295 Studies: CT HEAD W/O CONTRAST [2164-2-5] 2:14 PM - No evidence of intracranial hemorrhage or mass effect. Post- procedural changes of the frontal bones and overlying soft tissues, as well as presumable post-procedure changes of the frontal lobe resulting in unusual configuration of the frontal horns of the lateral ventricles. Brief Hospital Course: 36 yo Chinese speaking F with a 10 yr h/o schizophrenia s/p questionable surgical procedure of her brain in [Country 651] and SI x3 months admitted with Clozaril overdose. Pt reportedly took 500 25 mg tabs in a suicide attempt. She received activated charcoal in ED. She was intubated for airway protection given obtundation. She was extubated on [2-4]. 1. Clozaril overdose/Suicide Attempt s/p activated charcoal and intubation for airway protection. She was successfully extubated on [2-4]. Now stable on RA. Her LFT's were initially elevated likely secondary to Clozaril injestion, now WNL. Pt is to go to Psych unit today, now that medically stable. She was alert and oriented speaking softly in english prior to discharge. She was responding appropriately to questions. 2. Altered mental status appears improved. Etiology secondary to overdose. Toxic/metabolic causes were initially considered, however pt improved without intervention. Head CT shows no acute process. RPR and TSH normal. - B12 deficiency, she received a B12 injection during this admission. She will need to have a level checked in one month. 3. Lactic acidosis, resolved. 4. Leukocytosis - resolved. No evidence of infection. CXR and U/A negative, urine cx negative. Blood cultures NGTD. 5. FEN - tolerating house diet. 6. Code - Full 7. Communication - Mother, [Name (NI) 437] [Name (NI) ] [Telephone/Fax (1) 60311] Medications on Admission: Clozaril Silpiride (selective dopamine D2 antagonist ) Na Deoxyribonucleotide Tabs Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: deacones 4 Discharge Diagnosis: Clozaril overdose Suicide Attempt B12 deficiency Discharge Condition: Good Discharge Instructions: Please call your primary care physician if you experience shortness of breath or any other concerns. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ] [12-4] weeks. ICD9 Codes: 2762, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5878 }	Medical Text: Admission Date: [2178-7-25] Discharge Date: [2178-7-31] Service: NEUROLOGY Allergies: Dilantin Attending:[First Name3 (LF) 2569] Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: Intubation CT MRI Lumbar Puncture History of Present Illness: This is a 84 y/o woman with h/o seizures starting in [2178-9-20], HTN, spinal stenosis who was in her usual state of health this morning, when she reported to her daughter a sudden onset of headache followed by a "feeling of something bad". Her daughter took her to a pharmacy to get BP checked. It was 222/104. Upon returning home, the pt. started with an automatism, but was verbalizing appropriately. Daughter called EMS and patient was seizing by the time EMS arrived. Her daughter described the seizure as face contortion. The [Hospital1 ] ED attending reported a generalized seizure with R > L movements and R-sided gaze. She was initially given 4 mg ativan in the ED which temporarily stopped seizure activity, but she resumed seizing shortly thereafter. An additional 4mg ativan was given, which again worked temporarily. A final dose of 4 mg ativan was given, for a total of 12 mg, and propofol was started, given her allergy to dilantin. She was intubated for airway protection. Past Medical History: -seizures: Her first seizure of record was in [2178-9-20] but was not worked up fully. In [2178-3-21], she had an episode similar to today's episode starting with a HA and progressing to a seizure (confused with repetitive movements and right arm shaking, BP 233/110) and was brought to [Hospital1 2025] where she was intubated for airway protection. She had a full seizure workup at [Hospital1 2025] with LP which was negative for infection, EEG which was abnormal due to diffuse background slowing but showed no epileptiform discharges, MRI which showed evidence for PRES, CTA showed moderate narrowing of Right P2 segment and small areas of hypodensity in occipital and parietal lobes. . -HTN -hypercholesterolemia -gout -anxiety -spinal stenosis Social History: lives with daughter at home. Questionable medication compliance. Family History: n/a Physical Exam: Vitals: T 102.8; BP 170/75; P 70; O2- 100% ventilated (CMV, TV- 500, PEEP 5, Rate 12) . General: lying in bed intubated HEENT: NCAT, moist 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: no c/c/e. . Neurological Exam: Mental status: unersponsive on arrival to ED, no spontaneous movements, no purposeful withdrawal from pain, no doll-eye movement with eyes fixed forward gaze, pupils 2mm unreactive bilaterally, . Motor: Normal bulk. Normal tone. No adventitious movements. unable to assess strength . Reflexes: Bic T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes mute bilaterally. Pertinent Results: [2178-7-25] 08:58PM CK-MB-5 cTropnT-0.04* [2178-7-25] 12:12PM CK(CPK)-304* [2178-7-25] 04:58AM TYPE-ART PO2-207* PCO2-33* PH-7.48* TOTAL CO2-25 BASE XS-2 [2178-7-25] 03:30AM GLUCOSE-111* UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 [2178-7-25] 03:30AM ALT(SGPT)-10 AST(SGOT)-18 LD(LDH)-252* CK(CPK)-217* ALK PHOS-72 TOT BILI-0.4 [2178-7-25] 03:30AM VIT B12-294 [2178-7-25] 03:30AM %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE [2178-7-25] 03:30AM TSH-2.4 [2178-7-25] 03:30AM WBC-13.1* RBC-3.74* HGB-9.7* HCT-27.8* MCV-74* MCH-25.8* MCHC-34.8 RDW-17.5* [2178-7-24] 09:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-71* GLUCOSE-76 [2178-7-24] 09:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-57* POLYS-17 LYMPHS-60 MONOS-22 ATYPS-1 [2178-7-24] 09:00PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1370* POLYS-57 LYMPHS-31 MONOS-10 ATYPS-2 . Head CT: No intracranial hemorrhage or mass effect is identified. . MRI with/without Gad: Bilateral posterior foci and supratentorial signal changes predominantly in the subcortical region with a distribution suggestive of posterior reversible encephalopathy/hypertensive encephalopathy. No evidence of slow diffusion or abnormal enhancement seen in these regions. No mass effect or hydrocephalus . EEG [7-25]: This is a moderately abnormal EEG due to the presence of a slow background with occasional bifrontal slow waves seen. This pattern is consistent with an encephalopathy of toxic, metabolic, or anoxic etiology, or can be seen with disorders affecting midline or bilateral white matter areas, particularly in the frontal lobes. Occasionally, patients with raised intracranial pressure can have bifrontal slow waves. Clinical correlation is recommended. No evidence of ongoing or potential epileptogenesis is seen at this time . EEG [7-29]: BACKGROUND: Included a well-formed 9 Hz alpha frequency in posterior areas bilaterally during wakefulness. There was a faster superimposed beta rhythm as well. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient appeared to remain awake or minimally drowsy throughout the recording. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Mildly abnormal EEG in the waking state due to the frequent but brief theta slowing in the left temporal region. There were no areas of more persistent focal slowing, and there were no epileptiform features. Brief Hospital Course: ICU Course Neuro: Intubated in the ED for airway protection. After an initial examination, she was sent for a STAT head CT which showed no new hemorrhage or major territorial infarction (see results above). Following this, an LP was performed as there was concern for CNS infection as seizure source based on her fever. LP findings negative except as traumatic tap (see results above). MRI performed later the following morning showed findings consistent with hypertensive leukoencephalopathy. This was felt to be the etiology of her seizure, as pt. had no evidence of other pathology, such as stroke or mass, on her MRI. Patient was extubated on [7-26] without complications. Passed a speech and swallow for solids and thickened liquids on [7-27] and was transferred to the floor. . Seizure prophylaxis was maintained with propofol and Keprra 1000mg NG [Hospital1 ]. After extubation, only Keppra was continued. . CVS: Blood pressure in the ICU was managed with patient's home medication regimen: Metoprolol 100mg PO TID, Valsartan 180mg Daily, Lasix 10mg IV (takes 20 PO at home) as well as addition of prn Hydralazine IV for SBP greater than 160. . ID: Febrile on admission, but defervesced quickly. Blood cultures sent on admission and within 20 minutes of IV Vancomycin and Ceftriaxone starting. CSF sent for cultures, GS and HSV PCR, all of which returned negative. Initially covered broadly with empiric doses of ABX for suspected CNS infection with IV Ampicillin, Vancomycin, Ceftriaxone. Also treated with Acyclovir at CNS infection doses (10mg /kg Q8 hrs). These were d/ced as cultures came back negative. . Renal: Some renal insufficiency on admission which resolved with IV fluids. Received extra fluid boluses with each dose of Acyclovir. . Floor Course: Neuro: Pt. was initially continued on Keppra 1000 [Hospital1 ], and had no further seizures. Pt. became more confused on her second day on the floor. Infection was considered, however pt. was afebrile and CXR, UA, Urine Cx and blood cx were negative. NCSE was considered, however repeat EEG was negative. Med effect was considered, and symptoms resolved with decreasing Keppra dose to 750 [Hospital1 ] and d/cing Acyclovir when CSF HSV came back negative. Of note, BP control improved as MS improved it was felt that this may also have contributed. Pt. was seen by PT and OT, who recommended acute rehab given weakness below baseline. . CV: BP control was continued as above (see ICU course) Pt. was noted to have several episodes of narrow complex tachycardia with rates of 140s-160s on telemetry. These were asymptomatic and not associated with hypotension, although pt. was noted to have ST depressions in inferior and lateral leads during the episodes that resolved when her rhythm returned to baseline. Acute episodes responded to 10 mg IV Diltiazem and did not recur after Diltiazem 30 mg PO QID was started and Metoprolol titrated up to 125 TID per recommendation of the cardiology service. Diltiazem was increased to 60 QID on [7-31] given inadequate BP control on lower doses, and should continue to be titrated as necessary at Rehab. Once dosing is stable pt. could be converted to once a day long-acting CCB. Cardiology recommended a TTE, which was performed on the day of discharge. Results of this were pending at time of discharge and should be followed up by pt's physician at [Name9 (PRE) ]. The Echo lab here can be reached at [Telephone/Fax (1) 3312]. Medications on Admission: keppra 500 mg [Hospital1 ] lasix 20 qd lipitor 40mg qd diovan 160 qd metoprolol 100 tid klonopin 1mg TID PRN FA Discharge Medications: 1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 4. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Hypertensive Encephalopathy Generalized Tonic Clonic Seizure [1-22] hypertensive encephalopathy Hypertension, poorly controlled Discharge Condition: Improved- no further seizures, tolerating medications, BP controlled 130s-150s. Discharge Instructions: Please call your doctor or go to the ER if you have any further seizures, headache, nausea, vomiting, fevers, chills, numbness, weakness, or any other symptoms that concern you. . Please take all medications as prescribed Followup Instructions: Primary Care: Please call Dr. [Last Name (STitle) 69676] at [Telephone/Fax (1) 31553] to set up a follow up appointment for 1-2 weeks after you are discharged from [Hospital1 ]. Cardiology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. Phone:[Telephone/Fax (1) 4451] Date/Time:[2178-9-23] 9:40 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2178-7-31] ICD9 Codes: 2762, 2720, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5879 }	Medical Text: Admission Date: [2126-4-29] Discharge Date: [2126-5-5] Date of Birth: [2059-11-22] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Cephalosporins / IV Dye, Iodine Containing Contrast Media Attending:[First Name3 (LF) 165] Chief Complaint: chest discomfort Major Surgical or Invasive Procedure: [2126-4-30] Coronary artery bypass grafting x4, with the left internal mammary artery to the left anterior descending artery and reversed saphenous vein graft to the diagonal artery, obtuse marginal artery, and posterior descending artery History of Present Illness: 66M with history of hypertension and hyperlipidemia developed chest discomfort with exertion over the preceeding months. Stress test was abnormal and he was sent for cath. This revealed severe three vessel disease as well as a tight left main. He did not receive Plavix. He is transferred for surgical revascularization. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia Mitral Valve Prolapse, Mitral Regurgitation Tinnitus GERD Nephrolithiasis Cervical Radiculopathy Social History: Lives with: wife in [Name (NI) ] Occupation: retired- works part time as executive coach Cigarettes: Smoked no [x] ETOH: < 1 drink/week [x] [1-15] drinks/week [] >8 drinks/week [] Illicit drug use: none Family History: Mother died young of liver cirrhosis Father died at 92 Physical Exam: Admission: Pulse: 71 B/P 143/86 Resp: 18 O2 sat: 98%RA Height: 5'3" Weight: 150 General: NAD, WGWN, appears fit Skin: Dry [x] intact [x] no rash 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] +BS [x] Extremities: Warm [x], well-perfused [x] Edema _none___ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruits: no bruits Discharge: VS T 99.7 BP 112/65 HR 71 SR RR 20 O2sat 98%-RA Gen NAD Neuro A&O x3, nonfocal exam Chest CV-RRR, no murmur. Sternum stable, incision CDI Pulm basilar crackles Abdm soft, NT/ND/+BS Ext warm, well perfused. 1+ bilat LE edema Pertinent Results: Intra-op echo: Conclusions PRE BYPASS The left atrium is elongated. 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. No atrial septal defect is seen by 2D or color Doppler. There is a narrow jet of venous flow entering the right atrium near the inferior vena caval junction. Difficult to definitively define source - may represent coronary sinus flow or hepatic vein flow. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are simple 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. Mild (1+) mitral regurgitation is seen. There is no 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 atrially paced. Normal biiventricular systolic function. No change in valvular function. The thoracic aorta is intact after decannulation. No other changes from the pre-bypass study. Radiology Report CHEST (PORTABLE AP) Study Date of [2126-5-2] 8:12 AM Final Report: A small right pneumothorax may be slightly smaller compared with yesterday at 4 p.m. Left-sided pneumothorax remains questionable. [Hospital1 ]-basilar atelectasis and a small left effusion are unchanged. Postoperative changes to the mediastinum are stable. Right-sided internal jugular catheter remains in the low SVC. Cervical fusion hardware is again present. IMPRESSION: Slight decrease in size in small right apical pneumothorax. Presence of a left apical pneumothorax remains questionable. DR. [First Name8 (NamePattern2) 819] [Last Name (NamePattern1) ] There is no report history available for viewing. . [2126-5-5] 06:35AM BLOOD WBC-7.1 RBC-3.37* Hgb-10.5* Hct-31.4* MCV-93 MCH-31.2 MCHC-33.4 RDW-13.1 Plt Ct-315 [2126-5-4] 06:35AM BLOOD WBC-7.4 RBC-3.09* Hgb-9.5* Hct-28.8* MCV-93 MCH-30.9 MCHC-33.1 RDW-13.0 Plt Ct-242 [2126-5-5] 06:35AM BLOOD Glucose-111* UreaN-17 Creat-1.2 Na-141 K-4.0 Cl-103 HCO3-25 AnGap-17 [2126-5-4] 06:35AM BLOOD UreaN-16 Creat-1.1 Na-140 K-4.0 Cl-102 Brief Hospital Course: Mr [Known lastname 111941] was transferred to [Hospital1 18] from outside hospital after cardiac catheterization revealed severe three vessel coronary artery disease. He was transferred here for coronary revascularization. After typical preoperative workup he was brought to the Operating Room on [2126-4-30] where the patient underwent CABG with Dr. [First Name (STitle) ]. Please see the operative report for details, in summary he had: Coronary artery bypass grafting x4, with the left internal mammary artery to the left anterior descending artery and reversed saphenous vein graft to the diagonal artery, obtuse marginal artery, and posterior descending artery. His CROSS-CLAMP TIME was 80 minutes, with a BYPASS TIME of 92 minutes. He tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He woke from anesthesia neurologically intact and was extubated on the day of surgery. POD 1 found the patient extubated, alert, oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blockers were initiated and the patient was gently diuresed toward the preoperative weight. Also on POD1 the patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued per cardiac surgery protocol without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility.He worked daily with nursing and physical therapy to improve strength and endurance. On POD3 the patient developed a fever and workup was negative. He did develop a hematoma at the knee site of his EVH as well as a hematoma at the proximal thigh site. He was started on antibiotics. The hematoma at the knee resolved by discharge. The hematoma in the groin remained firm. The remainder of his hospital course was uneventful. 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 in good condition with appropriate follow up instructions. Medications on Admission: Chlorthalidone 25mg daily Omeprazole 20mg daily Pravastatin 20mg daily Multivitamin Aspirin 81mg daily Vitamin D Discharge Medications: 1. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 8. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease s/p CABG x4 Hypertension Hyperlipidemia Mitral Valve Prolapse, Mitral Regurgitation Tinnitus GERD Nephrolithiasis Cervical Radiculopathy Past Surgical History [2120]- cervical surgery for herniated disc Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Percocet Sternal Incision - healing well, no erythema or drainage Extensive ecchymosis of LLE, hematoma proximal/medial thigh Edema 1+ bilat LE 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 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 [Doctor First Name ], [Location (un) ] Phone:[Telephone/Fax (1) 170] Date/Time:[2126-5-9] 10:30 Surgeon: Dr [Last Name (STitle) ] [Name (STitle) ], Phone:[Telephone/Fax (1) 170] Date/Time:[2126-6-4] 1:15 Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075], [2126-5-29] at 12:30p Please call to schedule the following: Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8049] in [3-14] 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 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2126-5-5] ICD9 Codes: 4019, 2724, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5880 }	Medical Text: Admission Date: [2123-12-8] Discharge Date: [2123-12-17] Date of Birth: [2123-12-8] Sex: F Service: NB HISTORY: [Known lastname ] [First Name4 (NamePattern1) ] [Known lastname ] is a 34 [3-10] week infant born to a 35-year-old G2, P1 mother by a repeat [Name (NI) 32007] secondary to unstoppable preterm labor. MATERNAL HISTORY: Significant for type 1 diabetes with suboptimal glycemic control per her endocrine physician. [Name Initial (NameIs) ]'s hemoglobin Alc was 7.2, and she also had mild diabetic retinopathy. Mother is enrolled in a study through the [Last Name (un) ] that involves follow up of the baby. PRENATAL LABS: Mother's blood type 0 negative, antibody negative, RPR nonreactive, rubella immune, hepatitis surface antigen negative, GBS negative. At delivery, the infant emerged with spontaneous cry. Routine care after delivery was administered. Apgars were 9 and 9. The infant was transported to the NICU with blow by oxygen and admitted for prematurity. The infant's birth weight was 3090 grams which was greater than the 90th percentile. The head circumference on admission was 34 cm, which was at the 90th percentile and the length on admission was 47 cm which was 75th percentile. HOSPITAL COURSE BY SYSTEMS: The infant on admission required low flow nasal cannula just for 12-24 hours. Subsequently was weaned to room air without any complication. The infant had a few episodes of desaturations but no associated bradycardia. The last desaturation was on [2123-12-12] and she subsequently has not had anymore episodes. She has not required any caffeine for apnea of prematurity. Cardiovascular: The infant never had episodes of hypotension and thus never required pressure support. No murmur was ever appreciated and therefore did not require treatment for a PDA. FEN GI: The infant initially was started on IV fluids of D10W. She was started on enteral feeds on day of life one. She intermittently took good p.o. feeds but did require a PG tube in order to give her adequate nutrition. She has been able to feed all feeds by mouth starting on the day of life 5 and since then she takes approximately 160-180 ml/kg per day and she is being discharged home on Enfamil 20 K calories per ounce. DISCHARGE WEIGHT - 2960GM LENGTH - 47.5CM HC 33.5CM GI: She had a peak bilirubin on day of life 4 of 10.9 which did not require any phototherapy and subsequent bilirubin done on day of life 5 was 9.1. Hematology: The infant's blood type is 0 positive, antibody negative. She did not require any blood transfusion and her most recent creat was actually done on the day of admission, on [12-8], and it was 46.7. ID: Given mom's unstoppable preterm labor, the infant was put on amp and gent for 48 hours after blood cultures were drawn but cultures were negative and thus antibiotics were discontinued on day of life 2. The infant did not require any additional courses of antibiotics. Neurology: Given her gestational age of 34 [3-10], she did not require a screening head ultrasound. Sensory/audiology: Her hearing test is pending, and she did pass a car seat test. Ophthalmology: Since she is greater than 32 weeks, she did not require an exam for retinopathy of prematurity. DISCHARGE DISPOSITION: She will be discharged home. Her pediatrician is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [Location (un) 38640] and the parents have an appointment for the day after discharge, date to be determined. DISCHARGE EXAMINATION: The infant's weight on day of life 8, which is [2123-12-16], one day prior to discharge, is 2950 grams which is between the 75th to 90th percentile and the discharge length and head circumference are pending. On examination, general appearance, the infant is vigorous and active, pink and well perfused. Head and neck exam: Anterior fontanelle is open and flat. She opens her eyes bilaterally. Red reflexes are intact. Her palate is intact. Pulmonary: Clear to auscultation bilaterally. Cardiovascular: No murmurs, S1 and S2 regular rate and rhythm. Abdomen: Soft, nondistended. No hepatosplenomegaly. Extremities: Warm and well perfused, +2 femoral pulses. Negative Ortolani and Barlow. GU: Normal female preterm genitalia. The anus is patent. Neuro: Positive suck and positive Moro, appropriate for age. CARE AND RECOMMENDATIONS: Feeds at discharge: The infant is being discharged home on Enfamil 20 K calories, feeding ad lib. Mother is not breast feeding. The baby may be eligible for a special study formula with added DHA depending on results of markers for diabetes sent after birth. These results will be back in the next few weeks. MEDICATIONS: The infant is not being discharged home on any medication. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age if feeding breast milk. All infants fed predominately breast milk should receive vitamin D supplementation of 200 international units may be provided as a multi-vitamin preparation daily until 12 months corrected age. Car seat position screening was performed and the infant passed. State newborn screening was done and the results are pending. IMMUNIZATIONS: The infant received hepatitis B vaccine on [2123-12-12] and received Synagis vaccine on [2123-12-16]. Immunizations recommended: Synagis 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 between 32 and 35 weeks with 2 of the following: Daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. 3. Chronic lung disease. 4. Hemodynamically significant congenital heart disease. Influenzae 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 influenzae 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. Follow up appointments have been made with the primary pediatrician. DISCHARGE DIAGNOSIS: Prematurity, rule out sepsis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55750] Dictated By:[Name8 (MD) 75460] MEDQUIST36 D: [2123-12-16] 10:12:46 T: [2123-12-16] 11:27:48 Job#: [Job Number 75461] ICD9 Codes: 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5881 }	Medical Text: Admission Date: [2173-9-9] Discharge Date: [2173-10-10] Date of Birth: [2122-7-8] Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:[Male First Name (un) 5282] Chief Complaint: Acute renal failure and liver transplant evaluation Major Surgical or Invasive Procedure: Paracentesis Esophagogastroduodenoscopy Hysteroscopy and polypectomy History of Present Illness: Ms. [Known firstname ] [Known lastname ] is a 51 year old lady with history of ESLD secondary to HCV/EtOH (?) cirrhosis (c/b ascites, encephelopathy, and jaundice, variceal status unknown), HIV (recent VL undectectable per pt, off of HAART), diabetes mellitus, and hypertension who presents for liver transplant evaluation. Ms. [Known lastname ] is seen by a hepatologist Dr. [Last Name (STitle) ] in [Location (un) 6691], MA who referred her to Dr. [Last Name (STitle) 497] for transplant evaluation. Patient was seen in clinic and admitted for blood work and therapeutic paracentesis. She reports that she was diagnosed with HCV in [2165] and her course has become more complicated in the past year, with ascites, yellowed eyes, and episodes of "memory loss" that improve with lactulose. She has had multiple paracenteses in the past year- her last one was about two weeks ago, when she reports they removed about 6 liters. She denies a history of varices, but reports she has never had an EGD or colonoscopy. Patient reports she is currently with some abdominal and lower back discomfort secondary to her ascites, but denies focal abdominal pain. Reports she feels cold, but denies objective fevers. Denies nausea, vomiting, hematemesis, black tarry stools, and BRBPR, but reports occasional hemorrhoidal bleeds. On ROS, she does report some SOB associated with her increasing abdominal girth, which has also limited her ability to walk around. Also notes loose stools with her lactulose. Some itchy bumps on arms and chest in the past week, which she has been scratching. + vaginal bleeding attributed to recent d/c of tamoxifen; + hemorrhoids. Denies CP, palpitations, productive cough, headaches, visual changes, myalgias, arthralgias, and dysuria. Past Medical History: HCV- diagnosed in [2165] HIV- diagnosed in [2152]; off of HAART; VL undectable 2 months ago per patient Diabetes mellitus on insulin Hypertension Breast cancer s/p lumpectomy, radiation and tamoxifen in [2167] Hyperlipidemia Social History: Lives in [Location 6691], MA with her daughter and daughter's boyfriend and three grandchildren. Has two sons, one in North [Name (NI) ], and the other one "locked up." Currently on disability, but was previously employed in maintenance and food services at [Last Name (un) 6058]. Quit smoking in [2167], smoked 2-2.5 packs for 30+ years. History of heavy alcohol use in past- 6 pack + bottle of wine in past, but has been sober since [2164]. Remote history of cocaine, crack, LSD, and marijuana as a teen. Denies any history of heroin or IVDU. Family History: Mother with hepatitis C, "liver cancer," and diabetes. Sister passed away from diabetes. Physical Exam: On admission: VS: T 97.0 BP 126/89 HR 71 RR 20 O2sat 100% on RA Gen: thin woman, sitting in bed in NAD HEENT: + scleral icterus; buccal mucosal telangiectasias, clear oropharynx, and moist mucus membranes; poor dentition CV: RRR, no murmur, rubs, gallops Pulm: CTAB, no wheezes, rhonchi, rales Abd: soft, but tensely distended, + fluid wave; non-tender to palpation; +BS; no rebound or guarding; no hepatosplenomegaly appreciated; + umbilical hernia Extr: 3+ lower extremity edema in legs, 1+ in thighs; WWP, 2+ DPs and PTs Neuro: A&Ox3; delayed response time; no asterixis or tremor; CNII-XII evaluated and intact; 5/5 strength in upper and lower extremities; no pronator drift; sensation grossly intact Skin: multiple excoriations on arms and chest; no [Location (un) ] erythema or spider angiomas identified Pertinent Results: Admission Labs: [2173-9-9] 07:20PM WBC-5.5 RBC-2.92* HGB-9.4* HCT-27.2* MCV-93 MCH-32.2* MCHC-34.4 RDW-17.3* [2173-9-9] 07:20PM NEUTS-42* BANDS-0 LYMPHS-43* MONOS-8 EOS-4 BASOS-0 ATYPS-1* METAS-2* MYELOS-0 [2173-9-9] 07:20PM PLT SMR-VERY LOW PLT COUNT-49* [2173-9-9] 07:20PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2173-9-9] 07:20PM PT-18.2* INR(PT)-1.6* [2173-9-9] 07:20PM HCV Ab-POSITIVE* [2173-9-9] 07:20PM ETHANOL-NEG [2173-9-9] 07:20PM CEA-5.4* AFP-11.0* [2173-9-9] 07:20PM HBsAg-NEGATIVE HBs Ab-BORDERLINE HAV Ab-POSITIVE IgM HBc-NEGATIVE [2173-9-9] 07:20PM TSH-2.5 [2173-9-9] 07:20PM FREE T4-1.5 [2173-9-9] 07:20PM HDL CHOL-22 CHOL/HDL-5.6 [2173-9-9] 07:20PM calTIBC-157* FERRITIN-420* TRF-121* [2173-9-9] 07:20PM ALBUMIN-2.6* CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-2.1 IRON-139 CHOLEST-123 [2173-9-9] 07:20PM GGT-151* [2173-9-9] 07:20PM ALT(SGPT)-24 AST(SGOT)-53* ALK PHOS-82 TOT BILI-1.8* [2173-9-9] 07:20PM GLUCOSE-101* UREA N-25* CREAT-1.8* SODIUM-130* POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-18* ANION GAP-11 [2173-9-11] 09:53PM BLOOD Smooth-NEGATIVE [2173-9-18] 07:20AM BLOOD RheuFac-33* [2173-9-11] 09:53PM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:40 [Last Name (un) ] . Micro: [9-10] Peritoneal fluid- GS 1+ polys; cx no growth [9-10] URINE CULTURE (Final [2173-9-12]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. (pan sensitive) [9-10] HIV-1 Viral Load/Ultrasensitive: 30,600 copies HCV-Ab: Positive HCV VIRAL LOAD:1,770,000 IU/mL. HBsAg: Negative HBs-Ab: Borderline Positive -- C/W Titer Of Roughly 10 Miu/Ml HAV-Ab: Positive IgM-HBc: Negative HSV 1 IGG TYPE SPECIFIC AB 3.44 H HSV 2 IGG TYPE SPECIFIC AB >5.00 H Rubella IgG/IgM Antibody: positive RAPID PLASMA REAGIN TEST: NR VARICELLA-ZOSTER IgG SEROLOGY: pos CMV IgG ANTIBODY: pos CMV IgM ANTIBODY: pos [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB: Pos [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB: Pos [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB: Pos TOXOPLASMA IgG ANTIBODY: Equivocal 7 IU/ML [9-13] Peritoneal fluid- GS negative; 1PMN; cx negative (prelim) [9-16] Urine cx- MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION [9-17] Blood cx- pending [9-17] Peritoneal fluid- GS negative; cx- no growth (prelim) . Studies: [9-10] TTEcho: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. 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. There is no pericardial effusion. . [9-10] Abd U/S w/ Doppler: 1. Nodular hepatic architecture with no focal liver lesion identified. 2. Patent portal vein, however, a small nonocclusive thrombus is seen within the left portal vein. 3. Large amount of ascites. A mark was made at the right lower quadrant for a paracentesis to be performed by the clinical staff. . [9-14] EGD: Grade I varices. . [9-17] CXR: In comparison with the study of [9-15], there is no evidence of focal pneumonia. There are continued low lung volumes. Dobbhoff tube extends at least to the second portion of the duodenum. There is, however, an area of opacification in the right upper zone medially that appears to be contiguous with the medial aspect of the clavicle and could well represent an expansile lesion. For further evaluation, views of the clavicle and sternoclavicular joints are recommended. If this proves to be a skeletal finding, cross-sectional imaging would be helpful. . [9-17] Rt Clavicle XR: No expansile lesion identified. There are mild degenerative changes of the sternoclavicular joint. If there is pain relating to the right sternoclavicular joint, then MRI of the sternoclavicular joints could certainly be performed to further assess. . [9-21] CT Abd/Pelvis: 1. Massive ascites seen throughout the abdomen and pelvis. 2. No radiographic evidence of ileus. 3. Thickened endometrial wall vs endometrial cavity, recommend further evaluation with ultrasound to characterize the uterus as differential diagnosis includes endometrial carcinoma . [9-22] Peritoneal Fluid: NEGATIVE FOR MALIGNANT CELLS. . [9-22] Pelvic Ultrasound: Markedly abnormal endometrium, which is thickened, heterogeneous and vascularized as described above, concerning for endometrial neoplasm. Recommend tissue sampling for further evaluation. Brief Hospital Course: 51 year old woman with history of ESLD [1-26] HCV/EtOH (?) c/b ascites, encephelopathy and jaundice, HIV, DM, and HTN who presented for liver transplant evaluation with acute kidney failure. # ESLD- Patient was admitted from clinic for liver transplant evaluation. Her MELD was 20 on [9-10]. Transplant evaluation labs were sent, including: AFP 11, CEA 5.4, HCV VL 1.7 million, CMV IgG, IgM positive, RPR NR, toxo IgG equivocal, VZV IgG pos, HIV VL 30,600, Hep A IgG pos, Hep B sAg neg, sAb borderline pos, cAb IgM neg. EBV IgG and IgM positive, anti-smooth mscl negative, [Doctor First Name ] 1:40 pos, alpha 1 antitrypsin negative. PPD was placed and was negative. She had an abdominal U/S with dopplers which showed hepatic nodularity and a small non-occlusive thrombus in the left portal vein, but patent main portal vein. She underwent EGD, which showed grade 1 varices. She was evaluated by nutrition and started on tubefeeds to improve her nutritional status. She developed encephalopathy while hospitalized with asterixis on exam and mild confusion which improved with lactulose. She continued to have tense ascites requiring frequent paracenteses of 2-3L. Albumin was given directly after these procedures. She was also treated empirically with ceftriaxone for possible SBP, although all paracentesis were not consistent with SBP. Her bilirubin continued to rise throughout the admission, her encephalopathy was stable. She completed pre-transplant evaluation with the exception of a colonoscopy. A long discussion was held with the family and patient about utility of pursuing a liver transplant given poor prognostic comorbidities in her such as HIV, HCV, renal insufficiency, and a difficult social/financial situation. The pt stated on numerous occasions that she would rather go home and spend time with her family than continue with the transplant evaluation, and she was ultimately discharged home with hospice care. . # Impaired renal function - Baseline creatinine was around 1.0 in [2173-2-22] per outpatient ID records, but as of [Month (only) 205] patient has had worsening function attributed to diuretics & pre-renal causes. On admission, patient's was creatinine 1.8. UA showed 100+ hyaline casts and urine sodium <10. Diuretics were held and albumin administered with initial response (creatinine trended down to 1.3), but subsequently bumped back up to 1.6 and was no longer responsive to albumin. She was started on octreotide and midodrine for treatment of presumed HRS. Renal was consulted considering significant blood in her UA (attributed to her hemorrhoids), and proteinuria (attributed to her diabetes). MPGN related to HCV was felt to be unlikely given no acanthocytes on smear, but complements, cyro, and RF were sent. Her creatinine eventually increased and peaked at 3.1. She was treated for hepatorenal syndrome with daily octreotide, midodrine, and albumin. Her renal function improved slightly to 2.5 but did not normalize prior to discharge. Renal transplant team was consulted and concluded that she would not be a candidate for renal transplant even in the setting of liver transplant. . # Anemia - Normocytic. Pt had Hct drop to 19.3 from 21.5 on [9-12], without evidence of GI bleeding and received 1 unit pRBCs. She received a second unit on [9-16] with appropriate bump. Iron studies were sent and were not significant for iron deficiency. She was transferred to the MICU on [9-20] due to bleeding from her recent paracentesis site. Her hematocrit dropped to 22.8 at this time and she was given 2 units PRBCs. She was also give cryo for an FFP of 90 and FFP, although it was not felt that she was in DIC. This bleeding resolved, but she began to have vaginal bleeding in moderate amounts on [9-21]. She had workup for her vaginal bleeding (see below) and it eventually slowed. She required intermittent blood transfusions to maintain her hematocrit. She remained hemodynamically stable throughout. . # HCV/EtOH (?) Cirrhosis c/b ascites, encephelopathy, jaundice, and Grade I varices on EGD ([9-14]). Duplex doppler abdominal U/S showed a nodular hepatic pattern, non-occlusive left portal vein thrombus, and patent main portal vein. Serum EtoH negative and pt reports no EtOH since [2164]. Currently w/ acites and mild jaundice, but no active bleeding or encephelopathy. Patient was continued on her home nadolol and lactulose. Her diuretics were held given her renal function. She was given a low sodium diet with nutritional supplements, evaluated by nutrition with placement of a Dobhoff and initiation of tube feed nutritional supplements. LFTs were trended. She did not have any episodes of variceal bleeding. She underwent several therapeutic paracentesis (usually 2-3 liters) which were negative for SBP as above. . # HIV- Patient's ART was recently discontinued by her outpatient ID specialist Dr. [Last Name (STitle) 87563] secondary to an undetectable VL and labile renal function. During this hospitalization VL was 30,600 and CD4 count = 436. PPD was placed and was negative. ID was consulted and recommended deferring reinitiation of ART in the pre-transplant setting until patient's renal function stabilized. Patient was scheduled to see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] in [Month (only) 359], who will work in collaboration with Dr. [Last Name (STitle) 87563] to initiate an appropriate ART regimen. HIV genotype is pending. ID recommended sending HLA B5701 and intiated HAART therapy with etravirine, abacavir, lamivudine, raltegravir. . # Urinary tract infection- Patient was found to have UTI with pan sensitive Klebsiella pneumoniae on culture. She was treated with 3 days of ciprofloxacin. Later in admission she was found to have VRE UTI and treated with 10 day course of daptomycin. . # Tinea corporis- Patient complained of itching and was noted to have two round hyperpigmented plaques with scaling (KOH +)- one on her right chest and one on her neck. She was started on miconazole for tinea corporis and dermatology was consulted given multiple folliculocentric papular excoriations on her chest of unknown etiology. Dermatology recommended continuing anti-fungal treatment for the tinea corporis and symptomatic anti-pruritic treatments. They felt her excoriations were consistent with pityrosporum folliculitis (which she is predisposed to given her HIV and DM) and recommended continued topical anti-fungals and anti-pruritic treatments with sarna, loratidine, and atarax if needed. . # Vaginal bleeding - 2 weeks after admission pt developed profuse vaginal bleeding in setting of coagulopathy (with concomitant bleeding from paracentesis site and IV lines), she was transferred to the MICU where she was transfused and stabilized. An ultrasound was done which revealed a very thickened endometrium at 4cm, likely due to polyp. She had an endometrial biopsy with was negative for malignancy. Her vaginal bleeding continued and pt was using [3-29] pads per day, dropping HCT and requiring transfusions. Etiology of thick endometrium was likely hyper-estrogenic state, coagulopathy, and taking tamoxifen in the past for breast ca. When the bleeding did not subside, she had hysteroscopy with polypectomy, no ablation was done given too much bleeding during the procedure. After procedure, bleeding stabilized with exception of one large volume bleed, she continued to use [12-26] pads/day but did not require further transfusions. Discussion was had about possible hysterectomy but the surgery would be too high risk given her hepatic impairment. . # Diabetes mellitus- Patient was initially continued on her home lantus 16 units qHS and a sliding scale was added. After tube feeds were started, patient's sugars jumped up and she required a new regimen and her lantus was uptitrated. Her home sitagliptin was held while she was an inpatient. Feeding tube was taken out prior to discharge and she can resume her admission insulin requirements. . # Home hospice - pt was discharged on midodrine, omeprazole, cipro, lactulose, rifaximin, and PRN meds (simethicone, ketoconazole, cortisone, morphine, ativan) Medications on Admission: Medications at home: (from admission note) Lactulose (1x per day) Lantus 16 units qHS Prilosec Sitagliptin 50 mg (?) Nadolol 20 mg Lasix 40 mg Spironolactone 50 mg [pravastatin, zetia, calcium, lisinopril 10 mg ? per outpt ID note] Zerit liquid 40 mL [Hospital1 ] Kaletra 5 mL [Hospital1 ] Viread 300 mg (ART d/c-ed on [2173-7-7]) . Medications on transfer: Lantus 50 units daily Humalog sliding scale insulin Influenza Virus Vaccine 0.5 mL IM NOW X1 Ketoconazole 2% 1 Appl TP [Hospital1 ] Please apply to lesions on chest and neck. Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Acetaminophen 500 mg PO/NG Q6H:PRN Pain Lactulose 30 mL PO/NG Q6H titrate to [2-25] BM daily Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG QID:PRN bloating, gas pain Midodrine 10 mg PO TID Albumin 25% (12.5g / 50mL) 50 g IV ONCE Duration: 1 Doses ([9-24] @ 1643) Multivitamins 5 mL PO/NG DAILY CeftriaXONE 2 gm IV Q24H Nadolol 40 mg PO DAILY Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Octreotide Acetate 200 mcg SC Q8H Fexofenadine 60 mg PO DAILY:PRN itching Ondansetron 4 mg IV Q8H:PRN nausea Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Rifaximin 550 mg PO/NG [Hospital1 ] Heparin Flush (10 units/ml) 2 mL IV PRN line flush Sarna Lotion 1 Appl TP [Hospital1 ]:PRN itching Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN rectal discomfort Simethicone 40-80 mg PO/NG QID:PRN gas pain Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Discharge Medications: 1. [Hospital ] Hospice care of the Berkshires emergency kit for patient [Known firstname ] [Known lastname ] to be discharged from the hospital to home [10-9] 2. morphine concentrate 20 mg/mL Solution Sig: 5-20 mg PO q3-4hr as needed: 5-20mg PO/SL q3-4hr prn. Disp:100 ml Refills:0 3. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO q3hr as needed. Disp:50 Tablet(s) Refills:0 4. ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:0 5. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for itching. Disp:30 Tablet(s) Refills:0 6. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. Disp:100 Tablet, Chewable(s) Refills:0 7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours). Disp:3600 ML(s) Refills:0 9. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed) as needed for rectal discomfort. Disp:1 tube Refills:0 10. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:0 11. 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:0 12. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: HospiceCare of the Berkshires Discharge Diagnosis: Primary: Cirrhosis Hepatorenal syndrome Uterine polyp VRE UTI Anemia . Secondary: HIV HCV DM HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you at the [Hospital1 18]. You were admitted to the hospital because of kidney failure. While you were in the hospital you were treated with medications and your kidney function improved. You were also found to have a urinary tract infection which was treated with antibiotics. During your hospitalization we began evaluation for a possible future liver transplant. Your liver function continued to get worse, however. After a long discussion with you and your family, you decided that you would like to go home without pursuing the liver transplant. We removed your feeding tube before you went home and took a lot of fluid out of your abdomen. You should continue to have weekly taps to take fluid out of your belly when it becomes uncomfortable. You will also continue some medications for your kidneys and your liver (listed below). . Continue midodrine for your kidneys Continue omeprazole Continue ciprofloxacin to prevent infection Continue lactulose and rifaximin to help prevent confusion The rest of your medications are "as needed" for symptoms Followup Instructions: home hospice will arrange for the rest of your care Completed by:[2173-10-11] ICD9 Codes: 5849, 5990, 2851, 2761, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5882 }	Medical Text: Admission Date: [2167-12-29] Discharge Date: [2168-3-25] Date of Birth: [2092-9-1] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Iodine / cefepime Attending:[First Name3 (LF) 2763] Chief Complaint: HCAP and Vocal Cord Dysfunction Major Surgical or Invasive Procedure: Intubation Tracheostomy History of Present Illness: Mrs. [Last Name (STitle) 65107] is a 75 year-old woman with COPD, mild bronchiectasis and suspected vocal cord dysfunction admitted [12-25] from [Hospital3 ] to [Hospital 8] Hospital with PNA/Septic Shock. Patient met SIRS criteria on admission and received EGDT with 4L NS, 2 units PRBC and was transiently on norepinephrine. She was also started on Vanc,Zosyn,Aztreonam on [12-25]. Sputum culture grew ESBL E.Coli and MRSA and she was narrowed to Vanc/Ertapenem. Patient required intubation on resentation and was extubated on [12-28]. Following extubation she required non-invasive ventillation intermittently throughout the day. The patient's daughter subsequently requested transfer to [Hospital1 18] for further care. . On arrival to the MICU, the patient is somnolent but eaily awakes to touch and has expiratory stridor. Past Medical History: dCHF EF 60% DMII (A1c 6.8 [11/2167]) Mild Bronchiectasis Anxiety Microcytic Anemia ?Thalassemia Trait Hypertension GERD Hiatal Hernia on EGD [2161] s/p Cholecystectomy Social History: Originally from [Country 47535], moved here from [Country 47535] [2166-10-24]. Has 2 daughters (both physcians) one here and one in [Country 47535]. Her son also lives in US. She is a widow. Per family no tobacco, EtOH or drug use. Family History: Her father had COPD and asthma, no other respiratory or cardiac history. Physical Exam: Admission: VS: T: 98.4, P: 88, BP: 132/78, RR: 21, 97% on CPAP HEENT: cracked lips, no erythema Neck: supple, JVP not elevated, no LAD Lungs: Audible expiratory stridor, No inspiratroy wheezing CV: distant heart sounds, regular rhythm Abdomen: soft, non-tender, non-distended, bowel sounds present Neuro: Somnolent, awakes to touch, tracks with eyes, pupils 3->2mm BL . Discharge: VS: Tmax around 99, HR=100s-110s, BP=130s-160s/60s-90s, RR=20s, 99% on PSV 5/3 with FiO2=40% General: pleasant but at times confused and agitated, intermittently pulling on tracheostomy HEENT: Anicteric sclera, EOMI, PERRL Neck: Supple, trach in place CV: tachycardic but regular rhythm, distant heart sounds Lungs: diminished lung sounds bilaterally with crackles and rhonchi intermittently noted in left lung; trach suctioning significant for tan, thick sputum Abdomen: soft, NT/ND, normoactive bowel sounds, PEG tube in place Neuro: Mostly alert and interactive, at times somnolent. Able to walk about 50 feet with physical therapy on the vent. Able to tolerate PMV to speak for a short period of time. Speaks Bengali only. Pertinent Results: [2167-12-29] 10:59PM PT-11.4 PTT-22.0* INR(PT)-1.1 [2167-12-29] 10:59PM PLT SMR-NORMAL PLT COUNT-308 [2167-12-29] 10:59PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2167-12-29] 10:59PM NEUTS-76* BANDS-7* LYMPHS-6* MONOS-6 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-3* [2167-12-29] 10:59PM WBC-11.9* RBC-4.03* HGB-10.7* HCT-34.2* MCV-85 MCH-26.5* MCHC-31.3 RDW-17.2* [2167-12-29] 10:59PM CALCIUM-9.2 PHOSPHATE-3.9 MAGNESIUM-2.3 [2167-12-29] 10:59PM ALT(SGPT)-61* AST(SGOT)-27 TOT BILI-0.4 [2167-12-29] 10:59PM estGFR-Using this [2167-12-29] 10:59PM GLUCOSE-102* UREA N-35* CREAT-0.8 SODIUM-143 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-34* ANION GAP-13 [2167-12-29] 11:57PM TYPE-ART O2-35 PO2-84* PCO2-69* PH-7.35 TOTAL CO2-40* BASE XS-8 INTUBATED-NOT INTUBA ECHO [2167-12-31] Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. 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 an anterior space which most likely represents a prominent fat pad. CT Chest [2168-3-10] IMPRESSION: 1. Multicystic abnormality in the left lung apex, likely pneumatoceles, not significantly changed since [2168-2-22]. 2. Small left pneumothorax. 3. New left lower lobe pneumonia and accompanying nonhemorrhagic pleural effusion. 4. Diffuse bilateral bronchial wall thickening, mucoid impaction, and bronchiectasis, likely reflect chronic recurrent aspiration. Brief Hospital Course: This is a 75 year old woman with PMH of COPD, tracheobronchomalacia, bronchiectasis, diastolic CHF, Mycobacterium avium complex pulmonary colonization, recent MRSA and ESBL E.coli cavitary pneumonia, and DM2 who was transferred from [Hospital 8] Hospital for further management of HCAP/sepsis, ultimately requiring tracheostomy and PEG placement with course complicated by multiple pneumothoraces requiring several chest tube placements. . #. Respiratory Failure: Patient was intubated on admission to [Hospital 8] Hospital and was extubated there on [2168-12-28] before being transferred to [Hospital1 18]. She has a diagnosis of COPD and is likely hypercarbic at baseline. She had audible expiratory stridor on admission exam and required non-invasive ventilation after admission to the MICU. She then developed increased work of breathing and was re-intubated at [Hospital1 18]. Bronchoscopy was done and showed severe distal tracheal malacia and severe bilateral main bronchi malacia. A tracheostomy was performed [1-6]. She was given a prednisone taper, saline and albuterol nebs, and her HCAP was treated as below. She requires intermittent PSV ventilation, but has been tolerating trach collar for prolonged periods of time recently. . #. Multiple left sided pneumothoraces: She developed a left sided pneumothorax on [1-7] and chest tube was placed. She developed multiple left sided pneumothoraces throughout her hospital course requiring several chest tubes. She was pleurodesed by the thoracic surgeons on [2168-3-15] and the chest tube removed, but she developed a repeat pneumothorax requiring a pig tail chest tube placed. Thoracics initially recommended a repeat pleurodesis, but the daughter declined given that her mother experienced a lot of pain after her first one. Her last chest tube was removed [2168-3-24]. She should be monitored closely for any further pneumothoraces. . #. HCAP/Sepsis: Patient presented to [Hospital 8] Hospital in severe sepsis requiring aggressive care. Sputum culture grew ESBL E.Coli and MRSA. She was continued on a course of vancomycin and meropenem. BAL grew aspergillus and she was given a course of voriconazole. She developed several ventilator associated pneumonias throughout her course requiring multiple extended courses of meropenem for continued ESBL E. Coli in her sputum samples, but no MRSA or aspergillus. Her most recent 21 day course of meropenem ended [2168-3-25] and she is currently on inhaled colistin to suppress any future infections. . #. Positive sputum AFB/Mycobacterium avium complex: A sputum sample from [2167-12-29] was AFB positive. She was placed on tuberculosis precautions for two months while the sample was sent to the state lab for speciation. Her quantiferon gold was negative. Speciation revealed atypical mycobacteria, respiratory precautions were discontinued, and no further treatment was pursued. . #. Diastolic CHF: Patient has known CHF on Lasix and [First Name8 (NamePattern2) ] [Last Name (un) ] as an outpatient. Her [Last Name (un) ] has been held and her Lasix is currently dosed at 20mg IV BID with a goal of keeping her ins/outs even as she currently appears euvolemic. . #. Diabetes Mellitus: Her blood sugars were checked four times daily and she was maintained on Lantus and insulin sliding scale. . #. Anemia: Patient has baseline anemia of chronic inflammation and her hematocrit remained close to baseline in the mid 20s throughout her hospitalization. Her type and screen is positive for [Doctor Last Name ] antibody and her transfusion threshold is Hct<21. . #. Anxiety/depression/acute delirium: Patient has significant baseline anxiety and depression. Her citalopram was initially increased at 40 mg from 20 mg po daily at home. Her clonazepam was initially increased from 0.5 mg po BID to 1 mg po BID. She was also given prn lorazepam throughout her hospitalization. Unfortunately, she developed significant delirium related to her length of stay in the ICU and all benzodiazepines, SSRIs, and opiates were discontinued for the last couple weeks of her course with improvement in her mental status. She was instead transitioned initially to Seroquel 25mg twice daily which was then titrated down to 25mg at bedtime to decrease daytime somnolence. . #. Pain control: On Tylenol only at this point. Opiates are being held given delirium. . #. Seizures Prophylaxis: She developed new seizures as of [2168-1-28] thought to be secondary to cephalosporins and toxic metabolic contributions. She was started on Keppra for seizure prophylaxis and has been clinically stable since its initiation. Cephalosporins should be avoided if possible. . #. T5 compression fracture: She has no pain and has remained clinically stable in this regard. . #. Nutrition: PEG was placed without incident and she tolerated tube feeds well. She is currently on Two Cal HN with 21 grams/day Beneprotein at a rate of 50 ml/hr. These tube feeds are cycled from 8AM to 8PM. Residuals are checked every 4 hours and were being held for residuals > 200 ml. She is being flushed with 100 ml of water every 4 hours. . #. IV access: She had a right sided PICC line with some erythema around the site which was pulled on [2168-3-20] and a new PICC was placed in her left arm on [2168-3-22]. There was no growth from the PICC tip culture. . #. Communication: Patient's daughter, [Name (NI) ] [Name8 (MD) 61683] MD is a nephrologist in [Location (un) 2725], MA and can be reached at [Telephone/Fax (1) 91954] or [Telephone/Fax (1) 91955] . #. Code Status: DNR, patient already with tracheostomy, OK to continue vent support Medications on Admission: Home medications: Citalopram 20mg daily Clonazepam 0.5mg [Hospital1 ] PRN Anxiety Ferrous Gluconate 240 daily Fluticasone Nasal daily Advair 500/50 [Hospital1 ] Lasix 20mg daily Hydrocortisone 2.5% rectally Combivent QID PRN Lidocaine 5% ointment Losartan 50mg daily Montelukast 10mg HS Omeprazole 20mg [Hospital1 ] Simethicone 80mg Q6H Tiotropium 18mcg daily Vit B-12 1000mcg daily Vit D3 1000 unit daily Discharge Medications: 1. fluticasone 110 mcg/actuation Aerosol [Hospital1 ]: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [Hospital1 ]: 6-8 Puffs Inhalation Q2H (every 2 hours) as needed for SOB/wheezing. 3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [Hospital1 ]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 4. bacitracin-polymyxin B Ointment [Hospital1 ]: One (1) Appl Topical Q6H (every 6 hours) as needed for redden site. 5. colistin (colistimethate Na) 150 mg Recon Soln [Hospital1 ]: One [Age over 90 1230]y (150) mg Injection [Hospital1 ] (2 times a day): Inhaled colistin. Please administer albuterol prior to colistin administration. 6. bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 7. acetaminophen 650 mg/20.3 mL Solution [Hospital1 ]: 325-650 mg PO Q6H (every 6 hours) as needed for fever/pain. 8. thiamine HCl 100 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 9. niacin 50 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 10. miconazole nitrate 2 % Powder [Hospital1 ]: One (1) Appl Topical TID (3 times a day) as needed for yeast infection. 11. B-complex with vitamin C Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 12. ranitidine HCl 15 mg/mL Syrup [Hospital1 ]: One [Age over 90 1230]y (150) mg PO DAILY (Daily). 13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. camphor-menthol 0.5-0.5 % Lotion [Last Name (STitle) ]: One (1) Appl Topical QID (4 times a day) as needed for itching. 15. levetiracetam 100 mg/mL Solution [Last Name (STitle) ]: 1000 (1000) mg PO BID (2 times a day). 16. sodium chloride 0.65 % Aerosol, Spray [Last Name (STitle) ]: [1-25] Sprays Nasal QID (4 times a day) as needed for dry nasal. 17. insulin regular human 100 unit/mL Solution [Month/Day (2) ]: as directed Injection four times a day: per sliding scale. 18. quetiapine 25 mg Tablet [Month/Day (2) ]: One (1) Tablet PO HS (at bedtime). 19. Furosemide 20 mg IV BID Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: -Tracheobronchomalacia -COPD -VAP -Respiratory failure s/p tracheostomy and PEG requiring pressure support ventilation intermittently -Mycobacterium avium complex lung colonization -Multiple pneumothoraces requiring chest tube placements -Bronchiectasis -Delirium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were transferred from [Hospital 8] Hospital to [Hospital1 771] for further treatment of pneumonia and septic shock. Unfortunately, your hospitalization was prolonged with several complications. You had signifcant respiratory distress on arrival requiring intubation. Unfortunately, you were not able to be taken off of the ventilator and ultimately required tracheostomy with intermittent ventilator support to maintain proper oxygenation given your severe tracheobronchomalacia, bronchiectasis, and COPD. You also developed several pneumothoraces requiring multiple chest tubes. There was also initial concern for tuberculosis given some findings from your sputum, but thankfully your sputum grew out an atypical mycobacterium which is not concerning. Followup Instructions: Please follow-up with the physicians at [Hospital 100] Rehab MACU. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] ICD9 Codes: 0389, 5849, 4275, 4280, 5990, 2859, 4019, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5883 }	Medical Text: Admission Date: [2137-8-29] Discharge Date: [2137-9-12] Date of Birth: [2060-9-10] Sex: M Service: NEUROMEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old man with bulbar predominant myasthenia [Last Name (un) 2902]. His myasthenia was diagnosed in the spring of [2136]. His prior treatment has included Mestinon, prednisone, CellCept, IV Ig and Plasmapheresis. He had previously been admitted to the Neurology Service and was discharged to rehabilitation about one month prior to this admission. Over the two weeks prior to admission, his voice became less and less forceful and had an increasing nasal quality to it. He also had progressive dysphagia. He received an IV treatment at rehabilitation but did not have any significant improvement. With his worsening hypophonia and dysphagia, he was sent to the [Hospital6 1760] Emergency Department for further evaluation. PAST MEDICAL HISTORY: 1. Myasthenia [Last Name (un) 2902]. 2. Diabetes mellitus. 3. Right L5 radiculopathy, status post L5-S1 diskectomy. 4. Old right exotropia. 5. Glaucoma. 6. High cholesterol. 7. Hypertension. 8. BPH, status post TURP. ADMISSION MEDICATIONS: 1. Calcium carbonate 500 mg p.o. t.i.d. 2. Glyburide 5 mg p.o. q.d. 3. Metformin 1 gram p.o. b.i.d. 4. Protonix 40 mg p.o. q.d. 5. Lisinopril 10 mg p.o. q.d. 6. Paxil 10 mg p.o. q.d. 7. Zocor 40 mg p.o. q.d. 8. Flomax 0.4 mg p.o. q.h.s. 9. Nystatin swish and swallow. 10. Lumigan 0.03% drops. 11. Ativan 0.5 mg p.r.n. 12. Insulin sliding scale. 13. CellCept 1,500 mg p.o. b.i.d. 14. Prednisone 100 mg p.o. q.d. 15. Mestinon 75 mg p.o. q.i.d. 16. Mestinon Time Span 180 mg p.o. q.h.s. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.7, heart rate 112, blood pressure 122/43, respiratory rate 20, 02 saturation 97% on room air. General: He was uncomfortable appearing with perfuse secretions. Lungs: His lung sounds were coarse throughout. His negative inspiratory force was -12 and his FVC was 550. Cardiovascular: Tachycardiac without murmurs. Abdomen: Benign. Neurologic: He was awake and alert. His voice was very nasal and of very low volume. He was able to count to 45 in one breath. There was no diplopia or ptosis. He had mild neck flexor weakness. There was mild bilateral deltoid weakness. The rest of the examination was deferred at that time due to his worsening pulmonary status. HOSPITAL COURSE WHILE IN THE ICU: He was admitted to the Intensive Care Unit for close monitoring. His ICU course by system is as follows. 1. NEUROLOGIC: The etiology of his worsening myasthenia symptoms was unclear. However, it was found that he did have a pneumonia which may have triggered his worsening symptoms. His Mestinon was changed to Neostigmine 1.5 mg q. three hours. His prednisone was changed to Solu-Medrol 80 mg IV q.d. His status remained relatively stable over the first few days in the ICU. He was noted to have increased secretions and his Neostigmine dose was decreased and Scopolamine was briefly added but this did not seem to help with his secretions. His respiratory status declined slowly and then more acutely on [2137-9-2] requiring intubation. Because of his worsening status, he received plasmapheresis. This was started on [2137-9-1] and he received five rounds of plasmapheresis every other day. In addition, cyclosporin was added to his regimen on [2137-9-2] at a dose of 50 mg b.i.d. His goal level is 100 with a plan to increase very slowly at 0.5 mg per kilogram per day every month up to an approximate goal dose of 150 mg b.i.d. With the plasmapheresis and cyclosporin, his neurologic examination quickly improved in the ICU. He was able to be extubated on [2137-9-6]. His Neostigmine was converted back to PG Mestinon. He was continued on his other myasthenia [Last Name (un) 2902] medications. 2. CARDIOVASCULAR: The patient had intermittent tachycardia at times in the ICU of unclear etiology. In the setting of his respiratory distress and emergent intubation, his systolic blood pressure decreased into the 80s and he was briefly on Neo-Synephrine drip to maintain his blood pressures. He also had episodes of bradycardia in relation to the Neostigmine and this resolved when he was converted back to his Mestinon. 3. PULMONARY: On admission, his negative inspiratory force was -12, FVC 550, and he was able to count to 42 in one breath. Chest x-ray on admission showed retrocardiac opacity. Chest CT showed bilateral lower lobe consolidation, left greater than right consistent with aspiration pneumonia. He was initially started on ceftriaxone without significant improvement and, therefore, was changed to levofloxacin and then Flagyl and received a total of ten days of antibiotics. On [2137-9-1], he had increasing respiratory distress with markedly elevated carbon dioxide and was, therefore, placed on CPAP. On [2137-9-2], he had an acute desaturation into the 70s with a possible aspiration event and required emergent intubation. He was placed on IMV with trials of CPAP and was ultimately extubated on [2137-9-6]. 4. INFECTIOUS DISEASE: The patient was febrile at times in the ICU with a presumed source of his aspiration pneumonia. He received antibiotics for a total of ten days, initially ceftriaxone and then levofloxacin and Flagyl. 5. GASTROINTESTINAL: The patient underwent PEG tube placement on [2137-8-30] due to his inability to provide adequate nutrition orally. EGD at this time showed a single 4 mm ulcer in the stomach. He was placed on a proton pump inhibitor and H. pylori titers were checked which were negative. In the ICU, he later developed anemia. He, therefore, underwent repeat EGD on [2137-9-4] which showed healing of the previously seen ulcer. However, there were multiple erosions and ulcers in the second part of the duodenum. This was thought possibly to be related to his prednisone and CellCept. However, given his tenuous neurologic status these medications were not changed. He was continued on the proton pump inhibitor. The GI Service recommend a follow-up EGD in approximately six to eight weeks to check on the status of these erosions and ulcers. 6. HEME: On [2137-9-4], his hematocrit dropped to 26.2. He was transfused 2 units of blood. His workup included stool Guaiac which were negative, EGD, as above, and abdominal CT scan which was negative for retroperitoneal bleed. His PTT was also markedly elevated to as high as 126. This seemed to be related to subcutaneous heparin as it resolved after this was discontinued. The patient was, therefore, continued on Pneumoboots for DVT prophylaxis. 7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was kept on an insulin sliding scale. He briefly required an insulin drip. NPH was added to his regimen. Electrolytes were followed closely and repleted as needed. The Nutrition Service followed the patient and recommended tube feedings which the patient was tolerating. 8. DERMATOLOGY: The patient had a penile ulcer which was treated with sulfadiazine. 9. ACCESS: For access, the patient had a left subclavian Quinton catheter placed on [2137-9-1]. With the patient's improved neurologic and respiratory status after the plasmapheresis and cyclosporin, the patient was transferred to the Neurology floor on [2137-9-8]. At that time, he felt much improved. His only complaint at that time was hypophonia. He felt that his swallowing and breathing were at about baseline. PHYSICAL EXAMINATION UPON TRANSFER: General: The patient is a chronically ill appearing man in no acute distress. Lungs: He had coarse breath sounds bilaterally. Cardiac: Regular rate and rhythm without murmurs, rubs, or gallops. Abdomen: Benign. The G tube site was clean, dry, and intact. Neurologic: He was awake and alert. On cranial nerve examination, he had a right exotropia. His pupils were equal, round, and reactive to light. His extraocular movements were intact without nystagmus. There was mild bilateral facial weakness. He was able to fully close his eyes but these could be opened by the examiner. His tongue was midline. His tongue strength was decreased. On motor examination, there was mild 5- weakness of the triceps bilaterally. Sensation was intact to light touch. His reflexes were 2+ and symmetric. His toes were downgoing. His finger-nose-finger was normal. HOSPITAL COURSE WHILE ON THE NEUROLOGY FLOOR: 1. NEUROLOGY: The patient was continued on Mestinon, prednisone, CellCept, and cyclosporin. He received his fifth and final round of plasmapheresis on [2137-9-9]. His neurologic examination continued to slowly improve. His facial strength improved and he was able to press his lips and whistle. The volume of his voice continued to improve. On [2137-9-10], his cyclosporin dose was increased to 100 mg b.i.d. per the Neuromuscular Service. The plan of the Neuromuscular Service at this time is to continue on his current medications and then to perform IV Ig every two weeks with the next round being on [2137-9-23]. He has a scheduled follow-up in the [Hospital 7817] Clinic on [2137-9-23] at 4:00 p.m. 2. CARDIOVASCULAR: There are no significant issues at this time. 3. PULMONARY: The patient continued to have increased secretions but was able to clear these with coughing and suctioning. His chest x-ray on [2137-9-11] revealed a small left pleural effusion and stable left lower lobe consolidation. As the patient was afebrile with a stable respiratory status, antibiotics were not restarted. 4. INFECTIOUS DISEASE: The patient had a low-grade fever to 99.3 and a mildly elevated white count. Urinalysis was negative. Urine culture was consistent with contamination. Chest x-ray was stable, as above. Stool C. difficile was negative times two and a third sample was pending. He subsequently had temperatures in the normal range. 5. GASTROINTESTINAL: The patient was continued on a proton pump inhibitor and his tube feeds. He had no significant issues. He had a swallow study on [2137-9-11] which cleared him for a pureed solid and thin liquids, extra sauces. 6. HEME: The patient's hematocrit was stable. 7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient's sugars continued to remain high in the 200s and his NPH was gradually increased. PHYSICAL EXAMINATION ON DISCHARGE: Similar to as described above with moderate improvement in his facial strength. MOST RECENT LABORATORY DATA: White blood cell count 10.2, hematocrit 31, platelets 283,000. Sodium 139, potassium 3.7, chloride 102, bicarbonate 32, BUN 22, creatinine 0.7, glucose 224, calcium 8.2, magnesium 2.1, phosphorus 2.1. Cyclosporin 57. The patient has a CBC and chemistries pending from [2137-9-12]. The most recent chest x-ray is as above. CONDITION ON DISCHARGE: Stable. NEUROLOGIC FOLLOW-UP with Dr. [First Name (STitle) ] [Name (STitle) 557] DISCHARGE STATUS: To [Hospital ] [Hospital ] Hospital. DISCHARGE DIAGNOSIS: 1. Myasthenia [Last Name (un) 2902] crisis. 2. Aspiration pneumonia. 3. Diabetes mellitus. DISCHARGE MEDICATIONS: 1. Tylenol 325 to 650 mg PG p.r. q. four hours p.r.n. pain. 2. Lidocaine jelly 2% one application p.r.n. 3. Silver sulfadiazine 1% cream applied to penile ulcer b.i.d. 4. Lorazepam 0.5 to 1 mg IV q. four hours p.r.n. anxiety. 5. Lansoprazole 30 mg PG q.d. 6. CellCept 1,500 mg PG b.i.d. 7. Prednisone 100 mg PG b.i.d. 8. Mestinon 75 mg PG q. six hours and q.h.s. 9. Paxil 20 mg p.o. q.d. 10. Cyclosporin 100 mg PG q. 12. 11. Neutra-Phos one packet p.o. t.i.d. 12. Zinc sulfate 220 mg PG q.d. started on [2137-9-11] with a planned duration of 14 days. 13. Vitamin C 500 mg p.o. b.i.d. 14. NPH insulin 14 units q. 12 hours. 15. Insulin sliding scale (please see nursing sheet). 16. Tube feeds Probalance full-strength 70 cc per hour, free water flushes 30 cc q. four hours. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 17304] Dictated By:[Name8 (MD) 33494] MEDQUIST36 D: [2137-9-12] 10:38 T: [2137-9-12] 10:38 JOB#: [Job Number 94214] ICD9 Codes: 5070, 2859, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5884 }	Medical Text: Admission Date: [2152-9-26] Discharge Date: [2152-10-5] Date of Birth: [2122-10-16] Sex: M Service: CSU CHIEF COMPLAINT: The patient is a 29-year-old man with known history of aortic stenosis since childhood. He is a postoperative admission and admitted directly to the operating room. Chief complaint is increasing shortness of breath with activity and worsening valvular function by echocardiogram and MRI. HISTORY OF PRESENT ILLNESS: A 29-year-old man with history of AS diagnosed in [2143], followed by serial echocardiograms and MRI. This year the MRI showed worsening valvular function. Patient does complain of shortness of breath with activity. Also has a history of asthma. PREOPERATIVE MEDICATIONS: 1. Procardia XL 60 q.d. 2. Albuterol MDI b.i.d. 3. Pulmicort MDI q.d. 4. Amoxicillin before dental visits. Patient had a cardiac echocardiogram done on [8-1], which showed a bicuspid aortic valve with severe AR with a globally depressed LV function with an EF of 56 percent. He had a cardiac catheterization done on [7-22] that showed clean coronaries with 4 plus aortic regurgitation and mild pulmonary hypertension. Chest x-ray done preoperatively showed no cardiopulmonary processes. LAB DATA PRIOR TO ADMISSION: White count 7.7, hematocrit 41.5, platelets 219. PT 12.3, PTT 28.5, INR 1.0. Sodium 140, potassium 4.2, chloride 104, CO2 26, BUN 14, creatinine 0.8, glucose 86. ALT 12, AST 15, alkaline phosphatase 64, total bilirubin 0.5, total protein 7.8, albumin 4.8, hemoglobin A1C 5.5. Urinalysis preoperatively was negative. EKG showed sinus bradycardia with a occasional PVCs at a rate of 54. ALLERGIES: Patient states an allergy to penicillin. FAMILY HISTORY: Had an uncle who died at a young age of a MI. SOCIAL HISTORY: Lives with girlfriend. Occupation is a salesman. Tobacco use: Quit six years ago. Prior to that, smoked for seven years. Alcohol use: Drinks 5-6 drinks per week. Others: Rare marijuana use. PHYSICAL EXAMINATION: Height 5'8". Weight 195 pounds. Heart rate 58. Blood pressure 163/46. Respiratory rate 22. O2 saturation 98 percent on room air. General: Sitting in chair in no acute distress. Skin: With no lesions or sores. HEENT: Pupils are equal, round, and reactive to light. Anicteric. Extraocular motions intact. Neck is supple with no lymphadenopathy or JVD. Transmitted murmur. Chest was clear to auscultation. Heart: 3/6 systolic ejection murmur. Abdomen is soft, nontender, and nondistended with positive bowel sounds. Extremities: Warm and well perfused with no edema, no varicosities. Neurologically: Alert and oriented times three. Nonfocal exam. Pulses: 2 plus throughout. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the operating room. Please see the OR report for full details. In summary, the patient had an aortic valve replacement with a [Street Address(2) 17009]. [Male First Name (un) 923] mechanical valve. Cardiopulmonary pump time was 164 minutes with a cross-clamp time of 86 minutes. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was in normal sinus rhythm at 75 beats per minute with a mean arterial pressure of 66 and a CVP of 11. He had nitroglycerin at 0.5 mcg/kg/minute and propofol 20 mcg/kg/minute. Patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. During the course of the evening on the operative day, he was weaned from all cardioactive IV medications on postoperative day one. Patient's chest tubes were removed and he was transferred from the ICU to [Hospital Ward Name 121] 2 for continuing postoperative care and cardiac rehabilitation. Once on the floor, the patient had an uneventful postoperative course. He was begun on Coumadin on postoperative day two. At that time, his temporary pacing wires were removed over the next several days, so the patient's beta blocker and diuretics were adjusted. His Coumadin dose was also adjusted with an attempt to get to a goal INR of 3 to 3.5. During this period the patient's activity level was advanced with the assistance of Physical Therapy and the nursing staff. On postoperative day eight, the patient complained of a sore throat. At that time, he also had a fever to 100.5 with a white blood cell count of 16. A urinalysis done at that time was negative. A chest x-ray showed no effusions or infiltrates with a small amount of postoperative atelectasis. Blood cultures and sputum cultures were also sent at that time. Sputum Gram stain was negative and showed contamination with oropharyngeal flora. Blood cultures to date are negative. However, the patient did have an erythematous throat and he was dosed with Zithromax 500 mg at that time. He will be continued on Zithromax 250 mg q.d. x5 days. The following morning the patient had remained afebrile x24 hours and the decision was made that he was stable and ready to be discharged to home. At this time, the patient's physical exam was as follows: Vital signs: Temperature 99, heart rate 72, sinus rhythm, blood pressure 114/53, respiratory rate 20, and O2 saturation 91 percent on room air. Weight at time of discharge 88.7 kg, preoperatively 88 kg. Laboratory data on day of discharge: White count 13, hematocrit 26.1, platelets 245. PT 18, PTT 69, INR 2.1. Potassium 4.6, BUN 18, creatinine 0.8. Physical exam: Alert and oriented times three. Moves all extremities, follows all commands. Respiratory: Clear to auscultation. Cardiovascular: Regular, rate, and rhythm, S1, S2 with mechanical click. Sternum is stable. Incision with Steri-Strips, open to air clean and dry, no erythema. Abdomen is soft, nontender, and nondistended. Extremities are warm and well perfused with no edema. MEDICATIONS ON DISCHARGE: 1. Albuterol MDI two puffs b.i.d. and q.6h prn. 2. Flovent two puffs q.d. 3. Dilaudid 2-4 mg q.4-6h prn. 4. Metoprolol 75 mg b.i.d. 5. Ferrous sulfate 325 mg q.d. 6. Ascorbic acid 500 mg b.i.d. 7. Lisinopril 5 mg q.d. 8. Coumadin 7.5 mg on [10-5].5 mg on [10-6], check INR on [10-7], and then dosed per Dr. [Last Name (STitle) ]. 9. Azithromycin 250 mg q.d. x5 days. DISCHARGE DIAGNOSES: Status post aortic valve replacement with a number [Street Address(2) 17009]. [Male First Name (un) 923] mechanical valve. Asthma. CONDITION ON DISCHARGE: Good. FO[Last Name (STitle) 996]P: He is to have followup in the [Hospital 409] Clinic in two weeks. Follow up with Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] in [3-7] weeks. Follow up with Dr.[Name (NI) 55526] office by phone on [10-7] to transmit INR results and to get a Coumadin dose and follow up with Dr. [Last Name (STitle) 5874] in [3-7] weeks. Also the patient is to followup with Dr. [Last Name (Prefixes) ] in four weeks. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2152-10-5] 11:37:29 T: [2152-10-6] 05:11:00 Job#: [Job Number 55527] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5885 }	Medical Text: Admission Date: [2167-4-14] Discharge Date: [2167-4-22] Date of Birth: [2113-8-21] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1974] Chief Complaint: asthma exacerbation Major Surgical or Invasive Procedure: None. History of Present Illness: 53F h/o HTN, asthma, with several recent asthma flares p/w acute dyspnea 4d ago. She was admitted to MICU but never intubated. She was started on high dose steroids and frequent nebs with slow improvement. No evidence of pneumonia. Her O2 requirement has decreased steadily. Currenlty, she states breathing is little better. Has been c/o dizziness since admit. Past Medical History: 1. Asthma-has had multiple asthma exacerbations requiring 3 hospitalizations, steroids; no intubations 2. HTN 3. Hyperlipidemia 4. polio- uses crutches at baseline Social History: Lives with sister. Vietnamese-speaking. Goes to senior day care 3x/week with parents. No tob/ETOH. Family History: Non contributory Physical Exam: Vitals are 96.9---123/74---90----22---99% 2lNC PE: NAD OP clear and dry, no thrush Lungs: mod air flow, faint exp wheeze anteriorly CV: RRR, nml S1S2 Abd benign Pertinent Results: [2167-4-14] CHEST (PORTABLE AP): Heart is at the upper limit of normal. Lung fields are clear and symmetric. No focal consolidation or infiltrate is seen. There is no pneumothorax or pleural effusion. No evidence of congestive heart failure. Stable examination as compared to 3 days ago. Cardiac size at upper limit of normal. . [2167-4-15] ECG: Sinus tachycardia Nonspecific T wave changes in lead V3 Since previous tracing of [2167-4-14], ventricular rate faster, and further T waves changes present . [2167-4-20] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2163-8-4], the findings are similar. . [2167-4-20] CHEST (PORTABLE AP): There is no evidence of pneumonia. There are low lung volumes, which result in pulmonary vascular crowding, though mild superimposed vascular congestion is difficult to exclude. . Brief Hospital Course: 1) ASTHMA FLARE: Pt's presentation was consistent with asthma flare. There was no evidence of underlying or superimposed infection. While in the MICU, she was started on steroids, nebulizers, and singulair and advair were added to her long-term regimen given her poor asthma control. On the floor, these were continued and her steroids were tapered gradually. Her oxygenation improved and she was on room air. Her breathing was also much better and close to baseline by discharge. Medications on Admission: 1. Acetaminophen 650 mg QID prn fever/pain 2. Albuterol 90 mcg IH, 2 puffs tid prn 3. Albuterol sulfate 0.83 mg/ml IH, 1 unit qid prn SOB/cough 4. Clonazepam 0.5 mg po bid prn for sleep 5. Crolom 4% 1 gtt each eye q 6 hr prn 6. Docusate sodium 100 mg, [2-3] capsules po @hs prn constipation 7. Flonase 50 mcg NS, qd each nostril 8. HCTZ 25 mg po daily 9. Lipitor 20 mg po daily 10. Lisinopril 10 mg po daily 11. Loratidine 10 mg po daily 12. Naprosyn 375 mg po bid prn pain 13. Predisone taper finished 14. Prilosec OTC 20 mg po daily 15. Pulmicort 0.5 mg/2 m IH, one unit [Hospital1 ] Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 disk Refills:0 3. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 aerosol Refills:0 4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for 5 days. Disp:30 Tablet(s) Refills:0 8. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day) for 7 days. Disp:1 bottle Refills:0 9. Prednisone 10 mg Tablet Sig: taper as directed Tablet PO once a day for 10 days: 2 tabs (20mg) on [4-29]. 1 tab (10mg) on [5-2]. Half-tab (5mg) on [5-5]. Disp:10 Tablet(s) Refills:0 10. Prilosec Oral 11. Claritin Oral 12. Naprosyn Oral Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: PRIMARY: Asthma with exacerbation Discharge Condition: Good--oxygenating well. Discharge Instructions: 1. Take medications as prescribed. Your dose of HCTZ was reduced as your BP was slightly low. 2. Follow up as below. 3. Please call Dr. [Last Name (STitle) 8499] if you have any fevers, chills, worsening breathing. Followup Instructions: You have an appointment with Dr. [Last Name (STitle) 8499] on [5-14] at 2:30pm (his phone number is [Telephone/Fax (1) 7976] if you need to reschedule). You also have the following appointments with the lung doctor: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2167-5-14] 8:40 Provider: [Name10 (NameIs) 1570],[Name11 (NameIs) 2162] [Name12 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2167-5-14] 8:40 Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2167-5-14] 9:00 ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5886 }	Medical Text: Admission Date: [2174-8-15] Discharge Date: [2174-8-20] Date of Birth: [2108-8-19] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Mild dyspnea on exertion Major Surgical or Invasive Procedure: [2174-8-15] Three Vessel Coronary Artery Bypass Grafting(left internal mammary to left anterior descending, vein grafts to ramus and diagonal arteries. History of Present Illness: This is a 65 year old gentleman with a history of palpitations. A stress test was performed where he developed a 68 beat run of ventricular tachycardia. He was sent on for a cardiac catheterization which revealed left main and left anterior descending artery disease with a reduced left ventricular function. Give the severity of his disease, he was referred to Dr. [Last Name (STitle) ] for surgical revascularization. Past Medical History: Hyperlipidemia Hypertension Diabetes mellitus type 2 Rosacea Obesity History of right leg cellulitis Radical prostatectomy [2171] for carcinoma Discectomy (Cervical) [2158] - Anterior approach Basal cell excision on back Melanoma excision right cheek Social History: Lives with: Wife in [Location (un) 1514], NH Occupation: Retired Tobacco: On and off smoking over past 40 years. for less then 10 years was smoking 1 ppd. ETOH: Occassional use Family History: Mother with MVR/CABG at 80. Father with MI at age 50. Physical Exam: admission: Pulse: 65 SR Resp: 16 O2 sat: 97% B/P Right: 129/80 Left: 143/68 Height: 68" Weight: 250lb General: WDWN in NAD Skin: Dry, Warm and intact. Rosacea noted. HEENT: NCAT, PERRLA, EOMI, Anicteric sclera, OP benign, teeth in poor repair. + Rhinophyma. Neck: Supple [X] Full ROM [X] JVD[X] Chest: Lungs clear bilaterally [X] Heart: RRR, No M/R/G, Nl S1-S2 Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Trace Edema Varicosities: Superfical varicosity noted below knee on left. Likely medial to GSV and/or branch. Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [Name (NI) 167]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit: Quiet bruit L>R Pertinent Results: [2174-8-15] Intraop TEE: PRE-BYPASS: 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. 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. The aortic valve leaflets are mildly thickened with mild restrictionvalve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. An eccentric,postreriorly directederate (2+) mitral regurgitation is seen. There is no pericardial effusion. POST BYPASS:No change in [Hospital1 ]-ventricular systolci function. MR is still moderate in intensity. Intact aorta. No other changeS [2174-8-19] 03:22AM BLOOD WBC-7.2 RBC-3.37* Hgb-9.0* Hct-26.8* MCV-80* MCH-26.6* MCHC-33.4 RDW-15.2 Plt Ct-229# [2174-8-15] 12:15PM BLOOD WBC-7.8 RBC-3.26# Hgb-9.0# Hct-25.3# MCV-78 MCH-27.5 MCHC-35.3* RDW-14.5 Plt Ct-141* [2174-8-19] 03:22AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-135 K-4.2 Cl-101 HCO3-27 AnGap-11 [2174-8-15] 01:57PM BLOOD UreaN-23* Creat-0.8 Na-139 K-4.4 Cl-112* HCO3-23 AnGap-8 Brief Hospital Course: Mr. [Known lastname 6105] was admitted and underwent coronary artery bypass grafting by Dr. [Last Name (STitle) ]. For surgical details, please see operative note. Following the operation, he was transferred to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the floor on postoperative day one. He was begun on beta blockers and diuresed towards his preoperative weight. Physical Therapy worked with him for strength and mobility. He had preoperative ventricular bigeminy which persisted after surgery and prompted a transfer back to the ICU on [8-18]. He was seen by the Electrophysiology service who recommended increasing the beat blocker dose, which was done. His ectopy improved and he remained stable. CTs and pacing wires were removed according to protocols. His pain was well controlled with oral analgesics. The remainder of his hospital course was uneventful. POD# 5 he was cleared by Dr. [Last Name (STitle) ] for discharge to home with VNA. All follow up appointments were advised. Medications on Admission: Metformin 500mg twice daily Coreg 12.5mg twice daily Quinapril 40mg QD Tetracycline 500mg twice daily Norvasc 10mg daily Aspirin 81mg daily Zocor 20mg daily Lasix 20mg daily Viagra PRN Folic Acid 1mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 3. Quinapril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:135 Tablet(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for PAIN/TEMP. Tablet(s) 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1514] Regional VNA Discharge Diagnosis: Coronary Artery Disease s/p coronary artery bypass grafts Hypertension Hyperlipidemia Type II Diabetes Mellitus Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 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 Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [2174-9-8] @ 1:45 PM Cardiologist: Dr. [Last Name (STitle) 9751] - cardiac surgery will make appt for you Please call to schedule appointments with your Primary Care: Dr. [Last Name (STitle) 16258] in [3-21] 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 Completed by:[2174-8-20] ICD9 Codes: 2761, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5887 }	Medical Text: Admission Date: [2159-1-27] Discharge Date: [2159-2-9] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: OSH xfer for L-MCA syndrome Major Surgical or Invasive Procedure: PEG tube. History of Present Illness: 86y RHF with HTN, HL, afib on amio/BB/warfarin(INR=2.4@OSH) was air-lifted from [Hospital3 7569] this morning out of concern for acute stroke. She was last known well around 7-8am this morning. She awoke at ~7am in her USOH. Shortly thereafter, she recalls going to the bathroom. After finishing in the bathroom, she had difficulty getting up from the toilet (but does not specifically remember R-sided weakness), and fell between the toilet and the wall. Her husband found her around an hour later, and first called her grandson to help move her. They then called 911 to activate EMS. By report, the OSH assessment was NIHSS=19, but no details. Her VS and labs were unremarkable, except for 1. her INR therapeutic in the mid-2s, 2. elevated T.bili 1.7 and AST/ALT each in the 50s, unexplained. A NCHCT was performed, which was negative for e/o hemorrhage, but + for dense Left-MCA sign (elongated dense mid-to-distal-M1). The warfarin A/C is an absolute contraindication to IV t-[Last Name (LF) ], [First Name3 (LF) ] the patient was transferred here after conferring with our Stroke Fellow, Dr. [Last Name (STitle) 7741]. She arrived in NAD with VSS and prominent right-sided weakness, as reported. My NIHSS on arrival was 14 (see below for NIHSS and detailed Neurologic exam). I got the above collateral history from the patient, who was a slightly difficult historian primarily due to dysarthria, and her daughter, who arrived shortly after the patient. We got a NCHCT here, which confirmed absence of hemorrhage; CTA head/neck revealed near-total obstuction of the distal M1 on the Left, as well as collateral filling of several distal MCA-distribution vessels; CTP showed increased MTT throughout the Left MCA distribution, with a mismatched CBV result (mildly decreased volume in the Left MCA distribution, in contrast to the dramatically increased MTT; CBF was moderately decreased). We activated [Doctor First Name 10788] (attg/fellow @[Hospital1 112]) and anesthesiology, ~5-5.5h out from the onset at that point, and had the patient intubated in the ED and sent to [Doctor First Name 10788] for attempted interventional clot removal. By the time of intubation, the patient had recovered a modicum of RUE movement (she could flex the elbow and wrist weakly, on command), but exam was otherwise the same as before. The [Doctor First Name 10788] team was unsuccessful in retrieving the clot. Their angiography appears to confirm the M1 occlusion as well as collateral late filling distal MCA-vessels from what appears to me to be a branch of the ? middle meningeal artery. A stat NCHCT after the procedure revealed swelling and hyperintensity in the caudate/putamen and GP on the side of the infarct, with mass effect into the R-LV; difficult to tell at this stage how much is contrast dye from the [Doctor First Name 10788] procedure vs. how much is hemorrhagic conversion related to the procedure in the setting of INR 1.9. She was admitted to the "NICU" (formerly SICU-B) and signed out to the on-call Neurology [Male First Name (un) ] and the on-call SICU/NICU resident. This plan was discussed in detail all along the course of the aforementioned events with the ED team, the patient's family, the stroke fellow, and the stroke attending (Dr. [First Name (STitle) ]. Past Medical History: PMH: 1. HTN 2. HL 3. CAD/CHF with multivalvular disease including MR (details unknown to me at this time) s/p PPM 4. Hypothyroidism 5. chronic UTIs, pessary 6. PAF on amiodarone and on chronic A/C (warfarin) 7. h/o gallstones Social History: Retired. has Daughter who is HCP. Family History: noncontributory Physical Exam: Gen: lethargic. Pulmonary: Clear to ausculation in frontal fields. Mouth breather. GI: Soft, some tenderness around PEG site. Positive bowel sounds Skin: No rash Neuro: Lethargic. able to open her eyes by. There is some question as to her ability to track but has left gaze preference. She is hypophonic and get at least one word out (husbands name). She can moves her left toes to command only. She is unable to command move the rest of her extremities. Pertinent Results: [2159-1-27] 07:29PM PT-19.2* PTT-29.7 INR(PT)-1.7* [2159-1-27] 05:50PM %HbA1c-6.3* eAG-134* [2159-1-27] 05:14PM GLUCOSE-122* UREA N-23* CREAT-1.0 SODIUM-138 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15 [2159-1-27] 05:14PM ALBUMIN-3.8 CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-2.1 CHOLEST-98 [2159-1-27] 05:14PM VIT B12-1713* [2159-1-27] 05:14PM TSH-2.5 [2159-1-27] 12:30PM cTropnT-0.05* [2159-1-27] 12:30PM WBC-9.5 RBC-3.71* HGB-12.0 HCT-36.5 MCV-98 MCH-32.4* MCHC-33.0 RDW-14.7 CT head [2159-2-2]: HISTORY: Left MCA stroke with hemorrhagic transformation. Comparison is made with [2159-1-30]. Hemorrhage in the left caudate head and putamen with surrounding edema is relatively stable. The degree of effacement of the left lateral ventricle frontal [Doctor Last Name 534] is unchanged. There is minimal if any midline shift. No progression of hemorrhage is seen. There is opacification of the sphenoid sinuses unchanged. CXR : [2159-2-3]: Severe cardiomegaly and mild pulmonary edema have improved since [2-1], subsequently unchanged. Pleural effusions are small if any. Transvenous right atrial and right ventricular pacer leads are unchanged in standard placements. Right PIC line passes as far as the upper SVC, but the tip is indistinct. No pneumothorax. Brief Hospital Course: 86y F with a Left-MCA distal occlusion could be embolic, given her known a-fib, although the therapeutic INR mitigates this probability a bit. she was admitted to the NeuroICU for further treatment. She arrived in NAD with VSS and prominent right-sided weakness, as reported. NeuroIR team was unsuccessful in retrieving the clot. Their angiography appears to confirm the M1 occlusion as well as collateral late filling distal MCA-vessels from what appears to me to be a branch off the middle meningeal artery. A stat NCHCT after the procedure revealed swelling and hyperintensity in the caudate/putamen and GP on the side of the infarct, with mass effect into the R-LV contrast dye from the [Doctor First Name 10788] procedure vs. how much is hemorrhagic. She was transferred to the medical wards for further care. On the medical wards she had a stable course. She had a PEG tube placed. On examination she did very little and this did not improve throughout her course. the family was made aware that she has a possible poor outcome. Neurologic: - She was started ASA ([1-29]), and maintain BP goals between 120 and 160. She appeared to initially be sensitive to a drop in SBP less than 140. PT/OT were consulted. For risk factor reduction her LDL was 34. A TTE: EF 55-60%, Mild symmetric LVH, [12-17]+ MR, 3+ TR. Mild PA HTN. No SD. For her afib, initially held her anticoagulants. Her rate was controlled via her pacer. She was restarted on her coumadin with an Aspirin bridge. Goal INR [1-18]. Pulmonary: - On room air. Mouth breather. Gastrointestinal / Abdomen: - Famotidine for prophylaxis. A PEG was then placed on [2159-2-7]. Nutrition: - NPO, on Tube feeds. You will be placed on Jevity 1.2 at goal rate of 50cc/hr Medications on Admission: 1. "Lasix as needed" (dose unknown) 2. warfarin 2.5mg 5d/wk and 1.25mg 2d/wk 3. amiodarone 200mg daily 4. metoprolol 50mg [Hospital1 ] 5. synthroid 112mcg once daily 6d/wk 6. Crestor 10mg daily 7. Fluticasone 50mcg in 8. Refresh eye gtt [12-17] daily 9. Lovaza (omega-3 FAs) 1gm cap [Hospital1 ] 10. Ca++ 11. VitD 12. MVI 13. warm prune juice, per son 14. metamucil 15. PRN nitroglcn 16. nitrodur patch daily 17. Lidoderm patch for back/knee pain Discharge Medications: 1. levothyroxine 112 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for hypothyroidism (home med). 2. aspirin 81 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. Ondansetron 4 mg IV Q8H:PRN nausea / vomiting 5. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. acetaminophen 650 mg/20.3 mL Suspension Sig: One (1) PO Q6H (every 6 hours) as needed for fever/pain. 8. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob, wheeze. 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. heparin Sig: 5000 (5000) units Subcutaneous twice a day for 3 days: To be stopped once INR reaches goal [1-18]. 13. Jevity 1.2 Tube feeds: Goal rate 50cc/hr. Discharge Disposition: Extended Care Facility: [Hospital3 11496] - [Location (un) ] Discharge Diagnosis: New - Left MCA stroke with hemorrhagic transformation. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted as a transfer from another facility for right sided weakness. You were found to have a left MCA stroke and you had in intervention completed for clot retrieval. This had failed. You had a repeat CT of your head and this showed some conversion of the stroke to a hemorrhage. This remained stable in the ICU and you were transferred to the floor. On the medical floor you had an uncomplicated course. A PEG tube was placed for support of your nutrition. You were restarted on your Coumadin for an INR goal [1-18] with an Aspirin/ heparin SQ bridge. Followup Instructions: Neurology: Dr [Last Name (STitle) ] [Last Name (NamePattern4) ]: Date/Time: [3-26] at @ 2pm. Please call ([Telephone/Fax (1) 7394] one week prior to the appointment. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2159-2-9] ICD9 Codes: 431, 5119, 4019, 2724, 2449, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5888 }	Medical Text: Admission Date: [2172-9-27] Discharge Date: [2172-10-22] Date of Birth: [2124-5-25] Sex: M Service: SURGERY Allergies: Dilantin Attending:[First Name3 (LF) 14255] Chief Complaint: Acute Fulminant Liver Failure Major Surgical or Invasive Procedure: [2172-9-30]: Orthotopic liver transplant History of Present Illness: Patient is a 48M with h/o mental retardation, seizures and previous MV repair in [5-1] who had two witnessed GTC seizures while at his group home. He was promptly sent to an OSH. En route he received 4.5 mg of versed. His dilantin level was 8 so he was loaded with dilantin (1.4g) and 2L NS. He was noted to be febrile at 101.2 and was given gentamycin (has prosthetic mitral valve). On the evening of admission ([9-25]) WBC was 20.8 his liver enzymes were mildly elevated (ALT 51, AST 57, AP 150, TB 0.7) but progressively rose over the next 24 hours to ALT [2173], AST 2400, AP 117, TB 2.9 DB 1.8. His INR was noted to be INR 4.2. His lactate had fallen from 6.2 on admission to 2.9. Dilantin level was 26 (after bolus). Both Acetaminophen and Salicylate levels were less than 10. CPK was elevated at 2564. Troponin I was 0.50 and rose to 2.74. Creatinine was elevated at 1.6 but trended down to 1.16 (BUN 22). He was noted to be lethargic with slurred speech. DDx was post-ictal and/or encepalopathy [2-27] liver failure. An U/S was performed showing "hepatitis but no clotting". He was started on IV NAC. He was transferred to [Hospital1 18] for further eval of his liver failure. Upon arrival he is accompanied by staff from his group home. The patient is responsive, knows he is at a hospital, and is c/o thirst. Per his caretaker, this is his baseline. He will interact with others but really is unable to verbalize much. His speech is more slurred than usual and he appears more fatigued since his seizure. Based on his labs, he is a Child Class B, MELD of 25. Past Medical History: Mitral valve prolapse, hypothyroidism, cerebral AVM (per OSH notes, patient had abnormal CTOH in [2163] but since then all others WNL. ? embolic CVA from mitral valve?), cholelithiasis, anxiety, Lyme disease, mental retardation PShx: MV replacement [5-1] (Bovine) Social History: Lives in group home, elderly mother involved with decisions [Name (NI) ] [Name (NI) ], mother: [Telephone/Fax (1) 112398] Group Home: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Ctr [Telephone/Fax (1) 112399], Case [First Name9 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Doctor First Name 112400] Tevares Family History: Unknown Physical Exam: PE: 99.5, 120 (ST), 124/78, 23, 95RA [Last Name (LF) ], [First Name3 (LF) 2995] X 4, will obey some commands no carotid bruits tachycardic, systolic/diastolic murmur heard best in LUSB CTAB Soft NT, mildly distented, +BS no c/c/e Pulses palp (radial, femoral, DP b/l) Pertinent Results: [2172-10-21] 05:40AM BLOOD WBC-9.1 RBC-3.20* Hgb-10.4* Hct-32.0* MCV-100* MCH-32.7* MCHC-32.7 RDW-18.8* Plt Ct-243 [2172-10-22] 06:20AM BLOOD WBC-8.4 RBC-3.39* Hgb-11.0* Hct-33.2* MCV-98 MCH-32.5* MCHC-33.2 RDW-19.1* Plt Ct-231 [2172-10-19] 06:05AM BLOOD PT-12.8* PTT-29.1 INR(PT)-1.2* [2172-10-21] 05:40AM BLOOD Glucose-132* UreaN-39* Creat-0.7 Na-132* K-5.1 Cl-101 HCO3-23 AnGap-13 [2172-10-22] 06:20AM BLOOD Glucose-148* UreaN-40* Creat-0.9 Na-133 K-4.6 Cl-99 HCO3-22 AnGap-17 [2172-10-20] 05:10AM BLOOD ALT-114* AST-33 AlkPhos-172* TotBili-2.3* [2172-10-21] 05:40AM BLOOD ALT-103* AST-44* AlkPhos-175* TotBili-2.3* [2172-10-22] 06:20AM BLOOD ALT-100* AST-44* AlkPhos-176* TotBili-2.1* [2172-10-22] 06:20AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.5* [2172-9-27] 03:09AM BLOOD calTIBC-179 Ferritn-[Numeric Identifier 112401]* TRF-138* [2172-10-2] 04:09AM BLOOD Triglyc-199* [2172-10-15] 05:55AM BLOOD TSH-14* [2172-9-27] 12:55AM BLOOD TSH-1.7 [2172-10-16] 06:15AM BLOOD Free T4-0.68* [2172-10-21] 05:40AM BLOOD tacroFK-7.2 [2172-10-3] 7:10 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [2172-10-3]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2172-10-5]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 353-8754M [2172-9-30]. LEGIONELLA CULTURE (Final [2172-10-10]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Final [2172-10-19]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2172-10-5]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2172-9-27] for an orthotopic liver transplant for acute liver failure of unknown etiology. He was admitted to the SICU. Neuro: The patient has mental retardation at baseline. His presenting complaint at the OSH was seizures. Upon admission to the hospital, staff from his group home reported that his speech was more slurred than usual. Neurology evaluated the pt for recommendations on seizure prophylaxis. Ativan was discontinued and Keppra started per neurology recs for seizures. On [9-28], he became increasingly somnolent. On [2172-9-29] a bolt was placed to monitor intracranial pressures. And he was placed on continuous EEG monitoring. After 2 days of normal pressures, Bolt was removed on [10-1]. On [10-2] continuous EEG monitoring was stopped. On [10-6] Head CT showed mildly dilated ventricles w/o evidence of bleed. On [2172-10-11] a MRI showed cortical volume loss/cerebellar atrophy, no acute ischemic changes. Liver Failure: LFTs continued to rise. JP output was bilious. FFP was given for elevated INR 4.0. Head CT was negative for acute intracranial hemorrhage. L femoral CVL was placed. He was tachycardic. IVF boluses were given without improvement. UOP increased w/ albumin x 1. LFTs continue to trend into 10,000. IV Zosyn and Vancomycin were given empirically. Acyclovir IV was also started for herpetic lesions on lip. Transplant team was notified. Expedited liver transplant ensued and on [9-29] he was listed for a liver transplant for acute liver failure. On [2172-9-30], a liver donor offer was accepted and he underwent orthotopic deceased donor liver transplant (piggyback), portal vein to portal vein anastomosis, common hepatic artery (donor) to proper hepatic artery (recipient) common bile duct to common bile duct anastomosis. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] assisted by Dr. [First Name4 (NamePattern1) 3742] [Last Name (NamePattern1) ]. Please refer to operative note for details. Postop, he went back to the SICU for management. He received blood products per pathway and remained hemodynamically stable. IV lasix was given with good urine output. Immunosuppression consisted of tapering steroids and cellcept. Prograf was started on postop day 1. Acyclovir was stopped on [10-1]. Continuous EEG continued. Head CT was negative. Rhythmic rights-sided movements noted, He spiked fevers on [10-3] and was pancultured. Sputum isolated rare growth of staph coag positive. IV Meropenem was added. On [10-4] a-line was re sited on right, removed a-line on left and sent tip for culture. Lateral JP was removed on [10-4]. On [10-5], vanco was stopped. LFTs were elevated. Hepatic duplex was done demonstrating patent vessels, mild biliary dilation. TPN was started for nutrition. On [10-7] LFTs were notable for increasing Tbili. Hepatic ultrasound revealed a dilated common bile duct. An ERCP was completed and a stent was placed across a stricture near the biliary anastomosis (a pre-cut was required to place the stent). After ERCP, a CT scan of the abdomen was undertaken to evaluate for possible abscess in the abdomen/torso. Scan revealed possible RLL pneumonia, but no active intraabdominal process. Dobhoff was removed during ERCP. During his ERCP, his temperature spiked and he was pan-cultured (blood, urine and sputum cultures). These cultures remained negative. On [10-8], he was extubated. Post pyloric feeding tube was placed in IR. DHT advanced in IR and TF were started. TPN was dc'd. Neuro exam was improving. On [10-10], head MRI was done to evaluate upper extremity weakness. Speech and swallow evaluated. On [10-11] meropenem was dc'd and he was pan-cultured for increasing WBC. These cultures remained negative. Lasix was given for generalized edema. [10-12] was replaced. Dobhoff placed and tube feeds were given. Insulin was required for elevated glucoses form steroids and tube feeds. He was transferred out of the SICU on [10-14] to the medical-surgical unit. Lateral JP drain was removed on [10-14]. Speech and swallow evaluation noted soft signs of aspiration. He was kept NPO and reevaluated on [10-15]. He was cleared for PO diet of thin liquids and ground solids, understanding aspiration had not been fully ruled out. Repeat evaluation on [10-16] noted coughing with ground solids. Therefore, the following recommendations were made to switch to thin liquids and pureed solids. Meds were crushed with pureed solids with 1:1 supervision for meals and meds. Tube feeds continued with water flushes. Physical therapy and occupational therapy were consulted. Evaluations established that he required rehab as he was impaired motor function, impaired transfers, impaired knowledge, and was functioning far below his baseline. He requires multi disciplinary rehab with intensive daily OT/PT and SLP to maximize functional recovery for eventual return to group home. He requires [Doctor Last Name ] lift to get out of bed. Of note, TSH was elevated at 14 with free T4 of .68. Levothyroxine was increased on [10-20] to 225mcg daily. Repeat TSH should be done in 6 weeks. Immunosuppression consisted of tapering steroid per transplant protocol, cellcept 1 gram [Hospital1 ], and Prograf which was adjusted based on trough Prograf levels. Urine was collected by condom catheter to protect skin from incontinence. Sacrum was pink, but intact. Criticaid was applied. He was having BMs (x2 on [10-21]). He will transfer to [Hospital 5503] Rehab today. Medications on Admission: Levothyroxine 200' (per notes, 300' for two days of the week), Prozac 60', amoxicillin [2160] (during dental work), remeron 30 qPM, Compazine 5 PRN, Dilantin ER 300 qM, Effexor 100" Discharge Medications: 1. Famotidine 20 mg PO Q12H 2. Fluconazole 400 mg PO Q24H 3. Fluoxetine 60 mg PO DAILY 4. Heparin 5000 UNIT SC Q 8H 5. Glargine 5 Units Bedtime Insulin SC Sliding Scale using REG Insulin 6. LeVETiracetam 1000 mg PO BID 7. Levothyroxine Sodium 225 mcg PO DAILY check TSH in 6 weeks 8. Metoprolol Tartrate 50 mg PO BID Tachycardia Hold for HR < 60bpm or SBP < 100mmHg 9. Miconazole Powder 2% 1 Appl TP TID:PRN scrotum 10. Mycophenolate Mofetil Suspension 1000 mg PO BID 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 12. PredniSONE 17.5 mg PO DAILY 13. Sulfameth/Trimethoprim Suspension 10 mL PO DAILY 14. Tacrolimus 3 mg PO Q12H On lab draw days, hold medicaitn until trough level drawn 15. ValGANCIclovir Suspension 900 mg PO DAILY 16. Venlafaxine 100 mg PO BID 17. Outpatient Lab Work Stat labs every MOnday and Thursday for cbc, chem 10, ast, alt, alk phos, tbili, ua and trough prograf level. fax results to [Hospital1 18] Transplant Center [Telephone/Fax (1) 697] attn: RN coordinator Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital - [Location (un) 5503] Discharge Diagnosis: Acute Fulminant liver failure likely drug/toxin induced (phenytoin) s/p orthotopic liver transplant Discharge Condition: Mental Retardation at baseline Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] if the patient develops fever > 101, chills, nausea, vomiting, diarrhea, constipation, complaint of increased abdominal pain, incisional redness, drainage or bleeding, dislodgement or clogging of the feeding tube or other concerning symptoms. -Blood draw on Mondays and Thursdays for transplant lab monitoring Continue tube feeds via post pyloric feeding tube and encourage oral intake as tolerated. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2172-10-28] 9:00. [Hospital ] Medical Office Building, [Location (un) ] [Last Name (NamePattern1) ], [Location (un) 86], MA Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 14955], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2172-11-5] 2:00 [Hospital ] Medical Office Building, [Location (un) 436] [Last Name (NamePattern1) ], [Location (un) 86], MA Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2172-11-11] 9:20 [Hospital ] Medical Office Building, [Location (un) 436] [Last Name (NamePattern1) ], [Location (un) 86], MA Completed by:[2172-10-22] ICD9 Codes: 5070, 5845, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5889 }	Medical Text: Admission Date: [2158-7-24] Discharge Date: [2158-7-31] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 13159] Chief Complaint: Gastrointestinal bleeding Major Surgical or Invasive Procedure: [2158-7-24] EGD with clipping of blood vessel History of Present Illness: [Age over 90 ] yo admitted to [Hospital1 ] [Location (un) 620] with cholangitis s/p ERCP with sphincterotomy, brushings and double pigtail biliary stent placement on [2158-7-21] at [Hospital1 18]. Gastric biopsies were also taken given presence of duodenal ulcers/ erosions. Patient subsequently developed melanotic stool, HCT dropped from 26.7; she has received 4 units of prbc's at OSH. Transferred to [Hospital1 ] for possible EGD. On arrival to the MICU, patient's VS 98.7, 84, 146/51, 23, 99% RA. Patient reported feeling well, but tired. Denied N/V, fever, sweats, chills. Last BM day prior to arrival. Past Medical History: History of C. diff [2158-6-4] -- outside hospitalization for LLL PNA and R leg cellulitis, CHF, and AMI -- no further details are available Hypertension History of breast cancer 27 yrs ago s/p mastectomy Left cerebellopontine angle hemorrhage in [2152] with chronic small vessel ischemic disease in brain osteoporosis Raynaud's syndrome History of thoracic compression fractures Social History: Lives with son and husband. Daughter lives 1 mile away and patient often walks to visit her without assisted device. Never smoked or drank per daughter. Was a homemaker and prior to that was a secretary. Family History: No stroke history. Physical Exam: Vitals: 98.7, 84, 146/51, 23, 99% RA General: Alert, oriented, no acute distress, frail appearing, cachectic HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, systolic ejection murmur, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: [2158-7-24] 08:00PM GLUCOSE-94 UREA N-23* CREAT-0.4 SODIUM-146* POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-31 ANION GAP-9 [2158-7-24] 08:00PM estGFR-Using this [2158-7-24] 08:00PM ALT(SGPT)-84* AST(SGOT)-52* LD(LDH)-193 ALK PHOS-413* TOT BILI-1.3 [2158-7-24] 08:00PM ALBUMIN-2.8* CALCIUM-7.9* PHOSPHATE-2.4* MAGNESIUM-1.9 [2158-7-24] 08:00PM WBC-8.2 RBC-3.88* HGB-11.5* HCT-33.8* MCV-87# MCH-29.6 MCHC-34.0 RDW-16.3* [2158-7-24] 08:00PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2158-7-24] 08:00PM PLT COUNT-130* [2158-7-24] 08:00PM PT-11.2 PTT-24.4* INR(PT)-1.0 [2158-7-30] 08:20AM BLOOD WBC-8.6 RBC-3.54* Hgb-10.8* Hct-33.1* MCV-93 MCH-30.6 MCHC-32.8 RDW-16.2* Plt Ct-231 [2158-7-31] 07:10AM BLOOD WBC-7.4 RBC-3.44* Hgb-10.3* Hct-32.7* MCV-95 MCH-29.8 MCHC-31.3 RDW-16.1* Plt Ct-247 [2158-7-30] 08:20AM BLOOD Neuts-50.8 Lymphs-6.0* Monos-2.6 Eos-40.4* Baso-0.2 [2158-7-31] 07:10AM BLOOD Neuts-48.2* Lymphs-8.3* Monos-3.3 Eos-40.0* Baso-0.3 [2158-7-31] 07:10AM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-139 K-3.8 Cl-102 HCO3-32 AnGap-9 [2158-7-31] 07:10AM BLOOD ALT-86* AST-60* LD(LDH)-191 AlkPhos-530* TotBili-0.7 [2158-7-30] 08:20AM BLOOD ALT-106* AST-104* LD(LDH)-222 AlkPhos-519* TotBili-1.2 [2158-7-30] 08:20AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9 [2158-7-30] 01:00PM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND [2158-7-30] 01:00PM BLOOD ECHINOCOCCUS ANTIBODY (IGG)-PND Brief Hospital Course: [Age over 90 ] yo admitted to [Hospital1 ] [Location (un) 620] with cholangitis s/p ERCP with sphincterotomy, brushings and double pigtail biliary stent placement on [2158-7-21] at [Hospital 18] transferred to ICU for EGD in setting of GI bleed. . GI BLEED: Patient is s/p ERCP with sphincterotomy for cholangitis. She developed melena with a HCT drop from mid 30's to 27 on [7-22]. She received 4 units prbcs and has been hemodynamically stable. Transferred to [Hospital1 18] for urgent EGD, since etiology likely upper GI source given melena and recent ERCP including biopsy site. Differential includes lower GI bleed (diverticulosis, AVM, cancer), however unlikely given recent procedure and likely no need for further workup at this point. EGD showed a superficial vessel that was not bleeding and no bleeding at stomach biopsy site. Patient was treated with IV protonix drip. Her hematocrit drifted down slowly after the procedure but stabilized at about 29-30. She remained hemodynamically stable. Her diet was advanced and her proton pump inhibitor was transitioned to oral. The biopsies from her initial endoscopy showed "Oxyntic mucosa, within normal limits; no histologic evidence of H. pylori infection" and the brushings "NEGATIVE FOR MALIGNANT CELLS." Gastroenterology recommend she take omeprazole 40mg PO bid for 8 weeks (from [2158-7-28]) then transition to 40mg PO daily. She was restarted on aspirin 7 days after ERCP per GI recommendation. She has follow-up scheduled with them for repeat ERCP and stent removal in [Month (only) 359] as noted elsewhere. . Cholangitis: Diagnosed at outside hospital, s/p ERCP with sphincterotomy. Diagnosed at [Hospital3 4107]. Patient started on Vancomycin and Zosyn at [Hospital1 ] on [7-19] and changed to Unasyn on [7-23]. Transitioned to Ciprofloxacin 500 mg PO BID to complete total of 14 days antibiotics (finish [2158-8-2]). . Eosinophilia: The patient had normal eosinophil count on [7-20] when admitted to [Hospital1 ] [Location (un) 620]. Since that time eosinophils have trended up daily to peak of 40% of differential (absolute number 3400) on [7-30]. They were stable as percentage 40% with improved absolute number 2900 on [7-31]. Most likely this is due to the beta lactam antibiotics she was taking from [7-20] to [7-27] (Zosyn from [Date range (1) 32684] and then unasyn from [2069-7-21]). She did not have other findings of allergic reaction such as a rash. Other potential etiologies were considered such as parasitic diseases (strongyloidis, echinococcus, toxoplasma serology were sent and pending at discharge) but are very low likelihood. The degree of eosinophilia is moderate and there does not appear to be end organ damage with normal creatinine and urine eosinophils and normal troponin. She was evaluated by the allergy immunology service (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 32685]) who recommended weekly CBC with differential to trend continued improvement although it may take up to four weeks to normalize. If she continues to have a persistent eosoniphilia in one month then she should follow up with allergy-immunology. Of note, while low dose steroids can be used to treat eosinophilia, we would recommend against using steroids at this time, as the patient's comorbidities and improving eosinophilia increase the risks over the benefits of this treatment. . Delirium: During hospitalization patient experienced delirium for 1-2 days, mostly at night. Extensive evaluation was performed to determine the etiology of this and other than her age, lack of sleep and medical comorbidities as mentioned above, none was found. She was initally treated with scheduled quetiapine at bedtime to both prevent confusion and facilitate sleep but her QTc on this medication (and concomitant ciprofloxacin) was ~480, so it was stopped. Her delirium resolved on [2158-7-29] and she was at her baseline mental status per family. . Other inactive issues: HTN -- held home HCTZ, restarted on discharge CAD -- s/p MI, held ASA for 7 days post ERCP and in setting of GIB but restarted after discussion with GI. Atorvastatin was held in the setting of elevated liver enzymes and may be re-started in the future, she was continued on metoprolol . . TRANSITIONAL ISSUES: 1. Recheck CBC weekly with differential to trend eosinophilia. REsuls can be faxed to PCP (Dr. [Last Name (STitle) 4390] office fax: [Telephone/Fax (1) 18820] 2. Follow up on ERCP in six weeks 3. Consider restart statin pending improvement in liver function tests Medications on Admission: Medications On Transfer: 1. She received potassium 10 mEq IV today. 2. Unasyn 1 1.5 g every 6 hours IV. 3. Lopressor 25 mg p.o. b.i.d. 4. Nexium 80 mg IV every 10 hours. 5. Senna 2 tablets p.o. daily. 6. Colace 100 mg p.o. b.i.d. Preadmission medications listed are correct and complete. Information was obtained from Admission note. 1. Aspirin 81 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO 2X/WEEK (MO,TH) 3. Metoprolol Tartrate 25 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY Discharge Medications: 1. Metoprolol Tartrate 25 mg PO BID hold for SBP<100, HR<60 2. Nystatin Oral Suspension 5 mL PO QID Duration: 7 Days Swish and spit for oral thrush. 3. Hydrochlorothiazide 12.5 mg PO 2X/WEEK (MO,TH) 4. Omeprazole 40 mg PO BID Continue this for 8 weeks from [2158-7-28], then you can transition to 40mg PO daily. 5. Aspirin 81 mg PO DAILY 6. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #5 Tablet Refills:0 7. Docusate Sodium 100 mg PO BID 8. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: Gastrointestinal bleeding Cholangitis History of C diff Coronary artery disease Hypertension Recent pneumonia H/o Br CA [72] yrs ago s/p mastectomy 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 diagnosed with cholangitis and had an endoscopy to treat this. Soon thereafter you began to have melena (dark black stools that indicate gastrointestinal bleeding), and so you received blood transfusions, and a repeat endoscopy, at which time a blood vessel in your stomach was "clipped" to prevent it from bleeding. You were monitored after this procedure, to ensure that you had stopped bleeding. You also had some confusion in the hospital, which was attributed to your fatigue and medical illnesses. You were found to have a high number of eosinophils on your white blood cell count. This is likely due to one of the antibiotics you were taking (zosyn or unasyn). You were seen by the allergy immunology service. Your numbers were stable to improving at time of discharge. This lab test will be followed weekly while at you are at rehab. Followup Instructions: Department: [Hospital ] HEALTHCARE OF [Location (un) ] When: FRIDAY [2158-8-4] at 12:00 PM With: [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 3070] Building: [Street Address(2) 8172] ([Location (un) 620], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site Department: ENDO SUITES When: FRIDAY [2158-9-15] at 9:30 AM Department: DIGESTIVE DISEASE CENTER When: FRIDAY [2158-9-15] at 9:30 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 ICD9 Codes: 2930, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5890 }	Medical Text: Admission Date: [2195-7-10] Discharge Date: [2195-7-13] Date of Birth: [2144-7-8] Sex: F Service: NEUROLOGY Allergies: Naprosyn / Contrast Dye / IV Dye, Iodine Containing Attending:[Last Name (NamePattern1) 1838] Chief Complaint: right sided weakness, dysarthria Major Surgical or Invasive Procedure: [7-11] mechanical thrombectomy History of Present Illness: Ms. [Known lastname ] is a 51 yo RHF with prior history of syncope, left sided cerebellar hyperintensity found incidentally which has resolved with time, recent right basal ganglia infarct in [Month (only) 205] [2194], and hypertension who was transferred from an outside hospital more than 12 hours after new onset right sided weakness in arm and leg, dysarthria and dysphagia. Yesterday she had lightheadedness, blurred vision that was thought at an outside hospital to be dehydration. She was discharged home. At home, she was drinking extra fluids and the dizziness and headache resolved. On [7-10], she woke up at 1am to urinate and was fine, however, when she work up again at 5:30am she noticed that she had trouble ambulating. She thought at first both of her legs were weak and sat down. She tried to eat soup but couldn't hold the spoon in her right hand. Her daughter noticed that the tone of her voice had changed and was deeper. She was dysarthric and was having to concentrate and pause frequently to emphasize her words so that they could be understood. She felt that she has trouble swallowing. Her mentation was fine. Today, she does not have headache or lightheadedness. She was taken by ambulance first to [Hospital3 4107] who did a U/A, CXR and CBC which was normal for infection. They did a CT scan which was concerning for acute stroke and transferred her to [Hospital1 18] for neurologic evaluation. In our ED she was more than 12 hours since last seen well and a code stroke was not called. Past Medical History: 1)Syncope 2)CVA- R basal ganglia stroke [2195-5-22]. She was dysarthric and weak on the left side which was improving and almost back to her baseline. She was transferred from [Hospital1 ] to [Hospital1 756] for her care. She was recently discharged home from [Hospital3 ]. According to transfer papers, there were no risk factors identified but Ms. [Known lastname ] reports that she was hypertensive following the stroke. 3) HTN- not currently treated with any medications 4) She had a hyperintensity that resembled a nodule within the left cerebellum that enhanced with contrast found [2194-12-23] incidentally during syncopal workup which resolved without treatment by [2195-1-20]. She was followed by Dr. [Last Name (STitle) 724] who felt intially that it could be tumor but after it resolved felt that it was more likely infectious/inflammotory process. LP was done which negative and CSF cytology was normal. 5) History of PFO, ASD- She had TTE at [Hospital1 18] on [2194-12-2] and interpreted by Dr. [First Name4 (NamePattern1) 553] [Last Name (NamePattern1) ] who at that time felt that Ms. [Known lastname ] had an ASD with right to left shunt. TEE was then done for plan for intravascular closure but did not have evidence of an ASD or PFO by Doppler or by bubble study any evidence of right to left shunt. Social History: Patient was recently discharged from rehab and was living with her daughter and mother. [Name (NI) ] mother had moved to [Name (NI) 6607] to help take care of her. She has a visiting nurse. She has been using a walker but recently has been walking around inside the home without it. She used to work as a CNA. Family History: Grandmother had a stroke at age 69. Her brother and sister both have Diabetes. Physical Exam: AT ADMISSION: HEENT: Sclera anicteric. Oropharynx benign. Mucous membranes moist. Neck: No carotid bruits. Supple. No LAD. Cor: RRR, nl S1, S2. No m/r/g appreciated. Chest: CTAB. Abdomen: Soft, NTND. Back: No spinous process tenderness. No CVA tenderness. Ext: Warm, no edema. She has no tendernous, erythema, swelling or effusion in right knee. Neuro: MS: Alert, appropriately interactive. She becomes teary eyed and cries as giving the history. (appropriate because concerned about stroke). Orientation: Full. Attention: Names days of week backwards correctly. Speech/[Doctor Last Name ]: Fluent w/o paraphasic errors; Follows simple and complex commands without L/R confusion. Repetition, naming, [Location (un) 1131] intact. Memory: [1-22] at registration and at 5 minutes. Normal fund of knowledge. Calculations: Intact (9 quarters = $2.25). Praxis: Able to pantomime brushing hair and teeth. CN: II: Visual fields full to confrontation. Pupils equally round & reactive to light 4 mm to 2 mm. No relative afferent pupillary defect. Optic discs and retina normal. III,IV,VI: EOMI w/o nystagmus. No ptosis. V: Sensation intact to light touch. Bite strength equal bilaterally. VII: Appears to have right sided facial droop. VIII: Hears finger rub equally and bilaterally. IX,X: Voice normal. Palate elevates symmetrically. [Doctor First Name 81]: SCM and trapezii full. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. There is a downward drift on right. 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] L 5 5 5 5 5 5 5 5 5 5 5 5 5 R 4 5 4 4 5 4 4+ 4 4 5 4 4+ 4+ Coord: finger-to-nose-finger movements intact. Reflex: [Hospital1 ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 3 3 3 3 2 Plantar response was upgoing on right and downgoing on left. [Last Name (un) ]: LT and pinprick intact except she feels that there is diminshed sensation over latter aspect of right calf. Joint position intact. Vibration intact. No evidence of extinction. Gait: She is able to stand and bare weight but is unable to stand on right leg. She did not feel comfortable walking away from bed. She appeared unsteady due to weakness. Pertinent Results: [7-10] MRI Brain MRA Head/Neck FINDINGS: There are multiple areas of new infarction since the prior study. These are most prominent in the pons, predominantly on the left, where there is associated hemorrhage. There are also small infarctions in the right cerebellar hemisphere of the left occipital lobe, and the right cerebral peduncle. These all implicate posterior circulation abnormalities. The brain MRA demonstrates very poor signal arising from the basilar artery and its branches. The distal vertebral arteries are visualized on the non-contrast MRA but the vertebrobasilar junction is not. The axial T2-weighted images demonstrate a loss of the normal flow void in the basilar artery. The gadolinium-enhanced neck MRA source images demonstrate the distal vertebral arteries, the vertebrobasilar junction, and the distal basilar artery. This suggests that these vessels are patent but experiencing extremely slow flow, responsible for the poor visualization on the non-contrast time-of-flight images. However, the mid basilar is not opacified on the gadolinium MRA. Overall, these findings suggest a focal area of severe stenosis or thrombosis in the mid basilar artery with poor runoff for the vertebral arteries and reduced flow through the superior cerebellar and posterior cerebral arteries. This would explain the distribution of infarction seen on the diffusion images. The MRA also demonstrates loss of the A1 segment of the left anterior cerebral artery, which was present on the MR examination of [2195-2-4]. There is no evidence of infarction in the A1 distribution. Images of the remainder of the brain demonstrate no other areas of hemorrhage or infarction. The remainder of the intracranial branches appear normal. [7-11] CTA Head/Neck IMPRESSION: 1. Head CT shows a left paramedian pontine hypodensity indicative of infarcts seen on the MR [Name13 (STitle) ] done earlier. 2. CT angiography of the neck demonstrates no evidence of dissection, stenosis, or occlusion in the neck vessels. 3. CT angiography of the head demonstrates high-grade stenosis of the distal left vertebral artery and proximal basilar artery with diminished flow distally as described above. [7-22] MRI Head MRA Head/Neck IMPRESSION: Multiple new infarcts are now identified since the previous MRI examination of [2195-7-10]. Left thalamic and bilateral cerebellar infarcts are seen and some extension in the left pontine infarct is noted. Susceptibility artifact in the left mid brain and left cerebellum indicated petechial hemorrhages. Normal MRA of the neck. [7-12] MRA Head: IMPRESSION: High-grade lumen irregularity of the recanalized basilar artery which is difficult to evaluate in the setting of extensive motion artifacts, but may represent persistent stenosis.Suggest follow up imaging evaluation with CTA. Brief Hospital Course: 51yoW h/o prior R basal ganglia stroke, syncope, HTN, PFO/ASD, and prior left cerebellar mass p/w right arm and leg weakness, dysarthria and dysphagia, subsequently developing a basilar artery occlusion which was removed via mechanical clot retrieval. [] Acute Cerebral Infarction - The patient presented initially with right-sided weakness, dysarthria and dysphagia with an NIHSS of [2-24] more than 12 hours after the onset of symptoms after an initial evaluation at an outside hospital. She was not eligible for intravenous tPA or for mechanical thrombectomy initially. The patient said that her code status should be DNR/DNI. She was initially going to be uptitrated from Aspirin to Clopidogrel, but her MRI/MRA brain and MRA neck showed multiple bilateral posterior circulation strokes with flow voids in the basilar artery and poor flow in the vertebral arteries. The patient was placed on a Heparin infusion instead of Clopidogrel and was transferred to the Neuro ICU. The patient was asked by Dr. [First Name (STitle) 2643] if she would agree to a clot retrieval procedure if it became necessary at a later time. The patient said that she might potentially agree to a clot retrieval procedure. Later at 3pm on [7-11], the patient started drooling and had nystagmus in all directions. She deteriorated rapidly. She became anarthric and quadiparetic. Given her contrast allergy, she was premedicated before she underwent CTA head and neck. The CTA subsequently showed a basilar artery occlusion. The patient was unable to give consent at this time. Her daughter gave consent for a clot retrieval and/or balloon angioplasty and/or stenting procedure. The daughter agreed that her mother's code status could be reversed to FULL code during the procedure. She was intubated and brought to the angiography suite for emergent mechanical clot retrieval which resulted in partial recanalization. After two passes with the MERCI clot retrieval device, the proximal half of the basilar artery was partially opened up. However, the basilar artery reoccluded twice and required intra-arterial tPA, eptifibatide, and balloon angioplasty to remain patent. She was brought back to the Neuro ICU for further stabilization and management. Her daughter asked that her code status be changed to DNR at that time. Her exam improved and stabilized. On [7-13] while still intubated, she was alert, oriented to year and place. She was able to show two fingers with the left hand. She had 3/5 strength of the left forearm, 2/5 strength of the right arm, and 2/5 strength of both legs. MRA head, CTA head, and conventional angiogram showed a severe distal V4 segment stenosis of the left vertebral artery. This stenosis likely served as the nidus from which the proximal basilar artery thrombosis and occlusion evolved. There were multiple emboli from the proximal basilar artery to distal parts of the posterior circulation. Unfortunately, there was no prior vessel imaging from her [2195-5-22] or [2194-12-23] admissions for our review. Her prior HgbA1c and lipid panel from [2-/2195] were relatively unremarkable. TTE with bubble study did not reveal significant valvular disease or an intracardiac shunt. She had autoimmmune and coagulopathy studies sent. During conversation with her daughter [Name (NI) ], [Name (NI) ] said that once her mother was extubated, that her code status should be DNR/DNI. Given her stable clinical status, she was extubated just before 5pm on [7-13], but about 25 minutes later she suddenly became bradycardic and hypotensive. Code status was reconfirmed as DNR/DNI by the patient's daughter who was at the bedside. Attempts were made with IV fluids and three pressor agents to improve her hemodynamic status, but this never recovered, and the patient was declared deceased at 7:20PM. The family agreed to an autopsy. Medications on Admission: Aspirin 325mg QD - no missed doses Lipitor 80mg QD MVI Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Acute cerebral infarction Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5891 }	Medical Text: Admission Date: [2184-4-19] Discharge Date: [2184-4-28] Date of Birth: [2128-5-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 18369] Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: ICA stenting Endotracheal intubation History of Present Illness: 55 year-old Cantonese-speaking man with known aggressive nasopharyngeal carcinoma who presents with epistaxis. He is followed by Dr. [First Name8 (NamePattern2) 916] [Last Name (NamePattern1) ] in Heme Onc for nasopharyngeal carcinoma diagnosed in [8-/2183] after one year of right-sided headache, diplopia, fatigue, and 20-pound weight loss. Imaging showed nasopharyngeal carcinoma involving the bilateral prevertebral and veli palatini muscles, right foramen ovale, right cavernous sinus, right Meckel cave, and right orbital apex, right infratemporal fossa and carotid space, right petrous apex, and clivus. He has since undergone XRT, cyberknife, and 3 cycles of cisplatin/5-FU with stable findings on his most recent MRI nasopharynx on [2184-3-17] and decreased FDG avidity of his nasopharyngeal mass on his PET-CT on [2184-4-12]. . He was in his USOH until this evening at 10pm when he awoke with significant bleeding from nares. He subsequently began coughing vs. vomiting bright red blood. He went to [Hospital3 ] where Hct was found to be 21 (baseline Hct 30). He was noted to be was guaiac negative on exam. He was given 1 unit of O-neg pRBC, esomeprazole 40mg IV, zofran, and 1 L NS, and was then tranferred to [Hospital1 18] ED. . In the ED, initial vs were: T 98.2, P 84, BP 110/70, RR 18, O2sat 100% NRB. He acutely decompensated shortly after arrival. He was constantly clearing his throat, then began spitting up blood, dropping his sats and becoming apneic, so was emergently intubated. A large amount of blood was found in the oropharynx with immediate ABG 7.17/68/413. Subsequent ABG was 7.32/52/507 on AC 400/20/10/100%. Labs with Hct 24.8. EKG showed sinus tach @ 101 and no ischemic changes. CXR and CT chest showed peribronchovascular distribution of ground glass opacity c/w aspiration. CT neck showed blood filling the nares and nasopharynx without active arterial extravasation. ENT consulted and will see pt in ICU. In meantime, pt type & crossed. He was also given ondansetron 4mg IV, morphine 4mg IV x 2, and initially sedated with propofol but then switched to fentanyl and midazolam. Prior to transfer, he was hypotensive into the 70s and was given a total of 2L NS and 4 units of pRBC. Access is via 2 18g PIV; has also has an unaccessed portacath. VS: 89, 122/77, O2sat 100% on AC 400/20/10/50%. . On the floor, pt is intubated and sedated. His son is concerned that this may be related to MVA (rear-ended) a few days prior. The patient was a passenger and complained of mild headache and neck pain afterwards although experienced no loss of consciousness, dizziness, or bleeding; CT head and neck w/o contrast at [First Name4 (NamePattern1) 392] [Last Name (NamePattern1) ] negative for bleed or fracture. Past Medical History: Probable T4bN0/1M0 nasopharyngeal carcinoma as above. Diagnosed 9/[2182]. S/p XRT and bolus cisplatin from [Date range (2) 76684], Cyberknife therapy [Date range (1) 76685], and 3 cycles of adjuvant cisplatin/5-FU - last on [2184-3-19]. Social History: Originally from [Country 651], moved here in [2172]. Used to work as a chef. Has 2 sons in their 20s; HCP is older son. Currently living with 2 sons from 1st marriage. 2nd wife living separately since onset of medical illness as she has a 9 year-old daughter, but involved in care as able. - Tobacco: Formerly smoked 1 ppd but quit in 8/[2182]. - Alcohol: Formerly drank [12-7] shots liquor daily but quit in 8/[2182]. Family History: Father died in 60s from CAD. Mother died at 84 from lung ca. 2 older brothers, older sister, and [Name2 (NI) 1685] sister all reportedly healthy. Physical Exam: On admission: Vitals: T 97.6, P 86, BP 101/76, RR 13, O2sat 100% on PC 26/25/10/50% General: Intubated, sedated HEENT: Pupils 3mm and reactive, crusted blood in bilateral nares and oropharynx with tumor visualized eroding into posterior nasopharynx with no active bleeding on ENT scope, ETT and OGT present Neck: Supple, no LAD Lungs: Clear to auscultation anteriorly 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: Foley present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge exam Vitals: tc 98.0 122/80 71 18 99RA 3000/2600 General: Middle-aged man sitting in bed in NAD HEENT: Mucous membs moist, unable to visualize posterior pharynx. Neck: Supple, no LAD Lungs: Clear to auscultation BL, no wheezes, no rales CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, mild TTP in epigastrim, non-distended, bowel sounds present, no rebound tenderness or guarding, Ext: Right groin site mild echhymosis and TTP, no bruit C/D/I. Right > left upper extremity swelling with trace edema, radial pulses 2+ BL. DP/PT pulses 2+ BL. Pertinent Results: Admission labs: =============== [2184-4-19] 01:10AM BLOOD WBC-9.2 RBC-3.00* Hgb-8.6* Hct-24.8* MCV-83 MCH-28.6 MCHC-34.5 RDW-15.0 Plt Ct-414 [2184-4-19] 01:10AM BLOOD Neuts-91.2* Lymphs-4.1* Monos-3.5 Eos-0.8 Baso-0.3 [2184-4-19] 01:10AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1 [2184-4-19] 05:45AM BLOOD Fibrino-389 [2184-4-19] 01:10AM BLOOD Glucose-123* UreaN-14 Creat-0.9 Na-131* K-3.5 Cl-95* HCO3-27 AnGap-13 [2184-4-19] 01:10AM BLOOD Calcium-7.5* Phos-3.0 Mg-1.1* [2184-4-19] 05:49AM BLOOD Lactate-2.3* [2184-4-19] 09:45AM BLOOD Glucose-97 Lactate-1.8 Na-129* K-3.3* Cl-101 . Discharge labs: =============== [2184-4-27] 06:06AM BLOOD WBC-7.3 RBC-3.99* Hgb-11.6* Hct-34.8* MCV-87 MCH-29.1 MCHC-33.4 RDW-13.8 Plt Ct-513* [2184-4-27] 06:06AM BLOOD Glucose-89 UreaN-4* Creat-0.6 Na-132* K-3.7 Cl-96 HCO3-32 AnGap-8 . Imaging: ======== CT neck: Interval intubation and NG tube placement with mottled air and fluid density compatible with hemorrhage filling the nares and nasopharynx. There is a similar appearance of nasopharyngeal carcinoma as described on the [2184-3-17] MR accounting for differences in imaging technique, and if further evaluation for potential tumor progression is desired, MR is recommended. . CT chest: 1. Extensive aspiration, with hematoma seen within the tracheobronchial tree. 2. Endotracheal tube approximately 5 cm from the level of the carina. An NG tube tip is not seen but is at least as far as the stomach. . CXR: Central distribution of alveolar opacity consistent with aspiration, in this case of blood. . CT head: 1. No evidence of intracranial hemorrhage or acute large vascular territorial infarction. MRI would be more sensitive for an acute infarction, if clinically indicated. 2. Increased blood in the nasopharynx. Persistent blood or inspissated secretions in the paranasal sinuses. 3. Erosion of the right medial clivus and the medial margin of the right petrous carotid canal, as seen previously. The known nasopharyngeal tumor and posttreatment changes are not well evaluated on this exam. 4. Unchanged bilateral opacification of the mastoid air cells. . . [2184-4-12] PET scan: 1. Decreased FDG avidity in nasopharyngeal mass consistent with response to therapy. 2. FDG avid focus in the distal sigmoid colon is new since prior study. Although a GI malignancy is unlikely to appear over the course of 6 months, this focus of FDG avidity should be correlated with any recent sigmoidoscopy or coloscopy. . EKG: Sinus tach at 101 bpm, no ST-T changes, faster rate but otherwise consistent with prior ECG from [2184-1-12]. . MRI Nasopharynx [2184-4-22] IMPRESSION: 1. In this patient with known nasopharyngeal cancer, there has been mild interval decrease in the right nasopharyngeal mass lesion. Stable intracranial extension of the mass into the cavernous sinus via direct extension and perineural spread, as detailed above. Stable extension into the right cavernous sinus, encasing, but not significantly compressing the right internal carotid artery. . 2. Multiple new embolic infarcts seen throughout the right cerebral hemisphere and the splenium of the corpus callosum. . 3. Stable abnormal signal in the clivus and right lateral mass of C1, concerning for tumor extension. . 4. Extensive paranasal sinus disease, as described above Brief Hospital Course: 55-year-old man with nasopharyngeal carcinoma s/p chemoradiation presented with epistaxis and admitted to the MICU and found to have right cartid perforation now s/p carotid artery stent placement by interventinoal radiology. Hospital course was complicated by dysphagia and aspiration pneumonia and right upper extremity DVT. . # Epistaxis / Nasopharyngeal carcinoma: patient has history of nasopharyngeal carcinoma presenting with epistaxis. HCT on admission was 24.8 and patient received total of 8 units of pRBCs with HCT remaining stable at 31-32 subsequently. Patient was intubated for airway protection in setting of profuse bleeding. ENT and neurosurgery were consulted for possible embolization. He was taken for angio graphy which showed a pseudoaneurysm at the junction of the petrous and cavernous portion of the distal right ICA. Patient underwent IR-guided placement of a coated stent into right internal carotid artery. Started on plavix post-procedure and will need to continue plavix x 1 month. Post-procedure there was concern for possibility of hemorrhagic stroke and CT head was done which did not show any new infarcts. ENT examined patient with laryngoscopy/nasoscopy, findings were incrased blood in nasopharynx, erosion of right medial clivus and medial margin of right petrous carotid canal unchanged. It is likely that tumor or mass effect eroded into ICA wall and subsequently regressed, causing bleeding without visualized mass. Patient had a bronchoscopy with removal of blood (no clots of active bleeding seen), and subsequently successfully extubated on [4-20]. Repeat MRI shows interval decrease in size of nasopharyngeal disease with stable encacement of right carotid, invasion of foramen ovale/rotundum. Given encacement of carotid, chemotherapy will be deferred as it may increase risk of re-bleed. . # Aspiration pneumonia: Patient was febrile to 102 on [4-19] and chest xray was obtained which showed infiltrate consistent with aspiration. He was treated with 8 days of unasyn and remained afebrile for the remainder of hospital course. . # Dysphagia: Following extubation patient had dysphagia and was observed to aspirate while eating. Speech and swallow was consulted who initially recommended nectar thick liquids and no solids. He underwent repeat evaluation with video swallow study which showed improvment though he continued to aspirate to a limited extent. After discussion with the patient and family, it was decided to accept a small amount of aspiration to allow patient to eat. He was instructed to return to the hospital if dysphagia worsens. Dysphagia is likely related to a combination of intubation and instrumentation in a patient with a history of XRT therapy. Symptoms are expected to improve with time. # Ischemic infarcts: MRI obtained to evaluate nasopharyngeal carcinoma showed apparently new right sided ishcemic infarcts, no new neurological deficits were noted. Infarcts are likely related to manipulation of carotid artery. Given recent hemorrheage, he was not a candidate for TPA. . # Right upper extremity DVT: Patient developed right arm pain and R>L upper extremity swelling at the site of an infiltrated peripheral IV. Ultrasound showed non-occlusive DVT involving the axillary and brachial veins. Given recent hemorrheage, the risks of anticoagulation out weigh the benefits. He was treated conservatively with warm compresses. . # Hypotension: likely in setting of acute bleed. No fevers or leukocytosis to suggest sepsis initially though patient did spike temperature to 102 after bleeding episode which was thought to be in setting of aspiration. He required pressors initially and subsequently weaned off. Received a total of 8 units of pRBCs, 3L IVF and platelet transfusion in setting of bleed. WBC increased to 12 from admission likely due to aspiration of blood and possible pneumonia, started on unasyn as above for coverage of aspiration pneumonia. . # Nasopharyngeal carcinoma: Diagnosed [8-/2183] s/p XRT and bolus cisplatin plus Cyberknife therapy, and 3 cycles of adjuvant cisplatin/5-FU last on [2184-3-19]. He underwent MRI to evaluate progression of disease which showed interval decrease in size of nasopharyngeal disease with stable encacement of right carotid, invasion of foramen ovale/rotundum. Given encacement of carotid, chemotherapy was deferred as it may increase risk of re-bleed. . HCP is [Name (NI) ] (older son) - [Telephone/Fax (1) 76686]. [Doctor Last Name ] ([Doctor Last Name 1685] son) - [Telephone/Fax (1) 76687]. . Medications on Admission: Fluconazole 40 mg/mL susp 2.5 mL daily Lorazepam 0.5-1 mg daily before Cyberknife Maalox/benadryl/lidocaine qid prn pain Oxycodone 5-10 mg q6h prn pain Potassium chloride ER 20 mEq daily Prochlorperazine supp 25 mg pr [Hospital1 ] prn N/V Prochlorperazine maleate 10 mg tid prn nausea Ranitidine 15 mg/mL syrup 10 mL [Hospital1 ] (stop [1-/2184]?) Discharge Medications: 1. fluconazole 40 mg/mL Suspension for Reconstitution Sig: 2.5 mL PO once a day. 2. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for prior to Cyberknife . 3. lidocaine-diphenhyd-[Doctor Last Name ]-mag-[Doctor Last Name ] 200-25-400-40 mg/30 mL Mouthwash Sig: Thirty (30) mL Mucous membrane four times a day as needed for pain. 4. oxycodone 5 mg/5 mL Solution Sig: [4-13] mL PO every six (6) hours: Do not drive while taking this medicaiton. Disp:1 qs Refills:0 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) tablet PO three times a day as needed for nausea. 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 23 days: Final day [5-21]. Disp:24 Tablet(s) Refills:0 7. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for pain/fever. Disp:1 qs Refills:0 8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day. Disp:1 bo Refills:1 9. senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO at bedtime. Disp:1 bo Refills:1 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Carotid artery perforation . Secondary diagnosis Anemia due to acute blood loss Aspiration pneumonia Nasopharyngeal cardinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: As you know, you were admitted to the [Hospital1 ] for severe bleeding from your throat. We determined that you were bleeding from the right carotid artery (a large artery in your head). You were admitted to the intensive care unit and intubated to protect your lungs. We gave you blood transfusions to replace the blood lost and your blood level returned to a normal level. We placed a small tube (stent) in the artery to help keep it open. You will need to take a medication called Plavix every day for one month, final day [5-21]. We believe that the bleeding began as a result of the tumor in your head. You will need to follow up with Dr. [First Name (STitle) ] to discuss further plans for chemotherapy. . You developed a blood clot in your right arm and were treated with warm compresses to the right arm. When you return home, you should continue to apply warm compresses to the right arm for 1-2 weeks. You had difficulty swallowing and were seen by our swallowing specialists. It was determined that a small amount of food and liquid goes down the windpipe when you swallow which places you at risk for aspiration and infection. On repeat evaluation, you were better able to swallow. We recommend regular consistency liquids, and solid foods cut in to small bite sized pieces however even with this diet, there remains the possbility that you will continue to aspirate a small amount of food and may develop an infection. We recommend that you take your pills crushed in applesauce. If you develop worsening difficulty swallowing or fevers, please return to the hospital for evaluation. . Medication changes: START Plavix START Oxycodone for pain START acetaminophen for pain START Docusate to prevent constipation START Senna to prevent constipation Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2184-5-12] at 4:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6198], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is also with an interpreter. ICD9 Codes: 5070, 2851, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5892 }	Medical Text: Admission Date: [2110-6-13] Discharge Date: [2110-6-14] Date of Birth: [2050-6-20] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old lady with past medical history significant for irritable bowel syndrome, hypertension, and hypercholesterolemia, who presents with bright red blood per rectum. The patient had a routine screening colonoscopy on [2110-6-12] at 11:30 a.m. She was found to have a polyp, which was removed. The patient was also noted to have mild diverticulosis. Around 5:30 p.m., the patient started to pass bright red blood per rectum approximately 100 to 400 cc every hour. She denied fever, chills, nausea, vomiting, or abdominal pain. She went to an outside hospital ED, but was transferred to [Hospital1 18] since her doctor was Dr. [Last Name (STitle) 1940] who is associated with [Hospital1 18]. In the ED, her vital signs were temperature 98, blood pressure 149/78, heart rate 80, respiratory rate 17, and saturating 97 percent on room air. Two large bore IVs were placed and the patient was resuscitated with 2 liters of IV normal saline. Her hematocrit was noted to drop from 39 to 22. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Inflammatory bowel disease. MEDICATIONS: 1. Diovan. 2. Premarin. 3. Lipitor. 4. Hydrochlorothiazide. ALLERGIES: CODEINE CAUSING NAUSEA. PHYSICAL EXAMINATION: Afebrile, heart rate 80, blood pressure 100/65, respiratory rate 15, and saturating 100 percent on room air. General: Pale, diaphoretic, alert female. HEENT: Oropharynx clear. Sclerae anicteric, but pale. Cardiovascular: The patient is tachy without murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft and nontender, normoactive bowel sounds, positive bright red blood in bedpan. Extremities: No clubbing, cyanosis, or edema. Pulses were 1 plus bilaterally. LABORATORY DATA: Chem-7 was unremarkable. CBC was remarkable for anemia with hematocrit of 27. KUB showing no free air. HOSPITAL COURSE: The patient was admitted to the MICU. On presentation to the MICU, she had a single IV. Initially her heart rate was in the 80s and her systolic blood pressure was in the 120s. However, she became more unstable and her heart rate jumped to 112 to 115 and her systolic blood pressure fell to the mid 90s. At this time a second IV was placed. The patient was transfused with packed red blood cells through both IVs. She remained tachycardiac and producing large amounts of blood per rectum. The decision was made to place a central line to allow for aggressive volume resuscitation. During the placement of the central line, the patient was complaining of some back pain, however, the wire fed easily and a 3-lumen catheter was placed. On chest x- ray, the catheter appeared to leave the subclavian vein into an internal mammary vein. However, since the central line both flushed and true blood, it was left in place temporarily. However, after the transfusion of 3 units of packed red blood cells the patient was stable, producing less blood per rectum, non-tachycardiac, the base systolic blood pressure in the 120s. Thus the central line was discontinued. The patient was seen by Dr. [Last Name (STitle) 1940] and the GI fellow. They took the patient to Endoscopy where they found red blood in the transverse, left, sigmoid, and rectum. There was no blood in the right colon. The polypectomy site was identified opposite the valve. It had a red clot on it, but was not bleeding. The clot was washed off. No bleeding was noted. Then 10 cc of epinephrine was injected 1:10,000 dilution into and around the base of the polypectomy. After this, BL-CAP electrocautery was applied for hemostasis successfully. There was no bleeding at the conclusion of the procedure. After this procedure, the patient's hematocrit remained stable. She was advanced to a clear liquid diet without difficulty. She had no additional episodes of bright red blood per rectum. Her diet was further advanced. She was monitored overnight and remained hemodynamically stable. She was discharged home the following day with followup to see Dr. [Last Name (STitle) 1940]. No changes to her medications were made. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: Gastrointestinal bleed status post polypectomy. DISCHARGE MEDICATIONS: No changes were made to her outpatient regimen. FOLLOWUP PLANS: The patient was asked to follow up with Dr. [Last Name (STitle) 1940] on Monday. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 39096] Dictated By:[Doctor Last Name 2020] MEDQUIST36 D: [2110-6-16] 05:32:08 T: [2110-6-16] 06:14:05 Job#: [Job Number 20597] ICD9 Codes: 2765, 4019, 2720, 5789
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5893 }	Medical Text: Admission Date: [2113-12-4] Discharge Date: [2113-12-26] Date of Birth: [2043-2-11] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 473] Chief Complaint: pancreatic head mass Major Surgical or Invasive Procedure: s/p Whipple procedure [2113-12-5] History of Present Illness: Patient is a 70yF who developed epigastric pain in [Month (only) ] of [2112]. She was seen in [Location (un) 3844], ultimately had a stent placed, which was replaced three months later. This was on the findings of a biliary stricture. She subsequently has had an endoscopic ultrasound at [Hospital1 18] and stent exchange which confirmed a distal bile duct stricture and likely pancreatic head mass. A short-segment metal stent has been replaced into apposition and she has achieved excellent relief of any obstructive jaundice symptoms. Since her biliary obstruction was relieved, she has not had any further jaundice or any other symptoms of pruritis, nausea, vomiting or anorexia. Past Medical History: open CCY 40yrs ago, s/p back surgery, CAD w/three vessel CABG [2104], s/p hysterectomy, multiple laser eye surgeries secondary diabetic retinopathy, HTN, IDDM, s/p CVA [2108], glaucoma Social History: No tobacco, no EtOH, no environmental exposures. Lives with husband who has [Name (NI) 2481] disease. Family History: father-MI, DM sisters-lung cancer, leukemia, DM Physical Exam: Gen: awake, pale, NAD HEENT: EOMI, nares patent, oropharynx without erythema/exudate Neck: no masses, trachea midline CV: well healed sternotomy incision, II/VI systolic murmur, otherwise RRR Resp: coarse BS bilaterally but generally CTA Abd: soft, NT/ND, incision clean and dry with steri-strips in place, JP drain site with mild erythema but no discharge/oozing Ext: no c/c/e Neuro: aao x 4 Pertinent Results: [2113-12-22] 05:08AM BLOOD WBC-7.6 RBC-2.98* Hgb-9.6* Hct-27.6* MCV-93 MCH-32.3* MCHC-35.0 RDW-14.7 Plt Ct-132* [2113-12-21] 06:30AM BLOOD WBC-10.5 RBC-2.92* Hgb-10.0* Hct-27.3* MCV-94 MCH-34.2* MCHC-36.6* RDW-14.9 Plt Ct-131* [2113-12-22] 05:08AM BLOOD Plt Ct-132* [2113-12-21] 06:30AM BLOOD Plt Ct-131* [2113-12-24] 04:39AM BLOOD Glucose-122* UreaN-21* Creat-0.8 Na-144 K-3.2* Cl-108 HCO3-29 AnGap-10 [2113-12-23] 05:30AM BLOOD Glucose-157* UreaN-20 Creat-0.8 Na-140 K-3.6 Cl-103 HCO3-29 AnGap-12 [2113-12-22] 05:08AM BLOOD Glucose-231* UreaN-19 Creat-0.7 Na-136 K-3.9 Cl-101 HCO3-30 AnGap-9 [2113-12-18] 06:00AM BLOOD CK-MB-5 cTropnT-0.21* [2113-12-24] 04:39AM BLOOD Calcium-7.5* Phos-4.2 Mg-1.8 [2113-12-23] 05:30AM BLOOD Calcium-7.3* Phos-3.5 Mg-1.9 Brief Hospital Course: Patient admitted and underwent an uncomplicated pancreaticoduodenectomy on [2113-12-5]. She was transferred stable to the recovery room and then to the floor. POD1-POD8 she remained stable with no adverse postoperative events. Her diet was advanced to regular diabetic diet and she was out of bed. On POD8, however, she developed an episode of hypotension to the 80's systolic and had new onset vomiting. She remained afebrile, however, her urine output decreased to marginal levels. She was transferred to the intensive care unit where aggressive resuscitation was performed as well as cardiac enzymes. Her cardiac enzymes returned elevated with a troponin of 0.71. Her ekg did not show any acute changes. Upon transfer to the ICU, an NGT was placed revealing large amount of bilious fluid. She was kept NPO. During the course of her ICU stay, her troponins gradually trended down. Cardiology consulted and recommended heart rate control and a heparin gtt for a presumed NSTEMI. Her heparin gtt was discontinued and she had no other cardiovascular events. From a nutrition standpoint, she was kept NPO in the ICU and TPN was started for nutrtion. She was placed on erythromycin. On POD 12 she was transferred back to the floor with an NGT in place and remained NPO. On POD 13 her NGT was clamped however she developed emesis with few hundred cc's of bilious fluid expressed from NGT. She was continued with the NGT until POD 16 when she was able to pass a clamping trial with no nausea/vomting and it was discontinued. At this point, her diet was slowly advanced from sips which she tolerated well. At discharge, she was tolerating a regular diet. Of note, she did develop loose stool with C. Diff testing positive. She was started on flagyl for her colitis. During her hospital stay, her blood sugars were noted to be elevated to >200. [Last Name (un) ] consult was initiated and the patient was controlled with an insulin sliding scale as well as lantus. She was briefly maintained on an insulin drip, however, at the time of discharge her blood sugars were adequately controlled with a sliding scale/lantus combination. Medications on Admission: coumadin, lantus, potassium, lasix 20', mvi, synthroid, quinapril 40'', atenolol 50', darvocet, tegretol 100'', clonase, tamezopam, amytriptyline 100', seroquel 25', xalantan, zocor 20' Discharge Disposition: Home With Service Facility: VNA of [Location (un) 5450] Discharge Diagnosis: pancreatic head mass C. Difficile colitis Discharge Condition: good Discharge Instructions: Please call Dr.[Name (NI) 9886] office or come to the emergency room if you have fever, persistent abdominal pain, redness or oozing from your surgical sites, dizziness/weakness, or shortness of breath. Please do not drive while taking pain medications. You may shower, the steristrips on your abdominal wound will fall off on their own. Please take all of your discharge medications as instructed. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 468] in [9-29] days, call [Telephone/Fax (1) 2835] for an appointment. Completed by:[2114-1-16] ICD9 Codes: 9971, 2851, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5894 }	Medical Text: Admission Date: [2135-1-30] Discharge Date: [2135-2-8] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: Transfer from Nursing home for fever and elevated white count Major Surgical or Invasive Procedure: none History of Present Illness: 87 yo M with PMH of DM, CAD, ESRD on HD who was transferred from [Hospital 26563] Rehab to ED for eval of Fever. . Per referal note, patient 2 days ago developed increase leukocytosis and delirim. Apparently, he was started on iv vancomycin, Flagyl and Ceftazidime for PNA. On day of admission patient developed a fever to 101.2, pulse 76 BP 102/68R 18 and sat 92%. Blood Cx and Urine Cx were drawn. . Of note he was recently operated on by vascular [Doctor First Name ] for a R sup femoral and [Doctor Last Name ] angioplasty and stenting along with Left femoral patch angioplasty with bovine patch. He was discharged home on Levoflox for probable RLL PNA . In the ED, VS 100.8 HR 85 BP 81/28 RR 20 Sats 95%. A femoral line was placed and he was given 1000 cc NS. Given pooor response, and after CVP measure 12, patient was started on levophed and transfer to [Hospital Unit Name 153]. Past Medical History: PAST MEDICAL HISTORY: 1. ESRD secondary to hypertensive nephrosclerosis s/p right upper extremity AV graft 9'[56]'[33] in preparation for dialysis. Graft placement was complicated by cellulitis, for which he was treated with keflex 2. DM, on glyburide and glipizide at home 3. HTN, on clonidine, lisinopril, nifedipine 4. PVD s/p aortic bypass 5. CVA, with residual weakness of his left side 6. R CEA 7. Secondary hyperparathyroidism 8. Chronic anemia on procrit injections 9. Prostate CA on Lupron 10. Gout Social History: Denies past or present Tob, EtOH, or Illicit drug use. Was living at a senior facility in [Location (un) 745] with his wife prior to last admission. Now at [Hospital 100] Rehab. Family History: NC Physical Exam: T 99.7 BP 114/60 Hr 78 RR Sats 98% 4 L NC General: Patient in mild apparent distress, alert, responding to questions HEENT: dry oral mucose, no LAD, JVD Lungs: crackles bilaterally CV: Regular heart sounds, soft holosystolic murmur RLSB Back: sacral ulcers Abdomen: BS +, soft, non tender non distended Extremities: cold, distal pulses decreased, heel ulcers bilaterally, necrotic. 3-4th underneath nail toe right foot black. RU extremiti AVF , no trhill, no erythema. Left upper extremity- picc line Right femoral line in place Neuro: patient alert, oriented to person, movilizing grossly all extremities. Pertinent Results: [2135-1-30] 07:18PM LACTATE-1.6 [2135-1-30] 07:05PM GLUCOSE-200* UREA N-49* CREAT-4.2# SODIUM-137 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19 [2135-1-30] 07:05PM CORTISOL-19.5 [2135-1-30] 07:05PM WBC-30.5# RBC-3.05* HGB-9.1* HCT-29.6* MCV-97 MCH-29.8 MCHC-30.7* RDW-16.9* [2135-1-30] 07:05PM NEUTS-89* BANDS-1 LYMPHS-5* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2135-1-30] 07:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ [2135-1-30] 07:05PM PLT SMR-NORMAL PLT COUNT-275 [2135-1-30] 07:05PM PT-18.1* PTT-31.7 INR(PT)-1.7* Brief Hospital Course: Assessment and plan: 87 yo M with MMP including DM, HTN, CAD, PVD on HD with L arm fistula presents with septic shock. . 1. Sepsis: The pt was found to be hypotensive and febrile in the ED and admitted through sepsis protocol. He was infused with muliple boluses of normal saline, put on levophed for blood pressure support. He was covered with broad spectrum antibiotic empirically as culture data was sent. Blood cultures were found to be positive for gram postive cocci which was ultimately shown to be VRE. Vancomycin was changed to linezolid. The pt remained hypotensive on pressors for the next several days and a work-up was initiated to determine the source of infection. MRI of the foot was pursued to r/o osteomyelitis, and a CT of the abdomen was down to r/o an abdominal source of infection. The CT Abdomen and pelvis showed possible abscess in liver and spleen. There was also pancolitis. GI and Surgery were [Year/Month/Day 4221] for assistance in the management of these problems. For the pancolitis, the pt was kept NPO and he was treated for possible c. diff infection while c. diff cultures were sent and found to be positive. A RUQ U/S [2135-2-2] was pursued which showed evidence of hypoechoic lesion could be flegmon or mass. It was unable to be confirmed on imaging whether these lesions on CT which were new compared with a previous scan in [10-1] were abscesses vs possible mets from an unknown primary. IR was [Date Range 4221] for possible drainage or biopsy, however option declined given localization of lesions and the pts significant bleeding risk. The GI team suggested an MRI to further evaluate the liver lesions although this was unable to be pursued because the pt was too unstable requiring pressors for bp support. A TTE Echo was done to r/o endocarditis or abscess and was negative. Head CT was negative for abscess as well. . 2. CMO: On the morning of [2135-2-6], the ICU team discussed with Mr [Known lastname ] wife and daughter the different alternatives for Mr [Known lastname ] care. It was explained that the feeling of the medical staff and nurse staff was that Mr [Known lastname ] has been extremily uncomfortable with all the procedures that he undergoes during the day. Despite giving pain medicines he has shown signs of a lot of discomfort. We explained to the family that we would need a NGT place in order to feed him and give him some of his medicines now that he is having trouble swallowing given his mental status. Also we have explained that we still not have a clear dx on his liver lesions, and in order to obtained a dx he might need a surgical intervention for biopsy. It would be a long road ahead before he is able to go back to where he was previously. Ms [Known lastname ] feels that her husband would not want to have all this procedures done along the road and that we should change the focus of care towards making him as comfortable as possible. The antibiotics and pressors were d/c'ed. The plan was to have no more dialysis. There were no more lab draws. A morphine drip was started for pain. The pt remained arousable though sleepy. His blood pressure was in the 80s-90s systolic off pressors and his extremities continued to show evidence of perfusion. On the evening of [12-10], he skin became more pale and his sensorium less alert. At 2:08 am he was found to have ceased respirations and was without a heart rate on the monitor. By 2:15 am he was pronounced deceased. . 2. CAD: h/o MI. Continued sinvastatin, aspirin until made CMO. BB and BP medications were held in the setting of hypotension . 3. Peripheral vascular disease: continued plavix, Aspirin until CMO The vascular team followed the pt. . 4. DM: insulin sliding scale was continued before the pt was made CMO. . #. ESRD: The pt continued to recieve periodic dialysis sessions while in house until he was made CMO. . #. FEN: He was kept NPO given the colitis and sepsis. . # Hypothyroidism: continued levothyroxine until CMO. . # PPX: Pantoprazole, pneumoboots until CMO. . #Code: DNR-DNI was changed to CMO on [2-6] . # Communication: Next of [First Name8 (NamePattern2) ] [Known lastname ], [First Name3 (LF) ] wife, [Numeric Identifier 26800] Medications on Admission: 1. Clopidogrel 75 mg qday 2. Docusate Sodium 100 mg [Hospital1 ] 3. Epoetin Alfa Injection 4. Sertraline 100 mg daily 5. Fexofenadine 60 mg [Hospital1 ] 6. Amiodarone 200 mg qd 7. Aspirin 325 mg qday 8. Insulin Glargine 10u/hs. 9. Lisinopril 5 mg day 10. Multivitamin daily. 11. Oxycodone 5 mg q4h-6h 12. Pantoprazole 40 mg /day 13. Senna 8.6 mg [Hospital1 ] 14. Levothyroxine 50 mcg /daily 15. Metoprolol Succinate 25 mg sustain release 16. Simvastatin 40 mg /daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: gram positive VRE sepsis Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 5119, 2859, 2749, 4439, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5895 }	Medical Text: Admission Date: [2135-2-4] Discharge Date: [2135-2-23] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Subdural hematoma of the posterior fossa with mass effect and hydrocephalus Major Surgical or Invasive Procedure: Suboccipital craniectomy and evacuation of subdural hematoma [2135-2-5] PEG placement [2135-2-22] Posterior fossa wound revision [2135-2-22] History of Present Illness: 84 yo M with 2 days of headache and weakness presented to OSH with a subdural hematoma. Pt was anticoagulated on coumadin for mechanical heart valve. Pt was given 2 units of FFP and 10 mg IV vitamin K. On admission to, pt was confused, but moving all extremities with intact facial expression. Pt's mental status decreased s/p ED transfer, and pt was intubated for GCS 5. Past Medical History: Mitral valve regurgitation with prosthetic heart valve ([Hospital 10014]) Pacemaker Gastric ulcer CHF HTN Aortic valve insufficiency Hyperlipidemia Social History: Widowed Power of attorney Nephew Physical Exam: On admission: O: T:98.0 BP: 143/67 HR: 83 R 19 O2Sats 100%RA Gen: Intubated, sedated HEENT: Pupils: 2 mm, fixed Extrem: Pale Neuro: Mental status: Intubated, sedated. Orientation: unable to assess Cranial Nerves: I: Not tested II: 2mm fixed. Motor: Moving all 4 extremities Toes upgoing bilaterally Brief Hospital Course: 84 yo M with 2 days of headache and weakness presented to OSH and was found to have subdural hematoma. Pt is anticoagulated on Coumadin for mechanical heart valve. Pt was given 2 units of FFP and 10 mg IV vitamin K. Pt was confused on admission to [Hospital1 18], but moving all extremities with intact facial expression. Pt's mental status decreased s/p ED admission, and pt was intubated for GCS 5. Patient was taken to the OR emergently for a sub occipital craniotomy for evacuation of the SDH. He went to the ICU where he was found to have a LLL PNA and antibiotic therapy with vancomycin and Zosyn was started. Heparin drip was started on [2-10] to start anticoagulation given the patients mechanical heart valve and incidentally on [2-11] a left upper extremity DVT was diagnosed. On [2-15] patient was noted to be increasingly lethargic and continuously tachypneic, a pulmonary consult was obtained, they perceived his tachypneic to be central in nature. On this day, pt. was also noted to have CSF leaking from his incision, an additional staple was placed at the site of the leak and the drainage stopped, but the wound eventually opened and he had to be taken back to the OR for a wound revision which happened on [2135-2-21]. On this hospital stay, the patient failed multiple swallow evaluations by speech therapy and received a surgical PEG by GI on [2135-2-21]. On the day of discharge, [2135-2-23] pt. was evaluated for the development of hydrocephalus via CT scan which was negative. Anticoagulation was initiated with IV heparin for both his upper extremity DVT and his pre-existing mechanical heart valve. He will go to rehab with on going therapy and he is to be monitored closely there. Medications on Admission: ASA 81 mg q day Atenolol 25 mg Docusate 100 mg [Hospital1 ] Lovenox 80 mg [Hospital1 ] Ferrous sulfate 325 mg Lasix 160 QAM, 80 mg QPM Claritin 10 mg Nitroglycerin SL PRN PPI KCL tab 40 mEq q day Prazosin 1 mg cap [Hospital1 ] Psyllium Simvastatin 20 mg q day Travoprost Warfarin 2 mg Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [12-31] Drops Ophthalmic PRN (as needed). 2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [Month/Day (2) ]: One (1) Appl Ophthalmic PRN (as needed). 3. Docusate Sodium 50 mg/5 mL Liquid [Month/Day (2) ]: One (1) PO BID (2 times a day). 4. Simvastatin 10 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 5. Prazosin 1 mg Capsule [Month/Day (2) ]: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day (2) ]: One (1) Tablet, Delayed Release (E.C.) PO at bedtime as needed. 8. Hydralazine 10 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO Q6H (every 6 hours). 9. Ipratropium Bromide 0.02 % Solution [Month/Day (2) ]: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Acetaminophen 160 mg/5 mL Solution [Month/Day (2) ]: [12-31] PO Q6H (every 6 hours) as needed for fevers/pain. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day): Hold for SBP <110 and HR <60. 13. Clonidine 0.2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 15. Hydromorphone 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 17. Lasix 20 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO twice a day. 18. Heparin (Porcine) in NS 10 unit/mL Kit [Last Name (STitle) ]: One (1) Intravenous On going: IV heparin for anticoaculation, use weight base protocol to achieve theraputic PTT 40-60. . Discharge Disposition: Extended Care Facility: [Hospital 24759] [Hospital ] Rehab Hospital Discharge Diagnosis: posterior fossa subdural hematoma LUE DVT Wound dehisence Malnutrition Dysphagia Altered mentation Discharge Condition: Stable 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. ?????? 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. Pt. is leaving to rehab on a heparin drip, he need to be anticoagulated for an upper extremity DVT and for a mechanical valve. please check his ptt at 4:00pm and six hours there after, and adjust the drip as needed to achieve a theraputic PTT ( goal 40-60) then start coumadin therapy. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in __20 _days ( from [2135-2-22]) removal of your staples or sutures. ??????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:[2135-2-23] ICD9 Codes: 486, 4280, 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5896 }	Medical Text: Admission Date: [2129-10-26] Discharge Date: [2129-11-8] Date of Birth: [2058-4-17] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: exploratory laparotomy, sigmoid colectomy, [Doctor Last Name 3379] pouch [2129-10-26] Drainage of pelvic abscess by IR [2129-10-31] Abdominal closure, ventral herniorrhaphy [2129-11-4] History of Present Illness: 71 yoF with history of L CVA in [2122], and large ventral / incisional hernia comes in after being "found down covered in feces." She c/o tenderness in her belly, diffusely, and despite being found in feces, reports no bowel function for 6 days. Denies fevers or chills. Is currently tachycardic in the 120's, hypertensive to 160 systolicand tachypneic to 40's. She is a poor historian and review of systems is otherwise negative per report. Past Medical History: -Diverticulitis s/p IR drainage in [2-/2129] -Stroke in [2122] with residual right-sided weakness -Depression -COPD with limited pulmonary reserve -Anxiety -Large ventral hernia -Left-sided congenital hearing loss and R sided progressive hearing loss -H pylori treated [12/2128] -Osteoporosis -Tobacco abuse Past Surgical History: -Appendectomy at age 60 -Open cholecystectomy Social History: She lives in a senior living facility and uses a motorized wheelchair for ambulation. She is minimally active at baseline. Smoked regularly from age 15-30's and then stopped but restarted again at age 69 in the context of multiple stressors. She has stopped again as of a few weeks ago. Denies any alcohol or other drug use. Family History: Notable for severe asthma in her father. [Name (NI) ] premature CAD. Physical Exam: PHYSICAL EXAMINATION: upon admission [2129-10-26] Temp:96.0 HR:115 BP:190/95 Resp:30 O(2)Sat:99 normal Constitutional: Uncomfortable HEENT: Normocephalic, atraumatic Chest: Wheezes throughout Cardiovascular: Regular Rate and Rhythm Abdominal: Large abdomen, relatively soft with large firm ventral hernia that is extremely tender to palpation GU/Flank: No stool in the vault, however large soft stool on the patient's buttock and back is guaiac-negative Extr/Back: No cyanosis, clubbing or edema Skin: Mildly diaphoretic Neuro: Moving all extremities Psych: Patient extremely uncomfortable and writhing on the bed in pain, moving all extremities Pertinent Results: [2129-10-26] 08:08PM GLUCOSE-276* UREA N-29* CREAT-0.6 SODIUM-135 POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-7* [2129-10-26] 08:08PM CALCIUM-8.9 PHOSPHATE-2.3* MAGNESIUM-1.3* [2129-10-26] 08:08PM WBC-11.1* RBC-3.64* HGB-11.6# HCT-34.0 MCV-93 MCH-31.9 MCHC-34.1 RDW-12.9 [2129-10-26] 06:05PM GLUCOSE-226* LACTATE-3.1* NA+-136 K+-3.2* [2129-10-26] 04:09PM GLUCOSE-183* LACTATE-3.5* NA+-138 K+-3.1* CL--103 [2129-10-26] 04:09PM freeCa-1.26 [2129-10-26] 12:04PM GLUCOSE-240* UREA N-30* CREAT-0.5 SODIUM-135 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-32 ANION GAP-13 [2129-10-26] 12:04PM ALT(SGPT)-15 AST(SGOT)-13 ALK PHOS-132* TOT BILI-0.4 [2129-10-26] 12:04PM LIPASE-14 [2129-10-26] 12:04PM ALBUMIN-3.5 [2129-10-26] 12:04PM PLT SMR-HIGH PLT COUNT-519* [2129-10-26] 12:04PM PT-11.9 PTT-24.3 INR(PT)-1.0 [2129-11-8] 06:39AM BLOOD WBC-13.9* RBC-2.92* Hgb-8.8* Hct-26.9* MCV-92 MCH-30.2 MCHC-32.9 RDW-17.0* Plt Ct-857* [2129-11-7] 05:06AM BLOOD WBC-17.1* RBC-2.88* Hgb-8.9* Hct-26.3* MCV-91 MCH-31.0 MCHC-33.9 RDW-17.2* Plt Ct-784* [2129-11-6] 06:04AM BLOOD WBC-19.9* RBC-2.43* Hgb-7.7* Hct-22.7* MCV-93 MCH-31.8 MCHC-34.0 RDW-15.7* Plt Ct-660* [2129-11-8] 06:39AM BLOOD Plt Ct-857* [2129-11-7] 05:06AM BLOOD Plt Ct-784* [2129-11-6] 06:04AM BLOOD Plt Ct-660* [2129-11-7] 05:06AM BLOOD Glucose-96 UreaN-7 Creat-0.3* Na-138 K-4.0 Cl-103 HCO3-32 AnGap-7* [2129-11-6] 06:04AM BLOOD Glucose-101* UreaN-11 Creat-0.3* Na-135 K-3.6 Cl-99 HCO3-31 AnGap-9 [2129-11-5] 09:57AM BLOOD Glucose-195* UreaN-17 Creat-0.4 Na-134 K-4.2 Cl-97 HCO3-31 AnGap-10 [2129-10-29] 02:28AM BLOOD ALT-47* AST-30 LD(LDH)-166 AlkPhos-94 TotBili-0.7 [2129-10-28] 01:30AM BLOOD ALT-60* AST-35 LD(LDH)-128 AlkPhos-89 TotBili-1.7* [2129-11-7] 05:06AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9 [2129-11-6] 06:04AM BLOOD Calcium-8.6 Phos-2.8 Mg-2 [2129-10-26]: EKG: Sinus tachycardia. Possible right atrial abnormality. Possible prior septal myocardial infarction. Compared to the previous tracing of [2129-2-10] the heart rate is much faster with tall P waves [2129-10-26]: Cat scan abdomen and pelvis: IMPRESSION: 1. Multiple pelvic fluid collections/abscesses, measuring up to 7.6 cm, as above with significant fat stranding in the abdomen and numerous locules of gas extending anteriorly along the abdomen and into the patient's multiple ventral hernias, likely secondary to severe, ruptured, sigmoid diverticulitis/colitis. Mesenteric free fluid. No pneumatosis or portal venous gas seen. 2. Multiple ventral hernias, second lowest of which contains loops of nonobstructed small bowel and several locules of gas as well as small amount of free fluid, microperforation not excluded, although the gas may be extending from the ruptured sigmoid colitis. Lowest most ventral hernia contains foci of gas and hazy fat, incarcerated omental fat not excluded. No bowel obstruction seen. 3. Wedge-shaped hypodensity in the inferior aspect of the spleen, additional hypodensities seen more superiorly, new since the prior study, worrisome for infarcts vs. possibly infection. Adjacent mild splenic stranding. 4. Status post cholecystectomy. Increased intra- and extra-hepatic biliary dilatation, which may relate to post-cholecystectomy state, but increased since the prior study. Recommend correlation with LFTs and consider MRCPas clinically warranted [2129-10-30]: Chest x-ray: IMPRESSION: Left lower lobe collapse and/or consolidation and small left effusion, improved compared with one day earlier [2129-10-30]: cat scan of abdomen/pelvis IMPRESSION: 1. Cul de sac/left adnexal abscess has decreased in size since [2129-10-26]. No evidence of a new abscess. 2. Persisent free fluid around small bowel loops. No evidence of large or small-bowel obstruction. 3. Postsurgical changes as above with open abdomen. Result given by telephone to Dr [Last Name (STitle) ], clinical team member, at 1700 hours [2129-10-30] [2129-10-31]: IR drainage: IMPRESSION: Successful 8 French pigtail catheter placement into persistent pelvic abscess using left transgluteal approach. The findings were discussed with covering resident in the surgical ICU for placement of post-procedural drain orders [2129-11-1]: Echo: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. 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 pulmonary artery systolic pressure could not be determined. There is a minimally increased gradient consistent with trivial pulmonic valve stenosis. There is no pericardial effusion [2129-11-1]: Chest x-ray: HISTORY: Post-sigmoid colectomy, to assess for change. FINDINGS: In comparison with the study of [10-31], the right IJ catheter has been pulled back to about the junction of the jugular vein and the subclavian. The right PICC line has been pushed forward, though it is still not within the hemithorax There is increasing opacification at the left base consistent with atelectasis and effusion. Pulmonary vascularity now appears to be essentially within normal limits. Upper zones are clear in the lung. [2129-11-7]: Ultrasound: INDICATION: Right upper extremity swelling and pain. COMPARISONS: None available. FINDINGS: Grayscale and color Doppler images of the right internal jugular, subclavian, axillary, brachial, and cephalic veins were obtained. Normal flow and compressibility was demonstrated throughout. IMPRESSION: No evidence of DVT [2129-11-7]: Ultrasound lower ext: INDICATION: Right leg pain and swelling. COMPARISONS: None available. FINDINGS: Grayscale and color Doppler images of the right common femoral, right deep, superficial femoral veins, popliteal, posterior tibial, and peroneal veins were obtained. Normal flow, compressibility, and augmentation were demonstrated throughout. IMPRESSION: No evidence of DVT 10 4:04 am SPUTUM Source: Endotracheal. FINAL REPORT [2129-11-2] GRAM STAIN (Final [2129-10-30]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [2129-11-2]): Commensal Respiratory Flora Absent. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. CHLORAMPHENICOL =16MCG/ML INTERMEDIATE sensitivity testing performed by Microscan. TIMENTIN <=8MCG/ML SENSITIVE sensitivity testing performed by Microscan. CEFTAZIDIME sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA \| CEFTAZIDIME----------- =>32 R LEVOFLOXACIN---------- 0.5 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: On [2129-10-26], the patient was brought to the operating theatre for urgent laparotomy and abdominal washout for perforated sigmoid diverticulitis. Because of her large ventral hernias and COPD, her abdomen was left open with silastic mesh overlaid on omentum covering viscera. Post-operatively she was admitted to the SICU on acute care surgery. She was started on piperacillin-tazobactam and metronidazole. She was progressively weaned off vasopressors and mechanical ventilation. On [2129-10-29], she was started on vacomycin empirically for fevers. On [2129-10-30], piperacillin-tazobactam was changed to cefepime. CT torso showed persistent abscess in the pouch of [Location (un) ], which was subsequently drained by IR. On [2129-11-1], the patient was extubated, and was transferred to the floor. On [11-4] she returned to the operating room for reconstruction and closure of her abdominal wound. Her pain was controlled with dilaudid. She had her [Last Name (un) ]-gastric tube discontinued on [11-5] has been on a regular diet. Her foley catheter was discontinued on [11-6] and she has been voiding without difficulty. She has been evaluated by physical therapy and nutrition services.She did have a hematocit of 22.7 on [11-7] and received a blood transfusion. Her current hematocrit is 26.9. She was reported to have swelling of her upper extremities and had a negative ultrasound for DVT. Her JP drains have been discontinued. Her ostomy is draining liquid stool. Her final sputum report from [10-28] did show xanthomonas and will need to have a week course of bactrim. Medications on Admission: [Last Name (un) 1724]: Albuterol 90 mcg q4-6, Albuterol Nebs QID, Alendronate 70 qweek, klonopin 0.5'', Advair 250/50'', Lasix 20', Vicodin, Lisinopril 20', Omeprazole 20', home O2, Miralax 17g prn, Pravastatin 80', Spiriva 18 mcg', Chantix Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze/SOB. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: as needed for pain. 8. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 units cc Injection three times a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for diarrhea. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1820] [Last Name (NamePattern1) ] at [Location (un) 1821] for Nursing and Rehab Discharge Diagnosis: Perforated sigmoid diverticulitis with generalized peritonitis. Ventral hernia. COPD. 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 are being discharged from the hospital after having a resection of your colon. Please follow these instructions: you may resume your regular diet resume your pre-hospital medications you may be out of bed as tolerated Followup Instructions: Provider: [Last Name (NamePattern4) ]/EYE LIST OR EYE SURGERY Phone:[Telephone/Fax (1) 253] Date/Time:[2129-12-1] 12:00 Provider: [Name10 (NameIs) 6131] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 253] Date/Time:[2129-12-2] 1:30 Please follow up with the Acute Care Service in 2 weeks. You can schedule this appointment by callling #[Telephone/Fax (1) 600] Completed by:[2129-11-8*] ICD9 Codes: 7907, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5897 }	Medical Text: Admission Date: [2196-5-3] Discharge Date: [2196-5-16] Date of Birth: [2131-11-25] Sex: M Service: [Doctor First Name 147] Allergies: Heparin Agents Attending:[First Name3 (LF) 148] Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 64 year old male with extensive past medical history tranferred from [Location 56198]hospital with pancreatitis. The pateient was in his usual state of health unitl 2 weeks prior to admission. He began to experience nausea vomitting and a diarrheal illnes as well as increased abdominal girth. He denied any pain, hematemesis, dysuria, hematuria, weight loss or similar epsisodes. He had instance of atrial fibrillation at the outside hospital as well bloody stools and was on TPN. He was placed on Imipenem and blood cultures were negative times 3. A CT scan on [4-29] demonstrated pancreatitis with surrounding small bowel inflammation. Past Medical History: 1. hypertension 2. Alcohol abuse No past surgeries Social History: alcohol Family History: Negative for cancer or coronary artery disease Physical Exam: Physical exam on admission was as follows: Temperature 102.2, Pulse 123, Blood pressure 184/75, Respirations 26, Pulmonary artery pressure 33/19, Central venous pressure 7, ABG 7.50/30/69/24/0 on Room air. General: alert and oriented times three in No apparent distress but patient was tremulous Neuro: cranial nerves 2 through 12 were grossly intact Neck: no jugular venous distention, no bruits Cardiac: regular rate and rhythm, no murmurs Lungs: Clear to ausculation bilaterally Abdomen: distended, nontender, tympanetic, no hernias, rectal exam guiac positive, NG output light green Extremities: palpable pulses bilateraly An EKG showed normal sinus rhythm Pertinent Results: ---[2196-5-4] CT abdomen: 1. Small, bilateral pleural effusions with reactive atelectasis. 2. Large amount of peripancreatic inflammation which extends from the transverse mesocolon to the left pericolic gutter. No distinct localized collections are seen. The body and tail of the pancreas appeared to enhance homogeneously. There is heterogeneous enhancement of the head of the pancreas. 3. Ascites and free-fluid within the pelvis. ---[2196-5-4]: echo: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly 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. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There is a brief diastolic indentation of the right ventricular outflow tract without other evidence of right ventricular collapse or tamponade. ---CT abdomen [2196-5-15]: The pancreas remains edematous with a persistent slight heterogeneity of enhancement in the pancreatic head, without interval worsening. There is homogeneous enhancement in the body and tail of the pancreas. There are persistent fluid collections in the lesser sac and in the transverse mesocolon, as well as posterior to the gastroesophageal junction. Fluid is again noted tracking into the left paracolic gutter. There is no gas within the fluid collections. The pancreatic duct is not dilated. There is no intrahepatic or extrahepatic biliary dilatation. The liver, gallbladder, spleen, small bowel and colon appear unremarkable. There is fluid obscuring the right adrenal gland. The left adrenal gland is unremarkable. Bilateral renal cysts are again noted. Brief Hospital Course: The patient was admitted. He was placed on an amiodirone drip, and lopressor for atrial fibrillation. he was made NPO, and an NG tube was in place. His electrolytes were monitored closely and repleted as needed. He was placed on CIWA protocol for alcohol withdrawal. He was also continued on TPN. He was continued on his antibotics, which were discontinued on [2196-5-5]. He continued to be stable until hie had a temperature spike non [2196-5-7]. At this time it was noted that blood cultures and urine cultures taken to date were negative. Imipenem was restarted on hospital day 6 ([2196-5-8]). His NG tube was removed on Hospital day 7. Patient remained stable but had an illeus and was continued on TPN. Addiction services was consulted, but the patient had no interest in rehab after hospitalization. He was started on clears on Hospital day 9. Nutrition was also involved and suggested continuing TPN. The patient had a continuing benigh exam on Hospital day 11 and was passing flatus on a clear diet and on hospital day 12, the patient was changed to a regular diet and began taking his medications by mouth. He had a CT on [5-15] that wsa much improved. The patient was discharged home on Hospital day 14 ([2196-5-16]) in stable condition. Medications on Admission: -Atenolol 50 mg qd -Hydrocholorthiazide 25 mg once daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 4. MEDICAL ALERT BRACELET Have a medialert bracelet made stating "Heparin Antibodies - do not use heparin" and wear bracelet. Discharge Disposition: Home Discharge Diagnosis: pancreatitis PMH: HTN, ETOH abuse PSH: none Discharge Condition: good Discharge Instructions: Go to an Emergency Room if experience new and continuing nausea, vomiting, fevers (>101.5), chills. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 1231] Call to schedule appointment ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5898 }	Medical Text: Admission Date: [2160-5-22] Discharge Date: [2160-6-10] Date of Birth: [2114-3-20] Sex: F Service: MEDICINE Allergies: Methotrexate Attending:[First Name3 (LF) 12174] Chief Complaint: acute acetaminophen toxicity Major Surgical or Invasive Procedure: 1. EGD 2. Intubation, extubation 3. Colonoscopy History of Present Illness: Pt is a 46F w/hx of prior Tylenol OD requiring intubation w/ICP monitoring & ARF requiring CVVH ([10-13]), severe chronic pain secondary to Crohns and ankylosing spondylitis treated with prednisone daily, as well as DVT treated with coumadin who has been transfered from [Hospital6 6640] after significant opiate/acetaminophen ingestion over 48 hrs greater than 4hrs prior to presentation. Per report, pt presented to the OSH with RUQ [Hospital6 1676] pain and tachycardia and reported taking 72 vicodin within 48hrs. Initial labs revealed an acetaminophen level of 176.9, AST/ALT over 12K, INR 16.9, TBili 2.4 & Cr 1.9. She was loaded with acetylcysteine, given 2U FFP, Vit K 10 IM and 1500 in IVF and was transfered to [Hospital1 18] for further management. In the ED she is hypotensive to the 70's-80's and requiring pressor support with 2 pressors after 5L IVF, 3U FFP and 3U PRBCs. A R femoral a-line was placed with ultrasound guidance. She is very anxious, slurring her speech and appears confused. However, she is A&Ox3 and providing some history with redirection. She states that she has been trying to wean herself from long-acting opiates, having transitioned from Oxycontin to dilaudid. She was recently prescribed Vicodin and given 120 tablets. She states she did not know that Vicodin contained acetaminophen and did not intend to hurt herself. She denies suicidality or depression. She reports [10-13] generalized pain with acute worsening in the RUQ and epigastrium. Past Medical History: Past Medical History: h/o Tylenol OD [10/2159] c/b ARF, hepatic failure, VAP, foot necrosis [2-6] pressors; Bilateral DVT [1-/2160]; 8mm clean ulcer at prepyloric antrum seen on EGD [2160-4-15] (H.Pylori neg); Psychiatric disorder (anxiety vs bipolar); chronic pain; h/o domestic abuse; Crohn's disease; anklyosing spondylitis; Long term alcoholism; h/o Hep A; iron-deficiency anemia Past Surgical History: Distal ileum resection [2-/2160], CCY [2156], R hip replacement [2153] c/b multiple infections, L hip replacement [2156] also c/b infections, back/knee surgeries per past notes Social History: Pt denies EtOH abuse or use of illicits, denies depression or suicidality Family History: Father - colitis? (frequent stomach pain) Mother - RA, ankylosing spondylitis Grandmother - ankylosing spondylitis Physical Exam: ADMISSION PHYSICAL: V/S: T 98.1, P 103-115, BP 96-121/60-79, RR 18-27, Pox 98-100% Gen: Intubated and sedated Skin: Warm and dry; mild jaundice Head/Neck: Sclera anicteric, Pupils 3 mm reactive, ETT/OGT in place CV: Tachycardic, +S1S2, no m/r/g Lungs: CTAB Abd: Soft, non-distender, +tenderness RUQ, hyperactive BS Ext: 2+ pulses, no c/c/e Neuro: Sedated but arousable to verbal stimuli, follows commands, no clonus/hyperreflexia DISCHARGE PHYSICAL: afebrile, normotensive Gen: Pleasant female, sitting up in bed, awake, Mildly icteric. NAD. HEENT: Mild jaundice, mildly icteric sclera, MMM. erythematous rash on malar region PULM: no use of access mm, CTA B/L CVS: RRR. Nl S1/S2. [2-10] murmur most prominent at apex. ABD: +BS, distended, midline scar c/w prior resection, non-tender, no rebound or guarding, +hepatomegaly Extremities: gauze over left ankle, right ankle with erythematous clearing rash on ankle, similar over left wrist (improved), and back Neuro: Aox3. moving all extremities, no gross deficits, No asterixis. Pertinent Results: ADMISSION LABS: [2160-5-22] 07:05PM BLOOD WBC-11.5# RBC-2.69 Hgb-7.8* Hct-24.1* MCV-90 MCH-29.1 MCHC-32.5 RDW-14.9 Plt Ct-116# [2160-5-22] 10:38PM BLOOD WBC-24.0# RBC-4.55# Hgb-13.3# Hct-40.0# MCV-88 MCH-29.3 MCHC-33.4 RDW-14.9 Plt Ct-142* [2160-5-22] 07:05PM BLOOD Neuts-94.2* Lymphs-4.9* Monos-0.7* Eos-0.1 Baso-0.1 [2160-5-22] 07:05PM BLOOD PT-60.4* PTT-53.7* INR(PT)-6.6* [2160-5-22] 10:38PM BLOOD Fibrino-212 [2160-5-22] 07:05PM BLOOD Glucose-100 UreaN-31* Creat-1.4* Na-142 K-3.0* Cl-116* HCO3-11* AnGap-18 [2160-5-22] 10:38PM BLOOD Glucose-70 UreaN-37* Creat-1.8* Na-142 K-4.0 Cl-112* HCO3-12* AnGap-22* [2160-5-22] 07:05PM BLOOD ALT-8730* AST-[Numeric Identifier 5161]* AlkPhos-108* TotBili-1.5 [2160-5-23] 02:00AM BLOOD ALT-7060* AST-9040* CK(CPK)-166 AlkPhos-160* TotBili-3.9* [2160-5-23] 05:39AM BLOOD ALT-6330* AST-7790* CK(CPK)-123 AlkPhos-234* TotBili-4.8* [2160-5-23] 10:26AM BLOOD ALT-5920* AST-6130* AlkPhos-241* TotBili-5.5* [2160-5-23] 02:10PM BLOOD ALT-1870* AST-4420* AlkPhos-152* TotBili-5.3* [2160-5-23] 08:05PM BLOOD ALT-4730* AST-3200* AlkPhos-134* TotBili-5.4* [2160-5-24] 12:17AM BLOOD ALT-4348* AST-1308* CK(CPK)-44 AlkPhos-119* TotBili-4.7* [2160-5-24] 05:00AM BLOOD ALT-3791* AST-[2067]* CK(CPK)-34 AlkPhos-116* TotBili-4.7* [2160-5-24] 12:55PM BLOOD ALT-3726* AST-1263* LD(LDH)-265* AlkPhos-116* TotBili-4.5* [2160-5-24] 09:05PM BLOOD ALT-3188* AST-842* LD(LDH)-303* AlkPhos-131* TotBili-4.8* [2160-5-25] 01:56AM BLOOD ALT-2968* AST-649* LD(LDH)-282* AlkPhos-139* TotBili-5.0* [2160-5-22] 07:05PM BLOOD Lipase-70* [2160-5-22] 07:05PM BLOOD Albumin-2.8* Calcium-6.4* Phos-4.2 Mg-1.6 [2160-5-22] 07:05PM BLOOD Ammonia-28 [2160-5-22] 07:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-110* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2160-5-22] 07:24PM BLOOD Type-[Last Name (un) ] pO2-71* pCO2-25* pH-7.22* calTCO2-11* Base XS--15 Comment-GREEN TOP [2160-5-22] 07:24PM BLOOD Glucose-75 Lactate-2.2* K-2.4* DISCHARGE LABS: [2160-5-30] 05:25AM BLOOD calTIBC-248* Hapto-51 Ferritn-328* TRF-191* [2160-6-3] 06:38AM BLOOD WBC-4.9 RBC-3.06* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.2 MCHC-33.7 RDW-18.4* Plt Ct-244 [2160-6-3] 06:38AM BLOOD PT-13.6* PTT-28.8 INR(PT)-1.2* [2160-6-3] 06:38AM BLOOD Glucose-74 UreaN-7 Creat-0.5 Na-140 K-4.1 Cl-106 HCO3-30 AnGap-8 [2160-6-3] 06:38AM BLOOD ALT-214* AST-38 AlkPhos-218* TotBili-2.5* [2160-6-3] 06:38AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.6 [2160-6-5]: Na 142 K 4.1 Cl 106 HCO3 28 BUN 11 Cr 0.6 BG 76 Ca 9.0 Mg 1.7 P 4.1 ALT 133 AST 29 AP 187 Tbili 1.4 WBC 3.8 Hct 28.5 Hgb 9.7 Plt 292 INR 1.2 MICRO: Blood Culture, Routine (Final [2160-5-28]): NO GROWTH. Urine culture [2160-5-22]: [2160-5-22] 11:19 pm URINE Source: Catheter. FINAL REPORT [2160-5-25] URINE CULTURE (Final [2160-5-25]): THIS IS A CORRECTED REPORT [2160-5-25]. Reported to and read back by DR [Last Name (NamePattern4) 80602] [2160-5-25] 1125AM. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. PREVIOUSLY REPORTED AS ESCHERICHIA COLI PRESUMTIVE IDENTIFICATION([2160-5-24]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMIKACIN-------------- <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- =>512 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R STUDIES: CXR [2160-5-22]: IMPRESSION: Low lung volumes with probable bibasilar atelectasis. LIVER U/S [2160-5-22]: IMPRESSION: Limited duplex ultrasound with hepatic vasculature appearing grossly patent. PATHOLOGY [2160-5-29]: DIAGNOSIS: Proximal rectal mucosal biopsy: Colonic mucosa with focal surface erosion and lamina propria acute inflammation; no significant architectural distortion or features of chronic injury. Five levels examined. Note: The most likely etiology is a localized vascular or drug-related ischemic injury. Clinical correlation is recommended. COLONOSCOPY [2160-6-3]: Findings: Mucosa: Normal mucosa was noted. Cold forceps biopsies were performed for histology throughout the whole colon. Excavated Lesions A few non-bleeding diverticula were seen in the whole colon. Diverticulosis appeared to be of mild severity. The single shallow circular non-bleeding 1 cm ulcer was found in the distal rectum. Impression: Normal mucosa in the colon (biopsy) Ulcer in the colon Diverticulosis of the whole colon Otherwise normal colonoscopy to terminal ileum Recommendations: Single shallow circular non-bleeding 1 cm ulcer was found in the distal rectum. This was not bleeding. Normal mucosa to terminal ileum without gross evidence of colitis. Random biopsies performed. Please await biopsy results.Given patients narcotic requirement will require MAC anesthesia for future colonoscopy. Please return to [Hospital1 ]. COLONIC BIOPSIES: [2160-5-29]: Colonic mucosa with focal surface erosion and lamina propria acute inflammation; no significant architectural distortion or features of chronic injury. Five levels examined. [2160-6-3]: Colonic mucosa with no diagnostic abnormality. No granulomas or dysplasia are identified. Brief Hospital Course: Pt is a 46yo F with PMH of Crohn's disease, past chronic pain, presenting as a transfer from [Hospital6 6640] with acute liver failure status post vicodin overdose and attempted suicide. She was admitted to the surgical intensive care unit on [2160-5-22] with acute acetaminophen toxicity. Her mental status declined over the next 24 hours as her liver and kidney function declined, and she was intubated electively on [2160-5-23] for worsening mental status / airway protection. At the time of admission she was given a bolus of N-acetylcysteine (NAC) and started on a maintenance drip. She was volume resuscitated in the ED and initially required norepinephrine for blood pressure support however this was weaned off on hospital day #2. Starting on hospital day #[2-7] she began to show signs of improvement in terms of her liver and kidney function. She was extubated on [5-26] without difficulty. LFTs and creatinine at that point were improving daily. She was started on clears and advanced to a regular diet. Her mental status was back to baseline alert, oriented and conversant. Given Ms. [Known lastname 80603] complex social issues and history of narcotic abuse, she was deemed not a candidate for liver transplantation and transferred to medicine. She had a lower GI bleed, requiring transfusions in the ICU. A sigmoidoscopy showed a rectal ulcer. She subsequently had a colonoscopy with again evidence of rectal ulcer, but no active bleeding. Hepatic function continued to improve and psychiatry was consulted for assistance in management of suicide attempt. She was transferred the medical floors where she continued to improve. *PT IS MEDICALLY CLEARED AND STABLE FOR TRANSFER TO PSYCH FACILITY* # Acetaminophen overdose: Pt was treated with NAC and monitored in the ICU. She slowly improved and was extubated. LFT's were trended, initially with transaminases >10,000 that slowly improved over time. Her LFT's had almost completely normalized at the time of transfer. Psychiatry was consulted and recommended inpatient treatment once pt medically cleared. Once pt was stable, she was transferred to inpatient psychiatric admission. Labs for chem-7, AST/ALT, AP, Tbili 1x weekly # ESBL K. Pneumoniae UTI: Found on urine culture during admission to ICU, which grew resistant Klebsiella for which she was treated with meropenem. # Crohn's Disease: Patient currently on prednisone as an outpatient as poor response to methotrexate. Initially started on steroid bursts for concern of adrenal insufficiency while in the ICU. Eventually tapered to 10 mg prednisone po daily (home dose is 5 mg daily), with plans to continue the same dose. She had intermittent [Known lastname 1676] pain associated with her Crohn's. Her pain was controlled with Morphine IR. She will follow-up with GI on discharge for further management. # Lower GI bleed: Pt had bleed during MICU course. Flex sigmoidoscopy showed rectal ulcer that was presumable source of bleeding. Transfused 4 units of PRBC's with maintenace of hemodynamic stability. Coumadin for previous DVT's held (see below). Biopsies from the sigmoidoscopy showed focal surface erosion and lamina propria acute inflammation. On the medicine floors she had one more episode of bloody stools during her prep for colonoscopy. Follow up colonoscopy showed diverticulosis throughout with 1cm rectal ulcer and biopsies taken, with no active bleeding. She had no recurrent bleeding for >72hours prior to transfer. Her hematocrit was stable, at her baseline (Hct 27-29) on the day of discharge. Biopsies showed colonic mucosa with no diagnostic abnormality, no granulomas. Pt will follow-up with GI on discharge. # Gastric ulcer: seen on EGD from OSH. Pt was placed on Famotidine during this admission. Her coumadin was discontinued. She should have repeat EGD as an outpatient with GI. # Thrombocytopenia with history of hypercoagulation: Baseline platelet level from [Month (only) 956] was 200 thousands. Admission platelet 116 which drifted to 60's. Similar drop in [Month (only) 359] [2159] on prior admission for APAP overdose. No evidence of splenomegaly/sequestration or DIC as fibrinogen >400. Initial concern for HIT but HIT Ab's negative. Platelets eventually began to increase with resolution of hepatic decompensation. Platelets remained stable and were within normal limits on discharge. # History of DVT's, upper extremities from [1-/2160]: pt had been anti-coagulated previously on Coumadin, with INR supratherapeutic on admission (INR 6.6). Coumadin was held given GIB. Additionally, pt is not a good Coumadin candidate given past suicide attempts. # Tinea corporis: Treated with topical terbinazole. Oral medications not preferred given recent hepatic failure. Dermatology was consulted and scrapings were sent, with KOH showing septate hyphae. She was switched to Ketoconazole cream, to be applied twice daily to extremities. Pt was aware to keep extremities covered and to avoid direct contact with others to avoid spread. # Lower extremity wounds: Wound assessment: Type: r/t pressors Location:left medial ankle Size: approx. 5 x 4 cm Wound bed: red, friable with yellow biofilm Exudate: moderate-large (pt did not have absorptive dressing in place-Adaptic was in place instead and the dressing had not been changed for 3 days) Odor: none Wound edges: irregular Periwound tissue: scar, intact, dry Wound Pain: 0 /10 Recommendations: Elevate LE's while sitting. Moisturize B/L LE's, periwound tissue and feet [Hospital1 ] with Aloe Vesta Moisture Barrier Ointment. Left medial ankle ulcer: Commercial wound cleanser to irrigate/cleanse. Pat the tissue dry with dry gauze. Apply moisture barrier ointment to the periwound tissue with each drg change. Apply Aquacel AG (cut 4 x 4" in half) over the wound bed and barely dampen with normal saline Cover with dry gauze, ABD, Kling wrap Change dressing daily. Spiral Ace Wraps to B/L LE's from just above the toes to just below knees. (you will need two 4" aces for each leg) Elevate B/L LE's for 30 minutes prior to application. Remove ace wraps at bedtime. Pt will follow-up with plastic surgery on discharge for further management. TRANSITIONAL CARE: 1. CODE: FULL 2. CONTACT: CASE WORKER [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 1968] - [Telephone/Fax (1) 80604] Daughter [First Name4 (NamePattern1) 80605] [Last Name (NamePattern1) 80606] [Telephone/Fax (1) 80607] (HCP); cell [Telephone/Fax (1) 80608] Son [Name (NI) ] [Name (NI) 80606] (Alternate HCP if unable to reach [Name (NI) 80605]) [Telephone/Fax (1) 80609] [Sister, info from prior admission: [Name (NI) ] [Known lastname 40984]. Home: [Telephone/Fax (1) 80610], Cell: [Telephone/Fax (1) 80611]] 3. FOLLOW-UP: - PCP after psychiatric admission - GI with repeat EGD - Plastics 4. MEDICAL MANAGEMENT: - START Famotidine, Prednisone 10mg, Calcium, Vitamin D, Morphine for pain control, Ondansetron prn nausea, Trazodone prn insomnia, Continue colace - STOP Coumadin, NO Vicodin or any acetaminophen products 5. RISKS TO REHOSPITALIZATION: - Past suicide attempts, depression 6. OUTSTANDING TASKS: - scrapings from skin taken [2160-6-6] pending Medications on Admission: Coumadin Oxycontin Doxepin Prednisone Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: This medication can cause sedation and should not be taken while driving or doing heavy activity. DO NOT take more than the prescribed amount. . 6. ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: MEDICALLY CLEARED AND STABLE FOR DISCHARGE TO INPATIENT PSYCHIATRIC TREATMENT Primary Diagnoses: 1. Fulminant hepatic failure [2-6] Tylenol overdose 2. Suicide attempt 3. GI bleeding 4. Thrombocytopenia 5. Tinea corporis Secondary Diagnoses: 1. Crohn's disease 2. Chronic pain 3. Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 40984], It was a pleasure taking care of you during this admission. You were admitted after a toxic level of Vicodin ingestion. You had acute liver failure from this amount of Tylenol, which required a stay in the ICU for close monitoring. Your liver function slowly improved. You also had bleeding from the rectum and colonoscopy showed a rectal ulcer. You were transfused blood for this. Your blood levels thereafter remained stable. The psychiatrists saw you for the suicide attempt, and recommended inpatient treatment which you will continue when you leave here. During this hospitalization, you were found to have a urinary tract infection which was treated with intravenous antibiotics. You had a fungal infection in your skin, for which the dermatologists saw you and recommended cream. You will need to continue to apply this cream twice daily and keep your arms and legs covered to avoid direct contact with others. The following medications were changed during this admission: - STOP Vicodin, Oxycontin, or any other pain medications you were taking or had prescriptions for prior to this admission - STOP Coumadin - STOP Doxepin - Increase the dose of Prednisone from 5mg daily 10mg by mouth daily - START Calcium 500mg by mouth twice daily - START Vitamin D 1000mg by mouth daily - START Famotidine 20mg by mouth twice daily - START Trazodone 25mg by mouth at night as needed for insomnia - START Ondansetron 4mg tablet by mouth every 8 hours as needed for nausea - START Ketoconazole cream apply to right leg, back and left wrist twice daily until further advised by the dermatologists. - START Morphine IR 15mg by mouth every 4 hours as needed for pain This medication can cause sedation and should not be taken while driving or doing heavy activity. DO NOT take more than the prescribed amount. - CONTINUE Colace 100mg by mouth twice daily to prevent constipation IT IS VERY IMPORTANT THAT YOU DO NOT EVER OVERDOSE ON TYLENOL OR ANY OTHER MEDICATION AGAIN, AS THIS IS LIFE-THREATENING It was a pleasure taking care of you during this admission! Followup Instructions: Please follow-up with the following appointments: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2160-6-18] at 1:30 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 22561], 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 Your GI doctors recommended a repeat endoscopy to assess for the gastric ulcer seen previously. Please discuss this with them at your next appointment. They will help to arrange this. Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 18] DIVISION OF PLASTIC SURGERY Address: [Doctor First Name ], STE 5A, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 6331] Appointment: Friday [2160-6-27] 9:15am Department: DERMATOLOGY When: TUESDAY [2160-7-8] at 1 PM With: [Name6 (MD) 6821] [Name8 (MD) ], MD [Telephone/Fax (1) 1971] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please follow-up with the psychiatrists. You will need to schedule an appointment with your primary care doctor when you leave the inpatient psychiatric hospital. Please call your primary care doctor, Dr. [Last Name (STitle) 51466], after you are discharged to schedule a follow-up appointment. His office can be reached at [Telephone/Fax (1) 53977]. Completed by:[2160-6-10] ICD9 Codes: 5845, 5990, 2762, 2875, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5899 }	Medical Text: Admission Date: [2130-4-6] Discharge Date: [2130-4-18] Date of Birth: [2070-8-26] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: Splenic rupture Major Surgical or Invasive Procedure: [2130-4-6] Splenectomy [2130-4-14] VAC placement [2130-4-17] VAC replacement History of Present Illness: 59 year old gentleman with known hepatitis C and who presented to ED hypotensive and found to have hemoperitoneum. CT scan revealed splenic blush. He was taken to interventional radiology, but remained tachycardiac and unstable with rising lactate and therefore was taken to the operating room for emergency splenectomy. Past Medical History: Hepatitis C Gallstones Polysubstance abuse Depression with suicidal ideation psychotic with schizophrenic symptoms s/p crushed elbow s/p hernia repair h/o withdrawal seizures Social History: He was currently at [Hospital1 ]. Has h/o polysubstance abuse. Family History: Noncontributory Physical Exam: Upon admission to ED: BP 142/86 HR 86 T 97.1 RR 16 O2 Sat 99% Gen: No acute distress - A & O x3 HEENT:left post scalp lac ~2cm; PEARRLA Cor: RRR Chest: rhonci LLL Abd: soft, NT Pertinent Results: [4-5] Abd CT: Multiple splenic lacs with multifocal active extrav dr [Last Name (STitle) ] pole, posterior mid-pole), subcapsular hematoma and hemoperitoneum. No rib fractures. [4-5] Head CT: no acute hemmorhage; left subgaleal hematoma, no fx [4-5] C-spine CT: no acute fracture [4-6] Angio: active bleed f/splenic a. Embolized w/coils and thrombin [4-10] RLE U/S: No DVT [4-12] CT abd pelvis: Sm simple fluid in the post-splenectomy bed. Sm amount of pelvic fluid. No dehiscence. A 4.3 x 2 cm right groin hematoma. LLL pneumonia? [2130-4-6] 04:18PM LACTATE-3.5* [2130-4-6] 04:05PM GLUCOSE-171* UREA N-14 CREAT-1.0 SODIUM-143 POTASSIUM-4.9 CHLORIDE-116* TOTAL CO2-18* ANION GAP-14 [2130-4-6] 04:05PM CALCIUM-9.3 PHOSPHATE-4.4 MAGNESIUM-2.5 [2130-4-6] 04:05PM WBC-19.92# RBC-3.20 HGB-9.7* HCT-26.9* MCV-84 MCH-30.2 MCHC-36.0* [2130-4-6] 04:05PM PLT COUNT-89* [2130-4-6] 04:05PM PT-16.6* PTT-35.5* INR(PT)-1.5* [2130-4-6] 04:05PM FIBRINOGE-101* Brief Hospital Course: He was admitted to the Trauma Service and initially taken to Interventional Radiology for embolization of splenic artery; he became hemodynamically unstable and was then taken to the operating for splenectomy. A liver wedge resection was also performed. He received 9 units packed red cells (7 units prior to going to OR) 4 units fresh frozen plasma and 1 unit platelets given. Postoperatively, he was taken to the Trauma ICU where he remained for several days with ongoing tachycardia and hypotension; he required further crystalloid and blood products. The tachycardia and hypotension did eventually resolve. On [4-7] he was extubated, receiving PCA for pain control. His Hct remained stable. He was transferred to the regular nursing unit. He was noted with right leg swelling on [4-10] and underwent RLE LENIS which was negative for deep vein thrombus. Psychiatry was consulted given his history of substance abuse and for Methadone taper. Per patient's request he wanted to continue his taper while in the hospital until it was discontinued and did not want to follow up with the [Hospital 2514] clinic as an outpatient. He was also started on Remeron at hs per recommendation of Psychiatry. He was given an appointment to follow up with his outpatient mental health provider after discharge. On [4-12] he was noted with copious drainage from his abdominal incision site; CT of his abd/pelvis were done to rule out fascial dehiscence and none was noted. Hepatology was consulted and made several recommendations for continuing the Lasix which had already been started and to add, lactulose, spironolactone and albumin. A wound VAC was applied on [4-14] and removed on [4-16]. The wound continued to drain large amounts of ascitic fluid and the VAC was replaced. Plans for discharge to home with VAC were arranged. Instructions for follow up with the Liver Center were provided to him. He was evaluated by Physical therapy and was cleared for discharge to home. Skilled nursing services were arranged for providing wound care at home given the VAC dressing. Follow up discharge instructions were provided to him. Medications on Admission: [Last Name (un) 1724]: Ativan 0.5, ?Klonopin 1mg QID, ?Methadone 120mg daily, ?Celexa 60mg daily Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 2. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). Disp:qs ML(s) Refills:0 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:45 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Splenic laceration - Grade III-IV Ascites Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: It is important that you avoid being around people who have a cold or the flu. NO heavy lifting of greater than 10 lbs because of your abdominal incision. Your methadone was stopped while you were hospitalized. Do not start taking methadone again unless told to do so by a physician. Return to the Emergency room if you develop any fevers, chills, headaches, dizziness, chest pain, shortness of breath, redness/drainage from your incision, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [Last Name (STitle) ], Trauma Surgery, next week for removal of your staples and evaluation of your wound. Call [Telephone/Fax (1) 6429] for an appointment. Follow up with Dr. [Last Name (STitle) 7033] in the Liver Center in the next [1-6] weeks, call [Telephone/Fax (1) 2422] for an appointment. Follow up with your primary care doctor in the next 1-2 weeks, you will need to call for an appointment. You also haven an appointment with [Hospital1 1680] Counseling in [Location (un) 3786] on [2130-5-1] at 8:30am. Address is [Street Address(2) 31724], [Location (un) 3786], Ma, [Location (un) ]. Phone number: [Telephone/Fax (1) 36058] Completed by:[2130-5-5] ICD9 Codes: 2851, 2762, 5715, 2875

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