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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5900
} | Medical Text: Admission Date: [**2148-12-26**] Discharge Date: [**2148-12-30**]
Date of Birth: [**2148-12-26**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: This is a 2800 gram, 36 and [**5-6**]
week gestation male born to a 31 year old, gravida I, para 0,
now I, woman.
PRENATAL SCREENS: A positive, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, GBS unknown.
Pregnancy complicated by hyperemesis and hypertension. New
secondary to pregnancy induced hypertension. Rupture of
membranes approximately ten hours prior to delivery.
Intrapartum antibiotics started twelve hours prior to
delivery. No maternal fever or fetal tachycardia. Infant
delivered by cesarean section due to failure to progress.
Apgar eight at one minute and eight at five minutes.
Nurse practitioner called to evaluate the infant due to
grunting. Infant with grunting and retractions. Infant
brought to the Neonatal Intensive Care Unit for evaluation of
respiratory distress.
PHYSICAL EXAMINATION: On admission, birth weight 2800 grams,
length 18.5 inches, head circumference 34 centimeters.
Anterior fontanelle soft, flat, nondysmorphic, intact palate.
Tachypneic with shallow respirations, fair aeration, grunting
when disturbed, mild retractions, pink with needle cannula in
place. Grade II/VI murmur left sternal border, normal
pulses. The abdomen is soft, three vessel cord, no
hepatosplenomegaly. Normal male genitalia, both testes
descended into scrotum. No hip click. No sacral dimple.
Normal tone.
HOSPITAL COURSE:
1. Respiratory - The infant was admitted to the Neonatal
Intensive Care Unit for respiratory distress shortly after
delivery and was placed on nasal cannula and had increased
respiratory distress and required nasal CPAP 6.0 centimeters
of water, 25% FIO2. Arterial blood gas was pH 7.31, pCO2 46,
paO2 71, pCO2 24, base excess -3. The infant was also
tachypneic with respiratory rate 80 to 100. Infant
transitioned to room air from CPAP by day of life two. The
infant remains in room air with respiratory rate 50s to 60s,
no apnea or bradycardia this hospitalization.
2. Cardiovascular - The infant has remained hemodynamically
stable this hospitalization, no murmur, heart rate 120 to 140
with mean blood pressure 48 to 54.
3. Fluid, electrolytes and nutrition - Initially the infant
was NPO receiving 50cc/kg/day of D10W. Enteral feeds were
started on day of life two. The infant was advanced to full
volume feedings by day of life three. The infant is
currently taking a minimum of 60cc/kg/day of breast milk 20
or Enfamil 20 p.o. Glucose has remained stable and has been
69 to 114. The infant tolerated feeding advancement without
difficulty. Serum electrolytes were drawn on day of life one
which showed a sodium of 138, chloride 103, potassium 4.0,
bicarbonate 24. The most recent weight is 2640 grams.
4. Gastrointestinal - The infant had a bilirubin level drawn
on day of life three which showed a total bilirubin of 11.1
and a direct of 0.4. The infant is currently not under
phototherapy at this time and a repeat bilirubin level is
being checked on [**2149-1-10**].
5. Hematology - The infant has not received any blood
transfusions this hospitalization. The hematocrit on
admission was 42.0%.
6. Infectious disease - The infant received 48 hours of
Ampicillin and Gentamicin for respiratory distress. Blood
cultures remained negative to date. The complete blood count
on admission showed a white blood cell count of 16.7,
hematocrit 42.0%, platelet count 349,000, 68 neutrophils, 4
bands.
7. Sensory hearing screening was performed with automated
auditory brain stem responses. The infant passed both ears.
8. Psychosocial - Parents involved.
CONDITION ON DISCHARGE: Stable in room air.
DISCHARGE DISPOSITION: To Newborn Nursery.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], telephone [**Telephone/Fax (1) 54092**].
FEEDINGS AT DISCHARGE: Breast milk 20 calories per ounce or
Enfamil 20 calories per ounce p.o. ad lib, minimum
60cc/kg/day, breast feeding ad lib.
MEDICATIONS: None.
CAR SEAT POSITION SCREEN: Recommended prior to discharge.
STATE NEWBORN SCREEN: Sent on day of life three, results are
pending.
IMMUNIZATIONS: The infant has not received immunizations
this hospitalization. Hepatitis B vaccine is recommended
prior to discharge.
FOLLOW-UP APPOINTMENTS: Primary pediatrician is scheduled
for Friday, [**2149-1-3**].
DISCHARGE DIAGNOSES:
1. Prematurity, 36 and [**5-6**] week gestation male.
2. Status post respiratory distress.
3. Status post rule out sepsis, ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2148-12-30**] 16:23
T: [**2148-12-30**] 16:58
JOB#: [**Job Number 54093**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5901
} | Medical Text: Admission Date: [**2125-5-15**] Discharge Date: [**2125-6-1**]
Date of Birth: [**2125-5-15**] Sex: M
Service:
DISCHARGE DIAGNOSIS:
Premature male infant 34 weeks gestation.
HISTORY OF PRESENT ILLNESS: [**Known lastname **] is the former 2.040
kilogram male infant born at 34 weeks gestation to a 38
history notable only for a TAB at six weeks gestation.
Prenatal screens revealed mother is A negative, group B strep
unknown, remaining screens were noncontributory.
Rhogam was administered at 28 weeks. Pregnancy was otherwise
uncomplicated until hypertension developed one week prior to
delivery. Mother was placed on bed rest and admitted to [**Doctor First Name **]
worsening hypertension. She was started on magnesium sulfate
and one dose of antibiotics prophylaxis was administered one
hour prior to delivery. She was induced for progression of
pregnancy induced hypertension with subsequent fetal
bradycardia to 40 beats per minute leading to stat cesarean
section under general anesthesia.
The infant emerged with Apgars of 7 and 8. He was admitted
to the [**Hospital3 **] Special Care Nursery.
On admission he weighted 2.040 kilograms. His head
circumference was 32 cm and his length 47.5 cm all
appropriate for gestational age.
PROBLEMS DURING HOSPITAL STAY: 1. Respiratory: The infant
remained in room air throughout the hospital course. He had
a rare episode of apnea and bradycardia. He was free of
these episodes for five days prior to discharge.
2. Cardiovascular: There were no cardiovascular issues.
3. Infectious disease: An initial CBC was obtained, which
had a white count of 8.4 with 17 polys, 2 bands and 79
lymphocytes with a hematocrit of 54.8 and a platelet count of
151,000. There were no risk factors for sepsis and
antibiotics were not initiated. Blood culture obtained at
the time of CBC was negative at 48 hours.
4. Feeding and nutrition: At the time of discharge the
infant weighed 2.325 kilograms. He was feeding ad lib demand
of Enfamil 24 with iron ad lib demand and was taken upward of
145 cc per kilogram per day.
5. Hearing screening performed on [**5-26**] and was normal.
6. Circumcision performed on [**5-28**].
7. Hepatitis B immune vaccine given on [**5-26**].
8. Hematologic: Mother was A negative, baby A positive,
[**Name (NI) 36243**] negative. Peak bilirubin was 12.4 for which he
underwent 24 hours of phototherapy. Rebound bili was 6.6.
The patient is being discharged home with family. He will
have a follow up visit within five days of discharge at
[**Hospital1 **] [**Hospital1 8**] Center Dr. [**Last Name (STitle) 41658**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38370**]
Dictated By:[**Last Name (NamePattern1) 38304**]
MEDQUIST36
D: [**2125-5-30**] 09:12
T: [**2125-5-30**] 09:23
JOB#: [**Job Number 41659**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5902
} | Medical Text: Admission Date: [**2134-10-14**] Discharge Date: [**2134-11-8**]
Date of Birth: [**2066-11-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever and hypotension
Major Surgical or Invasive Procedure:
diagnositic and therapeutic paracentesis
PICC line placement
Skin biopsy
Bronchoscopy
Bone Marrow Biopsy
Wound Care
History of Present Illness:
67 yo male w/ MDS with recent admission from [**Date range (1) 73061**] to
surgical service for R. hemicolectomy with end ileostomoy and
mucous fistula admitted on [**2134-10-14**] with SIRS/early sepsis with
unknown source of infection.
.
Admission [**Date range (1) 73061**] was for evaluation for bilateral
erythema/blisters on arms after injections/ treatment with IM
vidaza for his MDS on [**9-20**]. His hospital course was
complicated by necrotic bowel and an exp lap was performed with
hemicolectomy and end ileostomy and mucous fistula ([**2134-9-28**]).
He required intubation for respiratory distress and
cardioversion for atrial fibrillation. Also developed VRE
(sensitive to daptomycin) in peritoneal fluid, discharged on
daptomycin.
.
ER visits [**10-12**] and [**10-13**]: Presented with concern of infected
wound dehisence, evalutated by surgery, discharged with bactrim
and keflex for presumed wound infection and concomittant UTI.
Represented the following day with hypotension, fever, Hct of 21
and INR of 8. Received total 6 Units PRBC, 1 unit FFP and IVF,
vitK. Rt IJ placed, started on Dapto/Zosyn.
.
SICU admission [**10-14**]: Presentation notable for skin lesion,
fever, hypotension, HCT drop, and elevated INR. He was continued
on daptomycin and pip-tazo. The patient has had volume
responsive hypotension with no current pressor requirement. He
underwent U/S-guided paracentesis w/ removal of 2700cc. He was
found to have erythema surrounding his abd incision with an
additional erythematous nodule on the R thigh. The etiology of
the patient's presentation has been unclear, however possible
infectious sources include a secondary wound infection vs.
hematogenous spread of an alternate underlying infection. The
patient's skin findings are felt to be more consistent with
inflammatory etiology (as opposed to infectious etiology).
Prelim biopsy for hip and peri-incisional biopsies read as
neutrophilic dermatosis (pyoderma gangrenosum), though cannout
rule out infectious process.
.
Upon admission to [**Hospital Unit Name 153**] patient reports intermittent abdominal
pain mid-abdomen fluctuating in intensity [**2134-4-24**], no radiation.
Occasional nausea, no vomitting. Ostomy output loose and brown.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations. He
feels generalized weakness. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias.
Past Medical History:
Myelodysplastic syndrome, Carpal tunnel syndrome, COPD.
Past Surgical History:
L knee surgery, back surgery.
Social History:
Retired, used to work for a chemical company. History of
asbestos and other chemical exposure. He has a history of
significant alcohol use, which he stopped approximately seven
years ago. 60 pack year history of tobacco use. Has a daughter.
Lives alone. Was going to the gym every other day and walking
4 miles before his necrotic bowel surgery.
Family History:
Per med record: Sister - died of scleroderma; Another sister -
died of unclear etiology; Brother - died of EtOH abuse; Daughter
with Marfan's; Two brothers are alive and well; Mother - died of
lung cancer; Father - died in an MVC.
Physical Exam:
GEN: no acute distress, lying in bed
HEENT: Dry mucous membranes with white plaque on tongue. No LAD.
Lungs: coarse breath sounds, expiratory wheezing on right,
rhonchi anteriorly, with bibasilar crackles bilaterally
CV: tachycardic, regular rhythm, normal S1 S2, no M/G/R. R IJ
site c/d/i
BACK: no focal tenderness, no CVAT
GI: abdomen with large midline open incision extended from pubic
symphisis to subxiphoid with serosanguinous drainage. Ostomy
with dark necrotic appearing mucosa.
GU: foley in place draining yellow urine.
MSK: no joint swelling or erythema
EXT: trace pitting edema bilaterally
SKIN: mucocutaneous fistula site with necrotic center. 2cm
nodular lesion on lateral aspect of R thigh with surrounding
erythema, warm, and tender to touch.
NEURO: CN2-12 grossly intact, UE 5/5 strength, LE RLE [**1-22**]
strength and LLE able to lift against gravity.
Pertinent Results:
Labs upon admission:
[**2134-10-13**] 06:35PM BLOOD WBC-8.0 RBC-2.38* Hgb-7.7* Hct-21.9*
MCV-92 MCH-32.2* MCHC-34.9 RDW-18.4* Plt Ct-70*
[**2134-10-13**] 06:35PM BLOOD Neuts-79.2* Bands-0 Lymphs-13.0*
Monos-3.9 Eos-3.6 Baso-0.2
[**2134-10-16**] 05:37AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL
[**2134-10-13**] 06:35PM BLOOD PT-51.0* PTT-45.9* INR(PT)-5.6*
[**2134-10-14**] 04:51AM BLOOD Fibrino-625*
[**2134-10-18**] 03:33AM BLOOD Gran Ct-1794*
[**2134-10-14**] 04:51AM BLOOD Ret Aut-3.1
[**2134-10-18**] 03:33AM BLOOD ACA IgG-PND ACA IgM-PND
[**2134-10-13**] 06:35PM BLOOD Glucose-108* UreaN-19 Creat-1.1 Na-129*
K-4.0 Cl-96 HCO3-26 AnGap-11
[**2134-10-14**] 04:51AM BLOOD ALT-24 AST-29 LD(LDH)-132 AlkPhos-78
TotBili-2.0*
[**2134-10-13**] 06:35PM BLOOD proBNP-1421*
[**2134-10-14**] 04:51AM BLOOD Albumin-2.4* Calcium-7.2* Phos-4.2 Mg-1.7
[**2134-10-14**] 04:51AM BLOOD Hapto-268*
[**2134-10-17**] 10:40PM BLOOD Ferritn-3219*
[**2134-10-17**] 10:40PM BLOOD Triglyc-79
[**2134-10-17**] 04:02AM BLOOD Osmolal-283
[**2134-10-17**] 04:02AM BLOOD TSH-2.4
[**2134-10-17**] 04:02AM BLOOD Cortsol-33.7*
[**2134-10-18**] 03:33AM BLOOD ANCA-NEGATIVE B
[**2134-10-18**] 03:33AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2134-10-14**] 04:44AM BLOOD Type-CENTRAL VE pO2-85 pCO2-38 pH-7.46*
calTCO2-28 Base XS-2 Comment-GREEN TOP
[**2134-10-13**] 06:46PM BLOOD Glucose-107* Lactate-1.3 Na-130* K-4.1
Cl-94* calHCO3-27
[**2134-10-13**] 06:46PM BLOOD Hgb-8.1* calcHCT-24
[**2134-10-14**] 04:44AM BLOOD freeCa-1.00*
Labs upon discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2134-11-8**] 00:10 1.8* 2.80* 8.1* 24.3* 87 28.9 33.4 13.8 26*
Platelets post transfusion: 54*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2134-11-8**] 00:10 103*1 35* 0.6 136 4.3 98 33* 9
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2134-11-8**] 00:10 30 15 161 60 0.5
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2134-11-8**] 00:10 3.5 8.7 3.0 2.1
AUTOANTIBODIES ANCA
[**2134-10-18**] 03:33 NEGATIVE B1
OLD S# [**Serial Number **]C
NEGATIVE BY INDIRECT IMMUNOFLUORESCENCE
IMMUNOLOGY [**Doctor First Name **]
[**2134-10-18**] 03:33 NEGATIVE
B-Glucan, Galactomannan: negative
.
CXR [**2134-10-13**]: Small bilateral pleural effusions. Equivocal signs
for mild
pulmonary vascular congestion. Otherwise, unremarkable.
.
CT Abdomen [**2134-10-13**]: 1. Large volume ascites with mild
peritoneal enhancement in the right paracolic gutter. Overall
appearance appears simple though given history of recent
surgery, peritonitis cannot be excluded. Consider paracentesis
with culture.
2. Post operative changes rel;ated to recent bowel resection
without evidence of bower obstruction or perforation.
3. Small bilateral pleural effusions with bilateral lower lobe
compressive
atelectasis.
.
Right hip skin biopsy [**2134-10-14**]: The findings in both specimens
are similar, with intense neutrophilic infiltration of the
dermis. The overlying epidermis exhibits neutrophilic
spongiosis with foci of spongiform pustulation; in specimen 2,
frank cleavage is noted through the spinous layer. No
micro-organisms are identified within the inflamed tissue in
PAS, GMS, and Gram stained sections
.
Paracentesis: Technically successful diagnostic and therapeutic
paracentesis yielding 2.7 liters of amber clear ascitic fluid,
which was sent for microbiology and cell count.
.
Liver/RUQ Ultrasound [**2134-10-18**]: Ascites. Sludge within the
gallbladder. No gallstones. No dilated bile ducts. No focal
lesions seen in the liver. Assessment was limited to the liver,
gallbladder and related structures.
.
CXR [**2134-10-19**]: In comparison with the study of [**10-17**], there are
continued low lung volumes. Persistent enlargement of the
cardiac silhouette with some indistinctness of pulmonary vessels
consistent with some elevation of
pulmonary venous pressure. Probable mild bilateral effusions
with compressive atelectasis. Silhouetting of the left
hemidiaphragm is consistent with substantial volume loss in the
left lower lobe.
.
Pertinent Imaging after ICU:
.
Paracentesis:
IMPRESSION:
Successful uncomplicated therapeutic and diagnostic
ultrasound-guided
paracentesis of 1.2 liters of clear ascites. Fluid was sent for
Gram stain, culture, cell count, protein, LDH and albumin.
.
CT Torso:
1. Multifocal ground-glass pulmonary opacities, most compatible
with
multifocal infectious process. New left lower lobe collapse.
2. Small-to-moderate bilateral pleural effusions, left greater
than right,
appear simple.
3. Unchanged moderate volume ascites, with mild peritoneal
enhancement again seen in the right paracolic gutter. This may
again be post-surgical, though clinical correlation is advised
to exclude peritonitis.
4. Unremarkable appearance of the large and small bowel, status
post right
hemicolectomy, with end ileostomy and mucous fistula in the
right abdomen. No evidence of abscess formation.
5. Splenomegaly
6. Anasarca.
.
CT Chest:
1. Markedly improved multifocal lung opacities. The largest area
that remains is in the left upper lobe.
2. Mild increase in size in moderate left pleural effusion.
Resolved left lower lobe collapse.
3. Splenomegaly
.
MRI Pelvis:
1. No interval change in the free fluid within the abdomen and
pelvis but no abscess seen.
2. Bilateral AVN, more significant on the right side.
3. Extensive subcutaneous edema.
.
Pathology: R buttock skin biopsy:
Superficial and deep perivascular, periappendageal and
interstitial dermatitis with prominent neutrophils and overlying
papillary dermal edema, epidermal hyperplasia, and spongiosis.
See note.
Note: The depth of the infiltrate is suggestive of an infection
such as bacterial cellulitis. The histologic pattern is not
typical of those observed with deep fungal or atypical
mycobacterial infections (unless inflammation is more prominent
deep to the tissue sampled in this biopsy). The depth of the
infiltrate and lack of a more florid neutrophilic infiltrate are
unusual for Sweet's syndrome, however, a variety of neutrophilic
inflammatory patterns may be observed in patients with
myelodysplastic syndrome (MDS) and in association with G-CSF (if
clinically applicable). The inflammation is peri-eccrine in
areas and focally there are neutrophils involving eccrine units.
This finding raises consideration of a neutrophilic eccrine
hidradenitis (NEH) in the differential diagnosis. NEH may be
observed in association with chemotherapeutic agents and G-CSF.
It was recently reported to occur with decitabine, a derivative
of azacytidine (Vidaza).
.
Special stains (Gram, [**Last Name (un) 18566**], PAS, and GMS) are negative for
organisms. Culture may be a more sensitive method to detect
organisms than histologic special stains. In summary, if
infection is excluded, the differential diagnosis includes a
neutrophilic infiltrate associated with MDS or a drug associated
NEH. Preliminary results of this case were discussed with Dr.
[**Last Name (STitle) 73062**] on [**2134-10-28**].
.
Microbiology Cultures:
Peritoneal:
[**2134-10-14**] 2:14 pm PERITONEAL FLUID
GRAM STAIN (Final [**2134-10-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-10-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-10-20**]): NO GROWTH.
FUNGAL CULTURE (Final [**2134-10-29**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-10-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Time Taken Not Noted Log-In Date/Time: [**2134-10-22**] 3:58 pm
PERITONEAL FLUID SOURCE IS PERITONEAL FLUID.
**FINAL REPORT [**2134-10-28**]**
GRAM STAIN (Final [**2134-10-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-10-25**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-10-28**]): NO GROWTH.
.
Tissue Cultures:
Time Taken Not Noted Log-In Date/Time: [**2134-10-27**] 4:01 pm
TISSUE Source: Skin biopsy.
GRAM STAIN (Final [**2134-10-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2134-10-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-11-4**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2134-10-28**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-10-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Time Taken Not Noted Log-In Date/Time: [**2134-10-27**] 4:01 pm
TISSUE Source: Skin biopsy.
GRAM STAIN (Final [**2134-10-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2134-10-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-11-4**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2134-10-28**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-10-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2134-10-26**] 12:10 pm Rapid Respiratory Viral Screen & Culture
**FINAL REPORT [**2134-10-29**]**
Respiratory Viral Culture (Final [**2134-10-29**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2134-10-27**]):
Respiratory viral antigen test is uninterpretable due to
the lack of
cells.
Refer to respiratory viral culture for further
information.
REPORTED BY PHONE TO DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 11:05AM [**2134-10-27**].
.
[**2134-10-26**] 12:10 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2134-10-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2134-10-28**]):
RARE GROWTH Commensal Respiratory Flora.
POTASSIUM HYDROXIDE PREPARATION (Final [**2134-10-28**]):
KOH REQUESTED PER DR. [**Last Name (STitle) 6401**] PG #[**Numeric Identifier 73063**].
NO FUNGAL ELEMENTS SEEN.
This is a low yield procedure based on our in-house
studies.
.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2134-10-27**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2134-10-27**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Please see OMR for BC/UC results. All negative with UC <
100,000 CFU.
.
Bone Marrow Biopsy: Completed Follow up.
Brief Hospital Course:
67 y/o male with MDS s/p R. hemicolectomy with end
ileostomy/mucous fistula on [**2134-9-28**], who presented with fluid
responsive hypotension and fever.
.
SIRS/Sepsis/Fever: Upon admission he was intermittently febrile,
and his hyoptension was fluid responsive. He did not require
vasoactive medication. Possible etiologies included
uperinfection of right thigh lesion with neutrophilic
dermatosis, post-operative wound infection with wound
dehiscence. CT torso was completed without evidence of
intraabdominal abscess. He was started on daptomycin and zosyn,
later stopped zosyn due to low platelets, switched to
ciprofloxacin and flagyl, then finally broadened to meropenum.
Discharged from MICU on daptomycin (6 total days given in MICU)
and meropenum (2 days given in MICU). He was also empricially
covered with meropenem. An infectious cuase for the hypotension
was never identified by culture or by serology. ID followed the
patient throughout his hospital course, and eventually
recommended d/c his antibiotics after his new diagnosis of
Sweet's syndrome. Additionally, A workup was also completed
including [**Doctor First Name **], ANCA, and anti-cardiolipin out of concern for
underlying autoimmune process that could explain the etiology of
his fevers. Rheumatology was also consulted, and did not did
not recommend any additional work up for his fevers. The most
likely etiology for the hypotension was secondary to a wound
infection and sepsis.
.
#MDS/Pancytopenia: Upon admission to the hospital his counts
steadily dropped throughout his stay in the MICU. There was
initial concern for leukemia in his bone marrow. Hemolysis labs
were negative. Reticulocyte count was low. HIT antibody was
negative. The differential diagnosis included worsening MDS,
AML progression, or other hematopeoieic malignancy. Hemolysis
and Smear analysis did not suggest DIC. His counts remained low
throughout the hospital course and his WBC count continued to
flucuated. He was supported with pRBC's and platelets. He had
a BM biopsy prior to discharge and his last ANC was 790.
- Please transfuse pRBC's for HCT < 25.
- Please transfuse platelets for count < 10 or active signs of
bleeding when < 30.
- He will need Bactrim, and Acyclovir for PPX due to his low
WBC.
.
#Sweet's Syndrome/Neutrophilic dermatosis: He was found to have
an erythematous nodule on his right leg and pain. A skin biopsy
was sent which was consistent with neutrophilic dermatosis.
Based upon the biopsy in addition to his clinical findings, a
diagnosis of Sweet's syndrome was proposed to explain his high
grade fevers in addition to his skin lesions. Corticosteroid
treatment was not initiated until multiple imaging studies
confirmed that there was no infectious process or abscess in his
abdomen after his recent surgery. Multiple cultures, both urine
and blood, were negative. A bronchoscopy was also preformed
after a CT revealed multiple opacities. Subsequently, the BAL
was only positive for yeast which was thought to be a
non-pathological. The Pulmonology Consult team felt that the
infiltrates and skin findings were consistent with Sweet's
syndrome. He also developed another sight of pain adjacent to
his R sacrum that also had a neutrophilic infiltrate, but not to
the degree of the R thigh skin biopsy. The differential
diagnosis was neutrophilic dermatosis vs. neutrophilic eccrine
hidradenitis. Based upon his clinical symptomology, he was
treated empirically for Sweet's syndrome with methylprednisone 1
mg/kg with a slow week taper to 0.5 mg/kg. He was then started
on oral prednisone 50 mg/day. He was also started on GI
prophylaxis with famotidine, Vit D, and calcium. A non-contrast
CT of the lungs demonstrated improvement of his multi-focal
opacities, his skin lesions continue to heal, and he has been
afebrile since the initiation of steroids.
- Please continue prednisone 50 mg/day. Do not taper dose. His
steroid course will be determined by Dr. [**Last Name (STitle) **] as an
outpatient.
- Please continue Ca/Vit D and Famotidine for steroid
prophylaxis
- Please continue PO dilaudid for Pain, may wean as patient
tolerates
.
# End ileostomy/mucous fistula s/p hemicolectomy: He presented
with wound dehisence. His intial presentation may have been
secondary to infection of his wound. He was initially started
on broad spectrum antibiotics with minimal improvement in his
wound healing. After the initiation of corticosteroids for
Sweet's syndrome the erythema along the margins of his wound
improved. He subsequently developed granulation tissue, and his
wound continues to demonstrate healing.
- Please continue daily wound care as outlined in attached notes
- Scheduled for follow up as outlined above
.
Hyponatremia: The patient had persistent hypnatremia that was
secondary to Hypervolemia due to fluid resuscitation, and
Sweet's syndrome with SIADH due to infilatrates in the lung.
Urine osms were consistenly elevated relative to [**Name2 (NI) **] osms.
His [**Name2 (NI) **] sodium remained > 128 while on the floor. He was
placed on fluid restriction and subsequently allowed to
autodiuresis. His sodium level stabilized and he was no longer
fluid restricted.
- No fluid restriction
.
# Hyperglycemia: His sugars have been monitor QID, and he has
been placed on an ISS with lantus to help regulate his blood
glucose levels. His sugars have flucuated between 150's -200's.
- Please keep blood glucose less than 180's.
.
# Decreased hearing: Patient had large cerumen plug in left
ear. Patient received ear drops which were ineffective. His
ear canals were clear by examination, and ENT was consulted for
hearing loss. It was believed to be sensorineural, and an
audiology test confirmed the hearing loss in his R ear. He will
be followed up by ENT for a hearing aide.
.
# Ascites: He had a paracentesis on [**2134-10-14**] with removal of
2.7L of fluid which did not demonstrate any infection. He had
an additional paracentesis which did not reveal SBP. He
continues to have ascites without any evidence of infection.
although the volume decreased throughout his hospital stay. It
was thought that his ascites may have been secondary to his poor
nutritional status upon presentation when his albumen was < 3.0.
.
# Stage II decubitus ulcer: Currently has a stage II decubitus
ulcer.
- Continue wound managment
.
# Incidential AVN (bilateral based upon MRI). He had an MRI of
the pelvis and legs which demonstrated AVN.
- Will need follow up as an outpatient
.
# History of AFIB w/RVR: Patient had atrial fibrillation during
his last hospital admission. He was in sinus rhythm during this
admission, and prior to discharge. His amiodarone was
discontinued.
.
# COPD: Hed did not have any evidence of an acute exacerbation
of COPD
- Continue albuterol inhalers PRN
Medications on Admission:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to groin.
2. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical WITH
EACH DRESSING CHANGE ().
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for Wheeze.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
.
Medications (on transfer to MICU):
Ondansetron 4 mg IV Q8H:PRN nausea
Micafungin 100 mg IV Q24H
Ciprofloxacin 400 mg IV Q12H
Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain
Acetaminophen 1000 mg PO/NG Q6H:PRN fever
Albuterol Inhaler 2 PUFF IH Q4H
Famotidine 20 mg IV Q12H
Insulin SC (per Insulin Flowsheet)
Daptomycin 600 mg IV Q24H
Piperacillin-Tazobactam 4.5 g IV Q8H
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough/sputum.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for sob/wheeze.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
12. insulin glargine 100 unit/mL Solution Sig: One (1) 23 units
Subcutaneous at bedtime.
13. Humalog 100 unit/mL Solution Sig: One (1) variable
Subcutaneous four times a day: ISS, Please see attached.
14. prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
16. sodium chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
18. Ondansetron 4 mg IV Q8H:PRN nausea
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
20. sodium chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
21. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-19**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary Diagnosis
MDS
Secondary Diagnosis
Sweet's Syndrome
Ascities
Hyponatremia
AVN bilaterally
Hyperglycemia
Poor wound healing
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear [**Known firstname **],
Thank you for receiving your care at [**Hospital3 **] Hospital. You
were admitted for low blood pressure neccessitating and ICU stay
and a new diagnosis of Sweet's syndrome. You were initially
given antimicrobial therapy for high fevers, however, no
infectious source was cultured. You also had numerous imaging
studies which did not reveal an infectious collection of fluid.
Several lesions on your skin were biopsied which showed an
inflammatory infiltrate. After the biopsy results returned, you
were started on steroids. You will need a slow taper of
steroids. You will need to go to a rehab facility to help
improve your physical strength.
.
The following medications were ADDED to your regiment:
Lantus
Humalog
Prednisone
Hydromorphone
Vitamin D (weekly)
Calcium Carbonate
Acyclovir
Bactrim
Famotidine
Trazadone
Guaifenesin
Zofran
Artificial Tears
.
The following medications were STOPPED:
Amiodarone
Oxycodone-Tylenol
heparin
silver sulfadiazine
.
The following medications were CHANGED:
None
Followup Instructions:
Please come to the [**Hospital 18**] medical complex for the following
Appointments:
[**2134-11-26**] 10:30a [**Doctor Last Name **],[**Last Name (un) 6410**] T
LM [**Hospital Unit Name **], [**Location (un) **]
OTOLARYNGOLOGY/AUDIOLOGY (NHB)
[**2134-11-25**] 02:00p ACUTE [**Hospital 23692**]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
SURGICAL ASSOC LMOB-3A (SB)
[**2134-11-19**] 01:45p [**Doctor Last Name **],TEACHING
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital **] CLINIC-CC2 (SB)
[**2134-11-15**] 12:30p [**Last Name (LF) **],[**First Name3 (LF) **] E.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
[**2134-11-15**] 12:30p [**Last Name (LF) **],[**First Name3 (LF) **] H.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Completed by:[**2134-12-26**]
ICD9 Codes: 0389, 2761, 5990, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5903
} | Medical Text: Admission Date: [**2127-7-1**] Discharge Date: [**2127-7-9**]
Date of Birth: [**2070-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tape / Percocet / Zyvox
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Trachaelbronchialmalcia
Major Surgical or Invasive Procedure:
[**2127-7-2**]: Right thoracotomy and tracheoplasty with mesh, right
mainstem bronchus/bronchus intermedius bronchoplasty with mesh,
left mainstem bronchus bronchoplasty with mesh, and flexible
bronchoscopy with aspiration.
[**2127-7-1**]: Dynamic flexible bronchoscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 56-year-old gentleman with a history of COPD who
was found to have severe tracheobronchomalacia. He [**Known lastname 1834**] a
placement of a tracheobronchial silicone Y stent on [**2127-5-20**].
Following this his dyspnea on exertion markedly improved.
Unfortunately, he did suffer a stent-related infection and this
needed to be removed. We spoke at length at the utility of
moving on to a surgical correction of his malacia with posterior
splinting with Marlex mesh. We talked about the risks of this
procedure including injury to the recurrent laryngeal nerve,
tracheal injury, esophageal injury, vessel,
heart, or diaphragmatic injury. We talked about the risks of
pneumonia or other infection as a result of this, as well as the
possibility of postoperative pain from the thoracotomy. We also
talked about the possibility that the cervical
trachea may develop or may present with symptomatic malacia
which would not be corrected by this intrathoracic procedure.
Finally, we discussed the possibility of improvement of the
malacia without betterment of his symptoms despite the stent
trial findings, if his underlying lung disease were to take
precedence. Mr. [**Known lastname **] and his partner had a chance to ask all
pertinent questions following this discussion and they wished to
proceed.
Past Medical History:
# HTN
# tracheobronchomalacia (90-95% collapse of mid-distal trachea,
b/l mainstem bronchi collapse 95%) s/p Y stent placement
- COPD x 4 yrs, RAD x 15 yrs (trigger floor wax)
- recent esophageal candidiasis while on steroids [**3-7**]
- GERD w/ laryngitis
- thalassemia minor
- hypogonadism
- osteopenia
- L arm neuropathy
anxiety
- infrarenal AAA 3.2cm, stable CT [**5-6**]
- hx cdiff (clinical dx, flagyl x 7 days)
# Sleep apnea
# GERD with laryngitis s/p Bravo procedure ([**2127-3-26**].
[**Doctor First Name 18348**], [**Location (un) 9095**] CT), and Nissen fundoplication [**2125**]
# Thalassemia minor
# Hypogonadism with decreased testosterone, reliance on patch
# hx HSV/shingles tx valacyclovir
# Osteopenia
# L arm neuropathy
# h/o MRSA
# Anxiety
# s/p tracheostomy (closed [**4-2**])
# s/p uvulopalatoplasty, rhinoplasty, adenoidectomy,
septoplasty, tonsillectomy
# s/p B knee surgery
# s/p B saphenous vein stripping
# s/p pilonidal cyst excision
Social History:
# Professional: RN at [**Hospital1 1012**]-affiliated VA
# Tobacco: Smoked from age 16 - mid 40s, maximum 2 ppd
Family History:
Noncontributory
Physical Exam:
VS: Temp 98.9, HR 104, BP 122/60, RR 18, 90% on RA
General: 56 year-old male no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card: RRR
Resp; scattered crackles throughout R>L
GI: benign
Extr: warm no edema
Incision: Right thoracotomy site clean, dry, intact
Neuro: non-focal
Pertinent Results:
[**2127-7-6**] WBC-4.5 RBC-4.81 Hgb-9.7* Hct-31.2* Plt Ct-209
[**2127-7-1**] WBC-5.5 RBC-6.43* Hgb-12.3* Hct-42.4 Plt Ct-219
[**2127-7-6**] Glucose-92 UreaN-10 Creat-0.9 Na-144 K-3.9 Cl-106
HCO3-31
[**2127-7-1**] Glucose-115* UreaN-14 Creat-1.3* Na-144 K-4.3 Cl-105
HCO3-29
CHEST (PA & LAT) [**2127-7-6**]
The heart size is normal. Mediastinal position, contour and
width are unremarkable. The appearance of the lungs is stable
including right mid lung scarring, left lower lobe linear
opacities consistent with atelectasis and there is no change in
small amount of right pleural effusion and right pleural
thickening. There is a small amount of right subcutaneous
emphysema.
The known severe emphysema is unchanged.
SPECIMEN SUBMITTED: LEVEL 7 LYMPH NODES.
Procedure date Tissue received Report Date Diagnosed
by
[**2127-7-2**] [**2127-7-2**] [**2127-7-7**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mb????????????
Lymph node, level 7:
One unremarkable lymph node, no malignancy identified.
Pathology Report Tissue: SKIN BX (PENIS)...1 JAR. Study Date of
[**2127-7-7**]
Report not finalized at time of discharge
Brief Hospital Course:
56M former smoker with TBM and COPD who presented to [**Hospital1 18**] on
[**2127-7-1**] s/p Y-stent removal for follow-up bronchoscopy and
Tracheoplasty. On [**2127-7-2**] Mr.[**Known lastname **] [**Last Name (Titles) 1834**] Right thoracotomy
and tracheoplasty with mesh. He tolerated the procedure well and
a right chest tube was left in place. Pt was extubated
transferred to the surgical ICU from the operating room.
Post-operative pain was controlled with an epidural catheter as
well as a PCA (split bupivacaine/Dilaudid) managed by the acute
pain service. Pt received scheduled nebulizer treatments. On
POD#2 PCA and epidural were increased, and clonidine was started
for improved pain control. The patients blood pressure was low
via arterial line with systolic pressures in the 70's and 80's.
The pts urine output was also decreased during this time for
which he was bolused with crystalloid and transfused with
Hespan. Diltiazem was held and narcotics were reduced with good
effect of SBP in the 120's and return of appropriate urine
output by the morning of POD#3. On POD#3 the chest tube was
removed and the patient was transferred from the ICU to the
surgical floor. Pt continued to improve with scheduled
nebulizer treatments, and was ambulating and tolerating a
regular diet. O2 was weaned as tolerated but still required to
maintain saturations >90%. Pts home medications were restarted
including his home dose of diltiazem which he tolerated well. On
POD#5 dermatology was consulted for a lesion on the patients
penis which was not improving with antifungal cream. A biopsy of
the lesion was taken by dermatology, of which the pathology was
pending at the time of discharge. On POD#6 pt was weaned off of
oxygen and maintained saturations above 90% with ambulation. Pt
was discharged home on POD#7 off of supplemental oxygen,
tolerating a regular diet, and ambulating without assistance.
Medications on Admission:
Duloxetine 40mg daily, fluticasone-Salmeterol 500-50 mcg/disk
[**Hospital1 **], montelukast 10mg daily, clonazepam 0.5mg [**Hospital1 **], gabapentin
100mg tid, pantoprazole 40mg daily, guaifenesin 1200mg [**Hospital1 **],
albuterol sulfate 2.5mg/3ml q4hprn, acetylcysteine 20% tid,
ipratropium bromide 0.02% q4h, MVI, testim 1% TP daily, cymalta
40mg daily,
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day).
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*1*
8. Hydromorphone 4 mg Tablet Sig: 1 or 1 [**1-29**] Tablet PO Q3H
(every 3 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation Q4H (every 4 hours).
12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q4H (every 4 hours).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
15. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO daily ().
16. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
18. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day).
Disp:*120 Troche(s)* Refills:*1*
19. Testim 50 mg/5 gram (1 %) Gel Sig: One (1) Transdermal
daily ().
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*300 ML(s)* Refills:*1*
21. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
VNA Services, INC
Discharge Diagnosis:
TBM, COPD, RAD x 15 yrs, GERD w/ laryngitis, thalassemia minor,
hypogonadism, osteopenia, L arm neuropathy, MRSA, anxiety,
infrarenal AAA 3.2cm stable CT [**5-6**], OSA
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, or cough
-Difficulty swallowing, nausea, vomiting
-Incision develops drainage or increased redness
You may shower: No tub bathing or swimming for 6 weeks
No driving while taking narcotics: Take stool softners with
narcotics.
wear your oxygen 2 liters continuously
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**2127-7-22**] 10:00am in the chest
disease center [**Hospital Ward Name **] building [**Hospital1 **] one. Please arrive 45
minutes prior to you appointment and report to the [**Location (un) 470**]
radiology for a chest XRAY.
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5904
} | Medical Text: Admission Date: [**2166-1-16**] Discharge Date: [**2166-1-20**]
Date of Birth: [**2141-4-18**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
drug overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 24 year old man with history of prior drug
overdose who was transferred from OSH with altered mental
status. Per report, he initially presented with complaints of
abdominal pain and nausea to [**Hospital3 22765**], then
became non-responsive ("catatonic state") but continued to
protect his airway. He had a metabolic workup, including chem10
(revealing only mildly elevated BUN at 21), CBC, and tox screen
(which was negative for amphetamines and positive for opiates).
He also had a head CT and chest x-ray, which were unremarkable.
Per OSH report, tox screen was positive for opiates. He was
given lorazepam 1mg x 1 and transferred to [**Hospital1 18**] for further
workup.
.
In the ED, his vitals were T98.9F, BP 117/100, HR 148, RR 20,
Sat 100%. He was initially given 5mg haloperidol for agitation,
but a subsequent EKG demonstrated prolonged QT interval. He
continued to be agitated, with visual hallucinations and was
unable to maintain his own safety without physical restraints. A
blood culture was drawn. Urine tox at [**Hospital1 18**] was positive for
both opiates and amphetamines. He received a total of 10mg IV
ativan in the ED prior to transfer to the MICU for further
workup and evaluation.
Past Medical History:
h/o drug overdose requiring dialysis
ORIF, rightleg fracture, Required fasciotomy [**2164**].
s/p recent surgery for tendon lenghtening [**2165-12-6**].
Social History:
Denies any alochol or illicit drug use. He does smoke 1ppd for
6-7 years. Per father has had a problem with percocet abuse in
the past. He has often requested more pain medications and has
made excuses for having percocets stolen.
Family History:
nc
Physical Exam:
VITALS: T98.7F, BP 150/83, HR 140's, RR 18, Sat 99%2L
GENERAL: Agitated, slurring speech, occasional yelling out;
visual hallucinations
HEENT: PERRL, EOMI, mucus membranes dry
CARD: Tachycardic no m/r/g
RESP: CTA bilaterally anteriorly
ABD: Soft, non-distended, non-tender, no HSM, normal active
bowel sounds
RECTAL: Deferred
BACK: Deferred
EXT: RLE in cast, LLE warm, well-perfused, with 2+ DP pulse
NEURO: A&O x 1
PSYCH: Visual hallucinations
Pertinent Results:
Lactate:3.0
.
Na 139 K 3.4 Cl 105 HCO3 23 BUN 18 Creat 1.0 Gluc 99
Ca: 8.7 Mg: 1.9 P: 3.9
.
ALT: 22 AST: 17 AP: 96 LDH: 132 Tbili: 0.2 Alb: 4.3
[**Doctor First Name **]: 29 Lip: 13
Serum Tox: ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Pending
Acetone: Negative
.
Urine Tox: positive for opiates and amphetamine, o/w negative
.
WBC 16.5
N:85.4 L:11.1 M:3.0 E:0.1 Bas:0.4
Hgb 14.4
Hct 41.4
Plt 281
MCV 74
.
PT: 14.2 PTT: 28.0 INR: 1.2
.
U/A: Yellow, Clear, SpecGr 1.027, pH 5.0, Tr prot, Tr ketones,
few bact, otherwise negative
.
STUDIES:
EKG [**2166-1-16**]: Tachycardic at 139bpm, QTc 444ms. No ST elevations
or depressions.
.
CT [**2166-1-16**] (from OSH, reviewed at [**Hospital1 18**] with radiology): ?
slightly enlarged ventricles for age, otherwise unremarkable.
.
CXR [**2166-1-16**] (from OSH): Normal chest x-ray.
Brief Hospital Course:
MICU COURSE:
The patient was admitted to the medical ICU for managment of
altered mental status. His urine studies were posative for
amphetamines and given his clinical picture of agitation,
hallucinations, and irritability he was treated for presumed
aphetamine toxicity along with possible wellbutrin overdose. He
was given IV fluids and IV lorazepam. He required leather
restraints overnight, and despite these suffered a minor fall.
His clinical condition improved over 24 hours and he no longer
required restraints or benzodiazepines for management of
agitation. He was transfered to the floor. QT interval was
initilly prolonged, but resolved. The psychiatry team evaluated
him and found that he had a history of depression, oppositional
defiant disorder, drug abuse, stealing, and suicide attempt.
They recommended in-patient psychiatric stabilization, and the
patient is therefore being transferred to deaconness 4.
Old records and communication with [**Hospital6 **]
showed that his cast on his right foot was from an achilles
release procedure and required the cast for 6 weeks. This is to
be followed up as an outpatient. He has a history in [**2164**] of
compartment syndrome in his right lower extremity,
rhabdomyolysis and renal failure. He had a CK elevation on
admission attributed to being found down. It elevated to 6000
and this was thought secondary to his fall; it trended down to
[**2157**] on the day of transfer. The orthopedics team evaluated him
and removed a cast. He has persistantly asked for escalating
doses of narcotics. We fell that [**1-1**] percocets Q 4 hours is an
adequate dose.
.
#) Microcytosis. normal iron studies. ?thalasemia trait. hct
stable.
.
#) Communication. [**Name (NI) **] father, [**Name (NI) 122**] [**Name (NI) **], [**Telephone/Fax (1) 76829**]
(unable to contact).
Medications on Admission:
percocet prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Drug overdose
Depression
Rhabdomyolysis
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital after a drug overdose and were
monitored in the intensive care unit initially. You were also
seen by psychiatry who recommended inpatient psychiatry unit for
further treatement. You also had some muscle injury from a fall
and received IV fluids. You were also seen by orthopedics who
recommended outpatient follow up with your surgeon.
Please return to the hospital if you fevers, chills, nausea,
vomiting
Followup Instructions:
Please follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 73578**] in 2
weeks after discharge from psych facility.
You should also follow up with your orthopedic surgeon as
scheduled next week.
Completed by:[**2166-1-21**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5905
} | Medical Text: Admission Date: [**2135-4-17**] Discharge Date: [**2135-4-18**]
Date of Birth: [**2064-1-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
[**Last Name (un) 15557**]
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
1 yo endocrinologist here at [**Hospital1 18**], h/o GIB (unknown source),
p/w black stools. Here with guaiac + brown stool with black
specks. SBP 116, HR 75.Warfarin recently stopped due to anemia
on routine blood work.
Past Medical History:
1. Seizure disorder 30 yrs ago, no recurrence ever on meds
2. h/o sigmoid volvulus [**2124**], Rx colectomy and ileoanal
anastemosis.
3. VF defect in [**2128**], after stopping his coumadin after a fall.
Adm to [**Hospital1 **] showed no acute stroke on MRI, but suggestion of PFO
on
bubble echo, and Rx with resumption of anticoagulants
4. Cataracts s/p bilateral surgery
5. Hypertension
6. After sz got a foot drop, c/b DVT x 3/PE x 1
7. Recent renal consult felt c/w nephrosclerosis
8. [**2-8**] with SBO and summer [**2133**] with SBO, EGD showed celiac on
bx, + ab, and pt Rx with diet after surgery for lysis of
adhesions
Social History:
[**Hospital1 18**] Endocrinologist; married with 4 children, lives in
[**Location (un) 55**]. Does not smoke. Social drinker
Family History:
Mother - 70's with encephalitis; father - esophageal cancer at
84 y.o.; paternal grandfather - 75 y.o. colon cancer; maternal
grandfather with DM.
Physical Exam:
Pertinent exam: Pale. CV, RS - normal
Abd - soft, nontender. Good bowel sounds. No distended.
Extremeties no edema.
Pertinent Results:
[**2135-4-18**] 01:05PM BLOOD Hct-38.2*
[**2135-4-17**] 12:50AM BLOOD WBC-8.1 RBC-3.35* Hgb-9.5* Hct-28.2*
MCV-84 MCH-28.4 MCHC-33.8 RDW-13.5 Plt Ct-261
[**2135-4-17**] 12:50AM BLOOD Neuts-55.4 Lymphs-27.3 Monos-5.6
Eos-11.4* Baso-0.2
[**2135-4-18**] 06:15AM BLOOD PT-13.9* PTT-26.0 INR(PT)-1.2*
[**2135-4-18**] 06:15AM BLOOD Fibrino-227#
[**2135-4-18**] 06:15AM BLOOD Glucose-82 UreaN-35* Creat-2.2* Na-139
K-4.4 Cl-107 HCO3-25 AnGap-11
[**2135-4-17**] 12:50AM BLOOD ALT-22 AST-19 AlkPhos-94 TotBili-0.2
[**2135-4-17**] 12:50AM BLOOD Lipase-35
[**2135-4-18**] 06:15AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1
[**2135-4-17**] 12:50AM BLOOD Albumin-3.8 Calcium-9.8 Phos-4.6* Mg-2.0
Cardiology Report ECG Study Date of [**2135-4-17**] 12:40:12 AM
Sinus rhythm with borderline A-V conduction prolongation. Early
R wave
transition. Non-specific ST-T wave changes. Compared to the
previous tracing
of [**2133-4-2**] there is no significant change other than the
borderline prolonged
P-R interval.
EGD:
Brief Hospital Course:
Gastrointestinal bleeding
Acute blood loss anemia
- initially in ICU, transfused 3 units of PRBC. Hct stabilized
and pt sent to floor. EGD done and results as above. Capsule
endoscopy was initiated prior to discharge. Pt to follow up with
primary gastroenterologist for results of capsule endoscopy. PPI
continued. Warfarin not initiated.
Hypertension - discharged only on valsartan. Doxazosin and
diltiazem held and to be restarted in clinic depending on BP.
History of deep vein thrombosis, pulmonary embolism, Chronic
kidney disease, osteoporosis, hypothyroidism - no acute issues.
Medications on Admission:
valsartan 80 mg daily
alprazolam 0.25 mg qhs:prn
calcitriol 0.25 mcg [**Hospital1 **]
diltiazem 240 mg daily
doxazosin 8 mg daily
Boniva q6months
levothyroxine 50 mcg daily
phenytoin ER 400 mg daily
citracal +D
ASA 81 mg daily
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Four (4)
Capsule PO once a day.
6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Citracal + D Oral
8. Ibandronate (boniva)
as directed q 6 months
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding
Acute blood loss anemia
Hypertension
History of deep vein thrombosis, pulmonary embolism, Chronic
kidney disease, osteoporosis, hypothyroidism
Discharge Condition:
stable. Hct stable.
Discharge Instructions:
As you are aware, you were admitted for possible bleeding and
transfused with 3 unit of blood. Your hematocrit has responded
well. The endoscopy you had did not show signs of bleeding.
Capsule study results should be available in [**4-9**] days. Please
contact Dr [**Name (NI) 96799**] regarding the results.
Do not take doxazosin and diltiazem till your follow up blood
pressure check with your primary care doctor. Discuss with him
regarding the timing of your medications.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) 2539**] in [**1-5**] days for follow up hematocrit and
blood pressure check.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 49151**]
Date/Time:[**2135-6-13**] 1:30
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2136-4-6**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2136-4-6**] 10:00
ICD9 Codes: 5789, 2851, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5906
} | Medical Text: Admission Date: [**2160-9-29**] Discharge Date: [**2160-10-14**]
Date of Birth: [**2160-9-29**] Sex: F
Service: NB
HISTORY: This is a 34-2/7-week gestation infant admitted to
the NICU for prematurity. She was born by cesarean section
to a 32-year-old gravida 1, para 0-2 mother with the
following prenatal screens: Blood type A positive, DAT
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, group B Strep unknown.
Estimated date of delivery was [**2160-11-8**] for an estimated
gestational age of 34-2/7 weeks at time of delivery.
This was a spontaneous twin pregnancy, which was complicated
by preterm labor, refractory to tocolysis. The betamethasone
course was completed four days prior to delivery.
Spontaneous rupture of membranes occurred 10 hours prior to
delivery yielding clear amniotic fluid. Mother experienced
intrapartum fever to 100.7 degrees. Intrapartum antibiotic
therapy administered five hours prior to delivery. Infant
was delivered by a cesarean section. This baby was vigorous.
She required bulb suctioning and free-flow oxygen and had
Apgars of 8 at 1 minute and 8 at 5 minutes.
PHYSICAL EXAMINATION UPON ADMISSION: A well-appearing infant
in no distress. Birth 2325 grams, 50th percentile. Head
circumference 32.5 cm, 75th percentile, and length 45 cm,
50th percentile. Temperature 100.5. Heart rate 160.
Respiratory rate 40. O2 saturation 96 percent. Blood
pressure 52/37 with a mean of 41. HEENT: Anterior fontanel
is soft and flat, nondysmorphic. Palate intact. Neck and
mouth normal. No nasal flaring. Normocephalic. Red reflex
present bilaterally. Chest: No retractions. Good bilateral
breath sounds, no crackles. Cardiovascular: Well perfused,
regular rate and rhythm. Femoral pulses normal. S1, S2
present. No murmur. Abdomen: Soft, nondistended, no
organomegaly, no masses. Bowel sounds active. Anus patent.
GU: Normal female genitalia. CNS: Active, responsive to
stimulus. Tone appropriate for gestational age and
symmetric. Moves all extremities equally and symmetrically.
Suck, root, and gag intact. Grasp and morrow symmetric.
Skin is intact. Musculoskeletal: Normal spine, limbs, hips,
and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Cardiovascular: This baby required normal saline boluses x2
for decreased perfusion. She remained cardiovascularly
stable throughout the hospitalization. Daily examination
revealed heart rates 120-150 with blood pressure mean 39-48.
Baby was noted to have an ejection click on day of life four.
She had an EKG, which was normal. She had a chest x-ray,
which was also interpreted as normal. Four extremity blood
pressures were all within normal limits. Hyperoxia test was
passed with a transcutaneous O2 saturation of greater than
300.
Cardiology was consulted to evaluate the baby's click, and
echocardiogram was performed on [**10-7**], which revealed normal
cardiac structures with a patent foramen ovale and baby has
remained cardiovascularly stable and no murmur or significant
click appreciated at the time of discharge.
Respiratory: Baby demonstrated mature pulmonary function and
has been in room air throughout her hospitalization. She has
not experienced any periodic breathing patterns.
Fluid, electrolytes, and nutrition: Baby initially was placed
NPO and peripheral IV fluids with D10W were initiated. Feeds
were initiated in the first 24 hours of life with breast milk.
She was fed a combination of by mouth and gavage feedings for
the first 10 days of life. Since that time, she has been all
by mouth feeds for the last 48 hours. She is taking a
combination of breast and Similac 24 adlib with an average
intake of 140 cc/kg on demand. She has had normal urine and
stool output.
GI: This baby was treated with phototherapy for physiologic
jaundice with a peak bilirubin of 12.4/0.4 on day of life
three. She continued under phototherapy until day of life
six at which time it was shut off. A rebound bilirubin was
obtained on day of life seven, which was 5.5. Baby was
started on Vi-Daylin multivitamins on [**10-13**], and was
increased at that time to 24 calories/ounce as a supplement
to breast feeding. Weight at time of discharge is 2420 grams.
Heme/ID: A CBC and blood culture obtained upon admission.
CBC revealed a white count of 15 with 15 polys, 0 bands, and
73 lymphocytes. Hematocrit 58.6 percent. Her platelets were
253. Baby received 48 hours of ampicillin and gentamicin,
which were discontinued in face of negative cultures and
improved clinical course. Baby required [**Name2 (NI) **] for neutral
thermal environment for the first week of life and
transitioned to a crib. She has been with her twin in an
open crib.
Neurologic: Infant is appropriate for gestational age.
Sensory: Hearing screening was performed with automated
auditory brain stem responses. The baby passed the hearing
screening.
Ophthalmology examination was not indicated at this
gestational age.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 45938**] of [**Hospital1 6687**].
FEEDS AT DISCHARGE: Breast milk with Similac powder for 24
calories/ounce.
MEDICATIONS: Vi-Daylin 1 cc by mouth each day.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine given on [**10-10**].
IMMUNIZATIONS RECOMMENDED:
i. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: 1) born at <32 wks; 2) born between 32 and 35 wks with
2 of the following: daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or school
age siblings; or 3) with chronic lung 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 the child??????s life), immunization
against influenza is recommended for household contacts and
out-of-home caregivers.
STATE NEWBORN SCREENING: Performed at recommended intervals
and results are pending at the time of discharge.
FOLLOW-UP APPOINTMENTS: Follow-up appointment with Dr.
[**Last Name (STitle) 45938**] is recommended upon return to [**Hospital1 6687**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34-2/7 weeks twin number one.
2. Sepsis suspect, ruled out.
3. Physiologic jaundice.
4. Ejection click with normal cardiac findings.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2160-10-14**] 01:50:21
T: [**2160-10-14**] 04:17:09
Job#: [**Job Number 56641**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5907
} | Medical Text: Admission Date: [**2188-11-19**] Discharge Date:
Service:
THIS IS AN INCOMPLETE DISCHARGE SUMMARY. PLEASE SEE
DISCHARGE ADDENDUM FOR COMPLETION OF THE [**Hospital **] HOSPITAL
COURSE, DISCHARGE DIAGNOSES AND DISCHARGE MEDICATIONS.
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
male with hypertension, portal vein thrombosis secondary to
pancreatitis leading to portal hypertension. No history of
coronary artery disease. He presented to the Emergency Room
on [**2188-11-19**], after having black, maroonish stools
since [**2188-11-15**]. The patient says he took
approximately six aspirin (325 mg strength) the week prior
for an upper respiratory tract infection.
The patient denies any abdominal pain, nausea, vomiting or
gastroesophageal reflux disease type symptoms. The patient
was very weak, dizzy, and lightheaded. He denies any chest
pain but did have shortness of breath.
In the Emergency Room, the patient was noted to have a blood
pressure of 120/50 with a heart rate of 80 and a hematocrit
of 15.3, with a baseline hematocrit of 30 to 36. An
nasogastric lavage was performed which was clear 300 cc. The
patient was subsequently admitted to the Medical Intensive
Care Unit.
PAST MEDICAL HISTORY:
1. Hypertension.
2. B12 deficiency, pernicious anemia.
3. Status post cholecystectomy.
4. Gastritis.
5. Empyema in [**2178**].
6. Choledocholithiasis.
7. Pancreatitis in [**2184**].
8. Right portal vein thrombosis.
9. Portal hypertension.
10. Ascites.
11. Colonic polyps on colonoscope in [**2188-8-26**].
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Norvasc 10 mg p.o. q. day.
2. Tylenol 650 mg p.o. q. day.
3. B12 injections q. month.
SOCIAL HISTORY: The patient lives at [**Location (un) 5481**]. He is a
retired engineer and is widowed. Drinks one alcoholic drink
per week. The patient quit tobacco 30 years ago. He
normally swims approximately three times a week and walks a
mile and a half per day without difficulties.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: In general, a pale appearing elderly
male in no acute distress. Temperature 97.8 F.; blood
pressure 125/53; heart rate 80; respiratory rate 18; oxygen
saturation 100% on room air. HEENT: Mucous membranes were
moist. Conjunctivae pale. No oral lesions detected. Neck:
Jugular venous pressure at 4 centimeters without
lymphadenopathy. Chest with diffuse expiratory wheezes
without crackles. Cardiovascular: III/VI systolic ejection
murmur at the left lower sternal border. Regular rate and
rhythm. Abdomen with positive bowel sounds, distended, no
hepatosplenomegaly, nontender. Plus/minus fluid wave.
Rectal examination revealed occult blood positive maroon
stool. Extremities with three plus pitting edema
bilaterally. Neurological: Alert and oriented times three,
moves all four extremities.
LABORATORY: White blood cell count 14.9, hematocrit 15.3,
platelets 227, differential is 73 polys, 19 lymphocytes, 6.6
monocytes. Sodium 141, potassium 4.6, chloride 106,
bicarbonate 21, BUN 49, creatinine 1.5, glucose 108.
ALT 27, AST 35, alkaline phosphatase 194, bilirubin 0.3. INR
1.1, PT 12.8, PTT 26.6, CK 163, MB 12, CK MB index 7.4,
troponin 3.
EKG with sinus rhythm at 80 beats per minute with PR
intervals of 168, QTC of 410; [**Street Address(2) 2914**] depressions
noted in II, III, AVF, V4 through V6, with T wave inversions
in V6 and I.
Chest x-ray with questionable pulmonary edema. No focal
consolidations.
HOSPITAL COURSE:
1. Upper gastrointestinal bleed: The patient was transfused
a total of 6 units of blood for a hematocrit of 30 which was
stable. The patient underwent an esophagogastroduodenoscopy
on [**2188-11-20**], which revealed Grade 3 varices which
were nonbleeding with a nonbleeding pedunculated polyp that
was benign appearing in the stomach. The patient was started
on Octreotide for a 72 hour course as well as Propranolol.
The patient will undergo a repeat esophagogastroduodenoscopy
prior to discharge in order to pursue variceal banding as
well as to re-evaluate the gastric polyp.
2. Ischemia: Upon admission, the patient was noted to have
inferior lateral ischemia changes on EKG as well as an
elevated troponin and MB fraction. The patient's cardiac
enzymes were cycled and peaked at a troponin of 10.8 and a CK
of 189 with a CK MB of 17. It was thought that this troponin
leak was secondary to demand ischemia from his anemia. The
patient will likely need an outpatient stress test in the
future. The patient remained completely chest pain free
during his hospital stay.
3. Congestive heart failure: The patient was noted to have
an intermittent oxygen requirement on [**2188-11-20**], with
his oxygenation saturation changing from 98% on room air to
90% on room air. The patient was noted to have crackled on
examination and was thought to be volume overloaded secondary
to his numerous blood transfusions. The patient responded
well to Lasix 20 mg intravenously.
An echocardiogram was performed on [**2188-11-21**], which
revealed an ejection fraction of greater than 60% with mild
left ventricular hypertrophy and two plus aortic
regurgitation which was worse than prior examination, two
plus mitral regurgitation, two plus tricuspid regurgitation,
moderate pulmonary artery systolic hypertension, and mild
aortic stenosis which was new since his prior examination.
The patient was continued on Spironolactone during his
hospital stay.
4. Ascites: The patient had portal hypertension secondary
to a portal vein thrombosis which was chronic and seemed to
have occurred during an episode of pancreatitis. The patient
had an abdominal ultrasound on [**2188-11-20**], which
showed moderate ascites with chronic occlusion of the right
portal vein with cavernous transformation and a heterogeneous
echogenic liver consistent with cirrhosis. The patient
underwent a diagnostic peritoneal tap on [**2188-11-20**],
which revealed culture negative, just ascites.
The patient was started on initially Ciprofloxacin and then
switched over to Ceftriaxone 2 grams q. 24 hours for
treatment. Throat culture negative; will check ascites for a
four or five day total course.
The patient likely has cirrhosis and will need to be followed
up with Dr. [**Last Name (STitle) **] in order to arrange for a liver biopsy to
confirm this diagnosis. In addition, the patient was started
on Propranolol and Spironolactone.
This is an incomplete discharge summary. Please refer to
following discharge addendum for completion of the [**Hospital 228**]
hospital course, discharge diagnoses and discharge
medications.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2188-11-22**] 15:37
T: [**2188-11-22**] 16:52
JOB#: [**Job Number 11659**]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5908
} | Medical Text: Admission Date: [**2115-9-19**] Discharge Date: [**2115-9-20**]
Date of Birth: [**2052-12-23**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Sent in by cardiologist for hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 yo male with advanced esophageal ca s/p palliative chemo/XRT,
recurrent pl effusions s/p L pleurex, CAD s/p POBA/PCI [**2101**] who
presents from cardiology clinic with tachypnea and hypotension.
The patient had 450cc drained from his pleurx yesterday ([**9-19**])
as usual. This morning he awoke with a [**Month/Year (2) **] and states he
developed some chest pain after a coughing spell "like a pulled
muscle, not cardiac" after coughing. He also notes feeling short
of breath, but not much more than he has in the past. Pt
attributes SOB to pain during inspiration. He went for a routine
clinic visit today to follow-up for his known pericardial
effusion. He was reportedly hypotensive to the 80's, tachypnic,
and complaining of pain. An echocardiogram performed earlier
today showed a moderate effusion without evidence of tamponade.
In clinic, his pulsus paradoxus was reportedly normal. Pt he
felt dizzy earlier in the week but currently denies any
dizziness or lightheadedness.
In the ED, initial VS were: 98.3 128 97/56 26 89%. Cardiology
was consulted and believed pt's symptoms were not secondary
tamponade physiology based on pt's echo and pulsus <3. Pt was
given 1L NS with improvement in sbp to 105. An ECG sinus
tachycardia, old inf TW flattening. CXR was notable for stable L
pleural effusion with pleurx in place and R pleural effusion,
unchanged from [**9-18**]. The patient was given iv dilaudid and
tachypnea improved.
On arrival to the MICU, the patient in laying comfortably,
saturating 97% on room air with HR 106, BP 110/69.
Past Medical History:
ONCOLOGIC HISTORY:
Mr. [**Known lastname 26973**] presented with a sensation of food getting stuck in
his chest in the fall of [**2112**]. Barium swallow demonstrated a
stricture in the distal esophagus. ECG demonstrated
circumferential narrowing and thickening at the GE junction (40
cm), and extended proximally to 35 cm. Biopsies were performed
and pathology demonstrated adenocarcinoma, mucin-producing with
few signet ring cells, moderately differentiated. He underwent
PET/CT scan [**2113-12-31**], which showed FDG uptake in the GE junction
but no evidence of regional or distant metastases. He was
referred for EUS staging, performed on [**2114-1-5**], which
demonstrated
a mass at the distal esophagus/GEJ consistent with known
adenocarcinoma, maximum depth 1 cm, with extension beyond the
muscularis propria. There were no concerning lymph nodes
identified. By EUS, the tumor was staged as T3N0Mx, Stage IIB
esophageal adenocarcinoma.
.
He began concurrent chemoradiation with cisplatin/5-FU on
[**2114-1-23**]. He had a J-tube placed prior to treatment. His last
radiation treatment was on [**2114-3-1**], total dose 5040 cGy. His
last
cycle of chemotherapy (C2D1) was [**2114-2-19**]. He underwent
[**Month/Day/Year 12351**]-[**Doctor Last Name **] esophagectomy [**2114-4-25**] which demonstrated residual
disease, including a positive proximal margin. Surveillance
endoscopy demonstrated friable and nodular distal esophagus and
biopsy demonstrated adenocarcinoma.
.
[**2114-9-3**] C1D1 Epirubicin, Oxaliplatin, 5-fluorouracil (5-FU given
by continuous infusion pump Mon-Fri x96 hours given his
difficulty swallowing pills)
[**2114-9-24**] C2D1 Epirubicin, Oxaliplatin, 5-fluorouracil
.
PAST MEDICAL HISTORY:
-Myocardial infarction in [**2101**] treated with plain old balloon
angioplasty to one vessel and a stent in another vessel.
-Choleocystectomy
-Kidney stones
-Osteoarthritis: mainly neck and right knee
-Low back injury
-GERD
Social History:
Married to his wife of 40 years. two children, & two
grandchildren.
He works in software and customer teaching for an electronic
access device maker.
Smoked half a pack to pack a day for approximately 30 years, but
quit in [**2101**] with his heart attack. He does not drink alcohol
regularly.
Family History:
Parents both died of heart attack. He has a sister who has had
breast cancer twice and a brother with diabetes. Family members
with emphysema
Physical Exam:
Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Labs
[**2115-9-20**] 04:16AM BLOOD WBC-8.4 RBC-4.07* Hgb-11.5* Hct-35.6*
MCV-88 MCH-
28.2 MCHC-32.2 RDW-16.6* Plt Ct-255
[**2115-9-20**] 04:16AM BLOOD Glucose-94 UreaN-14 Creat-0.5 Na-137
K-4.1 Cl-108 HCO3-23 AnGap-10
ECHO [**9-19**]
The left atrium is normal in size. Overall left ventricular
systolic function cannot be reliably assessed due to the
technically suboptimal nature of this study. However, the
inferior and posterior walls appear dyskinetic, and the overall
left ventricular ejection fraction is depressed (? 35%). Other
segmental wall motion abnormalities cannot be excluded with
certainty. The right ventricular free wall thickness is normal.
The right ventricular cavity is dilated with borderline normal
free wall function. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve is not well seen. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
a moderate sized pericardial effusion. The effusion appears
circumferential. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. No right atrial
or right ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2115-7-18**], the overall left ventricular ejection
fraction appears lower secondary to increased dyskinesis of the
inferior and posterior walls
CXR: IMPRESSION: Stable appearance of esophageal stent,
bilateral pleural
effusions, right greater than left, and bibasilar opacities,
possibly
reflecting atelectasis
MICRO: None
Brief Hospital Course:
62 yo male with advanced esophageal ca s/p palliative chemo/XRT,
recurrent pl effusions s/p L pleurex, CAD s/p POBA/PCI [**2101**] who
was sent in from cardiology clinic for hypotension and
tachypnea.
#Respiratory distress: Pt found to be tachypnic in ED and was
started on nasal canula. Most likely secondary to poor tidal
volumes in setting of chest wall strain from coughing yesterday.
Pt notes acute onset of pain after coughing last night and
physical exam notable for reproducable pain. ECG unchanged from
baseline and echo unremarkable for new wall abnormalities this
morning. While pleural effusion may be contributing to dyspnea,
CXR is largley unchanged from yesterday with stable R effusion
and drained L effusion with pleurex in place. No signs of
pneumothorax on CXR. His tachypnea improved with dilaudid and he
had no need for supplemental oxygen following admission. He was
discharged with a prescription of dilaudid for breakthrough
pain. His pleurx catheter was also drained prior to discharge.
#Hypotension: Most likely secondary to poor po intake. No signs
of tamponade or MI on cardio workup. No signs of pneumothorax on
CXR. Pt does promote poor po intake over recent weeks with 25lbs
weight loss. He has need admission previously for IV hydration.
Pt's hypotension has resolved thus far with hydration.
-Continued with hydration with bolus target sbp >105,
UOP>50cc/hr
-Continued to monitor for signs of PP
#Pericardial effusion: Chronic and followed by cards as an
outpt. Echo this am does not show tamponade physiology and pt
has no PP on exam. Furthermore, hypotension resolved with fluids
and no appreciable JVP on PE.
-Considered elective pericardial drainage
-Montitored for PP
#Esophageal Ca: Advanced now focusing on palliative chemo and
radiation. Followed by Dr. [**Last Name (STitle) 26981**] as an out pt.
-Continued with home megace
-Sent email to Dr. [**Last Name (STitle) 26981**]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid 250 mg PO BID
2. Aspirin 325 mg PO DAILY
3. Fentanyl Patch 25 mcg/h TP Q72H
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
5. Lorazepam 0.5 mg PO 4-6H:PRN nausea/insomnia
6. Megestrol Acetate 400 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Ondansetron 8 mg PO Q12:PRN nausea/vomitting
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Please monitor and hold for sedation, RR<12 or AMS
10. Senna 1 TAB PO BID:PRN constipation
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Ondansetron 8 mg PO Q12:PRN nausea/vomitting
2. Ascorbic Acid 250 mg PO BID
3. Aspirin 325 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fentanyl Patch 25 mcg/h TP Q72H
6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
7. Lorazepam 0.5 mg PO 4-6H:PRN nausea/insomnia
8. Megestrol Acetate 400 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Please monitor and hold for sedation, RR<12 or AMS
12. Multivitamins 1 TAB PO DAILY
13. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
take 1-2 tablets as needed for pain not controlled by oxycodone.
Do not take if drowsy or driving. Call your oncologist if
requiring more than 2 tablets in 24 hours
RX *hydromorphone [Dilaudid] 2 mg [**12-3**] tablet(s) by mouth up to
once every 6 hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary: hypotension, chest pain
Secondary: Pleural effusion, pericardial effusion, esophageal
cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Last Name (Titles) 26982**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of
breath and low blood pressure. We gave you fluids and treated
your pain, which helped you feel more comfortable and improved
your breathing. We also drained your pleurx catheter.
Please followup with your oncologist, see below. Please call
your cardiologist to schedule a followup appointment to check
the status of the [**Hospital1 **] collection around your heart in the next
week. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
We made the following changes to your medications:
-STARTED Dilaudid for pain control.
Please continue taking your other medications as usual.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2115-10-1**] at 9:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2115-10-1**] at 9:30 AM
With: [**First Name8 (NamePattern2) 4617**] [**Last Name (NamePattern1) 26978**], RN [**Telephone/Fax (1) 9644**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call your cardiologist Dr. [**Last Name (STitle) **] to schedule a
followup appointment to check the status of the [**Last Name (STitle) **] collection
around your heart in the next week.
ICD9 Codes: 4589, 5119, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5909
} | Medical Text: Admission Date: [**2153-9-14**] Discharge Date: [**2153-9-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transfer from OSH for subdural hematoma and unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o transferred from Mt. [**Hospital 69293**] Hospital after being found
at home, unresponsive, by his wife at 2:30 pm. He was "not
waking up" per her report. She called EMS who found him
responsive only to painful stimuluoi. He was tranported to [**Last Name (un) 1724**]
where he was found to have a large, Lt. - sided SDH with midline
shift, GCS of 4. He was also found to have an INR of 4.1 - he is
on coumadin for atrial fibrillation as an outpatient.
Transferred here for neurosurgery after being given FFP and
Vitamin K. On arrival here, pupils were dilated to 5 mm without
response to light. Neurosurgery was consulted, and they feel
that there would be no meaningful recovery from this injury and
no therefore no indication for intervention. A discussion was
started with the family about the withdrawal of care, and they
have decided to make him DNR, but would like other measures
undertaken short of compressions and shocks at the time of my
evaluation.
Past Medical History:
AFib on coumadin
CVA with residual lt. hemiparesis
HTN
Hyponatremia
Hypothyroidism
Social History:
Lives in [**Location **] with his wife.
Family History:
NC
Physical Exam:
Intubated, non-responsive, not on sedation
Cervical collar in place
[**Last Name (un) **] [**Last Name (un) **] rhythm
CTAB
Soft, ND, BS+
No edema
Pertinent Results:
[**2153-9-14**] 06:20PM GLUCOSE-154* UREA N-17 CREAT-1.0 SODIUM-136
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18
[**2153-9-14**] 06:20PM CK(CPK)-223*
[**2153-9-14**] 06:20PM cTropnT-<0.01
[**2153-9-14**] 06:20PM CK-MB-5
[**2153-9-14**] 06:20PM WBC-7.0 RBC-3.75* HGB-11.3* HCT-31.9* MCV-85
MCH-30.1 MCHC-35.4* RDW-13.1
[**2153-9-14**] 06:20PM NEUTS-91.3* BANDS-0 LYMPHS-5.9* MONOS-2.4
EOS-0.2 BASOS-0.2
[**2153-9-14**] 06:20PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2153-9-14**] 06:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Brief Hospital Course:
Pt was transferred from [**Hospital6 1597**] with a subdural
hematoma with midline shift as confirmed on CT scan. Shortly
after admission, patient was made comfort measures only by the
family and was extubated without complication. All medications
and treatments were stopped and patient was made comfortable
with morphine. Patient died without any complications and with
family present at the bedside.
Medications on Admission:
Digoxin
Coumadin
Lisinopril
Levothyroxine
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural Hematoma in the setting of elevated INR
Discharge Condition:
Expired
Discharge Instructions:
Pt. expired.
Followup Instructions:
None
ICD9 Codes: 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5910
} | Medical Text: Admission Date: [**2184-11-1**] Discharge Date: [**2184-11-13**]
Date of Birth: [**2184-11-1**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 37193**] [**Known lastname 74476**] was referred for
evaluation by the primary pediatrician for evaluation of
dusky episodes noted by the parents after a feeding.
[**Known lastname 37193**] is the 2930-gm product of a 36-6/7-week gestation
pregnancy, born to a 32-year-old G1, P0-now-1 mother by
cesarean section for failure to progress and non-reassuring
fetal heart rate tracing. Prenatal labs were blood type A
positive, antibody negative, HBSAG negative, RPR nonreactive,
rubella immune, GBS negative. This was an uncomplicated
pregnancy but there was a slight uncertainty about the dating
as the mother moved here from [**Country 6962**] at approximately 28
weeks gestation and her records from prior to the move were
uncertain. There was no maternal fever. Rupture of membranes
was at 14 hours prior to delivery with clear fluid. The
infant emerged vigorous and required only warming, drying,
and stimulation, bulb suction for resuscitation. Apgars were
8 at one minute and 9 at five minutes. She was admitted to
the newborn nursery on the day of admission. On day of life
three she was noted by the parents to have 4 episodes of
color change, all associated with feeding. They describe her
breast feeding without difficulty, then being burped, then
while being held in semi-upright position developing noisy
breathing and appearing to choke, associated with color
change in dark red or purple. She appeared to resolve these
episodes over several minutes with patting on her back. She
has not been vomiting prior to this. She never had these
episodes during feed or during sleep. She was admitted to the
NICU for further evaluation of these cyanotic episodes.
PHYSICAL EXAMINATION: Physical exam at birth had a weight of
2930 gm, 75th percentile; length of 47 cm which is 50th
percentile; and a head circumference of 33.5 cm which is
greater than 90th percentile. On admission the infant was
alert and active on an open warmer. The appearance was
consistent with gestational age of 36 weeks. HEENT showed
anterior fontanelle soft and flat, red reflex deferred, nares
patent, no macroglossia, mucous membranes moist, palate
intact. Neck - no mass. CV - normal rate, rhythm, no murmur,
2+ radial and femoral pulses, capillary refill brisk. Chest -
clear and equal, no increased work of breathing. Abdomen -
soft, nontender, nondistended, bowel sounds present, no mass,
no hepatosplenomegaly. GU - normal female external genitalia,
patent anus. Back - no cleft, tuft, or dimple. Extremities -
warm, well perfused; hips stable. Skin - pink, no lesions.
Neuro - alert, normal tone, moves all extremities well, good
suck, good grasp.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory - the
infant has remained on room air while in the NICU although
she did have episodes of apnea, bradycardia, and desaturation
at rest requiring blow-by oxygen on days of life 5 and 6 so
the infant has been monitored closely for these apneic
episodes with further studies being done. The most recent
apneic episode was a desaturation with a feeding on [**2184-11-9**]. The infant will be 3 days spell free prior to
discharge from the hospital. Between spells there is no
increased work of breathing. Sats have remained stable with
normal respiratory rates in between. The infant has not been
on any methylxanthine therapy.
Cardiovascular - the infant has not had a murmur, has normal
heart rates and blood pressures but due to the dusky episodes
with some bradycardia, a 4-extremity blood pressure was done
which was normal. EKG was done and read as normal. Pre-and-
post ductal sats were within normal range. Cardiology was
consulted and came and evaluated the infant and felt that no
further cardiovascular workup was needed and that the spells
were not related to a cardiovascular issue.
Fluids, electrolytes, nutrition - the infant has been ad lib
p.o. feeding by breast and feeding well, is voiding and
stooling normally. Electrolytes were measured on admission to
the NICU [**2184-11-4**] - sodium 149, potassium 4.4,
chloride 110, CO2 of 23, BUN 16, creatinine 0.7, calcium 9.3,
glucose 74. No further electrolytes have been measured.
Gastrointestinal - peak bilirubin level was 12.4/0.4 on day
of life seven. The bilirubin has come down to 10.5/0.3 on day
of life nine which is [**2184-11-10**]. No further bilirubins
have been measured. The infant has not required any
phototherapy.
Hematology - no blood typing has been done on this infant. A
crit on admission, day of life three, was 46 with a platelet
count of 358,000. No further crits or platelets have been
measured.
Infectious disease - a CBC and blood culture were screened on
admission to the NICU to rule out sepsis causing cyanosis.
The CBC was benign. The infant was not given any antibiotics.
The blood culture remains negative. The infant developed
yellow eye drainage in the left eye on [**2184-11-12**], and
although conjunctivae were not reddened, at the parents'
request erythromycin ointment was started. No eye culture has
been done.
Neurology - the infant has maintained a normal neurologic
exam. No neurologic evaluations have been done.
Sensory/audiology - a hearing screen was performed with
automated auditory brainstem response and the result is
pending.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 28812**], telephone #[**Telephone/Fax (1) 74477**].
CARE RECOMMENDATIONS: Ad lib p.o. feeding by breast with
supplementation as needed.
Medication - iron ferrous sulfate 0.3 mL p.o. daily; Tri-Vi-
[**Male First Name (un) **] multivitamins 1 mL p.o. daily; erythromycin ophthalmic
ointment both eyes q.8h.
Iron and vitamin D supplementation - 1) iron supplementation
is recommended for pre-term and low-birth-weight infants
until 12 months corrected age, 2) all infants fed
predominantly breast milk should receive vitamin D
supplementation at 200 international units which may be
provided as multivitamin preparation daily until 12 months
corrected age.
Car seat position screening - the infant had passed the car
seat position test for 90 minutes in an upright position in
the car seat.
State newborn screen was sent on day of life three; results
are pending.
Immunizations received - the infant received the hepatitis B
vaccine on [**2184-11-4**].
Immunizations recommended - 1) Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 4 criteria - a) born less than 32
weeks gestation, b) born between 32 and 35 weeks with two of
the following either day care during RSV season, a smoker in
the household, neuromuscular disease, airway abnormalities,
or school age siblings, c) chronic lung disease, or d)
hemodynamically significant congenital heart defect; 2)
influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers; 3) this infant has not
received the rotavirus vaccine. The American Academy of
Pediatrics recommends initial vaccination of pre-term infants
at or following discharge from the hospital if they are
clinically stable and at least 6 weeks or fewer than 12 weeks
of age.
Follow-up appointment is recommended with the pediatrician
after discharge from the hospital. VNA referral has been made
with VNA Care Group, telephone #[**Telephone/Fax (1) 14297**].
DISCHARGE DIAGNOSES:
1. Near-term infant.
2. Dusky episodes resolved.
3. Mild hyperbilirubinemia, resolving on own.
4. Sepsis ruled out.
5. Conjunctivitis, being treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) **]
Dictated By:[**Doctor Last Name 74478**]
MEDQUIST36
D: [**2184-11-12**] 23:32:01
T: [**2184-11-15**] 00:30:48
Job#: [**Job Number 74479**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5911
} | Medical Text: Admission Date: [**2113-4-10**] Discharge Date: [**2113-4-22**]
Service: MEDICINE
Allergies:
Zocor / Lipitor
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Worsening shortness of breath for 5-6 months. Critical AS.
Major Surgical or Invasive Procedure:
Core Valve placement
Endotracheal intubation
Cardioversion
History of Present Illness:
Mr. [**Known lastname 6330**] is a a very articulate [**Age over 90 **] year old [**Location 7972**] man
who has been in good health until the past two years when his
activity level has diminished. Over the past three months, he
had increasing dyspnea with exertion. He does not have chest
pain or syncope-presyncope but is limited to a few stairs or
walking across the room. His dyspnea resolves rapidly with rest.
He has not had PND, orthopnea, or other cardiovascular symptoms.
As part of assessment for percutaneous aortic valve therapy he
was found to have iliofemoral peripheral vascular disease. He
underwent stenting (x2 Bare Metal Stents) of his right iliac
artery on [**2113-3-2**], with excellent result. He was
discharged home on [**2113-3-3**] with VNA and has been doing well
since. He did complain of back pain to the VNA who sent a U/A
via his PCP. [**Name10 (NameIs) **] was positive for a UTI (unknown bacteria) and pt
is on day [**3-25**] of Cephalexin. Able to ambulate only 20 steps
before has DOE causing him to rest. Also has incontinance at
baseline, uses pads at home.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. He does have DOE after 20 ft. He has had TIA s/p
stenting of left cartotid artery [**2105**].
Past Medical History:
1. Hypercholesterolemia
2. Recurrent UTIs ([**12-21**] Foley catheters), urinary incontinence
3. Left carotid stenting in [**2105**] due to a TIA with mild left eye
droop
4. Bilat Total hip replacement [**2106**]
5. Stage III chronic kidney disease
6. Essential Thrombocytopenia
7. Stage 3 CKD
8. Aortic valve stenosis with valve area 0.5 cm2
9. Hypertension
10. NYHA class III CHF
Social History:
He lives with his wife in [**Name (NI) 89789**] MA. He has much support at
home including daily nursing and home health aide from VNA of
[**Hospital3 **]. One son lives next door and is frequently over to see
him several times a day; another son is also in to visit several
times a day. He uses a cane and has not had any falls. He does
not have lifeline in the home but son states there is almost
someone there during the day but not at night. He will be
accompanied by his son [**Name (NI) **] [**Name (NI) 6330**] (cell) [**Telephone/Fax (1) 89790**]. Uses a
walker at home. No history of falls.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Average Daily Living:
Live independently Yes [X] No [ ]
Bathing [X] Independent [ ] Dependent
Dressing [X] Independent [ ] Dependent
Toileting [X] Independent [ ] Dependent
Transferring [X] Independent [ ] Dependent
Continence [X] Independent [ ] Dependent
Feeding [X] Independent [ ] Dependent
Family History:
There is no history of hypertension, diabetes,stroke and
premature coronary artery disease. His mother and father both
died at age 85 of natural causes.
Physical Exam:
ON ADMISSION:
Pulse: 50-57 SR B/P: Right 136/73 Left 131/63 Resp: 18 O2
Sat: 99% RA Temp: 98.4
Height: 68 inches Weight: 76.8 kg
General: Alert, comfortable, sitting in bed.
Skin: no open areas, warm, dry
HEENT: supple, JVD 1/2 up bilat. PERLA, EOM's intact. MM moist.
Sclera non-icteric.
Chest: CTAB posteriorly
Heart: regular, 3/6 systolic murmur across precordium, no
radiation to carotids.
Abdomen: soft, NT, ND
Extremities: trace peripheral edema, bilat at ankles and feet.
No bruits.
Neuro: A/O HOH, appropriate.
.
ON ADMISSION TO CCU:
BP 130/74 (on .5 neo), HR 70, RR 18, O2 sat 100% on 500/16, 60%,
PEEP 5, T 34.9
General: initially intubated, sedated, paralyzed. Later, still
intubated but awake and following commands
HEENT: intubated, JVD difficult to visualized, moist mucosa
Chest: clear anteriorly
Heart: regular with frequent premature beats, very faint
systolic murmur
Abdomen: soft, nontender, nondistended
Groin: bilateral bandages in place, no evidence of swelling or
tenderness (R hip firm, which seems to be his baseline [**12-21**] THR).
No bruit.
Extremities: trace peripheral edema bilaterally, pulses
dopplerable faintly at PT (obtained by one examiner and not
another), warm but slightly mottled feet bilaterally
Neuro: after withdrawal of sedation, patient able to squeeze
hands, blink eyes to command. PERRL
.
On discharge:
Gen: alert, oriented x2
HEENT: supple,
CV: RRR, no M/R/G
RESP: [**Month (only) **] at bases, no crackles or wheezes
ABD: soft, NT, pos BS, had BM
EXTR: left groin with large resolving hematoma, no bruit noted.
right groin wtih pos bruit. No tenderness
NEURO: alert, conversant, less confused. Oriented x 2
Extremeties: no edema
Pulses:
Right: DP 1+ PT 1+
Left: DP 2+ PT 1+
Skin: intact
Pertinent Results:
ADMISSION LABS:
[**2113-4-10**] 12:40PM WBC-6.7 RBC-3.56* HGB-11.7* HCT-33.8* MCV-95
MCH-33.0* MCHC-34.7 RDW-15.3
[**2113-4-10**] 12:40PM PLT COUNT-191
[**2113-4-10**] 12:40PM NEUTS-66.0 LYMPHS-20.0 MONOS-6.4 EOS-6.4*
BASOS-1.1
[**2113-4-10**] 12:40PM PT-14.5* PTT-32.5 INR(PT)-1.2*
[**2113-4-10**] 12:40PM GLUCOSE-99 UREA N-32* CREAT-2.2* SODIUM-139
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
[**2113-4-10**] 12:40PM ALBUMIN-4.1 CALCIUM-9.8 PHOSPHATE-3.6
MAGNESIUM-2.3
[**2113-4-10**] 12:40PM ALT(SGPT)-17 AST(SGOT)-28 LD(LDH)-252*
CK(CPK)-56 ALK PHOS-133* TOT BILI-0.4
[**2113-4-10**] 12:40PM CK-MB-4
.
DISCHARGE LABS:
[**2113-4-22**] 06:50AM BLOOD WBC-9.8 RBC-2.93* Hgb-9.4* Hct-29.0*
MCV-99* MCH-32.2* MCHC-32.6 RDW-19.0* Plt Ct-217
[**2113-4-22**] 06:50AM BLOOD PT-44.0* INR(PT)-4.6*
[**2113-4-22**] 06:50AM BLOOD Glucose-91 UreaN-51* Creat-2.7* Na-138
K-4.6 Cl-106 HCO3-19* AnGap-18
[**2113-4-12**] 03:25PM BLOOD LD(LDH)-362* CK(CPK)-185 TotBili-1.5
.
ECHO ([**4-11**]): The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). with
mild global free wall hypokinesis. The aortic valve leaflets are
severely thickened/deformed. Mild (1+) aortic regurgitation is
seen.There is severe aortic stenosis. Moderate (2+) mitral
regurgitation is seen, with a restricted posterior leaflet.There
is also a mitraal valve cleft bettween P1 and P2. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Post TAVI
There is 2+ aortic regurgitation.The regurgitation is
parvalvular,
2+ mitral regurgitation similar to preprocedure
No pericardial effusion is seen
LV function is preserved
.
ECHO ([**4-18**]): The left atrium is mildly dilated. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is dilated
with mild global free wall hypokinesis. The aortic root is
mildly dilated at the sinus level. An aortic CoreValve
prosthesis is present. The prosthetic aortic valve leaflets
appear normal. The transaortic gradient is normal for this
prosthesis. There are two small paravalvular aortic
regurgitation jets, together constituting no more than mild (1+)
aortic regurgitation is seen. Moderate (2+) mitral regurgitation
is seen. Moderate [2+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normally-functioning CoreValve aortic prosthesis.
Symmetric LVH with normal global and regional systolic function.
Severe pulmonary hypertension with dilated right ventricle and
mild global systolic dysfunction and moderate to severe
functional tricuspid regurgitation.
.
EKG ([**4-19**]): Sinus bradycardia with first degree atrio-ventricular
conduction delay. Low QRS voltage in limb leads. Inferior wall
myocardial infarction of indeterminate age. Lateral myocardial
infarction of indeterminate age. Compared to the previous
tracing of [**2113-4-18**] multiple abnormalities persist without major
change.
.
Brief Hospital Course:
[**Age over 90 **]yoM with NYHA Class 3 CHF and severe AS, now s/p COREvalve
with post-procedure course complicated by hemodynamic
instability and new onset AF with RVR.
.
# Aortic stenosis: Corevalve procedure was without
complications. He was extubated immediately post-op.
Subsequent TTEs showed appropriate positioning and functioning
of the valve. Aspirin and Plavix were continued.
.
# Hypotension: In the immediate post-procedure period, he was
recurrently hypotensive, and did several hours after the
procedure, lose his pulse briefly. He regained blood pressure
and consciousness after 1 round of CPR. However, over the next
48 hours he had 3 more episodes of sudden, profound hypotension
to the 40s systolic with loss of consciousness. Each time he
regained consciousness within seconds without intervention.
This was all thought to be due to profound systemic dilatation
in the setting of the sudden relief of his outflow tract
obstruction He required intermittent neosynephrine in the first
48 hours post-procedure. Echo showed a collapsed LV and outflow
tract obstruction, prompting fluid resuscitation. His blood
pressures improved, but subsequently decreased due to atrial
fibrillation. His blood pressures again stabilized with rate,
and eventually rhythm control.
.
# Atrial Fibrillation. New diagnosis of Afib. On [**4-14**] amio
loaded and anticoagulation started with hep ggt. He was
cardioverted on [**4-18**] and continued on amiodarone and coumadin.
He remained in sinus bradycardia with stable blood pressures.
The decision was made to discontinue coumadin on [**2113-4-22**] given
bleeding risk and interaction with amio. Amiodarone was changed
to 200 mg daily.
.
# Thrombocytopenia. Patient with 191 -> 83 drop in platelets in
the several days post-procedure. D-dimer and FDP were elevated
but fibrinogen was not low and no evidence of hemolysis. RBC
morphology did not demonstrated schistocyes. HIT was thought to
be unlikely. Platelets returned to baseline over the next week.
.
# Anemia: HCT stable after 2u of pRBC on [**4-13**]. CT showed Left
pelvic hematoma with layering blood in the pelvis and a small
amount of peri-hepatic hemoperitoneum. No retroperitoneal
hematoma. Repeat b/l LE duplex - Normal appearance to right CFA,
and CFV Pseudoaneurysm no longer seen. Hct stabilized and no
further transfusions were required.
.
# Acute on chronic Diastolic CHF: After core-valve procedure
patient was hypotensive and very pre-load dependent with bedside
echo demonstrating low filling. Was treated with IVF boluses.
BP??????s subsequently stabilized and patient was LOS balance
positive upto 5L. Subsequently appeared clinically fluid
overloaded with crackles and wheezing on lung auscultation and
congested appearance of chest x ray, this prompted diuresis with
boluses of 10mg IV lasix. He was approximately euvolemic upon
discharge.
.
# Delirium. Patient developed confusion and disorientation
during hospitalization, which was likely secondary to prolonged
ICU course. He had no signs of active infection. He was given
seroquel prn and daily ECG was followed to monitor for QTc
prolongation. Seroquel was discontinued on discharge due to
sedation.
.
# CORONARIES: No history of CAD. ASA and pravastatin were
continued.
.
# Peripheral Vascular disase: S/P BMS to right iliac artery.
Pulse exam was stable - PT pulses dopplerable, DP very faint on
doppler
.
# CKD, Stage 3: Creatinine increased to 2.7 from baseline 2.2.
Believed to be pre-renal given FeUrea <25%. He was given 1 liter
NS bolus on the day of discharge. He will require daily Cr
checks.
.
# Dyslipidemia: Pravastatin was continued
.
CODE: Full
.
COMM: [**Name (NI) **]: [**Name (NI) **] [**Name (NI) 6330**], [**First Name3 (LF) **]. [**Telephone/Fax (1) 89791**]. Pt is illiterate.
.
Transitions of Care:
- Daily Cr checks
Medications on Admission:
confirmed with son and list
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lumigan 0.01 % Drops Sig: Two (2) drops Ophthalmic at
bedtime.
7. Cephalexin 500 mg po QID, day #5 of 7 for UTI
8. Tylenol 500 mg PO BID for back pain
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
11. Outpatient Lab Work
please check daily Cr, until begins trending down to baseline
2.2.
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Cape Regency, A [**Hospital 671**] HealthCare Center - [**Location 41366**]
Discharge Diagnosis:
Severe Arotic Stenosis s/p CoreValve placement
Delerium
Atrial fibrillation
Acute on Chronic kidney disease
Chronic thrombocytopenia and anemia
Acute on chronic diastolic congestive heart failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had a naortic CoreValve placed that has fixed your severe
aortic stenosis. The procedure went well but you had some
complications that include bleeding at the right and left groin
site, delerium and atrial fibrillation. Your groin sites have
been stable with no evidence of bleeding at present. The atrial
fibrillation was converted to a normal rhythm via a
cardioversion procedure and you were started on a medicine
called amiodarone to keep you in a normal rhythm. You will need
to have your thyroid, liver and lung function followed regularly
while you are on this medicine. You thyroid and liver function
tests were OK here in the hospital. You were also started on
coumadin to prevent a blood clot from the atrial fibrillation.
Your coumadin level is high now, probably from the interaction
with the amiodarone. This level will be followed closely from
now on. You were confused from being in the hospital and this is
clearing slowly.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. START amiodarone to keep you in a normal rhythm
2. START senna, colace and miralax to treat your constipation
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2113-5-12**] at 12:20 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2113-5-12**] at 11:00 AM
With: ECHOCARDIOGRAM [**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: 4241, 2930, 5990, 2762, 9971, 2875, 4280, 2720, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5912
} | Medical Text: Admission Date: [**2187-2-12**] Discharge Date: [**2187-2-15**]
Date of Birth: [**2109-8-5**] Sex: M
Service: GU
ADMISSION DIAGNOSIS: Benign prostatic hypertrophy.
POSTOPERATIVE DIAGNOSES: Benign prostatic hypertrophy,
postoperative anemia.
ADMISSION HISTORY AND PHYSICAL: Patient is a 77-year-old
male with a history of BPH and no other medical history who
presented for surgical resection after complaining of weak
stream.
PAST MEDICAL HISTORY: Includes BPH and mild exercise
intolerance.
PAST SURGICAL HISTORY: Of renal cyst aspiration, hernia
repair, cataract surgery, and colonoscopy and biopsy.
MEDICATIONS: Include aspirin 81 mg every day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Includes no tobacco use and [**2-16**] alcoholic
drinks a day with no drug use.
REVIEW OF SYMPTOMS: Otherwise noncontributory.
PHYSICAL EXAM: Revealed a 71 inch, 157 pound male with a
pulse of 68, blood pressure of 147/92 in no apparent distress
with clear lungs with a [**2-19**] murmur in left sternal border
with abdomen that is soft and nontender. No extremity edema.
HOSPITAL COURSE: Patient presented as above and underwent a
transurethral resection of the prostate for BPH on [**2187-2-12**]. This was a large resection, and postoperatively was
noted to have a great deal of hematuria requiring brisk CBI
immediately postoperatively. Because of the brisk CBI and
requiring bag changes approximately every 30 minutes, patient
was monitored overnight for 1-to-1 nursing care in the ICU.
Medically, however, patient remained stable throughout the
hospital course, and patient's hematocrit postoperatively was
in the 30s (stable at 30 at discharge). Patient did not
require any transfusions.
The patient's Foley was removed on postoperative day #2 after
urine was noted to be fruit punch color off of CBI. Patient
was then observed for another day of hospitalization, and
reported urinating well. But initially urinated several
clots. The urine color then became much lighter in color
after urination of clots. Patient reported sensation of
complete emptying upon discharge, and also reported a very
strong stream and good satisfaction of his urination.
Therefore, upon discharge on postoperative day #3, patient
was ambulating, voiding, without significant pain, and
tolerating POs without difficulty.
DISCHARGE CONDITION: Good.
DISCHARGE DIET: Regular.
DISCHARGE MEDICATIONS: Tylenol 650 mg p.o. q.4h. p.r.n.
pain, Colace 100 mg p.o. b.i.d. No antibiotics were given
upon discharge because 3 days of ciprofloxacin had been given
in the hospital.
FOLLOWUP: Will be with Dr. [**Last Name (STitle) 365**] in [**1-15**] weeks.
DISCHARGE ACTIVITIES: No restrictions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 27469**]
Dictated By:[**Name8 (MD) 20918**]
MEDQUIST36
D: [**2187-2-15**] 07:27:56
T: [**2187-2-15**] 08:49:15
Job#: [**Job Number 27470**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5913
} | Medical Text: Admission Date: [**2196-1-25**] Discharge Date: [**2196-2-8**]
Date of Birth: [**2149-10-8**] Sex: M
Service: SURGERY
Allergies:
Cefepime
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Biliary colic
Major Surgical or Invasive Procedure:
[**2196-1-25**] ERCP w/ sphincterotomy
open cholecystectomy
History of Present Illness:
46M with history of biliary colic, morbid obesity, HTN, lower
extremity
edema , who presents directly from ERCP where he underwent ERCP
and sphincterotomy. Pt tolerated the procedure well. Prior to
the
ERCP pt was admitted to [**Hospital **] hospital [**1-22**] for severe
recurrent epigastric pain after eating, lasting hours, in the
setting of elevated transaminases (AST:ALT 370:447 AP 166, TB 4,
lipase 22 ). Pt does have history of similar pain just a few
days
prior as well as approx one year ago which resolved on its own.
On [**1-18**] and again on [**1-22**] pt underwent RUQ U/S which showed
cholelithiasis but no evidence of cholecystitis. Pt denies fever
at any point, but does admit to recent nausea and vomiting.
Past Medical History:
obesity, depression, hypothyroidism, lower extremity edema,
biliary colic
Social History:
Lives alone in [**Location (un) 932**], unemployed. Denies cigs
or drugs, +etoh (1-2 drinks a night)
Family History:
Noncontributory
Physical Exam:
Upon presentation:
VS: 97.6, 128/85, 68, 18, 93% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes dry
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l,
ABD: Soft, obese, nontender, no rebound or guarding, normoactive
bowel sounds, no palpable masses
Ext: Severe LE edema.
Psych: flat affect.
Pertinent Results:
RENAL & GLUCOSE
Glucose 78
Urea Nitrogen 9 6 - 20 mg/dL
Creatinine 0.6 0.5 - 1.2 mg/dL
Sodium 136 133 - 145 mEq/L
Potassium 3.8 3.3 - 5.1 mEq/L
Chloride 100 96 - 108 mEq/L
Bicarbonate 27 22 - 32 mEq/L
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 206* 0 - 40 IU/L
Asparate Aminotransferase (AST) 98* 0 - 40 IU/L
Alkaline Phosphatase 121 40 - 130 IU/L
Bilirubin, Total 0.6 0 - 1.5 mg/dL
OTHER ENZYMES & BILIRUBINS
Lipase 24 0 - 60 IU/L
CHEMISTRY
Calcium, Total 8.4
Phosphate 3.3
Magnesium 2.0
IMAGING:
[**2196-1-25**] ERCP: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.CBD
was sweeped with balloon catheter and sludge was extracted.
Impression: Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
CBD and intrahepatic biliary tree was normal in calibre.
There was a filling defect that appeared like sludge in the
distal CBD.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
CBD was sweeped with balloon catheter and sludge was extracted.
[**2196-1-30**] BLE Duplex U/S: No evidence of DVT in bilateral lower
extremities.
[**2196-1-30**] CT TORSO (non-con):
IMPRESSION:
1. Bilateral heterogeneous opacification in the lungs, worst in
the left lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] represent atelectasis; however,
underlying infectious process such as pneumonia or aspiration
cannot be completely excluded and should be considered in the
correct clinical setting.
2. Status post cholecystectomy with percutaneous biliary drain.
3. Fat-containing ventral periumbilical hernia and a fluid
filled right
inguinal hernia.
[**2196-1-31**] CT TORSO (w/ con):
IMPRESSION:
1. Nondiagnostic examination in the evaluation of pulmonary
embolism
secondary to respiratory motion artifact.
2. No evidence of venous clot in the iliac veins or veins of the
pelvis.
3. Increasing size and number of lymph nodes both in the
mediastinum and
right inguinal area. Clinical correlation recommended to exclude
low grade
hematologic malignancy.
4. Areas of consolidation in bilateral lung bases and in the
right upper [**Month/Day/Year 3630**] may be on the basis of atelectasis, although
superimposed infection or central obstructing lesion cannot be
excluded based on this examination.
[**2196-2-1**] ECHO: Technically suboptimal study despite the use of
Definity. No clinically useful information was derived. If
clinically indicated, a radionuclide ventriculogram may be
better able to assess biventricular systolic function.
Brief Hospital Course:
He was admitted to the Acute Care Surgery Service as a direct
admission following ERCP. He was given IV hydration and made
NPO. His LFT's and bilirubin were followed closely and slowly
trended downward. Early discussions took place with patient for
operative management with cholecystectomy for which patient
wanted to discuss further with team and his family before
definitively consenting for this.
On [**1-26**] the he underwent a laparoscopic converted to an open
cholecystectomy. POD #1 his urinary output dropped and he
received fluid along with 1 unit pRBC with adequate urinary
response. On POD #2 he was advanced to a regular diet. He
continued to do well. However, overnight he began to drop his O2
sats and became tachycardic. In addition, his Cr rose to 1.6
from 0.9 the day before. A CXR was performed which showed mild
pulmonary vascular congestion. He was given a dose of Lasix with
no response. An ABG revealed hypoxemia with pO2 of 65. Given the
concern for PE and his ongoing hypoxia, he was transferred to
the ICU for close monitoring.
A CTA chest with PE protocol was unable to be performed because
the patient's Cr had bumped to 1.9. Therefore, a CT torso
without contrast was performed which showed a bilateral lower
[**Month/Day (4) 3630**] opacification (L>R) but was otherwise unremarkable. BLE
duplex U/S was negative for DVT. While in the unit, he became
hypotensive with systolic blood pressures ranging between
70s-80s. He was empirically started on vanc/zosyn. The next day
([**2196-2-1**]), his antibiotics were changed to vanc/Cipro/cefepime to
cover hospital acquired pneumonia. An NGT was placed with
immediate return of 500 cc of coffee ground fluid; his HCT was
found to be 22.8. He was transfused 2 units of pRBC's. GI team
was consulted regarding a potential upper endoscopy. However,
they felt EGD would require elective intubation and therefore
the procedure was deferred. The patient was aggressively fluid
resuscitated and his urine output remained adequate. The
following day his Cr dropped to 1.3 and he was sent for a CTA
with PE protocol which was indeterminate for PE due to motion
artifact but did not show thrombus in the aortoiliac or pelvic
veins. Serial HCT were trended and remained stable. An echo was
attempted [**2-1**] but the quality was suboptimal secondary to the
patient's large body habitus. He still had a significant
supplemental oxygen requirement.
Over the next few days in the ICU his respiratory status
remained tenuous. He was started on intermittent Lasix boluses
[**2196-2-1**] which resulted in large diuresis and he was able to be
weaned to nasal cannula. On [**2196-2-2**], he was started on 20mg PO
Lasix daily and was given 40mg IV Lasix as well as a dose of
Diamox. He again responded with a brisk diuresis but then became
hypotensive overnight requiring 2.5L of fluid boluses. His HCT
in the AM was 21 and he was transfused one unit pRBC's. The
patient also developed an urticarial rash on [**2196-2-2**] and this was
attributed to having switched his Cipro from IV to PO. The Cipro
was therefore discontinued and he was started on Levofloxacin.
His rash has virtually resolved at time of this dictation.
He remained on the Vancomycin and Levofloxacin for the pneumonia
for a total of 7 day course, stop date [**2196-2-10**]. He is also
receiving Flagyl for a presumed C. difficile colitis given his
stool volume. It should be noted that he has had 2 negative
stool for C. Diff cultures. His treatment with Flagyl will
continue for a total of 7 day course. A Flexi seal system was
placed rectally for stool containment and protection of
patient's skin given his large body habitus. Cholestyramine was
started as well.
He was also seen by Psychiatry for his anxiety and depression
and it was recommended to increase his Celexa to 40 mg daily
from 30 mg and to avoid benzodiazepines as this would put him at
risk for delirium.
He was evaluated by Physical therapy and is being recommended
for rehab after his acute hospital stay.
Medications on Admission:
Lisinopril 10mg PO daily
Levothyroxine 137 mcg PO daily
Lasix 20 mg PO daily
Celexa 30 mg PO daily
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
6. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation every six (6) hours.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
9. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for pruritis.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical
three times a day: apply to skin folds.
15. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. cholestyramine-sucrose 4 gram Packet Sig: Two (2) Packet PO
BID (2 times a day).
17. Vancomycin 1500 mg IV Q 12H Start: [**2196-2-3**]
stop date [**2196-2-10**]
18. levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) MG Intravenous Q24H (every 24 hours): stop
date [**2196-2-10**].
19. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) MG Intravenous Q8H (every 8 hours): stop date
[**2196-2-11**].
20. insulin regular human 100 unit/mL Solution Sig: One (1) Dose
Injection four times a day as needed for per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Choledocholithiasis
Upper Gastrointestinal Bleed
Acute Blood Loss Anemia
Pneumonia
Anxiety
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hopsital with gallstones and underwent
a procedure called an ERCP which looks inside of your biliary
system. You then had your galbladder removed. You did well in
the post operative period and your diet was advanced.
You should avoid fried and/or greasey foods; food choices should
include those that are low in fat.
You may resume your home medications as prescribed. If you have
been prescribed an anitibiotic please continue the course as
directed.
Return to the emergency room if your symptoms come back.
Followup Instructions:
Follow up in [**12-31**] weeks in Acute Care Surgery Clinic. Please call
[**Telephone/Fax (1) 600**] for an appointment.
Follow up with your primary care providers as directed.
Completed by:[**2196-2-9**]
ICD9 Codes: 486, 5789, 2851, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5914
} | Medical Text: Admission Date: [**2112-1-14**] Discharge Date: [**2112-1-21**]
Date of Birth: [**2059-9-23**] Sex: F
Service: UROLOGY
ADMITTING DIAGNOSIS: Pheochromocytoma.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
white female who was initially referred for evaluation of
microscopic hematuria and right adrenal mass. The patient
underwent a cystoscopy, which was normal. Review of outside
films did not demonstrate any ureteral or renal abnormality.
However, a magnetic resonance scan was performed which
demonstrated a 3.6 x 4.4 irregularly shaped right adrenal
mass with T2 hyperintensities. On further questioning, the
patient was found to have proximal palpitations, chest pain
and headaches all precipitated by exertion several times per
day for the last half year or so. The blood pressure was
checked by her school nurse during one of these episodes, and
her blood pressure was elevated to 190/120. The patient had
also developed night sweats starting [**9-/2111**], and reported a
[**11-30**] pound weight loss between [**7-/2111**] and 12/[**2110**]. The
patient had been treated with p.o. phenoxybenzamine and
nifedipine with partial resolution of her palpitations and
headaches. A 24-hour catecholamine study revealed elevated
normetaepinephrine of 493 and elevated combined metanephrine
and normetanephrine of 633. Vanillylmandelic acid or VMA was
normal at 5.3. The patient also had normal levels of urinary
17-ketosteroids, cortisol, chromogranin-A, aldosterone, and
plasma renin. The patient denied any flank
pain, fevers, chills.
PAST MEDICAL HISTORY:
1. Glaucoma.
2. Hypothyroidism.
PAST SURGICAL HISTORY: Glaucoma surgery.
MEDICATIONS ON ADMISSION:
1. Levothyroxine 50 mcg q day.
2. Phenoxybenzamine 10 mg b.i.d.
3. Nifedipine 30 mg q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a teacher at a local school.
The patient smokes about one and a half packs of cigarettes
per day for thirty years. The patient also drinks [**12-18**]
alcoholic beverages per day.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 95, blood pressure 137/77, respiratory
rate 16.
HEAD AND NECK: Within normal limits.
CHEST: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
GASTROINTESTINAL: Soft, nondistended, nontender, no CVA
tenderness, no palpable mass.
LABORATORY DATA: Please see History of Present Illness.
HOSPITAL COURSE: The patient was admitted on [**2112-1-14**] and
underwent a laparoscopic right-sided adrenalectomy. The
patient tolerated the procedure well and there were no
immediate postoperative complications. The patient's pain was
well controlled with intravenous morphine. The patient was
continued on intravenous fluids for hydration, and the
patient's hematocrit and creatinine were stable and normal.
On postoperative day one, the patient was continued on NPO
status, and the patient's diltiazem was continued, but her
alpha adrenergic blockers were discontinued. The patient's
blood pressure remained stable.
On postoperative day two, the patient had decreased breath
sounds on the left chest, and the patient's O2 saturations
began to decline. The patient denied any shortness of breath,
but an arterial gas revealed a pH of 7.38, PCO2 of 49 and a
PO2 of 45. The patient was transferred to the Intensive Care
Unit and was intubated for better oxygenation. A chest x-ray
revealed opacification of her left chest. The patient was
started on levofloxacin and Flagyl for possible pneumonia.
The patient's poor oxygenation was felt to be due to a
combination of her underlying chronic obstructive pulmonary
disease and possible atelectasis/pneumonia.
By postoperative day three, the patient had improved O2
saturations overnight, and her blood pressures were well
controlled on nifedipine. The patient was continued on
levofloxacin and Flagyl, and a follow-up chest x-ray also
showed only slight improvement on the left side. A
bronchoscopy performed on [**2112-1-17**] revealed some secretions
on the right lower lobe, but the left side was indeed clear.
On postoperative day four, the patient's respiratory status
slightly improved from the previous day. A chest x-ray also
showed some improvement and Pulmonary consult recommended
starting on systemic steroids, as well as inhaled steroids.
By postoperative day five, the patient's chest x-ray was
dramatically improved, and her O2 saturations remained
stable. The patient was extubated successfully. As the
patient appeared comfortable and in no respiratory distress,
it was felt that the patient would be transferred to the
floor on postoperative day five. The patient was continued on
Solu-Medrol 60 mg q eight which was eventually tapered.
On postoperative day six, the patient was weaned off her O2,
and her O2 saturations remained above 90%. Chest x-ray showed
marked clearing of the left side. The Foley was discontinued
and the patient was encouraged to ambulate t.i.d.
By postoperative day seven, the patient was in no further
respiratory distress. It was felt that the patient would be
ready for discharge home.
FOLLOW-UP INSTRUCTIONS: The patient was to follow-up with
Dr. [**Last Name (STitle) 4229**] within 2-4 weeks.
DISCHARGE STATUS: Home.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Inhaler four puffs inhalation b.i.d.
3. Percocet 5/325 mg tablets, 1-2 tablets p.o. q 4-6 hours
p.r.n. for pain.
4. Levofloxacin 500 mg p.o. q day.
5. Flagyl 500 mg p.o. t.i.d.
6. Prednisone 20 mg q day.
7. Prednisone 10 mg q day after finishing 20 mg dose.
8. Nicotine patch q 24 hours.
9. Synthroid 50 mcg q day.
10. Albuterol and Atrovent inhalers.
DISCHARGE DIAGNOSIS: Pheochromocytoma, status post
laparoscopic right adrenalectomy.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Name8 (MD) 3430**]
MEDQUIST36
D: [**2112-1-21**] 08:20
T: [**2112-1-21**] 10:52
JOB#: [**Job Number 98581**]
ICD9 Codes: 486, 496, 5180, 2851, 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5915
} | Medical Text: Admission Date: [**2178-5-8**] Discharge Date: [**2178-6-13**]
Service: ICU
CHIEF COMPLAINT: Decreased hematocrit, increased INR.
HISTORY OF THE PRESENT ILLNESS: The patient is an
84-year-old male who presented for outpatient ERCP and was
found to have a newly diminished hematocrit to 17 and newly
increased INR to 3.0. The patient had recently been
diagnosed with diabetes mellitus three months ago and started
on insulin. Approximately 3 1/2 weeks ago, the patient
developed dark urine and went to his primary care physician
who noted jaundice and had the patient go for a CT of the
abdomen where a mass in the head of the pancreas was seen.
The patient was scheduled for outpatient ERCP on the day of
presentation.
Upon presentation, he noted melenic dark black stools mixed
with some [**Male First Name (un) 1658**]-colored stools, fatigue, back pain, early
satiety and some decreased appetite. The patient was
admitted to the General Medical Service and Gastroenterology
was consulted for ERCP. The patient was evaluated and
concern for pancreatic carcinoma led to scheduling for an
ERCP. There was also concern for a possible biliary
obstruction given the elevated alkaline phosphatase of 1,818
and total bilirubin of 12.4 and so the procedure was also for
the purpose of decompression.
On the day after admission, the patient had received 2 units
of packed red blood cells and had a CT of the abdomen which
revealed a 3.2 cm mass in the head of the pancreas with clear
fat planes between the mass and all surrounding abdominal
organs with vascular structures intact with the exception of
the mass which abutted and possibly invaded the duodenum.
The SMV, portal vein, SMA, gastroduodenal artery and stomach
were all free from involvement. There was massive intra and
extrahepatic biliary ductal dilatation and pancreatic ductal
dilatation upstream to the pancreatic head mass. Incidental
finding of a small left renal cyst versus angiomyolipoma was
noted.
The patient had episodic desaturations to the low 70s to 80s
which improved to 90s with supplemental oxygen. Chest x-ray
done at one of the episodes revealed diffuse interstitial
opacities, raising a question of pulmonary edema versus
lymphangitic spread versus atelectasis with collapse versus
pneumonia. The patient received a trial of IV Lasix and
concern for ongoing clinical deterioration led to the
consideration for ICU level care.
On [**2178-5-10**], the patient was found to be very short of
breath, saturating mid 90s on a 100% nonrebreather. The
patient's white blood cell count was noted to continue to
rise into the mid 20s and his renal function was found to
decline with a creatinine of 2.2 concerning for ATN. There
was concern for evolving sepsis in the setting of biliary
obstruction and possible cholangitis. The patient had been
started on ceftriaxone and Flagyl for antibiotic coverage.
The patient was electively transferred to the ICU and
evaluated for emergent biliary decompression.
Infectious Disease was consulted and recommended that the
patient undergo treatment with Zosyn 2.25 grams IV q. eight
hours. The patient was admitted to the ICU. The patient's
hematocrit was noted to continue to be low and he was given 3
units of packed red blood cells along with vitamin K 10 mg
subcutaneously for an elevated INR. The patient's hypoxia
was thought to be secondary to multilobar pneumonia versus
evolving ARDS. There was concern about the need to intubate
preprocedure in order to enable the patient to undergo ERCP.
The patient's acute renal failure was thought secondary to
possible prerenal state in the setting of sepsis.
Renal was consulted for further evaluation of the patient's
acute renal failure and it was felt that the patient's acute
renal failure was secondary to acute interstitial nephritis
in the setting of treatment with Zosyn. The Zosyn was
discontinued and the patient underwent supportive care with
avoidance of nephrotoxins and discontinuation of the
patient's angiotensin receptor blocker.
At 7:35 p.m. on [**2178-5-10**], the patient was intubated for
progressive hypoxemia. The patient underwent emergent ERCP
which showed a giant ulcer in the posterior vault, evidence
of previous cholecystectomy, biliary stricture compatible
with known tumor in the head of the pancreas. The patient
was continued on broad spectrum antibiotics. There was
inability to place this biliary stent on the first attempt.
The patient returned to the ERCP Suite on [**2178-5-11**] and
sphincterotomy was performed with a coated walled stent
placed in the distal common bile duct. There was concern for
malignant ulcer in the posterior duodenal bulb, distal common
bile duct stricture consistent with the known tumor in the
head of the pancreas. Surgery was consulted for a possible
Whipple procedure; however, given the patient's current
clinical status at this time, no surgical intervention was
needed at the time.
The patient was followed by Renal who recommended the use of
diuretics for volume control. Cortisol levels revealed that
the patient did not have any evidence of adrenal
insufficiency. He transiently required pressors consisting
of Levophed but this was eventually able to be weaned off.
The patient was bronchoscoped for evaluation of pneumonia
versus ARDS. The patient's pancreatic and liver function
tests diminished after ERCP. The option of dialysis was
presented and the family elected not to partake of this. The
patient's volume was able to be controlled with intravenous
diuretics. The patient was ventilated with low tidal volumes
and increased respiratory rate per the ARDS net protocol.
An esophageal balloon was used to guide the patient's PEEP
requirement and this suggested ARDS as the patient had
increased chest wall and abdominal pressures. The patient's
ICU course was also complicated by hyponatremia which
warranted increased free water boluses. The patient required
an insulin drip for glycemic control which was worse in the
setting of infection. The patient underwent diuresis to try
to decrease the amount of FI02 that he was requiring.
By [**2178-5-23**], the patient showed improvement in his
ventilatory requirements as well as ability to come off
pressor agents. His acute renal failure continued to
improve. The Renal Service recommended a short steroid
course of prednisone to treat the patient's acute
interstitial nephritis. This was initiated with steady
improvement in the patient's creatinine which had reached a
high of 8.5. The patient developed some neutropenia which
was also felt to be due to a reaction of Zosyn. This
resolved spontaneously with discontinuation of the
medication. Also, in support of a reaction to Zosyn, the
patient developed a maculopapular rash. All of these
improved with the discontinuation of the drug.
The patient had been afebrile for a significant amount of his
ICU stay and around [**2178-5-21**], developed low-grade
temperature elevation and cultures were drawn. The patient
eventually grew MRSA from sputum, likely related to
ventilator-associated pneumonia. He was started on
vancomycin for treatment of this. Given the possible
presence of a drug reaction and some decreased urine output
and difficulty controlling the patient's volume, the patient
was diuresed with ethacrynic acid with good response. The
patient developed hematuria for which Urology consult was
obtained and this was thought to be secondary to ethacrynic
acid which is associated with gross hematuria and the patient
was diuresed further with Lasix in place of ethacrynic acid.
The patient developed a contraction alkalosis for which he
received Diamox with a good improvement. The patient's ARDS
was shown to resolve on serial chest x-rays. The patient
underwent weaning from the ventilator and his sedation was
changed from Ativan to propofol in the hope of achieving
sustained extubation.
On [**2178-6-4**], a family meeting was held with the plan to
discuss the need for reintubation after an extubation
attempt. The family elected to reintubate in the event of an
extubation failure. The patient was extubated successfully
on [**2178-6-4**]. He remained with a relatively high oxygen
requirement post extubation. He continued treatment for MRSA
pneumonia with vancomycin for a total course of ten days.
His acute renal failure resolved to a baseline creatinine of
1.4. As the patient was off sedation, his mental status
improved.
He developed oral lesions shortly after extubation which were
thought to be secondary to HSV.
The patient remained with tenuous respiratory status over the
next four days after extubation but did show slow but steady
improvement in his oxygen requirement.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus times 22 years.
2. Hypertension.
3. Hypercholesterolemia.
MEDICATIONS:
1. Humalog/Humulin sliding scale 17 units in the a.m., 8
units at h.s.
2. Lopressor 50 mg p.o. b.i.d.
3. Glyburide 5 mg p.o. b.i.d.
4. Cozaar 100 mg p.o. q.d.
5. Percocet p.r.n.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married and did not smoke or
drink. He use to work as a truck manager for Ford Motors.
FAMILY HISTORY: The patient has a sister with diabetes and
chronic renal insufficiency. There is no history of
pancreatic malignancy in his family.
LABORATORY/RADIOLOGIC DATA: The patient had a white blood
cell count of 14.3 on admission with a hematocrit of 16.4 and
platelets of 341,000. His INR was 3.9. His ALT was 167, AST
221, total bilirubin 17.2, alkaline phosphatase 2,024,
amylase 28, total bilirubin 17.2 with a lipase of 233.
CT of the abdomen revealed a 3.2 cm mass in the head of the
pancreas, clear fat planes between the mass and all
surrounding abdominal organs and vascular structures with the
exception of the duodenum. SMV, portal vein, SMA,
gastroduodenal artery, and stomach were all free from
involvement. Massive intra and extrahepatic biliary ductal
dilatation was noted, pancreatic ductal dilatation upstream
of the pancreatic mass was noted. Small left renal cyst
versus angiomyolipoma was noted.
Chest x-ray revealed biapical pleural thickening, small
bilateral pleural effusion.
HOSPITAL COURSE: The patient was an 84-year-old male with a
pancreatic mass status post ERCP and stenting for biliary
obstruction with a complicated ICU course significant for
respiratory failure and acute renal failure.
1. PULMONARY: The patient underwent extubation on [**2178-6-4**]
and had ongoing difficulties with secretions and aspiration.
The patient oxygenated with steady improvement over the
course of several days postextubation. He was initially able
to be weaned to 4 liters of nasal cannula. His ARDS
continued to resolve on serial chest x-rays. He underwent
several bedside swallow evaluations which initially showed
severe aspiration but with time he was able to pass a bedside
swallow examination. ENT evaluated his vocal cords for vocal
cord dysfunction and he appeared to be able to protect his
airway. He completed a ten day course of vancomycin for MRSA
pneumonia. He continued to have aggressive pulmonary toilet
and continued to do well from a respiratory standpoint.
2. RENAL: The patient's acute renal failure resolved
completely to be better than baseline, creatinine of 1.4.
The patient's acute interstitial nephritis was thought to be
secondary to Zosyn. He completed a short course of steroids
which were tapered and continued to make adequate urine
output over the course of his admission.
3. NEUROLOGIC: The patient initially had depressed mental
status which was thought secondary to the heavy sedation
while intubated. As the sedation wore off, his mental status
cleared and he was able to participate in discussions of
level of care and was quite lucid and cooperative.
4. CARDIOVASCULAR: The patient did undergo an
echocardiogram which revealed LV ejection fraction of 70%,
mild diastolic dysfunction, no regional wall motion
abnormalities, normal right ventricular systolic function,
mild 1+ mitral regurgitation, moderate pulmonary
hypertension, moderate 2+ tricuspid regurgitation, and no
evidence of pericardial effusion. The patient had some
hypertension after extubation and was initially started on
Lopressor. His Lopressor dose was limited by bradycardia
while asleep at night and thus his Losartan was reinitiated
after his renal function improved. He was titrated up on his
Losartan to the maximal dose. The patient did have one run
of nonsustained ventricular tachycardia while in the ICU
limited to three beats. Given his normal ejection fraction
and no evidence of coronary artery disease on echocardiogram,
this was observed with telemetry. The use of beta blocker
will be helpful in limiting ventricular ectopy.
5. ENDOCRINE: The patient was maintained on a regular
insulin sliding scale and fingerstick blood sugar monitoring
for his diabetes mellitus. After extubation, he did not
require an insulin drip and was able to be maintained with
subcutaneous insulin.
6. GASTROINTESTINAL: The patient was with a pancreatic mass
concerning for pancreatic adenocarcinoma. Surgery was
reconsulted after the patient was extubated but continued to
feel that the patient was too deconditioned to undergo such a
significant abdominal surgery. Discussion was held with the
patient and his family including his son, [**Name (NI) **], and wife
and he elected not to consider surgery for his pancreatic
malignancy. It was stressed that based on the CT abdominal
findings of his recent examination that the tumor may be
resectable and Surgery confirmed this. Despite this
knowledge, the patient continued to wish to defer on surgery.
He was given the option to reconsider should he change his
mind.
Gastroenterology was consulted because of the patient's
intolerance of tube feeds after extubation. They felt that
it was possible that the patient had gastric outlet
obstruction secondary to a malignant ulcer versus extrinsic
compression from a pancreatic mass. The patient was
gradually able to tolerate p.o. alimentation and underwent a
video swallow examination which showed that he could tolerate
thin liquids with a chin tuck and ground solids. If he is
able to take adequate p.o. nutrition through this way, no
further workup was warranted. If the patient is not able to
nourish himself orally, a permanent enteric feeding tube
would need to be considered versus chronic total parenteral
nutrition. If PEG or PEG J tube were to be considered, the
patient may need to undergo upper GI series and esophagram to
evaluate the anatomy for possible placement of one of these
tubes. Multiple attempts were made to pass a NG tube in the
postpyloric position and were met with difficulty suggesting
the possibility of the pancreatic mass limiting the ability
to achieve a postpyloric tube even through interventional
radiology.
The patient's LFTs improved steadily throughout his
hospitalization.
7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient
initially received tube feeds while intubated and then after
extubation was not able to tolerate even 10 cc an hour. He
was eventually able to pass a Speech and Swallow evaluation
and video swallow examination and Nutrition and Speech
Pathology aided in management of oral feeding. At the time
of this dictation, the patient was attempting to take in an
oral diet and if he fails this, consideration of an
alternative need for nutrition will need to be considered.
The patient also had his course complicated by hypernatremia
which was treated with free water boluses initially and then
IV D5W. It is hoped that the patient's hypernatremia will
improve as he begins to take more free water through oral
means.
8. PROPHYLAXIS: The patient was maintained on subcutaneous
heparin, Venodyne boots, and a proton pump inhibitor.
9. ACCESS: The patient has a left PICC line in place.
10. CODE STATUS: The patient was DNR, but okay to intubate
throughout most of his admission.
11. COMMUNICATION: Communication was maintained between the
patient's family including himself, his wife, and his son,
[**Name (NI) **].
12. HEMATOLOGIC: The patient had a stable crit in the low
30s throughout the ultimate dates of his ICU admission.
CONDITION AT TRANSFER: Stable.
DISCHARGE STATUS: The patient was discharged to
rehabilitation placement. The patient should be discharged
on 4 liters of supplemental oxygen nasal cannula.
MEDICATIONS AT DISCHARGE:
1. Losartan potassium 100 mg p.o. q.d.
2. Metoprolol 50 mg p.o. t.i.d.
3. Vancomycin 1 gram IV q. 24 hours to be continued for two
more days.
4. Protonix 40 mg p.o. q.d.
5. Heparin subcutaneously 5,000 units q. 12 hours.
6. Sarna lotion one application b.i.d. p.r.n.
7. Miconazole powder 2% one application b.i.d. p.r.n.
8. Desitin one application q.d. p.r.n.
9. Albuterol, Atrovent, MDI two puffs inhaled q. four hours.
10. Lacrilube ointment one application to each eye t.i.d.
p.r.n.
11. Acetaminophen 650 mg p.o. q. four to six hours p.r.n.
12. Clorhexadine gluconate 15 milliliters p.o. t.i.d. p.r.n.
13. Potassium chloride 60 mEq p.o. q.d. given in three
separate doses as 20 mEq p.o. t.i.d.
DIET: Thin liquids with chin tuck and ground solids. If the
patient is found aspirating on thin liquids, he should be
switched to nectar consistency liquids. His diet should be
[**First Name8 (NamePattern2) **] [**Doctor First Name **] diet.
DIAGNOSIS:
1. Pancreatic mass concerning for pancreatic adenocarcinoma.
2. Biliary obstruction secondary to pancreatic mass.
3. Adult Respiratory Distress Syndrome.
4. Aspiration.
5. Acute renal failure secondary to acute interstitial
nephritis from Zosyn.
6. Hypertension.
7. Diabetes mellitus type 2.
8. Hypernatremia.
9. Methicillin-resistant Staphylococcus aureus pneumonia.
10. Neutropenia and drug rash to Zosyn.
11. Coagulopathy.
12. Contraction alkalosis.
13. Toxic metabolic encephalopathy now resolved.
14. Giant ulcer in the posterior bulb of the duodenum.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2178-6-12**] 02:59
T: [**2178-6-12**] 19:12
JOB#: [**Job Number 15042**]
cc:[**Name8 (MD) 15043**]
ICD9 Codes: 5849, 5185, 2761, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5916
} | Medical Text: Unit No: [**Numeric Identifier 61305**]
Admission Date: [**2144-4-18**]
Discharge Date: [**2144-4-18**]
Date of Birth:
Sex:
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is an 82-year-old gentleman
with multiple comorbidities who presents with abdominal pain,
fever, and shock. There was a question of a history of Crohn
disease in the past, but in retrospect the patient probably
had intestinal ischemia. At rehabilitation center with a
fever to 101.8 and hypotension. He was transferred to [**Hospital3 11531**] where he required vasopressors, intubated, and
transferred.
PAST MEDICAL HISTORY: Notable for multiple comorbidities
including coronary artery disease, peripheral vascular
disease, chronic renal insufficiency. He has had multiple
bypasses and coronary artery bypass as well as above-the-knee
amputations and below-the-knee amputations.
PHYSICAL EXAMINATION: The patient was intubated and sedated
and in extremist, with a blood pressure of 80/40 which was
raised to 115/50 with vasopressors. The abdomen was distended
without masses. The extremities were cool status post the
above-mentioned amputations.
LABORATORY DATA: Evaluation included a white blood cell
count of 3500 with a left shift. INR was 1.7. Bicarbonate was
16. CPK was 449 with a MB fraction of 9. Creatinine was 1.8.
Blood gasses revealed a significant base deficit.
STUDIES: A CT scan was performed which showed pneumatosis of
the left colon.
HOSPITAL COURSE: The patient was admitted with a diagnosis
of colonic ischemia and infarction. This was thought to be
most likely an unsurvivable injury in this elderly man. A
long discussion was held with the family who wished
aggressive treatment on the basis of past wishes expressed by
the patient himself and understood the very low likelihood of
survival even with operation. The patient was then to the
operating room where there was an extensive infarction
throughout the majority of the intestinal tract. This was not
a survivable injury. The patient was closed. He was sent back
to the intensive care unit. After family members were able to
be assembled the patient had withdrawal of support. The
patient then expired shortly thereafter.
FINAL DIAGNOSES:
1. Intestinal infarction.
2. Coronary artery disease.
3. Chronic renal insufficiency.
4. Peripheral vascular disease.
5. Diabetes mellitus.
6. Status post multiple amputations.
SURGICAL PROCEDURE: Exploratory laparotomy.
DISPOSITION: Post was declined by the family.
[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]
Dictated By:[**Last Name (NamePattern4) 24987**]
MEDQUIST36
D: [**2144-7-10**] 14:14:44
T: [**2144-7-11**] 14:12:16
Job#: [**Job Number **]
ICD9 Codes: 0389, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5917
} | Medical Text: Admission Date: [**2146-5-29**] Discharge Date: [**2146-6-2**]
Service: SURGERY
Allergies:
Iodine / Shellfish
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Neck pain, right sided hip and leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname **] is a [**Age over 90 **] yr old female who arrived by ambulance to
[**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] after falling down stairs. She
was pulled by her dog on a leash as she was leaving her house.
She landed on the right side of her hip and leg. She began to
have neck pain immediately after the fall. She did not loose
consciousness after the fall.
Past Medical History:
Hypertension, Hyperlipidimia, Osteoporosis
Physical Exam:
Neuro: GCS 15, Alert and oriented X3, [**4-8**] motor strength equal
and bilateral
CV: RRR
Resp: CTA B/L
ABD: soft, non-tender, non-distended, +BS
EXT: right leg abrasion
Pertinent Results:
CT C-SPINE W/O CONTRAST [**2146-5-29**] 2:23 PM: Acute sagittal
fracture of the anterior arch of C1. Mild prominence of
prevertebral soft tissue anterior to the level of fracture.
Brief Hospital Course:
Patient was initially taken to an outside hospital where she was
found to have a C1 anterior arch fracture. She was transferred
to [**Hospital1 18**] as a trauma patient for further evaluation on [**2146-5-29**]
@17:11. Initial assesment by the trauma team found her to be
stable and she was taken to CAT scan suite for additional
studies.
Her C-spine CAT scan showed acute sagittal fracture of the
anterior arch of C1. Studies of her head, chest, abdomen,
pelvis, and T&L-spine showed no acute injuries, hemorrhage, or
fractures. Dr. [**Last Name (STitle) 548**] from neurosurgery was consulted on
hospital day #1 and patient was found to be neurologically
intact.
Patient was transferred to T-SICU under the care of [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **],
M.D. Patient remained stable overnight in the T-SICU. Patient
was transferred to acute trauma/surgery floor on Clinical
Center-6 on hospital day #2. Patient was evaluated by PT/OT on
hospital day #3 and recommended the patient to be discharged to
a rehabilitation facility. Patient continued to remain stable
through out hospital day #3. On HD#4 she had a hypertensive
episode to 210/50, which returned to 150/60 with IV hydralazine.
Pt was restarted on home medications Norvasc and HCTZ. Her BP
remained stable. On HD#5 Pt. reported some urinary urgency and
pain with a temp of 101.1. Repeat temp was 99.7 but due to
symptoms, Pt. was given Levofloxacin for presumed UTI to take at
rehab.
Medications on Admission:
Famotidine 20 mg IV every 2 to 4 hours
Metoprolol 5 mg IV every 6 hours
Acetaminophen 650 mg PO every 4 to 6 hrs as needed
Morphine Sulfate 2 mg IV every 2 hours as needed
Insulin Sliding Scale
Magnesium Sulfate 2 gm / 100 ml D5W IV as needed
Potassium Chloride 40 mEq / 500 ml D5W IV as needed
Calcium Gluconate 2 gm / 100 ml D5W IV as needed
Potassium Phosphate 15 mmol / 500 ml NS IV as needed
Heparin 5000 UNIT sub-cutaneous three times per day
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for BP <100, HR<60.
Disp:*60 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hydrochlorothiazide 25 mg Tablet Sig: 12.5 Tablets PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO EVERY OTHER DAY (Every Other
Day).
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
7. 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*
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
Disp:*60 Packet(s)* Refills:*2*
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] hospital
Discharge Diagnosis:
C1 Fracture
Discharge Condition:
Good
Discharge Instructions:
Return to Emergency Room for:
Fever>101.5
Numbness or tingling in extremities
Paralysis of extremities
Nausea/Vomiting
Incontinence of Bowel or Bladder
Followup Instructions:
Follow up in Trauma Clinic in 2 weeks. Please call
([**Telephone/Fax (1) 29931**] to schedule an appointment
Follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27267**] in one week.
Completed by:[**2146-6-2**]
ICD9 Codes: 5990, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5918
} | Medical Text: Admission Date: [**2181-2-28**] Discharge Date: [**2181-3-13**]
Service: MEDICINE
Allergies:
Nsaids / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Hypotension in Clinic
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
Mr [**Name13 (STitle) 21658**] is an 85 year old man, recently discharged from the
intensive care unit, with history of prior DVT (now s/p IVC
filter), HTN, CKD on HD, right lower extremity dry gangrene,
presenting from his PCP/cardiologist's office where the pt had a
chief complaint of worsening SOB and cough. Per ED notes
(patient is poor historian) the pt has "not looked great" for
the past few days. The pt is currently living at [**Hospital1 **],
denies nausea, vomiting. Has been regularly attending dialysis.
Mr [**Name13 (STitle) 21658**] has been residing at nursing home since his
discharge, and has been feeling more weak and short of breath
than usual in the last few days. Hemodyalisis has been limited
secondary to hypotension.
In the emergency department the pt's vital signs were: 98.5,
P90, NP 70/48, RR22 and O2sat 96% on 3L. In the ED the pt
received 2 or 3 liters IVF (although only 1L documented in ED
papers), and had a chest x-ray that showed a new left-sided PNA
and he got Vanc and Zosyn with improvement in SBP's to in low
100's.
Past Medical History:
HTN
thoracic and abdominal aortic aneurysm
h/o transitional cell bladder cancer
CKD
h/o lumbar laminectomy
tertiary hyperparathyroidism
BPH
DVT in the past, s/p IVC filter placement
bilateral cataracts s/p removal
glaucoma
s/p L TKR
?[**Name (NI) **] unclear per records
PVD ? Fem/[**Doctor Last Name **] bipass
Social History:
Formerly worked in family business, now retired. Was living
independently until [**12/2180**] hospitalization. More recently lived
in [**Hospital1 **].
Family History:
Non-contributory.
Physical Exam:
GENERAL: Elderly man, decorticate posturing, but moving upper
extremities
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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
Ext: cool feet bilaterally w/ right foot gangrene, LLE swelling
w/ +2 edema, not able to palpate pedal pulses; doplerable LLE
dp/pt and R dp.
Pertinent Results:
Admission labs:
[**2181-2-28**] 01:00PM BLOOD WBC-14.7*# RBC-2.79* Hgb-8.5* Hct-25.8*
MCV-92 MCH-30.3 MCHC-32.8 RDW-17.6* Plt Ct-303
[**2181-2-28**] 01:00PM BLOOD Neuts-66.8 Lymphs-13.5* Monos-5.4
Eos-14.1* Baso-0.2
[**2181-2-28**] 01:00PM BLOOD Glucose-103 UreaN-77* Creat-3.4* Na-130*
K-4.7 Cl-92* HCO3-27 AnGap-16
[**2181-2-28**] 01:10PM BLOOD Lactate-1.5
[**2181-2-28**] 01:00PM BLOOD CK-MB-3 cTropnT-0.24*
[**2181-3-1**] 12:57AM BLOOD CK-MB-4 cTropnT-0.24*
[**2181-2-28**] 01:00PM BLOOD CK(CPK)-48
[**2181-3-1**] 12:57AM BLOOD CK(CPK)-65
Micro:
Blood cx: 3 neg, 4 NGTD
Blood cx ([**2-28**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE, FROM ONE
SET ONLY.
Stool O+P: neg x2
Urine cx ([**3-9**]): ENTEROCOCCUS SP. >100,000 ORGANISMS/ML.
C diff: pending
Imaging:
CXR [**2181-2-28**]: Indistinctness of the left heart border which may
be related to overlying soft tissue, but infection is not
excluded.
CXR [**2181-3-4**]: Portable chest radiograph demonstrates a large-bore
catheter on the right extending into the cavoatrial junction.
The left IJ catheter has been removed. The left costophrenic
angle has been omitted from the study. There is a probable small
left pleural effusion. There is patchy atelectasis at the left
lung base. There is also mild patchy airspace opacity in both
lungs which could represent a combination of atelectasis or
aspiration, possibly infiltrate. There is mild congestive
failure. Heart is top normal in size.
LUE U/S [**2181-3-6**]: No evidence of deep vein thrombosis in the left
arm.
CXR [**2181-3-9**]: Since [**2181-3-6**], lung volumes are lower,
increasing bibasilar dependant atelectasis. Note that the right
costophrenic angle was excluded. Small left pleural effusion is
likely unchanged. Mild volume overload persists. A right PICC, a
right central venous line, and a gastrostomy tube are still in
place. There is no other change.
.
[**2181-3-9**] 11:13 am URINE Source: Catheter.
**FINAL REPORT [**2181-3-11**]**
URINE CULTURE (Final [**2181-3-11**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
1. Hypotension: The cause of the patient's hypotension was
unclear, since although he had a leukocytosis on admission,
there was no convincing infiltrate on chest x-ray, and the pt's
HD line appeared non-erythematous. The pt does have extensive
right lower extremity gangrene with ulceration of the right
ankle, which may be a potential nidus of infection. Microbiology
failed to grow out organisms other than Coagulase Negative
Staph, which may have been a contaminant. Given the pt's tenuous
status on admission the pt was treated initially with broad
spectrum antibiotics (Vanc and Zosyn) which were then tapered to
just Vanc to treat a presumed line infection for a 14-day
course. During the first few days of this admission the pt's
blood pressure was supported with peripheral vasopressin, which
was stopped successfully on [**3-3**] and [**3-5**], but on both days was
added back on during dialysis sessions during which the pt's
blood pressure would fall to the 70s systolic. On transfer to
the CCU the pt was no longer requiring vasopressin, although did
have SBP 60s with HD once, treated with 500cc IV fluid. Other
sessions of HD were associated with asymptomatic hypotension to
SBPs 80s, which improved without intervention with SBPs
typically in 90s. He remained afebrile, although cultures were
sent [**3-9**] for an elevated temp of 100.0. Urine cultures were
positive for VRE and patient was started on linezolid as
described below.
2. Tachycardia: During the pt's HD session on [**3-5**] the pt
developed a rapid heart rate in the 160s. Carotid massage was
attempted several times with no alteration in the rhythm. Then
adenosine 6mg was administered with no effect. Then adenosine
12mg was administered with a temporary drop in heart rate to the
40s, but then a return to the 160s. Then amiodarone was loaded
and the pt's heart rate improved to the 100s, and blood pressure
was initially low, but then systolics returned to the 100s.
During the episode of tachycardia, there were morphologies
suggesting AVNRT and afib. After initial amio dosing, heart rate
was subsequently normal and rhythm was sinus and he required no
more antiarrhythmics. Amiodarone was stopped.
3. PVD: Vascular saw the pt on admission in the ED and felt that
the gangrene was not the cause of the pt's symptoms. The patient
will be seen as an outpatient by Vascular surgery to determine a
date for outpatient right AKA.
.
4. Elevation in troponin: On admission the pt's Troponin T was
at recent baseline (0.26-0.37). Chronically elevated troponins
likely secondary to chronic renal failure. No chest pain, no
change on EKG.
5. End stage renal disease: During this admission nephrology saw
the pt and continued dialysis. Dialysis was limited at time by
hypotension and chest pain. Last HD was on [**2181-3-12**] and was
finished with no complications.
6. CAD: At rehab the pt was on ASA, statin and verapamil. ASA
and statin were continued, but verapamil was held in the setting
of hypotension.
7. Pain control: Patient vague regarding chronic pain, but may
be due to gangrenous right foot. Controlled with fentanyl patch
25mcg and oxycodone prn. Was cautious about uptitrating because
of tenious BP.
8. Rash/Eosinophilia: Pt developed rash and peripheral
eosinophilia which was stable at time of discharge. This was
thought to be possible med related. He should have follow up CBC
with diff as outpatient when off antibiotics. Zosyn was stopped
and he completed a course of Vanco on [**3-10**]. Strongyloides
antibody was sent.
.
9. VRE/URI: Found on surveillence urine culture for fever spike.
Patient barely makes urine bc of ESRD. D/ced foley but need to
d/w urology as it was placed under cystoscopy. Started on 14 day
course of linezolid 600mg PO BID for VRE UTI (day 1=[**3-11**]).
Urology was consulted for management of foley and transitional
cell cancer. They recommend keeping foley out if possible since
he does not have a history of retention. He will follow up with
Dr. [**Last Name (STitle) 770**] who is his outpatient urologist.
Medications on Admission:
Fentanyl 25mcg/h patch change q72h
Xalatan 0.005% eye drops 1 drop right eye qhs
Vancomycin 1g, HD protocol
Levitiracetam 100mg/ml 500mg [**Hospital1 **]
Aranesp 200mcg/0.4ml with HD
Novolin 300u/3ml per SS
Cal carbonate 1250mg/5ml tid
Heparin 5000 subq [**Hospital1 **]
Aspirin 325 daily
Verapamil 40 q12h
Timolol maleate 0.5% eye gtt 1 drop [**Hospital1 **] right eye
Simvastatin 40 2tab daily
Omeprazole 20mg daily
Diflucan 200 qod
Oxycodone 5mg 1cap prn
Miconazole nitrate 2% cream tid
Folic acid 1mg tab daily
Lidocaine 5% adhesive patch
Ipratropium bromide 0.02% soln inh q6h
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
2. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: Five (5) mL PO BID (2
times a day): (500 mg [**Hospital1 **]).
3. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Timolol Maleate 0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Camphor-Menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
9. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) syringe
Injection TID (3 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 4000-[**Numeric Identifier 2249**]
units Injection PRN (as needed) as needed for line flush:
DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL
NS followed by Heparin as above according to volume per lumen.
.
11. Oxycodone 5 mg/5 mL Solution [**Numeric Identifier **]: Five (5) mg PO Q4H (every
4 hours) as needed.
12. Acetaminophen 325 mg Tablet [**Numeric Identifier **]: 1-2 Tablets PO every eight
(8) hours as needed for pain or fever.
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. Linezolid 600 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO Q12H (every
12 hours) for 14 days: if on a dialysis day, please given dose
after dialysis, last dose [**2181-3-26**].
15. Calcium 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO three times a
day.
16. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
17. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) patch
Transdermal every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
End Stage Renal Disease on Hemodialysis
Peripheral vascular Disease
Line associated bacteremia
Supraventricular tachycardia
Dry Gangrene right foot
Discharge Condition:
Hemodynamically stable, BPs 90s/40s-50s, lower with HD
Discharge Instructions:
You were admitted to the hospital with low blood pressures. It
was unclear exactly why you had low blood pressures, but this
may have been related to an infection. You were treated for a
blood infection with an antibiotic called vancomycin and your
blood pressures improved. You were continued on hemodialysis for
your kidney failure. While you were here, you also developed a
urinary tract infection which we treated with another antibiotic
called linezolid. While you were hospitalized, you saw the
vascular surgeons who decided that you need to have your right
foot amputated but this can wait until you are healthier. You
will need to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for this.
.
Please tell your doctor if you develop chest pain, shortness of
breath, increased swelling of your arms or legs, or any other
concerning symptoms.
Followup Instructions:
Vascular surgery:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2181-3-28**] 10:00
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 7960**] Date/time: [**4-4**] at 4:00pm.
.
Nephrology:
Will be decided once [**Hospital **] clinic used as outpt is decided.
Please call [**Doctor First Name 12906**] [**Location (un) 21659**] who is a social worker for
updates.
.
Urology:
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**] Phone: ([**Hospital1 21660**]
[**Location (un) 86**], [**Numeric Identifier 21661**] Date/time: [**4-10**] at 1:45pm.
Completed by:[**2181-3-13**]
ICD9 Codes: 5856, 5990, 4280, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5919
} | Medical Text: Admission Date: [**2138-11-3**] Discharge Date: [**2138-11-17**]
Service:
ADMISSION DIAGNOSIS:
1. Status post fall with epidural hematoma and C6 fracture.
DISCHARGE DIAGNOSIS:
1. C6 burst fracture with epidural hematoma.
2. Paroxysmal atrial fibrillation requiring Amiodarone.
3. Cardiac pacer requiring interrogation.
4. Left lower lobe pneumonia.
5. Chronic ventilatory dependence with inability to wean.
6. Left upper extremity deep vein thrombosis.
7. Ability to anti-coagulate requiring IVC filter placement
for pulmonary embolism prophylaxis.
8. Malnutrition requiring tube feeds.
9. Fever of unclear origin.
PROCEDURES:
1. Evacuation of epidural hematoma C6 corpectomy and fusion
with cage on [**2138-11-4**].
2. Spinal fusion [**2138-11-7**].
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
man with a past medical history significant for hypertension,
paroxysmal atrial fibrillation, sick sinus syndrome, status
post pacer in [**2134**], left lower lobe pneumonia and
polypectomy. He also has a past medical history significant
for hernia repair times three, transurethral resection of
prostate, left total knee replacement and lumbosacral
decompression for spinal stenosis in [**2130**]. The patient fell
approximately a week prior to admission and had upper back
and neck pain. A CT at that time was negative. He was
diagnosed with a left lower lobe pneumonia and treated with
Levaquin. The patient continued with syncopal episodes and
fell on the night prior to admission.
On the day of admission, in the PCP's office the patient had
a syncopal episode with a blood pressure in the 50's. He was
unresponsive for several minutes but had a carotid pulse. He
was transferred to [**Hospital3 3834**] which CT of the C-spine
revealed a C6 fracture. Solu Medrol was bolused and started
as a drip. The patient was unable to move his lower
extremities, was insensitive from above the nipple to his
toes. He had minimal motor function in his bilateral upper
extremities and complained of C-spine pain.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Paroxysmal atrial fibrillation.
3. Sick sinus syndrome.
4. Pacer [**2134**].
5. Left lower lobe pneumonia.
6. Tachybrady syndrome.
7. Syncope.
8. Hearing loss.
PAST SURGICAL HISTORY:
1. Sigmoid polypectomy.
2. Hernia repair times three.
3. Transurethral resection of prostate.
4. Left total knee replacement.
5. Benign skin cancer removal on his forehead.
6. Lumbosacral decompression for spinal stenosis.
ALLERGIES: Sulfa.
MEDICATIONS ON ADMISSION:
1. Norvasc 5 mg once a day.
2. Amiodarone 200 mg once a day.
3. Coumadin three times a week.
4. Klonopin.
SOCIAL HISTORY:
Noncontributory.
PHYSICAL EXAMINATION: On admission the patient was afebrile
with normal vital signs. His GCS was 15, his pupils are
equal, round, and reactive to light and accommodation. His
heart was irregular. Lungs clear. Abdomen was soft,
nontender, nondistended. He had decreased rectal tone and he
was heme positive. He had no sensation from just above the
nipple line to his feet. He was unable to move his trunk or
lower extremities. He had bilateral upper extremity weakness
with 3/5 wrist extension and [**11-24**] grip. His dorsalis pedis
pulses were palpable bilaterally. He had no gross
deformities of his thoracic lumbar spine but was tender over
his cervical spine.
Of significance the patient's INR on admission was 5.1. His
electrocardiogram was V-paced with no acute ischemia.
IMAGING: CT of the spine showed a C6 burst fracture. Chest
x-ray with a question of a right seventh rib fracture.
Pelvis x-ray: No fracture. TLS: No fracture. CT of
abdomen and pelvis was no free fluid negative.
HOSPITAL COURSE: The patient was seen and evaluated by
Neurosurgery service in the Emergency Room. He was felt to
have a C6 burst fracture and there was concern of an epidural
hematoma given the fact that the patient had a pacemaker he
was unable to undergo an magnetic resonance scan and was
therefore scheduled for a CT myelogram. The patient was
given Factor VII emergently to reverse his anti-coagulation
as well as FFP. He was resuscitated, access was obtained and
he was transferred to the Intensive Care Unit. The rest of
his hospital course will be done by systems.
1. Neurologic. The patient was seen and evaluated by
Neurosurgery. He was taken to the operating room in the
early morning of [**2138-11-4**] for an evacuation of an epidural
hematoma and C6 corpectomy and cage placement.
Postoperatively the patient had little return of neurologic
function with minimum movement of his toes bilaterally and
triple flexion. On [**2138-11-7**] the patient returned to the O.R.
for a posterior fusion. Again, his neurologic postoperative
course showed minimal neurologic improvement. The patient
was awake, alert and following commands and was transferred
out of bed to the chair throughout his postoperative course
when it was felt to be safe by Neurosurgery.
2. Cardiovascular. Given the fact that the patient had
several bouts of syncope prior to admission and had a history
of tachybrady syndrome, paroxysmal atrial fibrillation as
well as sick sinus syndrome he was seen and evaluated by the
Cardiology service. His pacemaker was interrogated and felt
to be functioning fine. He was kept on his home dose of
Amiodarone. His cardiac enzymes were cycled and were found
to be negative. Cardiology felt that no further intervention
was needed during his hospital course.
3. Respiratory. The patient was intubated in the operating
room for his first surgery and was extubated postop. He had
an episode where he desated however and was felt to be unable
to maintain his respiratory drive. He was therefore,
semi-electively reintubated on postop day zero. The patient
had a prolonged ventilatory course and was unable to be
weaned off the ventilator despite diuresis, aggressive
pulmonary toilet and multiple bronchoscopies. He was
admitted with a left lower lobe infiltrate and did spike
fevers throughout his hospital course that were felt to be
secondary to this infiltrate.
4. Gastrointestinal: The patient had no issue from the
gastrointestinal standpoint. He was started on tube feeds
and advanced to goal uneventfully.
5. Genitourinary. The patient had Foley throughout his
hospital course. His urine output was adequate and he was
diuresed with Lasix with a good response. He did have an
episode of hypernatremia and hyperkalemia and thus free water
was given to the patient with resolution of this problem.
[**Name (NI) 227**] his fever spikes his urine was cultured throughout his
hospital stay.
6. Heme/Vascular. Given the fact that the patient was
unable to be anti-coagulated and was felt to be high risk for
pulmonary embolism, an IVC filter was placed in the patient,
was done on [**2138-11-4**] without problem. The patient's
coagulopathy was reversed with FFP. Given the fact that the
patient continued to have recurrent fevers he underwent
bilateral lower extremity ultrasounds to rule out deep vein
thrombosis as well as upper extremity ultrasound at the site
of PICC line given his left upper extremity swelling. His
lower extremity ultrasounds were negative but he did have a
left upper extremity deep vein thrombosis. Vascular surgery
was consulted and given the fact that this was asymptomatic I
felt this could be treated conservatively.
7. ID. The patient was placed on Levofloxacin for left
lower lobe pneumonia when he was admitted. Ancef was then
added for periop coverage given his prosthetic material in
his spine. He continued to spike fevers throughout his
hospital course and on [**2138-11-13**] did grow out gram positive
rods in his sputum. Otherwise, no clear source was found for
his fever.
8. FEN. As mentioned in gastrointestinal section the
patient was maintained on tube feeds. He did have an episode
of hypernatremia and hyperkalemia which was treated with free
water. His electrolytes were repleted as needed, otherwise
he had no issues.
9. General Disposition: Given the patient's inability to
wean off the vent and his family wishes on [**2138-11-17**] it was
decided that the patient would be removed from ventilatory
support. His daughter understood that the patient would not
survive this but she felt it was his wish to not live in his
current status therefore on [**2138-11-17**] he was extubated and
expired.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2139-1-5**] 15:13
T: [**2139-1-5**] 15:17
JOB#: [**Job Number 54139**]
ICD9 Codes: 5185, 9971, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5920
} | Medical Text: Admission Date: [**2186-10-20**] Discharge Date: [**2187-1-10**]
Date of Birth: [**2186-10-20**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **] is the 24-4/7-week gestation
infant born at 595 grams to a 25-year-old G3, P0 now 1 mother
with prenatal screens: [**Name (NI) **] type O-positive, antibody
negative, HBsAg negative, RPR nonreactive, rubella immune,
GBS unknown.
[**Hospital 37544**] medical history was significant for IDDM, asthma,
1st pregnancy TBA, 2nd pregnancy fetal demise at 23-weeks
gestation, history of tobacco. This pregnancy was complicated
by cervical incompetence. A cerclage was placed at 20-weeks
gestation at [**Hospital 1474**] Hospital. Mom reported a history of
domestic violence by the father who is currently incarcerated.
Approximately a few days prior to delivery, the mother was
transferred from [**Name (NI) 1474**] hospital to [**Hospital1 18**]. Mother was on
bed rest at [**Hospital1 18**] and she received betamethasone 2 doses.
Rupture of membranes occurred the morning of delivery with
fluid reported to be greenish-yellow. There was no maternal
fever at time of ruptured membranes. The mother was given
ampicillin and erythromycin. A decision to deliver infant by
C-section was made due to breech position under general
anesthesia. The infant emerged floppy and no spontaneous
respirations. Was bulb suctioned, dried, and stimulated.
Provided PPV. Heart rate was about 100, but remained floppy.
No grimace and no spontaneous respirations.
The infant had good bilateral aeration, heart rate, and
color. Though the tone and grimace remained depressed likely
secondary to general anesthesia. Initial Apgars were 3 and 6.
PHYSICAL EXAM ON ADMISSION: Birth weight of 595 grams which
is 10-25th percentile, head circumference of 20 cm which is
less than 10 percentile, length of 30.5 cm which is 10-25th
percentile. Infant's exam showed extremely premature infant,
nondysmorphic, intubated, pink with scattered bruising. AFSS.
Fused eyelids. Ears: Normally set. Palate: Intact. Clavicles:
Intact. Neck: Supple. CV: Regular rate and rhythm, no murmur,
2+ pulses, good peripheral perfusion. Abdomen: Soft, no bowel
sounds, no hepatosplenomegaly. GU: Normal preterm female,
patent anus, no sacral anomalies. Hips: Stable. Tone: Reduced
overall likely from anesthesia demonstrating slightly steady
improvement over time. On the skin, there was a right
scapular laceration with full thickness approximately 3/4-1
inch in length with no active bleeding.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: The infant was
intubated at delivery and admitted to the NICU on the
ventilator. Received single dose of surfactant and weaned to
low ventilator quickly thereafter. Caffeine citrate was
initiated on [**10-23**], day of life 3 and the infant weaned
to CPAP on day of life 5 which is [**10-25**]. She remained on
CPAP up until [**10-31**] at which time, due to increased
respiratory effort, she was reintubated and placed on low
ventilator settings again.
She remained intubated on low ventilator settings through til
[**2186-11-25**] which is day of life 36 at which time, she
extubated to CPAP and remained on nasal prong CPAP until
[**2187-10-18**] which is day 59 when she presented with
bloody stools. She was diagnosed with NEC. She was noted to have
apnea and lethargy. She was reintubated because of the severity
of her illness and her poor respiratory effort.
She remained intubated through til [**2186-12-27**] which is
day of life 68 when she then weaned to nasal cannula oxygen,
and she has remained on nasal cannula oxygen since that time.
She weaned off caffeine citrate on [**2187-1-3**]. She is
presently on nasal cannula at 50 cc per minute flow and 100%
FIO2 not having any apnea or bradycardic spells at this time.
Clear and equal breath sounds with mild retractions.
Cardiovascular: On day 2 of life, she presented with clinical
symptoms of a patent ductus arteriosus. Symptoms included
bounding pulses, a murmur, and metabolic acidosis. She was
treated with Indocin for a single course. A follow-up
echocardiogram was done on [**2187-10-24**] which showed no
PDA, a question of a small ASD or PFO at that time. Murmur
resolved just after the Indocin, and she has been free of a
murmur up until [**2186-12-10**], day of life 51, at which
time she presented with an intermittent murmur which has
continued through to this time and is thought to be a benign
PPS murmur. Heart rate and [**Year (4 digits) **] pressure have remained
hemodynamically stable.
Also initially at birth, she did require 1 normal saline
bolus for hypotension which quickly resolved after the normal
saline infusion. She has never required any dopamine for
[**Year (4 digits) **] pressure stability.
Fluid, electrolytes, and nutrition: She was NPO at birth, and
UAC and UVC were both placed. She was started on parenteral
nutrition on the day of birth. Enteral feedings were initiated
on day of life 6 with slow trophic feeds at that time. She
achieved full feedings by [**2186-11-3**] which is day of
life 14. Her calories were then increased to maximum caloric
density of 30 calories per ounce of PE 30 with Promod which
she achieved on [**2186-11-10**]. As stated above, when she
developed NEC her feeds were discontinued. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was
placed and remained in place for 4 days.
She remained NPO on PN and Intralipids through until
feeds were reintroduced. She slowly advanced on feedings
again and achieved full feedings by [**2186-12-3**] which
is day of life 44. At that time, her calories were then
further advanced to a maximum caloric intake of PE 30 with
Promod. Her feedings were well tolerated until [**2186-12-18**]. At that time, she had a recurrance of grossly [**Year (4 digits) **] y
stool. Her KUB was abnormal with large dilated loops. She was
felt to have a recurrance of medical NEC. She was made NPO and [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 37079**] placed at that time. She has remained NPO since that
time. She is presently on PN with intralipids. Her most recent
tryglyceride level is 76 done on [**2187-1-7**]. She was
started on iron and vitamin E on day of life 50,[**2186-12-9**]
and also earlier, day of life 15. Both times they were
discontinued when enteral feedings were discontinued.
She had a barium enema on [**2187-1-2**] which showed a colonic
stricture at the splenic flexture likely related to medical NEC.
Her most recent nutrition labs were done on [**2186-12-18**] with
albumin 3.1, calcium 9.3, magnesium 2.0, and phosphorous 5.2. On
[**2187-1-9**], her most recent set of electrolytes are sodium
141, potassium 4.3, chloride 103, and CO2 27. Her LFT's AST18 ALT
42 Alk Phos 1387.
Most recent length is 45 cm and head circumference of 27.5 cm
which were done on [**2187-1-8**].
She is presently NPO with a peak bilirubin level of 4.6/0.4
and received a total of 10 days of phototherapy, and she has
had medical neck x2. Remains NPO at this time with a benign
abdomen.
IV access: A central PICC line was placed on [**2186-12-23**].
PICC line is remains in place at this time.
Hematology: Her hematocrit at birth was 44.8. Her most recent
hematocrit was 34.2 with a reticulocytes of 7.5 and that was
on [**2187-1-8**]. Prior to surgery, her coagulation studies
were noted to be elevated on [**2187-1-8**] with PT 14.2, PTT
65.5, INR of 1.4. These studies were repeated on [**2187-1-9**]
PT 15.2 PTT 70.5 INR 1.6. Despite being given a dose at birth,
she was given a vitamin K injection on [**1-9**]. She was then
given 30 cc/kg of FFP in divided into two aliquots. Her repeat
coagulation studies on [**1-10**] in the a.m., a PT of 14.8, PTT
55.2, and INR 1.3.
During her life, she has received total of 7 pack red [**Month (only) **] cell
transfusions. She does not have any [**Month (only) **] from previous
transfusion left in the [**Month (only) **] bank.
Infectious disease: Due to suspected sepsis at birth, a CBC
and [**Month (only) **] culture were done on admission. The CBC was benign.
The [**Month (only) **] culture remains stable. But due to presumed sepsis
and chorioamnionitis at birth, she was treated for a total of
14 days, a decent sample due to a bloody tap. A repeat [**Month (only) **]
culture was drawn on day of life 8 which grew gram-positive
cocci which was felt to be a contaminant, but her antibiotic
therapy was changed from ampicillin to vancomycin at that
time. She received an additional 42 hours of antibiotics for
the total of 14 days at that time when the repeat [**Month (only) **]
culture did come back negative.
She was again treated day of life 22 for what was medical
neck at that time. Her CBC was left shifted with an oddity of
0.3. She was treated for a total of 14 days of ampicillin,
gentamicin, and clindamycin for medical neck. She, again,
presented with medical neck on [**2186-12-18**], day of life
59. Had a CBC at that time that was also left shifted.
Abnormal KUB with bloody stool. She was started on vancomycin
and gentamicin, and continued on those antibiotics through
until day of life 63 or [**12-22**], at which time the
vancomycin and gentamicin were changed to Zosyn; and she
continued the Zosyn for a total of 14 days of antibiotics for
that bout of medical neck. She has remained off of
antibiotics since that time and showed no signs of sepsis.
She did have a repeat lumbar puncture done prior to coming
off the Zosyn on [**2186-12-29**] and that LP wbc 3 rbce 18 pro
128 glu 37, and the CSF culture remained sterile.
Neurologic: She had a urine tox screen sent on [**1186-10-27**]
which was negative for benzos, barbituates, opiates, cocaine,
ampheatamines, and methadone. She had 3 cranial ultrasounds on
[**2186-10-20**], [**2186-10-30**], [**2186-11-20**] that were
all within normal limits. She will need another head ultrasound
prior to discharge from the NICU.
Sensory: A hearing screen will need to be done prior to
discharge to home.
Ophthalmology: Her most recent eye exam was done on [**2187-1-8**] which showed stage II, zone II ROP and followup is
needed the last week of [**Month (only) 404**] or the first week of [**Month (only) 956**].
She is followed by O'[**First Name9 (NamePattern2) **] [**Doctor Last Name **].
Endocrine: Numerous state screens have been sent on [**2186-10-23**], [**2186-11-4**], [**2186-11-16**], [**2186-11-26**], [**2187-1-3**]. The samples from [**2186-10-23**]
through til [**2187-11-16**] all show borderline low T4
anywhere from 4.8-5. She has not been treated for any
endocrine issues thus far, and most recent state screens thus
far have been normal.
Psychosocial: A [**Hospital1 **] social worker has been involved with
this family. Her name is [**Name (NI) 5036**] [**Name (NI) **], and she can be reached
at [**Telephone/Fax (1) 8717**] if there are any social service concerns.
Infant's condition at discharge is stable.
DISCHARGE DISPOSITION: Infant is to be transferred to
[**Hospital3 1810**] for colonic stricturoplasty scheduled for
[**2187-1-10**] with Dr. [**Last Name (STitle) **] [**Name (STitle) 1022**] as the pediatric surgeon.
PRIMARY PEDIATRICIAN: The family has not decided on a primary
care pediatrician at this time.
CARE RECOMMENDATIONS: NPO until ready to feed. The infant is
on no medications at this time. She will need her two month
vaccinations. She will need to have a head ultrasound prior to
discharge to home. Will need a car seat test prior to discharge
to home. State screens will need to be followed up.
IMMUNIZATIONS RECEIVED: The hepatitis B vaccine was given on
[**2186-11-29**], and she is due for her 2-month
immunizations which have not been given at this time due to
her clinical status.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1. Born at less than 32
weeks gestation; 2. Born between 32 and 35 weeks gestation
with 2 of the following: Daycare during the RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school-age siblings; or 3. With chronic
lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES: Respiratory distress syndrome,
extremely low birth weight premature infant, sepsis suspect,
medical NEC x2, back laceration from delivery, patent ductus
arteriosus treated, hyperbilirubinemia resolved, chronic lung
disease ongoing, presumed meningitis treated, distal
transverse colon stricture, retinopathy of prematurity,
anemia of prematurity, and coagulopathy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Name8 (MD) 65298**]
MEDQUIST36
D: [**2187-1-9**] 20:51:10
T: [**2187-1-10**] 04:55:46
Job#: [**Job Number 66303**]
ICD9 Codes: 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5921
} | Medical Text: Admission Date: [**2174-4-2**] Discharge Date: [**2174-4-9**]
Date of Birth: [**2099-2-19**] Sex: M
Service: MEDICINE
Allergies:
Gluten
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
75 yo M with refractory HCC on cycle 1 of 5FU, Hep B cirrhosis,
tumor obstruction of left portal vein, partial obstruction on
right followed by Dr. [**Last Name (STitle) **] for chemotherapy presents from home
via [**Location (un) 620**] ED. This morning he was found to be minimally
responsive and had flecks of blood on the pillow noted by family
the morning of admission. At [**Hospital1 **] [**Location (un) 620**] he was intubated for
airway protection in setting GCS 8, Head Ct was obtained and
negative for acute bleed, he recieved 5L IVF. Patient has HD
stable and was guiac + from rectal vault with brown stool.
On arrival to [**Hospital1 18**] ED, he was HD stable, afebrile, intubated.
Labs repeated and notable HCt 25, INR 1.7. Stools were guiac
positive [**Doctor Last Name 352**] stools, NG tube placed to suction red tinged
gastric contents without lavage. He was noted to develop
progressive abdominal distention. Given h/o ruptured hepatoma in
04 with hemoperitoneum he was sent for CT ab/pelvis prior to
trasfer to the floor which showed moderate ascites, no
intraperitoneal bleed, atelectasis vs consolidation at lung
bases and distended urinary bladder. It was also noted that his
BP was trending down and he was started on PRBCs, protonix IV,
octreotide gtt, cipro. The liver/omed teams were made aware of
the admission. At the time of transfer, vital signs: T97.5 BP
124/72 HR 76 RR 16 POx100% on AC.
Past Medical History:
-Hepatocellular CA recently treated with sorafenib (stopped
[**2174-3-2**]), planning to try 5-FU/leucovorin vs. palliative care -
he initially presented with a ruptured hepatoma in [**2168**]. He
underwent surgical resection and has had for recurrent disease,
radiofrequency ablation as well as trans arterial
chemoembolization. He tolerated the TACE poorly and has had
subsequent progression of disease and is not a candidate for RFA
or cyberknife therapy.
-Hepatitis B cirrhosis
-h/o reptured hematoma
-Prostate Ca
Social History:
-(+) EtOH/Tobacco in past; not anymore
-military (Korean/[**Country 3992**])
-Lives with 2 supportive sisters and GF from [**Name (NI) 2784**]
Family History:
Non-contributory
Physical Exam:
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-19**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
Admission Labs:
[**2174-4-2**] 06:56PM ASCITES TOT PROT-0.6
[**2174-4-2**] 06:56PM ASCITES WBC-470* RBC-85* POLYS-52* LYMPHS-6*
MONOS-0 MACROPHAG-42*
[**2174-4-2**] 03:30PM HCT-28.0*
[**2174-4-2**] 10:15AM PO2-225* PCO2-26* PH-7.46* TOTAL CO2-19* BASE
XS--2 COMMENTS-SPECIMEN T
[**2174-4-2**] 09:20AM COMMENTS-GREEN TOP
[**2174-4-2**] 09:20AM GLUCOSE-113* LACTATE-2.9*
[**2174-4-2**] 09:15AM GLUCOSE-121* UREA N-35* CREAT-1.0 SODIUM-126*
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-20* ANION GAP-13
[**2174-4-2**] 09:15AM estGFR-Using this
[**2174-4-2**] 09:15AM ALT(SGPT)-22 AST(SGOT)-36 CK(CPK)-35* ALK
PHOS-249* TOT BILI-3.4*
[**2174-4-2**] 09:15AM LIPASE-111*
[**2174-4-2**] 09:15AM cTropnT-<0.01
[**2174-4-2**] 09:15AM CK-MB-NotDone
[**2174-4-2**] 09:15AM CALCIUM-8.0* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2174-4-2**] 09:15AM AMMONIA-86*
[**2174-4-2**] 09:15AM WBC-7.4 RBC-3.13* HGB-8.1* HCT-25.3* MCV-81*
MCH-26.0* MCHC-32.1 RDW-24.7*
[**2174-4-2**] 09:15AM NEUTS-85.0* LYMPHS-8.7* MONOS-5.6 EOS-0.6
BASOS-0.1
[**2174-4-2**] 09:15AM PLT COUNT-168
[**2174-4-2**] 09:15AM PT-18.6* PTT-34.5 INR(PT)-1.7*
.
Labs on discharge:
[**2174-4-8**] 05:10AM BLOOD WBC-3.5* RBC-3.69* Hgb-10.1* Hct-30.9*
MCV-84 MCH-27.3 MCHC-32.6 RDW-22.6* Plt Ct-80*
[**2174-4-8**] 05:10AM BLOOD PT-18.6* PTT-64.1* INR(PT)-1.7*
[**2174-4-8**] 05:10AM BLOOD Glucose-91 UreaN-23* Creat-0.6 Na-132*
K-4.3 Cl-105 HCO3-19* AnGap-12
[**2174-4-7**] 05:35AM BLOOD ALT-19 AST-38 AlkPhos-201* TotBili-3.6*
[**2174-4-8**] 05:10AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.0
.
IMAGING:
CT Abd:
IMPRESSION:
1. Moderate-to-large amount of ascites in the abdomen. No
evidence of intraperitoneal or retroperitoneal bleeding.
2. Markedly distended urinary bladder with Foley catheter
balloon within the urethra, repositioning required.
3. Cirrhotic liver with hypoattenuating lesions consistent with
hepatocellular carcinoma, and hyperattenuating foci consistent
with prior
chemoembolization.
.
RUQ Ultrasound: ([**4-2**])
IMPRESSION:
1. Moderate ascites, spot marked for bedside paracentesis.
2. Doppler examination difficult given the abdominal ascites.
Nonocclusive
thrombus in the main portal vein, with slow flow. Hepatopetal
flow in the
left portal vein. Right portal vein not seen. Recommend repeat
Doppler
examination following paracentesis.
3. Cirrhotic liver, with limited evaluation for focal lesions.
.
RUQ U/S ([**4-6**]):
IMPRESSION:
1. Moderate ascites is slightly decreased since [**2174-4-2**].
2. No evidence of flow in the main and right portal veins,
consistent with
known thrombus, similar to [**2174-2-11**].
3. Cirrhotic liver with large infiltrative mass again seen.
.
.
MICRO:
[**2174-4-2**] 6:56 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2174-4-2**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
Brief Hospital Course:
In short, Mr [**Known lastname 11257**] is a 75M with metastatic
treatment-refractory HCC (Dx [**2168**]), course c/b ascites and
portal vein thrombosis, who presented with altered mental status
and concern for UGIB, s/p intubation for airway protection, now
improved to baseline. His hospital course is as follows:
.
# Altered mental status: Most likely hepatic encephalopathy.
Was given aggressive lactulose with marked improvement in his
mental status. He was also diagnosed with SBP as a possible
precipitant. CT head was unremarkable. He was extubated
without complications. RUQ ultrasound was negative for acute
thrombosis. EGD was negative for bleed. We continued his
lactulose and CTX with good effect. AOx3 on discharge.
.
# Respiratory failure: Intubated largely for airway protection.
Weaned quickly and extubated on [**2174-4-3**]. Was stable in the MICU
and on the floor thereafter.
.
# SBP: Diagnostic paracentesis on [**4-2**] with close to 250 PMNs.
Gram stain with PMNs. Given his clinical picture, pt treated
with a 5-day CTX course as well as with albumin.
.
# Metastatic HCC: s/p 5FU on [**2174-3-24**]. Poor prognosis. Discussed
possible hospice, but pt did not feel ready to make the
decision. Plan was discussed with Dr [**Last Name (STitle) **] and Dr [**First Name (STitle) 679**].
.
# Pancytopenia: Likely the result of his chemotherapy. EGD was
negative for acute bleeding.
.
# Urinary Retention: Urology was consulted for elevated bladder
scan and difficult Foley. They recommended keeping the Foley
catheter in place x2 weeks and to follow up as an outpatient. Pt
also developed low urine output, likely [**1-17**] low flow from severe
liver disease. Since pt comfortable and Cr 0.6, no intervention
done. Mild intermittent oozing at urethral meatus likely from
foley trauma.
.
# Full code
# Contact:
[**Name (NI) 28814**] (sister) [**Telephone/Fax (1) 28815**] (home), [**Telephone/Fax (1) 28816**] (cell)
[**Name (NI) **] (brother) [**Telephone/Fax (1) 28817**] (home)
[**Name (NI) 3551**] (sister) [**Telephone/Fax (1) 28818**] (cell)
Medications on Admission:
Spironolactone 25mg daily
Lactulose 15gm/15ml 1 tbsp daily
Omeprazole 20mg po daily
Prochlorperazine 10mg Q6-8hrs prn nausea
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day): Please titrate to [**2-16**] bowel movements per day.
Disp:*1350 ML(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
hepatic encephalopathy
.
metastatic hepatocellular carcinoma
hepatitis B cirrhosis
prostate cancer
Discharge Condition:
improved, mental status at baseline.
there is some oozing/bleeding at the urethral meatus [**1-17**] foley
trauma; foley flushes without any obstruction or clot to suggest
internal hemorrhage
Discharge Instructions:
You were admitted to the hospital with altered mental status
likely from hepatic encephalopathy. Please continue taking
lactulose to have [**2-16**] bowel movements a day. Take more lactulose
if you feel confused.
.
Your medications changes are as follows:
1. continue your spironolactone 25mg daily
2. continue your lactulose
3. changed your prilosec to high-dose pantoprazole (40mg twice
daily)
.
If you have any fevers, chills, chest pain, shortness of breath,
abdominal pain or any other concerning symptoms, please call
your physician.
Followup Instructions:
Please call your primary care physician for followup upon your
discharge: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 682**]
.
Please follow up with urology in 2 weeks for voiding trial and
PSA check: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] ([**Telephone/Fax (1) 5727**]) or Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**]
([**Telephone/Fax (1) 6445**]).
.
Other appointments:
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2174-4-14**] 11:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2174-4-21**] 11:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2174-4-28**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2174-4-9**]
ICD9 Codes: 2761, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5922
} | Medical Text: Admission Date: [**2127-4-17**] Discharge Date: [**2127-4-21**]
Date of Birth: [**2048-3-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79M with metastatic cholangiocarcinoma s/p metal biliary stent
placement [**11-8**], who presents with fever x 1 day following
repeat ERCP. Pt is a very poor historian, so most of the history
is obtained through chart review and ED providers. The patient
stated that he had the ERCP done, returned home, felt really
fatigued and unable to walk ([**3-7**] leg pain and weakness). His
wife called 911 and he was taken to [**Hospital1 18**] ED. Denied any chest
pain, abd pain, nausea, vomiting. +fevers to 104 at home, +
chills. No headaches. No LOC, no h/o syncope.
.
Patient had second, outpatient ERCP by Dr. [**Last Name (STitle) **] the day
prior to admission due to increasing pruritis and a CT at [**Hospital1 **] that suggesting tumor ingrowth into the stent. He was
pretreated with ampicillin 2gm IV, and gentamicin 80mg IV. ERCP
demonstrated a malignant-appearing biliary stricture affecting
the hilumand right and left ducts. There was debris visible with
in the stent at early cholangiogram. Occulsion cholangiograqm
revealed extensive stricturing of both left and right
intrahepatic ducts. Although a small left intrahepatic radical
opacified, it was not possible to advance the balloon catheter
in this direction. For this reason, no stent could be
introduced. Balloon sweeps were performed from just above the
stent and down through the stent, and a moderate amount of
debris was removed. Even after multiple sweeps, there was some
filling defect left in the upperprotion of the stent, consistent
with a degree of tumor ingrowth. Sticture not amenable to ERCP,
and suggested PTCA as next intervention if futher obstructive
symptoms occur. He was NOT discharged on any anti-biotic ppx.
.
Today pt presents with fever to 103.8, no [**Last Name (un) 103**] pain. no
nausea/no vomiting. c/o fatigue, with reported fevers at home of
103.8--pt took tylenol. In ED, hemodynamically stable.
clinically appears well. wcc is 20. pt was pancultured and
started on levo and flagyl per ercp fellow who review pt in am
for consideration of ir guided drainage if abscess present. ct
in er was equivocal regards to this. pt was therefore admitted
for iv rehydration, iv abx and possible ir procedure. Apparently
had an episode of unresponsiveness in the ED + incontinence.
Stat Head CT ordered--negative. Dr. [**Last Name (STitle) 3271**] requested a neuro
consult on the floor.
.
In the ED, initial VS were T98.8; HR 63; BP 107/57; rr 16, O2
sat 96%. No nausea/vomting reported. No abdominal pain. Blood cx
sent. IVF given, levo, flagyl given as well. Pt was schdeduled
to go to the regular floor but at 2305; pt was found to be
unresponsive, diaphoretic and incontinent of stool. T 102.0(R);
hr 57; BP 104/45; rr 21 O2 sat 97%2L. BS 246 at the time. Per
nsg report, got up to go to the bathroom, felt off, ? syncopal
event; got back into bed, was found by nurse to be unresponsive
and was incontinent of stool. Pt woke up after sternal rub,
alert and oriented x 3. CT scan was ordered in the ED--negative.
Of note, but had a recent 40-50lbs weight loss over last year.
.
Upon arrival to the [**Hospital Unit Name 153**], the patient's complaint was fatigue
and leg pain. Vital signs were stable. No abdominal pain, no
nausea, no vomiting.
Past Medical History:
1) Metastatic cholangiocarcinoma, diagnosed [**11-8**], s/p metal
stent placement.
2) Glucose intolerance
3) CAD, s/p old inferior MI, s/p cath [**2121**] demonstrating 60% LCx
lesion, no intervention . EF 45%.
4) PVD
5) hyperlipidemia
6) s/p pacemaker placement for bradycardia 4 yrs ago--[**Company 1543**]
Sigma 300 SDR. placed for sx bradycardia. programmed DDD with
max rate 80.
PSH:
7) intussusception repair as a child
8) herniorraphy
Social History:
The patient has been married for 47 years, has four children and
11 grandchildren. He does not smoke though he did in the remote
past having quit 20 years ago.
Family History:
[**Name (NI) **] father died of heart disease at age
88. [**Name (NI) **] mother had [**Name (NI) 4522**] disease, and apparently died of
complications of that in her late 60's. Two of the patient's
children are physicians.
.
Physical Exam:
PE: Temp: 99.5; HR 100; BP 106/63; RR 17; O2 sat 98%ra
HEENT: very dry mucus membranes. no thyromegaly. no scleral
icterus appreciated.
CV: regular S1 and S2. No murmurs, rubs or gallops appreciated.
LUNG: CTAB. no wheezes, rales, rhonchi
ABD: scar from previous surgery. +BS. soft, non-tender,
non-distended, no organomegaly appreciated. no RUQ tenderness
EXT: WWP, good palpable pulses.
NEUR: a and o x 3. responds to questions appropriately, but at
times tangential and a poor historian
SKIN: no rashes
Pertinent Results:
[**2127-4-16**] 10:00AM WBC-8.4 RBC-4.43* HGB-13.6* HCT-41.6 MCV-94
MCH-30.7 MCHC-32.7 RDW-14.2
[**2127-4-16**] 10:00AM NEUTS-78.9* LYMPHS-13.8* MONOS-5.1 EOS-0.8
BASOS-1.3
[**2127-4-16**] 10:00AM PLT COUNT-224
[**2127-4-16**] 10:00AM PT-15.2* INR(PT)-1.4*
[**2127-4-16**] 10:00AM ALBUMIN-3.8
[**2127-4-16**] 10:00AM ALT(SGPT)-99* AST(SGOT)-101* ALK PHOS-516*
TOT BILI-1.8* DIR BILI-0.4* INDIR BIL-1.4
[**2127-4-16**] 10:00AM UREA N-18 CREAT-1.1 SODIUM-138 POTASSIUM-6.0*
CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
[**2127-4-16**] 11:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2127-4-16**] 11:00AM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
troponin 0.04->0.02
ck-mb 7->3
.
AEROBIC BOTTLE (Final [**2127-4-20**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2127-4-18**] 11AM.
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2127-4-20**]):
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
.
surveillance blood cx from [**4-19**] and [**4-20**]: no growth to date
.
EKG:
Sinus rhythm with atrial sensing and ventricular pacing. No
previous tracing available for comparison.
.
CT OF THE ABDOMEN WITH IV CONTRAST: There are mild dependent
changes at the lung bases. A biliary stent is noted in the
common duct. Moderate intrahepatic biliary ductal dilatation is
noted. Near the porta hepatis and adjacent to the proximal end
of the biliary stent is an approximately 5.7 x 3.7-cm area of
hypodensity of the hepatic parenchyma with ill-defined borders.
Multiple smaller satellite low-attenuation hepatic foci with
similar ill- defined appearance are noted. There is associated
moderate intrahepatic biliary ductal dilatation. There is no
defined fluid collection and no subcapsular or perihepatic
fluid. There is no ascites or intraperitoneal focal fluid
collection or abscess. The pancreas, spleen, adrenal glands,
stomach and bowel are unremarkable. At the upper pole of the
right kidney is a 3.1-cm exophytic lesion which measures 28
Hounsfield units, higher than expected for a simple cyst.
Smaller bilateral parapelvic cysts are noted. There are
bilateral extrarenal pelves. There is no pathologic mesenteric
or retroperitoneal lymphadenopathy.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, urinary bladder
and pelvic loops of bowel are unremarkable. The prostate is
mildly enlarged. There is no free pelvic fluid or
lymphadenopathy.
BONE WINDOWS: No suspicious osteoblastic or osteolytic lesions
are identified.
IMPRESSION:
1. 5.7 x 3.7 cm region of low attenuation of the hepatic
parenchyma near the porta hepatis with ill-defined borders and
multiple smaller satellite hypodense foci. These findings are
thought more likely to represent primary cholangiocarcinoma with
intrahepatic metastases. The possibility of superinfection
cannot be definitively excluded. Evaluation with ultrasound
could be helpful to determine if there is a fluid component. If
so, this could be aspirated for diagnostic purposes.
2. Bilateral parapelvic renal cysts.
3. 3.1-cm exophytic lesion of the right kidney measures greater
density than expected for a simple cyst. Ultrasound is suggested
to determine if this is a cyst or possibly a solid lesion.
.
RUQ ULTRASOUND:
FINDINGS: There is mild edema within the gallbladder wall which
may be seen with liver disease. The gallbladder is relaxed and
no pericholecystic fluid is identified to suggest cholecystitis.
As noted on prior CT, there is intrahepatic biliary ductal
dilatation. Upper pole cyst is identified on the right kidney
measuring 3.1 cm x 3 cm x 2.1 cm. No fluid collections around
the liver or gallbladder are identified.
IMPRESSION:
1. No fluid collections identified in or around the liver or
gallbladder.
2. Intrahepatic biliary ductal dilatation also noted on CT one
day previous.
3. Edema within the gallbladder wall which may be seen with
liver disease. No evidence of acute cholecystitis identified.
.
AP CXR:
Heart size top normal. Lungs clear. No edema or pleural
effusion. Fullness in the mediastinum at the thoracic inlet to
the right of midline could be due to goiter or tortuous head and
neck vessels. Transvenous right atrial and right ventricular
pacer leads in standard placements. No pneumothorax or pleural
effusion.
.
HEAD CT W/O CONTRAST:
FINDINGS: No definite evidence of acute intracranial hemorrhage.
There is no shift of normally midline structures or
hydrocephalus. [**Doctor Last Name **]-white matter differentiation appears grossly
preserved. Several areas of relative [**Name (NI) 33214**] is seen
within vessels, including the MCAs and vertebrals, possibly
secondary to recent contrast administration. Visualized
paranasal sinuses appear normally aerated.
IMPRESSION: No evidence of acute intracranial hemorrhage. MRI
with diffusion-weighted images is more sensitive in the
evaluation for acute ischemia/infarct and for vascular detail.
Brief Hospital Course:
1) Gram negative septicemia due to cholangitis: Bacteremia may
have been secondary to manipulation during ERCP. RUQ ultrasound
showed no evidence of cholecystitis. Culture grew enterobacter.
Patient received ampicillin and gentamicin while in house and
was discharged on po cipro. Surveillance blood cultures remain
negative. Plan for total of 14 days of antibiotics. Patient is
hemodynamically stable. LFTs are steadily improving.
Percutaneous biliary drain was discussed but was not necessary
given bili trending down with the cleaning of the stent done on
initial ERCP.
.
2) Cholangiocarcinoma/locally metastatic, growing into the
stent, obstructing bile ducts: Patient is currently under
hospice care.
.
3) Syncope: Pacer was interrogated. Episode of ? VT noted but
did not temporally correlate with patient's episode. More
likely this was due to transient hypotension in the setting of
his sepsis. However, could certainly consider AICD once
bacteremia completely treated given concurrent low EF (EF
20-30%). However, patient is in hospice and likely would
refuse. This was not discussed during his inhospital course.
Neuro exam was normal and head CT was negative. Orthostatics
were negative. No significant arrhythmias on tele other than a
transient tachycardia EP believes was possibly afib/flutter,
ventricularly paced.
.
4) Renal cyst: Incidental finding on CT. Consider follow-up
ultrasound to better characterize, as recommended, if patient
agreeable.
.
5) h/o CAD: Patient is on an aspirin and a beta blocker. He
denied any chest pain. His statin was held due to bump in LFTs.
Could consider restarting at follow-up but likely little
benefit given overall prognosis and patient will continue to be
at risk of recurrent transaminitis.
.
6) h/o colitis: Patient was continued on his home Asacol,
Anaspaz
.
7) ARF: Resolved with IVF. Likely prerenal. Please resume
diovan at follow-up visit if creatinine and blood pressure
remain stable.
.
8) Coagulopathy: Resolved with vitamin K. Inr 1.9 on admit, now
1.4.
.
9) Dispo: discharged home with prior hospice services
.
10) Code status: DNR/DNI
Medications on Admission:
Meds from records--need to confirm with wife in AM
ASACOL 400MG--2 tabs three times a day per dr [**Last Name (STitle) 96328**]
ASPIRIN 81MG--One tablet twice a day
DIOVAN 80MG--One tablet by mouth every day
HYOSCYAMINE SULFATE 0.375MG--One tablet twice a day
METOPROLOL TARTRATE 25MG--One tablet twice a day
PRAVACHOL 20MG--One tablet at bedtime
TIMOLOL 0.25%--One gtt twice a day
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*120 Tablet, Sublingual(s)* Refills:*0*
4. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a
day for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
primary:
enterobacter septicemia due to cholangitis
secondary:
cholangiocarcinoma
syncope
Discharge Condition:
good: hemodynamically stable, afebrile, LFTs improved
Discharge Instructions:
Please call your doctor or go to the emergency room for
temperature > 100.5, worsening abdominal pain or fullness, or
other concerning symptoms.
Please take the antibiotics, as prescribed, until they are gone.
Please note you have been started on a new blood pressure
medication, which also helps with controlling the rate of your
heart. Please take, as prescribed.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6164**], on Monday, [**2127-4-28**] at 4:30 PM to follow-up this
hospital admission. Phone: [**Telephone/Fax (1) 4475**]
You can call to schedule follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **], only
as needed. Phone: ([**Telephone/Fax (1) 10532**]
ICD9 Codes: 5849, 4019, 4439, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5923
} | Medical Text: Admission Date: [**2121-11-20**] Discharge Date: [**2121-11-28**]
Date of Birth: [**2052-7-31**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2121-11-20**]
1. Exploratory laparotomy.
2. Extensive lysis of adhesions.
3. Segmental small-bowel resection with primary
anastomosis.
4. Repair of enterotomy
History of Present Illness:
The patient is a 69-year-old lady with a history of
ulcerative colitis and colectomy/ileoanal anastamosis/J-pouch in
[**2114**] at [**Hospital 26928**] Clinic. She presents with complaints of
abdominal pain, mostly left sided as well as nausea and small
amounts of emesis since yesterday morning. Reports she has not
had any episodes of small bowel obstructions in the past.
Reports last bowel movement was yesterday morning and that she
does not pass gas secondary to her prior surgery.
Of note she was seen by her gastroenterologist on [**2121-10-16**] with
complaints of lower abdominal pain. She has been treated with a
one month course of protonix. She was also worked up for
pouchitis in [**2120-1-28**] and was treated with flagyl. Her
last sigmoidoscopy was at that time and included biopsies, which
were unremarkable.
Past Medical History:
Past Medical History: Ulcerative Colitis (since [**2080**]),
fibromyalgia
Past Surgical History: colectomy and ileoanal anastomosis,
J-pouch ([**Hospital 26928**] Clinic), benign breast biopsy, TAH/BSO ([**2090**])
Social History:
The patient was a former smoker but stopped over
30 years ago. She does drink wine with dinner and maybe [**12-28**]
glasses after dinner. She has 1 cup of coffee a day.
Family History:
Remarkable for a mother, who died in her 80s
from an acute myocardial infarction. She does not know her
father's medical history. Her brother had complications of
congestive heart failure. No other family members have had an
idiopathic inflammatory bowel disease
Physical Exam:
Temp 96.1 HR 87 BP 143/82 RR 17 O2 sat 95RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: distended and tympanitic throughout, tender to palapation
in
left mid-abdomen, voluntary guarding, no rebound
DRE: refusing
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2121-11-20**] 11:55AM WBC-9.8 RBC-3.98* HGB-11.3* HCT-33.6* MCV-84
MCH-28.3 MCHC-33.6 RDW-14.4
[**2121-11-20**] 11:55AM NEUTS-85.5* LYMPHS-10.4* MONOS-3.4 EOS-0.6
BASOS-0.1
[**2121-11-20**] 11:55AM PLT COUNT-307
[**2121-11-20**] 11:55AM PT-12.3 PTT-23.6 INR(PT)-1.0
[**2121-11-20**] 11:55AM GLUCOSE-135* UREA N-17 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
[**2121-11-23**] Chest CTA :
1. No evidence of pulmonary embolism.
2. Airway thickening and patchy opacities right upper and middle
lobes
consistent with bronchopneumonia.
3. Small to moderate, bilateral pleural effusions with adjacent,
compressive atelectasis.
4. Oblong, 5mm perifissural nodule on the right has a benign
appearance.
According to [**Last Name (un) 8773**] society guidelines, in a low risk
patient 12 month
interval follow is recommended versus 6 month follow-up in a
high risk
patient.
Brief Hospital Course:
Mrs. [**Last Name (STitle) 10840**] was evaluated by the Acute Care service in the
Emergency Room and based on the CT scan from the referring
hospital and her exam she was taken to the Operating Room
urgently for an exploratory laparotomy as her small bowel was
completely obstructed. She tolerated the procedure well and
returned to the PACU in stable condition. She maintained stable
hemodynamics after extubation and her pain was controlled with
Dilaudid.
Following transfer to the Surgical floor she did well for about
24 hours then developed problems with desaturation, confusion
and rapid atrial fibrillation. She was subsequently transferred
to the ICU for further management. Her atrial fibrillation was
initially controlled with IV Lopressor and eventually an
amiodarone drip. Serial EKG's and enzymes were drawn which were
negative and her rate was eventually controlled. The Cardiology
service was consulted and recommended weaning the Amiodarone and
using oral Lopressor.
Her chest xray showed some new right perihilar consolidation
suspicious for pneumonia or aspiration but she was afebrile with
a normal WBC. Her respiratory status improved with nebulizers
and incentive spirometry. She did have a CTA to rule out PE
which was negative.
After returning to the Surgical floor she began to make
progress. She was tolerating a regular diet without any nausea
or fullness and her abdominal wound was healing well. Her pain
was controlled with Tylenol and Oxycodone and she was up and
walking though fatigued easily. The Physical Therapy service
evaluated her and recommended home PT at discharge to help her
get back to her baseline. She also remained in NSR for 48 hours
prior to discharge. After a longer than expected hospital
course she was discharged to home on 12//[**3-5**] and will have VNA
services along with follow up in the [**Hospital 2536**] Clinic in 2 weeks.
Medications on Admission:
vitB12, prozac 10', omperazole 20', imitrex 100', trazadone 50
qhs, Ca/vitD3, MVI
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Prozac 10 mg Capsule Sig: One (1) Capsule PO once a day.
6. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
VNA [**Hospital1 **] of [**Hospital1 1559**]
Discharge Diagnosis:
1. Complete small bowel obstruction
2. Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-5**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment or by the VNA.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-29**] weeks.
Call Dr. [**Last Name (STitle) 26929**] for a follow up appointment in [**12-28**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2121-11-28**]
ICD9 Codes: 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5924
} | Medical Text: Admission Date: [**2196-10-17**] Discharge Date: [**2196-10-20**]
Date of Birth: [**2129-8-12**] Sex: M
Service: NEUROLOGY
Allergies:
Tegretol / Dilantin Kapseal / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Bactrim
Attending:[**First Name3 (LF) 13017**]
Chief Complaint:
Seizure/Possible GI Bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 67 year old man with history of diabetes,
dyslipidemia, hypertension, coronary artery disease (s/p
multilple stents and CABG in [**2189**]), seizure disorder (on
lamotrigine only), macrocytic anemia, who initially presented to
the ED after finding himself down on the ground.
He was brought int to the ED by EMS, and initially evaluted,
with trauma survey overall negative, but facial/nasal bone
fractures. During his initial presentation to the ED he was not
complaining of any problems other than facial pain. He stated
that his blood sugar might have been low, but EMS stick was FS
of 250s. While in the ED he had a seizure ( described as Jerking
Tonic/Clonic, generlized, with face deviating to the left,
looked like grand-mal, brief). At this time he was incontinent
of stool, but not urine.
He was not given anything, and seizure spontaneosly resolved. FS
of 85, given some glucose. ? Epistaxis running down back of his
throat. He had an episode of coffee-ground emesis. Guaiac
negative from below. Per report, he was diaphoretic, and "sick
looking".
.
At this time Patient was not given any medications other than
glucose to correct his episode of hypoglycemia. Prior to
transfer he was started on Protonix IV, Zofran. Nurse also noted
"compartment syndrome in left forearm" - could be IV
infiltrating, and patient is not complaining of painin that arm.
Doppler was done - radial pulse present.
.
.
His presentation, vs were: 96.1-76-132/68-18-98%RA
Timing of Events in ED:
- Emesis 15 minutes prior to transfer to ICU.
- Seizure - 40 minutes prior to transfer.
- Neuro came by but patient was vomiting, thus deferred
evaluation.
- Prior to transfer, the patient had another episode of seizure,
and was given ativan and sent for another CT scan of his head to
rule out bleed.
.
Vitals prior to transfer - 83 Pulse, 18 Resp 100% Room Air, BP
125/55 (but had as low as 105 SBP). Afebrile entire ED stay.
.
Initial CT spine was notable for:
1. No acute cervical spine fracture or malalignment.
2. Mild degenerative changes, worst at C4-C5.
.
Initial CT head was notable for:
1. No acute intracranial abnormality.
2. Bilateral nasal bone fractures and nasal septal fracture.
3. New mild bifrontal prominence of CSF spaces.
.
The patient then was reportedly worse, had another seizure, was
given a total of 4 ativan IV, noted to have worsening mental
status. ED was concerned for evolving intracranial process, and
repeated CT, which was unchanged.
.
On arrival to the floor, the patient was only responding to
painful stimuli. His vitals were stable and he did not grimace
on palpation of his extremities, his abdomen or back, and was
moving his extremities spontaneously.
Past Medical History:
- DM-1: for almost 50 years, he has neuropathy and retinopathy.
-- CAD: 4 stents [**2180**], RCA stent [**11/2189**], 3v-cabg [**9-/2190**], NSTEMI
[**2190**]
- Syncopal episode in [**Month (only) 205**], attributed to arrhythmia. Underwent
cath. without stent placement.
- GTC Seizures (wife describes that normal semiology = "lets out
a cry," shakes all limbs for ~30 sec, groggy afterwards): ?
related to hypoglycemia, stable on Lamictal, no seizures for
several years (previously on PHB, stopped in [**2190**])
- Onychodystrophy
- Seborrheic dermatitis
Social History:
Lives with wife. Retired H.S. English teacher
(retired early [**12-16**] encephalopathy). [**Month/Day (2) **] several times weekly.
-Tobacco history: 2 cigars per week (equivalent to a 25 py hx).
-ETOH: Has 1 EtOH drink with dinner.
-Illicit drugs: Denies.
Family History:
Father and sister with [**Name2 (NI) **] at young age (40-50).
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: Afebrile, HR 81 regular, BP 133/47 RR 14 SpO2 98% RA
fingerstick 213
General: Responds to painful stimuli by grimacing, not talking,
not responding to commands.
HEENT: Sclera anicteric, pupils 4mm, reactive to light,
Neck: supple, JVP not elevated, no LAD,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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 in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, with the exception of his left arm, but radial is
dopplerable.
Skin Exam: Small abrasion on top of scalp, several excoriative,
well healed lesions throughout. Overall dry skin. Some dried
blood around nares.
Neurological:
Mental status:
Groans to noxious stimuli, but not rousable.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements could not be assessed, but
gaze is conjugate.
V, VII: Face symmetric.
VIII: Hearing not evaluable.
IX, X: Not tested.
[**Doctor First Name 81**]: Not tested.
XII: Not tested.
Tone normal in legs, gegenhalten in arms.
Power: Strong withdrawal in legs and arms.
Reflexes: B T BR Pa Ac
Right 2 2 2 3 0
Left 2 2 2 3 0
Right toes up; left down.
Sensation intact to noxious stimuli.
At discharge:
Pertinent Results:
[**2196-10-17**] 12:00PM BLOOD WBC-8.5 RBC-3.92* Hgb-12.8* Hct-40.0
MCV-102* MCH-32.7* MCHC-32.1 RDW-15.2 Plt Ct-527*
[**2196-10-18**] 03:46AM BLOOD WBC-14.3* RBC-3.36* Hgb-11.2* Hct-34.6*
MCV-103* MCH-33.4* MCHC-32.4 RDW-15.2 Plt Ct-431
[**2196-10-17**] 12:00PM BLOOD Glucose-156* UreaN-15 Creat-0.7 Na-142
K-4.9 Cl-104 HCO3-29 AnGap-14
[**2196-10-18**] 03:46AM BLOOD Glucose-244* UreaN-17 Creat-0.8 Na-135
K-4.7 Cl-101 HCO3-24 AnGap-15
[**2196-10-17**] 12:00PM BLOOD ALT-20 AST-27 AlkPhos-61 TotBili-0.5
[**2196-10-17**] 12:00PM BLOOD cTropnT-<0.01
[**2196-10-17**] 12:00PM NEUTS-83.9* LYMPHS-10.5* MONOS-3.4 EOS-1.4
BASOS-0.8
[**2196-10-17**] 12:00PM LIPASE-9
[**2196-10-17**] 12:11PM GLUCOSE-145* LACTATE-1.8 K+-4.4
[**2196-10-17**] 03:50PM URINE MUCOUS-RARE
[**2196-10-17**] 03:50PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2196-10-17**] 12:00PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-1.3*#
MAGNESIUM-2.1
[**2196-10-17**] 03:50PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2196-10-17**] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2196-10-17**] 03:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2196-10-17**] 06:07PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2196-10-17**] 06:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-70 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
ECG:
Sinus rhythm. Prolonged Q-T interval. Early R wave transition.
Low
QRS voltage in the limb leads. T wave inversions in leads V1-V3
which are new compared to tracing of [**2196-6-1**]. Cannot exclude
myocardial ischemia. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 144 102 460/465 76 17 87
CT Head without contrast:
FINDINGS: There is no evidence of acute hemorrhage edema, shift
of midline
structures or major vascular territorial infarction. There is
new bifrontal prominence of the CSF spaces, likely representing
old subdural hematoma or CSF hygroma. The ventricles and sulci
are prominent consistent with age-related atrophy.
Atherosclerotic calcifications of the carotid and vertebral
arteries are noted. There are fractures of the bilateral nasal
bones and nasal septum.
There is mild mucosal thickening and a mucus-retention cyst in
the right
maxillary sinus. The remaining visualized paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Bilateral nasal bone fractures and nasal septal fracture.
3. New mild bifrontal prominence of CSF spaces.
CT C-spine without contrast:
FINDINGS: There is no acute fracture, dislocation, or
malalignment of the
cervical spine. There is no prevertebral soft tissue edema. The
craniocervical junction is intact. There is a posterior
disc-osteophyte
complex at C4-C5 causing mild spinal canal narrowing. There is
mild facet
spondylosis on the left at this level.
The visualized portions of the lung apices again demonstrate
chronic fibrotic changes in the medial aspect of the left lung.
There is no cervical lymphadenopathy. The thyroid gland is
unremarkable. There are bilateral atherosclerotic calcifications
of the carotid bifurcations.
IMPRESSION:
1. No acute cervical spine fracture or malalignment.
2. Mild degenerative changes, worst at C4-C5.
Head CT without contrast - repeat:
FINDINGS: There is no evidence of acute hemorrhage, edema, shift
of midline structures, or major vascular territorial infarction.
Again noted is bifrontal prominence of the CSF spaces, likely
representing old subdural hematomas or CSF hygromas. The
ventricles and sulci are prominent consistent with age-related
atrophy. Atherosclerotic calcifications of the carotid and
vertebral arteries are again noted.
There are fractures of the bilateral nasal bones and nasal
septum. There is mild mucosal thickening and a mucus retention
cyst in the right maxillary sinus. The remaining visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Bilateral nasal bone fractures and nasal septal fracture.
3. Bifrontal prominence of CSF spaces.
CXR - 1 view:
FINDINGS: In comparison with study of [**2195-8-10**], the cardiac
silhouette remains within overall normal limits. Minimal
indistinctness of pulmonary vessels raises the possibility of
increased pulmonary venous pressure. There is suggestion of some
increased opacification at the right base and in the
retrocardiac region on this side. This could merely reflect
crowded vessels or atelectasis and a lateral view would be ideal
if clinically possible to better assess for possible pneumonia.
ECG:
Sinus rhythm with atrial premature depolarization. Low QRS
voltage in limb
leads. Diffuse non-diagnostic repolarization abnormalities.
Rightward
precordial R wave transition point. Compared to the previous
tracing of [**2196-10-17**] there is no diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 142 102 448/472 59 49 110
Brief Hospital Course:
This is a 67 year old man with history of diabetes,
dyslipidemia, hypertension, coronary artery disease (s/p
multilple stents and CABG in [**2189**]), seizure disorder (on
lamotrigine only), macrocytic anemia, who initially presented to
the ED after finding himself down on the ground, became more
unresponsive and confused after witnessed seizures, now in the
MICU, responsive only to painful stimuly. Neurology was urgently
consulted and he was subsequently transferred to the general
neurology service when altered mental status improved.
.
# Altered Mental status - due to post-ictal state. Resolved over
the next few days. The patient returned to his baseline mental
status.
.
# Seizure disorder - The etiology of his fall was most likely
due to low blood sugars. The EMS team did not find this due to
the [**Last Name (un) 56493**] effect ([**Last Name (un) **] has repeatedly counseled the patient
and his family on this). We loaded the patient on Keppra and
started maintance dosing. He tolerated this well and was
discharged on his prior home dose Lamictal as well as Keppra
750mg po bid. Of note, Lamictal level has now come back and
shows a level of 2.3. The level was drawn likely after the
patient had missed 2 doses, but this level indicates that the
patient may have missed a few doses at home prior to the initial
seizure.
.
# Nasal fracture - The patient arrived to the ED with bloody
mouth and nose. CT shows that he fractured his bilateral nasal
bones and nasal septum. Plastic surgery consulted and
recommended follow up in clinic on Friday [**2196-10-21**] with possible
closed reduction the following week. Plastics is concerned for
difficulties with breathing in the future. Respiratory status
remained stable while in house. The patient was provided with
their clinic phone number on discharge.
.
# Coffee-ground emesis - had o/ne episode of what was described
as coffee- ground emesis, after the seizure. At the time he was
diaphoretic, and looked unwell. He was hemydynamically stable
however. His [**Doctor Last Name 80870**] score is 1 (Score predicting resolution
without intervention: <4) thus he is unlikely to benefit from
Upper GI endoscopy. He is Guaiac negative and his likely source
of bleeding is epistaxis given trauma of his face. He was Guaiac
Negative in ED.
- GI consulted
- HCT remained stable
- no further emesis
.
**** OF NOTE - In regard to future ED Visits:
[**Known firstname **] [**Known lastname **] has a strong history of having generalized
seizures early in the morning when his blood glucose is low.
Often by time EMS checks his blood glucose after the event, the
result is normal or high due to the [**Last Name (un) 56493**] effect. If he
arrives in the emergency room in such a context, he should be
either loaded on an anti-epileptic medicine or started on a
standing IV ativan bridge (e.g.: ativan 1mg IV q6 hours) in
order to prevent further generalized seizures within 24 hours.
This is important as when the patient has several seizures
within a 24 hour period, he becomes very somnolent for days due
to a post-ictal state. Thank you for taking this into
consideration.
Medications on Admission:
-One Touch Ultra - Strips Strips 5-6 times a day as directed
-Bd Ultra-fine Iii - Pen Needles 31g [**3-28**]" as directed injecting
5 times daily
-Levemir 100 Unit/ml 14 in am and 2 in pm
-Simvastatin 40 Mg take 1 tablet (40MG) by ORAL route every day
in the evening
-Humalog 100 Unit/ml pen approx 15 units a day as directed
-Glucagon Emergency Kit 1 Mg Use as directed
-Ketostix Reagent Check for ketones when BS > 250 and cannot
explain one time
-Insulin Syringe 31 Gauge X [**3-28**]" 2 per day
-Bd Ultra-fine - Syringes 30g 1/2cc 3 times a day
-Toprol Xl 25mg 1 per day
-One Touch Ultra Soft - Lancets Lancet as directed
-Bd Ultra-fine Iii - Syringes 30g 5/16l 1/2 cc. Use one daily.
-Ketostix - Strips Bottle Use as directed
-Pen Needle 29 Gauge X [**11-15**]" as directed
-Bd Ultra-fine - Syringes 29g [**11-15**] C as directed
-Aspirin Ec 81mg 1 per day
-Enalapril Maleate 10 Mg 1 per day
-Lamictal 100mg twice a day
-Plavix once a day
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
6. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
8. Levemir 100 unit/mL Solution Sig: 10 units in the morning and
2 units at night unit Subcutaneous twice a day: as directed by
[**Last Name (un) **].
9. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
once a day: as directed by [**Last Name (un) **].
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
nasal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: no deficits
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you during your stay. You were
admitted to the hospital after a fall, suspected to be due to a
seizure related to low blood glucose. During your stay you had 2
more seizures. You were started on a new anti-seizure medicine
by the name of Keppra. Please take Keppra 750mg by mouth twice
daily in addition to your home Lamictal. Please avoid swimming
for at least the next 6 months to ensure your safety as it would
be extremely dangerous and possibly deadly if you were to have a
seizure while swimming. Likewise, it is [**State 350**] state law
that anyone who has suffered a loss of consciousness such as a
seizure, may not drive until they have been seizure-free for at
least 6 months.
Unfortunately, your fall prior to admission resulted in a
fracture of your nose. The plastic surgeon team was consulted
and are concerned that you may need a closed reduction of your
nasal bone in order to prevent breathing problems in the future.
Please follow up with them in clinic to further discuss this.
Please call their clinic as listed below.
Followup Instructions:
The Plastic Surgery team asks that you please call their clinic
tomorrow, [**2196-10-21**], to arrange follow up with Dr. [**Last Name (STitle) 90769**]. Their
phone number is ([**Telephone/Fax (1) 2868**]. They ask that you call tomorrow
as the nasal fracture may need to be fixed sooner than later.
We have left a message for Dr.[**Name (NI) 10444**] assistant to call you
to schedule an appoinment within the next 2-4 weeks. If you do
not hear from her, please call ([**Telephone/Fax (1) 2528**] to schedule this
appointment.
Please attend your previously scheduled appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10490**], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**]
Date/Time:[**2196-10-26**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2196-11-1**] 3:00
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2197-1-19**] 11:20
ICD9 Codes: 5789, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5925
} | Medical Text: Admission Date: [**2178-7-6**] Discharge Date: [**2178-7-9**]
Service:
REASON FOR ADMISSION: Transfer from an outside hospital for
chest pain/pressure presumed to be acute myocardial
infarction.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
with known coronary artery disease, status post acute
myocardial infarction the week prior to admission. The
patient was taken to the cath laboratory the week prior and
found to have three vessel disease with a significant right
coronary artery stenosis of 90%. She received a thrombectomy
and percutaneous transluminal coronary angioplasty with a
[**Age over 90 **] in the distal right coronary artery. The other
significant disease was a 30% left main coronary artery and a
70% proximal left anterior descending, as well as left
circumflex 99% lesion were not intervened upon at that time.
On her last hospital admission, she was found by
echocardiogram to have an ejection fraction of 50% with 2+
mitral regurgitation and inferolateral akinesis.
On the day of admission, [**2178-7-6**], the patient presented
to an outside hospital Emergency Room complaining of
"abdominal tightness" and pain between the shoulder blades,
similar to the symptoms that brought her to the [**Hospital1 **] hospital the week prior. An electrocardiogram
showed ST elevations in the posterolateral leads. Integrilin
was started and the patient was transferred to [**Hospital6 1760**] for emergency percutaneous
transluminal coronary angioplasty.
Catheterization findings: Hemodynamics: Initial normal-low
PA pressure, intermittent marked elevation with reflected V
wave. At conclusion of case, PA pressure was 22/12.
Coronary angiography: Right dominant circulation: Left main
coronary artery normal. Left anterior descending: 70%.
Left circumflex artery: 99% long occlusion from AV groove,
left circumflex into marginal, supplying lateral wall and
papillary muscle. Some collaterals from right to left.
Right coronary artery: Patent stented right coronary artery.
Small diseased posterior descending artery. TIMI three flow.
Intervention: Successful percutaneous transluminal coronary
angioplasty and stenting of the proximal circumflex to distal
OM1 was performed using five overlapping 2.5 mm stents for a
total [**Hospital6 **] length of approximately 80 mm. Left femoral
arteriotomy closure was performed using angioseal. The
patient was taken to the Coronary Care Unit for observation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease with right coronary artery [**Hospital6 **]
as mentioned (see history of present illness).
MEDICATIONS:
1. Plavix 75 mg q.d.
2. Aspirin 325 mg po q.d.
3. Lescol 80 mg q.d.
4. Toprol XL 25 mg q.d.
5. Lisinopril 5 mg q.d.
6. Lansoprazole 30 mg q.d.
ALLERGIES: Penicillin leads to rash.
SOCIAL HISTORY: The patient lives alone.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: Vital signs: Temperature 100.8.
Blood pressure 117/37. Heart rate 87. Respiratory rate 15.
Oxygen saturation 96% on four liters. General: Patient
lying in bed in no apparent distress, appears younger than
stated age, breathing comfortably. Head, eyes, ears, nose
and throat: Pupils equal, round and reactive to light and
accommodation. Mucous membranes moist. Neck supple, no
jugular venous distention. Chest: Coarse breath sounds with
upper airway noises. Cardiac: Regular rate and rhythm, 2/6
systolic murmur at the apex. Nondisplaced point of maximal
impulse. Abdomen: Nontender, nondistended, soft, positive
bowel sounds. Extremities: Warm, 2+ dorsalis pedis pulse
bilaterally, 2+ pitting edema, halfway up the leg to the
knee. Neurological: Awake, alert and nonfocal.
LABORATORY FINDINGS/INITIAL STUDIES: White blood cell count
9.0, hematocrit 28.8, platelet count 273,000. Chem-7:
Sodium 130, potassium 3.6, chloride 95, bicarbonate 26, BUN
15, creatinine 1.0, glucose 119. CK 150, arterial blood gas
7.5/33/94. Electrocardiogram showed a normal sinus rhythm at
98 beats per minute with normal axis and intervals. ST
depressions in leads V2 through V4. Catheterization report:
See history of present illness.
BRIEF HOSPITAL COURSE: The patient was admitted to the
Coronary Care Unit and placed on aspirin, Plavix,
fluvastatin, Integrilin. The patient was switched from
Toprol XL to Lopressor b.i.d. Her ACE was held given the
large dye load. Patient was placed on telemetry. A chest
x-ray was obtained and the patient was transfused one unit of
packed red blood cells due to a hematocrit of 26%. [**2178-7-7**], the patient's Metoprolol was changed to 25 q.a.m., 12.5
q.p.m. Lisinopril was started at 5 mg after creatinine came
back at 1.1. The patient was asymptomatic, but did complain
of occasional dyspepsia. The hematocrit after one unit of
packed red blood cells was at 26.9. The patient was
transfused an additional two units of packed red blood cells
which brought her hematocrit to 34.3. A chest x-ray was
obtained the previous day which showed a small bilateral
pleural effusions.
An echocardiogram was obtained which showed:
1. The left ventricular cavity size as normal. Overall left
ventricular systolic function is difficult to assess, but is
probably normal (left ventricular ejection fraction greater
than 55%).
2. There is a pericardial effusion. The valves were not
well visualized.
[**2178-7-8**]:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**First Name3 (LF) 51146**]
MEDQUIST36
D: [**2178-7-15**] 09:11
T: [**2178-7-19**] 14:33
JOB#: [**Job Number 51147**]
ICD9 Codes: 4280, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5926
} | Medical Text: Admission Date: [**2178-7-24**] Discharge Date: [**2178-8-3**]
Date of Birth: [**2100-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Myocardial infarction
Major Surgical or Invasive Procedure:
CABG x3 (LIMA->LAD, SVG->OM/PDA)
History of Present Illness:
Mr. [**Known lastname 79800**] is a 78M smoker with a history of end-stage renal
disease (on hemodialysis), hypertension, hyperlipidemia, and
stroke who presented to [**Hospital3 4107**] on [**2178-7-19**] after
waking up in the middle of the night with SOB. He was found to
have pulmonay edema and a new left bundle branch block, and he
ruled in for myocardial infarction with positive cardiac enzymes
(troponin peak of 30). He received heparin, which was
discontinued after his dialysis A-V fistula began to bleed, but
he was continued on clopidogrel. He [**Year (4 digits) 1834**] a pharmacologic
MIBI which showed an infero-posterior MI and lateral ischemia.
He was transferred to the [**Hospital1 18**] for further evaluation.
At [**Hospital1 18**], he had a cath on [**2178-7-24**] that showed three-vessel
disease and severe left ventricular systolic dysfunction. No
stents were placed, as the patient's anatomy was more amenable
to CABG. Cardiothoracic surgery saw the patient and plan to take
him for CABG on Tuesday. He also received HD before arriving on
the cardiology floor.
.
Past Medical History:
s/p CABG x 3
NSTEMI
CAD
HTN
DM
ESRD (on HD)
CVA
Social History:
Has not smoked cigarettes in 15 years but previously had a >120
pack-year history. No alcohol.
Family History:
No family history of premature CAD.
Physical Exam:
Vitals: T 98.7 BP 156/58 HR 72 RR 20 97RA
General: AO3 NAD
HEENT: PERRL EOMI
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: markedly decreased BS at R lung base, decreased BS
b/l
Cardiac: RRR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: mild edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no echymoses
Labs: See below
Pertinent Results:
[**2178-7-24**] 10:00AM GLUCOSE-135* UREA N-69* CREAT-6.4* SODIUM-133
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-22 ANION GAP-20
[**2178-7-24**] 10:00AM estGFR-Using this
[**2178-7-24**] 10:00AM ALT(SGPT)-17 AST(SGOT)-30 CK(CPK)-74 ALK
PHOS-73 AMYLASE-36 TOT BILI-0.3
[**2178-7-24**] 10:00AM cTropnT-3.88*
[**2178-7-24**] 10:00AM ALBUMIN-3.6
[**2178-7-24**] 10:00AM %HbA1c-5.5
[**2178-7-24**] 10:00AM TYPE-ART PO2-107* PCO2-40 PH-7.36 TOTAL
CO2-24 BASE XS--2
[**2178-7-24**] 10:00AM GLUCOSE-129* NA+-133* K+-4.5
[**2178-7-24**] 10:00AM HGB-10.1* calcHCT-30 O2 SAT-97
[**2178-7-24**] 10:00AM WBC-5.5 RBC-3.17* HGB-9.7* HCT-27.6* MCV-87
MCH-30.5 MCHC-35.1* RDW-15.2
[**2178-7-24**] 10:00AM PT-13.8* PTT-24.3 INR(PT)-1.2*
Cardiac Cath [**2178-7-24**]:
1. Selective coronary angiography of this right dominant system
demonstrated 3 vessel coronary artery disease. The LMCA was
moderately
calcified with a distal 30% lesion. The LAD was moderately
calcified
with a proximal 50% lesion after the take-off of D1. There was
mild
diffuse disease in the mid-LAD. The LCx was moderately
calcified with
an ostial 60-70% lesion. There was a proximal hazy 80% lesion
and a
large OM/LPL. There were multiple collaterals to the distal
RCA. The
RCA had a proximal 50% lesion, a mid 60% lesion and a mid total
occlusion. There was faint filling of the mid-distal RCA.
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with LVEDP of 17mmHg. The right sided filling
pressure was relatively normal, with [**Name (NI) 79801**] of 10mmHg. The
pulmonary
artery pressure was mildly elevated, at 37/14 mmHg. The
systemic
arterial pressure was elevated at 171/46 mmHg. There was no
gradient
between the LVEDP and the PCW. There was no gradient on
pullback from
the left ventricle to the aorta.
3. Left ventriculography showed left ventricular systolic
dysfunction,
with calculated ejection fraction of 40%. There was moderate to
severe
global hypokinesis, worst in the infero-lateral and infero-basal
segments. There was no mitral regurgitation.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe left ventricular systolic dysfunction.
3. Mild left ventricular diastolic dysfunction.
4. Mild pulmonary artery hypertension.
[**2178-8-3**] 01:00PM BLOOD WBC-6.9 RBC-2.91*# Hgb-8.6* Hct-26.3*
MCV-90 MCH-29.6 MCHC-32.7 RDW-15.2 Plt Ct-276
[**2178-8-1**] 08:30AM BLOOD PT-15.1* PTT-30.2 INR(PT)-1.3*
[**2178-8-3**] 05:50AM BLOOD Glucose-120* UreaN-53* Creat-7.8*# Na-134
K-4.7 Cl-97 HCO3-24 AnGap-18
[**Known lastname **],[**Known firstname 79802**] [**Medical Record Number 79803**] M 78 [**2100-7-6**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2178-7-31**] 2:07
PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2178-7-31**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79804**]
Reason: s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with
REASON FOR THIS EXAMINATION:
s/p ct removal
Final Report
REASON FOR EXAMINATION: Followup of a patient after removal of
the chest
tube.
Portable AP chest radiograph was compared to prior study
obtained yesterday on
[**2178-7-30**].
The patient was extubated with removal of the NG tube, Swan-Ganz
catheter, as
well as mediastinal drain and left chest tube. The
cardiomediastinal
silhouette is stable. No appreciable change in bibasilar
opacities consistent
with atelectasis is demonstrated, left more than right, expected
at this
stage. No appreciable pneumothorax is seen. There is no evidence
of failure
or significant increase in pleural effusion.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2178-7-31**] 5:23 PM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 79802**] [**Hospital1 18**] [**Numeric Identifier 79805**]
(Complete) Done [**2178-7-30**] at 8:35:00 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-7-6**]
Age (years): 78 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: intraop management
ICD-9 Codes: 402.90, 440.0
Test Information
Date/Time: [**2178-7-30**] at 08:35 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW3-: Machine: 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.5 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Inferobasal LV
aneurysm. Mild regional LV systolic dysfunction.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic arch diameter. Complex (>4mm) atheroma in
the aortic arch. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened
aortic valve leaflets.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
Mildly thickened mitral valve leaflets. Physiologic MR (within
normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
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. See Conclusions for post-bypass data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium and right atrium are normal in cavity size. 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.
Left ventricular wall thicknesses are normal. There is an
inferobasal left ventricular aneurysm. There is mild regional
left ventricular systolic dysfunction with the mid and apical
inferior and inferoseptal walls. The remaining left ventricular
segments contract normally.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion.
The aortic valve leaflets are mildly thickened. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits). There is no
pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the
results on [**Known lastname 79800**] at 8AM.
Post_Bypass:
Intact thoracic aorta.
Normal RV systolic function.
LVEF 45%.
Valves similar to prebypass study
POST-BYPASS:
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2178-7-31**] 11:27
?????? [**2172**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2178-7-30**] Mr.[**Known lastname 79800**] [**Last Name (Titles) 1834**] CABG x3 (LIMA->LAD,
SVG->OM/PDA) with Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **]. Please refer to
Dr[**Doctor Last Name 14333**] operative note for further details.
XCT=54min, CPB=61minutes. He was intubated and sedated when
transferred to CVICU. The drips were weaned to off and he was
extubated that night. POD#1 he went into AFib and was started on
Amiodarone, beta-blockers were optimized as BP would tol. Renal
was following due to Mr.[**Known lastname 79806**] ESRD and dependence on
hemodialysis.All lines and tubes were discontinued in a timely
fashion and he was transferred to the SDU for further telemetry
monitoring and recovery. The remainder of his postoperative
course was essentially uneventful. During dialysis on POD#4 he
was transfused one unit of PRBCs for a hematocrit of 21.3.
Follow-up HCT =26, and he Dr.[**First Name (STitle) **] cleared him for discharge.
POD#4 he was doing well and was discharged to home with VNA. All
follow-up appointments were advised.
Medications on Admission:
Hydralazine 50(2)
Labetolol 400(2)
Colace 100(2)
Ferrous 325(1)
Lipitor 80(1)
Plavix 75(1)
Lopid 300(2)
Levoquin 250(1)
Nephrocaps(1)
Neurontin 300(1)
prevacid 30(1)
ASA 325(1)
Tiazac CD 360(1)
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
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 7 days then decrease to 200(2)x 7 days, then decrease
to 200(1).
Disp:*120 Tablet(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**]
Discharge Diagnosis:
s/p CABG x3
Coronary artery disease
endstage renal failure
Diabetes mellitus
hypertension
COPD
GERD
h/o CVA
s/p NSTEMI
Discharge Condition:
good
Discharge Instructions:
take all medications as prescribed
Shower daily, no baths or swimming
No creams, lotions or powders to incisions
No lifting more than 10 pounds for 10 weeks
No driving for 4 weeks and off all narcotics
report any temperature of more than 101
report any drainage or redness of incisions
Followup Instructions:
Dr.[**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**Last Name (STitle) **] in [**11-19**] weeks([**Telephone/Fax (1) 4475**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2178-8-3**]
ICD9 Codes: 5856, 9971, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5927
} | Medical Text: Unit No: [**Numeric Identifier 71609**]
Admission Date: [**2154-5-1**]
Discharge Date: [**2154-8-25**]
Date of Birth: [**2154-5-1**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 71610**] was born at 27-
2/7 weeks gestation by cesarean section for severe pre-
eclampsia and breech presentation. The mother is a 25-year-
old, gravida 3, para 0, now 1, woman. Her prenatal screens
were blood type O positive, antibody negative, rubella
immune, RPR nonreactive, hepatitis surface antigen negative,
and Group B strep unknown. This pregnancy was complicated by
the onset of severe preeclampsia 48-hours prior to delivery
and intrauterine growth retardation. The mother was treated
with betamethasone and magnesium sulfate. The infant emerged
with Apgars of 6 at one minute and 8 at five minutes.
The birth weight was 829 gm (20th percentile), birth length
34 cm (25th percentile), and the birth head circumference
24.5 cm (25th percentile).
NICU COURSE BY SYSTEMS:
1. Respiratory Status: The infant was intubated at the time
of admission and received 1 dose of Surfactant. She
extubated to nasopharyngeal continuous positive airway
pressure on day of life #1 and then she transitioned to
nasal cannula oxygen on day of life #2.
She was treated with caffeine citrate for apnea of
prematurity from day of life #1 until day of life #21. She
continues to have 1-4 episodes of apnea and bradycardia in
a 24- hour period. On [**6-21**] she she began to have
worsening apnea/bradycardia.On [**6-24**] she was restarted on
caffeine citrate and placed on high flow nasal cannula
with improvement, on [**6-28**] she went back to low flow
cannula of 13 cc's liter flow. Caffeine was D'C d on [**7-3**].
It appears that her respiratory situation is compromised
by her abdominal girth impinging on her chest capacity.
She breaths with deep retractions out of proportion to her
mild chronic lung disease. On [**7-18**] Pulmonary consult was
obtained (Dr. [**Last Name (STitle) 37305**]. He will follow patient in Pulmonary
Clinic on [**8-16**] at CHMC. He requested an ultrasound to
determine diaphragmatic movement and this was done on [**7-23**]
with normal bilateral and symmetrical movement. Her most
recent cap blood gas on [**7-24**] was 7.37/50. She will be
going home on 25 cc's liter flow of oxygen and a
saturation monitor to maintain oxygen saturation greater
than 90%
2. Cardiovascular Status: She has remained normotensive
throughout her NICU stay. She has the presentation of a
new heart murmur on [**2154-5-14**] and a cardiac echo at
that time revealed a structurally normal heart, no patent
ductus, and mild PPS. I am unable currently to hear her
intermittant murmur.
3. Fluids/Electrolytes/Nutrition Status: Enteral feeds were
begun on day of life #6 and advanced to full volume
feedings by day of life #18 with a slow progression due
to abdominal distention. She worked up to total fluids 140
mL/kg/day of Neosure 26- calorie per ounce formula and
takes about 140 cc/kg /day of feeding.
Her weight at discharge is 2780 grams.
Endocrine: On routine nutrition labs it was noted that her
alkaline phosphatase was rising with normal calciums and
boarderline phosphate, extra Vitamin D was added to her
diet to give her a total intake of [**2147**] units/kg.
Follow-up alkaline phosphatase on [**6-27**] was was higher at
1627 with normal liver transaminases. Consult with
endocrine was obtained at which time they recommended
parathyroid hormone levels which was elevated at 191
(15-65), Ca,Phosperous and 25 hydroxy
vitamin D and alk phos .
Of note her Vit D, 25-OH total was 15, whereas the desired
levels are > 30 and closer to 40 NG/ML. Endocrinology
thought in the face of us having been giving her adequate
levels of Vit D in her formula, this deficiency
represented poor maternal intake. I have notified her
mother about this and she will speak to her physician
about checking her Vit D levels and the possibility she
might need supplements.
They recommended repeating these labs prior to discharge
with the goal of having her Vit D levels 30-40 aiming for
closer to 40 and at that time one could D'C the Vitamin D
and follow. On [**7-24**] Ca was 10, P 6.8, PTH 146 down from
191(nl 15-65) and 25 hydroxy vitamin D is pending.
Endocrine recommends repeating these levels in 1 month
post discharge.
4. Gastrointestinal Status: She was treated with
phototherapy for hyperbilirubinemia of prematurity from
day of #2 until day of life #10. Her peak bilirubin
occurred on day of life #2 and was total 5.3, direct 0.3.
Her last bilirubin on [**2154-5-12**] was total 2, direct
of 0.4. Her baseline exam was a distended abdomen. No
visile loops, and active bowel sounds. Her abdomen
remained markedly distended, such that it appeared to
compromise her pulmonary function. KUB done on [**6-25**] was
read as normal, however radiology recommended an abdominal
ultrasound to better look at liver and kidney size. This
was done on [**2154-6-26**] with normal liver, spleen and
pancreas, kidneys by verbal report were normal.
5. Hematology: She has never received any blood products or
transfusions. Her last hematocrit on [**7-24**] was 37.3 with
a reticulocyte count of 3.
6. Infectious Disease Status: She was started on ampicillin
and gentamicin at the time of admission for sepsis risk
factors. She completed 7 days of antibiotics for presumed
sepsis. Her blood culture did remain negative.
She stayed off antibiotics until day of life #51 when she
presented with nasal secretions which changed from clear
to green to yellow in color. She was started
on oral Keflex but increasing symptomatology
(apnea/bradycardia) resulted in a blood culture and
complete blood count with a white count of 13.6 with 15
polys and 6 bands. At time she was started on vancomycin
and gentamicin. The blood culture remained negative and
at 48 hours vanc and gent were D'C d. She remained on oral
Keflex for 7 days for nasal cultures positive for staph
aureus.
7. Neurology: Her first head ultrasound on [**5-8**] was
without any abnormalities. A follow-up ultrasound on [**5-31**], [**2154**] showed bilateral germinal matrix hemorrhage. A
follow-up on [**2154-6-14**] showed no change, with stable,
grade 1 hemorrhages.
8. Ophthalmology: Her eyes were last examined on [**2154-7-22**] showing mature retina OD and stage 1, retinopathy
3 clock hours os . F/U in [**3-2**] weeks at [**Location (un) 2274**]/Dr.[**Last Name (STitle) 40944**]
9. Psychosocial: Parents have been involved in the infant's
care throughout her NICU stay.
MEDICATIONS
Calciferol ([**2147**] units/0.05 mL) dose 0.25 mL daily.
Ferrous sulfate (25 mg/mL) 0.25 mL daily.
1. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
2. All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units
which may be provided as a multivitamin preparation daily
until 12 months corrected age.
Her state newborn screen was sent on [**5-4**] and
[**5-15**].
IMMUNIZATIONS: She received her first hepatitis B vaccine on
[**5-30**],
HIB on [**7-1**]
Pneumoccocal [**7-1**]
Pediarix on [**7-2**].
F/U at [**Location (un) 2274**]/WROX with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42446**] [**7-29**].
VNA to visit home day post discharge.
Early Intervention Referral made.
Opthamology f/u at [**Location (un) 2274**]/Dr. [**Last Name (STitle) 40944**] within 2-3 weeks of
discharge. Appt to be made by Dr. [**Last Name (STitle) 42446**].
Repeat labs of Ca/P/PTH and 25 hydroxy vitamin D in 1 month.
DISCHARGE DIAGNOSES: 1. Status post prematurity at 27 weeks.
2. Status post respiratory distress syndrome.
3. Retinopathy of Prematurity
4. Status post hyperbilirubinemia of prematurity.
5. Vitamin D deficiency/.
6. Chronic lung disease.
7. S/P Apnea of prematurity.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2154-6-23**] 07:33:39
T: [**2154-6-23**] 15:10:51
Job#: [**Job Number 71611**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5928
} | Medical Text: Admission Date: [**2174-5-3**] Discharge Date: [**2174-5-10**]
Date of Birth: [**2132-10-7**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Two week history of short term memory loss
Major Surgical or Invasive Procedure:
[**5-4**] Right EVD placement
[**5-9**] R frontal VPS
History of Present Illness:
This is a 41 y/o African American female brought to the ED by
her husband for a two week history of percieved short therm
memory loss. Patient was driving
to church in the past day or two and had to have her daughter
tell her how to get there and when taken to see her PCP she did
not remmber being in his office in the past.
Past Medical History:
HTN, Hospitalized last year at [**Hospital3 5365**] for w/u
hysterectomy for fibroids
Social History:
No Tobacco
No ETOH
Works as a manager
Family History:
NC
Physical Exam:
On Admssion:
PHYSICAL EXAM:
O: T: 98.2 BP: 148/103 HR:71 R 17 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, but not date
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-30**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
AT DISCHARGE:
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT, dressing over R scalp c/d/i
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, and date
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-30**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Gait: narrow based, good arm swing, independent
Pertinent Results:
CT head [**2174-5-3**]
1. Severe hydrocephalus with transependymal flow of CSF and
associated
effacement of the sulci.
2. No evidence of hemorrhage or obstructing mass.
MRI Brain [**5-3**] -
1. Moderate dilatation of all the ventricles with associated
transependymal CSF flow. The etiology of hydrocephalus is not
identified on this study.
2. No evidence of acute infarct or intracranial hemorrhage.
3. No abnormal leptomeningeal or parenchymal enhancement
CXR [**2174-5-4**]
The lung volumes are normal. No pleural effusions. Normal size
of
the cardiac silhouette. Normal hilar and mediastinal structures.
No evidence of pneumonia or other acute lung changes.
CT head [**2174-5-4**]
Interval decrease in ventricular size status post external
ventricular drain placement.
CSF:
[**2174-5-5**] 09:36AM CEREBROSPINAL FLUID (CSF) WBC-85 RBC-1650*
Polys-PND Lymphs-PND Monos-PND
[**2174-5-5**] 09:36AM CEREBROSPINAL FLUID (CSF) TotProt-156*
Glucose-57 LD(LDH)-72
[**2174-5-4**] 10:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-19* Polys-1
Lymphs-75 Monos-24
CSF culture [**2174-5-4**]
GRAM STAIN (Final [**2174-5-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
MRI Head CSF study [**5-5**]
1. Incomplete study as CSF flow study could not be performed.
Consider
performing when the patient is cooperative.
2. Moderate dilation of the lateral and the third ventricles
with narrowing of the superior portion of cerebral
aqueduct/near-total occlusion.
3. Ventricular catheter appears to be outside the confines of
the lateral
ventricle. To correlate with catheter function and the position
if necessary.
CT Chest [**5-6**]
1. No evidence of sarcoid.
2. Sub 4 mm pulmonary nodule in the left lower lobe. If there is
no history of smoking or other lung cancer risk factors, this
does not need followup. Otherwise, 12 month followup is
recommended.
3. Fatty liver and cholelithiasis.
CTA Chest [**5-8**]
1. No pulmonary embolus or acute intrathoracic process.
2. Cholelithiasis.
[**5-9**] CT head postop: Interval decrease in ventricular size
status post placement of right frontal external ventricular
drain with the catheter tip located in the frontal [**Doctor Last Name 534**] of the
right lateral ventricle.
ADMISSION LABS:
[**2174-5-3**] 12:12PM BLOOD WBC-5.9 RBC-4.87 Hgb-13.2 Hct-43.0 MCV-88
MCH-27.0 MCHC-30.6* RDW-12.9 Plt Ct-355
[**2174-5-3**] 12:12PM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
[**2174-5-3**] 12:12PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.3
DISCHARGE LABS:
[**2174-5-10**] 06:00AM BLOOD WBC-7.3 RBC-4.10* Hgb-11.2* Hct-35.6*
MCV-87 MCH-27.3 MCHC-31.4 RDW-13.2 Plt Ct-366
[**2174-5-10**] 06:00AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-135
K-3.9 Cl-102 HCO3-24 AnGap-13
[**2174-5-10**] 06:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
[**2174-5-6**] 03:25AM BLOOD HIV Ab-NEGATIVE
Brief Hospital Course:
Ms. [**Known lastname 4427**] [**Last Name (Titles) 1834**] a head CT in the Emergency room which
revealed enlargement of her ventricular system with
transependymal flow. She was admitted to the Neurosurgery
service in the ICU for close monitoring. Her exam remained
stable, but to prevent progression of hydrocephalus, patient was
taken to OR on [**5-4**] for placement of R EVD. She was made NPO and
was consented for the procedure. On [**5-4**], patient was taken to
the OR for placement of R EVD. There were no complications and
patient was transferred back to SICU for monitoring. CSF was
sent in OR for evaluation. She remained intact on exam
throughout the day, overnight she was seen to have religious
delusions. For concern of worsening hydrocephalus, a head CT was
done which was stable. On [**5-5**], patient was back to baseline.
CSF was sent for further evaluation and MRI CSF study was
ordered to help determine etiology of hydrocephalus and this was
inconclusive.
She had a CT head on [**5-5**] and this showed decompression of the
ventricular system. Repeat CSF studies were sent. On [**5-6**] she
was transferred to the SDU in stable condition. Her EVD
continued at 10cm above the tragus. She remained stable until
[**5-8**] when she became tachycardic and tachypneic and a CTA chest
was obtained. This showed no evidence of pulmonary embolus. She
was kept NPO on the morning of [**5-9**] in preparation for a Right
frontal VPS. She tolerated the procedure well with no
complications and post operatively she was transferred back to
the floor. She has a programmable valve set at 1.5.
On [**5-10**] Patient was deemed fit for discharge. She was given
instructions for followup and prescriptions for required
medications.
TRANSITIONAL CARE ISSUES:
Pt will need a repeat chest CT in 12 months to follow up the
lung nodule found incidentally on our scan here. She will need
one in 6 months if she has any tobacco or cancer hx we are
unaware of.
Medications on Admission:
Labetalol PO
Discharge Medications:
1. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
5. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q4H PRN ()
as needed for nausea.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
hydrocephalus
aqueductal stenosis
delerium
tachycardia
cholelithiasis
pulmonary nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge 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.
?????? Dressing may be removed on Day 2 after surgery.
?????? You have dissolvable sutures so you may wash your hair and get
your incision wet day 3 after surgery. 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.
We made the following changes to your medications:
1) We STARTED you on DOCUSATE 100mg twice a day to prevent
constipation while taking opiate pain medications.
2) We STARTED you on SENNA 8.6mg twice a day as needed for
constipation.
3) We STARTED you on PERCOCET 1-2 tabs every 4 hours as needed
for pain. Each tablet has 325mg of tylenol in it. Do not exceed
4,000mg of tylenol in a 24 hour period as this can cause fatal
liver damage. In addition, do not drive, operate heavy
machinery, drink alcohol or take other sedating medications
while taking this medication until you know how it will effect
you, as it can make you dangerously sleepy.
4) We STARTED you on ZOFRAN 4mg every 4 hours as needed for
nausea.
Please continue to take your other medications as previously
prescribed.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-5**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2174-5-10**]
ICD9 Codes: 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5929
} | Medical Text: Admission Date: [**2122-12-23**] Discharge Date: [**2123-1-28**]
Date of Birth: [**2068-1-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Mr. [**Known lastname **] is a 54-year-old gentleman with
biopsy-proven locally advanced T3N1M1A carcinoma of the mid
esophagus. He continues to have intense pain with increased
PET activity at the superior and inferior aspect of the stent.
Major Surgical or Invasive Procedure:
thoraco-abdominal esophagectomy, esophagogastroduodenoscopy,
J-tube revision [**2122-12-23**]
Port-O-Cath removal [**2123-1-22**]
EGD w/ pylorus dilitation
History of Present Illness:
54 yr old man cervical esophageal cancer requiring
Mr. [**Known lastname **] is a 54-year-old gentleman with
biopsy-proven locally advanced T3N1M1A carcinoma of the mid
esophagus. He has recently completed chemoradiotherapy on an
induction protocol. He has had a remarkable reduction in his
documented nodal disease as well as in the T stage. He
continues to have intense pain with increased PET activity at
the superior and inferior aspect of the stent.
Past Medical History:
Hepatitis C Virus
Hypertension
Prostate Cancer s/p brachytherapy.
Poorly differentiated squamous esophageal CA (stage III)
-dx'ed [**2122-7-20**] on multiple biopsies with EGD
-PET found supraclavicular nodes that appeared positive.
-s/p esophageal stent
-planned for surgery in 6 weeks
Gastric esophogeal reflux disease
Social History:
Previously worked at Digital and Polaroid. Lives with his
daughter. [**Name (NI) **] ?girlfriend. Used to smoke, quit after cancer
diagnosis. No EtOH currently, never heavy drinker. No IVDU.
Family History:
both brothers have prostate cancer, one passed away 2 month ago
from this
Physical Exam:
General: cachetic appearing African American male w/ c/o
epigastric pain on -chronic sq dilaudid PTA
chest: lungs CTA bilat. POC
Cor: RRR S1, S2
Abd: flat, soft, NT, J-tube in place.
Extrem: no LE edema.
Neuro: A+OX3 w/no focal neuro deficits
Pertinent Results:
[**2122-12-23**] 05:57PM GLUCOSE-147* UREA N-17 CREAT-0.7 SODIUM-134
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-17
[**2122-12-23**] 05:57PM WBC-17.2*# RBC-3.98* HGB-12.0* HCT-34.1*
MCV-86 MCH-30.1 MCHC-35.2* RDW-14.4
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2123-1-27**] 06:25AM 6.5 2.91* 8.2* 25.6* 88 28.2 32.2 14.5
391
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2123-1-27**] 06:25AM 391
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2123-1-26**] 11:00AM 144* 11 0.6 139 3.9 104 261 13
1 NOTE UPDATED REFERENCE RANGE AS OF [**2122-8-14**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2122-12-27**] 03:09AM 742* 160* 190 108 0.9
Source: Line-arterial
OTHER ENZYMES & BILIRUBINS Lipase
[**2122-12-26**] 03:33AM 8
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2123-1-26**] 11:00AM 8.3* 4.0 1.5*
HEMATOLOGIC calTIBC Ferritn TRF
[**2123-1-4**] 06:10AM 160* 859* 123*
LIPID/CHOLESTEROL Cholest Triglyc
[**2123-1-4**] 06:10AM 109 851
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
ANTIBIOTICS Vanco
[**2123-1-27**] 06:25AM 14.4*
LAB USE ONLY GreenHd EDTA Ho
CHEST (PA & LAT) [**2123-1-26**] 10:23 AM
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with esoph ca now s/p thoraco-abd esophagectomy.
REASON FOR THIS EXAMINATION:
?interval change
TWO VIEW CHEST X-RAY [**2123-1-26**]:
COMPARISON: Deceember 11, [**2122**].
INDICATION: Status post esophagectomy.
IMPRESSION: Stable postoperative appearance of mediastinum.
Improving multifocal pulmonary opacities.
BAS/UGI AIR/SBFT
Reason: please evaluate follow-through of barium from
oral-pharynx t
COMPARISON: Upper GI study of [**2122-8-31**].
LIMITED SINGLE CONTRAST UPPER GI STUDY: Contrast passes freely
down the remaining esophagus and gastric pull-up. Trace
aspiration was noted. Adjacent to the site of the drain, there
is appears to be a focal area of contrast extravasation. There
is delayed and slow emptying of contrast from the stomach.
Barium was administered through the J- tube which demonstrated
filling of the jejunal loops. The patient vomited approximately
150 cc of barium and the study was terminated due to patient
intolerance.
IMPRESSION:
1. Mild aspiration.
2. Focal contrast extravasation at the site of the leftsided
drain.
The study and the report were reviewed by the staff radiologist.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-1-27**] 2:47 PM
Reason: Please obtain UPRIGHT CXR to assess for pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with esoph ca now s/p thoraco-abd esophagectomy
now s/p EGD w/ balloon dilation of stricture
REASON FOR THIS EXAMINATION:
Please obtain UPRIGHT CXR to assess for pneumothorax
PORTABLE CHEST, [**2123-1-27**]
COMPARISON: [**2123-1-26**].
INDICATION: Status post EGD procedure. Evaluate for
pneumothorax.
There is no evidence of pneumothorax or pneumomediastinum.
Postoperative changes are noted in the mediastinum following
esophagectomy and pull-up procedure. There remains asymmetrical
perihilar haziness on the right as well as a moderate-sized
right pleural effusion. Minor atelectatic changes are seen
within the left lung base, also without interval change.
IMPRESSION: No evidence of pneumothorax or pneumomediastinum.
CXRY - protable [**2123-1-28**]
s/p PICC line placement
Placement of PICC line tip in distal SVC. Confirmed by
visualization of film by NP and IVRN.
MICROBIOLOGY DATA
[**2123-1-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {STAPH AUREUS COAG +} INPATIENT
[**2123-1-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2123-1-24**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2123-1-24**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2123-1-22**] CATHETER TIP-IV WOUND CULTURE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE}
INPATIENT
[**2123-1-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} INPATIENT
[**2123-1-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} INPATIENT
[**2123-1-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} INPATIENT
[**2123-1-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
LIMITED SINGLE CONTRAST UPPER GI STUDY: Contrast passes freely
down the remaining esophagus and gastric pull-up. Trace
aspiration was noted. Adjacent to the site of the drain, there
is appears to be a focal area of contrast extravasation. There
is delayed and slow emptying of contrast from the stomach.
Barium was administered through the J- tube which demonstrated
filling of the jejunal loops. The patient vomited approximately
150 cc of barium and the study was terminated due to patient
intolerance.
IMPRESSION:
1. Mild aspiration.
2. Focal contrast extravasation at the site of the leftsided
drain.
The study and the report were reviewed by the staff radiologist.
Weight [**2123-1-28**] 51.5kg
Brief Hospital Course:
54-year-old gentleman with biopsy-proven locally advanced
T3N1M1A carcinoma of the mid-esophagus
esophagoscopy,bronchoscopy, transthoracic near total
esophagectomy with rightthoracotomy, laparotomy and left
cervicotomy, left cervical esophagogastrostomy and left tube
thoracostomy. Patient tolerated procedure well. Transferred to
ICU for observation, intubated, sedated, neo gtt, IVF, NPO, CT
to sx- no leak,. Pain control w/ fentanyl gtt iv due to
non-effective epidural. ICU course significant for:
POD#2 pt was extubated and new epidural placed, w/ dilaudid
PCA,+ BS, + flatus; IVF, NPO.Abd JP drains intact and draining.
Inc- C/D/I.
POD#3- tube feedings started- probalance at 10/hr. O2 wean trial
- 90% on 4Lnc.
POD#5-Tube feedings held for residual >200cc overnight, IVF. CT
to waterseal; ambulation- physical therapy, lytes repleated.
Patient transferred out of ICU to floor. Pain control w/ PCA,
epidural d/c.
On Floor:
REsp- pod#6 O2 sat 94% on RA, improving to 98-99% RA pod#33 at
time of discharge. CT d/c pod#7 w/o complication. Periodic
CXRY-wnl, w/ some atelectasis improving over hospital course.
GI- POD#6-+ flatus, + BM; j-tube accidently d/c'd and replaced
w/o complication. Tube feeding resumed @30-40cc/hr w/ c/o
nausea, therefore held. Patient developed prolonged ileus
(bloating, nausea, distention) w/ multiple unsuccessful tube
feeding restarts until [**2123-1-17**]-(pod#24). J-tube placed to
gravity during this time. TPN started as below. Tube feedings
tolerated w/ slow advancement to max rate of 50/hr w/ goal as
stated. Patient has persistant c/o nausea and therefore
[**2123-1-27**]- EGD w/ pyloric dilitation. Pylorus patent on
visualization, dilitation done to affirm continued patency. Diet
advanced to clear, then full liquids post-op, then to mechanical
soft [**2123-1-28**]. See below and page 1 for specific tube
feeding/nutrition instructions.
Nutrition/ electrolytes-IVF w/ electrolyte replacement until TPN
started pod#21- [**2123-1-4**] and cont until [**2123-1-18**] when tube
feedings at 2/3 goal rate on pod#25([**2123-1-20**]). Lytes routinely
monitored and repleated. Diet advanced to clear, then full
liquids post-op, then to mechanical soft [**2123-1-28**]. See below and
page 1 for specific tube feeding/nutrition instructions. Weight
[**2123-1-28**] 51.5kg
RAD- UGI- SBFT pod#8- + ileus.
Incisions and Drains- Chest tube d/c pod# 7; JP drain d/c pod#8;
Incisions - thorocotomy, abdominal and cervical all healed,
staples removed, steri-strips off. Port-o-cath removal site-
left upper chest- C/D/I, change dsd qd. Sutures remain, to be
assessed and removed at follow-up appointment [**2123-2-4**].
Infectious Disease- Course of zosyn(prophylaxis) and fluconazole
(?esophogeal candidiasis). POD#27([**2123-1-21**]) patient developed
fever to 102, elevated WBC- cx results- [**5-18**] + BC, staph- MRSA,
Vancomycin started and cont per therapeutic levels for 14 day
course, levofloxacin- 10 day course. Source- infected port site-
removed in OR [**2123-1-22**]. Peripheral line placed. PICC line placed
[**2123-1-28**], confirmed placement in distal SVC by CXRAY [**2123-1-28**].
Pain control- Transitioned to percocet elixer and MSO4iv prn
pod#6. Slowly weaned to off over next 3-4 weeks.Pain med
restarted post-op [**2123-1-22**] for port removal. At discharge pt
receiving minimal pain med on prn basis.
Activity-Physical therapy, ambulation with encouragement. Pt
gradually independent w/ ambulation with encouragement.
Consistant encouragement w/ activity necessary.
Medications on Admission:
MS contin, Roxanol, magic mouthwash
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
give via j-tube.
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 12H (Every 12 Hours) for 11 days.
7. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for nausea.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day: give via j-Tube.
10. Hydromorphone 2 mg/mL Syringe Sig: 0.5 mg Injection Q6H
(every 6 hours) as needed for Breakthrough pain.
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
esophageal CA
prolonged post op ileus
POC bacteremia resulting in removal
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 1504**] if you have
fever, nausea/vomiting, inability to take in your feeds, or
dizziness/weakness, aor any other post surgical issues.
Followup Instructions:
Follow up appointment with Dr. [**Last Name (STitle) **] in Thoracic Surgery Clinic
[**2123-2-4**] at 3pm. [**Hospital1 18**], [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 8939**]. Please call [**Telephone/Fax (1) 170**] for any questions.
Completed by:[**2123-1-28**]
ICD9 Codes: 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5930
} | Medical Text: Admission Date: [**2157-10-6**] Discharge Date: [**2157-10-13**]
Date of Birth: [**2087-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Emergent Aortic Dissection
Major Surgical or Invasive Procedure:
[**2157-10-7**] Emergent Ascending Aortic Replacement
History of Present Illness:
Mrs. [**Known lastname **] is a 70-year-old female who was transferred
emergently from [**Hospital6 3872**] emergency room with
diagnosis of ascending aortic type A
dissection documented by CT scan and echocardiography. Review of
the CT scans here confirmed that. She was mentating and
clinically stable upon presentation to the CSRU and was taken
emergently to the operating room.
Past Medical History:
HTN
Current Smoker
Glaucoma
Hyperlipidemia
Physical Exam:
NEURO: Awake, alert, moving all extremities
PULM: Clear
HEART: RRR, normal s1-s2
ABD: Soft, nontender, nondistended, normoactive bowel sounds
EXT: Warm, no edema, + pulses
Pertinent Results:
[**2157-10-12**] 05:38AM BLOOD WBC-8.0 RBC-3.06* Hgb-9.0* Hct-27.5*
MCV-90 MCH-29.4 MCHC-32.9 RDW-13.8 Plt Ct-231
[**2157-10-12**] 05:38AM BLOOD Plt Ct-231
[**2157-10-12**] 05:38AM BLOOD Glucose-95 UreaN-35* Creat-0.8 Na-142
K-4.1 Cl-104 HCO3-31 AnGap-11
[**2157-10-12**] CXR
1) No pneumothorax.
2) Improved left lower lobe atelectasis.
3) Increased small right pleural effusion with no change in a
small left effusion.
[**2157-10-7**] EKG
Sinus rhythm 90. There has been arm lead reversal.
Non-diagnostic repolarization abnormalities.
Brief Hospital Course:
Ms. [**Name13 (STitle) 62701**] was admitted urgently to the [**Hospital1 18**] on [**2157-10-6**] for
surgical repair of her aortic dissection. She was taken directly
to the operating room where she underwent an ascending aortic
replacement. Postoperatively she was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, Ms. [**First Name (Titles) 62701**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. Her drains were removed. A right pneumothorax was
noted on chest xray and a right chest tube was placed without
difficulty. Her blood pressure was elevated postoperatively and
labetalol was started. Ms. [**Name13 (STitle) 62701**] was noted to have a weak gag
reflex and cough and a swallowing evaluation was performed.
After completing a bedside swallowing evaluation, it was found
that Ms. [**Name13 (STitle) 62701**] was able to appropriately swallow thin liquids
and solids without signs of aspiration. On postoperative day
three, Ms. [**Name13 (STitle) 62701**] was transferred to the cardiac surgical step
down unit for further recovery. She was gently diuresed towards
her preoperative weight. The physical therapy service was
consulted for assistance with her strength and mobility.
Labetalol and an ace inhibitor were used to effectively control
her hypertension. Ms. [**Name13 (STitle) 62701**] continued to make steady progress
and was discharged to her home on postoperative day six. She
will follow-up with Dr [**Last Name (STitle) **], her cardiologist and her primary
care physician as an outpatient.
Medications on Admission:
Norvasc
Multiple Brazilian medications.
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:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Pravastatin Sodium 20 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
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily) for 7 days.
Disp:*30 Patch 24HR(s)* Refills:*0*
7. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10
days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Labetalol 300 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Transdermal
once a day for 7 days: Start when you are done with the 21 mg
patches.
Disp:*7 patches* Refills:*0*
12. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal
once a day for 7 days: Start when you are done with the 14 mg
patches.
Disp:*7 patches* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Type A Aortic DissectionHTN
Glaucoma
Tobacco Abuse
Discharge Condition:
Good.
Discharge Instructions:
[**Month (only) 116**] shower, wash incision with soap and water and pat dry. No
lotions, creams, powders or baths. No lifting morethan 10 pounds
or driving until follow up with surgeon.
Call with temperature more than 101, redness or drainage from
incision, or weightgain more than 2 pounds in one day or five in
one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Make an appointment with a primary care physician as soon as
possible.
Completed by:[**2157-11-7**]
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5931
} | Medical Text: Admission Date: [**2170-2-20**] Discharge Date: [**2170-2-28**]
Service: MEDICINE
Allergies:
Celexa
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Resp distress/hypglycemia
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Pt is a [**Age over 90 **] yo male with a h/o CAD, s/p CABG [**2160**]; CHF ( EF 25%);
DM, CRF, NH resident, who was diagnosed with lobar PNA on [**2170-2-17**]
and was started on levofloxacin, but was noted to be in
increasing resp distess today and hypoxic to 79% on RA. No
fevers were reported but he had increased lethargy and decreased
po intake.
Past Medical History:
CAD s/p CABG [**60**], LIMA-LAD, SVG-OM, PDA
CHF EF 25%,
CRI (Cre 1.3-1.7)
Dysphagia
Depression
HTN,
s/p appendectomy and cholecystectomy
DJD, knee pain
DMII,
Severe valvular disease: 3+ MR, [**1-18**]+ TR, RV/RA dilatation
Social History:
nursing home resident. Intermittent confusion at baseline.
Distant tobacco history. NO ETOH
Family History:
non contributory
Physical Exam:
VS 100.0 152/98 142 36 100% on AC 500x16 5 100%
Gen: intubated, sedated
HEENT: surgical pupils
Neck: +JVD
CV: tachy, irregularly irregular, nl S1/S2, no murmurs
appreciated
Pulm: coarse breath sounds bilaterally
Abd: soft, NT/ND, +BS
Ext: no edema, ulcerations/scabs on arms and legs
Neuro: sedated
Pertinent Results:
Labs on Admission:
URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
RBC-63* WBC-5 BACTERIA-NONE YEAST-NONE EPI-<1
TYPE-ART PO2-110* PCO2-28* PH-7.46* TOTAL CO2-21 BASE XS--1 NOT
INTUBA
GLUCOSE-54* LACTATE-3.1* NA+-135 K+-4.6 CL--106
HGB-12.3* calcHCT-37 O2 SAT-98
LACTATE-3.7*
GLUCOSE-36* UREA N-41* CREAT-1.8* SODIUM-138 POTASSIUM-5.0
CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
CK(CPK)-219* CK-MB-7 cTropnT-0.15*
ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-4.1 MAGNESIUM-2.1
WBC-15.8*# RBC-4.11* HGB-12.6* HCT-38.8* MCV-94 MCH-30.6
MCHC-32.4 RDW-13.8
NEUTS-93* BANDS-3 LYMPHS-1* MONOS-3 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0 NUC RBCS-1*
HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL
MICROCYT-NORMAL POLYCHROM-NORMAL
PLT SMR-NORMAL PLT COUNT-203
PT-13.7* PTT-29.2 INR(PT)-1.2
Studies:
Echo [**2-21**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis. [Intrinsic left ventricular systolic
function may be more depressed given the severity of valvular
regurgitation.] No masses or thrombi are seen in the left
ventricle. The right ventricular cavity is moderately dilated.
Right ventricular systolic function appears depressed. The
ascending aorta is mildly dilated. There are complex atheroma in
the descending thoracic aorta. The aortic valve leaflets are
moderately 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 borderline pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
CXR [**2-21**]:
New left retrocardiac opacity, likely due to atelectasis and
effusion.
Worsening right middle and lower lobe pneumonia
Brief Hospital Course:
[**Age over 90 **] yo NH resident with a h/o CAD, s/p CABG [**2160**]; CHF ( EF 25%);
DM, CRF (baseline Cr 1.5 diagnosed with lobar PNA on [**2170-2-17**] and
was started on levofloxacin, but was noted to be in increasing
resp distess, hypoxic to 79% on RA, increased lethargy, and
decreased po intake.
In ED, he had a low grade temp and was in AF with RVR at 150;
SBP of 190 and tachypnic to 40's. First ABG was 7.46/28/110. He
was initially oriented to "hopsital" but later became
increasingly confused and somnolent and was intubated (code
status confirmed). He had an episode of hypoglycemia in ED (poor
po intake, given am dose of glyburide) and was started on D50
gtt. CXR revealed large RML and RLL PNA. Got CTX and Azithro in
ED. Initial lactate was 3.7. Got 1.5 L IVF and AF slowed to
120s.
Four sets of Trop were positive but stable with a negative MB
fraction, thought to be secondary to demand ischemia as per
Cardiololgy. He continues to be in AFib with controlled rate. Pt
was successfully extubated on [**2-22**]. OGT removed but noted to
have decreased gag reflex and he was kept npo initially while
awaiting swallow evaluation. Speech and swallow felt he was at
significant aspiration risk, however his daughter did NOT wish
to place an NGT or PEG, and wanted to allow him to eat despite
risk. He was given ground solids and thickened liquids and
restarted on his oral meds.
1. Pneumonia - pt with NH-acquired bilateral LL and RML PNA. Pt
was initially intubated in the ED, and he was kept intubated for
a couple of days while his mental status improved. He was
extubated on HD #2 and was able to maintain protection of his
airway.
He received 7 days of Vanco and Zosyn for broad spectrum
coverage including gram negatives and MRSA, however his sputum
culture was w/o growth. He was continued on IV levo and flagyl
for the next 8 days until discharge. He was discharged on po
levo to complete a 14 day course. He was continued on
supplemental O2 and his sats remained > 93%. He was given
alb/atrovent nebs as needed.
2. Pt developed diarrhea while on ABX for his PNA, likely
secondary to C.diff given leukocytosis and current ABX therapy.
Stool culture was negative for C. diff however given the high
suspician and improvement on flagyl he will be continued on po
flagyl for an additional 7 day course.
3. Delirium. Pt was unresponsive upon admission. This was
thought to be multifactorial in this elderly gentleman, due to
hypoglycemia, pneumonia, heart failure, and renal failure. As
these metabolic abnormalities improved, pt's mental status
improved, as well. His sedation was stopped around the time of
extubation, and pt was more alert and somewhat conversant
thereafter. His mental status improved back to baseline during
his stay.
4. CHF. A repeat echo showed EF 15-20%, 1+ AR, 2+ MR, 3+ TR, no
significant change since 3/[**2164**]. He was 8 L liters positive
during his ICU stay. He was diuresed with lasix IV prn until he
appeared clinically dry and his urine output decreased. He had
minimal po intake and was started on maintanence fluids. He will
need to be evaluated clinically and restarted on his standing
dose of lasix if indicated. His B-B was d/c'ed given LAFB and
RBBB and symptomatic hypotension and bradycardia. His HR
remained well controlled during his stay. His ASA and statin
were restarted once he was taking po's.
5. a fib - Pt was initially in a fib with RVR. This was a new
diagnosis and was thought to be multifactorial, due to the
combination of infection, dehydration, and underlying cardiac
disease (bifascicular block, significant TR). All AV nodal
blocking agents were held as pt became hypotensive after giving
12.5mg IV metoprolol. Pt was not anticoagulated due to risks of
bleeding versus benefit given his overall clinical situation.
Of note, pt had mildly elevated cardiac enzymes, including
troponins around 0.16. This was thought to be due to demand
ischemia in the setting of rapid a fib. His TSH was high, free
T4 low, thought to be secondary to sick euthyroid (will not
start med at this time).
6. acute on chronic renal failure secondary to prerenal azotemia
in the setting of infection, dehydration; Cr back to baseline at
discharge.
7. DM. His initial hypoglycemia resolved. Etiology thought to be
due to oral hypoglycemics in setting of renal failure and
infection. As per family's request we stopped checking finger
sticks and held oral agents while pt taking minimal po's. He was
on Glyburide 2.5 mg daily as an outpt. His blood sugars should
be followed and he should be restarted on Glyburide if
indicated.
8. Code - DNR/DNI. Spoke with pt's daughter and she emphasized
the goals of care for her father are to be "gentle with him".
She does not want aggressive treatment.
Medications on Admission:
atenolol 50mg po daily
lasix 60mg po daily
lisinopril 10mg po daily
spironolactone 25mg po daily (? d/c'ed)
aspirin 81mg po daily
lipitor 20mg po daily
senna [**Hospital1 **]
colace
timolol 0.5% 1 gtt [**Hospital1 **]
dorzolamide 2% gtt tid
prednisolone acetate 1% 1 gtt daily
atropine 1% 1 drop tid
erythromycin 5mg/g ointment ophtho tid
glyburide 2.5mg po daily
seroquel 75mg po daily, 62.5mg po qHS
reglan 5mg po tid
vit C
Zinc
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): please crush.
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please crush.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please crush.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: please crush.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2716**] [**Last Name (un) **] - [**Location (un) 55**]
Discharge Diagnosis:
Multilobar Pneumonia
Atrial Fibrillation with Rapid Ventricular Response
C. diff
Congestive Heart Failure
Renal Failure
Diabetes
Hypoglycemia
Discharge Condition:
Fair
Discharge Instructions:
Please call your primary care physician if you experience
worsening cough or shortness of breath.
He was diuresed with lasix IV prn until he appeared clinically
dry and his urine output decreased. He had minimal po intake and
was started on maintanence fluids. He will need to be evaluated
clinically and restarted on his standing dose of lasix if
indicated.
His Glyburide 2.5 mg daily is being held while he is taking
minimal po's. His blood sugars should be followed and he should
be restarted on Glyburide if indicated.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 2204**] in one to two weeks.
[**Telephone/Fax (1) 2936**]
2. Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2170-3-12**] 2:45
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5070, 5849, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5932
} | Medical Text: Admission Date: [**2155-10-24**] Discharge Date: [**2155-10-27**]
Date of Birth: [**2111-2-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
SI, ethylene glycol ingestion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 44year-old generally healthy male who was transferred
from an OSH s/p suicide attempt with ethylene glycol and
klonipin ingestion ~24h PTA. Pt notes that he has been depressed
for couple of years, but for the past couple of weeks has been
"wanting to die" which had not been the case before. He notes
that 2 weeks ago he ingested a cup full of antifreeze which
caused him to have N/V NBNB, abdominal pain, dizzyness and
suffer falls, no head trauma noted. All sx resolved this week
except for mild stomach upset. However, at 11pm on night PTA, he
ingested "1 coffee cup full" of ethylene glycol and 5 klonipin
as well as smoked 2 joints. Per report, he received the klonipin
from a friend, unknown dose, and had never taken benzos before.
He was found by his best friend this AM who brought him to the
OSH ED.
.
There, his vitals were T 98.1 BP 156/90 HR 78 RR 12. He had ABG
7.26/20/116, AG was 24 and osmolar gap of 28. He was given a
loading dose of fomepizole and received 1LD5W w/3amps of bicarb,
and had CT head negative for ICH. He was section XIIed and
transferred to [**Hospital1 18**] for further management. Before the past
couple of weeks, he has no h/o prior SI, no treaters.
.
ROS: The patient endorses episode of blood tinged stool 2 weeks
ago, otherwise denies any fevers, chills, weight change,
diarrhea, constipation, melena, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, focal weakness, vision changes,
headache, rash or skin changes except as above.
.
Past Medical History:
chronic tension type headaches
heart murmur since childhood
s/p BL inguinal hernia repairs
seasonal allergies
.
Social History:
works at [**Company 80079**] Tech - Lighting department, smokes 1/2ppd,
4 hard liquor drinks/week. + marijuana, no other illicits, no
IVDU.
.
Family History:
none known
Physical Exam:
Vitals: T: 97.5 BP: 150/84 HR: 82 RR: 23 O2Sat:100%RA wt 69.7kg
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, +systolic murmur, no G/R, normal S1 S2, radial pulses
+2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. No asterixis. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
OSH at 15:12 [**10-24**]:
ABG: 7.26/20/116
AG: 24
Serum osm 327, calculated osm 299, Osmolar gap:28
bicarb 24
serum tox: etoh <10, acetaminophen <2, TCA (-), salicylate 2,
+cannabinoids o/w negative
WBC 12.2 N 64.3 L 25.7 E 1.7 B 2.0 HCT 41.7
PT 12.4 INR 0.98 PTT 33.4
Micro OSH:
U/A (-)
.
[**2155-10-24**] 10:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2155-10-24**] 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2155-10-24**] 10:40PM URINE RBC-1 WBC-11* BACTERIA-FEW YEAST-NONE
EPI-0
.
[**2155-10-24**] 10:49PM TYPE-ART PO2-127* PCO2-29* PH-7.41 TOTAL
CO2-19* BASE XS--4
.
[**2155-10-24**] 11:10PM ALBUMIN-1.9* PHOSPHATE-1.2*
[**2155-10-24**] 11:10PM ALT(SGPT)-9 AST(SGOT)-9 LD(LDH)-93* ALK
PHOS-29* TOT BILI-0.1
.
Trend:
Cr: OSH 1.4, [**Hospital1 18**] 0.6 -> 1.3 -> 1.4 -> 1.7
.
Admit CXR: IMPRESSION: No active disease
Brief Hospital Course:
44 year-old generally healthy male who was transferred s/p
suicide attempt with ethylene glycol ingestion ~24h PTA.
Currently stable w/resolution in acidosis.
.
# Ethylene glycol ingestion: 24 hours PTA, ~500cc. At outside
hospital, he was initially acidotic w/pH 7.26, then improved to
7.41. He received loading dose of fomepizole there. Initial
osmolar gap 28. He subsequently received 2 more doses of
fomepizole here, with a final level of 19. He was seen and
followed by toxicology who recommended discontinuation of the
fomepizole after the third dose.
.
# Acute Renal failure: On admission, he had a creatinine of
0.6, which rose to a peak of 1.7. This has now plateaued at
1.5. This acute renal failure is likely secondary to ethylene
glycol toxicity, and should improve over the next several weeks.
.
# Suicide attempt: He presented with a high lethality, low
rescue potential suicide attempt, with significant
premeditation. He had no outside treaters. He was section
XIIed and followed by psychiatry. He will be transferred to an
psychiatric facility at discharge.
.
# Systolic murmur: Patient claims he has had this since birth.
Patient will need outpatient echocardiogram. Until then,
patient will need endocarditis prophylaxis for procedures.
.
# Diastolic hypertension: While hospitalized, he has had
intermittent diastolic blood pressures of 90. This most likely
reflects chronic essential hypertension. He will be started on
low dose amlodipine at discharge, and should subsequently be
followed by his PCP.
.
# Comm: best friend, [**Name (NI) **], [**Telephone/Fax (1) 80080**]
Medications on Admission:
none
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 934**]
Discharge Diagnosis:
Ethylene glycol ingestion
Suicidality
Acute renal failure
Diastolic hypertension
Discharge Condition:
Good. Section XII.
Discharge Instructions:
You were admitted with a suicide attempt with ethylene glycol.
.
You were initially in the ICU, and then transferred to the
floor. You had renal damage from the ingestion, but your kidney
function has stabilized.
.
You should return to the emergency room for any concerning
symptoms.
Followup Instructions:
Follow up with your PCP on discharge from the psychiatric
hospital.
.
BMP should be checked on [**10-30**], results sent to his PCP or by [**Name Initial (PRE) **]
medical team ( Dr. [**Last Name (STitle) 41445**] in [**Location (un) 5503**]).
ICD9 Codes: 5849, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5933
} | Medical Text: Admission Date: [**2108-2-15**] Discharge Date: [**2108-2-24**]
Date of Birth: [**2041-7-11**] Sex: F
Service: [**Hospital1 **]
CHIEF COMPLAINT: Shortness of breath, malaise, difficulty
lying flat secondary to increased labored breathing
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname 33876**] is a 60 year old
female with end-stage Alzheimer's dementia, severe peripheral
vascular disease, chronic obstructive pulmonary disease and a
history of Hodgkin's disease who presents with several weeks
of increasing shortness of breath. Two days prior to
admission the patient completed a ten day course of
Levofloxacin with bronchitis. Since then the patient has
demonstrated increase in labored breathing, particularly with
lying flat, worsening wheezes and a nonproductive cough. She
has also demonstrated malaise and refused to get out of bed
for the last two days. The patient has also notably been
increasingly confused and disoriented over the last two days.
Of note, the patient has been contact[**Name (NI) **] by the patient's
adult day group where she goes for dementia and they have
noted there decreased energy, confusion and decreased p.o.
intake. According to the patient's daughter there have been
no fevers, nausea, vomiting, diarrhea, headache nor rash.
However, the patient has noticed significant orthopnea and
paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY: 1. Hodgkin's lymphoma 14 years ago,
status post radiation splenectomy and lymph node dissection;
2. Hypercholesterolemia; 3. Hypertension; 4. Dementia,
Alzheimer's; 5. Hypothyroidism; 6. Lung diseases, quarterly
quantified, the patient has had pulmonary function tests
which demonstrated neither restrictive nor obstructive
pattern, but she has a 200 year pack year of smoking; 7.
Cerebrovascular accident with no residual deficit; 8.
Peripheral vascular disease; 9. Bilateral carotid disease
status post left endarterectomy; 10. Congestive heart
failure, stress test [**2107-2-24**] showed an ejection
fraction of 54%, no reversible defects noted; 11. History of
cellulitis.
ALLERGIES: Erythromycin causes nausea and vomiting.
MEDICATIONS ON ADMISSION: Metoprolol 25 mg p.o. b.i.d.;
Aspirin 81 mg p.o. b.i.d.; Humibid 600 mg b.i.d.,
discontinued on the [**2-13**]; Lipitor 20 mg p.o. q.d.;
Ruminal 4 mg p.o. b.i.d.; Seroquel 25 mg p.o. q.h.s.;
Unithroid 75 mcg p.o. q.d.; Flovent dose unavailable;
Ventolin dose unavailable; ten day course of Levofloxacin
discontinued on [**2-16**].
PHYSICAL EXAMINATION: The patient's vital signs on
presentation were as follows, temperature 98.0, blood
pressure 136/70, heartrate 96. She was breathing at 28,
sating 96% on room air. Physical examination was remarkable
for the following. General, she was mildly tachypneic but
she was orthoptic when laid flat. The patient had no obvious
jugulovenous distension at that point. Cardiovascular was
significant for borderline tachycardia and lung examination
was notable for diffuse end expiratory wheezes and prolonged
expiratory phase. There were no rhonchi or crackles. She
had no hepatosplenomegaly and there was trace bilateral
pitting edema.
LABORATORY DATA: Electrocardiogram on admission showed
decreased voltage, normal sinus rhythm of 96 with premature
ventricular contractions, normal axis, normal intervals,
normal right atrial enlargement. Right ventricular and poor
R wave progression that was not new. The patient's complete
blood count on admission was as follows, white count 16.3, of
note the patient has a baseline leukocytosis which is chronic
and has been worked up extensively per the daughter. The
hematocrit was 34.5, platelets 34 showing 1% neutrophils, 20%
lymphocytes and 60% monos. Her PT was 12.3, PTT 27.2 and INR
1.0. Her urinalysis was unremarkable. Her chem-7 was
significant for a sodium of 133, total carbon dioxide 21, BUN
20, creatinine 1.1. Chest x-ray showed no congestive heart
failure or cardiomegaly, no infiltrates or effusions. On
[**2-23**], she had the following laboratory data, white blood
cell count was up to 26.5, hematocrit 35.8 and her platelets
280. Her total carbon dioxide had increased to 29, her
sodium to 143, her BUN 59 and her creatinine ranged stable at
1.0. The patient had a computerized tomography/angiography
which was limited by the patient's motion but there was no
obvious pulmonary embolus. The patient had creatinine
kinases of 153, 298 and 340. The patient had a chest x-ray
on [**2108-2-20**] which showed evidence of prior
granulomatous infection. She had a video swallowing study
which demonstrated no overt evidence of aspiration.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2108-2-23**] 15:25
T: [**2108-2-24**] 15:03
JOB#: [**Job Number 33877**]
ICD9 Codes: 4280, 2720, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5934
} | Medical Text: Admission Date: [**2188-2-11**] Discharge Date: [**2188-2-13**]
Date of Birth: [**2104-1-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ditropan XL / Norvasc
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Atrial fibrillation with rapid ventricular response
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year old female with chronic afib, HTN, HLD, CAD, stage IV
CKD (HD MWF), COPD, dCHF (EF >55%) with multiple admissions for
CHF exacerbations, and with recent thrombosis of her left upper
extremity AV [**First Name3 (LF) **] treated with thrombectomy on [**2187-12-21**], who c/o
dyspnea and was noted to be in RAPID AFIB at HD.
.
Today, 1.5 hrs into HD, the pt became tachycardic w/ HRs in the
170s, so HD was stopped with 15 min left, after having gotten 2L
IVF off. She was mentating okay per EMS and had no sx. EMS gave
2.5 mg cardizem. Pt has been noted to be fluid responsive on
previous admissions.
.
In the ED, she was given 500 cc and another 500 cc, w/ hr going
down to 130, and bp in the 100s. She got 10+5mg of dilt IV w/
pressures dropping to the 70s, with some change in mentation, so
dilt was held. 2nd bolus of 500cc + 500cc was given and since
she had labile bp, it was decided to trasnfer her to CCU. She
got 25 mg po metoprolol and 5 mg metoprolol IV.
.
Vitals on transfer were hr 86, bp 85/45, rr 20, 100% RA. Rhythm
was reported to be still in afib.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1.) Stage 4-5 CKD c/b anemia and secondary hyperparathyroidism;
on HD since [**2187-5-9**], does make some urine
2.) Hypertension
3.) Hyperlipidemia
4.) CAD: per patient, no records at [**Hospital1 18**]
5.) dCHF
6.) R carotid stenosis
7.) Depression
8.) Asthma
9.) Osteoporosis
10.) Osteoarthritis
11.) Thyroid disease- h/o both hypo and hyperthyroidism
12.) Vitamin D deficiency - 25 OH 19 in [**2-/2186**]
13.) Benign adnexal cyst: followed [**8-/2186**] and planned again for
imaging [**8-/2187**]
14.) Chronic Aspiration: based on video swallow eval [**8-/2186**]
15.) Chronic labyrinthitis
16.) h/o L pneumothorax
.
PAST SURGICAL HISTORY:
1.) [**4-/2187**] LUE AV [**Year (4 digits) **] (Dr. [**First Name (STitle) **]
2.) hx bilat cataract surgery
3.) R hip fx s/p ORIF
4.) [**10/2187**] LUE AV [**Year (4 digits) **] thrombectomy and stent placement
Social History:
Patient is widowed, and she lives with her son, [**Name (NI) **]
[**Name (NI) 96427**], and his fiance, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1169**], with [**Last Name (NamePattern1) 269**] assistance and
private home care services. Denies any current or past smoking,
current or past alcohol, or current or past drug use. Has care
at the [**Location (un) 3137**] Center. Dialysis in [**Location (un) 1468**].
Family History:
Son with heart surgery for unknown reason in [**2187**]. No
family history of kidney disease.
Physical Exam:
ADMISSION EXAM:
95.2 126/59 60 100% CMV assist control 400/14 FIO2 40%,
PEEP 5
GENERAL: 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 not visualised.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-12**] holosystolic mumur in apex
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Some inspiratory
crackles in the bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Purpura on shins
bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM:
98.9 126/46 70 19 99%2LNC
GENERAL: 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 not visualised.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-12**] holosystolic mumur in apex
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Some inspiratory
crackles in the bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Purpura on shins
bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
LABS ON ADMISSION:
[**2188-2-11**] 10:15PM BLOOD WBC-10.8 RBC-3.29*# Hgb-9.7* Hct-28.9*
MCV-88# MCH-29.6 MCHC-33.6 RDW-15.6* Plt Ct-300
[**2188-2-11**] 10:15PM BLOOD Neuts-87.3* Lymphs-8.1* Monos-2.7 Eos-1.4
Baso-0.5
[**2188-2-11**] 10:15PM BLOOD PT-22.7* PTT-35.1 INR(PT)-2.2*
[**2188-2-11**] 10:15PM BLOOD Glucose-95 UreaN-13 Creat-2.0*# Na-141
K-3.9 Cl-100 HCO3-32 AnGap-13
[**2188-2-11**] 10:15PM BLOOD cTropnT-0.02*
[**2188-2-11**] 10:15PM BLOOD Calcium-7.8* Phos-2.3* Mg-2.0
.
LABS ON DISCHARGE:
[**2188-2-13**] 05:12AM BLOOD Hct-27.0*
[**2188-2-12**] 05:08AM BLOOD WBC-7.0 RBC-3.04* Hgb-9.1* Hct-27.2*
MCV-89 MCH-29.9 MCHC-33.5 RDW-16.1* Plt Ct-250
[**2188-2-13**] 05:12AM BLOOD PT-16.6* PTT-34.9 INR(PT)-1.6*
[**2188-2-13**] 05:12AM BLOOD Glucose-93 UreaN-36* Creat-3.6* Na-140
K-4.5 Cl-100 HCO3-30 AnGap-15
[**2188-2-13**] 05:12AM BLOOD Calcium-8.8 Phos-4.2# Mg-2.2
.
[**2188-2-11**]
pCXR
FINDINGS: Single supine AP portable view of the chest was
obtained. Again
seen, there are increased diffuse interstitial opacities
bilaterally, may be due to pulmonary edema, although appears
less severe than on the prior study. Slight blunting of the
bilateral costophrenic angles may be due to small bilateral
pleural effusions. Cardiac and mediastinal silhouettes are
stable. Left subclavian stent is again seen.
Brief Hospital Course:
84 year old female with chronic afib, HTN, HLD, CAD, stage IV
CKD (HD MWF), COPD, dCHF (EF >55%) who presented w/ AFIB w/ RVR
and labile BPs after undergoing HD.
.
# AFIB w/ RVR: Pt has a hx of chronic AFIB and presented today
with RVR, likely in the setting of being over diuresed. Per
prior cardiology consult note, "It is most likely that the
patient has baseline low blood pressures from poor autonomic
tone and other factors, and her blood pressures are further
reduced during tachycardic
episodes in the setting of her diastolic dysfunction and left
ventricular hypertrophy. Midrodrine should help the poor
autonomic tone. She cannot augment her cardiac output enough
when she is hemodynamically challenged (such as during fluid
removal). It is also possible that because of her hyperdynamic
LV function and LVOT gradient, she develops severe LVOT
obstruction when her stroke volume is reduced and when she is
tachycardic - similar to a patient with hypertrophic
cardiomyopathy. We would also recommend reducing the rate of
fluid removal during HD." Pt was placed on amiodarone and
metoprolol, and converted to sinus rhythm. Of note, she did not
have, but needs to be, continued on the above nodal blocking
agents on discharge. She was continued on warfarin. Discharge
INR is 1.6 and this should be checked daily with goal INR [**1-11**].
CXR, TSH and LFTs were checked upon initiation of amio. CXR was
negative for evidence of fibrosis, TSH was wnl, LFTs were normal
except for an alk phos of 116, which is stable from prior vales.
These can be trended by her new cardiologist.
.
# Hypotension: Pt had labile blood pressures in the ED and on
transfer to the CCU. However, urine output was good and pt was
mentating well so displayed no signs of end-organ ischemia. Pt
has had previous episodes of becoming hypotensive after HD, also
in the setting of possible worsening of baseline LVOT
obstruction. Hypotension improved with rate control and with
conversion to normal sinus rhythm. Patient will also continue
midodrine with HD, as before.
.
# DHF: pt has known DHF w/ hyperdynamic LV and gradient across
LVOT. Likely exacerbated by aggressive diuresis per HD. Favor
slow rate of removal of IVF during HD. Patient tolerated
Wednesday HD session and -1L fluid was removed without
complication.
.
# CKD: Pt HD dependant since [**2187-5-9**] MWF. Underwent HD w/
likely resultant hypovolemia. Continuing midodrine with HD, and
plan as above. Patient's renagel pills were too big to swallow.
Per renal, these can be stopped for now given low phosphate.
.
# HLD: stable. Pt continued on atorvastatin 40 mg daily.
.
# CAD: pt has previous hx of CAD, but no record in BDIMC and
last MIBI normal, recent echo showed no WMAs. Continued on
aspirin 81 mg daily.
.
# Constipation: continued senna, colase, polyethylene glycol prn
.
# Nutrition: continued multivitamin, folic acid
.
# Depression: continued home venlaflaxine
Medications on Admission:
1) Coumadin 5mg PO daily
2) Renegel 800mg PO TID
3) 1200 cc fluid restriction
4) Effexor 75mg PO daily
5) Vit B complex 1 tab PO daily
6) Colace 100mg PO BID
7) Lactulose 22.5mL 15gm PO BID
8) Lipitor 40mg PO QHS
9) Aspirin 650mg PO TID
10) Bumex 1mg tab PO 4x weekly on non-HD days
11) Midodrine 2.5mg PO daily on MWF before HD
12) Protonix 40mg PO daily before meals
13) Iron 325mg PO daily
14) Folic acid 1mg PO daily
15) Nephrocaps 1mg PO daily
16) Ipratroprium and Albuterol PRN but never given
17) Zofran 4mg Q8H PRN nausea/vomitting but nothing given
recently
18) Bisacodyl 1 tab PR PRN constipation
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
4. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. lactulose 10 gram/15 mL (15 mL) Solution Sig: One (1) PO
twice a day as needed for constipation.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. midodrine 5 mg Tablet Sig: 0.5 Tablet PO MWF
(Monday-Wednesday-Friday): take with HD.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. ipratropium bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed for SOB.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO TID (3 times
a day) as needed for pain.
17. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3137**] Care Center - [**Location (un) 1468**]
Discharge Diagnosis:
PRIMARY:
1. atrial fibrillation with rapid ventricular rate
2. end stage renal disease, on hemodialysis
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:
Dear Ms. [**Known lastname 96427**],
.
You were admitted to the hospital for atrial fibrillation with
fast heart rate during your dialysis session. The cause was
likely aggressive fluid removal during dialysis, and your heart
which can only tolerate gentle fluid removal.
.
Your heart rate was controlled with two medications, amiodarone
and metoprolol. Please continue these medications as prescribed.
You tolerated hemodialysis here, with one liter of fluid
removed, without complication, on your date of discharge.
.
MEDICATION CHANGES:
- START amiodarone 200 mg daily
- START metoprolol tartrate 12.5 mg twice a day
.
Please seek medical attention for any concerns. Please attend
your follow-up appointments below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2188-3-11**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2188-2-13**]
ICD9 Codes: 5856, 496, 2724, 4240, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5935
} | Medical Text: Unit No: [**Numeric Identifier 61203**]
Admission Date: [**2148-5-11**]
Discharge Date: [**2148-5-16**]
Date of Birth: [**2148-5-11**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Name2 (NI) **] is a 32 and 3/7
weeks gestational age twin II admitted for prematurity.
MATERNAL HISTORY: Mother is a 33-year-old G1/P0 (to 2) [**Location 61204**] woman with the following prenatal screens; O
positive, antibody negative, RPR nonreactive, rubella immune,
hepatitis B surface antigen negative, GBS unknown.
ANTENATAL COURSE: Estimated date of delivery was [**2148-7-3**] by last menstrual period which was [**2148-9-26**] for
an estimated gestational age of 32 and 3/7 weeks. This was a
diamniotic-dichorionic twin gestation complicated by preterm
labor leading to admission for tocolysis and betamethasone on
[**5-2**]. Progression of labor led to a cesarean section
today under spinal anesthesia. Rupture of membranes was at
delivery yielding clear amniotic fluid. No intrapartum fever
noted or other clinical evidence of chorioamnionitis.
NEONATAL COURSE: The infant was vigorous at delivery. Orally
and nasally bulb suctioned, dried, subsequently pink, and in
no distress on room air. Apgar's were 8 and 9 at one and five
minutes of age.
PHYSICAL EXAMINATION ON ADMISSION: In general, this is a
well-appearing infant in no distress. Birth weight of 1640
grams, head circumference of 29 cm, length of 42 cm. Heart
rate of 170, respiratory rate of 30s to 40s, blood pressure
of 60/45 with a mean of 52, oxygen saturation of 95% on room
air. HEENT with anterior fontanel open and soft,
nondysmorphic, palate intact. Neck and mouth normal.
Normocephalic with no nasal flaring. Chest reveals no
retractions with good breath sounds bilaterally. No crackles.
Cardiovascular exam was well perfused, a regular rate and
rhythm. Femoral pulses normal with no murmur. The abdomen was
soft and nondistended. No organomegaly. No masses. Bowel
sounds were active. The anus was patent with a 3-vessel
umbilical cord. GU revealed a normal penis with right
testicle descended but left testicle undescended. CNS exam
revealed active and alert. Tone was appropriate and
symmetric, moved all extremities symmetrically. Grasp was
symmetric, and gag was intact. Skin exam was normal.
Musculoskeletal exam with normal spine, limbs, hips, and
clavicles.
HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: The patient has been stable on room air since
the time of admission. Has had no apnea of bradycardia of
prematurity.
2. CARDIOVASCULAR: The patient has been stable from a
hemodynamic standpoint throughout his admission with no
murmur noted on exam.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
initially NPO on total fluids of 100 cc/kg per day and
then was started on enteral feedings on day of life 1 and
worked slowly up by 15 cc/kg twice daily. Is currently
feeding breast milk or Special Care 20 calories per ounce
at 120 cc/kg per day and total fluids of 140 cc/kg per
day. Was planned to continue and advance to 15 cc/kg
b.i.d.
4. GI: Most recent bilirubin was 6.4/0.3 on the day of
transfer, which is day of life #5. The patient has never
been under phototherapy.
5. INFECTIOUS DISEASE: Initial CBC was obtained which was
benign with a white count of 12.1 with 32 polys and 7
bands. The patient was started on ampicillin and
gentamicin which were stopped after 48 hours of negative
blood culture.
6. NEUROLOGY: A head ultrasound was not indicated.
7. SENSORY: A hearing screen was not yet performed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: [**Hospital1 1474**] level II nursery.
NAME OF PRIMARY CARE PEDIATRICIAN: A primary care
pediatrician has not yet been identified.
CARE AND RECOMMENDATIONS AT DISCHARGE:
1. Feedings at discharge are breast milk or Special Care at
20 calories per ounce at 120 cc/kg per day with plan to
advance 15 cc/kg twice daily to a maximum feed of 150
cc/kg per day.
2. The patient is on no medications.
3. State screening will be sent on the day of transfer.
4. The patient has not yet received any immunizations.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 and 3/7 weeks gestation.
2. Twin gestation.
3. Rule out sepsis; resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58729**]
MEDQUIST36
D: [**2148-5-16**] 11:58:38
T: [**2148-5-16**] 12:38:12
Job#: [**Job Number 61205**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5936
} | Medical Text: Admission Date: [**2173-7-19**] Discharge Date: [**2173-7-28**]
Date of Birth: [**2092-3-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Fever.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
81 yo M with h/o COPD, dementia, Parkinson's, schizophrenia,
who was BIBA from [**Doctor First Name 3504**] [**Doctor First Name **] NH where he was found to be
febrile to 102.8 today. Per report, the patient had T 102.8, P
100, BP 130/80, RR 24, O2 sat 90% RA. The patient needs
assistance with ADLs, is combative and non-verbal at baseline.
In the ED: T 101.8; HR 130s; BP 120/92; RR 36; O2 sat 95% on 5L
NC. Lactate 2.8. WBC 9.9. EKG wtih afib. CXR with multifocal
opacities. Received Vanco, Levo, Flagyl. Blood cx drawn. Patient
received Diltiazem 10 mg IV once.
Past Medical History:
1. COPD/emphysema
2. A fib
3. Parkinsons
4. Osteomyelitis
5. Schizophrenia
Social History:
Lives in the nursing home. At baseline, needs assistance with
ADL. The rest of Social history is unknown.
Family History:
Unknown.
Physical Exam:
VS: 100.2 rectal; HR 121; BP 95/71; RR 33; O2sat 95% on 5L
GENERAL: cachectic; combative; non-verbal
HEENT: NC, AT, poor dentition
Neck: No JVP
CV: irregulary irregular; no m/r/g
PULM: CTA bilaterally
ABD: + BS, soft, NT, ND
EXTR: no edema
Pertinent Results:
EKG: afib rate 128; no comparison available
CXR: 1. Multifocal airspace opacities, likely representing
aspiration or aspiration pneumonia, given mostly dependent
distribution. Followup radiograph recommended in six weeks to
document resolution. 2. 9-mm nodular opacity in the left upper
lung zone, which may represent a lung nodule. This can be
further evaluated with concomitant PA and lateral views at the
time of pneumonia followup.
Brief Hospital Course:
1. Aspiration pneumonia:
Initially treated for an aspiration pneumonia (Vanc/Zosyn). His
saturations improved and he was weaned off oxygen. When the
patient was made CMO, antibiotic were stopped and he was treated
supportively.
2. Failure to thrive:
The patient was 43 kg on admission and dehydrated. He had an
NGT placed and was started on tube feeds given an inability to
take any PO. After the NG was pulled, an attempt was made to
replace - the patient did not tolerate this. Given his lack of
quality of life and poor long-term prognosis, he was made
comfort measures only.
3. Atrial fibrillation:
Initially difficult to rate control, however, improved after
hydration. He was continued on outpatient digoxin and low dose
diltiazem while NG was in place. IV Lopressor was used after NG
was pulled.
4. Psych/Schizophrenia:
Continued on fluphenazine and benzotropine while NG was in
place. Later, for intermittent agitation, the patient was given
zyprexa.
Medications on Admission:
1. Benztropine Mesylate 0.5 mg PO BID
2. Carbidopa-Levodopa (10-100) 2 TAB PO TID
3. Prilosec [**Hospital1 **]
4. Multivitamins 1 CAP PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Senna 2 tabs qd
7. Colace
8. Fluphenazine 4 mg PO QHS
9. Compazine prn
10. MOM prn
11. Dulcolax prn
12. Tylenol
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, apparent discomfort.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
1. Multifocal Pneumonia.
2. Delirium.
3. Failure to Thrive
Secondary:
1. Dementia.
2. Schizophrenia
3. Parkinson's disease
4. COPD
6. Atrial fibrillation
Discharge Condition:
Stable.
Discharge Instructions:
Patient was hospitalized in the ICU with an aspiration pneumonia
which was treated with antibiotics. Given his ongoing risk of
aspiration, we attempted to place an NG tube. The patient did
not tolerate this intervention. We then had a discussion with
his health care proxy and [**Name2 (NI) 73091**] that given his end-stage
dementia a PEG tube was not indicated. The decision was made to
transition the patient to comfort care.
Followup Instructions:
Patient will be discharged to long-term care facility for
ongoing comfort care.
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5937
} | Medical Text: Admission Date: [**2188-7-12**] Discharge Date: [**2188-7-18**]
Date of Birth: [**2136-5-20**] Sex: F
Service: PODIATRY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4342**]
Chief Complaint:
Left foot infection
Major Surgical or Invasive Procedure:
Left foot I&D [**2188-7-12**], Left foot debridement [**2188-7-16**]
History of Present Illness:
52 yo DM2, IVDU, many foot infections in the past, presents to
the ED 3 days after stepping on a nail with her left foot.
.
Since that time, she has been experiencing fevers (but patient
is unsure how high), rigors, and nausea/vomitting x1. She has
been noticing drainage from a ulcer over the area of the foot
where the nail impaled her foot. She reports that she was unable
to come to the ER because ambulating was painful and she could
not obtain a ride. She reports poor po intake x1 day. Pain is
located in the anterior left foot and ankle, and is rated as
[**10-10**].
.
Of note, patient was admitted [**5-10**] with a right fourth digit
ulceration and osteomyelitis. Though surgery was planned, the
patient left AMA after her boyfriend was not allowed to sleep in
her hospital bed.
.
In the [**Hospital1 18**] ER, she was febrile to 104. She was noted to be
tachycardi with an EKG apparently consistent with MAT vs Afib,
which is new for her. Glucose was noted to be 500 but there was
no gap. A dime size necrotic lesion was noted over the plantar
sufrace of the first MTP joint. She received a 2L NS, tetanus
booster, morphine 4 mg IV, regular insulin 10 U, Vancomycin 1 g
IVx1, and Zosyn, 4 g IV x1. LEFT IJ was placed.
.
Patient was transferred to the OR by podiatry for I and D of
left foot. There was minimal blood loss, of about 15 cc. She
received 500 cc of saline. Local anesthesia was utilized with
MAC. The patient was transferred to the ICU for further
monitoring.
.
In the ICU patient reports [**10-10**] left foot pain, but otherwise
feels well. She was occassionally tachy to 140 and had HTN to
240's. This improved with morphine and lisinopril. Her cr fell
from 1.3 to 1.2.
Iron studies had a pattern (low TIBC, Tf) c/w Anemia of chronic
inflammation
Past Medical History:
H/o multiple diabetic ulcers s/p toe amputations
-Poorly controlled DM II
-Anxiety
-Depression
-H/o non-compliance and behavioral problems
-Peripheral neuropathy
-Hepatitis B core Ab positive, surface Ab and Ag negative
-Hx of Hepatitis C (neg vl since [**2182**])
-H/o IVDU and ETOH abuse
-HTN
-Peripheral vascular disease
-H/o osteomyelitis
-hysterectomy and removal of uterus and cervix due to
persistent, severe cervical dysplasia
-vaginal pap 2/09 WNLs
-terminated in [**2182**] from [**Hospital1 **] Psych (Dr. [**Last Name (STitle) 6496**] because pt not
keeping appts, abusing klonopin and doxepin b/c not fufulling
terms of contract with providers
Social History:
The patient was evicted from an apartment in [**Hospital1 778**] in [**5-8**]
after her boyfriend was arrested for drugs. She moved into a
room in an apartment in [**Location (un) 686**]. She denies current drug use
but her urine tox was positive for cocaine. Past notes indicate
heroin use as well. She was on methadone for many years. She
currently denies any smoking saying she quit in [**6-7**], but has
smoked in the past. She drinks ETOH occasionally. Domestic
violence: has experienced violence in the past. She currently
has a male partner who is >15 years younger than her and is an
alcoholic who is HIV+. Her adult daughter lives nearby. She is
on disability and does not work.
Family History:
She had one brother who was a police officer who committed
suicide. Diabetes runs in her family. She has no FH of cancer.
Physical Exam:
ICU Vitals: T: 102.2 BP: 162/84 P: 124 R: 14 O2: 100% 2lNC
.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: dressing to LLE, c/d/i, no swelling or edema
CN 2-12 intact - No JPS in RLE. Sensitive only to deep
palpation. Poor JPS of Hands. Preserved light touch.
Pertinent Results:
ADMISSION LABS:
[**2188-7-12**] 04:45PM BLOOD WBC-7.3# RBC-3.01* Hgb-8.1* Hct-23.8*
MCV-79* MCH-27.0 MCHC-34.1 RDW-14.3 Plt Ct-335#
[**2188-7-12**] 04:45PM BLOOD Neuts-82.1* Lymphs-13.0* Monos-4.3
Eos-0.2 Baso-0.5
[**2188-7-12**] 04:45PM BLOOD PT-14.3* PTT-31.4 INR(PT)-1.2*
[**2188-7-12**] 04:45PM BLOOD Glucose-510* UreaN-17 Creat-1.3* Na-127*
K-3.4 Cl-94* HCO3-27 AnGap-9
[**2188-7-12**] 10:42PM BLOOD Calcium-7.2* Phos-1.0*# Mg-1.5* Iron-7*
[**2188-7-12**] 10:42PM BLOOD calTIBC-146* Ferritn-219* TRF-112*
DISCHARGE LABS:
[**2188-7-18**] 06:00AM BLOOD WBC-3.8* RBC-2.92* Hgb-8.2* Hct-24.8*
MCV-85 MCH-28.1 MCHC-33.2 RDW-15.0 Plt Ct-376
[**2188-7-18**] 06:00AM BLOOD Plt Ct-376
[**2188-7-18**] 06:00AM BLOOD Glucose-282* UreaN-10 Creat-1.1 Na-139
K-3.3 Cl-100 HCO3-34* AnGap-8
[**2188-7-18**] 06:00AM BLOOD Calcium-8.2* Phos-4.4 Mg-1.7
FOOT XR [**7-12**]
There is a large ulcer crater at the plantar aspect of the
forefoot, at the second and third distal metatarsals. There is
associated periosteal reaction and ill definition of the cortex
of the head of the second
metatarsal, suspicious for osteomyelitis. Significant
circumferential foot
swelling noted. This is on a background of extensive
postsurgical changes,
which otherwise are grossly stable.
CXR [**7-12**]
No acute pulmonary process. Right internal jugular central line
as above with no pneumothorax noted.
[**2188-7-16**] Radiology CHEST PORT. LINE PLACEM: IMPRESSION: 1. New
bibasilar consolidations which are prominent on the left are
concerning for pneumonia. 2. New left small pleural effusion.
[**2188-7-16**] Radiology CHEST (PA & LAT): (WET READ): Interval
repositioning of left PICC line which is not seen beyond the
mid-SVC where it may terminate versus become obscurred by the
right internal jugular
central venous catheter. No catheter is seen within the right
atrium. Ill-
defined costophrenic opacity could represent early infection.
Small left
pleural effusion unchanged.
[**2188-7-17**] Radiology CHEST (PA & LAT): No change in right
costophrenic opacity and pleural effusion since exam of [**2188-7-16**].
Left PICC terminates in proximal SVC.
[**2188-7-16**] Radiology FOOT AP,LAT & OBL LEFT: FINDINGS: In
comparison with the study of [**7-12**], there has been resection of
the distal half of the second metatarsal and the proximal
portion of the proximal phalanx. Gas is seen projected over the
region, though it could merely be trapped underneath the
overlying bandage.
[**2188-7-16**] Pathology Tissue: LEFT 2nd DIGIT PHALAX, Left: Not
finalized.
[**2188-7-12**] 5:02 pm SWAB Source: left foot.
**FINAL REPORT [**2188-7-16**]**
GRAM STAIN (Final [**2188-7-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2188-7-16**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2188-7-16**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
[**2188-7-16**] 10:45 am SWAB Site: FOOT LEFT 2ND FOOT ULCER.
GRAM STAIN (Final [**2188-7-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): RESULTS PENDING.
[**2188-7-16**] 8:28 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2188-7-17**]**
GRAM STAIN (Final [**2188-7-17**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2188-7-17**]):
TEST CANCELLED, PATIENT CREDITED.
[**2188-7-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2188-7-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2188-7-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2188-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
Brief Hospital Course:
This is a 52 yo DM2, IVDU, many foot infections in the past,
presents to the ED 3 days after stepping on a nail with her left
foot. She was found to be septic (fever, tachycardia,
leukocytosis) and was admitted to the medicine service. She was
started on broad spectrum antibiotics and local wound care.
Podiatry performed a bedside debridement and wound cultures grew
MSSA. She was then switched to Nafcillin IV q6h. Daily wet to
dry dressing changes were performed. Daily labs were drawn and
electrolytes repleted as necessary.
On [**2188-7-16**], she was taken to the OR for left foot debridement
packed open. Cultures were taken. Please see operative report
for full details.
All of her home medications were continued. On [**2188-7-16**], a PICC
line was placed. Upon awaiting her PICC line placement, the
radiologist contact[**Name (NI) **] Dr. [**Last Name (STitle) **] regarding new bilateral
infiltrates concerning for pneumonia. She was switched back to
vancomycin and zosyn with a medicine consult. Repeat CXR showed
no change in the opacity. Sputum culture was sent which was
contaminated and pt refused a repeat culture. Her vitals and O2
sats remained stable during her admission. Outpatient [**Company 191**] follow
up was obtained and pt was encouraged to keep appointment. She
was also given the [**Hospital **] clinic number to establish follow up
for her diabetes insulin regimen.
Physical therapy was consulted but the patient refused to be
evaluated. Pt also refused rehab facility.
Her OR wound cultures showed no growth to date and pathology was
not finalized at the time of discharge.
On [**2188-7-18**] her PICC line was pulled and she was discharged with
10 days course of Augmentin with instructions to perform daily
dressing changes and to ambulate to left heel in a surgical shoe
with assistance of a walker.
Medications on Admission:
-insulin regular human recombinant 100 units/mL 0.1 units/kg [**Hospital1 **]
-metformin [**2178**] mg once a day (does not appear to be using)
-GlipiZIDE XL 10 mg once a day (does not appear to be using)
-Lantus 100 units/mL 12 units at bedtime
-Klonopin 1 mg q6hours prn
-doxepin 150mg qhs
-clonidine 0.1 mg/24 hr 1 PATCH 1X/W (does not appear to be
using)
-Neurontin 600 mg TID
-lisinopril 40 mg once a day
-Celexa 20mg once a day
-ibuprofen 800 mg TID prn with food
-Fioricet 325 mg-50 mg-40 mg 2 tab(s) Q4H prn
-Flonase 2 spray(s) once a day
Discharge Medications:
1. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Insulin
Insulin SC Fixed Dose Orders
Bedtime
Glargine 21 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Doxepin 25 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Left foot ulcer infection
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:
Please resume all pre-admission medications. If you were given
new prescriptions, please take as directed.
.
Keep your dressing clean and dry at all times. You will need to
change your dressings daily.
.
You are to remain WEIGHT BEARING to your left heel in a surgical
shoe at all times with the assistance of a walker.
.
Call your doctor or go to the ED for any increase in LEFT foot
redness, swelling or purulent drainage from your wound, for any
nausea, vomiting, fevers greater than 101.5, chills, night
sweats or any worsening symptoms.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] next week. #[**Telephone/Fax (1) 543**]
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**] DPM 48-135
Completed by:[**2188-7-18**]
ICD9 Codes: 0389, 5849, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5938
} | Medical Text: Admission Date: [**2111-4-4**] Discharge Date: [**2111-4-20**]
Date of Birth: [**2031-10-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
respiratory distress and hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 79F w/ DM type 2, s/p recent admission to [**Hospital1 18**]
in [**2111-1-31**] -[**2111-2-18**] for subdural hematoma/ intraparenchymal bleed
after a fall with hospital course complicated by altered mental
status requiring intubation, DKA, PNA, UTI and s/p PEG, and
recent admission following that for aspiration PNA, which was
treated with Vancomycin and Cefepime.
The patient was discharged from the hospital on [**2111-4-4**] and
represented with respiratory distress and hypoglycemia. Her
baseline mental status since her subdural hematoma is
non-verbal, not following commands, sometimes opens eyes,
therefore history is obtained through records. According to the
NH records the patient was found several hours after admission
to be minimially responsive and in respiratory distress. A
fingerstick glucose revealed hypoglycemia at 25. She was given
an amp of D50 and was more arousable, however she continued to
be in respiratory distress with O2sats in the 60s. She was
transferred to the [**Hospital1 18**] for further workup.
In the ED, the pt presented with the following VS: 36.2 C, HR
117, BP 140/66, RR 36, O2Sat 87% on NRB. Pt maintained her
pressure throughout her ED stay, HR ranged between 108-117. Her
O2Sats subsequently were 100% on Facemask. She was given empiric
Vancomycin, Zosyn and Levoquin for HAP before a CXR was done. As
the patient appeared wheezy on exam she also received Solumedrol
80mg x1 as well as Ipratropium and Albuterol nebs.
CXR revealed no new infiltrate.
She was admitted to the intensive care unit initially, where she
was treated supportively with IVF and Pain Control. Her oxygen
requirement abated upon admission to the MICU and she was weaned
easily off of her nasal canula.
Past Medical History:
- recent SDH followed by neurosurgery, new aphasic baseline
- DM2 w/retinopathy and neuropathy
- Arthritis
- Right Hip fracture [**2108**]
ADMISSION MEDS
Levetiracetam 1000 mg PO QAM, 500mg QPM
Cholecalciferol (Vitamin D3) 400 unit DAILY
Calcium Carbonate 500 mg PO BID
Lansoprazole 30 mg PO DAILY
Amantadine 100mg DAILY
Bisacodyl 5 mg DAILY as needed.
Senna 8.6 mg [**Hospital1 **] as needed.
Heparin 5,000 TID sc
Oxycodone 5 mg PO Q12H as needed
Acetaminophen liquid 325-650 mg PO Q6H as needed.
Albuterol Sulfate Neb Q6H
Insulin Glargine 50 units Subcutaneous qAM.
Insulin Regular per sliding scale.
Social History:
Previously lived at home with her husband, one -two drinks per
night, no tobacco, walked with a walker
Family History:
non-contributory
Physical Exam:
VITAL SIGNS ON FLOOR: 97.0 130/62 118 24 95%
PHYSICAL EXAM:
Gen: lying in bed, NAD, not following commands
Heent: No JVD.
CV: tachycardic, RRR, no audible murmurs/rubs or gallops
Pulm: CTAB anteriorly
Abd: soft, non-tender, + BS, non-distended, PEG tube in place
Extremities: lower extremities contracted, no open wounds, 1+
DP, cool, upper extremities with increased tone R>L
Neuro: open eyes, tracks movement and blinks to threat, no focal
cranial neuropathies noted on limited exam as pt cannot follow
commants, upgoing toes bilaterally, unable to speak, 1+ reflexes
in upper extremities
Pertinent Results:
ADMISSION LABORATORIES
[**Age over 90 **]|99|18 / 249 AGap=21 92
4.7|20|0.5\ 24.0 \______/ 715
Ca: 9.4 Mg: 1.7 P: 4.5 / 32.6 \
Fibrinogen: 895 N:95.5 Band:0 L:2.1 M:1.6 E:0.7
Bas:0
Hypochr: 2+ Anisocy: 1+ Macrocy: 1+
Microcy: 1+
BLOOD CULTURES [**2111-4-4**]: NGTD
C. DIFF [**2111-4-6**] 12:38 pm STOOL POSITIVE
CXR [**2111-4-5**]: Patchy density in the left lower lobe may represent
linear atelectasis or infection. Healed rib fractures are seen
in the left side. No frank consolidation or failure.
KUB [**2111-4-10**]: A gastrostomy tube overlies the expected region of
the stomach. There is no supine evidence of free intra-abdominal
air. No dilated loops of small or large bowel are detected to
suggest obstruction. Air and stool is identified within the
colon without evidence of pneumatosis or wall thickening.
Osseous screws are identified within the left proximal femur.
Degenerative changes in the lower lumbar spine are not well
evaluated on this study.
HEAD CT [**2111-4-3**]: Bifrontal areas of encephalomalacia and
contusion are
identified which have further evolved since the previous CT and
MRI
examination. No new hemorrhage is identified. No mass effect or
midline
shift seen. There is moderate brain atrophy seen including
dilatation of the fourth ventricle and prominence of temporal
horns, which could be due to mild communicating hydrocephalus.
There is no midline shift seen. There is no new area of
hemorrhage identified.
EEG: This 24-hour bedside EEG telemetry with video captured no
clear electrographic seizures. Interictal discharges were seen
independently in the left temporal region, right temporal
region, or
more broadly over the right hemisphere. The background was slow
and
disorganized with frequent bursts of generalized delta frequency
slowing
suggestive of an encephalopathy. Infections, medication effects,
and
metabolic disturbances are among the most frequent causes of
encephalopathy. Delta frequency slowing was also seen
independently in
the left and right temporal regions suggestive of subcortical
dysfunction.
PERTINENT LABS
HEMATOLOGY
[**2111-4-4**] 07:53AM BLOOD WBC-11.8* RBC-3.32* Hgb-10.3* Hct-30.0*
MCV-91 MCH-30.9 MCHC-34.2 RDW-18.0* Plt Ct-690*
[**2111-4-4**] 07:25PM BLOOD WBC-10.6 RBC-3.44* Hgb-10.5* Hct-31.5*
MCV-92 MCH-30.5 MCHC-33.2 RDW-17.4* Plt Ct-767*
[**2111-4-5**] 03:39AM BLOOD WBC-24.0*# RBC-3.54* Hgb-10.6* Hct-32.6*
MCV-92 MCH-29.8 MCHC-32.5 RDW-17.8* Plt Ct-715*
[**2111-4-6**] 05:55AM BLOOD WBC-18.2* RBC-2.91* Hgb-8.7* Hct-26.9*
MCV-93 MCH-29.8 MCHC-32.2 RDW-17.9* Plt Ct-713*
[**2111-4-7**] 05:55AM BLOOD WBC-11.5* RBC-3.43* Hgb-10.2* Hct-31.9*
MCV-93 MCH-29.7 MCHC-32.0 RDW-17.8* Plt Ct-730*
[**2111-4-11**] 06:00AM BLOOD WBC-11.0 RBC-3.52* Hgb-10.6* Hct-32.8*
MCV-93 MCH-30.1 MCHC-32.3 RDW-16.8* Plt Ct-676*
[**2111-4-17**] 05:45AM BLOOD WBC-14.7* RBC-3.58* Hgb-10.6* Hct-32.9*
MCV-92 MCH-29.5 MCHC-32.1 RDW-17.2* Plt Ct-598*
[**2111-4-18**] 06:30AM BLOOD WBC-15.4* RBC-3.65* Hgb-10.9* Hct-33.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-18.0* Plt Ct-619*
COAGULATION
[**2111-4-11**] 06:00AM BLOOD PT-13.3 PTT-29.8 INR(PT)-1.1
CHEMISTRIES
[**2111-4-4**] 07:53AM BLOOD Glucose-260* UreaN-17 Creat-0.4 Na-129*
K-4.8 Cl-96 HCO3-25 AnGap-13
[**2111-4-5**] 03:39AM BLOOD Glucose-249* UreaN-18 Creat-0.5 Na-135
K-4.7 Cl-99 HCO3-20* AnGap-21*
[**2111-4-10**] 10:00AM BLOOD Glucose-180* UreaN-23* Creat-0.4 Na-140
K-4.5 Cl-103 HCO3-27 AnGap-15
[**2111-4-11**] 06:00AM BLOOD Glucose-193* UreaN-26* Creat-0.4 Na-141
K-4.7 Cl-102 HCO3-25 AnGap-19
[**2111-4-16**] 05:40AM BLOOD Glucose-101 UreaN-17 Creat-0.4 Na-135
K-4.8 Cl-99 HCO3-24 AnGap-17
[**2111-4-17**] 05:45AM BLOOD Glucose-129* UreaN-17 Creat-0.4 Na-133
K-4.9 Cl-96 HCO3-25 AnGap-17
[**2111-4-18**] 06:30AM BLOOD Glucose-189* UreaN-15 Creat-0.3* Na-127*
K-4.9 Cl-93* HCO3-25 AnGap-14
Brief Hospital Course:
79 year old woman s/p recent admissions for SDH and aspiration
PNA, who presents with respiratory distress and hypoglycemia.
Given that her CXR was essentially without changes (new liner
atelectasis vs infection) and more importantly that her oxygen
requirement abated upon initial admission to the MICU, this was
likely a mucous plug or aspiration pneumonitis that quickly
resolved.
1 RESPIRATORY DISTRESS/ASPIRATION/MUCOUS PLUGGING
She was given steroids in the ED. She was briefly admitted to
the medicine ICU. Upon arrival to the unit, her oxygen
equirement was abating without further intervention. This was
felt to be mucous plugging vs aspiration pneumonitis. Chest PT
was started in the hospital. HOB was elevated at 30 degrees.
She had one additional desaturation episode that was likely
aspiration pneumonitis that improved without antibiotics.
2 APHASIA/INTRACRANIAL BLEED
Extensive workup including CT head, EEG, MRI, large volume LP
recently for MS changes, were unrevealing except for large
hematoma of the right frontal lobe with bifrontal gliosis and
small SDH.
She was previously started on amantadine, as the drug can be
used for some frontal lobe disorders; however, with no
significant improvement seen, this was discontinued. She was
continued on Levetiracetam for seizure prophylaxis. She has
neurosurgical follow-up
Neurology was consulted and recommended EEG. This showed no
epileptiform activity.
Per neurology, the prognosis for meaninful recovery was poor.
Palliative care was consulted and involved with discussion of
hospice options.
3. C. DIFFICILE
The patient had leukocytosis and frequent loose stools, and
tested newly positive for the C. diff A toxin. She was started
on flagyl on [**2111-4-6**] for planned 14 day course. Her stool became
more formed, but she developed a worsening WBC and higher stool
output; she was transitioned to PO vancomycin to run from
[**Date range (1) 14233**].
4 SINUS TACHYCARDIA
Persistent chronic tachycardia without apparent etiology. Recent
CTA negative for PE. TSH was within normal limits.
5. REACTIVE THROMBOCYTOSIS stable, elevated
6. HYPONATREMIA
Tube feeds and free water boluses adjusted accordingly.
7 DIABETES MELLITUS:
Patient was hypoglycemic on admission being transferred without
tube feeds running. Her glargine was halved and later titrated
upwards while she had consistent tube feeds. She is being
discharged on 45 units of glargine daily.
8 PPx: heparin SQ
9 FEN: continued tube feeds
10 Code status - DNR/DNI
12 Communication - husband [**Name (NI) **] ([**Telephone/Fax (1) 14234**])
Medications on Admission:
Levetiracetam 1000 mg PO QAM, 500mg QPM
Cholecalciferol (Vitamin D3) 400 unit DAILY
Calcium Carbonate 500 mg PO BID
Lansoprazole 30 mg PO DAILY
Amantadine 100mg DAILY
Bisacodyl 5 mg DAILY as needed.
Senna 8.6 mg [**Hospital1 **] as needed.
Heparin 5,000 TID sc
Oxycodone 5 mg PO Q12H as needed
Acetaminophen liquid 325-650 mg PO Q6H as needed.
Albuterol Sulfate Neb Q6H
Insulin Glargine 50 units Subcutaneous qAM.
Insulin Regular per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Intraparenchymal hemorrhage
Subdural Hemorrhage
Aphasia
C. difficile associated diarrhea
C. difficile infection, new
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with respiratory distress, thoguht to be a
mucous plug that resolved on its own. While you were here you
had diarrhea and were diagnosed with an infection called C.
difficile. You were started on antibiotic called flagyl.
If you develop worsening breathing or worsening respiratory
symptoms, please return to the hospital.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2111-4-14**] 11:00
ICD9 Codes: 5070, 5185, 2761, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5939
} | Medical Text: Admission Date: [**2120-1-30**] Discharge Date: [**2120-2-3**]
Date of Birth: [**2062-12-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mild dyspnea on exertion and decreased exercise tolerance
Major Surgical or Invasive Procedure:
[**2120-1-30**] Minimally Invasive Mitral Valve Replacement utilizing a
33 millimeter CE Pericardial Valve
History of Present Illness:
Mr. [**Known lastname 101992**] in a 56 year old male with history of childhood heart
murmur. Prior to this year, he has not undergone cardiac
evaluation. An echocardiogram in [**2119-9-28**] revealed
mod-severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 32922**] prolapse and an LVEF of 65%. There
was moderate left atrial enlargement and only trace AI. Stress
echocardiogram in [**2119-10-28**] found no evidence of ischemia and
did not produce anginal symptoms. Subsequent cardiac
catheterization in [**2119-10-28**] confirmed [**3-1**]+ MR and an LVEF of
55%. Coronary angiography revealed a right dominant system and
normal coronary arteries. Based on the above results, he was
referred for cardiac surgical intervention. Overall, Mr. [**Known lastname 101992**]
remains mostly asymptomatic. He admits to mild DOE, slightly
decreased exercise tolerance and occasional palpitations. Prior
to his diagnosis of MR, he had been exercising several times per
week, including biking and tennis. He denies chest pain, SOB,
syncope, presyncope, orthopnea, PND, cough and pedal edema. He
denies history of rheumatic fever.
Past Medical History:
Mitral regurgitation; History of Gingival Disease and excessive
Tooth Decay; Legally Deaf in Right Ear - s/p Inner Ear Surgery;
s/p Hernia Repair; s/p Tonsillectomy
Social History:
Quit tobacco over 4 years ago but currently enjoys an occasional
cigar. He admits to occasional ETOH drink. No history of
excessive ETOH abuse. He is single and without children. Works
in finance, and currently lives with a friend.
Family History:
Father died of CHF at age 69. Mother and Sister have "mitral
valve disease".
Physical Exam:
Vitals: BP 132/66, HR 65, RR 14, SAT 96% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign, EOMI, sclera anicteric
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 3/6 systolic murmur best heard
LLSB which radiates to axilla
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: alert and oriented, CN 2-12 grossly intact, MAE, [**5-31**]
strength, no focal motor deficits noted
Pertinent Results:
[**2120-2-1**] 06:10AM BLOOD WBC-9.4 RBC-2.98* Hgb-9.3* Hct-26.4*
MCV-89 MCH-31.2 MCHC-35.3* RDW-13.6 Plt Ct-100*
[**2120-2-1**] 06:10AM BLOOD Glucose-121* UreaN-15 Creat-1.0 Na-138
K-4.4 Cl-105 HCO3-26 AnGap-11
[**2120-2-1**] 06:10AM BLOOD Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 101992**] was admitted and underwent a minimally invasive mitral
valve replacment utilizing a 33 mm CE pericardial tissue valve.
For further details, see operative note. Following the
operation, he was brought to the CSRU for invasive monitoring.
He required no inotropic support. Within 24 hours, he awoke
neurologically intact and was extubated. He did well and
transferred to the SDU on postoperative day one. Chest tubes
were removed without complication. Low dose beta blockade was
resumed. He was gently diuresed toward his preoperative weight.
He remained in a normal sinus rhythm. He made steady progress
and by postoperative day 4, he was cleared for discharge to
home. .
Medications on Admission:
Toprol XL 25 mg qd
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:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. 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*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral regurgitation - s/p Minimal Invasive Mitral Valve
Replacement utilizing a 33 millimeter CE Pericardial Valve
History of Gingival Disease and excessive Tooth Decay
Legally Deaf in Right Ear - s/p Inner Ear Surgery
s/p Hernia Repair
s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. Monitor wounds for signs of infection. Please call
with any concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**5-1**] weeks
Dr. [**Last Name (STitle) **] in 2 weeks
Dr. [**Last Name (STitle) **] in 2 weeks
Completed by:[**2120-2-3**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5940
} | Medical Text: Admission Date: [**2162-11-9**] Discharge Date: [**2162-11-16**]
Date of Birth: [**2085-10-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing chest discomfort and a positive thallium stress test
Major Surgical or Invasive Procedure:
s/p off pump cabg x1
History of Present Illness:
77 yo male with known CAD and prior stenting to RCA and PTCA to
diagonal. Re- presented with chest discomfort and had a positive
thallium stress test. Admitted for cardiac cath.
Past Medical History:
CAD with RCA stenting ( [**2154**] and [**2159**]) and PTCA of diagonal [**2159**]
HTN
elev. chol.
prostate CA with XRT/ seeding/ hormonal therapy
s/p appy [**2115**]
Social History:
retired lieutenant firefighter
quit tobacco 15 years ago, smoked [**1-28**] cigars/day for 20 years
drinks 2 glasses of wine per day
lives with wife
Family History:
brother died of MI at age 82
Physical Exam:
5'5" 165#
140/60 HR 54 RR 20 sat 94% on RA
NAd
S1 S2, RRR, no murmur, rub or gallop
no carotid bruits
glasses
lungs CTAB
extrems with positive peripheral pulses, warm, without
varicosities
abd soft, NT, ND
Pertinent Results:
[**2162-11-15**] 05:01AM BLOOD WBC-6.4 RBC-3.24*# Hgb-10.7* Hct-29.0*
MCV-89 MCH-33.0* MCHC-36.9* RDW-15.6* Plt Ct-161
[**2162-11-10**] 06:10AM BLOOD WBC-5.2 RBC-3.50* Hgb-12.3* Hct-35.3*
MCV-99* MCH-35.2* MCHC-35.5* RDW-14.4 Plt Ct-177
[**2162-11-15**] 05:01AM BLOOD Plt Ct-161
[**2162-11-14**] 10:44AM BLOOD PT-12.4 PTT-27.3 INR(PT)-1.0
[**2162-11-10**] 08:57AM BLOOD PT-13.2 PTT-66.7* INR(PT)-1.2
[**2162-11-15**] 05:01AM BLOOD Glucose-135* UreaN-21* Creat-0.7 Na-137
K-4.1 Cl-98 HCO3-29 AnGap-14
[**2162-11-10**] 06:10AM BLOOD Glucose-112* UreaN-22* Creat-0.9 Na-139
K-3.6 Cl-101 HCO3-29 AnGap-13
[**2162-11-10**] 06:10AM BLOOD ALT-38 AST-36 CK(CPK)-50 AlkPhos-73
TotBili-0.6
[**2162-11-10**] 06:10AM BLOOD Albumin-4.0 Mg-2.1
[**2162-11-10**] 10:44AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
[**2162-11-10**] 06:10AM BLOOD TSH-1.3
cath: LM mild dz
LAd 90%
Cx mild dz.
RCA patent stents, 50% mid lesion
LAd with residual dissection, 60% after PTCA
CXR; tortuous ascending aorta, mediastinum full at thoracic
inlet, deflection of trachea to right and indenting of anterior
aspect of trachea above aortic arch, likely secondary to
enlarged thyroid
Brief Hospital Course:
Admitted [**11-9**] for elective cath with Dr. [**Last Name (STitle) **]. See cath results
above.
Referred to Dr. [**Last Name (STitle) **] for CABG. Underwent off pump CABG x1
(LIMA to LAD)on [**2162-11-11**]. Transferred to the CSRU in stable
condition on titrated neosynephrine and propofol drips.
Extubated that evening, alert and oriented, on no drips.
Swan removed and gentle diuresis was started. He continued on
ASA and plavix. Transferred to the floor on POD #1 to begin
increasing his activity level. He went into AFIB on the floor
and was treated and started on amiodarone. He was transfused 2
units of PRBCs for a HCT of 25. Chest tubes were removed on POD
#4. He was in sinus rhythm 73 on POD #4.Pacing wires were
removed and lopressor was DCed. CXR showed no evidence of PTX,
with small bilat. pleural effusions.He continued to make good
progress and was discharged to home with services on POD #5.
T 97.8 HR 77 138/78 R 20 95% RA sat. 74.5 kg (pre-op 75)
Medications on Admission:
Plavix 75 mg daily
ASA 325 mg daily
HCTZ 12.5 mg daily
cardizem 300 mg daily
lipitor 80 mg daily
zetia 10 mg daily
cardura 2 mg daily
MVI one daily
folate 80-0 mcg daily
B6 100 mcg daily
B12 250 mcg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: [**11-15**] to [**11-21**].
Disp:*14 Tablet(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
starting [**11-22**] and then continuing.
Disp:*30 Tablet(s)* Refills:*2*
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
13. Diltiazem HCl 120 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO once a day.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
14. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
s/p off pump cabg x1
htn
elev. chol.
prostate Ca with XRT, seeding and hormonal therapy
CAD with prior PTCA and stenting
Discharge Condition:
good
Discharge Instructions:
may shower over incicsion and pat dry
no lotions, powders or creams on incisions
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call with fever, redness or drainage from incision, or weight
gain more than 2 pounds in one day or five in one week
Followup Instructions:
see Dr.[**Doctor Last Name 23605**] in [**12-27**] weeks; please follow up with PCP [**Last Name (NamePattern4) **]:
enlarged thyroid
see Dr. [**Last Name (STitle) **] in the office in 4 weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) **] in 3 weeks
Completed by:[**2162-12-6**]
ICD9 Codes: 4111, 2851, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5941
} | Medical Text: Admission Date: [**2110-6-5**] Discharge Date: [**2110-6-6**]
Date of Birth: [**2032-12-15**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfonamides
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Tachypnea/ectopy/altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line placement
History of Present Illness:
Ms. [**Known lastname 6930**] is a 77 yo F with h/o COPD and h/o NSCLC, CAD,
longstanding hypertension, CHF with preserved EF, recurrent c
diff infections and diabetes who was brought into the hospital
for dyspnea, transferred to the floor initially and then
transferred soon after to the MICU for tachypnea, ectopy, and
altered mental status.
According to her family, she did not sound like her usual self
on the day of admission, and they stopped by to check on her as
they live in adjacent apartments. She was found to be short of
breath and tripoding. She was hypertensive on arrival of EMTs to
200 systolic.
In the ED, she was initiated on CPAP but was off around one half
hour later. She was thought to be in CHF exacerbation, and
received lasix 80mg IV x1 and SL NTG x2.
When she arrived to the floor, she was tachypneic and
tachycardic with frequent ectopy. She was sent to the unit for
further management shortly after arrival to medical floor.
Past Medical History:
1. Non-small-cell lung cancer: CT guided needle biopsy for
diagnosis. PET/CT scan [**10-20**] demonstrated left lower lobe cancer
and 1.1cm left upper lobe nodule. s/p RFA and fiducial seed
placement [**2-20**] since patient is not a surgical candidate for
wedge resection. Saw Dr. [**Last Name (STitle) **] with radiation oncology.
2. COPD: on 2L O2 at home, spirometry [**10-21**] showed FEV1
0.84L(42% predicted)
3. CHF: ECHO [**1-20**] showed severe TR and EF ~ 55-60%
4. 3 vessel CAD s/p drug-eluting stent to mid-LAD and OM1 in
[**1-19**]
5. Atrial Fibrillation on coumadin
6. HTN s/p bilateral renal artery stenting
7. Anemia
8. Type 2 Diabetes Mellitus: on insulin
9. Peripheral Neuropathy
10. Ischemic ulcer s/p femoral-popliteal bypass
11. s/p Amputation of right and left second toes ([**1-20**])
12. s/p R hallux arthroplasty ([**8-20**])
13. s/p bilateral cataract surgery
[**16**]. Depression
15. s/p Cholecystectomy
[**18**]. s/p Hysterectomy
17. Chronic low back pain
18. Lumbar radiculopathy
19. Hemorrhoids
20. Ulcerative proctitis
Social History:
[**Female First Name (un) 100604**] lives in [**Location 686**] on the [**Location (un) 448**] of the family
house. She has to climb 13 steep steps to reach her home, which
she finds very difficult and tiring. She sleeps upright in bed
and uses a walker at baseline. Her sister, cousin, nephew and
[**Name2 (NI) 802**] live in the same building and they are in frequent
contact. [**Name (NI) **] boyfriend, aged 71, stays with her on the [**Location (un) 19201**] and takes good care of her, doing most of the household
chores. She is also cared for by a visiting nurse who comes
every day, a home health aide 3x/week, a homecare provider
2x/week, PT 2x/week, and a social worker 1x/week.
The patient was previously a hairdresser, beautician and
saleslady. Until the age of 40, she smoked 2 packs per day and
drank a 6-pack of beer almost every day. When she turned 40, she
quit her alcohol and tobacco use and returned to school to
become a social worker. She [**Location (un) **] ever working in a shipyard or
plumbing. She attends St. [**First Name4 (NamePattern1) 26785**] [**Last Name (NamePattern1) 9125**] in [**Location (un) 65712**] with
her family.
Family History:
Diabetes, CHF: Mother, Brother, Grandparents, Uncle
Does not know information about father's health.
Son is age 60 and is healthy. Daughter is age 58 and had a
cancerous growth excised from her knee.
Physical Exam:
VS - 96.6 101 122/72 30 97% 2L NC
Gen: 77 yo F with mild agitation, mild respiratory distress
HEENT: EOMI, anicteric, PERRL. MM moist. OP clear.
Neck: Large neck veins, JVP at earlobes
CV: irregularly irregular distant
Chest: scattered rhonchi with basilar rales
Abd: soft distended, hypoactive BS nontender
Ext: no edema, cool feet
Neuro: a&o x 2. strange affect.
Pertinent Results:
[**2110-6-5**] 10:00AM WBC-22.7* RBC-5.47* HGB-12.5 HCT-43.2 MCV-79*
MCH-22.8* MCHC-28.9* RDW-17.0*
[**2110-6-5**] 10:00AM NEUTS-87* BANDS-7* LYMPHS-6* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2110-6-5**] 10:00AM cTropnT-0.05*
[**2110-6-5**] 10:00AM CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2110-6-5**] 10:00AM GLUCOSE-134* UREA N-14 CREAT-0.9 SODIUM-148*
POTASSIUM-2.5* CHLORIDE-96 TOTAL CO2-27 ANION GAP-28*
[**2110-6-5**] 10:10AM LACTATE-7.7*
[**2110-6-5**] 11:53AM LACTATE-5.0*
[**2110-6-5**] 04:00PM cTropnT-0.15*
[**2110-6-5**] 07:45PM WBC-18.7* RBC-5.43* HGB-12.7 HCT-42.2 MCV-78*
MCH-23.4* MCHC-30.1* RDW-18.0*
[**2110-6-5**] 07:45PM CK-MB-NotDone cTropnT-0.16*
[**2110-6-5**] 07:53PM LACTATE-8.4*->17
INR 8 -> 16
Brief Hospital Course:
Ms. [**Known lastname 6930**] is a 77yo female with history of COPD, NSCLC, CAD,
longstanding hypertension, CHF and recurrent c. diff infections
presents with septic shock and profound lactic acidosis and
ultimately abdominal catastrophe.
1)Respiratory Failure: The patient was breathing in the 40's to
compensate for her acidemia and was beginning to tire out
overnight, neccesitating intubation. She is being maximized on
her minute ventilation to facilitate blowing off the acid, while
avoiding breath stacking given her severe underlying obstructive
disease. Once the lactate returned so high, this seemed to
explain that her hyperventilation was in compensation for
significant acidosis and not because of heart failure as
initially believed. ABGs were closely monitored and she remained
acidemic. Once the decision was made to withdraw care by her
family, the breathing tube was removed and the she expired soon
after.
2)Septic Shock: Unclear source. The assumption is an
intraabdominal catastrophe, possibly bowel ischemia given her
distended abdomen (which was not present on presentation to the
ED). While it is possible that the bowel abnormalities developed
secondary to hypotension, it still remains the only obvious
source of infection, given that she has a history of recurrent
c. diff infections. KUB was unrevealing. She was not stable
enough to undergo CT scan. She may have had a cardiac event with
a sudden decrease in CO, resulting in lactic acidosis and gut
ischemia. More likely she has stunned myocardium in the setting
of sepsis. Once the central line was placed, she was agressively
resuscitated with normal saline to maintain MAP>65 and CvO2>70.
Surgical consult was obtained and declined the patient as a
surgical candidate.
.
#. Rhythm: afib. patient has frequent short runs of NSVT which
improved on amiodarone. The ectopy was likely secondary to her
profound acidemia and electrolyte derangements.
.
#. Coronaries: shock could have been ischemic in etiology, ekg
was concerning for ectopy with NSVT, afib with RVR, but no
STTWC. Initial troponins were slightly elevated in the setting
of renal failure, tachycardia and sepsis. Held [**Known lastname 4532**] and
statin.
.
#. Leukocytosis: See sepsis discussion above. Had history of
recurrent c diff infections. She was pancultured. CXR did not
reveal consolidation. We were considering GI source with
elevation in LDH, concern for ischemic bowel.
She was maintained on vanco po, vanco iv and levo, zosyn for
double gram negative coverage.
.
#. Acute renal failure: creatinine was elevated above baseline -
it has bumped in the past when dehydrated from infection. This
was likely secondary to prerenal azotemia with poor forward
flow.
.
#. Coagulopathy: Patient appeared to be in DIC, but never bleed
actively.
.
.
.
.
.
.
Medications on Admission:
Albuterol Sulfate
Chlorothiazide 250 mg DAILY
Citalopram 40 mg every morning
Clopidogrel 75 mg Tablet DAILY
Fluticasone-Salmeterol 250-50 twice a day
Furosemide 100 mg twice a day
Gabapentin 600 mg twice a day
Hydromorphone 4 mg every four (4) hours as needed for pain
Humalog Mix 75-25 36 units am and 16 units pm
Ipratropium Bromide
Imdur 60 mg once a day
Metoprolol XL 150 mg twice a day
OxyContin 10 mg twice a day
oxygen - 2 liters per minute continuous flow as needed. O2
saturation at rest 93%, with minimal execise 84%
Potassium Chloride 60 mEq Tab once a day
Simvastatin 40 mg once a day
Trazodone 100 mg HS as needed
Warfarin 2 mg once a day
Aspirin 325 mg DAILY
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired on [**2110-6-6**] at 3:15pm.
ICD9 Codes: 0389, 2762, 4271, 5849, 4280, 4019, 4439, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5942
} | Medical Text: Admission Date: [**2105-8-10**] Discharge Date: [**2105-8-20**]
Date of Birth: [**2038-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
fever and coccygeal pain
Major Surgical or Invasive Procedure:
1. bedside debridement of right ischial necrotic tissue [**2105-8-11**]
History of Present Illness:
67-year-old man with paraplegia (as a result of an inflammatory
spinal cord process of unknown etiology), a chronic indwelling
Foley catheter, and a known sacral decubitus ulcer was evaluated
on an outpatient basis on [**8-1**] and was found to have a
leukocytosis (WBC 14K); Staph aureus was cultured from his
sacral decub. Cefpodoxime 200 mg twice daily was started.
Despite this intervention, he remained febrile, and he began
having yellow drainage from his ulcer. He was therefore brought
to the ED on [**8-10**]. There, he was hypotensive (80s/60s). Blood
and urine cultures were drawn, dexamethasone was given, empiric
vanc, levoflox, and flagyl were started, and 3.6 liters of fluid
were infused. He was admitted to the ICU.
On further review of systems, the patient reports a history of
progressive night sweats with chills over the past 5-6 months.
He's also had a cough productive of increasing amounts of white
sputum for the two months PTA. He has limited sensation but has
felt increased pain in his sacral decub recently. His
left-sided, burning chest pain, right-sided abdominal pain, and
R>L shoulder pain all started with the onset of his paresis and
have progressed steadily since then.
Blood pressure promptly returned to the range of the patient's
relatively low baseline with early goal directed therapy. He
was admitted to the ICU under the sepsis protocol but required
ICU-level care for less than 48 hours.
Fevers are most likely due to sacral osteomyelitis. Bone scan
non-diagnostic, but suggestive of osteomyelitis. MRI likely not
possible due to IVC filter; would confirm this with radiology.
Since we can probe to bone on physical exam, then the diagnosis
becomes increasingly likely. Referred to orthopedics consult
for bone biopsy and discussion of possible ulcer debridement.
Vancomycin and ciprofloxacin were started pending biopsy.
Continue aggressive wound care.
3. Pulmonary Embolism: Goal INR [**3-14**]. Warfarin currently being
held. Anticipate resuming it today; will need to monitor INR
closely on combination of warfarin and cipro.
4. Asthma: Continue advair and albuterol.
5. CAD: ASA, simvastatin
6. CHF: Monitor fluid status and respiration; if flashes in
context of fluid loading for sepsis protocol diurese.
7. Depression: continue citalopram.
8. Back Pain/Chronic Pain: Continue Dilaudid, baclofen, and
gabapentin.
9. FEN/GI: On HH diet. Replete lytes as indicated.
10. PPX: Bowel regimen, anti-coagulation with coumadin, PPI.
11. Communication: Patient declines to name family members or
other persons who could make decisions on his behalf or be
contact[**Name (NI) **] regarding this admit.
12. Code: Full-discussed admit, no advanced directives or HCP.
13. Access: RIJ CVC (presep) placed in ED [**8-10**], R AC PIV.
14. Dispo: Pending osteomyelitis work-up.
Past Medical History:
1. Inflammatory disease of the spinal cord of uncertain
etiology. MRA [**10-15**] negative for vascular malformation. Initial
CSF analysis showed elevated protein (82) without oligoclonal
bands. NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8. Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement. He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.
2. Chronic sacral decubitus ulcer, previously treated with a VAC
dressing
3. Multiple UTI (including Pseudomonas)
4. Pulmonary embolus [**11-14**] s/p IVC filter placement
5. Asthma
6. Two-vessel coronary artery disease s/p CABG 4-5 years ago
7. Systolic CHF (EF 25-30% on [**2-15**] TTE)
8. Repaired liver laceration
9. Chronic back pain
10. Vitiligo
11. Feeding tube
12. Depression
13. MRSA from sacral swab and sputum
14. Prior transient episodes of leg paralysis
15. Right frontal lobe brain lesion biopsied [**11-14**] and c/w
gliosis; resolved on repeat imaging
16. Abnormal visual evoked potentials
Social History:
He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**]. He is retired from a job in the
maritime industry. Divorced 24 years ago. Three children.
Quit smoking [**2076**]. Quit drinking [**2080**]. No history of illicit
drug use or abuse.
Family History:
No stroke, aneurysm, no seizure, no AAA.
Physical Exam:
97.7, 98/68, 80, 20, 97%
Gen: Well appearing male in NAD lying in bed.
HEENT: MMM, lips slightly pale, smooth tongue.
Chest: CTA bilaterally, no w/r/r.
CV: RRR, physiologic splitting S2, no m/r/g.
Abd: Soft, nontender/nondistended, g-tube in place, c/d/i.
Extremities: Warm, well perfused, no C/C. Trace pedal edema
bilaterally.
Skin: Vitiligo on hands. Large round 10 cm diameter pressure
decubitus ulcer on sacrum with appropriate dressing. Appears
clean with granulation tissue in center, no s/sx of infection.
Neuro: CN grossly intact. A&O x 3, pleasantly conversant.
Pertinent Results:
[**2105-8-20**] 07:25AM BLOOD WBC-7.6 RBC-3.66* Hgb-9.8* Hct-30.4*
MCV-83 MCH-26.9* MCHC-32.3 RDW-18.8* Plt Ct-319
[**2105-8-19**] 05:00AM BLOOD PT-14.3* PTT-30.4 INR(PT)-1.3*
[**2105-8-20**] 07:25AM BLOOD Glucose-142* UreaN-9 Creat-0.5 Na-140
K-4.3 Cl-104 HCO3-29 AnGap-11
[**2105-8-13**] 06:55AM BLOOD ALT-10 AST-8 AlkPhos-100 TotBili-0.1
[**2105-8-20**] 07:25AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
[**2105-8-10**] 07:00PM BLOOD Cortsol-7.9
[**2105-8-10**] 07:00PM BLOOD CRP-120.3*
[**2105-8-10**] 08:25PM BLOOD Lactate-0.8
[**2105-8-10**] 07:09PM BLOOD Lactate-0.7
[**2105-8-10**] 02:22PM BLOOD Lactate-2.5*
[**2105-8-17**] 4:00 pm TISSUE ISCHIAL BONE.
GRAM STAIN (Final [**2105-8-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2105-8-20**]):
ESCHERICHIA COLI. RARE GROWTH.
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
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2105-8-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2105-8-18**]):
NO FUNGAL ELEMENTS SEEN.
URINE CULTURE (Final [**2105-8-12**]):
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
STUDY: Left upper extremity venous ultrasound.
INDICATION: 67-year-old male with redness, swelling, and pain in
the left upper arm. Assess for DVT.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left internal
jugular, left subclavian, left axillary, left basilic, left
cephalic, and left brachial veins are performed. Normal
compressibility and waveforms are demonstrated.
IMPRESSION: No evidence of deep vein thrombosis of the left
upper extremity.
MRI OF THE PELVIS WITHOUT AND WITH IV CONTRAST:
IMPRESSION:
1. Large right decubitus ulcer involving the right posteromedial
buttock and right proximal medial thigh with right ischial
tuberosity osteomyelitis.
2. Midline sacral decubitus ulcer with probable osteomyelitis
involving the S4 vertebral body and absence of the S5 vertebral
body and coccyx suggesting osseous destruction.
3. No evidence of fistulous connection between the GI tract with
either the sacral or decubitus ulcer. No focal fluid collections
to suggest an abscess are present.
4. Diffuse signal abnormality and enhancement of the visualized
pevlic musculature suggestive of a myositis which may be
inflammatory in nature.
BONE SCAN: IMPRESSION:
Limited study but findings consistent with osteomyelitis of the
distal sacrum, coccyx, and right ischium.
CXR: Clear Chest
Brief Hospital Course:
1. Acute Osteomyelitis secondary to Decubitus Ulcer due to E.
Coli
- S/p Bone Biopsy
- E. Coli -> Vancomycin/Zosyn for total 6 weeks
- Flagyl x 6 weeks
- PRS was consulted for wound care, and recommended Dakins
solution with wtd dressings
- ID consultation
- Follow up with [**Hospital **] clinic 8/20/07@0930
2. Hypotension - Chronic
- Presumed neurogenic due to spinal cord injury
3. UTI - Enterococcal
- Vancomycin day [**10-23**] (for this)
4. Pulmonary Embolism
- IVC Filter
- Coumadin held for biopsy, restarted at 2 QHS
5. Depression
- Antidepressants were continued
6. CAD Native Vessle, Systolic CHF
- Aspirin
- B-Blocker
- ACEI
7. Parapalegia
- Kinaire Bed
- Turns Q2h
- PT evaluation
8. Lung Nodule
- Outpatient Workup
11. Communication: Patient declines to name family members or
other persons who could make decisions on his behalf or be
contact[**Name (NI) **] regarding this admit.
12. Code: Full-discussed admit, no advanced directives or HCP.
Medications on Admission:
1. trazadone 25 mg at bedtime
2. coumadin 2 mg qPM
3. tylenol 650 mg q8h prn
4. dilaudid 2 mg q4h prn
5. prostat 30 cc tid
6. xanax 0.25 mg po bid (started [**8-8**])
7. vitamin C 500 mg [**Hospital1 **]
8. aspirin 81 mg po daily
9. baclofen 5 mg po three times daily
10. bisacodyl supp every other day
11. cefpodoxime 200 mg twice daily
12. citalopram 40 mg po daily
13. docusate 100 mg po bid
14. omeprazole 40mg po daily
15. senna 2 tabs [**Hospital1 **]
16. simvastatin 40mg po qhs
17. advair 250/50 [**Hospital1 **]
18. neurontin 800mg tid
19. magnesium gluconate 500mg po bid
20. MVI with minerals daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q4H (every 4 hours) as needed for wheeze.
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
18. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Sodium Hypochlorite 0.5 % Solution Sig: One (1) Appl
Miscellaneous ASDIR (AS DIRECTED).
20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
21. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for pain.
22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation Q6H (every 6 hours) as needed.
23. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
twice a day for 5 weeks.
25. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 5 weeks.
26. BED
Kinair Bed
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute Osteomyelitis
Septic Shock - E. Coli
Decubitus Ulcer
Chronic Hypotension (neurogenic)
UTI Bacterial (Enterococcal)
Pulmonary Embolism
Depression
CAD Native Vessle
Systolic CHF
Parapalegia
Lung Nodule
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital if you experience high fevers, chills,
nausea/vomitting, bleeding from the ulcers
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2105-9-28**] 9:30
ICD9 Codes: 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5943
} | Medical Text: Admission Date: [**2133-2-20**] Discharge Date: [**2133-2-25**]
Date of Birth: [**2054-5-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vancomycin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain, dark stools
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
78 yo female with significant history of coronary artery disease
s/p CABG, ischemic cardiomyopathy s/p BiV-ICD placement and
ventricular tachycardia who presents with acute onset of likely
GI bleed and left-sided chest pain. The pain was located under
her left breast radiating to her back that awoke her from sleep
around 3 AM on the day of admission, [**8-7**] in severity. She
reports taking a few nitroglycerin tablets with some relief in
her pain. The pain was reported as being constant in nature as
achey in character. She also reports that she had significant
dyspnea on exertion this morning, upon walking to the bathroom,
which is not typical for her, no shortness of breath at rest. At
baseline, she can walk less than a city block without stopping
for rest. She received nitroglycerin and aspirin prehospital.
She reports no fever or chills, no cough. On further questioning
the patient does report having some dark stool intermittently
for the last month or so.
.
In the ED, initial VS were pain [**4-7**], T 97.2, P 64, BP 163/64, R
16, Sat 97%. On physical exam, patient had guaiac positive black
stool. ECG reportedly showed paced rhythm, with LAD, RBBB, new
ST depressions in V3 and V5, as well as new TWF in V3. Labs were
significant for hematocrit of 25 from baseline 34. Troponin was
noted to 0.04, which is below her baseline. In addition,
potassium was elevated at 5.5, creatinine elevated at 1.8 from
baseline of 1.5, and INR was 1.3. Patient was administered
full-dose aspirin and started on a nitroglycerin gtt. GI was
consulted for GI bleed, and recommended protonix bolus and gtt,
transfusion of 2 units PRBCs and possible EGD on [**2-20**].
Transfusion has not started at the time of transfer. Chest X-ray
was performed and showed no acute cardiopulmonary process.
Patient was chest pain free at the time of transfer. Peripheral
line and EJ line was placed in ED.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CAD status post inferoposterior wall MI, CABG in [**2106**]
(LIMA-LAD, SVG-OM, SVG-PDA, known SVG to PDA stenosis)--> Taxus
stent to SVG - PDA in [**2125-2-26**]--> stenting of anterograde limb
of PDA in [**2127-9-28**]. Demonstration of SVGSVG-rPDA
demonstrated 40%ostial lesion consistent with in-stent
restenosis.
- Permanent atrial fibrillation
- Ischemic CM, EF 22% on PMIBI [**2130-7-29**]. NYHA Class III.
- [**2131-5-2**] Biventricular ICD implant ([**Company 2267**] Cognis).
- [**2131-5-4**] LV lead revision
- Ventricular tachycardia status post ICD placement; generator
change 6.05
3. OTHER PAST MEDICAL HISTORY:
- Hypertension/LVH.
- Type 2 diabetes (HbA1c 7.5 in 6.10), followed at the [**Last Name (un) **]
by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10083**].
- Mild AS/AR.
- Hypothyroidism
- Irritable bowel syndrome/diverticulosis
- Chronic kidney disease
- Anemia
- Arthritis
- Breast CA, s/p R mastectomy and XRT [**2108**]
- Gastritis on EGD, w/ hiatal hernia
- diverticulosis
Social History:
- Widowed. Previously owned toy stores with husband. Lives
independently at home in [**Location (un) **]. Independent for all
ADLs.
- Tobacco history: none
- ETOH: none
- Illicit drugs: none
Family History:
Mother died at 53 of an MI, also had a stroke. Brother died of
MI at 40; sister died of MI in her 60s, another brother died of
congenital heart defect at 32(valve). Father died at 86.
Children both have diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: 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 JVD at level of the jaw.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM:
Vitals - Tm/Tc 97.8 HR 59-66 BP 110-125/55-64 RR 18-20 02 sat
100% RA
In/Out: Last 24H: -300, Last 8H: 0/1100
Weight: 67.9 (up 0.2 kg from yesterday)
Tele: paced
FS: 129
GENERAL: 78 yo female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Conjunctiva pink with injection on right side only that
extends to lower eyelid, no pallor or cyanosis of the oral
mucosa.
NECK: Supple with JVD at 3cm above clavicle
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. Systolic mumur [**2-2**] in RUSB. Murmur
radiating to bilateral carotids. No thrills, lifts.
LUNGS: CTAB no w/r/r
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ DP/PT, no pedal edema
GAIT: in bed, awaiting PT to see. ambulated with PT using
walker, steady on feet
Pertinent Results:
ADMISSION LABS:
WBC-5.0 RBC-2.76*# Hgb-8.2*# Hct-0*# MCV-90 MCH-29.9 MCHC-33.1
RDW-13.4 Plt Ct-164
Neuts-63.9 Lymphs-24.6 Monos-7.3 Eos-3.4 Baso-0.8
PT-14.1* PTT-57.0* INR(PT)-1.3*
Glucose-161* UreaN-65* Creat-1.8* Na-135 K-6.7* Cl-103 HCO3-22
AnGap-17
CK-MB-4
.
CHEST X-RAY ([**2133-2-20**]): Compared with prior, there has been no
significant interval change. The lungs remain clear. There is no
pleural effusion. There is no pulmonary vascular engorgement.
Cardiac silhouette is enlarged, but stable in configuration.
Biventricular pacing device again seen with multiple leads in
stable positions. Atherosclerotic calcifications seen throughout
the aorta. Median sternotomy wires and mediastinal clips again
noted.
IMPRESSION: No acute cardiopulmonary process.
.
DC LABS:
[**2133-2-25**] 06:30AM BLOOD WBC-6.5 RBC-3.38* Hgb-10.3* Hct-30.1*
MCV-89 MCH-30.4 MCHC-34.2 RDW-13.7 Plt Ct-145*
[**2133-2-25**] 06:30AM BLOOD Glucose-104* UreaN-47* Creat-2.2* Na-137
K-4.6 Cl-101 HCO3-30 AnGap-11
[**2133-2-25**] 06:30AM BLOOD Calcium-10.4* Phos-3.5 Mg-2.6
.
ENDOSCOPY [**2133-2-23**]:
Impression: Irregular z-line.
Abnormal mucosa in the esophagus (biopsy)
Slightly thickened gastric folds.
Polyp in the first part of the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up biopsy results. If duodenal polyp is
adenomatous, may need repeat endoscopy.
The findings do not account for the symptoms
Brief Hospital Course:
Ms. [**Known lastname **] is a 78 year old woman with significant history of
coronary artery disease s/p CABG, ischemic cardiomyopathy s/p
BiV-ICD placement and ventricular tachycardia who presented with
acute onset of likely GI bleed with resultant
exertionalleft-sided chest pain. She underwent an endoscopy
which didnt show any active signs of bleeding and was dc/ed to
[**Hospital 100**] Rehab d/t orthostatic hypotension.
.
# Gastrointestinal bleed: Ms. [**Known lastname **] experienced a hematocrit drop
from baseline of 34 to 24 in setting of guaiac positive dark
stool. Differential diagnosis for upper GI bleed included
bleeding ulcer, gastritis, or variceal bleed. She has history of
gastritis on previous EGD and diverticulosis on prior
colonoscopy. On admission, Ms. [**Known lastname **] was started on a protonix
drip, and GI was consulted who performed EGD on [**2-23**] which
demonstrated no acitve site of bleeding and no lesion that may
have been responsible for the GIB. Ms. [**Known lastname **] [**Last Name (Titles) 35325**] 3 units of
blood on the first day of admission which resulted in resolution
of her chest pain.
.
# Chest pain: Ms. [**Known lastname **] experienced left-sided chest pain which is
similar to her prior anginal symptoms. There were no discernible
EKG changes but these are difficult to interpret in the setting
of BiV pacing. Her MB was flat and troponins were less than
baseline (normally elevated secondary to CKD). Patient received
full-dose aspirin and was initiated on a nitroglycerin gtt in
the ED with resolution of her pain. Pain did not recur after
weaning the nitroglycerin drip and receiving 3 units of PRBCs
until 2 days later on [**2-22**]. Beta blockade and lisinopril were
initially held but were restarted at lower dose on [**2-21**].
Lisinopril however was held at the time of dc due to a Cr bump.
.
# Ischemic cardiomyopathy: Ms. [**Known lastname 96778**] furosemide and
spironolactone were initially held given concern for GI bleed.
Before d/c her Cr was high so lasix and lisinopril were held.
.
# Atrial fibrillation: CHADS2 score of 4. Ms. [**Known lastname **] states that
her physicians told her to stop dabigatran several months ago
and according to GI note from [**Month (only) 404**] her dabigatran had already
been stopped. Her outpatient cardiologist, Dr. [**Last Name (STitle) **], was
contact[**Name (NI) **] and an appt was set up. On discharge, she was
prescribed dabigatran 75 [**Hospital1 **] and set up with outpt f/up.
.
# Type 2 diabetes mellitus: Home lantus and a sliding scale were
continued in lieu of her januvia and sulfonyluea.
.
# Hypothyroidism: Continued home levothyroxine
.
TRANSITIONAL ISSUES: The pt developed some orthostatic
hypotension just before the time of discharge and her Cr spiked,
likely in the setting of being NPO for a long period and getting
lisinopril and lasix. These meds were held at the time of dc and
she will need a CHEM 7 before these meds can be restarted.
Medications on Admission:
Metoprolol succinate 200 mg PO daily
Lisinopril 10 mg PO daily
Furosemide 40 mg PO daily
Aspirin 81 mg PO daily
Isosorbide mononitrate 30 mg PO daily
Rosuvastatin 20 mg PO daily
Levothyroxine 0.1 mcg PO daily
Omeprazole 20 mg PO daily
Insulin glargine 16 units PO QAM
Insulin Humalog per sliding scale patient only takes when BS>400
Januvia 50 mg PO PO daily
Glipizide 2mg [**Hospital1 **]
Ferrous sulfate 325 mg PO daily
Vitamin B6 100 mg PO daily
Vitamin B12 100 mcg PO daily
Doxercalciferol
Multivitamin 1 tab PO daily
Loperamide PO PRN
Discharge Medications:
1. Outpatient Lab Work
Please have your labs drawn at rehab [**2-27**] and have those
results faxed to your PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 1728**] [**Telephone/Fax (1) 7922**]
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
10. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. insulin glargine 100 unit/mL Cartridge Sig: Sixteen (16)
units Subcutaneous qAM.
13. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
14. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
15. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual Q 5 minutes x3 as needed for chest pain: take as
directed.
16. Pradaxa 75 mg Capsule Sig: One (1) Capsule PO twice a day.
17. Hectorol 0.5 mcg Capsule Sig: Two (2) Capsule PO twice a
day.
18. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Blood loss from unknown source (likely GI)
Chest pain from blood loss
Secondary diagnosis:
Coronary artery disease
Cardiomyopathy (weak heart muscle)
Hypertension
Diabetes
Chronic kidney disease
Atrial fibrillation
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:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital for chest pain and dark stools. You met with the
GI doctors, and an EGD scope procedure was performed. You also
had a biopsy done, the results of which are pending on
discharge. Your bleeding stopped after 3 units of blood, and
your blood counts remained stable. Your chest pain was felt to
be related to the bleeding, and this improved.
.
You had mild worsening of your kidney function, which was likely
related to dehydration. This improved with IV fluids. You will
require a repeat blood test to ensure that your blood counts and
kidney function are stable. You should have this test done on
friday, if the kidneys look better, we will restart you on your
lasix and lisinopril.
.
MEDICATION CHANGES:
- INCREASE omeprazole to 20 mg twice a day
- HOLD your Lasix (Furosemide)
- HOLD your Lisinopril
*if your kidney function is improving on Friday [**2-27**], please
resume both Lasix 40mg daily and Lisinopril 10mg daily
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 2 days or 5 lbs in
3 days, follow a low salt diet and restrict your fluids to 1500
ml/ day.
Please have your hematocrit and BMP drawn on Friday [**2-27**]
Followup Instructions:
Please draw Hct and BMP on Friday [**2-27**] and fax to Dr. [**First Name (STitle) **]
[**Name (STitle) 1728**] [**Telephone/Fax (1) 7922**]
Department: GASTROENTEROLOGY
When: THURSDAY [**2133-3-5**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**State **]When: MONDAY [**2133-3-9**] at 9:45 AM
With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: CARDIAC SERVICES
When: FRIDAY [**2133-7-10**] at 10:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*Dr. [**Last Name (STitle) **] is working on a [**Month (only) 958**] appointment for you. She
will contact you directly if she can fit you in.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 5789, 2851, 2724, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5944
} | Medical Text: Admission Date: [**2167-7-25**] Discharge Date: [**2167-7-30**]
Date of Birth: [**2090-9-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Weakness/fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo Male with hx of AVR, CAD s/p CABG, MDS- pancyopenia,
non-hodgkins lymphoma, and Parkinson's who was relaeased from
the hospital 2 months ago for a pneumonia. He brought in from
his ECF because of fever to 105 and new weakness, and sob. He
says he has had a cough and SOB for the last few weeks. Today he
was unable to get up and go to the bathroom. He denies any
fevers prior to today. He denies any pains including chest and
abdominal pain. In the ED a CXR showed possible RLL PNA versus
atelectasis. His UA was neg, he got 3 sets of blood cultures. He
was given Vanc/zosyn/azithro in the ED for emperic coverage of a
HCAP, tylenol 325 after 650 earlier in the day for his fever and
4L of IVF. His EKG showed sinus tachycardia in the ED.
On arrival to the MICU,
in rigors, not febrile at this time, has cough, no pain.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. AS s/p porcine Aortic Valve Replacement ([**2162-3-3**])
2. CAD s/p CABG x 2 (LIMA to LAD, SVG to OM [**2162-3-3**])
3. CKD
4. Depression / anxiety, currently treated only with diazepam
qhs. Previously on Effexor and benzo and Seroquel (stopped in
[**2157**] due to EPS/?PD)
5. hyperlipidemia on crestor
6. Hypothyrodism
7. Tremor
8. Gait disorder, thought by Dr. [**Last Name (STitle) **] to be primarily due to
posterior column dysfunction
9. BPH s/p TURP, no longer on Flomax; nocturia x hourly
10. non-Hodgkin's Lymphoma s/p chemo/BMT @OSH was in remission
until current thrombocytonia
11. OSA on prior sleep study; pt refuses CPAP; wife says no
snoring. M-III to M-IV airway, with extra neck soft tissues.
Social History:
Married, kids in CA (just visited, as above), lives with wife.
Retired from cigarette sales ~15y ago.Chronic/progressive health
problems as above. Smoked heavily in military ~50y ago, but quit
cigs and now smokes occasional cigars "do not inhale" for many
years. Says 1-2 beers per night, but formerly drank heavily (up
to ~15 years ago when he retired). Denies any h/o illicit drug
use or supplements.
Family History:
Non-contributory
Physical Exam:
Admission Exam:
Vitals: T: 98.6 BP: 166/87 P: 136 R: 39 O2: 99
General: Alert, rigors
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Tachycardic, crisp S1, s2, no rubs, gallops
Lungs: Scattered wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge exam:
Pertinent Results:
[**2167-7-25**] 04:50PM WBC-6.9# RBC-3.59* HGB-10.4* HCT-32.3*
MCV-90# MCH-29.1# MCHC-32.2 RDW-22.5*
[**2167-7-25**] 04:50PM NEUTS-57 BANDS-4 LYMPHS-23 MONOS-11 EOS-0
BASOS-0 ATYPS-4* METAS-0 MYELOS-0 BLASTS-1* NUC RBCS-1*
[**2167-7-25**] 04:50PM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2167-7-25**] 04:50PM PLT SMR-VERY LOW PLT COUNT-31*
[**2167-7-25**] 04:50PM PT-13.6* PTT-28.1 INR(PT)-1.3*
[**2167-7-25**] 04:50PM CALCIUM-8.7 PHOSPHATE-1.2*# MAGNESIUM-1.8
[**2167-7-25**] 04:50PM CK-MB-1 cTropnT-<0.01
[**2167-7-25**] 04:50PM CK(CPK)-71
[**2167-7-25**] 04:50PM GLUCOSE-113* UREA N-22* CREAT-1.4* SODIUM-133
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
[**2167-7-25**] 05:04PM LACTATE-0.9
[**2167-7-25**] 06:30PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2167-7-25**] 06:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2167-7-25**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2167-7-25**] 06:30PM URINE UHOLD-HOLD
[**2167-7-25**] 06:30PM URINE HOURS-RANDOM
CXR [**7-25**] PA and lateral
The patient is status post median sternotomy for CABG. Heart
remains mildly enlarged with left ventricular predominance. The
patient is status post aortic valve replacement. The
mediastinal contours are unchanged, with mild calcification of
the aortic knob again demonstrated as well as a mildly tortuous
course of the thoracic aorta. The pulmonary vascularity is not
engorged. Streaky opacities in the lung bases are nonspecific,
possibly reflecting atelectasis though infection cannot be
excluded. No pleural effusion or pneumothorax is visualized.
There are no acute osseous abnormalities.
IMPRESSION:
Streaky bibasilar opacities, which could reflect atelectasis
though infection cannot be completely excluded.
Brief Hospital Course:
76 yo Male with hx of AVR, CAD s/p CABG, MDS- pancyopenia,
non-hodgkins lymphoma, and Parkinson's who was relaeased from
the hospital 2 months ago for a pneumonia who returns with a
HCAP and new a. fib w/ rvr. Was treated in the ICU and
transferred to the floor to complete 10 day course of
antibiotics.
1) HCAP pneumonia/sepsis- Pt initially sirs criteria, and
presented with dry cough x2 weeks, new weakness, and his CXR was
concerning for a new RLL inflitate. With the pt's history of
Parkinson's disease, was at risk for aspiration due to
dysphagia, and thus cause recurrent pneumonia. Pt's fever curve
improved with vancomycin, cefepime and azithromycin for a 10 day
course (through [**2167-8-6**]). Blood cultures were negative. Pt's dry
cough did not improve with cough syrup, tessalon perles and
nebulizer treatments and thus had an ENT consult which found
mild irritation of vocal cords most likely related to acid
reflux or viral infection. Laryngoscopy did not show vocal cord
paralysis and structurally normal. Cough mildly improved while
on the floor, but still with significant cough at discharge. He
was started on prednisone 40 mg PO daily for a 4 day total
course to end on [**2167-8-2**].
2) New Atrial fib w/ rvr in 120s likely due to stress of
increasing cardic output in septic picture. Other concerns
included his thyroid medicine and new ischemia but TSH normal
and cardiac enzymes were negative. Pt was rate controlled with
metoprolol 50mg TID and was successfully converted to NS rhythm.
Echo was done which showed LVEF>55%, no thrombus. Pt's CHADS2
score at 1. Aspirin was held due to thrombocytopenia.
Metoprolol was discontinued given his reactive airways and
wheezing. On stopping, patient tended to be borderline
tachyardia with intermittent atrial fibrillation and bigeminal
PACs. When his pulmonary symptoms resolve, metoprolol should be
considered if his tachycardia/afib persists at rehab.
3) Parkinson's disease: Was continued on home pramipexole during
course and was evaluated by speech and swallow for dysphagia; pt
was cleared for regular solid PO intake.
4) MDS/Non-Hodgkin's lymphoma: s/p chemo and BMT, chronic
thrombocytopenia. Pt had no bleeding issues. Patient required
transfusion of 1 unit of platelets prior to PICC line placement
but otherwised remained above transfusion threshold without
evidence of bleeding.
5) Hyperlipidemia: Rosuvastatin was continued throughout course.
6) BPH: Tamsulosin was continued throughout course.
7) Depression/Anxiety: Stable, PRN diazepam. Was requiring
approximately one additional dose of diazepam daily.
8) Hypothyroid: continue home Levothyroxine Sodium 50 mcg PO
DAILY. TSH normal.
9) Left ear ceurmen: Stable.
10) Constipation: Continued Lactulose, Polyethylene Glycol,
Docusate Sodium 100 mg PO BID, and Senna 1 TAB PO BID.
# Transitional issues:
- Consider starting patient on metoprolol for new atrial
fibrillation, was started in house, then discontinued given
reactive airways. Should be restarted if he continues to have
tachycardia/afib once pulm symptoms resolve.
- Patient should continue full treatment for HCAP with
vancomycin 1g IV Q12 and Cefepime 2 g IV Q12H through is PICC
line, both through [**2167-8-6**].
- PICC line okay to use by nursing staff at rehab. CXR confirmed
placement on [**7-29**] and has been used here.
- Patient started on prednisone 40 mg PO daily for reactive
airways, which should continue through [**8-2**].
- Patient started on high dose PPI while in house given ENT
evaluation of laryngeal inflammation from possible reflux. This
should be discussed with PCP and [**Name9 (PRE) 31042**] in 2 weeks.
Continued high dose PPI has multiple risks and these should be
weighed.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Record.
1. Diazepam 5 mg PO DAILY:PRN anxiety
2. Lactulose 15 mL PO DAILY constipation
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Acetaminophen 325-650 mg PO Q4H:PRN pain/fever
6. Codeine Sulfate 15-30 mg PO Q4H cough
7. Guaifenesin-Dextromethorphan 15 mL PO Q4H:PRN cough
8. Benzonatate 200 mg PO TID:PRN cough
9. Docusate Sodium 100 mg PO BID
10. Senna 1 TAB PO BID
11. pramipexole *NF* 0.5 mg Oral TID Parkinson's
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
13. Levofloxacin 500 mg PO Q24H PNA Duration: 13 Days
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Tamsulosin 0.4 mg PO HS BPH
16. Carbamide Peroxide 6.5% 5 DROP AD QHS Duration: 4 Days
Left ear at bedtime
17. Rosuvastatin Calcium 10 mg PO DAILY
Discharge Medications:
1. Carbamide Peroxide 6.5% 5 DROP AD QHS Duration: 4 Days
Left ear at bedtime
2. Acetaminophen 325-650 mg PO Q4H:PRN pain/fever
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
4. Benzonatate 200 mg PO TID:PRN cough
5. Codeine Sulfate 15-30 mg PO Q4H cough
6. Diazepam 5 mg PO DAILY:PRN anxiety
7. Docusate Sodium 100 mg PO BID
8. Guaifenesin-Dextromethorphan 15 mL PO Q4H:PRN cough
9. Lactulose 15 mL PO DAILY constipation
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. pramipexole *NF* 0.5 mg Oral TID Parkinson's
14. Rosuvastatin Calcium 10 mg PO DAILY
15. Senna 1 TAB PO BID
16. Tamsulosin 0.4 mg PO HS BPH
17. CefePIME 2 g IV Q12H
Continue through [**8-6**].
18. Vancomycin 1000 mg IV Q 12H
Continue through [**8-6**].
19. PredniSONE 40 mg PO DAILY Duration: 3 Days
Continue through [**8-2**].
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
Discharge Diagnosis:
Primary:
Health care associated pneumonia
New atrial fibrillation
Secondary:
Myelodysplastic syndrome
Thrombocytopenia
Discharge Condition:
Patient is afebrile with stable vitals. Satting mid 90s on RA.
He is in and out of a fib and borderline tachycardic in the
90s-100s. Lung exam with inspiratory and expiratory wheezing
and transmitted upper airway sounds, breathing is nonlabored.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - With walker or aid.
Discharge Instructions:
Dear Mr. [**Known lastname 35501**],
You were admitted to the [**Hospital1 69**]
for symptoms concerning for pneumonia. We treated your pneumonia
with antibiotics and your fevers resolved. You will need to
continue taking antibiotics at the rehab facility. A PICC line
was placed in your left arm and it's placement was confirmed
with an x-ray, so your antibiotics can be given at rehab. You
were also started on steroids (prednisone) for a total of 5 days
to help with your breathing.
It was a pleasure taking care of you at the [**Hospital1 18**].
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2167-8-6**] at 3:20 PM
With: [**First Name8 (NamePattern2) **] [**Known firstname **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appt with Dr. [**Last Name (STitle) 35507**] at [**Hospital 10596**]. You will be called at home/rehab with the appointment.
If you have not heard or have questions, please call ([**Telephone/Fax (1) 35513**].
Department: DERMATOLOGY
When: MONDAY [**2167-8-17**] at 9:30 AM
With: [**Doctor Last Name 3833**] [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2167-10-15**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Known firstname **] [**Last Name (NamePattern1) **], MD [**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 [**2167-11-25**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2167-7-30**]
ICD9 Codes: 0389, 486, 2724, 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5945
} | Medical Text: Admission Date: [**2130-3-20**] Discharge Date: [**2130-3-31**]
Date of Birth: [**2080-6-9**] Sex: F
Service: SURGERY
Allergies:
Tegretol
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Coffee Ground Emesis
Urinary Tract Infection
Fever
Hypotension
Major Surgical or Invasive Procedure:
Right subclavian central line
History of Present Illness:
49 F with developmental delay, RA, paraplegia [**2-10**] L1-L2
compression fx, anasarca [**2-10**] FSGS, s/p recent prolonged
hospitalization from [**2130-1-25**] to [**2130-3-15**]. The discharge summary
was reviewed, and is briefly summarized below.
.
She initially presented with diffuse edema involving the entire
body, that had worsened over the past 2-3 months. She was found
to have FSGS by renal biopsy. Her hospitalization was also
significant for an L1-L2 vertebral compression fracture with
near paralysis of her lower extremities. She underwent T10-L4
posterior fusion that was complicated by wound infection and VRE
bacteremia. She underwent wound exploration with incision and
debridement on [**3-10**]. She was discharged to [**Hospital1 **] on
[**3-15**] to complete a course of linezolid.
.
At [**Hospital1 **], she was found to have a UTI and was
started on Amikacin on [**3-19**]. Also had multiple episodes of
emesis o/n. Febrile to 102.7 at 01:00 on [**3-20**]. Then on am of
[**3-20**], had approx 200 cc of coffee ground emesis. Sent to [**Hospital1 18**]
for further management.
.
In [**Hospital1 18**] ED, NG lavage with return of blood that did not clear
after 500 cc saline. Received 2L NS for BP 84/64, and levoflox /
Flagyl. Also received 2 units FFP for INR 1.4.
.
Admitted to MICU where bedside EGD showed grade 3 esophagitis
without active bleed.
Past Medical History:
1. Osteoarthritis.
2. Rheumatoid arthritis.
3. Osteoporosis with vertebral compression fractures - normal
BMD at the femoral neck, osteopenia at the trochanter, and
osteoporosis at the total hip ([**2129**])
4. Developmental delay.
6. Sleep apnea; since [**2116**] on nocturnal ventilation with BiPAP
at 18/12 cm H20 plus 4 liters of nasal cannular oxygen titrated
in, else will desaturate to 45%
7. Obesity.
8. History of leg ulcers.
9. Leg swelling - since [**2116**], followed by podiatry and vascular
surgery (Dr. [**Last Name (STitle) **]
10. Pilonidal cyst removal - [**2117**], complicated by wound
dehiscence
11. R knee replacement - [**2126**]
12. SLE - dx [**2120**], diagnosis not documented well
Social History:
Developmentally delayed. Had been living with mother and sister
until recent hospitalization, now at [**Hospital1 **].
Family History:
Non-contributory
Physical Exam:
Vitals - T 98.1, BP 119/66, HR 99, RR 29, O2 sat 100% on 2L NC,
wt 87.6 kg
General - obese female, appears comfortable, in NAD, speeking
full sentences
HEENT - PERRL, OP clr, MM sl dry
Chest - CTAB
CV - RRR, nl s1, s2, no m/r/g
Abdomen - NABS, soft, mild tenderness to palpation in RLQ, no
g/r
Extremities - diffuse 3+ bilat edema
Back - incision intact, with serous drainage from inferior
aspect; min surrounding erythema at inferior; ~4cm R gluteal
stage II decub with serousanguinous drainage with min
surrounding erythema
Pertinent Results:
Admission Labs:
[**2130-3-20**] 12:30PM BLOOD WBC-25.1*# RBC-3.28* Hgb-9.4* Hct-29.7*
MCV-91 MCH-28.8 MCHC-31.8 RDW-15.8* Plt Ct-281
[**2130-3-20**] 12:30PM BLOOD PT-15.7* PTT-33.4 INR(PT)-1.4*
.
Labs at Transfer From MICU to Floor
[**2130-3-25**] 05:36AM BLOOD WBC-12.6* RBC-3.22* Hgb-9.5* Hct-28.4*
MCV-88 MCH-29.4 MCHC-33.3 RDW-16.6* Plt Ct-173
[**2130-3-25**] 05:36AM BLOOD Neuts-89.8* Lymphs-7.2* Monos-2.2 Eos-0.7
Baso-0.2
[**2130-3-25**] 05:36AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
[**2130-3-25**] 05:36AM BLOOD PT-15.5* PTT-37.3* INR(PT)-1.4*
[**2130-3-25**] 05:36AM BLOOD Glucose-101 UreaN-3* Creat-0.2* Na-141
K-4.1 Cl-112* HCO3-25 AnGap-8
[**2130-3-25**] 05:36AM BLOOD ALT-7 AST-5 LD(LDH)-213 AlkPhos-92
TotBili-0.3
[**2130-3-25**] 05:36AM BLOOD Albumin-1.6* Calcium-8.1* Phos-2.7 Mg-2.2
.
CHEST (PORTABLE AP) [**2130-3-20**] 12:52 PM
AP CXR: Nasogastric tube has been placed, coiling in the
proximal stomach. Cardiac and mediastinal contours are stable
allowing for marked patient rotation. No focal areas of
consolidation within the lungs, and there are no definite
pleural effusions. Right costophrenic angle has been excluded
from the study and cannot be assessed. Mild elevation of right
hemidiaphragm is noted.
.
CHEST (PORTABLE AP) [**2130-3-25**] 5:55 AM
1. Slightly increased right pleural effusion, unchnaged left
pleural effusion.
2. Mild interstitial pulmonary edema, stable.
.
CT L-SPINE W/ CONTRAST [**2130-3-21**] 12:02 PM
IMPRESSION: While no abnormal enhancement is noted, significant
metallic streak artifact and subcutaneous soft tissue stranding
extending down to the spinal canal is present. It is
indeterminate how much of this represents postoperative change
vs. possible infection/phlegmon.
.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2130-3-21**] 11:43 AM
1. Acute cholecystitis.
2. Bilateral small pleural effusions and adjacent atelectasis.
3. Right adrenal mass, unchanged.
4. Abdominal rectus sheath hematoma and left-sided abdominal
wall fluid collection, unchanged.
5. Status post posterior fusion of multiple thoracolumbar
vertebrae,
unchanged in construct from [**2130-3-2**].
.
ECG (MICU admission [**3-20**]):
Sinus tach @ 114; baseline artifact; diffuse TWF across
precordium; aside from tachycardia, no change from [**2130-2-9**]
.
EGD (MICU admission [**3-20**]):
Impression: Grade 3 esophagitis in the lower third of the
esophagus and middle third of the esophagus. Otherwise normal
EGD to second part of the duodenum.
.
[**2130-3-23**] 8:24 am STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2130-3-23**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2130-3-21**] 6:12 pm SWAB Source: sacral.
Staphylococcus aureus and beta streptococcus).
PROBABLE ENTEROCOCCUS. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
YEAST. RARE GROWTH.
.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
.
ANAEROBIC CULTURE (Final [**2130-3-25**]): NO ANAEROBES ISOLATED.
.
Brief Hospital Course:
She was admitted to MICU under the care of the Medicine Service.
A bedside EGD was performed which showed grade 3 esophagitis
without active bleed, and UGI bleed resolved with PPI's. Her
Hct was stable at 28 after receiving 2units of FFP (in ED) and
2units of PRBC (on the floor). Her hypotension was persistent
thought secondary to her cholecystitis seen on her abdominal CT
as well as her MDR-resistant pseudomonal UTI. A CVL was placed
and she was started on Levophed for blood pressure support. She
was continued on Amikacin for her pseudomonal UTI and started on
Zosyn for her cholecystitis. Her linezolid from a previous VRE
bacteremia was continued until [**3-24**]. General Surgery was
consulted and initially felt that she did not require surgical
intervention at the time and she was planned for percutaneous
cholecystotomy.
She managed to defervesce without percutaneous drainage and was
weaned off pressors on [**3-23**] and her blood pressure normalized.
Foley was changed and repeat UA improved. A one week course of
Amikacin was completed for her pseudomonal UTI, her course of
Linezolid completed on [**3-24**], and she was transferred to the
floor on Zosyn.
She was re-evaluated by General Surgery on [**3-26**], the decision to
proceed with a lap chole on [**3-27**] was made. She was taken to the
operating room where the laporascopic chole was converted into
an open cholecystectomy secondary to a gangrenous gallbladder.
Postoperatively her care was transferred to the General Surgery
service.
Her staples were removed on day of discharge; she will require
follow up with Dr. [**Last Name (STitle) **] mid [**Month (only) 547**].
On HD#10 she was given a clear diet, this was slowly advanced.
Her nutritional status will require close monitoring; it is
being recommended that calorie counts be initiated once at
rehab. She had been on Megace prior to hospitalization, this was
restarted prior to her discharge. Boost Plus supplements have
also been added to her diet. She previously had a rectal tube
that was placed while on the Medicine service; this was
discontinued.
She was hypernatremic with a Na of 148 during her early
hospitalization while on the Medicine service; it was felt
iatrogenic secondary to IV fluid. Her last Na on [**3-30**] was 143.
She did require intermittent IV Lasix for diuresis and was
continued on 20 mg IV BID. Her Lasix was changed to 20 mg po
daily; she was not on this medication prior to her
hospitalization. It is being continued as she still has some
volume overload issues; continued use should be re-evaluated
once her volume status stabilizes.
Physical and Occupational therapy consults were placed and they
have recommended rehab stay after her acute hospitalization.
Medications on Admission:
Cyanocobalamin 1000 mcg SQ Q30d
Aranesp 0.06 mg SQ QTh
fondaparinox 2.5 mg SQ QD
Zofran 8 mg IV Q8h PRN
Amikacin 250 IV Q12h
Lipitor 80 QD
Iron 300 QD
Vit D 50000Qsu
Megace 400 QD
Linezolid 600 [**Hospital1 **]
Calcium 500 TID
Reglan 10 Q6h prn
Senna [**Hospital1 **]
Colace 100 [**Hospital1 **]
Bisacodyl 5 QD
Calcitriol 0.25 QD
Lisinopril 5 QD
MVI QD
Vit C 500 [**Hospital1 **]
Tylenol prn
Calcitonin 200 IU QD
Dilaudid [**2-12**] PO Q4h prn
Ketoconazole 2% cream
Ketoconazole 2% shampoo
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per insulin sliding
scale.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Erythromycin 5 mg/g Ointment Sig: One (1) dose Ophthalmic QID
(4 times a day): administer OS.
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
11. Megace Oral 40 mg/mL Suspension Sig: Ten (10) ML's PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Upper GI Bleed
MDR-psuedomonal Urinary Tract Infection (sensitive to amikacin)
VRE Wound Infection
Sepsis
Acute Cholecystitis
Discharge Condition:
Stable
Followup Instructions:
Follow up next with Dr. [**Last Name (STitle) **] in General Surgery Clinic; call
[**Telephone/Fax (1) 92654**] to schedule a time for this appointment for
sometime in [**Month (only) 547**].
Previous scheduled appointments:
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2130-3-28**] 11:30
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2130-5-1**] 2:00
.
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2130-5-22**] 3:00
Completed by:[**2130-3-31**]
ICD9 Codes: 0389, 4280, 5990, 5180, 2760, 2768, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5946
} | Medical Text: Unit No: [**Numeric Identifier 62011**]
Admission Date: [**2198-5-8**]
Discharge Date: [**2198-5-30**]
Date of Birth: [**2198-5-8**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 8665**] [**Known lastname **], twin number two,
was born at 32 weeks gestation by Cesarean section for
worsening pregnancy induced hypertension. Mother is a 36
year-old, Gravida I, Para 0 now II woman. Prenatal screens
included blood type B positive, antibody negative,
Rubella immune, RPR nonreactive, hepatitis B surface antigen
negative and group B strep negative. This pregnancy was
complicated by pregnancy induced hypertension, prompting
maternal admission six days prior to delivery. The mother
received a complete course of Betamethasone prior to
delivery. The infant emerged vigorous. Rupture of membranes
occurred at the time of delivery. Apgars were 7 at 1 minute
and 8 at 5 minutes. Birth weight was 1,705 grams. Birth
length was 43 cm. Birth head circumference was 29.5 cm.
PHYSICAL EXAMINATION: Admission physical examination reveals
an active, pink, non dysmorphic, preterm infant. Anterior
fontanel soft and flat. Positive bilateral red reflex.
Comfortable respirations. Lungs clear. Heart was regular
rate and rhythm. No murmur. Benign abdomen. Non focal and
age appropriate neurologic examination. Skin without
lesions. Normal hips. Spine intact.
HOSPITAL COURSE: NICU course by systems:
Respiratory status: She has remained in room air throughout
her NICU stay. She has had rare episodes of apnea and
bradycardia, but none for greater than 5 days by the time of
discharge. On examination, her respirations are
comfortable. Lung sounds are clear and equal.
Cardiovascular status: [**Known lastname 8665**] has remained normotensive
throughout her NICU stay. On examination, her heart has
regular rate and rhythm, no murmur. She is pink and well
perfused.
Fluids, electrolytes and nutrition: At the time of
discharge, her weight is 2,245 grams. Her length is 45.5 cm
and her head circumference is 32 cm. Enteral feeds were
begun on day of life number one and advanced without
difficulty to full volume feeding. At the time of discharge,
she is breast feeding and supplementing with 24 calories per
ounce breast milk on an ad lib schedule.
Gastrointestinal: She never received phototherapy. Her peak
bilirubin occurred on day of life number four and was total
of 5.2, direct of 0.2.
Hematology: Her hematocrit on day of life number one was
48.9. That is her most recent hematocrit. She never received
any blood product transfusions during her NICU stay.
Infectious disease: She was started on Ampicillin and
Gentamycin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours and the
blood culture was negative and the infant was clinically
well. On day of life 17, she completed a 5 day course of
Nystatin powder for a milial diaper rash.
Neurology: Patient maintained a normal neurologic examination
during hospitilization. Screening HUS was not performed given
advanced gestational age and benign course.
Audiology: Hearing screening was performed with automated
auditory brain stem responses and the infant passed in both
ears.
Psychosocial: Parents have been very involved in the
infants' care throughout their NICU stay.
CONDITION: The infant is discharged in good condition. She
is discharged home with her parents.
PRIMARY PEDIATRIC CARE: Provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44797**] at
[**Apartment Address(1) 62009**], [**Hospital1 8**], MA, [**Telephone/Fax (1) 62012**].
RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings: Breast feeding with supplemental 24 calorie per
ounce breast milk or formula as needed to maintain weight
gain.
2. Medications: Tri-Vi-[**Male First Name (un) **] 1 ml p.o. daily. Ferrous sulfate (25
mg/ml) 0.2 ml p.o. daily.
3. She passed a car seat position screening test.
4. Her last state screen was sent on [**2198-5-11**].
5. She received her first hepatitis B vaccine on [**2198-5-23**].
6. Recommended immunizations:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 and 35 weeks with two of the following: Daycare during
RSV season , a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; or (3)
with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for house hold
contacts and out of home caregivers.
FOLLOW UP:
1. Early intervention at the [**Hospital1 8**]-[**Location 17065**] Early
Intervention Program, telephone number [**Telephone/Fax (1) 45540**].
2. Care group [**Hospital6 **]. Telephone number
[**Telephone/Fax (1) 14297**].
3. Lactation consultant support by [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 62013**]. Telephone
number [**Telephone/Fax (1) 61687**].
DISCHARGE DIAGNOSES:
1. Status post prematurity at 32 weeks gestation.
2. Twin number two.
3. Sepsis ruled out.
4. Status post apnea of prematurity.
5. Status post milial diaper rash.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-ABQ
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2198-5-30**] 16:00:54
T: [**2198-5-30**] 16:39:03
Job#: [**Job Number 62014**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5947
} | Medical Text: Admission Date: [**2134-10-14**] Discharge Date: [**2134-10-21**]
Date of Birth: [**2062-5-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
fevers, MS changes, increased upper respiratory congestion
Major Surgical or Invasive Procedure:
CT scan of the abdomen, head
central venous line placement
Peripheral intravenous central catheter placement
nasogastric tube placement
History of Present Illness:
72 y/o male nursing home resident brought in by ambulance for
fever to 103.6, mental status change, and increased upper
respiratory congestion. Nurses noted change in mental status
since 6AM on morning of admission, as well as low grade fevers
starting the day prior with max to 103.6 at 6AM th emornig of
admission. At baseline he is disoriented to person, place, and
time. He is exclusively bedbound. He has had several days of non
productive cough, distended abdomen, and large-loose/oozing
stools. EMS noted patient lying in bed, extremely diaphoretic,
with fever to 103.6, and distended abdomen.
.
In ED, code sepsis initiated, right IJ sepsis line placed,
intubated for airway protection, blood, urine cultured, given
Vanco 1g IV, levofloxacin 500 mg IV, clindamycin 600 mg IV, and
1g Ceftriaxone IV. CXR did not show any infiltrate, CT of
Abdomen showed enlarged sigmoid colon and bibasilar
consolidations, and Head CT showed old infarct and atrophy. He
was admitted for treatment of sepsis.
Past Medical History:
Hypertension
h/o right MCA CVA and left PCA CVA with severe encephalomalacia
predominantly within the right temporal parietal and
left occipital lobes and residual left sided weakness
Seizures
Dementia
h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3696**] Syndrome (colonic pseudo-obstruction)
h/o aspiration PNA
Gastritis with h/o GI bleed
Anemia of CHronic Disease
s/p laminectomy for disc herniation with internal fixation
s/p left total hip replacement
s/p IVC filter for DVT
legally blind
Social History:
Lives in [**Location **] St. [**Doctor Last Name 11042**]/[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] in [**Location (un) 16174**]. His son is
his health care proxy. [**Name (NI) 4084**] a smoker. No alcohol use in the
past ten years.
Family History:
NC
Physical Exam:
T 97.8 BP 133/72 HR 78 on Vent AC 500 x 14 with FiO2 0.60 PEEP 5
General: Intubated and sedated, responds with eye opening and
mouth opening to sternal rub
PERRL
NG tube in place with bloody output. ET tube in mouth. Poor
dentition.
NO LAD, normal carotid pulses
No supraclaviular or axilllary LAD
Lungs clear anterioroly without wheezing. Mild decreased breath
sounds at right base, otherwise claer posteriorly without
wheezes.
Heart: RRR. No M/G/R.
ABD: high pitched bowel sounds, distened, tense, tympanic
RECTAL: no masses, normal prostate, guaiac positive, no gross
blood or melena
BACK: sacral decubitus ulcer
EXT: tight, shiny skin, bood upper ext pulses, good femoral and
popliteal pulses, weak DP pulses. Left heel with ulcer and
tendon exposure.
NEURO: Hyperreflexic and tonic/clonic on the left upper and
lower ext compared to right. Toes upgoing bilaterally. Myoclonus
of left lower extremity with ankle flexion.
Pertinent Results:
[**2134-10-14**] 10:40AM BLOOD WBC-12.2*# RBC-6.46*# Hgb-19.7*#
Hct-58.0*# MCV-90 MCH-30.5 MCHC-34.1 RDW-15.0 Plt Ct-156
[**2134-10-14**] 11:59PM BLOOD WBC-13.0* RBC-4.02* Hgb-12.3* Hct-35.9*
MCV-89 MCH-30.7 MCHC-34.3 RDW-15.1 Plt Ct-64*
[**2134-10-16**] 03:33AM BLOOD WBC-10.6 RBC-3.93* Hgb-12.0* Hct-34.6*
MCV-88 MCH-30.5 MCHC-34.7 RDW-15.0 Plt Ct-66*
[**2134-10-20**] 05:35AM BLOOD WBC-7.6 RBC-3.33* Hgb-10.4* Hct-29.4*
MCV-88 MCH-31.1 MCHC-35.2* RDW-14.7 Plt Ct-109*
[**2134-10-21**] 05:49AM WBC 6.7 RBC 3.40* HGB 10.6* HCT 30.0* MCV
88 MCH 31.3 MCHC 35.5* RDW 14.7 PLT 127*
[**2134-10-14**] 10:40AM BLOOD Neuts-79.1* Lymphs-16.3* Monos-4.4 Eos-0
Baso-0.2
[**2134-10-15**] 03:02AM BLOOD Neuts-79.7* Bands-0 Lymphs-16.3*
Monos-3.2 Eos-0.1 Baso-0.7
[**2134-10-14**] 12:05PM BLOOD PT-15.2* PTT-29.3 INR(PT)-1.4*
[**2134-10-15**] 03:02AM BLOOD PT-14.5* PTT-40.0* INR(PT)-1.3*
[**2134-10-18**] 12:07PM BLOOD PT-13.4* PTT-70.2* INR(PT)-1.2*
[**2134-10-14**] 08:33PM BLOOD Fibrino-269 D-Dimer->[**Numeric Identifier 961**]*
[**2134-10-14**] 08:33PM BLOOD FDP-160-320*
[**2134-10-15**] 03:02AM BLOOD Fibrino-287
[**2134-10-14**] 12:05PM BLOOD Glucose-165* UreaN-70* Creat-4.4*#
Na-160* K-2.5* Cl-120* HCO3-23 AnGap-20
[**2134-10-14**] 11:59PM BLOOD Glucose-162* UreaN-58* Creat-3.0* Na-159*
K-4.1 Cl-128* HCO3-20* AnGap-15
[**2134-10-15**] 11:55AM BLOOD Glucose-150* UreaN-46* Creat-2.6* Na-156*
K-3.8 Cl-129* HCO3-18* AnGap-13
[**2134-10-17**] 08:17PM BLOOD Glucose-135* UreaN-28* Creat-1.7* Na-149*
K-3.1* Cl-117* HCO3-22 AnGap-13
[**2134-10-20**] 05:35AM BLOOD Glucose-127* UreaN-20 Creat-1.5* Na-144
K-3.4 Cl-114* HCO3-22 AnGap-11
[**2134-10-21**] 05:49AM GLU 116* BUN 15 Cr 1.4* Na 144 K 3.5 Cl
114* HCO3 23 AG 11
[**2134-10-14**] 12:05PM BLOOD ALT-753* AST-531* CK(CPK)-440*
AlkPhos-117 Amylase-202* TotBili-0.6
[**2134-10-14**] 11:59PM BLOOD ALT-494* AST-249* Amylase-338*
[**2134-10-16**] 03:33AM BLOOD ALT-291* AST-90* LD(LDH)-307*
CK(CPK)-421* AlkPhos-66 Amylase-170* TotBili-0.5
[**2134-10-20**] 05:35AM BLOOD ALT-166* AST-94* LD(LDH)-325*
Amylase-143*
[**2134-10-14**] 12:05PM BLOOD Lipase-126*
[**2134-10-14**] 11:59PM BLOOD Lipase-650*
[**2134-10-18**] 12:07PM BLOOD Lipase-180*
[**2134-10-14**] 12:05PM BLOOD CK-MB-2 cTropnT-0.37*
[**2134-10-14**] 08:33PM BLOOD CK-MB-5 cTropnT-0.28*
[**2134-10-15**] 03:02AM BLOOD CK-MB-6 cTropnT-0.20*
[**2134-10-16**] 03:33AM BLOOD CK-MB-3 cTropnT-0.12*
[**2134-10-14**] 08:33PM BLOOD Albumin-2.8* Calcium-6.7* Phos-4.2 Mg-2.1
Iron-36*
[**2134-10-16**] 03:33AM BLOOD Albumin-2.4* Calcium-6.9* Phos-2.0*
Mg-2.0
[**2134-10-20**] 05:35AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1
[**2134-10-14**] 08:33PM BLOOD calTIBC-178* Ferritn-1353* TRF-137*
[**2134-10-17**] 08:17PM BLOOD Triglyc-83 HDL-34 CHOL/HD-3.6 LDLcalc-73
[**2134-10-14**] 08:33PM BLOOD Osmolal-359*
[**2134-10-16**] 03:33AM BLOOD Osmolal-320*
[**2134-10-14**] 12:05PM BLOOD Cortsol-54.9*
[**2134-10-15**] 06:40AM BLOOD Vanco-9.6*
[**2134-10-14**] 12:26PM BLOOD Type-[**Last Name (un) **] pO2-46* pCO2-35 pH-7.43
calTCO2-24 Base XS-0 Comment-GREEN TOP
[**2134-10-14**] 08:47PM BLOOD Type-MIX Temp-37.9 Rates-/20 Tidal V-470
PEEP-5 FiO2-60 pO2-54* pCO2-52* pH-7.19* calTCO2-21 Base XS--8
-ASSIST/CON Intubat-INTUBATED
[**2134-10-15**] 06:02AM BLOOD Type-ART Temp-36.7 pO2-177* pCO2-31*
pH-7.34* calTCO2-17* Base XS--7 Intubat-INTUBATED
[**2134-10-15**] 07:02PM BLOOD Type-[**Last Name (un) **] Temp-38.4 pO2-39* pCO2-38
pH-7.33* calTCO2-21 Base XS--5
[**2134-10-14**] 12:26PM BLOOD Lactate-3.1*
[**2134-10-14**] 02:36PM BLOOD Glucose-140* Lactate-1.7 Na-160* K-2.3*
Cl-131*
[**2134-10-15**] 06:02AM BLOOD Lactate-2.0
[**2134-10-14**] 02:36PM BLOOD O2 Sat-99
[**2134-10-14**] 08:47PM BLOOD O2 Sat-77
[**2134-10-15**] 12:01PM BLOOD O2 Sat-81
[**2134-10-14**] 02:36PM BLOOD freeCa-1.07*
[**2134-10-15**] 03:36AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEG
NEGATIVE HEPARIN PF4 ANTIBODY BY [**Doctor First Name **]
[**2134-10-14**] 12:05 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2134-10-17**]**
URINE CULTURE (Final [**2134-10-16**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2134-10-14**] 8:39 pm urine/serology
**FINAL REPORT [**2134-10-15**]**
Legionella Urinary Antigen (Final [**2134-10-15**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
Performed by Immunochromogenic assay.
Reference Range: Negative.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2134-10-14**] 11:30 am BLOOD CULTURE
**FINAL REPORT [**2134-10-20**]**
AEROBIC BOTTLE (Final [**2134-10-20**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2134-10-20**]): NO GROWTH.
[**2134-10-14**] 11:00 am BLOOD CULTURE
**FINAL REPORT [**2134-10-20**]**
AEROBIC BOTTLE (Final [**2134-10-20**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2134-10-20**]): NO GROWTH.
[**2134-10-15**] 1:01 am STOOL CONSISTENCY: WATERY
**FINAL REPORT [**2134-10-15**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2134-10-15**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2134-10-15**] 6:32 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2134-10-15**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2134-10-15**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Time Taken Not Noted Log-In Date/Time: [**2134-10-15**] 7:24 am
ASPIRATE Source: Nasopharyngeal aspirate.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
Rapid Respiratory Viral Antigen Test (Final [**2134-10-15**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
[**2134-10-19**] 05:14PM
CLOSTRIDIUM DIFFICILE TOXIN B ASSAY Results Pending
EKG: Sinus Tach at 118, Q waves in II, III, aVF (old), no ST
segment depression or elevations, no T wave inversions
.
Radiology:
CXR: Gas distention, mostly in colon results in relatively
high-positioned diaphragms obscuring slightly the lung bases.
There is, however, no evidence of any acute parenchymal
infiltrate in either side of the thorax nor is there evidence of
pulmonary congestion. No
pneumothorax identified. Heart size difficult to assess, but no
gross enlargement suspected.
.
CT ABDOMEN:
1. Distended loop of sigmoid colon with no transition point is
again
identified. There is no evidence of obstruction. The diagnosis
of [**Last Name (un) **] syndrome should again be considered. There is no
evidence of perforation.
2. Bilateral lower lobe dense consolidations consistent with
pneumonia or aspiration.
3. Hypodensities within the kidneys are not completely
characterized with this non-contrast enhanced-study.
.
CT HEAD: Extensive encephalomalacic changes are again noted in
right
parietal and temporal lobes and the left occipital lobe.
Hypodensity in the periventricular white matter is also seen in
both cerebral hemispheres. Findings are unchanged from the prior
examination. There is no new acute intracranial hemorrhage,
shift of midline structures, or hydrocephalus. There is a
moderate amount of atrophy. Moderate mucosal thickening is seen
in the ethmoid sinuses. Soft tissues and osseous structures are
normal.
.
[**2134-10-18**] ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The ascending aorta and arch are mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is an anterior space which most likely
represents a fat pad.
IMPRESSION:Mild symmetric left ventricular hypertrophy with
preserved globall and regional biventricular systolic function.
Mild aortic regurgitation.
.
[**10-18**] Abd xray for NGT placement:
FINDINGS: A single supine abdominal radiograph reviewed. NG tube
overlies the left upper quadrant likely in the stomach. Multiple
gas-filled bowel loops are identified, mostly large bowel. No
distended small bowel loops are identified. Note is made of
particularly distended gas-filled sigmoid colon, relatively
unchanged from [**2134-10-14**]. IVC filter, lower lumbar fusion
device, and total left prostheses again noted. Surgical clips
present in the pelvis.
IMPRESSION: Distended air-filled sigmoid unchanged from [**10-14**], [**2133**]. NG tube in stomach.
Brief Hospital Course:
A/P: 72 y/o male nursing home resident with h/o HTN, h/o CVA,
dementia, Ogilve's Syndrome, and h/o aspiration PNA presented
with fevers, altered mental status, and cough with upper
respiratory congestion, from his nursing home and was intubated
for airway protection, and given broad spectrum antibiotics for
sepsis.
.
ICU Course:
1. Sepsis: The initial differential diagnosis included
infectious sources from: Respiratory (Institutional Acquired
PNA, asp PNA, Influenza, Legionella), GI (given distended
abdomen), and GU (though less likely given negative initial U/A,
prostate not boggy on exam), decubitus ulcers (less likely given
no evidence of cellulitis). He got vanco, levo, clinda,
ceftriaxone in ED.
- The infection was treated with Vanco to cover MRSA given
nursing home dwelling, Levofolxacin for possible GI source/asp
PNA, and Flagyl for C.Diff given abd distention/diarrhea.
- IJ CVL was placed to help give IV fluids to keep MAP>65 and
venous O2 sat >70%.
- Blood cultures, urine cultures were sent and blood cultures
were negative x2 and the urine culture came back positive for e.
coli that was later determined to be resistant to cipro and
levofloxacin. Pt was kept on the broad spectrum antibiotics
until the culture returned and pt was left on just levofloxacin
on HD#3 but was switched to ceftriaxone on HD#4 when the
sensitivities showed that the e. coli was resistant to levo and
susceptible to ceftriaxone.
- Legionella urinary antigen was negative.
- Sputum for gram stain, culture, and viral screen was negative
- Influenza was ruled out and droplet precautions were removed.
- Pt became afebrile HD#2.
.
2. Respiratory Distress: Pt was intubated for airway protection
given altered mental status. CT showed a possible lower lobe PNA
vs Asp PNA. Oxygenation and ventilation were sufficient on pre
intubation blood gases.
- Pt was originally put on AC ventilation HD#1 and was weaned
the next day. Repeat arterial blood gas showed good oxygenation
and ventilation. Pt was extubated on HD#2.
.
3. Hypernatremia: Pt was severely hypernatremic to 160 on
admission. He appeared dry in the ED and received 9 L NS HD#1.
Once he was volume repleted (CVP >10), the hypernatremia was
slowly corrected with D5 1/2 NS.
.
4. Non Gap Acidosis: Primary mild metabolic acidosis with
respiratory compensation. Likely renal losses given hypokalemia.
No diarrhea was noted.
- HCO3 and chemistries were followed and corrected.
.
5. Acute Renal Failure: Likely prerenal due to sepsis and was
corrected with volume repletion.
.
6. Elevated Cardiac Enzymes: Elevated in the setting of sepsis
and RF. Trending down with treatment of sepsis, no EKG changes.
Likely due to demand ischemia given tachycardia. Enzymes did
trend down. EKG showed q waves evident of old infarct.
.
7. Transaminitis and elevated Amylase/Lipasewas likely due to
tissue hypoxia, and was not high enough for shock liver and with
no recent alcohol use and no evidence of biliary tract
obstruction to suggest alternate reason for increase. LFTs and
anylase and lipase trended down.
.
8. Anemia: History of ACD
- Iron studies c/w ACD.
.
9. Mild Coagulapathy/thrombocytopenia: HIT Antibody neg. DIC
labs neg. Likely decreased from inflammatory/infectious process
of sepsis. Plt returned to nl at time of discharge.
.
10. FEN: Tube feedings started HD#3 through NGT and free water
replacement through NGT also to help correct Na.
.
11. PPX: SQ heparin, PPI, HOB elevation at 30%
****HD#3 Pt was HD stable and transferred to the floor. ****
.
1. Sepsis: Resolved and hemodynamically stable on HD#3. A
urinary source was suspected given E.Coli UTI. Blood cultures
were negative, Leigonella negative, CXR w/equivocal lower lobe
pneumonia. Initially with broad spectrum abx, now HD stable on
monotherapy with levofloxacin day 4 (started [**2134-10-14**]). HD#4 e
coli from urine was noted to be levofloxacin and cipro resistant
but susceptible to everything else and ceftriaxone was started.
Pt is to continue on total of 14 day course of ceftriaxone
(started [**2134-10-18**]) requiring 10 more days of treatment after
discharge. Pt remained afebrile. Pt's BPs remained low in
100-110s but stable.
.
2. Altered Mental Status: Baseline disorientation due to
dementia. Likely metabolic encephalopathy, hypernatremia. Pt
had improving alertness following antibiotics, correction of
serum sodium.
.
3. Hypernatremia: Pt was severely hypernatremic to 160 on
admission and appeared dry in ED. He was s/p 9 L NS on HD#3.
The sodium was down-trending to 150 with free water flushes
through NGT on HD#3. The pt received a PICC line HD#5 because
labs could not be drawn and to help rehydrate the pt more. A
right arm PICC was placed in IR. D5W was given at 100cc an hr
for 2500cc with 40 of K to help correct his hypernatremia and
hypokalemia. HD#6 his labs were wnl. He was maintained on D5
1/2 NS at 125cc/hr with 40mEq of K to keep his labs wnl.
Pt was being given free water and K through the NGT also to help
correct his electrolyte imbalances, but the NGT came out the
evening of HD#5 and was replaced HD#6 and tube feeds and free
water replacement were continued.
.
4. Acute Renal Failure: Likely prerenal due to sepsis. Improving
with fluid hydration. Creatinine down-trending to 1.4 on
discharge.
.
5. NSTEMI: Elevated in the setting of sepsis and renal failure.
Now trending down with treatment of sepsis. no EKG changes.
Likely due to demand ischemia given tachycardia. Start
b-blocker, aspirin now that HD stable. Check ECHO to eval for
systolic [**Last Name (LF) 69556**], [**First Name3 (LF) **]-motion abnormality. Restart low dose
metoprolol, ASA, statin.
- ECHO done [**10-18**]: Mild symmetric left ventricular hypertrophy
with preserved globall and regional biventricular systolic
function. Mild aortic regurgitation.
.
6. Transaminitis/Chemical Pancreatitis: Likely due to tissue
hypoxia, not high enough for shock liver. No recent alcohol use.
No evidence of biliary tract obstruction to suggest gallstone
pancreatitis.
LFTs were consistently returning to baseline. Should be
rechecked one week post-discharge to reassess.
.
8. Anemia: Pt has a history of anemia of chronic disease and
iron studies obtained on this admission were consistent with
that diagnosis. His HCT was stable at 30 at time of discharge
and his PLT count had returned to [**Location 213**].
.
9. h/o CVA with seizures. Not on antiseizure meds. Plavix was
continued for secondary prevention.
.
10. h/o dementia: Chronic. Likely conmination of CVA's and
organic dementia (evidence of atrophy on CT of head).
.
11. h/o Gastritis: PPI was continued. Hct was stable at time of
discharge. Stool was guaiac positive. Pt had rectal tube
inserted while in ICU that was removed once on the floor.
.
12. Bowel distension - Had been noted in past hospitalizations
and rectal tube inserted to relieve distention and given a
diagnosis of Ogilve's Syndrome.
- Rectal exam was grossly positive for blood (pt did have a
rectal tube two days prior), no stool impaction noted.
- C diff B toxin was sent but was still pending at time of
discharge. Stool tested negative for c diff A toxin.
- GI suggested aggressive bowel regimen and outpt f/u
colonoscopy (pt on home regimen of senna, colace, lactulose).
.
13. FEN:
- TF down NGT.
- NGT came out [**10-17**] and S&S saw and assessed pt prior to new NGT
being put in. They recommended pt be NPO as he was not able to
handle secretions, and to continue the NGT, TF, suctioning.
They recommended reassessing within 1-2wks.
- NGT was replaced, xray confirmed placement, TF and free water
replacement restarted.
.
14. PPX: SQ heparin, PPI
.
CODE: FULL per son, possibility of pt requiring a PEG tube was
discussed as was fact that with each illness and
hospitalization, pt's mental status is likely to deteriorate
further.
.
COMMUNICATION: with son, HCP [**Name (NI) **] [**Name (NI) **] cell [**Telephone/Fax (1) 69557**], home
[**Telephone/Fax (1) 69558**], work [**Telephone/Fax (1) 69559**]
Medications on Admission:
Vit D 400 units Daily
MVA 1 tablet Daily
Clopidogrel 75 mg Daily
Propoxy/APAP 100-650 mg with dressing changes
Colace 100 mg [**Hospital1 **]
Heparin 5,00o units TID
Lactulose 30 ml TID
Baclofen 5 mg TID
Senna 2 Tab QHS
Risperdal 0.25 mg QHS
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
3. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Cap PO DAILY
(Daily).
4. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
5. Baclofen 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a day).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime).
7. Risperidone 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
8. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
10. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
12. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
14. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback [**Last Name (STitle) **]: One
(1) gm Intravenous Q24H (every 24 hours) for 10 days.
Disp:*10 gm* Refills:*0*
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
16. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
urosepsis
altered mental status
acute renal failure
transaminitis/chemical pancreatitis
large bowel distention
Secondary:
dementia
amemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted for a urinary tract infection that caused you
to become septic and hypotensive. You required a stay in the
ICU in order to treat your infection and low blood pressure.
You needed a lot of fluid resuscitation and antibiotics.
You are requiring a nasogastric tube in order to receive
nutrition. You will be re-evaluated in approximately a week to
see if you are able to safely handle your own secretions. You
may be able to have the NGT out at that time.
Please notify a doctor if pt experiences:
- fever >101.5
- severe abdominal distention
- is unable to tolerate tube feedings
- severely decreased urine output
- severe constipation
- breathing difficulties
- signs/sx of stroke
- changes in mental status
- any other questions or concerns
Please take all medications as directed.
Please follow up with your PCP and GI for your colonoscopy.
Followup Instructions:
Please follow up with your PCP or the doctor who takes care of
you at the rehabilition center within 1-2wks of discharge.
You will need to call the gastroenterology department at:
[**Telephone/Fax (1) 463**], in order to schedule a colonoscopy to examine your
large bowel. If you wish you may also set up an appointment to
see a gastroenterologist by calling [**Telephone/Fax (1) 69560**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 0389, 5070, 5849, 5990, 2760, 2762, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5948
} | Medical Text: Admission Date: [**2172-3-11**] Discharge Date: [**2172-3-16**]
Date of Birth: [**2110-7-17**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
RIght sided weakness
Major Surgical or Invasive Procedure:
MRI/MRA
TTE
History of Present Illness:
61yo M with recent admission for Fournier's gangrene s/p
debridement, longstanding DM1, HTN, CRI now presenting with
sudden onset nonfluent aphasia and right hemiparesis. He has
been
doing quite well at home following a prolonged hospitalization
one month ago, ambulating without assist, feeling well. Off all
antibiotics. His wife heard him yelling upstairs around 4:45pm.
She went to him to notice him slumped to his right side and she
inquired what was wrong and he reported "I don't know." No
apparent speech deficit at that time per wife. taken to [**Hospital3 **] where head CT revealed left thalamic hemorrhage with
left posterior [**Doctor Last Name 534**] lateral ventricle spread. The patient given
dilantin IV, and was med-flighted to [**Hospital1 18**] for further care.
Here the patient has a nonfluent aphasia and cannot provide
further history, his speech comprehension is intact and he is
quite frustrated by his productive speech deficit. He denies any
headache at present. He is aware of his right arm weakness.
Denies diplopia.
He is now off all antiobiotics and has been afebrile recently.
No
chills. no SOB. no CP. No diarrhea or constipation of late. No
change in urinary habits. no new rashes.
Past Medical History:
IDDM diagnosed age 10, CRI baseline 2.0, CAD s/p MI [**2165**], HTN,
Depression, PVD, Hypercholesterolemia, GERD, OA, Carotid artery
disease (L ICA occlusion, R ICA 39% stenosis)
PAST SURGICAL HISTORY:
s/p CABG x4 [**2-21**], s/p L CFA-AKPop BPG w/ NRSVG [**6-18**], s/p R TMA
[**6-17**], s/p R BKPop-Peroneal w/ NRVSG [**4-17**], s/p L cataract [**2166**], R
cataract [**2165**]
Social History:
Married, no alcohol, no tobacco use, no illicit drug use.
Family History:
Patient with strong family history of DM-I with his father and
siblings affected at age < 15, most with chronic sequelae of
disease. Father passed away from MI.
Physical Exam:
T 98, BP 162/85, HR 72, R 18, 100% RA
gen- well appearing, cooperative with exam, NAD
HEENT- NCAT, MMM, OP clear
Neck- no nuchal rigidity, no bruits bilat
CV- RRR, no MRG
Pulm- CTA B
Abd- soft, nt, nd, BS+
Groin/genitalia- granulating tissue with surgical packing, no
eschar or apparent purulent discharge.
Skin- chronic venous changes, weak distal pulses (1+) but
present.
-Mental Status: Speech is nonfluent. he follows all midline and
appendicular commands. He is Attentive to the exam. he is unable
to read.
-Cranial Nerves: Olfaction not tested. pupils with slight
irregularity barely reactive 3 to 2mm and sluggish. He appears
to have a slight R sided field cut to visual threat. There is no
ptosis bilaterally. Funduscopic exam revealed multiple cotton
wool spots, no hemorrhages, unable to see optic discs. EOMI
without nystagmus. No gaze preference. Facial sensation reduced
to light touch. Slight R NLF effacement. Hearing intact to
finger-rub bilaterally. Palate elevates symmetrically. 5/5
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
-Motor: Normal bulk. No adventitious movements noted. No
asterixis noted. prominent right drift.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 3 4 4 3 4 4 3 5 * * * * *
* unable to test
-Sensory: Diminished to all modalities on the left. s/p R
metatarsal amp.
-Coordination: No intention tremor. [**Doctor First Name 6361**] nl on the left. No
dysmetria on FNF on the left.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 2 0
Plantar response was flexor bilaterally.
Pertinent Results:
[**2172-3-13**] 06:25AM BLOOD WBC-7.7# RBC-3.77* Hgb-12.0* Hct-34.0*
MCV-90 MCH-31.7 MCHC-35.2* RDW-14.4 Plt Ct-343
[**2172-3-12**] 02:03AM BLOOD WBC-4.4 RBC-3.63* Hgb-11.3* Hct-32.2*
MCV-89 MCH-31.2 MCHC-35.2* RDW-14.5 Plt Ct-268
[**2172-3-11**] 07:27PM BLOOD WBC-5.4 RBC-3.75* Hgb-11.5* Hct-33.2*
MCV-88# MCH-30.7 MCHC-34.7 RDW-14.4 Plt Ct-303
[**2172-3-11**] 07:27PM BLOOD Neuts-61.1 Lymphs-24.1 Monos-8.2 Eos-6.1*
Baso-0.6
[**2172-3-13**] 06:25AM BLOOD PT-14.0* PTT-27.5 INR(PT)-1.2*
[**2172-3-12**] 02:03AM BLOOD PT-13.3 PTT-28.6 INR(PT)-1.1
[**2172-3-11**] 07:27PM BLOOD PT-13.2 PTT-27.7 INR(PT)-1.1
[**2172-3-12**] 03:50PM BLOOD Glucose-154* UreaN-27* Na-135 K-4.6
Cl-103 HCO3-27 AnGap-10
[**2172-3-11**] 07:27PM BLOOD Glucose-69* UreaN-38* Creat-1.4* Na-134
K-4.8 Cl-99 HCO3-29 AnGap-11
[**2172-3-12**] 02:03AM BLOOD Glucose-103 UreaN-35* Creat-1.1 Na-135
K-7.0* Cl-104 HCO3-29 AnGap-9
[**2172-3-12**] 03:50PM BLOOD CK(CPK)-50
[**2172-3-12**] 02:03AM BLOOD CK(CPK)-51
[**2172-3-13**] 06:25AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.5*
[**2172-3-12**] 02:03AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.7 Cholest-115
[**2172-3-12**] 02:03AM BLOOD %HbA1c-7.0*
[**2172-3-12**] 02:03AM BLOOD Triglyc-52 HDL-36 CHOL/HD-3.2 LDLcalc-69
CY Head: Left basal ganglia hemorrhage with intraventricular
extension and
mild mass effect, unchanged in copmarison to CT from
approximately two hours prior.
MRI Head: Absence of flow signal in the left internal carotid
which could
be secondary to occlusion in the neck. MRA of the neck can help
for further assessment. Faint flow in the left middle cerebral
artery secondary to collateral across the circle of [**Location (un) 431**].
Brief Hospital Course:
Pt admitted to the Neuro-ICU for further management of his
hemorrhage. He was monitored with cardiac telemetry and
frequent neuro checks. He had follow-up imaging which revealed
stable size of bleed. He was transfered to the neuro step down
unit. On the floor he had elevated BP's and was started on his
home medications. His blood sugars were markedly elevated and
[**Last Name (un) 3208**] was consulted for help with control. He was restarted on
his home regemin and a sliding scale. PT/OT and Speech were
consulted. Plastics was contact[**Name (NI) **] to help in wound care recs
for his recent sacral infection. They recommended wet to dry
dressing changes twice a day. His BP improved on his home
medications. He continued to imrpove throughout the stay. He
will follow-up in stroke clinic as an outpt.
Medications on Admission:
Aspirin 325mg daily
Piroxicam (? paroxitine) 20mg daily
Gabapentin 600mg TID
metoprolol 50mg [**Hospital1 **]
HCTZ 25mg daily
Omeprazole 40mg daily
Diovan 320mg QPM
Atorvastatin 80mg daily
temazepam 15mg QHS
Protonix 40mg daily
Humalin
Humalog sliding scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin Regular Human Injection
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for pain.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for pain.
10. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
19. Insulin NPH & Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left thalamic hemorrhage
Discharge Condition:
Right hemiparesis, aphasia
Discharge Instructions:
You were admitted because of a bleed in your brain. It has
caused weakness and numbness on your right side and difficulty
speaking. You will need rehab after discharge. If you have any
new weakness or tingling, please return to the ER.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2172-3-20**] 10:00
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2172-4-28**] 3:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-7-1**]
10:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 431, 5859, 4439, 2720, 311, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5949
} | Medical Text: Admission Date: [**2151-4-2**] Discharge Date: [**2151-4-9**]
Date of Birth: [**2084-9-21**] Sex: M
Service: Coronary Care Unit
ADMISSION DIAGNOSIS: ST-elevation myocardial infarction.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male with a past medical history of prostate cancer who is
admitted to the [**Hospital1 69**] for a
ST-elevation myocardial infarction.
The patient reported chest discomfort on the evening prior to
admission. He subsequently ate dinner and went outside to
shovel snow. At that time, he developed [**7-29**] substernal
chest pain that was nonradiating. He denied any shortness of
breath, nausea, or vomiting. He denied diaphoresis.
The patient was taken to an outside hospital where an
electrocardiogram showed ST elevations in the inferior leads.
At the outside hospital, the patient was given aspirin,
heparin, and morphine. The patient underwent thrombolysis
with TNK. He substernal chest pain persisted, and he was
transferred to [**Hospital1 69**] for
rescue cardiac catheterization.
In the Catheterization Laboratory, the patient was found to
have a totally occluded distal right coronary artery and
diffuse left anterior descending artery disease. Stenting of
the right coronary artery led to TIMI-II flow from the
midvessel.
The patient was randomized to the Cool myocardial infarction
protocol. A transvenous pacer was placed in the setting of
Wenckebach and bradycardia to the 30s with hypotension. The
patient was then transferred to the Coronary Care Unit with
an intra-aortic balloon pump and on dopamine.
PAST MEDICAL HISTORY: Prostate cancer; status post
prostatectomy in [**2150-10-20**].
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. He quit smoking
five months prior to admission.
FAMILY HISTORY: Family history was unremarkable.
REVIEW OF SYSTEMS: No shortness of breath, diabetes, or
strokes.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 97.8 degrees
Fahrenheit, heart rate was 74, blood pressure was 110/68,
respiratory rate was 16, and oxygen saturation was 99% with
an FIO2 of 40%. The patient was on a dopamine and with an
intra-aortic balloon pump. In general, the patient was alert
by not oriented. His pupils were dilated. The mucous
membranes were moist. There was no lymphadenopathy in the
head or neck. The sclerae were anicteric. There were no
bruits. The heart sounds revealed normal first heart sounds
and second heart sounds. The rate was regular. The chest
was clear to auscultation anteriorly. The abdomen was
nontender and nondistended. Bowel sounds were present. The
extremities revealed no clubbing, cyanosis, or edema. The
right groin had an intra-aortic balloon pump. The left groin
had a pacer wire with a small hematoma.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 13.5, hematocrit was
39.7, and platelets were 345. INR was 1.2 and partial
thromboplastin time was 26. Sodium was 138, potassium was
3.8, chloride was 103, bicarbonate was 29, blood urea
nitrogen was 15, creatinine was 1.2, and blood glucose was
132. Creatine kinase was 1244. MB was 128. ALT was 23, AST
was 122, amylase was 196, and alkaline phosphatase was 62.
Troponin was greater than 50. Albumin was 3.1.
PERTINENT RADIOLOGY/IMAGING: Arterial blood gas showed
7.21/41/82 with a lactate of 54.
Electrocardiogram revealed a sinus rhythm at a rate of 70.
There was Mobitz type I block. There were persistent ST
elevations of 2 mm in leads II, III, and aVF. There were ST
depressions of 1 mm in V1 through V5, I, and aVL.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR SYSTEM: The patient was admitted to the
Coronary Care Unit after cardiac catheterization for an acute
inferior ST-elevation myocardial infarction. He returned
from the Catheterization Laboratory on a dopamine drip with
an intra-aortic balloon pump.
The patient was initially maintained on aspirin. Beta
blockers and ACE inhibitors were initially held as the
patient was requiring pressors on the balloon pump. A lipid
profile was checked, and the patient was initially started
Lipitor.
On the evening of his admission to the Coronary Care Unit, it
was noted that his pacer wire was not sensing or pacing. It
was subsequently discontinued. The patient's dopamine was
weaned off. The patient was then started on a low-dose ACE
inhibitor as well as Plavix. A beta blocker was not started
as the patient was noted to have a Wenckebach heart block.
The patient's intra-aortic balloon pump was weaned from 1:1
to 1:2. The patient underwent an echocardiogram on [**4-4**]
which revealed an ejection fraction of 25% with severe global
left ventricular hypokinesis. There was akinesis in the
inferior, inferolateral, and inferoseptal areas with relative
sparing of the apex and anterior walls.
The patient was noted to volume overloaded on [**4-3**] and
was diuresed with a dose of Lasix.
On the evening of [**4-3**], the patient complained of left
shoulder pain which was sharp in nature and radiated to the
anterior chest wall. The pain was worse with coughing. The
patient denied any nausea, vomiting, or shortness of breath
at that time. He stated that the pain was different from his
pain when he had his myocardial infarction.
A STAT echocardiogram was obtained which showed no change
from the echocardiogram the day before. A rub was heard at
this time. It was felt that the patient was suffering from
post myocardial infarction pericarditis. Nonsteroidal
antiinflammatory drugs were avoided to treat this given the
risk after myocardial infarction. The patient was started on
Tylenol. At this time, the patient was also noted to be in
atrial fibrillation, and he was started on a heparin drip.
The patient was given morphine for his pain at this time and
subsequently developed hypotension with a systolic blood
pressure of 80. He transiently required dopamine to maintain
his blood pressure; however, this was quickly weaned off.
The intra-aortic balloon pump was discontinued on [**4-3**].
It was felt that the patient would eventually require a
coronary artery bypass graft. The Cardiothoracic Surgery
Service was consulted on [**4-4**]. At that time, the patient
had developed a cough and a likely pneumonia. Therefore, the
Surgery Service felt that it would be best to delay a
coronary artery bypass graft until that had resolved.
On [**4-4**], the patient was noted to be in atrial flutter
with some episodes of Wenckebach and pauses up to four
seconds. The patient was maintained on heparin and was
eventually transitioned to Coumadin. He remained relatively
stable from a cardiovascular point of view and was
transferred to the Cardiology floor on [**4-6**].
The patient's pain from his pericarditis resolved on the
standing Tylenol regimen. The patient was monitored on
telemetry and his pauses resolved. On [**4-8**], the patient
was started on a beta blocker. It was felt that the patient
should be risk stratified, and an Electrophysiology
consultation was obtained. The patient was to follow up with
the Electrophysiology Service for risk stratification as an
outpatient.
The patient underwent a repeat echocardiogram on [**4-8**]
which showed an ejection fraction of 30%, with 1+ mitral
regurgitation, and inferior hypokinesis.
The patient was felt to be safe for discharge home on [**4-9**]. He was to follow up with the Cardiothoracic Surgery
Service for coronary artery bypass graft after resolution of
his pneumonia. He was also to follow up with the
Electrophysiology Service for risk stratification.
2. RENAL ISSUES: Upon admission, the patient was noted to
have an anion gap acidosis with an elevated lactate which was
felt to be secondary to poor perfusion.
The patient improved with improved perfusion with the
intra-aortic balloon pump. Repeat arterial blood gases study
were normal.
3. INFECTIOUS DISEASE ISSUES: On [**4-4**], the patient was
noted to have a cough. He was initially started on
azithromycin. A chest x-ray was checked which showed a
likely pneumonia, and the patient was then started on
levofloxacin.
The patient subsequently developed a right-sided pleural
effusion associated with his pneumonia which was noted on
[**4-7**]. The patient underwent a thoracentesis on [**4-7**].
Analysis of the pleural fluid revealed a white blood cell
count of 490, red blood cells of [**Pager number **], neutrophils of 46,
lymphocytes of 18, monocytes of 14, with a protein ratio of
less than 0.5, and an LDH ratio of less than 0.6. The pH was
7.55. Given the LDH in the fluid, it was sent for cytology
to rule out malignancy. At the time of discharge, this was
still pending.
After his thoracentesis, the patient's respiratory status
improved and he was felt to be safe for discharge on [**4-9**]. He was to complete a 14-day course of Levaquin. The
patient was to return for coronary artery bypass graft after
resolution of his pneumonia.
4. HEMATOLOGIC ISSUES: The patient was noted to have a drop
in his hematocrit to 28 from 34 after his cardiac
catheterization. He was transfused 2 units of packed red
blood cells on [**4-5**].
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once per day.
2. Plavix 75 mg p.o. once per day.
3. Pravastatin.
4. Captopril 12.5 mg p.o. three times per day.
5. Lopressor 12.5 mg p.o. twice per day.
6. Levofloxacin 500 mg p.o. every day (for a 14-day course).
7. Coumadin 5 mg p.o. once per day.
DISCHARGE DIAGNOSES:
1. Status post acute ST-elevation myocardial infarction
(involving the inferior area).
2. Cardiogenic shock.
3. Ejection fraction of 30%.
4. Post myocardial infarction pericarditis.
5. Atrial flutter.
6. Pneumonia; complicated by peripneumonic effusion.
7. Lactic acidosis.
8. Prostate cancer; status post prostatectomy in [**2150-3-20**].
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to complete
his course of levofloxacin for his pneumonia and was then to
follow up with the Cardiothoracic Surgery team for coronary
artery bypass graft in approximately one month's time.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2151-7-8**] 10:43
T: [**2151-7-15**] 19:18
JOB#: [**Job Number 49432**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5950
} | Medical Text: Admission Date: [**2148-2-28**] Discharge Date: [**2148-3-4**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
Abdominal right upper quadrant pain
Major Surgical or Invasive Procedure:
[**2148-3-2**] Laparoscopic cholecystectomy
[**2148-2-29**] ERCP
History of Present Illness:
88M hx of CAD s/p MI and [**Name Prefix (Prefixes) **] [**2147-1-20**] off plavix, HTN, HLD,
distant bladder Ca [**2137**]. On day of presentation out of his usual
state of health noticed mid-epigastric and anterior chest pain
that woke him up from his post lunch nap. He described as
pressure-like, [**8-28**] starting in mid-epigastrium and radiating to
anterior chest. He subsequently developed chills at home. He
came to the ED as was concerned that pain was similar to
previous MI. Had N w/ V x 1 in the ED waiting room NB/NB. Pain
subsided after maalox and gingerail in the ED. Pnt denies
diarrhea. Reports relative constipation over the past few weeks.
Last BM 1 day prior to presentation. Passing gas normally since.
His daughter notice that he has appeared yellow over the past
week. He reports 30lb unintentional weightloss over the past 3
months. He denies any chronic abdominal pain, but does mention
similar pain 3 weeks ago which resolved with vomiting. Denies
feeling more tired than usual. Denies night sweats, fevers or
chills except as above. No recent sick contacts or suspicious
meals. No recent travel. Pain worse with inspiration. Of note,
per his medical chart has ongoing leukocytosis (13-18) of
unclear cause for the past several months.
.
In the ED Initial vitals were 98.6 HR 78 BP 173/73 RR 20 O2 97%,
physical exam was notable for jaundice and distended abdomen
with mild epigastric tenderness. EKG was unchanged from baseline
and trop X1 was negative. Her other labs were notable for Alkp
1112, T.Bili 3.3, ALT/AST = 218/269, Lip =80, WBC = 15.8 with
79% neutrophils. Cr/BUN 1.3/35 was at the lower end of his
baseline. RUQ US revealed stones in the gallbladder, a distended
CBD 1.5cm with sludge, no ductal stone but distal end was not
visualized. Patient was given IV Got IV cipro 400 + flagyl 500mg
+ IV NS 1000cc. He also ate in the ED w/o N or V. Pnt was seen
in the ED by GI who recommended Abx coverage with Unacyn and
doing ERCP tomorrow.
Past Medical History:
- Coronary artery disease s/p NSTEMI with DES to RCA in [**1-29**] at
[**Hospital1 18**] (Dr. [**Last Name (STitle) **]
- Echo [**4-/2147**]: mod MR, Mod TR, Mod PHTN, LVEF = 45%
- Hypertension
- Hyperlipidemia
- Macular Degeneration
- Cataracts
- Bladder cancer s/p BCG injection
- Depression / anxiety
- BPH on finasteride and tamsulosin
- Diverticulosis with Hx of GIB [**4-/2147**]
- On [**8-/2147**] was hospitalized for syncope and found to have Hct
of 24 and guiac positive stools. Pnt refused in house
colonoscopy. Was followed as outpatient with subsequent stable
hematocrits.
- Leukocytosis: per OMR WBC counts have been ranging from 11.8
to 18 since [**4-/2147**], unclear whether this was worked up.
Social History:
Patient lives with his wife. [**Name (NI) **] has four daughters. [**Name (NI) **] does not
drink alcohol. He smoked from ages 19 to 23, approximately 1
PPD. He is independent and very active, does not use any
ambulatory devices at baseline. Former Navy.
Family History:
- Father died of CHF
- Mother died of breast cancer
- Sister died of lung cancer
- No family history of sudden death
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Temp:98.6 HR:78 BP:173/73 Resp:20 O(2)Sat:97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact sclera anicteric. Surgical pupils bilat
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nondistended, Soft epigastric tenderness with
guarding no rebound mild right upper quadrant tenderness
negative [**Doctor Last Name **] sign
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry, No rash
Neuro: Speech fluent
Pertinent Results:
[**2148-2-28**] 09:30PM URINE RBC-[**3-23**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0
[**2148-2-28**] 08:56PM LACTATE-1.2
[**2148-2-28**] 05:45PM GLUCOSE-147* UREA N-35* CREAT-1.3* SODIUM-136
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-16
[**2148-2-28**] 05:45PM ALT(SGPT)-218* AST(SGOT)-269* ALK PHOS-1125*
TOT BILI-3.3*
[**2148-2-28**] 05:45PM cTropnT-<0.01
[**2148-2-28**] 05:45PM WBC-15.8* RBC-4.00* HGB-11.7*# HCT-35.6*
MCV-89 MCH-29.2 MCHC-32.8 RDW-15.4
[**2148-2-28**] 05:45PM NEUTS-79.0* LYMPHS-17.3* MONOS-2.7 EOS-0.6
BASOS-0.4
[**2148-2-28**] 05:45PM PLT COUNT-227
[**2148-2-28**] 05:45PM PT-12.1 PTT-23.8 INR(PT)-1.0
[**2148-2-28**] Gallbladder Ultrasound
IMPRESSION:
1. Marked intrahepatic biliary dilatation which is new since the
previous
study of [**2147-1-21**]. Common bile duct measures up to 1.5
cm, slightly
increased in size since the previous study. In addition,
echogenic material within the common bile duct likely represents
sludge. No discrete duct stone is identified; however, the
distal common bile duct is not visualized on this study due to
overlying bowel gas. MRCP/ERCP could be performed for further
evaluation.
2. Cholelithiasis.
[**2148-2-29**] ERCP
IMPRESSION: Severe bulging of the major papilla with an impacted
stone partially protruding was noted.
Pus was noted draining around the impacted stone.
A single periampullary diverticulum with large opening was found
at the major papilla
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique
Multiple large stones ranging 1-1.5cm in size were noted in the
CBD.
The CBD was dilated to approximately 18mm diffusely.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Given the large size of the biliary stones, a sphincteroplasty
was performed with a balloon to 12mm.
Five large brown stones were extracted successfully using a
balloon catheter.
No further large filling defects were noted in the CBD, however,
given suspicion of smaller stone fragments, A 5cm by 10FR Double
pigtail biliary stent was placed successfully.
Excellent drainage of contrast and bile was noted
Brief Hospital Course:
88M hx of CAD s/p MI and [**Name Prefix (Prefixes) **] [**2147-1-20**] off plavix, HTN, HLD,
distant bladder cancer who is admitted with picture concerning
for acute cholangitis s/p ERCP with stone removal and
sphincterotomy.
Patient admitted to the Medicine Service initally; his hospital
course as follows per dictation of Medical house staff:
.
# Ascending cholangitis: He initially presented with RUQ pain,
new jaundice, but no fevers. Leukocytosis and CBD dilatation on
RUQ U/S. ERCP was performed and several stones were removed,
with evidence of purulence around a larged impacted stone. A
double pigtail stent was placed and his abdominal pain subsided.
He was started on Unasyn and will continue on antibiotics for a
14-day course. He was initially kept NPO for 24 hours, then his
diet was advanced slowly, as tolerated. He did not have any
recurrence of his epigastric pain. Of note, he has had chronic
leukocytosis as of late, which will likely improve now that
stones have been removed. Per surgery, the patient was
transferred to their service for likely cholecystectomy during
this admission. He will return in 6 weeks for an ERCP and stent
evaluation.
.
#. Weight loss: He reported a 30lb weight loss over 3 months. He
is otherwise active and feels well beyond the present illness.
He did have an episode of gross GIB in [**4-/2147**] which was not
investigated. These may warrant malignancy workup focusing on
the GI tract if this should be relevant to the patient's wishes
and goals of care as an outpatient.
.
# Coronary artery disease: He is s/p NSTEMI with DES to RCA in
1/[**2147**]. He is off Plaxix. Trop was neg x1 and EKG unchanged from
baseline. Suspicion for ACS was low. Once he was no longer
NPO, he was restarted on his home aspirin, statin, lisinopril
and metoprolol post procedure.
.
# BPH: His home doses of finasteride and tamsulosin restarted
after procedure.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
[**Hospital **] hospital course after care transferred to the Acute
Care Surgery Service on [**2148-3-1**]:
He underwent ERCP on [**2148-2-29**] with sphincterotomy where large
brown stones were extracted successfully. His post-ERCP labs
were followed and on [**2148-3-2**] he was taken to the operating room
for laparoscopic cholecystectomy without any complications.
On POD#1 his diet was advanced for which he is tolerating
without any issues. His pain is controlled on oral medication
and he is ambulating independedntly.
He will follow up in [**Hospital 2536**] clinic in [**2-22**] weeks and with GI in 6
weeks for ERCP and possible stent removal. During her
hospitalization the patient was cared for by the rotating acute
care surgical service.
Medications on Admission:
FINASTERIDE - 5 mg Tablet - one Tablet(s) by mouth one daily -
No
Substitution
LISINOPRIL - 5 mg Tablet - one Tablet(s) by mouth one daily - No
Substitution
METOPROLOL TARTRATE - 25 mg Tablet - one Tablet(s) by mouth
twice
daily - No Substitution
PAROXETINE HCL - 10 mg Tablet - one Tablet(s) by mouth daily -
No
Substitution
SIMVASTATIN - 40 mg Tablet - two Tablet(s) by mouth daily - No
Substitution
TERAZOSIN - 5 mg Capsule - one Capsule(s) by mouth one daily -
No
Substitution
IRON - 325 mg (65 mg Iron) Capsule, Sustained Release - one
Capsule(s) by mouth one daily - No Substitution
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. paroxetine HCl 10 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
9. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with gallstones and underwent
an operation to remove your gallbladder.
You may be discharged on medications to treat the pain from your
operation. These medications will make you drowsy and impair
your ability to drive a motor vehicle or operate machinery
safely. You MUST refrain from such activities while taking
these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-2**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Follow up in [**Hospital 2536**] clinic in [**2-22**] weeks, call [**Telephone/Fax (1) 600**] for an
appointment.
Follow up with [**Name6 (MD) **] [**Name8 (MD) 84650**], MD, Gastroenterology in 6 weeks
for ERCP and for evaluation of removal of biliary stent and
re-evaluate biliary tree. Call [**Telephone/Fax (1) 13246**] for an appointment.
The following appointment was made prior to your hospital stay;
if you are unable to keep this appointment you [**First Name8 (NamePattern2) **] [**Doctor First Name **] to
contact the provider to cancel/reschedule:
Provider: [**First Name8 (NamePattern2) 3296**] [**Last Name (NamePattern1) 3297**],[**First Name7 (NamePattern1) 3295**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] IM (NHB)
Date/Time:[**2148-3-6**] 2:30
Completed by:[**2148-3-4**]
ICD9 Codes: 0389, 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5951
} | Medical Text: Admission Date: [**2147-4-5**] Discharge Date: [**2147-4-11**]
Date of Birth: [**2070-6-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Morphine / Pentothal / Percodan / Talwin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE/ presyncopal events
Major Surgical or Invasive Procedure:
[**2147-4-5**] - AVR with 21 mm CE pericardial valve
History of Present Illness:
76 yo female with several episodes of pre-syncope while dancing
. Has DOE and ETT was positive. Echo revealed AS with normal EF.
Cath showed severe AS with [**Location (un) 109**] 0.6 cm2, minimal CAD, AV gradient
56 mm mean. Referred to Dr. [**Last Name (STitle) 1290**] for AVR
Past Medical History:
AS
HTN
elev. chol.
NIDDM
diverticulosis
hiatal hernia
obesity
PNA X 3
PSH: C-sections x3, right TKR, chole, bladder suspension with
urethral sling,appy,coccygectomy,
Social History:
lives with husband
quit smoking 30 years ago
rare ETOH
Family History:
brother had CABG at age 66
mother/brother/sister with CHF
Physical Exam:
HR 88 RR 16 BP 106/60
5'3" 195#
NAD
no jaundice
EOMI, carotid bruits versus transmitted AS murmur
CTAB
3/6 SEM radiates throughout precordium
abdomen midline scar
2+ radial/DP/PT pulses RKR scar
no varicosities
neuro nonfocal
Pertinent Results:
[**2147-4-7**] 05:40AM BLOOD WBC-15.3* RBC-2.66* Hgb-7.9* Hct-23.5*
MCV-88 MCH-29.7 MCHC-33.6 RDW-15.6* Plt Ct-126*
[**2147-4-9**] 09:25AM BLOOD Hct-30.9*#
[**2147-4-7**] 05:40AM BLOOD Plt Ct-126*
[**2147-4-11**] 05:49AM BLOOD UreaN-11 Creat-0.6 K-4.0
[**2147-4-9**] 09:25AM BLOOD Mg-2.0
[**2147-4-9**] CXR
Small left-sided effusion. Status post aortic valve replacement.
No consolidation demonstrated.
[**2147-4-5**] ECHO
PRE-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). 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 severely
thickened/deformed. Mild to moderate ([**1-30**]+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
Insufficient time to measure MV or AO valve gradient/area before
beginning CPB. LVOT = 1.8. Annulus = 2.2.
Post-CPB: Well seated and functioning aortic valve prosthesis.
No leak, no AI. Other parameters remain as pre-bypass. Intact
aorta. Good biventricular
systolic function.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2147-4-5**] for surgical
management of her aortic valve disease. She was taken to the
operating room where she underwent an aortic valve replacement
utilizing a 21mm pericardial valve. Postoperatively she was
taken to the cardiac surgical intensive care unit. On
postoperative day one, she awoke neurologically intact and was
extubated. She was then transferred to the cardiac surgical step
down unit for further recovery. Mrs. [**Known lastname **] was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with her postoperative strength and
mobility. Her pacing wires and drains were removed per protocol
without incident. On postoperative day five, Mrs. [**Known lastname **] had a
fever spike. She was pan cultured and empirically started on
ciprofloxacin.Her urine culture was positive for E.Coli and
ciprofloxacin was continued. She complained of numbness of her
right lateral thigh which improved slowly. It was presumed that
this was related to a right lateral femoral cutaneous nerve
neuropathy likely from positioning. Mrs [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
six. She will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
zocor 40 mg daily
glucotrol 5 mg daily
zestril 10 mg daily
ASA daily
fish oil daily
folic acid daily
Vit. C daily
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(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:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day) for 5 days.
Disp:*10 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
s/p AVR
AS
elev. chol. HTN
UTI
NIDDM
diverticulosis
GERD
hiatal hernia
obesity
s/p bladder suspension
Discharge Condition:
stable
Discharge Instructions:
1) You may shower and pat wound dry
2) No lotions, creams or powders on incisions
3) No driving for one month
4) No lifting greater than 10 pounds for 10 weeks
5) Call for fever, redness, or drainage
6) Take lasix with potassium for five days then stop.
7) Take ciprofloxacin for five days then stop.
8) Take vitamin C and iron for 1 month and stop.
9) Call with any questions or concerns.
Followup Instructions:
see Dr. [**Last Name (STitle) 1290**] in the office in 4 weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) 58201**] in [**1-30**] weeks
see Dr. [**Last Name (STitle) 5310**] in [**3-3**] weeks
Completed by:[**2147-4-28**]
ICD9 Codes: 4241, 5180, 5990, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5952
} | Medical Text: Admission Date: [**2110-1-6**] Discharge Date: [**2110-1-14**]
Date of Birth: [**2057-11-19**] Sex: F
Service: Cardiovascular Surgery
HISTORY OF PRESENT ILLNESS: This is a 52 year old female
patient with worsening dyspnea on exertion. Her workup has
revealed significant aortic stenosis. Cardiac
catheterization also revealed 70% occlusion of her left main
coronary artery, and she was referred for a coronary artery
bypass as well as aortic valve replacement.
PAST MEDICAL HISTORY: Significant for aortic stenosis,
gastroesophageal reflux disease, hypercholesterolemia,
asthma, and osteoporosis. The patient has had Hodgkin's
disease as a teenager which was treated with x-ray therapy as
well as chemotherapy. She has hyperthyroidism treated with
Iodine therapy. She has a history of ovarian cancer. In
[**2096**] she underwent a total abdominal hysterectomy and
bilateral salpingo-oophorectomy. She is status post
splenectomy, status post appendectomy, status post right
thigh lipoma, she has a remote smoking history.
MEDICATIONS ON ADMISSION: Synthroid 150 mcg alternating with
125 mcg. Lipitor 20 mg p.o. q.d. Omeprazole 20 mg p.o. q.d.
Claritin 10 mg p.o. q.d. TUMS, Miacalcin nasal spray.
Hycosamine cough syrup prn. Serevent 2 puffs b.i.d. Flovent
2 puffs b.i.d. Rhinocort b.i.d. as well.
ALLERGIES: Penicillin, Sulfa, Entex, Amoxicillin and Lescol.
HOSPITAL COURSE: Cardiac catheterization revealed a left
ventricular end diastolic pressure of 24 and aortic valve
area of 0.79 with 2+ aortic regurgitation, a left ventricular
ejection fraction of 49%, 2+ mitral regurgitation and 70%
left main coronary artery occlusion. The patient was an
outpatient admission directly to the Preoperative Holding
Area. She went to the Operating Room on [**2110-1-6**]
where she underwent an aortic valve replacement with a #21
[**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. She also had ascending
aortic graft in the super coronary position which was the #22
Gel-weave graft. She also underwent coronary artery bypass
graft times two with left internal mammary artery to the left
anterior descending and the saphenous vein to the obtuse
marginal. Postoperatively she was on Levophed and
transported from the Operating Room to the Cardiac Surgery
Recovery Unit in good condition. The night of surgery the
patient was weaned from mechanical ventilation and
successfully extubated. The following morning, the patient
was noted to have noncapture of her atrial and epicardial
wires requiring pacing and she had a Mobitz II second degree
heartblock. For this reason the Electrophysiology Service
was consulted and after some manipulation of her epicardial
pacing wires as well as the pacemaker itself they did have
adequate capture and they continued to follow the patient.
The patient remained in the Intensive Care Unit for the next
48 hours or so. On postoperative day #2 the patient was
noticed to be in normal sinus rhythm with a rate in the 90s.
The electrophysiology Service signed off of her case and they
felt it was very unlikely that she would need any further
intervention as far as the heartblock or rhythm issue. her
chest tubes were discontinued on postoperative day #2 as
well. On postoperative day #3 the patient remained
hemodynamically stable. She was on no vasoactive drips. She
was in normal sinus rhythm with a rate of approximately 100
and blood pressure was 1-teens/50s on 2 liters of nasal
cannula, her oxygen saturation was 94% and she as initiated
on Lopressor and did not have any detrimental blocking effect
from that. The patient was ultimately transferred on
postoperative day #3 to the Telemetry Floor from the Cardiac
Surgery Recovery Unit. The patient had a physical therapy
evaluation and was begun on increasing mobility and cardiac
rehabilitation. On postoperative day #4 the patient remained
asymptomatic, she remained on a 2 liter nasal cannula with
stable vital signs. She was continuing with diuresis and
physical therapy was progressing her from an ambulation
standpoint. The following day, postoperative day #5, the
patient remained on Bumex for diuresis. She remained on
Lopressor 25 mg b.i.d. and was progressing well from a
rehabilitation standpoint, although she was not yet
ambulating independently. Over the next couple of days, the
patient continued to progress although was noted to have
significant diarrhea, on postoperative day #6 Clostridium
difficile cultures were sent and ultimately were negative,
however, her symptoms did improve once she was started on
Flagyl orally. Today, postoperative day #8, [**1-14**], the
patient remains in good condition and ready to be discharged
home.
Her condition today reveals she is afebrile with normal sinus
rhythm with a rate in the 60s. Her blood pressure is 104/51.
She is on room air with an oxygen saturation of 92%. Her
weight today is 64 kg which is up marginally from her
preoperative weight of 60 kg. On physical examination her
wounds are clean, dry and intact. Her cardiac examination is
regular rate and rhythm. Her lungs are clear to auscultation
bilaterally. Her abdomen is soft, nontender. She still has
1 to 2+ edema bilaterally in both of her feet.
The patient has a chest x-ray pending from today, this has
not yet been obtained. The most recent laboratory values are
from today [**2110-1-14**], which revealed a white blood
cell count of 16,900 which is down from 17.1 which was
previously 20. Today her hematocrit is 28.4, her platelet
count is 492,000. Her most recent potassium is from [**1-13**] which was 4.0.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Metoprolol 25 mg p.o. b.i.d.
3. Tylenol #3 q. 4-6 hours prn pain
4. Prilosec 20 mg p.o. q.d.
5. Lipitor 20 mg p.o. q.d.
6. Salmeterol inhaled b.i.d.
7. Flovent inhaled b.i.d.
8. Synthroid 150 mcg alternating with 125 mg every other day
9. Multivitamin
10. Ferrous Sulfate and zinc
11. Bumex 1 mg p.o. t.i.d.
12. Potassium chloride 20 mEq p.o. b.i.d.
13. Flagyl 500 mg p.o. t.i.d. times one more week
14. Colace 100 mg p.o. b.i.d. as long as needed
15. She is also using Lidocaine and Chlorhexidine mouthwash
prn
16. She has Ativan prn as well for anxiety
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis, status post aortic valve replacement
2. Coronary artery disease, status post coronary artery
bypass graft
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2110-1-14**] 12:14
T: [**2110-1-14**] 12:58
JOB#: [**Job Number 30571**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5953
} | Medical Text: Admission Date: [**2199-4-29**] Discharge Date: [**2199-5-6**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
worsening shortness of breath
Major Surgical or Invasive Procedure:
Cor Valve placement
History of Present Illness:
Patient is a [**Age over 90 **]yo male with hx CAD s/p CABG x1([**2173**]), PCI
([**2185**]), afib, dual chamber PPM, CVA, renal insufficiency s/p rt
renal artery stent, carotid disease, with known aortic stenosis
s/p valvuloplasy ([**8-/2197**]) who presents with symptoms of
shortness
of breath after slowly walking 1 block, inability to climb
stairs
without stopping due to shortness of breath. He denies chest
pain, lightheadedness. Past medical history includes B-cell
lymphoma for which he was treated with chemotherapy, no
radiation, now in remission ([**2192**]). He was seen 4 months prior
for evaluation for aortic treatment options and was found to be
of prohibitively high risk for surgical AVR. He was considered
for [**Year (4 digits) 10723**]/TAVR but did not meet criteria for available high
risk arm of study. He has been stable on medical management,
however, his family notes a decline in function and worsening
fatigue over the last 3 weeks. He admits to frequent naps, and
shortness of breath after walking 20 feet. He was again seen and
evaluated for conventional surgical AVR. He was deemed of
prohibitive surgical risk due to advance age and comorbidities.
After informed consent and extensive discussions with patient
and his son and daughter, he was screened for the [**Name (NI) 10723**]/TAVR
continued access extreme risk arm of the study. He met all
inclusion criteria, and did not meet any of the exclusion
criteria. He was screened and accepted and now returns for
elective [**Name (NI) 10723**]/TAVR.
NYHA Class: III
Past Medical History:
CAD, s/p CABG in [**2173**]
[**2185**] s/p Cx stenting
Atrial fibrillation
[**Company 1543**] Adapta dual-chamber pacemaker
Aortic stenosis - s/p valvuloplasty [**8-/2197**]
Renal artery stenosis, s/p left renal artery stenting [**5-22**]
Hypertension
? Hyperlipidemia
Hypothyroidism
CVA, TIA x 2
s/p remote inguinal hernia repair
Cataract surgery
Hard of hearing
[**2192**]: Large cell Lymphoma, s/p R-CHOP (completed treatment in
[**9-21**]). Currently in remission
right axillary node dissection
tonsillectomy
Social History:
Patient lives alone in [**Location (un) **], CT. He lives close to his
daughter, [**Name (NI) **] [**Name (NI) 24715**], who is his primary caretaker. [**Name (NI) **] denies
any hx of smoking, EtOH, or drug use
Family History:
Family History: Brother died of an MI in his late 50's-early
60s. Sister died of a heart condition her 60's.
Physical Exam:
Physical Exam on Admission:
Pulse: 66
B/P: 96/50(right) 90/50(left)
Resp: 18
O2 Sat: 99
Temp: 97.8
Height: Weight: 170 lbs
General: alert, pleasant well-developed elderly male in NAD at
rest. Noticealbly SOB with ambulation
Skin: color pale pink, skin warm and dry, well healed sternal
incisional scar, no lesions.
HEENT: normocephalic, anicteric, good dentition, oropharynx
moist, upper bridge. Carotid bruits vs. referred murmer
Neck: supple, trachea midline, carotid bruits vs. referred
murmer
Chest: prominent clavicles, well healed sternotomy
Heart: murmer throughout
Abdomen: soft, nontender,nondistended, (+)BS, 80%meal intake
Extremities: no peripheral edema, no obvious deformities
Neuro: pleasant, A+Ox3, gross FROM
Pulses: palpable peripheral pulses.
Physical Exam on Discharge:
Tmax/Tcurrent: 98.5/98.5 HR: 74 RR: 20 BP: 116-127/51-57O2 sat:
98% RA
I/O:
24h: 940/850
8H; none
General Appearance: No acute distress, AAOx2
Eyes / Conjunctiva: PERRL
Cardiovascular: [**1-21**] sys murmur with 3/6 diastolic murmur, +s1
and s2, no JVD seen
Peripheral Vascular: 2+ DP
Respiratory / Chest: CTAB
Abdominal: Soft, Non-tender
Extremities: no edema
Skin: intact
Neurologic: Attentive, Follows simple commands, strength 5/5
upper and lower extremeties, speech clear, no focal defecits.
Pertinent Results:
Labs on Admission:
[**2199-4-29**] 01:10PM WBC-3.6* RBC-3.23* HGB-8.9* HCT-28.9* MCV-90
MCH-27.6 MCHC-30.8* RDW-17.2*
[**2199-4-29**] 01:10PM GLUCOSE-72 UREA N-32* CREAT-1.6* SODIUM-136
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2199-4-29**] 01:10PM ALT(SGPT)-13 AST(SGOT)-22 CK(CPK)-32* ALK
PHOS-127 TOT BILI-0.7
[**2199-4-29**] 01:10PM proBNP-6595*
[**2199-4-29**] 01:10PM ALBUMIN-3.4*
[**2199-4-29**] 01:10PM PT-14.6* PTT-31.7 INR(PT)-1.4*
[**2199-4-29**] 01:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2199-4-29**] 01:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Imaging:
Chest x-ray pre op
There is interval increase in right pleural effusion, currently
moderate.
Small amount of left pleural effusion is new as well. Patient
is in mild
interstitial edema. Heart size and mediastinum are
unremarkable. Pacemaker leads terminate in the expected
location of right atrium and right ventricle.
TTE [**2199-4-30**]
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size is normal. with mild global free wall hypokinesis.
An aortic [**Month/Day/Year **] prosthesis is present. The transaortic
gradient is normal for this prosthesis. A paravalvular aortic
valve leak is probably present. Moderate to severe (3+) aortic
regurgitation is seen (with holodiastolic flow reversal
demonstrated in the descending thoracic aorta in suprasternal
notch views). The mitral valve leaflets are mildly thickened.
Mild to moderate ([**12-17**]+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion
TTE [**2199-5-1**]
Overall left ventricular systolic function is normal (LVEF>55%).
An aortic [**Month/Day/Year **] prosthesis is present. The prosthesis is
well seated with thin/mobile leaflets and normal gradients. An
eccentric anterior perivalvular jet of at least mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-17**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2199-4-30**],
the severity of aortic regurgitation is now reduced. The other
findings are similar.
TTE [**2199-5-2**]
Overall left ventricular systolic function is normal (LVEF 70%).
An aortic [**Month/Day/Year **] prosthesis is present. A paravalvular aortic
valve leak is present at the aorticopulmonic crux/septum. The
[**Month/Day/Year **] stent may not be fully expanded at the aorticopulmonic
crux/septum. A component of intravalvular regurgitation cannot
be excluded. The aortic regurgitation appears moderate (2+) by
color flow Doppler.
Compared with the findings of the prior study (images reviewed)
of [**2199-5-1**], the appearance of aortic regurgitation by color
flow Doppler is increased.
TTE [**2199-5-3**]
The right atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. 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 normal (LVEF>55%). An aortic
[**Month/Day/Year **] prosthesis is present. Mild to moderate ([**12-17**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-17**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2199-5-2**], no
change.
TTE [**2199-5-6**]:
PRELIM: The estimated right atrial pressure is 0-5 mmHg. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Moderate (2+) aortic regurgitation is seen. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is no pericardial effusion.
DISCHARGE LABS:
[**2199-5-6**] 07:22AM BLOOD WBC-5.2 RBC-3.11* Hgb-8.7* Hct-29.0*
MCV-94 MCH-28.0 MCHC-29.9* RDW-18.3* Plt Ct-182
[**2199-5-6**] 07:22AM BLOOD PT-20.8* PTT-34.1 INR(PT)-2.0*
[**2199-5-6**] 07:22AM BLOOD Glucose-75 UreaN-31* Creat-1.2 Na-136
K-4.6 Cl-105 HCO3-22 AnGap-14
[**2199-5-4**] 04:42AM BLOOD ALT-11 AST-30 LD(LDH)-283* AlkPhos-147*
TotBili-0.9
[**2199-5-6**] 07:22AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.2
[**2199-5-6**] 07:22AM BLOOD proBNP-2941*
Brief Hospital Course:
[**Age over 90 **] year old male with severe aortic stenosis s/p [**Age over 90 **]
placement x 2 c/b AR.
# Aortic stenosis s/p [**Age over 90 **]: 2 corevalves were placed due to
complicated aortic anatomy. He received 2 units PRBC during
procedure for bleeding. Patient was hemodynamically stable upon
arrival to CCU, briefly requiring phenylephrine. He received a
third unit PRBC on arrival to CCU for Hct 25 and bumped
appropriately, after which his Hct stabilized and he required no
further transfusions. He was extubated the same evening he
arrived to the CCU. Bedside echo post-procedure showed moderate
to severe aortic regurgitation. After groin hemostasis was
achieved, he was started on a heparin drip. CK and LFTs checked
8 hours post-procedure were normal. He was monitored for PAD
pressures with swan ganz catheter and gently diuresed for
pressures consistently > 25. HR optimized already by pacemaker.
blood pressure was optimized with nitro gtt (for HTN) and
phenylephrine gtt (for hypotension) per study protocol during
the post-op period. Pt was quickly weaned off the drips and
remained hemodynamically stable. Swan ganz removed on POD#2.
Repeat echo on POD#4 showed mild to mod aortic regurgitation and
on POD#6 showed mod AR. Pt felt well so was discharged. Per pt,
his son lives next door and visits daily, so would be able to
help out at home and with medications if needed.
# AR: expected to improved somewhat post-procedure as pt
stabilizes out. He remained hemodynamically stable and repeat
echo did show some improvement in AR. Immediately
post-procedure, AR was measured as mod to severe, while
subsequent measurements were graded as mild to mod vs mod.
Optimized BP and HR as above to manage this.
# Anemia: pt lost approximately one liter of blood during
procedure, received 3 units with appropriate increase to Hct
31.Pt also experienced some oozing at the site of his neck
catheter and was thought to have a hematoma there. patient was a
difficult cross match so 6 units were matched prior to his
arrival and another 3 after he required 3 units PRBC
post-procedure. He stabilized, however, so received only a total
of 3 units.
# CAD: s/p CABG in [**2173**] with patent LIMA-LAD: continued ASA.
restarted metoprolol on POD#1. held lisinopril due to contrast
load and expectation of contrast nephropathy. started 2.5mg
lisinopril daily on [**5-4**].
# Afib/ pacemaker: held coumadin for procedure and started pt
on heparin drip after groin hemostasis achieved. When Hct stable
and there was no evidence of bleeding at the swan ganz catheter
site, coumadin was restarted at home dose with heparin subQ for
DVT ppx. pacemaker interrogated prior to procedure.
# confusion: pt intermittently experienced mild confusion at
night and in early AM in ICU, thought to be mild delirium [**1-17**] pt
not sleeping well at night. He cleared during the day as was
AAOx3. On the day of discharge, he admitted to feeling like he
"wasn't sure what was going on" and noted that his surroundings
just seemed unfamiliar. However, he was AAOx3 at this time and
could still say he was in the hospital for [**Month/Day (2) **]. Pt thought
to benefit most by getting home to familiar environment.
Assurances were made that family would be present and closely
monitor the patient once he went home (they live next door).
# Hypertension: restarted metoprolol on POD#2 as above
# Hyperlipidemia: continued pravastatin
# h/o renal artery stenosis: s/p stenting so pt started on
lisinopril as above for HTN/cardioprotection
# foley catheter: nurse had trouble getting foley out on POD#3.
It was lodged at urethral opening and balloon would not fully
deflate. called urology. they said to pull really hard on empty
syringe attached to balloon's port and if it would not deflate
to just pull the foley. said they would not do anything beyond
that so instructed them the primary team could go forward with
their suggestions. able to deflate the balloon a little more
with large empty syringe but it never fully deflated and a small
ridge persisted where the balloon was supposed to fully deflate.
pulled foley without any apparent complications. nurse filed
incident report on the device.
TRANSITIONAL ISSUES:
- follow up AR with hemodynamic monitoring and echo
- f/u with Dr. [**Last Name (STitle) **] re: [**Last Name (STitle) **] protocol s/p discharge
- f/u patient status at home for safety
Medications on Admission:
Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One
(1) Cap PO DAILY (Daily).
Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM -
discontinued 5 days ago
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeast [**State 2748**]
Discharge Diagnosis:
aortic stenosis
coronary artery disease
hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 24716**],
It was a pleasure caring for you. You were admitted to the [**Hospital1 1535**] for treatment of your aortic
valve disease. You received a [**Hospital1 **] replacement of your
aortic valve and needed to have the new valve replaced within 24
hours. It now appears to be functioning well.
It is important for you to follow-up closely with your
cardiologist and to take all of your medications as prescribed.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 24717**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days. Please get your
INR checked when you see Dr. [**Last Name (STitle) 24717**] this week.
.
We have made the following changes to your medication regimen:
1. STOP taking Aggrenox
2. START taking a baby aspirin daily
3. Change metoprolol to a long acting version that you only need
to take once a day, stop taking the twice daily metoprolol
4. START lisinopril to lower your blood pressure and help your
heart pump better
Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2199-6-17**] at 9:00 AM
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
.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 24718**], MD
Specialty: Primary Care Provider
[**Name Initial (PRE) **]: Thursday [**5-9**] at 11:15am
Address: 27 [**Location (un) 24719**] DR, [**Location (un) **],[**Numeric Identifier 24720**]
Phone: [**Telephone/Fax (1) 24721**]
Please get your INR checked at this visit
.
Department: CARDIAC SERVICES
When: THURSDAY [**2199-5-30**] at 3:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4241, 2930, 2851, 4280, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5954
} | Medical Text: Admission Date: [**2167-4-20**] Discharge Date: [**2167-4-28**]
Date of Birth: [**2103-2-26**] Sex: F
Service: ORTHOPAEDICS
Allergies:
morphine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
L3-S1 anterior spinal fusion [**2167-4-20**]
T10-S1 posterior spinal fusion [**2167-4-21**]
History of Present Illness:
Ms. [**Known lastname **] has a long history of back pain due to scoliosis. She
is electing to proceed with surgical intervention.
Past Medical History:
HTN
hyperlipidemia
hypothyroidism
arthritis
gout
GERD
scoliosis
Social History:
Denies tobacco
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2167-4-25**] 01:50PM BLOOD WBC-8.2 RBC-3.60* Hgb-10.9* Hct-30.9*
MCV-86 MCH-30.4 MCHC-35.4* RDW-14.9 Plt Ct-167
[**2167-4-25**] 03:16AM BLOOD WBC-8.0 RBC-3.34* Hgb-10.2* Hct-28.9*
MCV-86 MCH-30.4 MCHC-35.2* RDW-15.5 Plt Ct-142*
[**2167-4-24**] 02:04AM BLOOD WBC-10.5 RBC-3.09* Hgb-9.6* Hct-26.7*
MCV-87 MCH-31.0 MCHC-35.8* RDW-15.0 Plt Ct-113*
[**2167-4-23**] 04:19AM BLOOD WBC-9.5 RBC-2.98* Hgb-9.2* Hct-25.8*
MCV-86 MCH-31.0 MCHC-35.9* RDW-14.6 Plt Ct-86*
[**2167-4-25**] 01:50PM BLOOD Glucose-97 UreaN-12 Creat-0.4 Na-139
K-3.6 Cl-100 HCO3-33* AnGap-10
[**2167-4-24**] 02:04AM BLOOD Glucose-99 UreaN-14 Creat-0.5 Na-139
K-4.2 Cl-105 HCO3-30 AnGap-8
[**2167-4-22**] 01:54AM BLOOD Glucose-183* UreaN-16 Creat-0.5 Na-138
K-4.6 Cl-109* HCO3-27 AnGap-7*
[**2167-4-25**] 01:50PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
[**2167-4-24**] 02:04AM BLOOD Calcium-8.8 Phos-1.4* Mg-1.9
[**2167-4-21**] 04:48PM BLOOD Calcium-8.6 Phos-3.1 Mg-1.3*
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2167-4-20**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T10-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was low and she was
transfused multiple units PRBCs. Her large blood loss
necessetated an ICU stay. A bupivicaine epidural pain catheter
placed at the time of the posterior surgery remained in place
until postop check when it was removed due to a LLE motor block.
She was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#2
from the second procedure. She was fitted with a TLSO brace.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
famotidine
synthroid
losartan
gabapentin
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
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 BID (2 times a
day) as needed for constipation.
9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation
Discharge Diagnosis:
Scoliosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar 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:
o2-3 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.
oLimit 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 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. No
NSAIDs.
-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.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: as tolerated
Thoracic lumbar spine: when OOB
Treatment Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2167-4-27**]
ICD9 Codes: 2851, 4019, 2720, 2749, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5955
} | Medical Text: Admission Date: [**2175-4-18**] Discharge Date: [**2175-4-24**]
Date of Birth: [**2114-1-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion.
Fatigue.
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 4 [**2175-4-18**].
History of Present Illness:
Mr. [**Known lastname 61380**] is a 61 yo male pt who had a physical exam in [**11-24**]
leading to a new diagnosis of type 2 diabetes with abnormal EKG
referred to Dr. [**Last Name (STitle) 32255**]. Subsequent stress test positive leading
to cardiac cath [**2175-3-8**]. Cath showed EF 39%, apical AK, HK
distal/anterior walls, LAD 99%, OM1 50-60%, OM2 90%, RCA 60-70%.
Past Medical History:
Hypertension.
Diabetes.
Asthma.
Intermittent claudication.
Myocradial infarction.
Social History:
Lives in [**Location 5289**] with wife. Drives. Retired school teacher.
Quit tobacco 30 years ago with 36 pack year history. Denies
ETOH use -- history of abuse.
Family History:
Unknown.
Pertinent Results:
[**2175-4-20**] 06:50AM BLOOD WBC-10.4 RBC-3.17* Hgb-9.4* Hct-27.9*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.4 Plt Ct-157
[**2175-4-20**] 06:50AM BLOOD Plt Ct-157
[**2175-4-19**] 01:56AM BLOOD PT-13.0 PTT-30.3 INR(PT)-1.1
[**2175-4-20**] 06:50AM BLOOD Glucose-113* UreaN-26* Creat-1.2 Na-143
K-4.6 Cl-108 HCO3-28 AnGap-12
[**2175-4-19**] 10:42AM BLOOD Mg-2.0
[**2175-4-19**] 10:55AM BLOOD Glucose-199* K-5.0
Brief Hospital Course:
61 yo male pt admitted [**2175-4-18**] and proceeded to the OR for CABG
x 4 with LIMA to the LAD, SVG to the OM1, SVG to the OM2, SVG to
the PDA with Dr. [**Last Name (STitle) **]. He was extubated on her operative
day.
On POD one he was transferred to the inpatient/telemetry floor
for ongoing management.
On PODs three through five he became hypotensive with
ambulation/stairs and was thus kept in-house to monitor
hemodynamics.
On POD six ([**4-24**]) he was cleared by physical therapy without
further hypotensiona dn was discharged home.
Medications on Admission:
Aspirin 81 mg daily.
Multivitamin daily.
Atenolol 50 mg daily.
Metformin 1000 mg daily
Lisinopril 10 mg daily.
Lipitor 10 mg daily.
Diazepam 5 mg [**Hospital1 **].
Primatene mist 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:*0*
3. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**4-26**]
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] homecare
Discharge Diagnosis:
Coronary artery disease.
Hypertension.
Diabetes type 2.
Asthma.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily wash incisions with soap and water and rinse well.
Do not apply any creams, lotions, powders, and ointments.
No driving x 6 weeks.
No lifting greater than 10 pounds.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) 22980**] in [**1-22**] weeks.
Follow-up with cardiologist in [**2-24**] weeks.
Completed by:[**2175-4-25**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5956
} | Medical Text: Admission Date: [**2129-9-5**] Discharge Date: [**2129-9-9**]
Date of Birth: [**2067-3-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 11974**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
SVT ablation
Cardiac catheterization
History of Present Illness:
62 yo male with a history of tobacco abuse and regular alcohol
use as well as little interaction with the medical system who
presented to the ED with a 1 week history of worsening dyspnea.
Pt reports he began feeling short of breath the monday previous
to presentation worse with lying flat and exertion. He states
previously he could climb several flights of stairs while
presently he can only walk 50 ft without becoming extremely
short of breath. Additionally he has been unable to sleep for
the past week [**2-23**] to being unable to lie flat. He denies
similar symptoms in the past but does note increased fatigue and
left sided chest heaviness for the past 2 years. He also notes a
history of dizziness with standing and one episode of LOC in
[**2128-1-23**] for which he was seen in the ED. He denies that
his work as a construction worker has been affected by his
symptoms.
.
He was seen at the [**Hospital 778**] clinic and sent to the ED due to
tachycardia. In the ED he was noted to be in a wide complex
regular tachycardia concerning for V-tach. On evaluation by
cardiology the rhythm was noted to be an SVT and he was
transferred to the cath lab for an ablation procedure. Carotid
massage resulted in termination of the rhythm on a p-wave.
However, pre-op holding, pt was found to be very tachypnic and
using abdominal/accessory muscles to breathe. CXR showed
pulmonary edema. He was given 30mg total IV lasix, 1mg Inderal,
and 2mg IV morphine. He was placed on a NRB mask and was then
moved up to the CCU. At time of transfer he had put out 400cc
pale urine. He was denying chest pain, palpitations, tachypnea.
He did have recurrence of his SVT x 3 during which he was
asymptomatic and which broke with carotid massage. Echo showed
LVEF of [**11-5**]%.
Past Medical History:
1. CARDIAC RISK FACTORS: tobacco abuse
2. CARDIAC HISTORY: No known cardiac history
3. OTHER PAST MEDICAL HISTORY: No significant past medical
history or surgical history
Social History:
- Tobacco history: patient quit smoking a few weeks ago but
previously endoresed a 20 pack year history.
- ETOH: The patient notes consuming [**8-30**] drinks per week. He
states he normally has 4-5 beers per night on the weekend. His
last drink was 8 days prior to admission.
- Illicit drugs: denies
Family History:
His grandfather died from unknown cardiac disease in his 50s.
He denies known CAD or arrythmias in his family.
Physical Exam:
Admission Physical Exam:
VS: T=98.4 BP=88/57 HR=71 RR=24O2 sat=97% on 100% non rebeather
GENERAL: tachypnic, sitting straight up in bed, mildly
distressed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 18-20 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or
kyphosis.Tachypnic, no accessory muscle use. Crackles
bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Discharge Physical Exam:
Vitals - Tm/Tc:99.2/98.1 BP: 102-104/57-70 HR: 74-83 RR: 20 02
sat: 95% RA
Tele: SR, no SVT
GENERAL: 62 yoM in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP at 14 cm
CHEST: CTABL no wheezes, crackles right base, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities.
SKIN: no rash, left antecub area with improving erythema, mod
tenderness. No drainage.
PSYCH: A/O
Pertinent Results:
Admission labs/studies:
WBC 6.5 Hgb 13.9 Hct 40.7 Plts 225
Na 139 K 5.0 Cl 106 HCO3 24 BUN 20 Cr 0.9 Gluc 122
Ca 9.5 Mag 1.8 Phos 3.6 Lactate 1.8
CKMB 5 Trop-T <0.01 proBNP 2803
ALT 53 AST 30 LDH 162 alkphos 74 Tbili 0.6
Endocrine Studies:
[**2129-9-5**] 03:41PM BLOOD TSH-<0.02*
[**2129-9-6**] 05:59AM BLOOD T4-11.6 T3-259* calcTBG-0.73*
TUptake-1.37* T4Index-15.9* Free T4-2.2*
[**2129-9-7**] 04:55AM BLOOD Anti-Tg-952* antiTPO-GREATER TH
Iron Studies:
[**2129-9-6**] 05:59AM BLOOD calTIBC-264 Ferritn-179 TRF-203
A1c:
[**2129-9-6**] 05:59AM BLOOD %HbA1c-5.5 eAG-111
Lipid Panel:
[**2129-9-6**] 05:59AM BLOOD Triglyc-80 HDL-36 CHOL/HD-4.4 LDLcalc-107
EKG: Wide complex tachycardia at 125 BPM, left axis deviation
TTE: Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = [**11-5**] %). No masses or
thrombi are seen in the left ventricle. RV with depressed free
wall contractility. No aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. Tricuspid regurgitation is present
but cannot be quantified. There is no pericardial effusion.
Pertinent studies:
TTE ([**2129-9-6**])- Biventricular hypokinesis suggestive of a
diffuse process (apical function suggests a non-ischemic
etiology). Pulmonary artery systolic hypertension. Mild mitral
regurgitation. Increased PCWP.
Compared with the prior study (images reviewed) of [**2129-9-5**],
left ventricular cavity size is slightly smaller and global left
ventricular systolic function is improved. The heart rate is
much slower.
Cardiac cath ([**2129-9-7**])-
1. Coronary arteries had no angiographically-apparent
flow-limiting lesions.
2. Severe systolic ventricular dysfunction.
Discharge Labs:
[**2129-9-9**] 07:10AM BLOOD WBC-6.5 RBC-3.93* Hgb-12.4* Hct-34.9*
MCV-89 MCH-31.5 MCHC-35.5* RDW-13.0 Plt Ct-166
[**2129-9-9**] 07:10AM BLOOD Glucose-115* UreaN-21* Creat-0.8 Na-137
K-4.3 Cl-102 HCO3-28 AnGap-11
[**2129-9-8**] 04:46AM BLOOD ALT-30 AST-16 LD(LDH)-141 AlkPhos-68
[**2129-9-9**] 07:10AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8
Brief Hospital Course:
Primary Reason for Hospitalization:
62 yo male with significant alcohol and tobacco use who presents
with dyspnea secondary to flash pulmonary edema in the setting
of CHF and SVT.
Active Issues:
# Flash pulmonary edema- Patient was acutely dyspneic with
pulmonary edema on CXR and without peripheral edema at the time
of admission. pro BNP was also elevated. He diuresed well with
IV Lasix boluses, and was immediately weaned from non rebreather
to nasal cannula and maintained good saturations. With
continued diuresis, patient's respiratory status improved and he
tolerated lying flat without issue. At the time of discharge he
was maintaining good oxygen saturations on room air.
.
# SVT: Given termination of arrythmia on a p wave with carotid
massage, felt to be consistent with either a bypass tract, AVNRT
and less likely an atrial tachycardia. SVT responded to carotid
massage on multiple occasions, but returned shortly after.
Patient was started on metoprolol 25 mg po BID for rate control
which was increased to QID. TSH was low with mildly elevated T4,
consistent with hyperthyroidism. Patient was started on
methimazole. On HD3, patient was taken for an ablation of his
atrial tachycardia. A left sided bypass tract was identified and
ablated. He tolerated the procedure well with no ongoing
tachycardia. Metoprolol was changed carvedilol prior to
discharge.
.
# Acute CHF: Unclear etiology of CHF but likely acute
exacerbation of chronic disease. There was initially concern for
ischemic causes given LBBB on EKG, however cardiac
catheterization on HD2 and had no flow-limiting lesions. It was
felt that his cardiomyopathy was likely multi-factorial in
nature and a result of his alcohol use, thyroid disease in
addition to his tachyrhythmia. A cardiac MRI was performed to
assess for other causes of cardiomyopathy, results were pending
at the time of discharge. The patient was successfully diuresed
as noted above with IV Lasix and transitioned to 40 mg of PO
Lasix daily. He was also started on 5 mg lisinopril and 6.25 mg
daily carvedilol [**Hospital1 **] when blood pressures tolerated. These
medications were continued at discharge.
.
#Hyperthyroidism: Given new onset of tachycardia, patient was
checked for underlying endocrine or electrolyte abnormalities on
admission. TSH was low, and free T4 was elevated. Patient was
started on methimazole 10mg po BID. Liver function tests were
checked 2 days after starting the medication and were normal.
Anti-Tg and Anti-TPO were significantly elevated. The patient
has follow-up with endocrine as an outpatient and will require a
thyroid US and thyroid scan.
.
Fever: Pt had one fever to 100.8. This was not associated with
an elevation in white blood cell count or any symptoms of
infection. Urine cultures were negative and blood cultures were
pending at the time of discharge.
.
#Transitional issues:
-Patient maintained full code status throughout hospitalization.
-He will follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85803**] NP[**MD Number(3) **] [**Hospital 778**] clinic
on [**9-14**], Endocrinology on [**9-28**] and Dr. [**Last Name (STitle) **] from Cardiology on
[**9-30**].
.
Pending Studies:
Cardiac MRI report
Thyroid stimulating immunoglobulin
Blood cultures
Medications on Admission:
None
Discharge Medications:
1. methimazole 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
4. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Systolic Congestive Heart Failure
Hyperthyroidism
Supraventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had trouble breathing and it was found that your heart was
very weak. This is possibly because of a combination of your
high heart rate, your alcohol intake and your high thyroid
hormone levels. We have done an ablation of your heart that has
interrupted the cause of the fast heart rate. You were seen by
an endocrinologist who prescribed a medicine to lower your
thyroid levels. You will need follow up with them after you go
home to get the thyroid hormone level right. It is very
important for your heart and general health to stop smoking and
drinking alcohol. This will allow your heart to get stronger.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start taking Carvedilol twice daily to slow your heart rate
and help your heart
2. Start Lisinopril to lower your blood pressure and help your
heart pump better
3. Start methimazole to treat your high thyroid levels
4. Start furosemide to remove extra fluid.
Followup Instructions:
Name: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 85803**] PA
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
When: Wednesday, [**9-14**], 1:00 PM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2129-9-28**] at 5:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD & [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2129-9-30**] at 2:20 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
ICD9 Codes: 4254, 4280, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5957
} | Medical Text: Unit No: [**Numeric Identifier 106721**]
Admission Date: [**2133-11-4**] Discharge Date: [**2133-11-13**]
Date of Birth: Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with
known history of coronary artery disease, who reported recent
episodes of chest pain without radiation to jaw or shoulder.
Episodes always alleviated with rest. Two stress tests in
the past were negative. His last episode of chest pain was
seemingly on [**2133-10-25**]. He underwent a stress test on
[**2133-11-4**]. The patient had chest pain, and his EKG showed ST
changes. The patient was admitted to the ER of [**Hospital1 18**] and
underwent a cardiac catheterization, which revealed 3-vessel
disease. The catheterization results were as follows: 80
percent proximal RCA, 80 percent left main, 60 percent mid
LAD, 70 percent diagonal 1, 40 percent left circumflex, 80
percent OM2, 80 percent PDA with an EF of 56 percent.
PAST MEDICAL HISTORY: His past medical history is
significant for:
Hypertension.
BPH.
Hypercholesterolemia.
Aortic stenosis.
He has GERD, gastroesophageal reflux disease.
He has osteoarthritis of his hips.
He suffers from anemia and anxiety.
PAST SURGICAL HISTORY: He has had no prior surgical history.
MEDICATIONS AT HOME: His medications at home are as follows:
1. Lipitor 40 mg q.d.
2. Lisinopril 40 mg q.d.
3. Doxazosin 2 mg q.d.
4. Atenolol 25 mg q.d.
5. Aldactone 25 mg q.d.
6. HCTZ 12.5 mg q.d.
7. Norvasc 10 mg q.d.
8. ASA 81 mg q.d.
9. Zantac p.r.n.
10. Tums p.r.n.
11. Imitrex p.r.n.
ALLERGIES: He really has no known drug allergies except a GI
upset to AMPICILLIN.
FAMILY HISTORY: His family history is significant for
coronary artery disease. His dad died from MI at the age of
79. Both his brother and his mom have CHF.
REVIEW OF SYSTEMS: His review of systems is positive for
migraines, positive for lichen planus on his shins.
PHYSICAL EXAMINATION: His physical examination
preoperatively is as follows: His height was 5 feet 7
inches, his weight 168 pounds. He was alert and oriented x3.
His lungs were clear to auscultation. Heart rate was regular
rate and rhythm, positive S1, S2, positive 3/6 systolic
ejection murmur. His abdomen was soft, nontender, and
nondistended, positive for bowel sounds. His extremities
were warm, well perfused, no cyanosis, no clubbing or edema,
no varicosities. His pulses were 2 plus throughout, and he
had a question of carotid bruits with the murmurs from his
heart that were also radiating to his right carotid.
LABORATORY DATA: His preoperative laboratories were as
follows: His chest x-ray was normal. His UA was negative.
His EKG with sinus bradycardia at 56 beats per minute. His
white blood cell count was 10.9. His hematocrit was 32.4.
His platelets 202,000. Sodium 142, potassium 4.2, chloride
106, bicarbonate 26, BUN 20, creatinine 1.1, glucose 83, PT
14, PTT 57.1, INR 1.2, ALT 25, AST 21, amylase 105, total
bilirubin 1.0, and hemoglobin A1c 4.
HOSPITAL COURSE: On [**2133-11-6**], the patient went to the
operating room and underwent a coronary artery bypass graft
x5, mid LAD, saphenous vein graft, OM1, OM2 direct, and right
ventricular branch of the RCA. The patient tolerated the
procedure well. His bypass time was 91 minutes, the cross-
clamp time was 65 minutes. His vitals when he was admitted
to the CSRU are as follows: His heart rate was 80 beats per
minute, apaced, mean arterial pressure was 70, CVP was 11, PA
diastolic was 15, PA mean was 23. He was on a propofol drip
being titrated and Neo-Synephrine at 0.3 mcg/kg per minute,
and he was transferred successfully to the CSIU.
On postoperative day 1, the patient was hemodynamically
stable. His blood pressure was 116/39, heart rate 79. He
was extubating and saturating at 96 percent. He received Neo-
Synephrine 1.5 and Lasix. Plan was to wean him off. On
postoperative day 2, chest tubes were discontinued. Lasix
was at 20 b.i.d., and the plan was to have him transferred to
the floor. He was hemodynamically stable at that time.
On postoperative day 3, the patient was hemodynamically
stable. His physical examination was as follows: He had 1
to 2 plus edema in his extremities. His left lower extremity
vein harvest site was clean, dry, and intact. His sternal
incision was also clean, dry, and intact and no erythema, no
drainage. His tracing wires were removed. His lungs were
clear throughout. His heart was regular rate and rhythm.
The patient was ambulating well, but had some increasing
blood pressure and heart rate while ambulating. The plan was
to start Lopressor at 12.5 mg b.i.d. and disconnect the PCA
wires if his heart rate was okay. The plan was also to
continue diuresis and change his Lasix to p.o. On
postoperative day 4, the patient was doing well, continued to
be out of ventilator, and his creatinine had increased this
morning to 1.7, and wires were discontinued, and his physical
examination was unremarkable, and he was hemodynamically
stable. On postoperative day 5, his creatinine decreased.
Today, his physical examination was unremarkable except for 1
to 2 edema in his extremities, and he had some rhonchi in the
bases bilaterally. His hematocrit had dropped from 26 to 23,
and a Foley was reinserted 2 days ago for BPH. The patient
also received a chest x-ray today that revealed a left lower
lobe atelectasis. On postoperative day 6, the patient was
hemodynamically stable, 91 sinus rhythm, blood pressure
120/52. His chest x-ray results were he had a small left
effusion and left-sided atelectasis. He had some trace
edema, and his lungs were clear, and his heart rate was
regular in rhythm and in rate. The patient continued to
receive diuretics, and his Lasix was increased to 40 mg
b.i.d., and he was encouraged to ambulate.
On postoperative day 7, which was [**2133-11-13**], the patient was
stable with temperature 99, pulse 83, sinus rhythm, blood
pressure 112/46. The patient was doing well. The patient
today was discharged. His discharge physical examination was
as follows: He was alert and oriented x3. His lungs were
clear bilaterally. His heart was regular in rate. His
abdomen was soft and nontender. His extremities were warm
with trace edema. His external incision site was clean, dry,
and intact, no erythema, no drainage. His left lower
extremity, where he received his vein harvest, was clean and
dry.
CONDITION ON DISCHARGE: The patient was discharged in good
condition to home with VNA.
DISCHARGE DIAGNOSES: His discharge diagnoses are as follows:
Status post coronary artery bypass graft x5.
Hypertension.
Hypercholesterolemia.
Benign prostatic hyperplasia.
Gastroesophageal reflux disease.
FOLLOWUP: The patient was recommended to follow up with Dr.
[**Last Name (STitle) 311**] in 2 to 3 weeks, Dr. [**Last Name (STitle) **] in 2 to 3 weeks, and Dr.
[**Last Name (STitle) **] in 4 weeks.
DISCHARGE MEDICATIONS: Discharge medications were as
follows:
1. Aspirin 325 mg p.o. q.d.
2. Colace 100 mg p.o. b.i.d.
3. Hydromorphone 2 mg 1 to 2 tablets p.o. q.4-6h. p.r.n.
4. Doxazosin 2 mg p.o. h.s.
5. Lasix 40 mg 2 tablets p.o. b.i.d.
6. Lopressor 25 mg p.o. b.i.d.
7. Ibuprofen 400 mg 1 tablet p.o. q.8h. p.r.n.
8. FeSO4 325 mg 1 tablet p.o. q.d.
9.
Pantoprazole 40 mg 1 tablet q.d.
10. Ascorbic acid 500 mg 1 tablet p.o. b.i.d.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 11830**]
MEDQUIST36
D: [**2133-11-13**] 15:30:40
T: [**2133-11-14**] 07:14:00
Job#: [**Job Number **]
ICD9 Codes: 4241, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5958
} | Medical Text: Admission Date: [**2160-10-16**] Discharge Date: [**2160-11-18**]
Date of Birth: [**2092-2-20**] Sex: F
Service: Surgery
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 44935**] is a
68-year-old primarily Russian-speaking female who has been
diagnosed with myeloproliferative disorder several years ago.
The patient has been closely followed by her primary care
physician, [**Name10 (NameIs) **] she also has a hematologist/oncologist. The
patient has undergone radiation treatment for her
splenomegaly several years ago. The spleen has recently
increased in size, and the patient has been somewhat
symptomatic.
The patient's comorbidities included coronary artery disease
(with a myocardial infarction in [**2153**]) as well as a history
of hypertension. In addition, she had a left-sided
nephrectomy and breast carcinoma with a left-sided mastectomy
in [**2148**].
The patient presented to General Surgery for a possible
surgical solution of her splenomegaly due to her
myeloproliferative disorder. The patient received all of her
previous treatments at outside facilities. The patient was
consequently scheduled for an elective open splenectomy by
the General Surgery staff.
On [**2160-10-16**], the patient underwent open splenectomy
by Dr. [**Last Name (STitle) **]. The procedure was without any
complications. The estimated blood loss was approximately
600 cc, and the patient received one unit of packed red blood
cells. Please see the full Operative Report for details.
PAST MEDICAL HISTORY:
1. Myeloproliferative disorder.
2. Coronary artery disease.
3. Status post myocardial infarction in [**2153**].
4. Hypertension.
5. Breast carcinoma; status post left-sided mastectomy in
[**2148**].
PAST SURGICAL HISTORY:
1. Left-sided mastectomy for breast carcinoma in [**2148**].
2. Status post left-sided nephrectomy.
3. Status post eye surgery.
MEDICATIONS ON ADMISSION:
1. Hydroxyurea 500 mg p.o. q.d.
2. Ambien 10 mg p.o. q.h.s. as needed.
3. Trazodone 50 mg p.o. as needed.
4. Lopressor 50 mg p.o. b.i.d.
5. Allopurinol 300 mg p.o. q.d.
6. Norvasc 5 mg p.o. q.d.
7. Prilosec.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed alert and oriented, in no apparent distress. An
elderly, primarily Russian-speaking, female. Temperature was
98.4, blood pressure was 142/74, heart rate was 78,
respiratory rate was 17, oxygen saturation was 97% on room
air. Head, eyes, ears, nose, and throat examination was
within normal limits. No signs of lymphadenopathy. Full
range of motion in the neck. No carotid bruits were
detected. Cardiovascular examination revealed a regular rate
and rhythm. No murmurs, rubs, or gallops. Pulmonary
examination revealed clear to auscultation bilaterally. The
abdomen was soft, nontender, and nondistended. An enlarged
spleen extending below the umbilicus was palpable in the left
upper quadrant. Bowel sounds were present. Chest
examination revealed the site of prior mastectomy.
Extremities were warm and well perfused. No signs of edema.
HOSPITAL COURSE: Given the history of myeloproliferative
disorder and significant splenomegaly, a surgical
intervention was undertaken. On [**2160-10-16**], the
patient underwent open splenectomy. The procedure was
without any complications with an estimated blood loss of
approximately 600 cc. Please see the full Operative Report
for details.
The patient was extubated successfully and transferred to the
Postanesthesia Care Unit in stable condition. She was
originally made nothing by mouth and was adequately
resuscitated with intravenous fluids. She was transfused
with one unit of packed red blood cells in the operating
room.
She was placed on a beta blocker and subcutaneous heparin.
Her pain was adequately controlled. She was placed on
prophylactic antibiotics.
The patient maintained a low-grade fever and remained
somewhat tachycardic. She was further resuscitated with
fluids given her low urine output. A nasogastric tube was
placed. Her postoperative hematocrit was 34.2 with a white
blood cell count of 11.
Given the symptoms of nausea, a KUB of the abdomen was
obtained which showed diffuse dilatation of the small bowel
and colon; consistent with postoperative ileus.
On postoperative day three, the patient was noted to be
hypotensive, and she was noted to have her hematocrit
decrease from 36 to 21.2. At that point, she was taking
aspirin.
The patient was quickly taken to the operating room on
[**2160-10-19**] for exploratory laparotomy and evaluation
of the bleed. Intraoperatively, the patient was found to be
coagulopathic, but no discrete source of the bleed was found.
The patient was transfused with several units of packed red
blood cells as well as platelets. Several liters of blood
were aspirated from the abdomen.
Before the exploratory laparotomy, she was found to have an
INR of 4.3. She had been on Lovenox and Coumadin. After the
exploration, the patient was transferred to the Intensive
Care Unit. A central line was placed. The patient remained
intubated. Her hematocrit was increased with several
transfusions. Her urine output remained adequate. She was
maintained on intravenous fluids. Several blood cultures
were taken which showed no growth.
The patient was extubated on postoperative day five and two.
Total parenteral nutrition was started given that the patient
had been without any oral intake for several days. She
continued to have a low-grade fever. The patient was
consequently transferred to the regular floor on
postoperative day six and three.
The Nutrition Service was consulted, who followed the patient
throughout her hospitalization.
An electrocardiogram performed at the time showed a sinus
rhythm, and no change compared to the baseline tracing
available.
The patient continued to be coagulopathic even without
receiving any Coumadin or other anticoagulation products.
Her wound remained clean, dry, and intact. There was some
abdominal distention noted. She was started on clear
liquids, and her diet was very slowly advanced; which she
tolerated well.
Given the persistent elevated temperatures and distended
abdomen, a computed tomography of the abdomen was performed
on [**2160-10-25**]. There was no evidence of abscess.
However, diffuse ascites were noted. In addition, bilateral
pleural effusions were noted; which were associated with
atelectasis at both lung bases. A successful
ultrasound-guided paracentesis of the ascites was performed
on [**2160-10-25**]. The patient would have several such
paracentesis procedures. Cultures were obtained from the
fluid which showed no microorganisms; only polymorphonuclear
leukocytes. In addition, the white blood cell count in the
fluid was low and not suggestive of any infection. The
patient was consequently placed on Unasyn for empiric
coverage. The patient also had several urine cultures
obtained which grew Escherichia coli as well as
Corynebacterium species. In addition, her sputum grew yeast.
As perviously mentioned, her blood cultures grew nothing.
The patient continued to be diuresed. Her hematocrit
remained stable; although, she continued to be anemic, and at
some point required more blood.
The patient was consequently restarted on Coumadin. In
addition, the Renal Service was consulted given the ascites;
with the specific question of whether ascites were from a
renal etiology and also the significance of proteinuria which
was noted on routine urinalysis.
In addition, the CAT scan that was obtained on [**2160-10-25**] showed evidence of portal vein thrombosis which was
confirmed by the ultrasound. It was thought that the
significant ascites that seemed to reaccumulate after
therapeutic paracenteses were due to the portal vein
thrombosis and not renal failure. The patient's creatinine
did increase slightly but then returned back to the patient's
baseline of approximately 1.5.
On [**2160-10-27**], the patient appeared to have a
relatively sudden onset of chest discomfort as well as
tachypnea. There was no nausea, vomiting, or diaphoresis.
She appeared to be tachypneic with a respiratory rate of
approximately 35, but her blood pressure and heart rate were
stable, and her oxygen levels remained the same. A arterial
blood gas was obtained at that time which showed a pH of
7.53, PO2 of 75, and PCO2 of 19, with a base excess of -3,
and total CO2 of 16. She ruled out for a myocardial
infarction by cardiac enzymes, and her lung scan was low
probability of any pulmonary embolism. A venous ultrasound
of the lower extremities was also negative for any clots.
Given these symptoms, the patient was again admitted to the
Intensive Care Unit for closer monitoring. She was continued
on Unasyn and intravenous heparin. She continued to make
adequate urine. She remained on beta blocker. Her
electrocardiogram showed no changes. However, the chest
x-ray did show left lower lobe consolidation.
The patient remained stable and was transferred out of the
Intensive Care Unit to the regular floor. She continued to
be coagulopathic with an INR of 2.6 on [**2160-10-30**]. She
was also noted to have a white blood cell count of 48 and a
platelet count of approximately 2 million. Her liver
function tests were elevated; consistent with portal vein
thrombosis seen on the CAT scan and ultrasound.
The Hematology/Oncology Service was consulted given the
elevated white blood cell count and platelets. The patient
was restarted on Hydroxyurea. Her white blood cell count and
platelet count decreased slowly with this medication. In
addition, the patient underwent one round of plasmapheresis
which she tolerated well. While on Hydroxyurea, the
patient's white blood cell count decreased significantly and
was noted to be 0.4 several days later. Consequently,
Hydroxyurea was stopped. The patient was placed on
neutropenic precautions. Hydroxyurea was discontinued. The
patient was place G-CSF (growth factor) to which she
responded well, and G-CSF was discontinued several days
later.
The Renal Service continued to follow the patient, and they
thought that her proteinuria was secondary to a nephrotic
syndrome. They recommended further diuresis and oral fluid
restriction.
The patient continued to improve, and her ascites decreased
significantly toward the end of her hospitalization. She was
making significant urine. Her liver function tests improved
and were essentially normal. She was continued on Coumadin
with a stable regimen of 2.5 mg toward the end of her
hospitalization. She continued to tolerate an oral diet
without any difficulties. The staples were removed on
postoperative day 18.
While the patient was on neutropenic precautions; secondary
to a low white blood cell count, she was maintained on
cefepime intravenously which was discontinued when the
neutropenic precautions were removed. Her lower extremity
edema decreased significantly as well.
DISCHARGE DISPOSITION: The patient continued to improve
significantly and was discharged to home on [**2160-11-18**].
PERTINENT LABORATORY VALUES ON DISCHARGE: Her laboratories
upon discharge were as follows: White blood cell count was
7.9 and hematocrit was 27.8 (differential with 70%
neutrophils), platelet count was 389. INR was 2.2.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Myeloproliferative disorder.
2. Status post open splenectomy; complicated by
intra-abdominal bleed, status post re-exploration and
aspiration of intra-abdominal bleed.
3. Portal vein thrombosis.
4. Anemia.
5. Coagulopathy.
6. Hypertension.
7. Coronary artery disease.
MEDICATIONS ON DISCHARGE:
1. Coumadin 2.5 mg p.o. q.d.
2. Potassium chloride 20 mEq p.o. b.i.d. (while the patient
is taking lasix).
3. Lasix 80 mg p.o. b.i.d.
4. Lisinopril 5 mg p.o. q.d.
5. Ambien 5 mg p.o. q.h.s. as needed (for insomnia).
6. Colace 100 mg p.o. b.i.d.
7. Allopurinol 200 mg p.o. q.d.
8. Protonix 40 mg p.o. q.d.
9. Lopressor 75 mg p.o. b.i.d.
10. Artificial Tears one to two drops as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to take 2.5 mg of Coumadin q.d., and she
was to see her primary care physician (Dr. [**Last Name (STitle) 44936**] in
approximately two to three days for an INR check and any
adjustment of Coumadin. The INR goal is approximately 2.5;
but one needs to be careful given the history of coagulopathy
with this patient.
2. The patient was to follow up with her
hematologist/oncologist (Dr. [**First Name8 (NamePattern2) 565**] [**Last Name (NamePattern1) **]) in approximately
one week.
3. The patient was to follow up with her surgeon (Dr.
[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]) in approximately two to three weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2160-11-18**] 15:32
T: [**2160-11-18**] 16:11
JOB#: [**Job Number 19921**]
cc:[**Hospital6 44937**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5959
} | Medical Text: Admission Date: [**2105-8-18**] Discharge Date: [**2105-8-21**]
Date of Birth: [**2037-7-19**] Sex: F
Service: MEDICINE
Allergies:
Zestril
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Chief Complaint: Bradycadia
.
Reason for MICU transfer: hyperkalemia
Major Surgical or Invasive Procedure:
Attempt to remove a blood clot from the AV graft (thrombectomy),
not successful
placement of left subclavian tunnelled hemodialysis line
History of Present Illness:
68 year old female with ESRD on HD who presented from AV Care
with bradycardia to the 30. The pt went to her normal HD
yesterday at the [**Hospital **] Clinic where her R AVG was
found to be thrombosed. She was unable to get her HD, last HD
was last Friday. She set up for a thrombectomy at AV Care today,
but when on the table for the procedure, her heart rate was
noted to be 32. The procedure was aborted and the patient and
sent to the ER for evaluation.
.
K on arrival to the ED was 7.4. Bradycardic to the 30s with a
junctional rhythm. She received Calcium, insulin, and D50 with
improvement in K to 6.9 and HR to 60s. Renal and transplant
surgery were both contact[**Name (NI) **] in the [**Name (NI) **]. She was noted to be going
back into a junctional rhythm prior to transfer. Another 2g of
calcium carbonate were ordered, but there were no doses
availible in the ED. She is being admitted for emergent HD.
.
On the floor, she has no complaints other than being hungry.
Past Medical History:
ESRD [**2-4**] diabetic nephropathy, on renal transplant list, HD MWF
@ [**Location (un) **] [**Location (un) **] Dialysis Center
Type II DM
HTN
asthma
Social History:
She is married. She and her husband are independent in their
ADLs. She emmigrated from Barbados in [**2084**]. She used to work
baby sitting for a physician here at [**Hospital1 18**], but she is not
working due to disease. She never smoked or drank alcohol. She
denies IVDU but has received blood transfusions.
Family History:
(per OMR, confirmed)
Her parents both had DM (deceased age 71-mother and 80-father).
She has 2 siblings with DM2 and one of her children as well, who
also has CKD.
Physical Exam:
Vitals: T: BP:113/97 P: 46 R9: 18 O2: 97%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: bardycardia, irregular, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
Admission Labs:
[**2105-8-18**] 12:15PM BLOOD WBC-6.6 RBC-5.46* Hgb-11.8* Hct-38.8
MCV-71* MCH-21.6* MCHC-30.3* RDW-18.4* Plt Ct-263
[**2105-8-18**] 12:15PM BLOOD Neuts-60.4 Lymphs-24.4 Monos-5.6 Eos-8.7*
Baso-0.8
[**2105-8-18**] 12:15PM BLOOD PT-12.1 PTT-26.4 INR(PT)-1.0
[**2105-8-18**] 12:15PM BLOOD Glucose-276* UreaN-72* Creat-13.3*#
Na-129* K-7.4* [**2105-8-18**] 12:15PM BLOOD Calcium-8.7 Phos-6.9*#
Mg-2.6
[**2105-8-18**] 12:20PM BLOOD Glucose-262* Lactate-1.6 Na-127* K-8.3*
Cl-91* calHCO3-22
.
Echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The right ventricular free wall is
hypertrophied. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Right ventricular hypertrophy. Diastolic dysfunction. No
pathologic valvular abnormality seen. No evidence of restrictive
filling of left ventricle. The findings could be consistent with
infiltrative process but are more likely due to effects of
hypertension/renal failure.
Compared with the prior study (images reviewed) of [**2103-7-5**],
mild symmetric LVH and right ventricular hypertrophy are seen on
the current tracing.
.
Discharge Labs:
[**2105-8-21**] 05:58AM BLOOD WBC-8.2 RBC-4.87 Hgb-10.5* Hct-35.2*
MCV-72* MCH-21.5* MCHC-29.7* RDW-18.2* Plt Ct-211
[**2105-8-21**] 05:58AM BLOOD Glucose-166* UreaN-31* Creat-7.4*# Na-134
K-5.7* Cl-94* HCO3-30 AnGap-16
[**2105-8-21**] 05:58AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.1
Brief Hospital Course:
68yo F with ESRD, type II DM, and HTN who missed HD yesterday
[**2-4**] graft thrombosis who presented to the ED after thrombectomy
was aborted in the setting of bradycardia.
.
# Bradycardia: Initial junctiona rhythm resolved with HD and
resolution of hyperkalemia. On HD 3, patient had sinus
bradycardia with ventricular escape beats. Potassium was not
elevated at the time. EP felt related to high doses nodal
agents for BP control. Her labetolol and am clonidine were held,
she underwent HD, and her rhythm improved. BPs remained in the
130s for most of the day but eventually increased to 190. Per
discussion with patient??????s nephrologist we continued nifedipine
and hydralazine. Clonidine was given in place of home guafacine.
Pt did not have any more bradycardic episodes and remained in
sinus rythm in the 60s for teh rest of the admission. LFTs
checked for reduced hepatic clearance of labetolol? but were
normal. D/c home on regimen of nifedipine, hydralazine, and
guafacine. Her regimen will be further adjusted by her
nephrologist, Dr. [**Last Name (STitle) 4883**].
.
# Hypertension: Had restarted home regimen (labetolol,
nifedipine, hydralazine, clonidine in place of home guafacine),
but pt developed a second episode of bradycardia concerning for
medication toxicity (see above). She required a nitro gtt for
control on hospital day #1, but for > 24 hours prior to
discharge she maintained BP < 180 on just nifedapine, clonidone,
hydralazine (held labetolol).
.
# Thrombosed HD graft: IR unable to perform thrombectomy. Got
tunneled HD line.
She will need a thrombectomy to reopen her AV graft. She is
scheduled to follow up at [**Hospital **] Care Center with Dr [**Last Name (STitle) **].
.
# ESRD: Awaiting transplant. Continued nephrocaps. Low K/phos
diet, and phos binder was uptitrated.
.
# DM: Pt takes 30 units of 50/50 [**Hospital1 **]. Had some hypoglecemia,
maintained just on sliding scale while admitted. Per pt, eats
more sugary food at home. resume home regimen upon d/c.
.
# Asthma: Well-controlled per pt history. Con't home Advair with
albuterol PRN.
Medications on Admission:
(per OMR)
amitriptyline 25 mg Tablet 1 Tablet(s) by mouth HS
B complex-vitamin C-folic acid [Nephrocaps] 1 mg Capsule by
mouth once a day
calcium acetate 667 mg Capsule 3 Capsule(s) by mouth three times
a day
fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose Disk
with Device 1 Disk(s) inhaled twice a day
guanfacine 1 mg Tablet 1 Tablet(s) by mouth hs
insulin lispro protam & lispro [Humalog Mix 50-50] 100 unit/mL
(50-50) Insulin Pen 30 units SC twice a day
labetalol 200 mg Tablet 1 Tablet(s) by mouth twice a day
nifedipine 90 mg Tablet Extended Release 1 Tablet(s) by mouth
once a day
pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth every twenty-four(24) hours
sevelamer carbonate [Renvela] 800 mg Tablet 1 Tablet(s) by mouth
three times a day
aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth DAILY
docusate sodium 100 mg Capsule 1 Capsule(s) by mouth twice a day
sennosides [senna] 8.6 mg Tablet 2 Tablet(s) by mouth HS
.
Per CVS (do not have inhalers or phos binders on record there)
hydralazine 50mg TID
Sensipar (cinacalcet) 30mg qd
labetolol 300mg 2 tablets [**Hospital1 **]
guansacine 2mg at HS
.
Per [**Location (un) **]
labetolol 300mg 2 tablets [**Hospital1 **]
guansacine 2mg at HS
Hydralazine 100mg TID
sevelamer carbonate [Renvela] 800 mg Tablet 1 Tablet(s) by mouth
three times a day
nifedipine 90 mg Tablet Extended Release 1 Tablet(s) by mouth
once a day
amitriptyline 25 mg Tablet 1 Tablet(s) by mouth HS
B complex-vitamin C-folic acid [Nephrocaps] 1 mg Capsule by
mouth once a day
Discharge Medications:
1. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for Constipation.
2. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB,
wheeze.
5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. insulin lispro protam & lispro 100 unit/mL (50-50) Suspension
Sig: Thirty (30) units Subcutaneous twice a day.
7. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO HS (at bedtime).
8. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
three times a day: with meals.
Disp:*360 Tablet(s)* Refills:*0*
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. guanfacine 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Dialysis dependent chronic renal failure/End Stage Renal Disease
Hyperkalemia
Bradycardia
AV graft thrombosis
.
Secondary:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 8631**] [**Known lastname **],
.
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] intensive care unit because of elevated potassium. Your
potassium level is controlled by dialysis, however your AV
fistula was found to have a clot in it. Because of that you were
unable to get dialysis and as a result your potassium elevated
causing your heart rate to slow.
.
You were admitted, had a temporary line placed to resume
dialysis, and with treatment your potassium normalized and your
heart rate and rhythm, normalized.
.
Also, you had severely elevated blood pressure, because your
blood pressure medications were held prior to your procedure.
You required IV medications to help control it. We think that
because we gave you extra IV blood pressure medicines, your
heart rate slowed down again, but this got better on it's own.
We are not giving you your labetolol right now. Dr. [**Last Name (STitle) 4883**]
will be adjusting your blood pressure medicines when you see him
at dialysis.
.
We made the following changes to your medications:
- Please STOP taking labetolol for now.
- Please increase your sevelemer to 3200mg (4 tablets) with each
meal.
Followup Instructions:
Please resume your typical dialysis schedule.
.
Department: ADVANCED VASC. CARE CNT
When: TUESDAY [**2105-8-25**] at 9:00 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Department: TRANSPLANT CENTER
When: THURSDAY [**2105-9-10**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: TRANSPLANT CENTER
When: TUESDAY [**2106-3-23**] at 9:00 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5856, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5960
} | Medical Text: Admission Date: [**2193-2-28**] Discharge Date: [**2193-3-7**]
Date of Birth: [**2174-10-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Tylenol Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 12649**] is an 18yo man with no significant past medical
history who is transferred to [**Hospital1 18**] for liver transplant
evaluation following toxic acetaminophen ingestion. He told the
team at [**Hospital1 2177**] that he laid hands on gf on [**2-22**], was put in jail
briefly, seen in court and lost custody on [**2-26**]. He took the
overdose of about 10 extra strength tylenol pills on the evening
of [**2-26**], went to sleep, then called 911 and went to ED about 12
hrs later. He denies that this was a suidice attempt, but
reportedly has told some physicians that it was. Initial
acetaminophen level was 162 at 12 hrs. He did well at [**Hospital1 2177**],
eating but his transaminases began rising and he had recurrent
nausea, emesis. He refused several NAC doses. He was transferred
to [**Hospital1 18**] due to concerns pt might need liver transplant.
Past Medical History:
-denies hx of suicide attempts
-no hx of inpatient psychiatric tx
-though patient denied seeing a psychiatrist in the past, mother
notes the pt. has been tx'd for anxiety/panic with Prozac and
Klonopin
Social History:
Difficult childhood with reported DYS/ DSS involvement. Did not
finish senior year of high school. Was at [**Location (un) 18488**] Vocational
school. Wants to go to college and possibly obtain radiology
tech or culinary training. Has very supportive grandmother
living in [**Name (NI) 12000**] to whom he has been close and with whom he
has been in contact recently. [**Name2 (NI) **] 3 brothers, 1 sister, helps
family wi childcare - not employed. Hx of multiple sexual
partners since age 13. Has had jail time in past. Smokes 4 cig/
day per prior note from pediatrics at [**Hospital1 2177**]
Pt reports occasional use of MJ q 2-3 weeks, last 1 wk ago, but
denies IVDU, cocaine, or other illicit drugs. Only drinks EtOH
occasionally by report.
Family History:
Patient does not know
Physical Exam:
AF 120's/70's 50's 12 95%RA
Gen: Blunted affect, NAD
Heent: Icteric sclera. MMM
Heart: RRR no rmg
Lungs: CLear
Abd: Slight pain to palapation over R and LUQ's. No peritoneal
signs. +BS
Ext: No c/c/e.
Pertinent Results:
[**2193-2-28**]
7:28p
146 107 23 / AGap=22
------------- 93
4.1 21 3.5 \
Ca: 9.4 Mg: 1.3 P: 3.0
ALT: 5480 AP: 241 Tbili: 5.4 Alb: 3.9
AST: 6014 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Comments: Verified By Dilution
Other Blood Chemistry:
HBsAg: Negative
HBs-Ab: Positive
HBc-Ab: Negative
HAV-Ab: Negative
HCV-Ab: Negative
78
9.1 \ 16.1 / 181
/ 44.8 \
PT: 26.8 PTT: 38.4 INR: 4.5
Fibrinogen: 185
[**2193-3-1**] 10:45AM BLOOD HIV Ab-NEGATIVE
[**2193-3-5**] 05:55AM BLOOD Type-[**Last Name (un) **] pO2-103 pCO2-39 pH-7.29*
calHCO3-20* Base XS--6 Comment-GREEN TOP
[**2193-2-28**] 07:28PM BLOOD Glucose-93 UreaN-23* Creat-3.5* Na-146*
K-4.1 Cl-107 HCO3-21* AnGap-22*
[**2193-3-1**] 03:01AM BLOOD Glucose-122* UreaN-27* Creat-4.4* Na-140
K-3.7 Cl-106 HCO3-21* AnGap-17
[**2193-3-1**] 05:44PM BLOOD Glucose-152* UreaN-27* Creat-4.8* Na-147*
K-3.2* Cl-106 HCO3-18* AnGap-26*
[**2193-3-4**] 05:20AM BLOOD Glucose-111* UreaN-56* Creat-8.9* Na-140
K-4.1 Cl-105 HCO3-16* AnGap-23*
[**2193-3-5**] 05:33AM BLOOD Glucose-134* UreaN-64* Creat-8.5* Na-140
K-3.7 Cl-105 HCO3-18* AnGap-21*
[**2193-3-5**] 05:33AM BLOOD ALT-845* AST-42* LD(LDH)-320*
AlkPhos-197* TotBili-2.7*
[**2193-2-28**] 07:28PM BLOOD ALT-5480* AST-6014* AlkPhos-241*
TotBili-5.4*
Approved: SAT [**2193-3-2**] 6:46 PM
[**2193-3-6**] 05:21AM BLOOD PT-13.4 INR(PT)-1.1
[**2193-3-6**] 05:21AM BLOOD Glucose-97 UreaN-62* Creat-7.6* Na-141
K-3.8 Cl-107 HCO3-19* AnGap-19
[**2193-3-6**] 05:21AM BLOOD ALT-609* TotBili-2.0*
[**2193-3-6**] 05:21AM BLOOD Calcium-8.9 Phos-6.1* Mg-2.1
ABDOMEN U.S. (COMPLETE STUDY) [**2193-3-1**] 8:18 AM
ABDOMEN U.S. (COMPLETE STUDY)
Reason: tylenol od
[**Hospital 93**] MEDICAL CONDITION:
18 year old man with
REASON FOR THIS EXAMINATION:
tylenol od
HISTORY: Tylenol overdose.
COMPARISON: No previous studies.
FINDINGS: The liver appears normal in echotexture without focal
lesions. The portal vein is patent with appropriate direction of
flow. There is a small amount of perihepatic free fluid. The
gallbladder wall is edematous, but the gallbladder is not
distended. This finding is likely related to the presence of
ascites. The spleen is normal in size. The pancreas appears
unremarkable. The right kidney measures 10.4 cm, and the left
kidney measures 11.4 cm. Both kidneys appear echogenic,
suggestive of intrinsic renal disease. There is no
hydronephrosis or renal stones. The aorta is normal in caliber.
IMPRESSION:
1) Perihepatic free fluid.
2) Gallbladder wall edema without gallbladder distention, likely
related to ascites.
3) Echogenic kidneys, suggestive of intrinsic renal disease.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Discharge labs:
[**2193-3-7**] 05:29AM BLOOD Hct-37.9*
[**2193-3-6**] 05:21AM BLOOD PT-13.4 INR(PT)-1.1
[**2193-3-7**] 05:29AM BLOOD Glucose-77 UreaN-55* Creat-6.1*# Na-144
K-3.9 Cl-109* HCO3-20* AnGap-19
[**2193-3-7**] 05:29AM BLOOD ALT-473* TotBili-1.8*
[**2193-3-7**] 05:29AM BLOOD Calcium-9.0 Phos-6.3* Mg-2.1
Brief Hospital Course:
1) Tylenol toxicity: The patient ingested a toxic amount of
acetaminophen in a likely suicide attempt with a peak level of
162 at 12 hours post presentation. He was managed at [**Hospital1 2177**] and
then transferred to the [**Hospital1 18**] SICU for liver transplant
evaluation. He received 16 doses of NAC at [**Hospital1 2177**] and was continued
on N-acetyl cysteine which was stopped on [**3-2**]. His AST/ALT peak
were on admission at 3742/4615 and they consistently trended
down until discharge. He was somewhat encephalopathic on
presentation but this improved by the time of transfer to the
medical team. His PT/INR peaked at 21.0/2.8 and then trending to
normal levels at discharge. Because his LFT's and synthetic
function recovered, he was not a transplant candidate.
Hepatology expects a full recovery of his liver function and he
likley will not need hepatology follow up as an outpatient but
this can be arranged if LFT abnormalities persist after [**12-20**]
weeks from now.
2) Acute tubular necrosis (ATN): He developed acute renal
failure, with a creatinine that went from 3.5 to a peak of 8.9.
Renal was consulted who felt that this was ATN, commonly seen
following acetanimophen toxicity from nephrotoxic metabolites.
He was oliguric but his urine output did not drop below 500 cc
per day. As he continued to have adequate urine output, he did
not need dialysis. He developed an anion gap acidosis, peak AG
of 25 likely secondary to uremia, and was put on sodium citrate
twice daily which he refused to take. Despite this, his acidosis
improved to AG of 15 at discharge. At the time of this summary,
his creatinine was 7.6 which had trended down from a peak 2 days
previous of 8.9. Nephrology expects this to recover completely
as complete renal recovery is the normal prognosis of ATN. His
BUN peaked at 64 and was down slightly to 62 at discharge. This
should normalize completely as well, as increases in BUN often
accompany renal insufficiency. His phosphorous trended upward to
a peak of 6.3 at the time of this summary. This should improve
along with creatinine clearance as phosphorous is cleared by the
kidney. Nephrology service recommended a normal diet at the time
of discharge. If his phosphorous goes above 8, nephrology
service recommends Amphogel 30 ml PO TID with meals. However, as
the patient was refusing medications and his phosphorous was
below 8, this was not started in the hospital. Oral fluid intake
should be strongly encoraged with a goal of at least 2-3 liters
of total fluid daily. Electrolytes should be checked every other
day, with the first check on [**2193-3-9**]. Potassium should be
repleted with the following sliding scale:
3.8-4.0 - 20 meq PO KCL
3.6-3.7 - 40 meq PO KCL
3.3-3.5 - 60 meq PO KCL
<3.3 - 80 meq PO KCL
Magnesium should be repleted with the following scale:
1.9-2.0 - 400 mg MagOx PO once
1.6-1.8 - 800 mg MagOx PO once
<1.5 - 800 mg MagOx PO x 2 doses, 12 hours apart
3) Probable suicide attempt: The patient denied that this was a
suicide attempt. A 24 hour sitter was continued due to the
patient's flight risk. Psychiatry was consulted and recommended
inpatient psych admission. The patient did not feel that he
needed inpatient psychiatric admission, however this is required
given the patient's chance of repeating this episode. The
patient is expected to be discharged to an inpatient psychiatric
facility.
4) HTN - The patient was noted to be consistently slightly
hypertensive, and had a systolic blood pressure averaging in the
140's - 150's. This should be followed as an outpatient, and an
antihypertensive such as HCTZ can be considered after his kidney
function normalized completely. A beta blocker would be
contraindicated with his low pulse, and ACE would be
contraindicated in the setting of acute renal failure.
5) Microcytic anemia - The patient was noted to have microcytic
anemia of unknown etiology. His hematocrit trended down from
baseline around 42 to 37 at the time of discharge. The patient
had no signs or symptoms of blood loss and was not transfused.
Iron studies showed decreased TIBC and transferrin, and elevated
ferritin with normal iron level. The slight decrease could be
explained by hydration in addition to the metabolic insult
leading to decreased production. His hematocrit is felt from a
medical perspective to be stable at this time. The patient could
be evaluated as an outpaitent for alpha and beta thalessemia by
hemogloibin electrophoresis.
Despite the above issues, the patient was medically stable for
discharge to an outpatient level of care as of [**2193-3-6**]
with primary care follow up.
Medications on Admission:
none
Discharge Medications:
none -
potassium/magnesium repletion as indicated above.
Amphogel if needed for phosphorous about 8.0 as above.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Tylenol overdose
Liver Failure, resolved
Acute Renal Failure, resolving
probable hypertension
Microcytic anemia
suicide attempt
Discharge Condition:
Patient had > 1000 cc urine output daily. He was eating and
drinking well and medically stable to leave the hospital.
Discharge Instructions:
You are being discharged to [**Doctor Last Name 1263**] for mental health reasons.
If you have these symptoms, call your doctor or go to the ER:
- lack of urine output
- belly pain
- nausea/vomiting
- headaches/visual changes
- feelings of hurting yourself
Followup Instructions:
With psychiatry as indicated at discharge from your facility.
With the [**Hospital **] Care Center at [**Hospital6 **], ([**Telephone/Fax (1) 60565**]. You are currently scheduled for an appointment on
Friday [**3-15**] at 10:40 am with Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **]. The
Adolescent Center is located on the [**Location (un) 442**] of the [**Hospital **]
Care Center (ACC) at [**Location (un) 24902**].
You should have basic laboratory tests (CBC, Chem 10, INR) drawn
at this time.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5845, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5961
} | Medical Text: Admission Date: [**2157-10-24**] Discharge Date: [**2157-11-4**]
Date of Birth: [**2109-1-23**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Flexeril
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hyponatremia, Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48yo F w/ HCV cirrhosis c/b encephalopathy, ascites, edema/TIPS
[**11-8**], hydrothorax, thrombocytopenia, chronic hyponatremia
(baseline 124-128), adrenal insufficiency, GERD, anxiety
directly admitted for worsening hyponatremia.
Diagnosis of adrenal insufficiency made [**12-12**] during
hospitalization for SOB, hyponatremia, fluid overload. Cortisol
[**2156-12-10**] was 0.1. At 30 min, cortisol was 1.6. at 60 min, cortisol
was 2.4. ACTH < 5. CBG [**2156-12-11**] 27 (nl). Endo Inpt consulting team
recommended stress dose steroids if needed but did not
recommended chronic replacement steroids as outpatient since she
was on inhaled steroids. Pt was seen by Dr [**Last Name (STitle) 10759**] on
[**2156-12-28**]. She noted that diagnosis of AI was based on
hyponatremia, relative hyperkalemia and eosinophilia. She did
note that HypoNa could be [**1-7**] third spacing [**1-7**] cirrhosis and
chronic diuretics. She noted that pt only had mildly orthostatic
symptoms but these were unchanged whether or not patient was on
oral steroids. She also noted that pt never had N, V, weight
loss, decreased appetite, hypotension. She did note that off
diuretics, patient became short of breath. She then repeated
cortisol and ACTH levels which were persistently low and
subsenquently started Prednisone 5 mg po qd. Adrenal glands
were noted to be normal on abdominal US. Patient has most
recently been on Hydrocortisone 20 mg po q am and 10 mg po qhs.
On [**10-8**] Na 137, [**10-17**] Na 126, [**10-20**] Na 120 (OSH), [**10-24**] Na 115.
On [**10-20**], her diuretics were held [**1-7**] hyponatremia. She reports
good compliance with medical regimen and has been avoiding free
water. She reports compliance with her low salt diet. She has
had increasing dizziness, nausea, worsening LBP over the last
few days.
She arrived directly on the floor and labs showed the Na of 115.
She was transferred to the unit for closer monitoring and
potential need for hypertonic saline.
On admission to the unit, she reported dizziness, nausea, and
fatigue. She has had no seizure like activity or LOC. She denies
[**Last Name (LF) **], [**First Name3 (LF) **], photophobia, CP, palpitations. With abdominal pain in
RUQ which is unchanged from previous. She denies any fevers,
chills. Denied change in BMs (normally [**1-8**] daily). No
increased peripheral edema.
Past Medical History:
1. HCV cirrhosis s/p TIPS [**11-8**] c/b hydrothorax, encephalopathy,
and ascites
2. Hyponatremia baseline 128-133
3. Asthma
4. Adrenal insufficiency (thought to be [**1-7**] chronic advair use)
5. GERD
6. Anxiety
7. Hyperglycemia thought [**1-7**] cirrhosis
8. Recent intubation thought [**1-7**] transfusion-related acute lung
injury. Led to prolonged ICU stay then rehab. Also treated for
PNA
9. Recent UTI
Social History:
- Recreational drugs: Past IV drug use with needle sharing, last
use 7 years ago. Past drug-snorting.
- Alcohol: Past alcohol use, last drink at age 46.
- Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history
- Personal: Single with one child. Lives with mother, who
manages medications
- Employment: Former waitress, unemployed on disability.
Family History:
Mother w/ DM2, HTN, and hyperlipidemia. Father w/ COPD and EtOH
cirrhosis.
Physical Exam:
VS: 97.7 102 122/51 16 96% i/o 1120/805
Gen: alert to person, place, time, situation. comfortable,
Neuro: fields nl to confrontation
HEENT: EOMI OP clear
Breast: no disharge expressed from nipple
Cards: RRR + murmur
Resp: Clear bilat. nl effort
Abd: BS+, mildly protuberant. no rebound or guarding. soft
Ext: no edema, no hyperpigmentation of scars.
Pertinent Results:
[**2157-10-24**] 09:31PM PT-18.9* PTT-53.9* INR(PT)-1.7*
[**2157-10-24**] 09:31PM
WBC-11.5* RBC-3.21* HGB-11.7* HCT-32.9* MCV-103* MCH-36.6*
MCHC-35.6* RDW-18.5* NEUTS-79.8* LYMPHS-11.9* MONOS-7.0 EOS-1.0
BASOS-0.2
[**2157-10-24**] 09:31PM
ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-2.7 MAGNESIUM-2.1 LIPASE-125*
[**2157-10-24**] 09:31PM
ALT(SGPT)-120* AST(SGOT)-200* LD(LDH)-325* ALK PHOS-447*
AMYLASE-185* TOT BILI-7.6*
[**2157-10-24**] 09:31PM
GLUCOSE-100 UREA N-19 CREAT-0.6 SODIUM-115* POTASSIUM-5.8*
CHLORIDE-83* TOTAL CO2-27 ANION GAP-11
[**2157-10-24**] 10:24PM LACTATE-1.8
[**2157-10-24**] 11:00PM URINE
RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 BLOOD-NEG
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM
UROBILNGN-NEG PH-6.5 LEUK-NEG OSMOLAL-449
[**2157-10-24**] 11:00PM URINE [**2157-10-24**] 11:00PM URINE HOURS-RANDOM UREA
N-644 CREAT-60 SODIUM-22 POTASSIUM-38
Brief Hospital Course:
A/P: 48yo woman with history of HCV and ETOH induced cirrhosis
complicated by encephalopathy, ascites, s/p TIPS [**11-8**],
hydrothorax, thrombocytopenia, adrenal insufficiency, and
chronic hyponatremia admitted for worsening hyponatremia.
# Hyponatremia: Upon admission patient was noted to have sodium
of 115. She has been admitted multiple times with similar
problems. [**Name (NI) **] was admitted to the ICU and improved with
3%NS and fluid restriction. She has a long history of being
noncompliant with fluid restriction as an outpatient. During
her hospital course her sodium slowly improved from 121-->
126--> 127. Was continued on fluid restriction with continued
diuresis via lasix and spironolactone. As there was also a
question that some of this could be adrenal insufficiency, she
was continued on [**Hospital1 **] hydrocortisone 20mg and 10mg for
physiologic dosing. Briefly treated with IV lasix and albumin
with good effect. Discharged on lasix, spironolactone and
1000ml fluid restriction.
# Hyperkalemia: Potassium initially elevated on admission to
5.8. No ECG changes. Transtubular potassium gradient was
suggestive of hypoaldosteronism at 5.6. However, it was
difficult to determine TTKG in patient with decreased distal
delivery of sodium. Ultimately it was unclear if patient is
truly adrenally insufficienct as hyponatremia is also result of
cirrhosis. Resolved with treatment as described above. Upon
discharge K was 4.0
# HCV cirrhosis s/p TIPS [**11-8**] complicated by hydrothorax,
encephalopathy, ascites, and thrombocytopenia. T. Bili has
improved since prior admission and trending down upon this
admit. ALT/AST, Alk phos, and amylase were increasingly
elevated with unclear etiology. LFTs were trended and resolved
to baseline. MELD calculated and found to be 20. Was continued
on lactulose and rifaximin. Continued on diuresis as described
above, with the brief addition of IV lasix.
# Vertebral compression fractures: Evaluated by IR for
vertebroplasty on last admission. IR determined that she was
not to be candidate during this admission secondary to continued
coagulopathy. Was continued on lidocaine transdermal patch, ice
packs, and oxycodone prn. Also on MS contin [**Hospital1 **]. PT was
consulted and evaluated the patient, stating she was able to
discharge to home. Did have acute episodes of increase pain,
but always relieved by oxycodone 5mg. Patient was concerned
upon discharge that her pain would be difficult to control at
home as her mother is her primary caregiver and does not give
her PRNs. Discussed at great length that we could not increase
scheduled as she becomes too somnolent and it is not safe.
Discharged on MS contin and oxycodone for breakthrough.
# History of Adrenal Insufficiency: Upon evaluation she had no
sodium wasting in urine or othrostatic hypotension. Potassium
levels were noted to be fluctuating. Hydrocortisone continued
at physiologic dosing. To follow-up with Endocrine as an
outpatient.
# Asthma: Not an active inpatient issue, continued on inhalers.
# Type 2, DM: Managed as on outpatient with humalog ISS and
glargine. While in patient her glargine and ISS were adjusted
for improved glycemic control. Discharged on both these
medications.
Medications on Admission:
Albuterol
Calcium Carbonate
Clotrimazole
Dexamethasone 4 mg IV bid
Fluticasone-Salmeterol (100/50)
FoLIC Acid
Insulin
Lactulose
Lidocaine 5% Patch
Magnesium Oxide
Montelukast Sodium
Morphine Sulfate
Morphine SR (MS Contin)
OxycoDONE (Immediate Release)
Pantoprazole
Rifaximin
Vitamin D
Discharge Medications:
1. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6)
hours as needed for 20 doses.
Disp:*20 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Clotrimazole 10 mg Troche [**Hospital1 **]: One (1) Troche Mucous membrane
5X DAY ().
Disp:*150 Troche(s)* Refills:*0*
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Folic Acid 1 mg Tablet [**Hospital1 **]: Five (5) Tablet PO DAILY (Daily).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
8. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO three times a day.
9. Morphine 15 mg Tablet Sustained Release [**Hospital1 **]: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
10. Spironolactone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Hydrocortisone 20 mg Tablet [**Hospital1 **]: 0.5-1 Tablet PO Twice
daily, 20mg at 10AM and 10mg at 5pm: Take one tablet each
morning at 10AM and [**12-7**] tablet each evening at 5pm.
Disp:*45 Tablet(s)* Refills:*2*
13. Furosemide 80 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day.
14. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Forty Five (45) ML PO TID
(3 times a day).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: Two (2)
Tablet PO once a day.
16. Insulin Lispro 100 unit/mL Insulin Pen [**Month/Day (2) **]: One (1) unit
Subcutaneous four times a day as needed for glucose correction:
Please give as directed on your discharge insulin sliding scale.
Check fingersticks four times daily.
Disp:*QS pen* Refills:*2*
17. Lancets Misc [**Month/Day (2) **]: One (1) lancet Miscellaneous four
times a day.
Disp:*QS lancet* Refills:*2*
18. Alcohol Prep Pads Pads, Medicated [**Month/Day (2) **]: One (1) pad
Topical four times a day.
19. Insulin Syringes (Disposable) Syringe [**Month/Day (2) **]: One (1)
syringe Miscellaneous twice a day.
20. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray [**Month/Day (2) **]:
One (1) spray Nasal twice a day: Alternate nostrils daily.
Disp:*QS unit* Refills:*1*
21. Insulin Glargine 300 unit/3 mL Insulin Pen [**Month/Day (2) **]: Thirty Four
(34) unit Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Primary: Hyponatremia, adrenal insufficiency
Secondary: Hepatitis C, Cirrhosis
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
1)You were admitted to the hospital with low sodium. You also
developed worsening fluid in your legs while you were in the
hospital. We increased your dose of diuretics. You were kept on
a strict regimen of 1000ml (1 liter) of fluid intake. Please
continue to monitor your intake of fluids and keep it within the
1 liter.
2)In the hospital you had a test to rule out tuberculosis on
your arm. Please schedule an appointment with your primary care
physician (you may not need an appointment, but can just stop
by) on Monday to have this looked at.
3)Please take all medications as listed in the discharge
instructions. Your ipratroprium bromide was held while in the
hospital, please discuss this medication with your regular
doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] it. You have also been prescribed a
new medication called Clotrimazole. Please continue to take
this medication as directed.
4)Please attend all appointments as listed below.
5)If you experience any fevers, chills, chest pain, shortness of
breath, dizziness or any other concerning symptoms please return
to the emergency room.
Followup Instructions:
Please keep all your appointments.
You have the following appointment scheduled to see how you are
doing after discharge:
Dr. [**Last Name (STitle) **]
[**Name (STitle) 3628**] [**Location (un) **]
[**2157-11-24**] at 8am
([**Telephone/Fax (1) 1582**]
Please see you primary care physician on [**Name9 (PRE) 766**], [**2157-11-7**] to have your TB test read. This was placed on your left
arm.
ICD9 Codes: 2761, 5715, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5962
} | Medical Text: Admission Date: [**2107-7-19**] Discharge Date: [**2107-7-31**]
Date of Birth: [**2051-5-31**] Sex: M
Service: COLORECTAL SURGERY/GREEN SURGERY
HISTORY OF PRESENT ILLNESS: This is a 56-year-old man with a
history of ulcerative colitis since [**2098**]. The patient was
hospitalized almost annually for flareups. His current flare
began three weeks ago at which time he was admitted to [**Hospital3 9683**] for the past three weeks. He was recently started
on IV hydrocortisone and sent home several days prior this
admission. The patient complained of increasing symptoms
over the weekend with severe lower abdominal pain with po
intake, low grade fevers, nausea, vomiting, and [**6-26**] bloody
bowel movements per day.
PAST MEDICAL HISTORY: Ulcerative colitis.
PAST SURGICAL HISTORY: None.
MEDICATIONS:
1. Hydrocortisone 100 mg tid.
2. Two Ativan prn.
3. Iron.
4. Folic acid.
5. Prevacid.
ALLERGIES: 6-mercaptopurine, reaction jaundice.
SOCIAL HISTORY: No tobacco and occasional alcohol.
FAMILY HISTORY: Mother with [**Name (NI) 4522**] disease.
REVIEW OF SYSTEMS: No chest pain, shortness of breath,
palpitations, no dysuria, hematuria, or hematemesis.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
at 99.4, heart rate 100, blood pressure 117/86, respirations
16, and pulse oxygenation 98% on room air. He was alert and
oriented times three in no acute distress. His sclerae were
anicteric. His mucous membranes were moist. His heart rate
was regular, rate, and rhythm with no murmurs, rubs, or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was soft, tender in the lower quadrants to
palpation, with no guarding and positive bowel sounds.
Rectal examination was grossly heme positive, with positive
external hemorrhoid visualized. His extremities were warm
and well perfused with no edema.
A CT scan of the abdomen on admission showed no evidence of
free air obstruction or abscess with diffuse colonic
thickening and loss of haustral folds and multiple nodular
filling defects in the transverse colon. Please see full
report for details.
LABORATORIES ON ADMISSION: A complete blood count is as
follows: White blood cell count 8.0, hematocrit 33.1,
platelet count 201. White blood cell count differential 90%
neutrophils, no band neutrophils, 6.4 lymphocytes, 3.2%
monocytes. Electrolytes as follows: Sodium 136, potassium
3.9, chloride 100, HCO3 29, BUN 15, creatinine 0.8, glucose
of 187.
The patient was admitted to the Colorectal Service under Dr.
[**Last Name (STitle) 1888**], and he was written for a diet of nothing by mouth, IV
fluids, medicated with IV steroids, antibiotics, and was
given a routine preoperative assessment with
electrocardiogram and chest x-ray.
On postoperative day two, the patient received a peripherally
inserted central catheter line for administration of total
parenteral nutrition. He was started on a morphine sulfate
PCA for pain control. He was visited by the enterostomal
nurse therapist for education and discussion of ileostomy
care.
On hospital day four, the patient was taken to the operating
room for a restorative proctocolectomy, diverting ileostomy.
Please see full operative report for details of the
procedure. Following the procedure, the patient was
hypotensive with elevated heart rate and decreased urine
output. He was infused with both his Lactated Ringers as
well as Hespan for volume resuscitation. His urine output
responded marginally to these boluses. The patient's
postoperative hematocrit and electrolytes were all within
normal limits except for a magnesium of 1.3 for which he was
given 2 grams of magnesium intravenously.
After several hours of time postoperatively, the patient was
noted to have dysnomia and difficulty speaking a Neurology
consult was obtained at the time. Please see full Neurology
consult note for details. A CT scan of the head was obtained
with no abnormalities noted. The patient was transferred to
the Surgical Intensive Care Unit team care for monitoring and
volume resuscitation on a Neo-Synephrine drip.
On postoperative day one, the patient's blood pressure
stabilized, and the patient was taken to MRI for further
evaluation of his speech difficulties. The MRI was
suggestive of an acute left temporal infarct with no mass
effect or midline shift and no acute occlusion. Please see
full MRI report for details. The patient was further worked
up for cause of the left temporal infarct and on an
transesophageal echocardiogram was noted to have a small
atrioseptal defect with right to left flow.
Clinically, the patient's aphasia was improving. His
colostomy was viable and putting out small amounts of liquid
brown stool. The patient remained on total parenteral
nutrition with consultation from a nutritionist on staff, and
the patient was seen by Dr. [**Last Name (STitle) **] for evaluation of
closure of the atrioseptal defect.
On hospital day 11, postoperative day six, the patient was
deemed stable enough to return to the surgical floor and was
transferred from the Intensive Care Unit. He was able to
tolerate regular diet. His pain was well controlled. He was
able to ambulate and had no further neurological changes or
complaints.
On postoperative day eight, he was deemed in stable enough
condition to transfer to home with visiting nurse services.
Addendum: Patient underwent a colonoscopy on hospital day
two, which showed severe ulcerations of the colon. Please
see full colonoscopy report for details of procedure.
DISCHARGE DIAGNOSIS:
1. Ulcerative colitis primary status post restorative
proctocolectomy with diverting ileostomy.
2. Left temporal lobe cerebral infarct.
3. Atrioseptal defect.
4. Secondary hypotension, hypovolemia.
CONDITION ON DISCHARGE: Good and stable.
DISCHARGE STATUS: To home with visiting nurses.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg tablet one tablet po q day.
2. Clopidogrel 75 mg tablet one tablet po q day.
3. Tylenol #3 30/300 1-2 tablets po q4h as needed for pain.
4. Loperamide 2 mg one capsule po qid.
5. Prednisone 5 mg tablets three tablets po q day x1 week,
then two tablets 10 mg po until followup with Dr. [**Last Name (STitle) 1888**].
6. Pravastatin 20 mg tablet one tablet po q day.
FOLLOW-UP PLANS:
1. Patient is to followup with Dr. [**Last Name (STitle) 1888**] in Colorectal
Surgery in [**1-20**] weeks, and has been the office number to call
for an appointment.
2. Dr. [**Last Name (STitle) **], Interventional Cardiology for repair of
atrioseptal defect. The patient has been given office number
to call for an appointment. In addition, the patient is
referred to Visiting Nurses Association Services for dressing
changes, dry gauze twice a day as well as ostomy care routine
twice a day. He is instructed to take a regular diet and
regular activity as tolerated.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 5657**]
MEDQUIST36
D: [**2107-8-8**] 11:17
T: [**2107-8-16**] 08:12
JOB#: [**Job Number 51943**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5963
} | Medical Text: Admission Date: [**2185-6-26**] Discharge Date: [**2185-6-30**]
Date of Birth: [**2108-12-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76M oxygen-dependent COPD (on 3 L with baseline pOx 90-92%)
presents with 2 week history of dyspnea on exertion with
associated neck discomfort he describes as "chest heaviness,"
and new productive cough. Current "exacerbation" was similar to
prior exacerbation a couple of years ago; however, his
associated neck discomfort was not present.
Dr. [**Last Name (STitle) **], his outpatient pulmonologist, placed him on a
prednisone burst and avelox on [**6-13**], for presumed COPD
exacerbation. He completed a 7-day course of Avelox, and then
was renewed for another 7 day course 2 days ago for persistent
symptoms. He was put on 60mg daily of prednisone and two days
ago weaned down to 40mg daily. He continued to have difficulty
with SOB and breathing.
He has had sick contacts including a son with pneumonia
recently. He denies fever, chills, but does endorse mild
productive cough. No smoking or recent healthcare exposures.
He endorses dyspnea when laying flat, but he does not endorse
any weight gain or increased swelling in his lower extremities.
He takes lasix 20mg prn at home and took one tablet 1.5 weeks
ago, but hasn't needed it since. Given his persistent dyspnea
and his chest heaviness, he called Dr. [**Last Name (STitle) **] today, who
recommended he presented to ER. He describes the chest heaviness
as located in the top of his chest, at the base of his neck,
that does not radiate and has been fairly constant recently. It
is exacerbated with exertion and improved with rest.
In the ED, initial VS were: 97.6 109 154/73 18 88% 3L Nasal
Cannula. Initially trigerred for respiratory distress given
solumedrol, ipratroprium/albuterol nebs with improved
respiratory status. Labs revealed elevated white count thought
secondary to recent prednisone burst. D-Dimer was negative. ABG
on 3 liters of oxygen 7.4/36/53. BNP/Troponin T were 527 and <
0.01, respectively. CXR was performed without significant change
from prior. EKG with scooped ST segments in the inferior leads.
Given neck pain noted and concern that this could represent a
cardiac equivalent, Aspirin 325mg was given. Vitals on transfer:
BP 125/59, HR 90, RR 18, pOx 89 on RA.
On arrival to the MICU, patient's VS 97.8, 155/61, 97, 25, 90%
3L. Pt resting comfortably in the chair, speaking in full
sentences, in NAD. Currently complaining of the same chest
heaviness he has been having recently, but otherwise feels well
and much better than when he initially presented.
Past Medical History:
COPD Stage II (moderate) based FEV1 63% of predicted, based on
spirometry [**12/2184**]
Sub 5-mm noncalcified nodule in the right middle lobe [**3-20**] CT
Obstructive sleep apnea, moderate per sleep study [**3-20**]
Diastolic CHF
Hypertension
Osteoarthritis
Herniated disc L2-3
s/p bilateral knee replacements
Social History:
Married and works as a funeral home director. Denies ETOH or
drugs, quit smoking 11 years ago but smoked [**3-18**] ppd x > 50 yrs.
Family History:
Father died of lung cancer, no fam h/o heart disease or MIs.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.8, 155/61, 97, 25, 90% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Tachycardic, reg rhythm, normal S1/S2, no murmurs/rubs/
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
ital signs: Tmax 98.2 BP 137/68 HR 96 91-93% 5L O2 sat
General: in NAD, appears stated age.
HEENT: OP moist, no LAD, PERRL. JVP not elevated
Lungs diminished bilaterally, prolonged expiratory phase with
forced expiration
CV tachycardic without murmurs
Abdomen soft, NT, ND, NABS
Ext: no edema
Neuro: alert/oriented X3, moving all extremities.
Pertinent Results:
ADMISSION LABS:
[**2185-6-26**] 01:45PM BLOOD WBC-19.5*# RBC-5.82 Hgb-16.8 Hct-54.1*
MCV-93 MCH-28.8 MCHC-31.0 RDW-14.4 Plt Ct-280
[**2185-6-26**] 01:45PM BLOOD Neuts-90.8* Lymphs-6.7* Monos-1.7*
Eos-0.4 Baso-0.4
[**2185-6-26**] 01:45PM BLOOD PT-10.1 PTT-26.8 INR(PT)-0.9
[**2185-6-26**] 01:45PM BLOOD Glucose-135* UreaN-27* Creat-1.0 Na-140
K-4.5 Cl-107 HCO3-20* AnGap-18
[**2185-6-26**] 10:18PM BLOOD CK(CPK)-47
[**2185-6-26**] 01:45PM BLOOD cTropnT-<0.01 proBNP-527
[**2185-6-26**] 01:45PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3
[**2185-6-26**] 01:56PM BLOOD Type-ART pO2-53* pCO2-36 pH-7.40
calTCO2-23 Base XS--1 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2185-6-26**] 01:56PM BLOOD Lactate-2.1*
CE Trend:
[**2185-6-26**] 01:45PM BLOOD cTropnT-<0.01 proBNP-527
[**2185-6-26**] 10:18PM BLOOD CK-MB-4 cTropnT-<0.01
[**2185-6-26**] 10:18PM BLOOD CK(CPK)-47
[**2185-6-27**] 03:27AM BLOOD CK-MB-4 cTropnT-<0.01
[**2185-6-27**] 03:27AM BLOOD CK(CPK)-41*
[**2185-6-27**] ECHO:
Poor image quality. The left atrium is elongated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. The right
ventricular cavity is dilated The ascending aorta is mildly
dilated. The aortic valve is not well seen. No aortic
regurgitation is seen. No mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2183-11-3**],
the degree of pulmonary hypertension detected is now severe.
Imaging:
CXR [**6-26**] - no infiltrates, bibasilar atelectasis.
Chest CT [**6-29**]
IMPRESSION:
1. Suspected tracheobronchomalacia as described.
2. Extensive diffuse atherosclerosis.
3. Evidence of small airway disease.
4. Several pulmonary nodules as described that should be
reevaluated in [**7-26**] months interval with chest CT.
Lung scan [**6-30**]:
Low probability for PE
Micro
[**6-26**] MRSA screen negative, blood cultures pending
Brief Hospital Course:
76 yo M w/ COPD stage II (on 3L O2 at home) p/w dyspnea and neck
discomfort for the past 2 weeks, after failing outpt therapy
with avelox and prednisone, found to have acute respiratory
failure, likely multifactorial, as well as secondary
polycythemia.
ACUTE ISSUES
# Acute hypoxic respiratory failure - Pt p/w 2 week of dyspnea,
failing outpt treatment with Avelox and prednisone for presumed
COPD exacerbation. He was initially admitted to the ICU, and
treated supportively with antibiotics of CTX/azithromycin,
prednisone and nebulizers, briefly and then transferred to the
floor. He was seen by the pulmonary consult service of Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. He was continued on prednisone, just
azithromcyin with no evidence of pneumonia on imaging, and
nebulizers. He was also diuresed given concern that there was a
component of volume overload leading to his worsening hypoxia.
He was ultimately discharged home on a prednisone taper, spiriva
and increased home oxygen.
## Chronic hypoxic respiratory failure, with chronic COPD. He
was admitted with acute exacerbation of chronic hypoxia. His
chronic hypoxia was evaluated with chest CT, ECHO, repeat PFTs
and lung scan. ECHO showed worsening pulmonary artery
hypertension. Thus lung scan was performed to identify chronic
thromboembolic disease as a cause of PAH, which was negative.
Chest CT showed question of TBM, and bronchiolitis, and lung
nodules, but not significant interestitial disease. PFTS were
stable. He was discharged home with O2 at 5L, with plan for
further outpt pulmonary workup. He was discharged on
advair,,spiriva, albuterol and prednisone.
# Neck discomfort - Pt has associated neck discomfort with
dyspnea that did not accompany pt's last COPD exacerbation. He
ruled out for MI, but did have ST depressions on EKG.
Consideration could be made for stress test as outpatient.
# Chronic diastolic CHF - Pt w/ EF > 55% and mild symmetric left
ventricular hypertrophy with normal cavity size and moderately
dilated right ventricular cavity with moderate global free wall
hypokinesis. HE was diuresed with some improvement in his
respiratory status, and discharged on 20 mg po daily of
furosemide.
# Leukocytosis - Most likely due to prednisone he was on as an
outpatient as he is afebrile and non-toxic appearing and so do
not have a high suspicion that this is from infection. He
remained afebrile.
# Polycythemia, secondary - Pt noted to have a HCT of 54.1 and
unclear how long this as persisted as last HCT hasn't been since
[**84**]/[**2184**]. Likely polycythemia due to chronic hypoxia.
# Obstructive sleep apnea - Pt has hx OSA and uses CPAP at home.
- cont CPAP at night.
Transitional issues:
1. Lung nodules. Will need repeat Chest CT 6-12 months.
Communicated by letter to pcp, [**Name10 (NameIs) **] and patient.
2. ST depressions on ekg. Could consider stress test if
respiratory status improves.
3. Chronic diastolic CHF. Discharged on higher dose of
furosemide, 20 mg po daily - will need bmp in 1 week.
4. Pending tests. Blood cultures from admission pending at
discharge.
Medications on Admission:
Albuterol sulfate 90 mcg HFA Aerosol Inhaler: 2 puffs q4-6h prn
chest tightness/SOB
Fluticasone-salmeterol [Advair Diskus] 250-50 mcg: 1 inhalation
[**Hospital1 **]
Furosemide 20 mg Tablet: 1 Tablet PO daily prn increased dyspnea
Ibuprofen 800 mg Tablet: 1 Tablet(s) by mouth three times a day
Moxifloxacin [Avelox] 400 mg Tablet: 1 Tablet PO daily x 7 days
Portable oxygen 2 liters/minute with exertion
Prednisone 20 mg Tablet: 3 Tablets PO daily
Sennosides-docusate sodium [PERI-COLACE] 8.6 mg-50 mg PO BID
Discharge Medications:
1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
Disp:*30 capsules* Refills:*1*
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. prednisone 10 mg Tablet Sig: Taper PO once a day for 21 days:
5.5 tabs for 2 days, 5 tabs for 2 days, then decrease by 5 mg
([**2-14**] tab) every 2 days, until at 20 mg.
Disp:*qs Tablet(s)* Refills:*0*
6. Oxygen
3-5L O2 continuouis via nasal cannula; pulse dose for
portability
Diagnosis: COPD
Discharge Disposition:
Home
Discharge Diagnosis:
Acute respiratory failure
Chronic hypoxia
Pulmonary hypertension
Acute bronchitis
Hypertension
Discharge Condition:
90% on 5L. ambulating independently.
Discharge Instructions:
You were admitted with difficulty breathing. You did not have a
pneumonia, and likely this was caused by a bronchitis, that made
your breathing worse than usual. We did several tests to look
for other causes,and to find out why your oxygen is always low,
and Dr. [**Last Name (STitle) **] is going to continue that evaluation.\
Weigh yourself every day, and call Dr. [**First Name (STitle) 572**] or Dr. [**Last Name (STitle) **] if
your weight drops or increases by more than 2 lbs over 2 days.
Your oxygen is still lower than usual, but you feel well. You
will need to continue to use 5L of oxygen at all times, and
especially when you are walking. Use your CPAP at night. If
you get more short of breath, you should call Dr.[**Name (NI) 6005**]
office.
Medication changes:
Start:
Prednisone taper - 55 mg for 2 days, decrease by 5 mg every
other day until you are taking 20 mg, then stop tapering until
you see Dr. [**Last Name (STitle) **]
[**Name (STitle) **] Spiriva 1 capsule daily
Increase:
Furosemide 20 mg to every day
Followup Instructions:
Department: GASTROENTEROLOGY
When: FRIDAY [**2185-7-8**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
****The Pulmonary Dept is working on an appt for you in the next
few weeks and will call you at home with the appt. If you dont
hear from them by Friday, please call them directly to book.
ICD9 Codes: 4168, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5964
} | Medical Text: Admission Date: [**2113-3-2**] Discharge Date: [**2113-3-10**]
Date of Birth: [**2033-12-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
s/p lumbar puncture
History of Present Illness:
78 year old russian speaking male who presents with two days of
fever. He has also been complaining of headache and increased
lethargy. In addition he had some cloudy urine today. Initial
history was obtained from his daughter. [**Name (NI) **] denies any neck
stiffness or pain. Says he only has headache which is located
at the top of his head. He has no chest pain, no abdominal
pain. He was feeling slightly lightheaded at home but this has
resolved.
His temperature in the ED was 102. A LP was performed and he
was treated with 2 g Ceftriaxone, Tylenol, Vancomycin,
Ampicillin, Dexamethasone, and ASA.
Past Medical History:
1. hypertension
2. BPH s/p TURP X2
3. prostate cancer s/p XRT
4. colonic polyps
Social History:
Married. No smoking, no alcohol. He is retired engineer from
[**Country 532**]. He exercises avidly doing calisthenics every day, 20
minutes.
Family History:
NC
Physical Exam:
VS: Temp 102.6, Pulse 96, BP 126/70, RR 24, 97% on RA
Gen: alert, oriented, cooperative male in NAD
HEENT: MM dry, OP clear, PERRL
Neck: supple, no lymphadenopathy
Lungs: clear to auscultation bilaterally
CV: RRR, nl S1S2, no murmers
Abd: soft, non-tender, non-distended, positive BS
Ext: no edema
Neuro: grossly intact, moving all extremities, no sensory
deficits
Pertinent Results:
EKG: NSR at 82, nl axis, nl intervals, no old to compare
Imaging:
CXR: 1. Markedly tortuous aorta with prominance of the arch
contour.
2. No definite pneumonia.
Head CT: No evidence of intracranial hemorrhage or no evidence
of mass effect.
[**2113-3-2**] 10:10PM CORTISOL-29.5*
[**2113-3-2**] 09:27PM CORTISOL-18.5
[**2113-3-2**] 08:42PM GLUCOSE-118* UREA N-24* CREAT-0.9 SODIUM-143
POTASSIUM-4.2 CHLORIDE-118* TOTAL CO2-17* ANION GAP-12
[**2113-3-2**] 08:42PM CALCIUM-7.0* PHOSPHATE-1.8*# MAGNESIUM-1.7
[**2113-3-2**] 08:42PM CORTISOL-4.6
[**2113-3-2**] 08:42PM WBC-10.9 RBC-3.10* HGB-9.9* HCT-27.8* MCV-90
MCH-31.8 MCHC-35.6* RDW-13.4
[**2113-3-2**] 08:42PM PLT COUNT-139*
[**2113-3-2**] 03:02PM POTASSIUM-3.8
[**2113-3-2**] 03:02PM HCT-28.0*
[**2113-3-2**] 11:49AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2113-3-2**] 11:49AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2113-3-2**] 11:49AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2113-3-2**] 11:40AM SODIUM-141 POTASSIUM-2.8*
[**2113-3-2**] 11:40AM CK(CPK)-246*
[**2113-3-2**] 11:40AM CK-MB-2 cTropnT-0.01
[**2113-3-2**] 11:40AM WBC-10.3 RBC-3.05*# HGB-9.7*# HCT-27.1*#
MCV-89 MCH-31.9 MCHC-35.9* RDW-13.2
[**2113-3-2**] 11:40AM PLT COUNT-133*
[**2113-3-2**] 11:40AM PT-14.2* PTT-25.2 INR(PT)-1.3*
[**2113-3-2**] 10:34AM LACTATE-1.4
[**2113-3-2**] 10:32AM TYPE-ART PO2-103 PCO2-27* PH-7.52* TOTAL
CO2-23 BASE XS-1
[**2113-3-2**] 10:32AM GLUCOSE-160* LACTATE-1.2 NA+-136 K+-3.1*
CL--106
[**2113-3-2**] 10:32AM freeCa-1.14
[**2113-3-2**] 07:56AM GLUCOSE-146* UREA N-25* CREAT-1.1 SODIUM-138
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-22 ANION GAP-19
[**2113-3-2**] 07:56AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2113-3-2**] 07:56AM WBC-7.6 RBC-4.13* HGB-12.8* HCT-36.8* MCV-89
MCH-30.9 MCHC-34.7 RDW-13.3
[**2113-3-2**] 07:56AM PLT COUNT-168
[**2113-3-2**] 12:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-73*
GLUCOSE-77
[**2113-3-2**] 12:30AM CEREBROSPINAL FLUID (CSF) WBC-156 RBC-10*
POLYS-78 LYMPHS-3 MONOS-0 MACROPHAG-19
[**2113-3-1**] 10:55PM K+-3.1*
[**2113-3-1**] 10:49PM CK(CPK)-585*
[**2113-3-1**] 10:49PM CK-MB-4 cTropnT-<0.01
[**2113-3-1**] 10:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2113-3-1**] 10:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2113-3-1**] 10:35PM URINE RBC-[**2-12**]* WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2113-3-1**] 10:35PM URINE MUCOUS-OCC
[**2113-3-1**] 09:49PM LACTATE-1.6
[**2113-3-1**] 09:40PM GLUCOSE-161* UREA N-32* CREAT-1.2 SODIUM-128*
POTASSIUM-6.8* CHLORIDE-95* TOTAL CO2-22 ANION GAP-18
[**2113-3-1**] 09:40PM CK(CPK)-787*
[**2113-3-1**] 09:40PM CK-MB-4 cTropnT-<0.01
[**2113-3-1**] 09:40PM WBC-9.8# RBC-4.06* HGB-13.1* HCT-35.4* MCV-87
MCH-32.2* MCHC-37.0*# RDW-13.3
[**2113-3-1**] 09:40PM NEUTS-83.7* LYMPHS-10.0* MONOS-5.4 EOS-0.3
BASOS-0.5
[**2113-3-1**] 09:40PM PLT COUNT-206
TEE: [**2113-3-8**]
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and systolic function
are normal. The sinuses of Valsalva are dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve.
IMPRESSION: No echocardiographic evidence for endocarditis. Mild
mitral
regurgitation. Mild aortic regurgitation.
[**2112-3-8**]: CT of C/A/P
IMPRESSION:
1. No evidence of aortic dissection. No evidence of proximal
pulmonary embolism. Please note that evaluation of small
peripheral pulmonary arteries in lower lobes are somewhat
limited due to atelectasis and technique.
2. Bilateral pleural effusion with atelectasis.
3. Incidentally noted aberrant right subclavian artery with
dilated origin, probably representing Kommerell diverticulum.
4. Cholelithiasis.
Brain MRI: [**2113-3-7**]
Findings consistent with leptomeningitis most prominently
demonstrated in the left frontal region. There is no evidence of
abscess formation
Brief Hospital Course:
A/P: 78 year old male with fevers, headache - LP c/w meningitis.
.
1. Fever and headache: Patient's LP consistent with bacterial
meningitis. He was initially covered with Vancomycin,
Ampicillin, Ceftriaxone, Decadron and Acyclovir. Patient quickly
defervesed initially, but became hypotensive. Patient had 3
large bore IVs placed on the floor, when his SBP dropped to 70s.
Patient received > 7L NS boluses and was eventually taken to the
ICU for observation. There, he received a L of Ringer's Lactate
and his SBP stabilized in 110s range. Patient was mentating
throughout. His lactates remained flat. Patient then returned to
the medical floor. His HSV PCR was negative and Acyclovir was
stopped. Patient's Vanco also stopped. Patient then developed a
severe headache and an MRI of the brain revealed evidence of
leptomential infection w/o abscess. ID consulted. Patient's
Vancomycin, Ampicillin and decadron discontinued and patient
continued on Caftriaxone. Patient's initial blood cultures from
day of admission returned positive for peptostreptococcus and
patient continued on Ceftriaxone. Patient then began to spike
temps to > 102 and all subsequent blood cx negative. Patieent
also had CT of the chest/abdomen/pelvis, which was negative for
embolic disease. A TEE was negative for vegetation. ID then
recommended changing abx to Ampicillin form Ctx for better
peptostreptococcus coverage. Patient continued on ampicillin as
ID attempted to get sensitivities for the peptostreptococcus.
The patinent will need to continue on Ampicillin for 2 weeks, or
until the Infectious Disease team at the [**Hospital3 **] instructs
differently. Patient will need to have blood cultures drawn for
fever > 101.5. He will also need Urinalysis and urine culture if
he complains of dysuria and chest X-Ray if he develops hypoxia
or shortness of breath. Patient's headache was managed with
tylenol.
.
2. Hypotension - Patient dropped SBP down to 70's and c/o
dizziness. SBP returned to 110s with > 7L fluid bolus challeng.
Initially had EKG to eval for cardiac cause of hypotension,
which was nonfocal. His lactates remained flat and did not point
to septic source. Patient felt to be profoundly hypovolemic.
Patient's SBP remained stable after fluid resisitation. Patient
was noted to have brown trace guiac positive stool, and his HCT
dropped from mid 30s to 28 in setting of fluid resisitation. He
was NG lavaged and this was negative. His HCT remained [**Last Name (un) 2677**] in
30 range. Patient also had no further episodes of hypotension.
.
3. Hypoxia: Patient was noted to be slightly hypoxic on the
medicine floor after fluid resusitation. By exam and CXR, he was
is CHF. Patient given PRN lasix and O2 sats remained stable on
room air from that point onwards. Patient was restarted on his
HCTZ and beta blockers were held.
.
4. PPx
- SC heparin
- Bowel regimen
.
4. FEN
- regular diet
.
5. Access: PICC
.
6. Code: FULL
Medications on Admission:
1. HCTZ 25mg daily
2. Univasc 7.5 mg daily
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 14 days.
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours for
4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Meningitis
Peptostreptococcus Bacteremia
Hypovolemia/Hypotension
Hypertension
Benign Prostatic Hypertrophy
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as perscribed. Please report to your
primary care physician or the emergency room with ahy fevers,
chills, headache, nausea, light-headedness, light sensitivity,
neck stiffness, abdominal pain.
Patient will need a CBC with diff and chem 10 and liver function
tests checked on [**2113-3-15**] and on [**2113-3-20**].
PLEASE BRING YOU [**2113-3-15**] labs results with you to your [**First Name (Titles) **] [**Last Name (Titles) **] infectious disease appointment on
[**2113-3-16**]
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule
appointment
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2505**] MD [**Telephone/Fax (1) 457**]- [**2113-3-16**] at 3PM-PLEASE
SEND PATIENT's LABS results from [**2113-3-15**] with him to this
appointment
Completed by:[**2113-3-10**]
ICD9 Codes: 5119, 2762, 4280, 7907, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5965
} | Medical Text: Admission Date: [**2173-2-11**] Discharge Date: [**2173-2-18**]
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
PERFORATED DUODENUM
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a 88yoF with c/o abd pain and n/v/d x 3 days.
Pt reports being unwell x 3 days - initially generalized
malaise, followed by n/v and diarrhea (worsened than usual
diarrhea). After vomiting, she had sudden onset of periumbilical
pain. Pain sharp, constant, worsens w/ movement.
She denies fever/chills. Denies NSAIDS.
She was initially admitted to [**Hospital3 3765**] [**2173-2-10**] w/
diagnosis of pancreatitis ([**Doctor First Name **] 196, Lipase 140). CT abdomen
performed [**2173-2-11**] (after prep for ? IV contrast allergy) showed
retroperitoneal air concerning for posterior perforated duodenal
ulcer. Pt transferred to [**Hospital1 18**].
On arrival, pt reports mild generalized abd pain, despite IV
morphine.
Of note, pt has had chronic diarrhea which has been worked up
w/o
final diagnosis. Initially, celiac disease was suspected and
trial on gluten-free diet seemed to improve diarrhea. However,
she was told by her physician she did not have celiac disease.
Past Medical History:
htxn, hypothyroidism, chronic diarrhea (? celiac disease),
diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain
Social History:
daily brandy 2oz HS, widow, lives at [**Location **] Commons [**Hospital3 12272**]
Family History:
mother had chronic diarrhea as well
Physical Exam:
At discharge:
V.S: 98.2, 63, 121/65, 18, 94% RA
Gen: A and O x 3, NAD
Resp: LSCTA bilat, denies SOB
CV: RRR, no m/r/g
Abd: soft, nt, nd, + bs
Ext: no c/c/e
Pertinent Results:
[**2173-2-13**] 07:35AM BLOOD WBC-7.2# RBC-3.50* Hgb-11.3* Hct-34.6*
MCV-99* MCH-32.4* MCHC-32.7 RDW-13.4 Plt Ct-247
[**2173-2-11**] 03:36PM BLOOD Neuts-32* Bands-37* Lymphs-20 Monos-3
Eos-0 Baso-0 Atyps-3* Metas-5* Myelos-0 Other-0
[**2173-2-11**] 03:36PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
[**2173-2-13**] 07:35AM BLOOD PT-12.3 PTT-26.2 INR(PT)-1.0
[**2173-2-17**] 07:00AM BLOOD Glucose-66* UreaN-17 Creat-0.6 Na-137
K-3.4 Cl-103 HCO3-26 AnGap-11
[**2173-2-15**] 09:10PM BLOOD CK(CPK)-31
[**2173-2-11**] 03:36PM BLOOD Lipase-74*
[**2173-2-16**] 07:25AM BLOOD CK-MB-2 cTropnT-0.03*
[**2173-2-17**] 07:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: negative x 2
.
HELICOBACTER PYLORI ANTIBODY TEST: NEGATIVE BY EIA.
.
MRSA SCREEN: No MRSA isolated
.
Blood Culture, Routine [**2173-2-17**]: NO GROWTH X2
.
UGI SGL CONTRAST W/ KUB [**2173-2-15**]
No gross extravasation of contrast on this technically limited
examination. Known retroperitoneal free air on CT examination,
compatible
with duodenal ulcer perforation.
.
CHEST (PORTABLE AP) [**2173-2-13**]
Features of worsened CHF along with new opacities at the lung
bases. The latter could be due to atelectasis or pneumonia.
.
ABDOMEN (SUPINE ONLY) [**2173-2-12**]
Significant free intraperitoneal air largely unchanged from
prior study. Retroperitoneal air is likley present; however its
evaluation is limited. No bowel obstruction or dilatation.
.
Brief Hospital Course:
Pt was admitted to the TICU from OSH, she was evaluated by
surgery, abx and a protonix drip were started, NGT was placed,
CXR done without evidence of free air and she was closely
assessed overnight and schedule for upper GI in the am.
.
She was transferrd to [**Hospital Ward Name 1950**] 5 with IV hydration secondary to
dehydration/NGT, a foley and telemetry secondary to new IV beta
blocker. Her protonix drip was changed to IV q 12 hrs. The
patient had an upper GI study which indicated no gross
extravasation of contrast on this technically limited
examination, because patient could not shift positions as
requested. Known retroperitoneal free air on CT examination,
compatible with duodenal ulcer perforation. Her NGT was removed
and she was continued on po protonix and her medications were
changed to oral.
.
Patient was fluid overloaded and several doses of IV lasix were
administered with good effect and electrolytes were repleated as
necessary. [**2173-2-15**] the patient had an episode of new onset
tachycardia/A-Fib. She was administered IV lopressor with good
effect and her electrolytes were rechecked and repleated as
needed.
.
The patient's foley was d/c'd and she voided with out any
issues. C-dif x2 was sent secondary to loose stool-both
negative. She was started on her home dose of immodium.
.
Physical therapy recommended home physical therapy or rehab. The
patient and family discussed this issue and decided on home
physical therapy, the patient is already set up with the VNA and
will continue this.
.
Discharge paperwork was reviewed with paitent and family. She
was started on protonix, handout was provided and the purpose of
the medication was reviewed. Her PCP was [**Name (NI) 653**] regarding
her situation, change in medications and an appointment was made
for 1 week. She will also follow up with Dr. [**Last Name (STitle) 1924**] on [**2173-3-2**]
Medications on Admission:
quinapril 10mg daily, aldactone 25mg daily, HCTZ 25mg daily,
levoxyl 75mcg daily, ativan 0.5mg HS prn, glucosamine,
chondroitin, Ca, vitamin D, ibuprofen?
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain: For neck pain. Please do not exceed
more than 4000 mg in 24 hours. .
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
Discharge Disposition:
Home With Service
Facility:
deaconness abundant life homecare
Discharge Diagnosis:
Primary:
Perforated Duodenum
Pancreatitis
Dehydration
Fluid over load
New on set A-fib
.
Secondary:
htxn, hypothyroidism, chronic diarrhea (? celiac disease),
diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Medications:
1. Protonix:
-You were started on this medication because of your duodenal
ulcer.
-This medication will help prevent future ulcerations, by
decreasing stomach acid swallowing.
-You should take this every 12 hrs.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 1924**] on [**2173-3-2**]. Please call his
office for the time [**Telephone/Fax (1) 7508**].
2. An appointment has been made for you to see [**Name8 (MD) 80591**] [**First Name5 (NamePattern1) 80592**] [**Last Name (NamePattern1) 80593**] on [**2173-3-1**]. If you can not make this
appointment please call to reschedule [**Telephone/Fax (1) 21640**].
Completed by:[**2173-2-18**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5966
} | Medical Text: Admission Date: [**2117-1-4**] Discharge Date: [**2117-1-7**]
Date of Birth: [**2077-4-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Malignant Hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
39 year-old male with a history of untreated hypertension who
presents with headache, neck pain, dizziness and back pain on
the morning of admission. Notably, the patient was diagnosed
with uncontrolled hypertension when he lived in [**Country 2045**] and was on
nifedipine for this (which he took intermittently). Since coming
to the US several years ago, he has neither seen a medical
doctor nor been on any medications. He states he has
intermittent back and neck pain for several weeks. Neck pain
was especially bad the morning of admission and associated with
pain on head movement. In the past, he has used Motrin PRN for
this pain but has not taken in at least 1 week.
In the ED, 270/140. Given Labetalol bolus and then started on
labetalol drip and admitted to the ICU for management. Not given
any PO except for 40 KCL mEQ PO x1. He was actually weaned off
of labetlol drip prior to arrival to the floor. On the floor her
received labetelol, HCTZ and norvasc, with highly labile blood
pressures (systolic ranging from 140-190 and diastolic ranging
from 105-120). He remained asymtpomatic. An echocardiogram was
performed with results as below, but given the concern of
coarctation of the aorta, the patient was sent for urgent
MRA-Aortogram, which did not demonstrate coarctation.
Past Medical History:
Hypertension diagnosed in [**Country 2045**] and on medication. Has not taken
medication or been to a physician since emigrating to the US
several yrs ago. No other medical problems, past surgeries or
hospitalization.
Social History:
Denies past drug use. No current EtOH or tobacco use. Social
smoker briefly several yrs ago. Lives with wife, 12 yo daughter
and 1 [**Name2 (NI) **] son. [**Name (NI) 1403**] as a valet at [**Hospital 86**] [**Hospital3 1810**].
Several siblings in [**State 108**] and [**Country 6607**]. No other family members
in the [**Name (NI) 86**] area.
Family History:
Mother with severe hypertension. None of his 8 siblings is known
to have HTN. No FH of CAD, DM, cancer.
Physical Exam:
98.5, 186/120, 81, 20, 100%RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, S1/wide split S2, II/VI systolic ejection murmur
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
intact. 5/5 strength all 4 extremities. No cerebellar
dysfunction on FTN or [**Doctor First Name **].
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
Pertinent Results:
[**2117-1-6**] 05:20AM BLOOD WBC-4.4 RBC-4.42* Hgb-13.3* Hct-36.7*
MCV-83 MCH-30.0 MCHC-36.2* RDW-12.9 Plt Ct-186
[**2117-1-5**] 05:55AM BLOOD WBC-4.5 RBC-4.54* Hgb-13.7* Hct-38.2*
MCV-84 MCH-30.2 MCHC-35.9* RDW-13.0 Plt Ct-187
[**2117-1-4**] 09:36AM BLOOD WBC-4.2 RBC-5.17 Hgb-15.8 Hct-42.4 MCV-82
MCH-30.6 MCHC-37.3* RDW-12.9 Plt Ct-229
[**2117-1-4**] 09:36AM BLOOD Neuts-52.4 Lymphs-38.3 Monos-6.0 Eos-2.2
Baso-1.0
[**2117-1-4**] 09:36AM BLOOD PT-12.6 PTT-23.7 INR(PT)-1.1
[**2117-1-6**] 05:20AM BLOOD Glucose-108* UreaN-19 Creat-1.8* Na-139
K-3.0* Cl-99 HCO3-31 AnGap-12
[**2117-1-5**] 05:55AM BLOOD Glucose-102 UreaN-18 Creat-1.7* Na-138
K-2.8* Cl-102 HCO3-28 AnGap-11
[**2117-1-4**] 02:51PM BLOOD Glucose-108* UreaN-17 Creat-1.5* Na-141
K-3.4 Cl-106 HCO3-28 AnGap-10
[**2117-1-4**] 09:36AM BLOOD Glucose-132* UreaN-19 Creat-1.8* Na-138
K-2.6* Cl-98 HCO3-29 AnGap-14
[**2117-1-5**] 05:55AM BLOOD CK(CPK)-5409*
[**2117-1-4**] 02:51PM BLOOD ALT-19 AST-54* LD(LDH)-337* CK(CPK)-3687*
AlkPhos-74 TotBili-0.8
[**2117-1-4**] 09:36AM BLOOD CK(CPK)-3681*
[**2117-1-4**] 09:36AM BLOOD cTropnT-<0.01
[**2117-1-4**] 09:36AM BLOOD CK-MB-6
[**2117-1-6**] 05:20AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0
[**2117-1-5**] 05:55AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
[**2117-1-4**] 02:51PM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9
[**2117-1-4**] 09:36AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2117-1-4**] 11:14PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2117-1-4**] 12:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2117-1-4**] 11:14PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2117-1-4**] 12:00PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2117-1-4**] 11:14PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2117-1-4**] 12:00PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0
[**2117-1-4**] 11:14PM URINE Mucous-RARE
[**2117-1-4**] 11:14PM URINE Hours-RANDOM Creat-51 Na-144 K-22
TotProt-27 Prot/Cr-0.5*
[**2117-1-4**] 11:14PM URINE Osmolal-444
[**2117-1-4**] 11:14PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
ECG Study Date of [**2117-1-4**] 10:39:32 AM
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy. Marked repolarization abnormalities consistent with
left ventricular strain pattern. No previous tracing available
for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 168 102 404/463 59 61 -124
CT HEAD W/O CONTRAST Study Date of [**2117-1-4**] 9:35 AM
FINDINGS: Non-contrast head CT. There is no intra-axial or
extra-axial
hemorrhage, shift of normally midline structures, mass effect,
or evidence of acute infarction. Ventricles and sulci appear
normal for a patient of this age. Basilar cisterns are patent.
Paranasal sinuses, mastoid air cells, and middle ear cavities
are well aerated. The calvarium is intact.
IMPRESSION: No acute intracranial process.
CHEST (PA & LAT) Study Date of [**2117-1-4**] 10:22 AM
IMPRESSION: Mild cardiomegaly with LV configuration. Consider
echocardiogram to further assess.
TTE (Congenital, complete) Done [**2117-1-5**] at 2:51:51 PM
FINAL
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no left
ventricular outflow obstruction at rest or with Valsalva. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated. The aortic valve is bicuspid (true bicuspid valve with
equal anterior and posterior leaflets). There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. The mitral valve appears structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. The left ventricular inflow pattern suggests impaired
relaxation. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Impression: true bicuspid aortic valve with minimal stenosis and
mild regurgitation; moderate concentric left ventricular
hypertrophy with hyperdynamic left ventricle; coarctation of the
aorta could not be excluded on the basis of this study, and
should be strongly considered
DUPLEX DOPP ABD/PEL Study Date of [**2117-1-5**] 8:11 AM
IMPRESSION:
1. No evidence for renal artery stenosis by Doppler ultrasound.
2. Increased echogenicity of the renal parenchyma bilaterally
consistent with diffuse parenchymal disease. Normal sized
kidneys.
MRA CHEST W/O CONTRAST Study Date of [**2117-1-6**] 9:53 AM
IMPRESSION:
1. Normal appearance of the thoracic aorta. No evidence of
aortic
coarctation.
2. Bicuspid aortic valve.
Brief Hospital Course:
1. Malignant Hypertension
- Initially treated with Labatelol drip in [**Hospital Unit Name 153**], transitioned to
oral agents
- Labatelol, Norvasc and HCTZ
- Still with highly labile BP, with severe diastolic
hypertension
- Will likely need ACE inhibitor given hypertensive nephropathy,
but this should be started in the outpatient setting given need
to follow electrolytes over next several weeks
- No signs of coarctation on MRA despite suspicion on TTE
- Would obtain urine metanepharines as an outpatient, given
would not return prior to discharge here. This is not an
unreasonable diagnosis, given not only severe hypertension but
relatively high heart rates while in house (90's)
- No signs of renal artery stenosis on ultrasound
- Mother also with hypertension
- Patient will need medication education (although his wife is a
pharmacy technician and is very concerned about his compliance
and will work with him on this)
2. Acute Renal Failure on acute on Chronic Kidney Disease Stage
II:
- concern for hypertensive nephropathy with CK-induced
nephropathy causing the acute renal failure
- Pt not in grossly proteinuric range of note
- Cr mildly improved since here with hydration though FeNa>3%
- Renal US consistent with hypertensive nephropathy
- should be started on outpatient ACE
- Will need outpatient nephrology referral
3. Left Ventricular Hypertrophy
- Would keep his heart rate on the lower side given high wall
thickness and liekly diastolic dysfunction
- Echo as above
Patient has a new PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 6087**] through [**Hospital1 3278**]
Health Plan. he has a follow up initial appointment in 8 days.
Medications on Admission:
Motrin PRN (last taken >1 wk PTA)
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*60 Capsule(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Malignant Hypertension
Acute Renal Failure
Chronic Kidney Disease Stage II
Hypokalemia
Left Ventricular Hypertrophy
Discharge Condition:
Good
Discharge Instructions:
It is critically important that you follow up with your new PCP
[**Name Initial (PRE) 7928**]. Your medications are not at their final doses, and will
continue to need adjustments.
Your kidneys have been damaged by the high blood pressure, and
you will likely be referred to a kidney doctor by your new PCP.
Take all your blood pressure medications.
Return to the hospital with headache, change in vision,
confusion, chest pain, fever/chills
Followup Instructions:
You have an appointment on [**2116-12-15**] at 09:40 with your new PCP
[**Name9 (PRE) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] at Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 81247**] Phone: [**Telephone/Fax (1) 6087**]
ICD9 Codes: 5849, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5967
} | Medical Text: Admission Date: [**2157-5-27**] Discharge Date: [**2157-5-31**]
Date of Birth: [**2091-4-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
s/p Minimally invasive Aortic Valve Replacement (#25mm [**Company 1543**]
Mosaic Porcine) and Drug eluding Stent to Right Coronary artery
[**5-27**]
History of Present Illness:
66 year old male with history of aortic stenosis followed by
serial echocardiograms. Underwent cardiac catherization which
revealed right coronary artery stenosis.
Past Medical History:
aortic stenosis
hyperlipidemia
Social History:
Occupation: CONSTRUCTION WORKER
Lives with: WIFE
[**Name (NI) 1139**]:QUIT 18 YRS AGO
ETOH: OCCASIONAL WINE
Family History:
noncontributory
Physical Exam:
Pulse: 65 Resp: 12 O2 sat:
B/P Right: 105/55 Left: 110/60
Height: Weight:
General:
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 [] Irregular [x] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: radiation of cardiac
murmur
Pertinent Results:
[**2157-5-31**] 05:50AM BLOOD WBC-7.1 RBC-3.35* Hgb-10.2* Hct-29.9*
MCV-89 MCH-30.4 MCHC-34.0 RDW-14.0 Plt Ct-98*
[**2157-5-27**] 02:00PM BLOOD WBC-17.2*# RBC-3.14*# Hgb-9.4*#
Hct-28.1*# MCV-90 MCH-29.9 MCHC-33.3 RDW-13.5 Plt Ct-99*
[**2157-5-31**] 05:50AM BLOOD PT-14.3* PTT-27.6 INR(PT)-1.2*
[**2157-5-27**] 02:00PM BLOOD PT-16.3* PTT-40.3* INR(PT)-1.5*
[**2157-5-30**] 05:55AM BLOOD Glucose-126* UreaN-19 Creat-0.9 Na-140
K-4.1 Cl-100 HCO3-30 AnGap-14
[**2157-5-28**] 02:28AM BLOOD Glucose-132* UreaN-14 Creat-0.9 Na-138
K-6.0* Cl-110* HCO3-25 AnGap-9
[**2157-5-30**] 05:55AM BLOOD ALT-6 AST-27 LD(LDH)-262* AlkPhos-52
Amylase-26 TotBili-0.7
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82232**] (Complete)
Done [**2157-5-27**] at 11:46:31 AM 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: [**2091-4-2**]
Age (years): 66 M Hgt (in): 66
BP (mm Hg): 109/67 Wgt (lb): 185
HR (bpm): 56 BSA (m2): 1.94 m2
Indication: Intraoperative TEE for AVR - minimaly invasive.
Aortic valve disease. Chest pain. Coronary artery disease. Left
ventricular function. Mitral valve disease. Preoperative
assessment. Prosthetic valve function. Right ventricular
function.
ICD-9 Codes: 786.05, 786.51, 440.0, 424.1, 424.0, 799.02, 963.1,
441.2, 394.0, 424.2
Test Information
Date/Time: [**2157-5-27**] at 11:46 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW5-: Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *38 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 23 mm Hg
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Severe regional LV
systolic dysfunction. Severely depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in ascending aorta. Simple atheroma in
aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Moderate [2+] TR.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. There is severe
regional left ventricular systolic dysfunction with hypokinesia
of the apex, anterior wall, anteroseptal, septal and
anterolateral walls. Overall left ventricular systolic function
is severely depressed (LVEF= 25-30 %).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5.The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (valve area 0.8-1.0cm2).
Mild (1+) aortic regurgitation is seen.
6.The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen.
7.Dr. [**Last Name (STitle) **] was notified in person of the results on [**2157-5-27**]
at 1000am.
Post bypass
1. Patient is AV paced and receiving an infusion of
phenylephrine, milrinone and epinephrine.
2. Biventricular systolic function is unchanged.
3. Bioprosthetic valve seen in the aortic position. Leaflets
move well and the valve appears well seated.
4. Peak gradient across the aortic valve is 15 mm Hg.
5. Trace mitral regurgitation.
6. Aorta is intact post decannulation.
7. However just before leaving the room an echo dense mass about
2 cm in size seen in the ascending aorta about 3 cm above the
aortic valve. Images reviewed by Drs [**First Name (STitle) 6507**], [**Name5 (PTitle) 168**] and
[**Name5 (PTitle) **]. Mostly likely an artifact. No action to be taken at
this time. No evidence of aortic dissection.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2157-5-27**] 18:45
?????? [**2151**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Was admitted same day and went to operating room and underwent
cardiac intervention and aortic valve replacement. See
operative reports for further details. He was transferred to
the intensive care unit for hemodynamic monitoring. In the
first twenty four hours he was weaned from sedation, awoke
neurologically intact, and was extubated without complications.
Episodes of atrial fibrillation was treated with betablockers
and amiodarone, he converted back to normal sinus rhythm. He
was weaned from nitroglycerin and milirone on post operative day
one. On post operative day two he was transfered to the floor
for the remainder of his care. Physical therapy worked with him
on strength and mobility. He continued to have episodes of
atrial fibrillation requiring amiodarone and betablockers, last
episode of [**5-30**]. Due to thrombocytopenia he was checked for
HITT which was negative and platelet count improving. He was
started on coumadin for atrial fibrillation, carvediolol and
lisinopril for heart failure. He was ready for discharge home
with services post operative day four.
Medications on Admission:
lopressor 100 twice a day
multivitamin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
please take two tablets for 7 days then decrease to 1 tablet
daily .
Disp:*37 Tablet(s)* Refills:*0*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
please take 2.5mg [**6-1**] and have blood drawn [**6-2**] with results to
Dr [**Last Name (STitle) 1147**] for further dosing. .
Disp:*30 Tablet(s)* Refills:*0*
11. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing for atrial fibrillation
goal INR 2.0-2.5
Results to Dr [**Last Name (STitle) 1147**] office # [**0-0-**] fax # [**Telephone/Fax (1) 60930**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic stenosis s/p Minimally invasive Aortic Valve Replacement
(#25mm [**Company 1543**] Mosaic Porcine)
Coronary artery disease s/p stent to Right coronary artery
(DES)
Acute on chronic systolic heart failure
Post operative atrial fibrillation
hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, 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 [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 4 week ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 12167**] in [**2-15**] weeks ([**0-0-**])
[**Year (4 digits) **]: PT/INR for coumadin dosing: goal INR 2.0-2.5 for atrial
fibrillation first draw [**6-2**] with results to Dr [**Last Name (STitle) 1147**] office
phone # [**0-0-**] fax # [**Telephone/Fax (1) 60930**]
Completed by:[**2157-5-31**]
ICD9 Codes: 4241, 9971, 2875, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5968
} | Medical Text: Admission Date: [**2189-9-2**] Discharge Date: [**2189-9-8**]
Date of Birth: [**2126-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Nifedipine / Metoprolol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2189-9-2**] - Aortic valve replacement (23mm St. [**Male First Name (un) 923**] mechanical
valve), Ascending aorta replacement(30mm Gelweave tube graft).
History of Present Illness:
62 year old gentleman with a history of a bicuspid Aortic valve
and moderate Aortic stenosis who has been followed by serial
echocardiograms. He notes increasing exertional dyspnea and
fatigue over the past several months.
Past Medical History:
Bicuspid aortic valve
Aortic stenosis
Aortic aneurysm
Hypertension
GERD
Social History:
Lives with: significant other, [**Name (NI) **]
Occupation: Retired maintainance technician
Tobacco: None
ETOH: 7/week
Family History:
Father had bicuspid Ao valve and AVR-died 69yo of "clot".
Brother has bicuspid valve and arrhythmia problem.
Physical Exam:
Pulse: 55 Resp: 16 O2 sat:
B/P Right: 110/74 Left: 118/70
Height: 72" Weight: 210 lbs
General: NAD, well appearing
Skin: Dry [x] intact [x]
HEENT: NCAT [] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] JVD[x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] [**2-14**] sys murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema -none
right groin cath site- no erythema or drainage, tiny hematoma at
puncture site, non-tender
Varicosities: None [] small spider veins
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit- Right: Left: none
Pertinent Results:
[**2189-9-2**] ECHO
PREBYPASS No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Overall right ventricular systolic function is
normal with normal free wall contractility. The aortic root is
mildly dilated at the sinus level. There is a focal
calcification in the aortic root measuring 8mm x 4mm. The
ascending aorta is markedly dilated with a maximum diameter of
5.1 cm. The aortic arch is normal. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve is bicuspid with severely
thickened/deformed aortic valve leaflets. A fibrinous
echodensity is present on the aortic side of the non-coronary
cusp of the aortic valve, consistent degenerative disease
(suggest clinical correlation). There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at
the time of the study.
POSTBYPASS The patient is A-paced and is on an intermittent
phenylephrine infusion. A new mechanical aortic valve is seen.
It is well-seated with washing jets in the expected locations.
There is trace aortic insufficiency in total. Calculated aortic
valve area is 2.0 cm2 with peak and mean gradients of 36 mmHg
and 18 mmHg respectively at a cardiac output of about 6
liters/minute. An ascending aortic graft is seen. Thoracic aorta
is otherwise normal. Left ventricular systolic function
continues to be normal (LVEF>55%). Mild (1+) mitral
regurgitation persists.
Pre-op
[**2189-9-2**] 09:38AM HGB-13.5* calcHCT-41
[**2189-9-2**] 09:38AM GLUCOSE-103 LACTATE-1.2 NA+-137 K+-3.7
CL--105
[**2189-9-2**] 12:30PM PT-16.2* PTT-31.0 INR(PT)-1.4*
[**2189-9-2**] 12:30PM WBC-13.6*# RBC-2.70*# HGB-8.8*# HCT-26.2*#
MCV-97 MCH-32.7* MCHC-33.6 RDW-12.9
[**2189-9-2**] 02:07PM UREA N-10 CREAT-0.6 SODIUM-140 POTASSIUM-4.4
CHLORIDE-111* TOTAL CO2-22 ANION GAP-11
[**2189-9-6**] 07:15AM BLOOD WBC-6.9 RBC-2.88* Hgb-9.4* Hct-28.2*
MCV-98 MCH-32.8* MCHC-33.5 RDW-13.0 Plt Ct-255#
[**2189-9-7**] 09:25AM BLOOD PT-22.5* PTT-59.2* INR(PT)-2.1*
[**2189-9-6**] 07:15AM BLOOD Glucose-104* UreaN-7 Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-29 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 85120**] was admitted to the [**Hospital1 18**] on [**2189-9-2**] for surgical
management of his aortic valve stenosis and ascending aortic
aneurysm. He was taken directly to the operating room where he
underwent an aortic valve replacement with a 23mm St. [**Male First Name (un) 923**]
mechanical valve and replacement of his ascending aorta. His
bypass time was 89 minutes with a crossclamp time of 66 minutes.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring. Over the next
several hours, he awoke neurologically intact and was extubated.
On POD 1 the patient was transferred to the telemetry floor for
further recovery. All chest tubes and pacing wires and other
lines were removed per cardiac surgery protocol. Initially beta
blocker was started at a low dose due to a systolic blood
pressure. Betablocker was increased slowly because the patient
did have junctional rhythm with stable systolic pressure. Low
dose lisinopril was also resumed. He was diuresed toward the
preoperative weight. He was started on Coumadin with heparin
bridge for aortic mechanical valve. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #6 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics and his INR was therapuetic. Couamdin
dosing will be followed by the [**Hospital **] [**Hospital 197**] clinic with a
goal INR 2.5-3.0. The patient was discharged home with visitng
nurse services in good condition with appropriate follow up
instructions.
Medications on Admission:
Lisinopril 5', HCTZ 25', protonix 40', MVI
Discharge Medications:
1. Aspirin 81 mg [**Hospital 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 [**Hospital 8426**], 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. Pantoprazole 40 mg [**Hospital 8426**], Delayed Release (E.C.) Sig: One
(1) [**Hospital 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 [**Hospital 8426**], Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg [**Hospital 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 [**Hospital 8426**](s)* Refills:*0*
5. Acetaminophen 325 mg [**Hospital 8426**] Sig: Two (2) [**Hospital 8426**] PO Q4H (every
4 hours) as needed for pain.
6. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day: 20mEq [**Hospital1 **]
x 1 week the 20mEq QD x 1 week.
Disp:*45 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Lisinopril 2.5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO once a day.
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
8. Metoprolol Tartrate 25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO TID
(3 times a day).
Disp:*90 [**Hospital1 8426**](s)* Refills:*2*
9. Lasix 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO twice a day: [**Hospital1 **] x
1 week then QD x1 week.
Disp:*21 [**Hospital1 8426**](s)* Refills:*0*
10. Warfarin 5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO ONCE (Once) for
1 doses.
Disp:*1 [**Hospital1 8426**](s)* Refills:*0*
11. Warfarin 2 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: INR
goal 2.5-3 mech AVR.
Disp:*120 [**Last Name (Titles) 8426**](s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Aortic stenosis/Ascending aortic aneurysm, s/p Aortic valve
replacement (23mm St. [**Male First Name (un) 923**] mechanical valve), Ascending aorta
replacement(30mm Gelweave tube graft).
Hypertension
GERD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace bilateral pedal edema
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
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) 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) **] at [**Hospital 18**] clinic [**2189-9-24**] at 1:45 PM,
**Please have CXR done prior to clinic appointment
Cardiologist Dr.[**Last Name (STitle) 4610**] [**2189-10-7**] at 2:00 PM
Please call to schedule appointments with your:
Primary Care Dr.[**Doctor Last Name 27303**] [**Telephone/Fax (1) 85121**] in [**4-13**] 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: Mechanical aortic valve
Goal INR 2.5-3.0
First draw [**2189-9-9**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then as directed by Dr [**Last Name (STitle) 4610**] through [**Hospital **] [**Hospital 197**]
Clinic
Results to [**Hospital1 **] coumadin clinic-fax [**Telephone/Fax (1) 33001**]
Completed by:[**2189-9-8**]
ICD9 Codes: 4241, 2762, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5969
} | Medical Text: Admission Date: [**2123-10-8**] Discharge Date: [**2123-10-13**]
Date of Birth: [**2052-2-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn
Attending:[**First Name3 (LF) 14229**]
Chief Complaint:
1. Hypotension, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Pt is a 71 female, h/o PVD s/p right AKA [**2123-9-24**], DM, CHF,
CAD s/p stents, chronic atrial fibrillation, and multiple other
medical problems, who presents with hypotension, fever, and AMS.
Pt was d/cd from [**Hospital1 **] on [**2123-10-4**] s/p right AKA. At rehab, pt was
noted to be lethargic the past two days. Per report with bloody
diarrhea x 2 on [**2123-10-7**]. As the day wore on yesterday, pt c/o
tiredness and weakness. Notes said that despited many naps
throughout the day, Ms. [**Known lastname 105375**] remained lethargic and tired.
Pt was unable to answer basic questions, with poor memory. On
labs [**2123-10-7**]- Total WBC 27.8, 90% neutrophils and 4% bands.
BUN/cr 48/2.5 with baseline cr of 0.8-0.9. Yesterday, BP went to
50/30. Then noted to be stable in the 80s-90s/60, P 88-96,
RR:[**9-17**], T: 100.2. U/A from rehab [**2123-10-8**] shows few bacteria, 2+
LE, [**11-25**] WBC, though [**11-25**] epi. She was transferred to [**Hospital1 18**] ED
for further evaluation.
.
Upon arrival to ED, VS: T: 100.5; BP: 83/69; P: 95-115
(aflutter/fib), 97% on 3L. Pt got two units of fluids but was
still hypotensive. A femoral line was placed and dopamine gtt
started. HR increased to the 150s and dopamine titrated off and
levophed started.
Pt was given 1 g vancomycin, 500 mg levaquin, 500 mg flagyl in
ED.
.
Upon arrival to [**Hospital Unit Name 153**] "I feel ok." No SOB/CP. No cough. No
abdominal pain. +diarrhea x 2 days. No dysuria.
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:
VS: T: 98.4; HR: 108; BP: 80s systolic, RR: 14; O2: 96% 2L
Gen: Laying in bed in NAD
HEENT: MMM
Neck: JVP difficult to assess [**3-10**] neck girth
CV: irregularly irregular. S1S2
Lungs: Cta B/L anteriorly with decreased BS throughout
Abd: Soft, mildly tender throughout. No rebound. No guarding.
Ext: Right AKA with staples. C/D/I. LLE: browning of skin
without edema. DP not felt
Neuro: "[**Hospital3 **]", "[**10-8**]". No focal deficits.
Pertinent Results:
Admission Labs:
[**2123-10-8**] 06:50PM PT-20.4* PTT-47.1* INR(PT)-2.8
[**2123-10-8**] 06:50PM PLT SMR-NORMAL PLT COUNT-391
[**2123-10-8**] 06:50PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2123-10-8**] 06:50PM NEUTS-95.3* BANDS-0 LYMPHS-2.3* MONOS-1.9*
EOS-0.4 BASOS-0
[**2123-10-8**] 06:50PM WBC-28.0*# RBC-3.96* HGB-11.2* HCT-33.8*
MCV-85 MCH-28.2 MCHC-33.0 RDW-15.1
[**2123-10-8**] 06:50PM CRP-178.4*
[**2123-10-8**] 06:50PM CORTISOL-25.8*
[**2123-10-8**] 06:50PM CALCIUM-8.4 PHOSPHATE-4.5 MAGNESIUM-1.9
[**2123-10-8**] 06:50PM CK-MB-7
[**2123-10-8**] 06:50PM cTropnT-0.07*
[**2123-10-8**] 06:50PM LIPASE-22
[**2123-10-8**] 06:50PM ALT(SGPT)-12 AST(SGOT)-26 CK(CPK)-503* ALK
PHOS-86 AMYLASE-18 TOT BILI-0.4
[**2123-10-8**] 06:50PM GLUCOSE-102 UREA N-53* CREAT-2.0* SODIUM-121*
POTASSIUM-5.1 CHLORIDE-92* TOTAL CO2-21* ANION GAP-13
[**2123-10-8**] 07:11PM LACTATE-1.6
[**2123-10-8**] 07:15PM URINE RBC-<1 WBC-[**12-26**]* BACTERIA-FEW
YEAST-MANY EPI-[**12-26**] RENAL EPI-0-2
[**2123-10-8**] 07:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2123-10-8**] 07:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2123-10-8**] 09:47PM URINE OSMOLAL-183
[**2123-10-8**] 09:47PM URINE HOURS-RANDOM UREA N-123 CREAT-9
SODIUM-55
.
Other Pertinent Labs:
[**2123-10-9**]: Protein electrophoresis, pending
[**2123-10-10**] 03:50AM BLOOD Fibrino-673*#
[**2123-10-8**] 06:50PM BLOOD cTropnT-0.07*
[**2123-10-9**] 05:35AM BLOOD CK-MB-5 cTropnT-0.05*
[**2123-10-10**] 03:50AM BLOOD TSH-0.35
[**2123-10-10**] 03:50AM BLOOD Free T4-1.6
[**2123-10-9**] 07:17AM BLOOD Cortsol-36.1*
.
.
Radiology
[**2123-10-10**]: Chest Film - Tip of the left subclavian line lies at
the junction of the SVC and innominate vein. Patchy
opacifications are seen in the right upper and lower lobes and
perihilar edema is seen suggesting the presence of failure and
pneumonia.
.
[**2123-10-9**]: 1. Interval development of bowel wall thickening/edema
best appreciated in the sigmoid colon and extending into the
descending colon. The differential diagnosis includes
infectious, inflammatory or ischemic etiologies. 2.
Redemonstration of interstitial opacities and small pleural
effusions at the bases
.
.
Discharge Labs:
[**2123-10-13**] 05:19AM BLOOD WBC-11.2* RBC-3.51* Hgb-9.9* Hct-31.0*
MCV-88 MCH-28.3 MCHC-32.0 RDW-16.4* Plt Ct-254
[**2123-10-13**] 05:19AM BLOOD Plt Ct-254
[**2123-10-13**] 05:19AM BLOOD Glucose-198* UreaN-9 Creat-0.8 Na-138
K-4.6 Cl-105 HCO3-26 AnGap-12
[**2123-10-13**] 05:19AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.7
Brief Hospital Course:
Impression/Plan: 71 yo F with MMP h/o PVD s/p right AKA [**2123-9-24**],
DM, CHF, CAD s/p stents, chronic atrial fibrillation, and
multiple other medical problems, presents with hypotension and
tachycardia.
.
1. Hypotension and Tachycardia - patient was admitted to the
[**Hospital Unit Name 153**] from rehab on [**2123-10-8**] with symptoms of hypotension,
elevated WBC and tachycardia. Patient had recently undergone a
right AKA on [**2123-10-4**]. Pt was febrile at rehab with question of
bloody stool as well as dirty U/A. The patient was started on
levaquin and Flagyl at [**Hospital 100**] REhab and transferred to the [**Hospital Unit Name 153**].
Based upon impression of chest film on admission, PNA did not
seem as likely originally, C. Diff was sent as patient had
previosuly been on antibiotics in hospital. [**Hospital Unit Name **] surgery was
[**Hospital Unit Name 4221**] to see the patients Rigth AKA who agreed it did not
look like a source of infection. As the patient [**Last Name (un) 19692**] hypotensive
on admission in the ED a femoral line was placed and the patient
was started on a dopamine drip. On admission to the [**Hospital Unit Name 153**] the
patient met SIRS criteria with increased HR to the 150's while
on dopamine. Dopamine was titrated off and Levophed was started
as a pressor instead. Hypotension was thought likely to be
secondary to SIRS vs. Afib with RVR. On [**2123-10-10**], the patient
was weaned off levophed and remained hmeodynamically stable. The
patient was transferred to the floor without pressors or fluid
support, tolerating a PO diet. Patient had a left subclavian
line placed in the [**Hospital Unit Name 153**] that was found to be erythematous. A
PICC line was placed for continued antibiotics and the Left
centeral line was discontinued.
.
2. ID: initially thought to have a UTI and was treated with
levo, vanc because of recent hospitalization and flagyl while
awaiting c. diff studies given history that she has had c.diff
colitis in the past. Upon transfer from the unit, the patient
was found to have erythema of the right AKA stump that was new,
thought possibly to be a cellulitis, as well as chronic right
lower lobe opacity concerning for persistent nosocomial
pneumonia. The patient was initially given Levofloxacin,
Vancomycin, and Clindamycin on transfer from the [**Hospital Unit Name 153**] to the
floor that was changed to Vancomycin and Imipenim to better
cover possible nosocomial pneumonia. The patient will be
discharged with plans to complete 14 day course of Vancomycin
and Imipenim. Patient's stool should be followed for diarrhea
with thoughts towards C. Diff.
.
2. Hematocrit drop - on the day of transfer patient was noted to
have a 4 point Hct drop, with guaiac positive stools. The
patient was transfused one unit of blood with appropriate Hct
bump and stable Hematocrit for remainder of stay on floor. She
can have an outpatient colpnoscopy whenever infectious issues
are resolved. Her hematocrit remained stable through the rest
of her stay and did not require further blood transfusions.
.
3. Afib with RVR- Patient with known afib. In setting of
hypotension and tachycardia, patient was givena Diltiazem drip
for rate control originally. The patient's tachycardia resolved
and the patient was transitioned back to her normal regimen of
dilt 30mg po [**Hospital Unit Name **] and metoprolol 25mg po tid. The patient was on
3mg coumadin on admission, with therapeutic INR, which was held
in the setting of HCt drop described above. As the patient's Hct
was stable thereafter, coumadin was reinitiated at 3mg po qhs,
with 5mg given [**2123-10-12**] to reach therapeutic INR and will return
back to 3mg dose at rehab with goa INR [**3-11**].
.
5. Acute renal failure- Creatinine 2.0 on admission to ED and
2.5 at rehab with baseline of 0.8. Likely in setting on renal
hypoperfusion and decreased intravascular volume. With volume
resuscitation patient's ARF resolved, with most recent
creatinine 0.8
.
6. Increased troponin - Patient found to have troponin to 0.07.
This was thought likely to be secondary from demand ischemia
(atrial fib/flutter), hypotension, and elevated in setting of
acute renal failure. Patient's second set of troponin's was
trending downward and additional cardiac cycles were not
repeated. EKG at time of troponin leak did not show any ischemic
changes and MBI flat.
.
7. Abdominal pain - With abdominal pain in ED. Prelim CT ab
shows some bowel wall thickening which is non-specific.
Abdominal pain resolved through hospital stay, C. Diff was
negative.
.
b. CHF- With diastolic dysfunction. On lasix at home. Patient
received 60mg IV Lasix day prior to discharge as found to be I >
O. Patient will be discharged continuing home regimen of Lasix
40mg [**Hospital1 **].
.
9. DM- Patient was maintained on Glargine and insulin sliding
scale. As finger sticks remained elevated, glargine was
increased from 18 to 20 units on day of discharge.
.
10. COPD- Continued combivent, fluticasone inhalers.
.
11. Psych- Depression and anxiety. Patient maintained on home
regimen of medications
.
12. Myoclonic tremors: Continued on previous regimen of
Gabapentin.
.
13. Pain- Patient's pain well controlled with Fentanyl patch
75mg/hr as well as oxycontin 10mg po bid, oxy-acet 1-2tabs po
q4-6hr PRN and morphine with dressing changes.
.
Medications on Admission:
Medications on admission:
Diltiazem SR 120 qday
fentanyl 75 mcg/hr TD q3
Fluticasone 2 puffs [**Hospital1 **]
combivent 2 puffs q6
ASA 325 qday
Celexa 60 qday
Lasix 80 mg qday
neurontin 600 [**Hospital1 **], 900 qhs
Lantus 18 units sc qhs
RISS
synthroid 200 mcg qday
Lisinopril 5 mg qday
Methylfenadate 10 qam, 5 at noon
Metoprolol 25 tid
Morphine 8 mg sl qam (with dressing changes)
Oxycodone SR 10 po q12
Protonix 40 qday
Zocor 20 qhs
Topamax 25 [**Hospital1 **]
Coumadin dosed by level
Levaquin po qday x 10 days for PNA (unclear exact date started)
Flagyl 500 po tid x 14 days (first dose [**2123-10-8**])
.
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at [**Month/Day/Year 21013**])).
2. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
4. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
5. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO [**Month/Day/Year **] (4
times a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Morphine 10 mg/5 mL Solution Sig: Ten (10) ml PO Q6H (every
6 hours) as needed for dressing changes.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
17. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
18. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO at
[**Hospital1 21013**]: Please dose based on levels with goal INR [**3-11**].
20. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at [**Month/Day (3) 21013**]: with sliding scale insulin per attached
scale.
21. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
22. Imipenem-Cilastatin 500 mg Recon Soln Sig: Five Hundred
(500) mg Recon Soln Intravenous Q6H (every 6 hours) for 13
days.
23. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous
Q 24H (Every 24 Hours) for 13 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
SIRS
hypotension
nosocomial pneumonia
cellulitis
diastolic heart failure
Atrial fibrillation with rapid ventricular rate
anemia
diabetes mellitus, insulin dependence
depression
anxiety
myoclonic tremores
pressure ulcers
Discharge Condition:
good, on 2L O2 with sats in upper 90'2, HR in 80's and
normotensive and afebrile
Discharge Instructions:
Please continue to take all medications as prescibed. Please
call or return if you have an increase in fevers, chills or
shortness of [**Hospital6 1440**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**8-15**] days.
ICD9 Codes: 0389, 486, 5849, 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5970
} | Medical Text: Admission Date: [**2131-9-20**] Discharge Date: [**2131-10-2**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
[**9-20**] Exploratory laparotomy with resection of anastomosis,
Hartmann's with ascending colostomy
[**9-21**] Placement of central venous catheter
[**9-21**] Left chest tube insertion
[**9-22**] Left chest tube insertion (#2)
[**9-26**] Left chest tube removal and left apical chest tube
replacement
[**9-28**] Left VATS exploration with doxycycline pleurodesis
History of Present Illness:
Mr. [**Known lastname 93929**] is a 82 year old male who was admitted to [**Hospital1 18**] on
[**9-20**] from the surgical clinic with a wound infection. He is s/p
a laparoscopic colectomy on [**9-10**] for an obstructing mass at
splenic flexure which was biospy proven adenocarcinoma of the
colon, he had an un-complicated post-operative course except for
a localized wound cellulitis. He was discharged home on oral
antibiotics for seven days. He was seen in the surgical clinic
on [**9-20**] with reports of drainage from wound over the last four
days, initially it was serous but it changed to more feculent
material. The wound was completely opened in the ED with
findings of wound dehiscence of th superior portion and feculent
drainage. A CT scan revealed free air with no level of
obstruction, contrast did not reach level of anastomosis. He was
taken to the OR with findings of breakdown of the anastomosis
with leakage of stool; he [**Month/Day (1) 1834**] a resection of anastomosis
with placement of a colostomy.
Past Medical History:
Past Medical History:
Adenocarcinoma of colon
Aortic sclerosis
Past Surgical History:
[**9-10**] Laparoscopic colectomy
Mastoid surgery at age 5
Remote testicular surgery at age 10
Social History:
Non-smoker, has [**2-17**] drinks of alcohol each week
Family History:
Non-contributory
Physical Exam:
On admission to surgical service:
97.5 70 94/61 20 100% room air
Gen: Alert and oriented to time, place, and person
Lungs: Cleart to auscultation bilaterally
CV: Regular rate and rhythm
Abd: Soft, non-tender, non-distended; +erythema along wound,
+feculent material from wound
Pertinent Results:
Admission:
[**2131-9-20**] 01:10PM BLOOD WBC-15.0* RBC-4.08* Hgb-10.8* Hct-32.3*
MCV-79* MCH-26.4* MCHC-33.3 RDW-14.8 Plt Ct-575*#
[**2131-9-20**] 01:10PM BLOOD Neuts-79.4* Lymphs-15.2* Monos-4.0
Eos-1.4 Baso-0.1
[**2131-9-20**] 01:10PM BLOOD PT-12.5 PTT-25.7 INR(PT)-1.1
[**2131-9-20**] 01:10PM BLOOD Glucose-90 UreaN-13 Creat-1.0 Na-138
K-4.7 Cl-101 HCO3-27 AnGap-15
[**2131-9-20**] 01:10PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0
During hospitalization:
[**2131-9-22**] 01:18AM BLOOD WBC-19.4*# RBC-3.03*# Hgb-8.3*#
Hct-23.6*# MCV-78* MCH-27.3 MCHC-34.9 RDW-14.9 Plt Ct-505*
[**2131-9-24**] 06:20AM BLOOD WBC-20.1* RBC-3.68* Hgb-10.1* Hct-29.1*
MCV-79* MCH-27.5 MCHC-34.8 RDW-15.5 Plt Ct-544*
[**2131-9-21**] 01:35AM BLOOD CK-MB-3 cTropnT-0.02*
[**2131-9-21**] 05:46PM BLOOD CK-MB-7 cTropnT-<0.01
[**2131-9-22**] 01:18AM BLOOD CK-MB-5 cTropnT-<0.01
[**2131-9-21**] 01:35AM BLOOD CK(CPK)-88
[**2131-9-21**] 05:46PM BLOOD CK(CPK)-855*
[**2131-9-22**] 01:18AM BLOOD CK(CPK)-826*
[**2131-9-20**] 1:10 pm SWAB
**FINAL REPORT [**2131-9-26**]**
GRAM STAIN (Final [**2131-9-20**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2131-9-24**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM NEGATIVE ROD #1. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PROBABLE ENTEROCOCCUS. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2131-9-26**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
[**2131-9-29**] 9:43 am URINE
**FINAL REPORT [**2131-9-30**]**
URINE CULTURE (Final [**2131-9-30**]): NO GROWTH.
[**2131-10-1**] 7:06 am SWAB Site: ABDOMEN Source: abdominal
wound.
GRAM STAIN (Final [**2131-10-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Pending):
ANAEROBIC CULTURE (Pending):
Discharge:
[**2131-10-2**] 07:15AM BLOOD WBC-12.1* RBC-3.64* Hgb-9.9* Hct-29.3*
MCV-81* MCH-27.2 MCHC-33.8 RDW-16.8* Plt Ct-410
[**2131-10-2**] 07:15AM BLOOD Plt Ct-410
[**2131-9-29**] 06:20AM BLOOD Glucose-86 UreaN-7 Creat-0.7 Na-139 K-4.0
Cl-104 HCO3-26 AnGap-13
[**2131-9-29**] 06:20AM BLOOD Calcium-8.0* Phos-4.3 Mg-2.3
OPERATIVE REPORT
FIRST ASSISTANT: [**Doctor First Name **] [**Doctor Last Name **], RES
PREOPERATIVE DIAGNOSIS: Anastomotic leak following partial
colectomy with dehiscence of abdominal closure.
POSTOPERATIVE DIAGNOSIS: Anastomotic leak following partial
colectomy with dehiscence of abdominal closure.
OPERATION: Exploratory laparotomy, lysis of adhesions,
resection of colonic anastomosis and closure of distal colon
and end colostomy.
INDICATION: 82-year-old male had undergone transverse
colectomy 10 days ago for colon cancer. He did well
postoperatively and was discharged home. Shortly prior to his
discharge home he had some erythema around some staples and
was placed on Keflex for cellulitis. Once he went home, I was
called about 3 days later to say he had a small amount of
drainage from his wound but was otherwise feeling well and I
advised him to apply gauze to this and keep me informed. On
the night before admission I was called to say that he noted
a temperature of 99.3. He was due to see me in the office
this morning and therefore I said that we would address this
issue then. When I saw the patient in the office, his wound
was clearly contaminated with fecal material and I took out
some staples which revealed more fecal material. I therefore
transferred him to the emergency room and saw him after the
Resident team had removed the rest of the staples and
confirmed the findings of a partial dehiscence of his
abdominal wall incision, as well as fecal matter within the
wound.
We did obtain a CAT scan to just make sure that there was not
a significant collection of fluid anywhere in the peritoneal
cavity that we might not be able to address readily in
surgery and then took him to the operating room.
PREPARATION: Once the patient was suitably anesthetized, the
abdomen was prepared and draped appropriately.
INCISION: The old incision was reopened and extended below.
FINDINGS: There was actually a paucity of any reaction anywhere
in
the peritoneal cavity except for under the incision and by
the anastomosis. The anastomosis was clearly the source of
the problem. The small bowel was adherent to 1 area of this
anastomosis and was taken off it without injuring it.
TECHNIQUE: We dissected the small bowel off the anastomosis
and mobilized the colon proximally and distally to the
anastomosis. The bowel was controlled distally and then
stapled closed with an Endo [**Female First Name (un) 3224**] green cartridge and then the
colon was resected back past the anastomosis. At this point,
the right colon was gently mobilized and enough of it brought
medially to reach a right lower quadrant circular incision
that we made to accommodate the colon as a colostomy. The
colonic anastomosis was resected with another application of
the [**Female First Name (un) 3224**] and the fresh colon was then brought out through the
right lower quadrant incision which we made to accommodate
the colostomy. We then irrigated copiously with saline and
then closed the abdominal wall after debriding it with #1
PDS. We left the wound open and then matured the colostomy
with 3-0 Vicryl. The patient tolerated the procedure well and
was returned to the recovery room.
CT ABDOMEN W/CONTRAST [**2131-9-20**] 2:53 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: fistula
Field of view: 35 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with recent colectomy, now concerned for
enterocut fistula
REASON FOR THIS EXAMINATION:
fistula
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 82-year-old man with a transverse colectomy for
adenocarcinoma approximately one week ago now with concern for
an enterocutaneous fistula.
COMPARISON: No prior studies are available for comparison.
TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis
was performed after the administration of oral and intravenous
contrast. Coronal and sagittal reformations were obtained.
CT OF THE ABDOMEN: The lung bases demonstrate small pleural
effusions and dependent atelectasis. The liver, adrenal glands,
spleen, and pancreas appear normal. A 4mm hypodensity in the
right lobe of the liver is incompletely characterized. The
gallbladder is distended but thin walled without any
intraluminal stones or sludge identified. The kidneys enhance
and excrete contrast symmetrically without hydronephrosis. Two
small incompletely characterized cysts, the larger measuring 9
mm, are seen in the right kidney. There is a small cortical
defect in the left kidney which could represent prior infection.
No dilated loops of bowel are identified. The patient is status
post a transverse colectomy and surgical suture material is seen
in the mid abdomen connecting remaining loops of colon. There is
a large anterior abdominal wall defect in the region of the
anastomosis. Contrast has reached the mid small bowel. There is
an extensive amount of free intraperitoneal air still evident.
There is a small amount of subhepatic/subphrenic ascites.
Mesenteric stranding in the region of the surgery is also seen
as well as multiple surgical clips.
Multiple small retroperitoneal lymph nodes are seen, which do
not meet criteria for pathologic enlargement. There is
atherosclerosis of the abdominal aorta and its branches.
CT OF THE PELVIS: The bladder, prostate, seminal vesicles, and
rectum appear unremarkable apart from minor prostatic
calcifications. No free fluid is seen in the pelvis. No
drainable fluid collections are seen in the abdomen or pelvis.
OSSEOUS STRUCTURES: There is grade 1 anterolisthesis of L4 on L5
with extensive degenerative change at this level. There is a
rounded region of sclerosis in the sacrum, likely a bone island.
No concerning lytic or sclerotic lesions are identified.
IMPRESSION:
1. Post-surgical changes in the abdomen and large anterior
abdominal wall defect with persistent extensive pneumoperitoneum
and a small amount of ascites. No drainable fluid collections.
2. Small bilateral pleural effusions with associated
atelectasis.
3. 4-mm hypodensity in the right lobe of the liver, incompletely
characterized.
4. IncoRADIOLOGY Final Report
CHEST (PORTABLE AP) [**2131-9-21**] 3:18 PM
Reason: improvement in L pneumo
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with s/p traverse colectomy, anastomic leak -
s/p L chest tube for PTX
REASON FOR THIS EXAMINATION:
improvement in L pneumo
AP CHEST, 3:19 P.M., [**9-21**].
HISTORY: Left chest tube. No pneumothorax.
IMPRESSION: AP chest compared to 1:57 p.m.:
Left pneumothorax has decreased only minimally, still quite
large, despite placement of left pleural tube. Mediastinum,
however, has returned to the midline. Heart mildly enlarged.
Right lung is low in volume but essentially clear. Findings were
discussed with the house officer caring for this patient, by
telephone, at the time of dictation.
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2131-9-21**] 8:49 AM
Reason: s/p triple lumen placement
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with
REASON FOR THIS EXAMINATION:
s/p triple lumen placement
INDICATION: 82-year-old man status post central venous catheter
placement.
No prior studies are available for comparison.
FINDINGS: Right-sided subclavian approach central venous
catheter is noted with its tip projecting at the level of the
right subclavian and internal jugular junction. A NG tube is
visualized with its tip projecting over the stomach. The cardiac
silhouette is within normal limits. The aorta is tortuous with
calcification in its arch. Lung volumes are low. Bibasilar
linear opacities likely represent atelectasis. Mild blunting of
the left costophrenic angle may represent small pleural
effusion. Free air below the right hemidiaphragm is noted.
Thoracic scoliosis is noted.
IMPRESSION:
1. Right central venous catheter with its tip projecting at the
level of the right subclavian and internal jugular junction.
2. Pneumoperitoneum.
3. NG tube with its tip projecting over the stomach.
Findings were discussed with Dr. [**Last Name (STitle) **] on [**2131-9-21**].
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2131-9-22**] 12:20 PM
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN
Reason: Status of PTX
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with s/p traverse colectomy, anastomic leak -
repositioning of L chest tube for PTX; assess for interval
change in lung expansion
REASON FOR THIS EXAMINATION:
Status of PTX
PORTABLE CHEST ON [**2131-9-22**] AT 12:15.
INDICATION: Left chest tube placement.
COMPARISON: [**2131-9-22**] at 05:28.
FINDINGS:
The left pneumothorax persists and is unchanged. The right lung
appears better aerated. NGT has been removed and left CVL
remains in place.
IMPRESSION: No change in the left PTX.
CHEST (PORTABLE AP) [**2131-9-27**] 7:57 AM
Reason: assess for interval changes
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with s/p CT x2 for PTX.
REASON FOR THIS EXAMINATION:
assess for interval changes
INDICATION: Status post chest tube placement, for evaluation of
pneumothorax.
PORTABLE AP CHEST.
COMPARISON: [**2131-9-26**].
The heart size is normal. Aorta is unfolded. A small left-sided
pneumothorax is noted. Two chest tubes are seen in place with
interval removal of one of the chest tubes. Small bilateral
pleural effusions are again noted with low lung volumes.
IMPRESSION:
1. Small left-sided pneumothorax and bilateral small pleural
effusions. Interval removal of the third chest tube from the
left.
2. Low lung volumes.
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2131-9-28**] 8:56 AM
CT CHEST W/O CONTRAST
Reason: Please eval PTX/chest tubes; please obtain in early AM
[**Hospital 93**] MEDICAL CONDITION:
82 year old man w/ continuous air leak
REASON FOR THIS EXAMINATION:
Please eval PTX/chest tubes; please obtain in early AM
CONTRAINDICATIONS for IV CONTRAST: None.
REASON FOR EXAMINATION: Evaluation of a long standing pleural
effusion.
COMPARISON: Serial chest radiograph from [**2131-9-21**] to
[**2131-9-28**].
FINDINGS:
Multiple mediastinal nodes are mildly enlarged measuring up to 1
cm in the supracarinal location . The hilar lymphadenopathy is
hard to estimate due to lack of contrast but no significant
lymphadenopathy is present. There is no axillary
lymphadenopathy. The heart is mildly enlarged with tiny
pericardial effusion. Coronary calcification involves both right
and left coronary arteries. Aortic valve calcifications are
present.
Several left intrapleural air collections are small involving
the apex, the lateral and the anterior low pleural spaces. The
apical chest tube ends anteriorly with adjacent pleural surfaces
all apposed. Subcutaneous emphysema is minimal. The right
pleural effusion is small, larger than the left. Bibasilar
consolidation with is most likely atelectasis, but aspiration
cannot be excluded.
The images of the upper abdomen demonstrate mild ascites. No
significant abnormalities demonstrated within the liver,
kidneys, spleen, adrenals and pancreas. Surgical clips are in
the left upper abdomen. There are no bone lesions suspicious for
malignancy.
IMPRESSION:
1. Several small intrapleural air pocket on the left. CT is not
able to show a pleural defect from central venous line
insertion; no large defect is present. The bilateral pleural
effusions are small, right worse than left with adjacent
consolidation most likely atelectasis.
2. Mild ascites.
3. Coronary calcifications.
OPERATIVE REPORT
[**Last Name (LF) 1533**],[**First Name3 (LF) 1532**] P.
Signed Electronically by [**Doctor Last Name 1533**],[**Last Name (un) **] on TUE [**2131-10-2**]
8:56 AM
Name: [**Known lastname **],[**Known firstname 870**]
Unit No: [**Numeric Identifier 93930**]
Service:
Date: [**2131-9-28**]
Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 67965**]
PREOPERATIVE DIAGNOSIS: Left pneumothorax.
POSTOPERATIVE DIAGNOSIS: Left pneumothorax.
PROCEDURE: Left VATS exploration and doxycycline
pleurodesis.
ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33888**]
ANESTHESIA: General endotracheal plus 40 cc of 0.375%
Marcaine with epinephrine and local and rib blocks.
IV FLUIDS: 1800 cc.
URINE OUTPUT: 180 cc.
ESTIMATED BLOOD LOSS: Less than 25 cc.
INDICATIONS FOR PROCEDURE: Mr. [**Known lastname 93929**] is an 82-year-old
gentleman who had recently undergone a transverse colectomy
for colon cancer and subsequent to that developed an
anastomotic leak requiring reoperation and creation of an end
colostomy [**Doctor Last Name 3379**] pouch. The day after this reoperation, he
was noted to have a left pneumothorax following placement of
a central line. The initial attempts at treatment of this
involved 2 tubes and finally a third tube was placed which
was able to resolve the pneumothorax. However, the air leak
did not resolve. CT scan was unrevealing of the problem.
PROCEDURE IN DETAIL: The patient was positioned supine and
through a single-lumen endotracheal tube, flexible
bronchoscopy was performed at the segmental airway level
bilaterally. There was no endobronchial obstruction. There
was no blood, plugging, purulence encountered. There was no
mucosal damage which would have potentially led to
bronchopleural fistula.
The patient then had the double-lumen endotracheal tube
placed and he was positioned in the left thoracotomy
position. He was prepped and draped in the usual sterile
fashion. He had 3 chest tube wounds. Two of these 3 wounds
were dehiscing and the third wound was opened as we had just
removed the remaining chest tube. Therefore, I decided to
prep these copiously using direct iodine application to the
tract and tube site and then placed the initial videoscope
through one of the chest tubes. Upon introduction of this
into the chest, I noted that there were some filmy adhesions
and some fibrinous material in the chest but that there was a
good view. The lungs themselves looked slightly emphysematous
and had quite a lot of anthracotic markings. There was no
obvious bulla and clearly no obvious laceration or injury to
the lung on initial glance. I placed a new port posteriorly
at the tip of the scapula and then used one of the previously
placed chest tube ports as the second utility incision for an
instrument. I was able to free up the adhesions and then
manipulate the lung so that I could view it in 360 degrees,
including all aspects of the intralobar fissure. There was no
obvious sign of visceral pleural defect whatsoever. I then,
therefore, dunked the lung underneath 500 cc of sterile
water. I systematically submerged the upper lobe in its
entirety and then followed this was submersion of the lower
lobe in its entirety. Even with this process and lung
inflation to a pressure of 20 cm of water which resulted in
good inflation, I did not observe any air streaming from the
lung whatsoever. Therefore, we elected to perform doxycycline
pleurodesis. We had 500 mg of doxycycline and we injected
that into the chest and let it circulate around evenly. We
placed two 19-French [**Doctor Last Name 406**] drains in the chest and brought
these out through separate tunneled stab incisions. We closed
the wounds very loosely with 3-0 and 4-0 Vicryl. All sponge
and needle counts were correct x2 and I was present and
scrubbed for the entire procedure. The patient was extubated
and taken to the recovery room in good condition.
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2131-9-29**] 8:05 AM
CHEST (PORTABLE AP)
Reason: r/o pneumo8am please
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with s/p CT x1, with pneumothorax
REASON FOR THIS EXAMINATION:
r/o pneumo8am please
HISTORY: Pneumothorax.
Single portable chest radiograph again demonstrates two
left-sided chest tubes. There is a small left-sided pleural
effusion. There is mild bibasilar atelectasis. Trachea is
midline. Cardiomediastinal contours are unchanged. No
pneumothorax is detected. S-shaped scoliosis of the cervical,
thoracic and lumbar spine is again noted. Surgical clips project
over the left upper quadrant.
IMPRESSION:
Left-sided pleural effusion. No pneumothorax. Bibasilar
atelectasis persists.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2131-9-30**] 12:08 PM
[**Hospital 93**] MEDICAL CONDITION:
82 year old man s/p VATS/pleurodesis
REASON FOR THIS EXAMINATION:
Please eval for PTX, on water seal; please perform study between
12 noon and 1 PM
PA AND LATERAL CHEST X-RAY, [**2131-9-30**]
COMPARISON: [**2131-9-29**].
INDICATION: Chest tube placed to waterseal. Question
pneumothorax.
Two chest tubes remain in place in the left hemithorax. On the
lateral view, there is a small air-fluid level present
anteriorly consistent with an anterior loculated
hydropneumothorax. The chest tubes are located posterior to this
area. Cardiac and mediastinal contours are stable. Moderate
right pleural effusion with intrafissural component is
unchanged. Small-to-moderate left pleural effusion has slightly
increased laterally, but there has been overall improved
aeration in the left lower lobe with improving atelectasis in
this region.
IMPRESSION:
1. Small left loculated anterior hydropneumothorax.
2. Bilateral pleural effusions, right greater than left.
3. Improving aeration left lower lobe.
Date: [**2131-10-1**]
Signed by [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 69152**], RN on [**2131-10-1**]
Affiliation: [**Hospital1 18**]
Mr [**Known lastname 93929**] was seen to apply an ABD binder and to adjust it
around
the colostomy. The pouch was starting to lift on the medial edge
therefore it was changed. The stoma is dark burgundy and
protruding. Peristomal skin and mucocutaneous junction are
intact. Pouched with [**Location (un) **] high output pouch with [**First Name8 (NamePattern2) **] [**Last Name (un) **]
seal.
Have placed a medium ABD binder around his ABD and then made an
opening in it to allow the pouch to hang out through the
opening.
He expects to go to rehab soon will update his referral and
provide him with d/c ostomy supplies and written ostomy care
instructions.
Brief Hospital Course:
Mr. [**Known lastname 93929**] had no intra-operative complications, he was given
intravenous antibiotics of Levaquin and Flagyl pre-operatively
which were continued post-operatively. His white blood cell
count on admission was 15k. Post-operatively he was hypotensive
with low urine outputs despite fluid boluses and was admitted to
the surgical intensive care unit for further management and
resuscitation. A cardiac work-up was negative for ischemia.
Upon admission to the intensive care unit a central line was
placed with difficulty on the right side and successful
placement on the left internal jugular vein for central venous
pressure monitoring, this was complicated by a left pneumothorax
requiring placement of a chest tube. On POD 2 his urine output
and creatinine had improved with fluid resuscitation from 1.8 to
1.3. His pain was well controlled with a Morphine PCA, he
remained afebrile, and his abdominal wound dressing changes
continued with wet to dry dressing changes of normal saline. On
POD 3 a chest x-ray demonstrated persistent left pneumothorax
which was treated with placement of a second chest tube, a
thoracic surgery consult was placed with recommendation of
continuing current treatment. He was transfused two units of
PRBC's for a hematocrit of 24.3 with a repeat hematocrit of
28.2.
On POD 4 he was stable for transfer to an in-patient nursing
unit, his diet was advanced which he tolerated well, and he had
+air from the ostomy. On POD 6 a chest x-ray demonstrated an
increased pneumothorax; thoracic surgery removed one of the two
left sided chest tubes and replaced one in the apex on the left
side at the bedside, an air leak continued from both chest
tubes. He tolerated the procedure well, his oxygenation was
stable on 2 liters nasal cannula. A repeat chest x-ray showed
minimal improvement in the pneumothorax. On POD 8 he had a CT
scan of the chest which demonstrated small intrapleural air
pockets with bibasilar atelectasis. Since the air leak continued
and there was minimal improvement in the pneumothorax he was
taken to the operating room on POD 8 for a left VATS,
exploration, and mechanical pleurodesis with Doxycycline by
thoracic surgery. He had no intra-operative complications and
returned to an in-patient nursing unit.
On POD [**12-26**] his pain was well controlled with Percocet, he
remained afebrile, and two left sided chest tubes were
maintained on suction. His abdominal wound was debrided at the
bedside and was noted to be granulating well; his white blood
cell count was elevated to 19k therefore an abdominal and pelvic
CT scan was done. The CT scan demonstrated a large anterior
abdominal wall defect involving the subcutaneous fat extending
to the anterior abdominal musculature, he also had small
loculated fluid collections in the abdomen and pelvis between
loops of bowel which appeared to be benign. His diet was
advanced to regular food which he tolerated well and his ostomy
was functioning well. The abdominal wound dressing changes were
changed to dry dressings three times a day since it still had
"wet" appearance with cream colored drainage. He was also
provided an abdominal binder to wear throughout the day with a
hole cut out for the ostomy appliance.
On POD [**9-17**] both chest tubes had no air leaks and were placed to
water seal, a repeat chest x-ray demonstrated no pneumothorax so
both chest tubes were removed by thoracic surgery; post removal
chest x-ray demonstrated small stable apical pneumothorax. He
was oxygenating well on 2 liters nasal cannula and continued to
received aggressive pulmonary toileting. On POD [**11-18**] he was
oxygenating well on room air, had minimal pain, was tolerating a
regular diet, and his ostomy was functioning well. He remained
afebrile with a white blood cell count of 12.1k.
His abdominal wound measured 17cm by 3cm with visible fascia and
sutures; he continued to receive dressing changes three times a
day with packing of dry, sterile gauze. There was still cream
colored drainage present with pink granulating tissue as well.
He was discharged to [**Hospital1 **] Rehabilitation facility
in good condition on [**10-2**]. He will receive 2 more days of oral
antibiotics of Levaquin and Flagyl which will total 14 days of
treatment. He will continue to receive physical therapy to
increase his functional mobility. He will also receive further
teaching and instruction regarding care of his ostomy. He will
follow-up in the surgical clinic in [**12-18**] weeks for evaluation of
his abdominal wound. He will follow-up in the ostomy clinic
after discharge from the rehabilitation facility.
Medications on Admission:
Toprol XL
Percocet prn
Colace
Keflex
ASA
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: Last dose pm of [**10-4**].
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days: Last dose on [**10-4**].
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily): Hold for
HR < 60
Hold for SBP < 100.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day: Give until patient ambulating.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Adenocarcinoma of colon with wound dehiscence
Left pneumothorax
Discharge Condition:
Good
Discharge Instructions:
Notify MD/NP/PA/RN at rehabilitation facility if you experience:
*Increased or persistent pain not relieved by pain medications
*Fever > 101.5 or chills
*Shortness of breath or difficulty breathing
*Nausea or vomiting
*Inability to pass gas or stool through ostomy; inability to
pass urine
*If abdominal wound develops erythema, drainage, or a foul odor
*Any other symptoms concerning to you
You need to wear the abdominal binder at all times throughout
the day
You may shower and wash incision and abdominal wound with soap
and water, dresssing changes will be done three times a day by
the nurses.
Please take all medications as ordered
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**12-18**] weeks, call ([**Telephone/Fax (1) 9011**]
for an appointment.
Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] after discharge from the
rehabilitation facilty for review of your medications and
physical exam, call [**Telephone/Fax (1) 904**] for an appointment.
Completed by:[**2131-10-2**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5971
} | Medical Text: Admission Date: [**2165-9-29**] Discharge Date: [**2165-10-9**]
Date of Birth: [**2165-9-29**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname **] is a pre-term infant with
respiratory distress, admitted to the Neonatal Intensive Care
Unit for further management of prematurity and respiratory
symptoms.
para 0 now I mother.
PRENATAL SCREENS: O positive, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, GBS unknown. Reported benign antepartum until
morning of delivery, with rupture of membranes followed by
labor onset. Received one dose of antibiotics six hours
for fetal bradycardia. Abjurers were 8 at one minute and 9
at five minutes.
PHYSICAL EXAMINATION: On admission, weight 2735 grams (90th
percentile), length 48 cm (75th percentile), head
circumference 33.5 cm (75th percentile). Examination notable
for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-term infant with mild respiratory distress, color
pink in oxygen, anterior fontanel soft and flat, normal
facies, intact palate, mild retractions, intermittent
grunting, fair air entry, no murmur, palpable femoral pulses,
abdomen soft, flat, nontender, without hepatosplenomegaly,
normal phallus, testes in scrotum, stable hips, fair
perfusion, normal tone and activity.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: Infant initially placed on CPAP of 6 cm of
water and 40% FIO2. Initial blood gas was 7.36, 47, 76, 28.
Due to increased FIO2 requirement to 60%, the infant was
intubated on day of life one, and was placed on ventilator
setting of 25/5 with a rate of 30. At that time, he received
two doses of Survanta, and was weaned to 16/5 and a rate of
16 in room air. He was extubated on day of life two to CPAP,
and was transect to nasal cannula by day of life four, and he
remained in nasal cannula of 200 cc, 25%, until day of life
eight. He currently remains in room air, with saturations
greater than 95%, and respiratory rate 40 to 50. He has not
had any apnea or bradycardia this hospitalization, and has
not received methylxanthine therapy.
2. Cardiovascular: On day of life three, the infant was
noted to have bradycardia with heart rate to the 60s.
Cardiology was consulted at that time, and an
electrocardiogram was done, which revealed a prolonged QTC
interval of .455. Otherwise the electrocardiogram showed
normal sinus rhythm. Two electrocardiograms
were repeated prior to discharge for prolonged QTC. The
electrocardiogram on [**10-3**] also revealed a normal
newborn tracing with a QTC of .423, electrocardiogram on
[**10-8**] revealed normal sinus rhythm with QTC of .441.
Cardiology recommends only follow up 1-2 months after discharge.
The infant's blood pressures have been stable, with mean blood
pressure of 37 to 45, with heart rate 100 to 130, no murmur.
3. Fluids, electrolytes and nutrition: The infant was
started on 60 cc/kg/day of D-10-W intravenously. He received
one D-10-W bolus for a D-stick of 48 initially, and was
nothing by mouth until day of life four, at which time he was
started on enteral feedings of a minimum of 60 cc/kg/day of
breast milk or Enfamil 20 calories/ounce. He was advanced to
a minimum of 80 cc/kg/day of breast milk at 20 calories/ounce
ad lib and has been taking approximately 148 cc/kg/day of
breast milk 20 calories/ounce and breast feeding. The infant
tolerated feeding advancement without difficulty. The most
recent electrolytes on day of life six were sodium 145,
chloride 110, potassium 4.3, TCO2 24, calcium 8.6, with an
ionized calcium of 1.24. The most recent weight is 2675
grams, head circumference 33.5, length 48 cm.
4. Gastrointestinal: Maximum bilirubin level of 13.2 with a
direct of 0.3 was on day of life five. The infant did not
receive phototherapy this hospitalization. The most recent
bilirubin on day of life seven was 10.8, with a direct of
0.3.
5. Hematology: The infant did not receive blood transfusion
this hospitalization. The most recent hematocrit on day of
delivery was 47.5%.
6. Infectious Disease: CBC and differential with blood
culture were drawn on admission. The white blood cell count
was 12.3, 32 polys, 1 band, 56 lymphs, 346,000 platelets.
The infant was also started on ampicillin and gentamicin at
that time, which was discontinued at 48 hours. The blood
cultures remain negative to date.
7. Neurology: The infant does not meet criteria for head
ultrasound.
8. Sensory: Hearing screening was performed with automated
auditory brain stem responses. The infant passed both ears.
Ophthalmology: The infant does not meet criteria for eye
examination.
9. Psychosocial: Parents are involved. [**Hospital1 346**] social worker can be reached at
[**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Former 34 week gestation male,
stable in room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**Hospital 9583**] Pediatrics
CARE RECOMMENDATIONS:
1. Feedings at discharge: Breast milk or Enfamil 20
calories/ounce, breast feeding ad lib, minimum 80 cc/kg/day.
2. Medications: None.
3. Car seat position screening was performed, infant passed.
4. State newborn screens were sent on [**10-3**] and
[**10-4**], results are pending.
5. Immunizations received: The infant received hepatitis B
vaccine on [**10-4**].
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
7. Follow-up appointments:
a. [**Hospital 9583**] Pediatrics within two days (Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 45542**]).
b. Cardiology Dr. [**Last Name (STitle) 45543**]/[**Location (un) 10123**] ([**Telephone/Fax (1) 37115**]) CH at 1-2 months.
DISCHARGE DIAGNOSIS:
1. Premature male, 34 weeks gestation
2. Status post respiratory distress syndrome
3. Status post rule out sepsis
4. Sinus bradycardia
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2165-10-9**] 03:33
T: [**2165-10-9**] 04:00
JOB#: [**Job Number **]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5972
} | Medical Text: Unit No: [**Numeric Identifier 64121**]
Admission Date: [**2179-7-14**]
Discharge Date: [**2179-7-29**]
Date of Birth: [**2100-10-28**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) 5586**] [**Known lastname 64122**] was a 78-year-old
man with a past medical history of diabetes,
hypercholesterolemia, hypertension, AAA repair and colon
cancer, who presented with fatigue and chest pain. He
initially presented to [**Hospital6 **], where he was
found to have atrial fibrillation and a non-ST elevation
myocardial infarction with a troponin I of 0.91 and a CK of
84. While at [**Hospital6 **] he developed recurrent
symptoms and was transferred to [**Hospital1 188**] for further care. Upon his arrival he was found to have
cardiogenic shock and was intubated and taken urgently for
cardiac catheterization.
PHYSICAL EXAMINATION: Initial vital signs were temperature
99.4, blood pressure 78/48, heart rate 119, respiratory rate
20. In general he was intubated and sedated. His pupils
were equal, round and reactive to light. He was lying flat
so jugular venous distention could not be evaluated. There
was no apparent goiter. His lungs were clear anteriorly. He
had a regular rhythm and rate with a normal S1 and S2. There
were no murmurs, rubs or gallops. The PMI was lateral. The
abdomen was soft and mildly distended with normal bowel
sounds. There was no guarding. His stool was OB positive.
Extremities were cool with dopplerable pulses. Neurological
exam was limited due to his sedation.
PERTINENT LABORATORY/RADIOLOGY/OTHER FINDINGS: His initial
ECG on [**2179-7-15**], showed sinus tachycardia at a rate of 110,
there was a late transition consistent with possible prior
anterior infarction, there was left axis deviation,
nonspecific ST-T wave changes. Cardiac catheterization was
performed on [**2179-7-14**]. This showed severe 3 vessel disease
with severe systolic and diastolic ventricular dysfunction.
An echocardiogram was performed on [**2179-7-15**]. This showed
severe left ventricular systolic dysfunction on a poor
quality study. A repeat echocardiogram was performed later
that day that confirmed left ventricular systolic dysfunction
and found no significant valvular dysfunction. He again went
for cardiac catheterization on [**2179-7-15**], during which he
had percutaneous intervention of the left main coronary
artery, the left anterior descending, the left circumflex and
a diagonal branch. A chest x-ray was performed on [**2179-7-15**]
which showed pulmonary edema and an intra-aortic balloon
pump. Another echocardiogram was performed on [**2179-7-16**],
which again showed severe systolic dysfunction, with no
significant valvular disease. On [**2179-7-21**] a CT of the
chest, abdomen and pelvis showed a left upper lobe mass
invading the left superior pulmonary vein, left iliac bone
metastasis and liver lesions, likely metastases, and
borderline thickening of the gallbladder.
HOSPITAL COURSE: Mr. [**Name14 (STitle) 64123**] initially presented with
cardiogenic shock in the setting of acute coronary syndrome.
He was intubated and taken to the cardiac catheterization
laboratory. Cardiac catheterization showed severe 3 vessel
disease. Cardiac surgery consultation was obtained, but it
was determined that he was not a good candidate for surgical
revascularization. He, therefore, went back to the cardiac
catheterization lab the next day for high-risk intervention
with placement of an intra-aortic balloon pump. Over the
next several days his cardiogenic shock improved and he was
weaned off the intra-aortic balloon pump and pressors,
however, he remained intubated due to hypoxia and congestive
heart failure. Pulmonary consultation was obtained. A CT of
the chest and abdomen was obtained for further evaluation and
demonstrated metastatic cancer. The decision was made to
treat him medically in consultation with his healthcare
proxy, however, his hypoxia failed to improve. On [**2184-7-26**]
there was a meeting with the family, the healthcare proxy and
the clinical team, and the decision was made to pursue
comfort measures only. He was subsequently extubated and
died on [**2179-7-29**] at 4:08 a.m. Autopsy was declined.
CONDITION ON DISCHARGE: Expired.
DISCHARGE STATUS: Expired.
DISCHARGE INSTRUCTIONS: Not applicable.
DIAGNOSES:
1. Congestive heart failure.
2. Acute myocardial infarction.
3. Metastatic cancer from a probable lung source.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
Dictated By:[**Last Name (NamePattern1) 64124**]
MEDQUIST36
D: [**2184-7-7**] 12:50:33
T: [**2184-7-7**] 13:38:15
Job#: [**Job Number 64125**]
ICD9 Codes: 2762, 5070, 4280, 0389, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5973
} | Medical Text: Admission Date: [**2164-10-23**] Discharge Date:
Date of Birth: [**2138-6-3**] Sex: M
Service:
ADDENDUM: Under the Infectious Disease section; of note, the
patient was found to have small bilateral pleural effusions,
right greater than left, as well as some right atelectasis.
The patient had an intermittent low-grade temperature during
the hospitalization which resolved at the time of discharge;
however, the patient was started on an oral course of
levofloxacin 500 mg p.o. q.d. and he was to complete a 10-day
course on [**11-3**], and was to continue this on discharge
until [**11-3**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 2396**]
MEDQUIST36
D: [**2164-10-30**] 14:10
T: [**2164-10-30**] 16:16
JOB#: [**Job Number 16916**]
(cclist)
ICD9 Codes: 2765, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5974
} | Medical Text: Admission Date: [**2164-6-15**] Discharge Date: [**2164-6-23**]
Date of Birth: [**2103-12-24**] Sex: M
Service: MEDICINE
Allergies:
bupropion
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 60 year old gentleman with a history of metastatic
esophageal adenocarcinoma (HER-2 positive), s/p esophagectomy,
s/p 2 cycles of cisplastin and 5-FU with last chemo on
[**2163-7-22**], currently with a J-tube, who presents with cough and
fever.
In brief, with regards to his metastatic esophageal cancer he
underwent esophagectomy in 9/[**2162**]. He subsequently was noted to
have metastatic disease to the brain for which he underwent a
craniotomy. He has had several anastomotic dilations for
stricture/dysphasia which have been complicated by aspiration
pneumonia. His last dilation was [**2164-4-2**]. This admission was
also complicated by a pnemonia with radiographic evidence of a
RLL opacity. He also underwent laparoscopic jejunostomy feeding
tube placement as well as biopsy of an esophago-gastric conduit
and bronchoscopy with bronchoalveolar lavage. Unfortunately the
esophago-gastric anastomosis biopsy revealed adenocarcinoma.
Since this discharge, he has had recurrent episodes of coughing
and increased sputum production. His tube feeds have been
decreased in an attempt to improve his symptoms w/ notable
decrease in the amount of regurgitated fluid.
For the past week, he has noted increase in cough and sputum
production. He has been increasingly tired. Today, a family
member took his vitals and noted HR 125 and RR 28 prompting
referral to the ED by his oncology fellow. He also felt
subjectively febrile. He reports always coughing and choking w/
eating. He denied abdominal pain, chills, diarrhea or
constipation, chest pain or palpitations or any other symptoms
that were concerning to him.
In the ED, initial VS were: 101.0 131 101/61 2 90% 3L. A chest
xray revealed a RLL opacity concerning for pna. He was given
cefepime and tylenol. A request for ICU admission was made in
setting of tachycardia and hypotension. He arrived in the MICU
where he was stabilized on BiPap and then transferred to the
floor.
Review of systems:
(+) Per HPI
(-) Denies chills, recent weight gain. Denies headache, sinus
tenderness, congestion. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
1) severe rheumatoid arthritis, previously on enbrel and now on
prednisone alone. History of multiple joint surgeries related to
RA.
2) atrial fibrillation s/p cardioversion [**2163-8-19**]
3) RLL PE in [**7-4**]
4) right axillary DVT [**2163-8-17**]
5) LUL PE in [**2164-1-17**] - while on coumadin. Now on enoxaparin.
.
Past Surgical History:
1) R forearm surgery
2) minimally invasive eosphagectomy [**2163-9-19**] & J-tube placement
3) s/p Esophagogastroduodenoscopy and dilation of a stricture
([**1-5**])
.
.
Onccologic History:
- [**2163-5-30**]: EGD with large circumferential mass at GE junction.
Biopsy showed adenocarcinoma.
- [**2163-5-31**]: CT abdomen/pelvis with distal esophageal mass and a 3
cm partially necrotic lymph node in the hepatogastric ligament.
EUS staging on [**6-6**] - Tx, N2, Mx. FNA of gastrohepatic node
positive for adenocarcinoma.
- [**2163-6-8**]: PET with FDG avid left paratracheal lymph node
immediately anterior to esophagus at level of aortic arch, 7 mm,
SUV max 4.5, multiple small (2-6 mm) pulmonary nodules too small
to fully characterize, and a large 2.9 cm lymph node in the
gastrohepatic ligament with SUV max 11.4. The primary distal
esophageal mass was also highly FDG avid.
- [**Date range (2) 6545**]: chemoradiation with cisplatin (75 mg/m2, D1
and D29) and 5-FU (1000 mg/m2/day D1-4, D29-32)
- [**Date range (1) 6546**]/11: admission for PE (RLL segmental) causing pleuritic
chest pain; therapeutic lovenox initiated
- [**Date range (3) 6547**]: admission with new atrial fibrillation and
acute right axillary DVT. CT showed improving PE. Cardioverted.
Therapeutic lovenox continued.
- [**2163-8-26**] PET/CT: Gastrohepatic and left paratracheal lymph nodes
now without FDG-avidity.
- [**2163-9-19**]: Dr. [**First Name (STitle) **] performed minimally invasive esophagectomy
showing pathologic complete response including 15 negative
nodes.
- [**2163-11-15**], [**2163-12-13**], [**2163-12-30**]: esophageal stricture dilation.
Port
removed on [**2163-12-13**] and J-tube removed on [**2163-12-30**].
- [**Date range (3) 6566**]: admission with aphasia. Brain MRI showed
solitary 1.9 cm left frontal lobe mass. CT torso with segmental
LUL PE (new since [**2163-10-26**]), stable 9 mm right hilar lymph nodes
and right upper lobe pulmonary nodules, no clear metastatic
disease. Resection of brain mass on [**2164-1-20**] ([**Doctor Last Name **]) showed
metastatic adenocarcinoma, CK7/CK20 positive, TTF-1 negative,
consistent with upper GI origin. HER-2 positive by FISH.
- [**2164-2-7**]: Cyberknife to resection cavity
- [**3-7**]: dilation of anastomotic stricture
- [**2164-3-27**]: CT chest with 7 mm RUL subpleural nodule (previously 5
mm) and new 7 mm LUL nodule, and increased right hilar and
mediastinal adenopathy (may be reactive)
- [**2164-4-2**]: J-tube placement, dilation of stricture, biopsy of
gastric conduit revealed adenocarcinoma
- [**5-4**] MRI brain: Marked decrease in enhancement at left frontal
resection site. No new lesion.
Social History:
- Tobacco: quit in [**2161**], 30-35 years 1ppd
- Alcohol: [**12-26**] cocktails every few weeks
- Illicits: negative
- Housing: lives w/ wife
- Employment: on disability for past 10 years related to RA,
former manager of bottling plant and [**Location (un) 6350**] [**Location 6351**].
- Family: wife, four children
.
Family History:
His mother and [**Name2 (NI) 1685**] sister have [**Name2 (NI) **]. There is no family
history of cancer. No clotting disorders in the family.
Physical Exam:
Vitals: 115 96% on 4L 103/63 99.0.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: There are significantly decreased breath sounds in the
right lower lung base. + egophony.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, his J-tube exit site is dressed w/ c/d/i.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS
[**2164-6-15**] 03:00PM BLOOD WBC-6.8 RBC-4.25* Hgb-10.4* Hct-33.6*
MCV-79* MCH-24.5* MCHC-31.0 RDW-16.7* Plt Ct-394
[**2164-6-15**] 03:00PM BLOOD Neuts-58 Bands-13* Lymphs-12* Monos-16*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2164-6-15**] 03:00PM BLOOD Glucose-120* UreaN-17 Creat-0.6 Na-137
K-3.7 Cl-97 HCO3-29 AnGap-15
[**2164-6-15**] 03:11PM BLOOD Lactate-3.1*
RELEVANT LABS
[**2164-6-16**] 04:09AM BLOOD WBC-6.4 RBC-4.00* Hgb-9.7* Hct-31.4*
MCV-79* MCH-24.3* MCHC-31.0 RDW-16.7* Plt Ct-397
[**2164-6-17**] 07:45AM BLOOD WBC-6.1 RBC-4.00* Hgb-9.7* Hct-31.2*
MCV-78* MCH-24.2* MCHC-31.0 RDW-17.0* Plt Ct-432
[**2164-6-18**] 07:40AM BLOOD WBC-6.3 RBC-4.24* Hgb-9.8* Hct-33.4*
MCV-79* MCH-23.2* MCHC-29.5* RDW-16.4* Plt Ct-504*
[**2164-6-19**] 06:06AM BLOOD WBC-7.7 RBC-4.26* Hgb-10.0* Hct-33.6*
MCV-79* MCH-23.5* MCHC-29.8* RDW-16.6* Plt Ct-534*
[**2164-6-20**] 06:32AM BLOOD WBC-10.4 RBC-4.70 Hgb-11.3* Hct-37.6*
MCV-80* MCH-24.0* MCHC-30.1* RDW-16.6* Plt Ct-532*
[**2164-6-21**] 06:35AM BLOOD WBC-9.5 RBC-3.97* Hgb-9.4* Hct-31.6*
MCV-80* MCH-23.7* MCHC-29.6* RDW-17.4* Plt Ct-468*
[**2164-6-22**] 06:55AM BLOOD WBC-13.2* RBC-4.28* Hgb-10.0* Hct-34.6*
MCV-81* MCH-23.4* MCHC-29.0* RDW-17.5* Plt Ct-459*
DISCHARGE LABS
[**2164-6-23**] 07:55AM BLOOD WBC-11.2* RBC-4.28* Hgb-10.1* Hct-34.1*
MCV-80* MCH-23.7* MCHC-29.7* RDW-17.6* Plt Ct-450*
PERTINENT MICRO/PATH
1. RESPIRATORY CULTURE (Final [**2164-6-23**]):
SPARSE GROWTH Commensal Respiratory Flora.
ALCALIGENES (ACHROMOBACTER) SPECIES. MODERATE GROWTH.
Cefepime >16 MCG/ML. MEROPENEM <= 1 MCG/ML.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ALCALIGENES (ACHROMOBACTER) SPECIES
|
AMIKACIN-------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>32 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=2 S
ACID FAST SMEAR (Final [**2164-6-20**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
2. [**2164-6-21**] 8:17 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2164-6-22**]**
C. difficile DNA amplification assay (Final [**2164-6-22**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
PERTINENT IMAGING
1. CXR ([**2164-6-15**])
IMPRESSION: There is continued opacification of the right lung
base, possibly reflecting a combination of pleural effusion with
atelectasis, though infection cannot be excluded. Small right
pleural effusion is unchanged.
2. VIDEO OROPHARYNGEAL SWALLOW ([**6-19**])
Single aspiration event with thin barium. For details, please
see report by the speech and swallow division on OMR.
3. Upper GI Series ([**6-19**])
No evidence of fistula formation.
4. CT Abdomen and Pelvis ([**6-20**])
No bowel obstruction. No reflux of contrast administered via
the J-tube
into the duodenum or proximal jejunum. No CT explanation for
patient's
presentation.
Bilateral pleural effusions, increased on the right since
[**2164-1-17**]. The
small left effusion is unchanged.
Brief Hospital Course:
This is a 60 year old gentleman with a history of metastatic
esophageal adenocarcinoma (HER-2 positive), s/p esophagectomy,
s/p 2 cycles of cisplastin and 5-FU with last chemo on
[**2163-7-22**], currently with a J-tube, who presents with cough and
fever.
.
Aspiration pneumonia: The initial differential of his cough
included aspiration pna vs pneumonitis vs fistula vs post
obstructive pna. Pt reported chronic coughing/choking w/ eating
suggesting aspiration. A possible fistula was suggested during
recent endoscopy ([**3-/2163**]) which was covered by metal stent.
Given ulcerated and friable esophagus noted, new or recurrent
fistula possible. Patient was initially started on Ceftriaxone
and Metronidazole (day 1 = [**6-15**]) IV to cover for aspiration
pneumonia. CXR showed RLL opacity but there was a question of
chronicity as this has been seen on prior imaging. GI was
consulted in regards to a possible T-E fistula. He had a
swallow study as well as upper GI series and CT abdomen, none of
which saw evidence of a fistula. There was some concern for
reflux of his tube feeds exacerbating his risk for aspiration,
however the CT abdomen showed no evidence of reflux of tube
feeds into the esophagus. The swallow study showed one
aspiration event with thin liquids and new PO recommendations
were made. Nutrition was also consulted and made
recommendations re: tube feeds. See below for changes made to
diet and tube feeds. The patient was clinically well after
being placed on I.V. antibiotics. The GI service as well as
thoracic surgery saw him and did not feel he would benefit from
further aggressive intervention. Given his past history of TB,
he was ruled out via induced sputums. One of these sputums grew
gram negative rods, so he was switched to Zosyn. The organism
was identified as Achromobacter. He was on IV antibiotics for 7
days and transitioned to Levofloxacin based on sensitivities.
He will complete 7 days of Levofloxacin for a total of a 14 day
course.
.
Metastatic Esophageal Adenocarcinoma (HER-2 positive):
Metastatic to brain with extention to gastric-esophageal
anastamosis. S/p chemoradiation, partial esophagectomy,
craniomety and multiple anastomotic dilations for
stricture/dysphasia symptoms. Due to have CT torso in [**Month (only) 205**] with
anticipated discussion for further surgical intervention versus
restarting chemo. Plan as per Dr. [**Last Name (STitle) **]. Patient will have
appointment scheduled for within 1-2 weeks.
.
Atrial fibrillation: Sinus Rhythm. Patient was on amiodarone 200
[**Hospital1 **] as an outpatient as well as metoprolol 25 [**Hospital1 **]. During this
hospitalization, he had brief episodes of afib with RVR to the
120s/130s. We uptitrated his metoprolol to 50 [**Hospital1 **] and these
episodes resolved. He will f/u with Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] of [**Company 191**]
for further management.
.
Recurrent DVT/PE: H/o RLL PE, right axillary DVT and LUL PE. He
was continued on lovenox.
.
Hypothyroid: Continued levothyroxine daily.
.
Anxiety: Continued ativan 0.5 mg qHS for insomnia.
.
Rheumatoid Arthritis: Continued prednisone, oxycodone and
sennosides.
TRANSITIONAL ISSUES
Patient has follow-ups with [**Company 191**] PCP as well as his Oncologist,
Dr. [**Last Name (STitle) **]. His risk for readmission is significant given
his morbidities relating to esophageal cancer treatment.
Patient was satisfied with the new swallow recommendations as
well as new tube feed formula. He is a poor candidate for more
invasive surgical interventions at this time and this was
explained to him by GI as well as Thoracic surgery.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6549**] O2 provider
Discharge Diagnosis:
Primary Diagnosis: aspiration pneumonia
Secondary Diagnosis: esophageal cancer
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 6352**],
It was a pleasure taking care of you at [**Hospital1 18**]. You presented to
the hospital because of cough and difficulty breathing secondary
to pneumonia. You were admitted and placed on broad spectrum
antibiotics. You will need to continue antibiotics when you
leave. We did imaging to rule out concerning pathology in your
esophagus as well as at the site of your J-tube. You were
evaluated by Nutrition Services as well as Speech Therapy who
recommended some changes to your tube feeds as well as
swallowing technique.
Please make the following changes to your medications:
- Please STOP Metoprolol Tartrate 25mg twice a day
- Please START Metoprolol Tartrate 50 mg, take twice a day,
until your next primary care physician [**Name Initial (PRE) 648**].
- Please START Levofloxacin 750mg by mouth once daily for 7 more
days starting today, [**6-23**], last day is [**2164-6-29**]
Please continue with your other home medications as prescribed.
Followup Instructions:
Please follow-up with the following appointments:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2164-7-4**] at 12:30 PM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] in the [**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Notes: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: Hematology/ Oncology
Name: Dr. [**Known firstname **] [**Last Name (NamePattern1) **]
When: Dr. [**Last Name (STitle) 6567**] office is working on a follow up apointment
for you in [**9-8**] days after your hospital discharge. You will be
called by the office with your appointment date and time. If you
have not heard from the office in 2 business days please call
the office number listed below.
Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 6568**]
Department: RHEUMATOLOGY
When: TUESDAY [**2164-7-3**] at 1:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
Completed by:[**2164-6-25**]
ICD9 Codes: 5070, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5975
} | Medical Text: Admission Date: [**2158-5-4**] Discharge Date: [**2158-5-8**]
Date of Birth: [**2102-7-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nsaids / Sulfa (Sulfonamide Antibiotics) / Peanut
/ Shellfish / Bactrim
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Hypoxia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
55 y/o F PMH fibromyalgia, osteoarthritis, HTN, DM who presents
with hypoxia. Patient presented to pre-op eval for right knee
replacement and found to have O2 sat 86% consequently referred
to ED. On arrival to ED VS T 96.7, BP 115/49, 117, 22, 67% RA.
100% NRB and 92-95% 4L. HR 95-112. Afebrile. Patient given 125mg
solumedrol IV, tylenol 1 gm po, Azithromycin 500 mg, Duonebs x
3, Oxycodone 30 mg po x 2, Lasix 20 mg IV, Vancomycin 1 gm IV.
Patient admitted to the ICU for close monitoring.
.
Patient reports progressive SOB for the last several months -
with minimal exertion and at rest. Reports orthopnea, PND
("gasping for air") for the past several months and lower
extremity edema for the last 1 month. Occasionally associated
chest pain. Patient recently treated for bronchitis and finished
levaquin 4 days ago - no fevers since completing ABx. No
worsened cough. Patient denies recent sick contacts. Denies
recent travel but is immobile at baseline. Extensive review of
systems revealed bloody nose for the past 1 month at night with
hemoptysis. Patient reports that oxygen level has been reported
to be low at prior doctor's appointment. She had a sleep study
in [**2127**] - does not sleep well and has daytime sleepiness.
Past Medical History:
- Fibromyalgia
- Lumbar disc degeneration
- Osteoarthritis
- Obesity
- Chronic Opiate Use and Chronic pain
- HTN
- Pre-diabetic
- Depression, Anxiety, PTSD
- GERD
Social History:
Lives with partner. Non-[**Name2 (NI) 1818**], non-drinker. No IV drug use.
Family History:
Mother passed away age 80 - breast cancer. Father age 80 - liver
and pancreatic cancer.
Physical Exam:
Upon admission:
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 112 (107 - 119) bpm
BP: 130/92(99) {130/74(87) - 148/92(100)} mmHg
RR: 24 (12 - 24) insp/min
SpO2: 88%
Heart rhythm: ST (Sinus Tachycardia)
GEN: obese, slow speech but alert and oriented x 3.
HEENT: PERRL, EOMI, anicteric, MMM, unable to assess jvd
RESP: Decreased breath sounds throughout due to body habitus.
CV: RR, distant heart sounds due to body habitus.
ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: + 3 pitting edema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
.
At discharge:
Vitals: 98.8 97.9 108/61 109 20 95% on 2L
I/O: 0/[**Telephone/Fax (1) 26490**]/3100
FS: 125-166-119-140
General: Alert, oriented, no acute distress, morbidly obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD at 8cm, no LAD, no thyromegaly
Lungs: Bibasilar crackles
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: +BS, soft, non-tender, non-distended, no rebound
tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, 3+ bilateral LE edema to
thighs
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
Labs upon admission:
[**2158-5-4**] 10:00AM BLOOD WBC-6.6 RBC-4.01* Hgb-13.1 Hct-39.3
MCV-98 MCH-32.5* MCHC-33.2 RDW-14.6 Plt Ct-211
[**2158-5-4**] 11:14AM BLOOD PT-12.2 INR(PT)-1.0
[**2158-5-4**] 10:00AM BLOOD UreaN-9 Creat-0.7 Na-142 K-4.0 Cl-100
HCO3-34* AnGap-12
[**2158-5-4**] 10:00AM BLOOD ALT-51* AST-41* AlkPhos-111* TotBili-0.3
[**2158-5-4**] 10:00AM BLOOD proBNP-243*
[**2158-5-4**] 11:14AM BLOOD cTropnT-<0.01
[**2158-5-5**] 04:55AM BLOOD CK-MB-1 cTropnT-<0.01
[**2158-5-4**] 10:00AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.2
[**2158-5-4**] 11:35AM BLOOD Type-ART pO2-215* pCO2-60* pH-7.36
calTCO2-35* Base XS-6 Intubat-NOT INTUBA
[**2158-5-4**] 03:04PM BLOOD Type-ART pO2-70* pCO2-65* pH-7.37
calTCO2-39* Base XS-8
Labs prior to discharge:
[**2158-5-8**] 08:25AM BLOOD WBC-6.9 RBC-4.44 Hgb-14.3 Hct-43.7 MCV-98
MCH-32.1* MCHC-32.7 RDW-14.3 Plt Ct-282
[**2158-5-8**] 08:25AM BLOOD Glucose-111* UreaN-23* Creat-1.0 Na-145
K-4.7 Cl-97 HCO3-38* AnGap-15
[**2158-5-5**] 04:55AM BLOOD CK(CPK)-50
[**2158-5-4**] 10:00AM BLOOD ALT-51* AST-41* AlkPhos-111* TotBili-0.3
[**2158-5-5**] 04:55AM BLOOD CK-MB-1 cTropnT-<0.01
[**2158-5-4**] 11:14AM BLOOD cTropnT-<0.01
[**2158-5-4**] 10:00AM BLOOD proBNP-243*
[**2158-5-5**] 04:55AM BLOOD TSH-0.77
[**2158-5-8**] 12:49PM BLOOD Type-ART Temp-36.7 pO2-59* pCO2-55*
pH-7.42 calTCO2-37* Base XS-8 Intubat-NOT INTUBA
Micro:
[**2158-5-4**] blood culture negative
[**2158-5-4**] MRSA screen negative
Imaging:
[**2158-5-4**] CXR: The lung volumes are low. Hazy perihilar opacities
are suggestive of mild pulmonary edema. Bibasilar opacities are
likely due to atelectasis. No definite pleural effusion is
idnetified. The visualized cardiomediastinal and hilar contours
are within normal limits.
IMPRESSION: 1. New mild pulmonary edema. 2. Bibasilar
opacities, probable atelectasis.
[**2158-5-4**] CTA: 1. No evidence of pulmonary embolism. 2.
Bilateral ground-glass opacities, possibly related to areas of
edema: bilateral subsegmental atelectasis as well as areas of
bilateral ground-glass opacity, possibly edema. 3. Hepatic
steatosis.
[**2158-5-4**] EKG: sinus tachycardia at 115
[**2158-5-5**] CXR: In comparison with the study of [**5-4**], there has
been some improvement in the degree of pulmonary edema,
especially since this is a AP rather than PA view. Continued
enlargement of the cardiac silhouette. Mild atelectatic changes
at the bases.
[**2158-5-5**] TTE: Suboptimal image quality. The left atrium is normal
in size. 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. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. with normal
free wall contractility. 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.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. No aortic
regurgitation is seen. Tricuspid regurgitation is present but
cannot be quantified. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
55 yo morbidly obese female with history of fibromyalgia,
osteoarthritis, HTN, and DM presented to the ED with hypoxemia,
likely a combination of underlying hypoventilation likely
secondary to obesity and narcotics with a component of diastolic
heart failure.
ICU Course: Admitted for hypoxia. ABG consistent with chronic
hypoventilation. CTA negative for PE, but with evidence of
pulmonary edema. Working diagnosis was pulmonary edema
(hypoxia, peripheral edema, orthopnea) in setting of chronic
hypoventilation of obesity. She was diuresed with IV Furosemide
and negative 4L in 24 hours. Oxygen saturation improved to
92-94% on 3-4L by NC. No antibiotics were given on arrival to
ICU as felt likely to not have pneumonia. Echo was done at
bedside that showed....... Additionally, she was noted to be on
multiple sedating medications for chronic pain/depression.
Doses were confirmed with pharmacy. Her large doses of sedating
meds at night likely contributing to chronic retention.
Medical floor course:
# Hypoxemia: Likely combination of decompensated heart failure,
and hypoventilation from narcotics and obesity. Diuresed well to
lasix, with improvement in SOB and hypoxemia. She will benefit
from an outpatient sleep study.
# Diastolic heart failure: Signs and symptoms of acute on
potentially undiagnosed chronic dHF with an mildly elevated BNP
which is often underestimated in the setting of obesity. She
was diuresed with lasix boluses. Her beta blocker was
continued, and an ACE inhibitor was initiated.
# Tachycardia: Stable for patient given prior office notes. CTA
negative for PE. Most likely a result of chronic pain. Improved
with diuresis.
# Fibromyalgia/Chronic pain: She was continued on her home dose
of Cymbalta, Oxycontin, and Oxycodone.
# Hypertension: Normotensive during admission. A clonidine
taper was initiated while in house and will be continued as an
outpatient. She was started on an ACE inhibitor which was
uptitrated as the clonidine was decreased.
# Diabetes: A1C 6.4 in 3/[**2158**]. Held Metformin while inpatient
and in setting of recent CTA. Sugars well controlled, did not
required insulin coverage.
# Depression: Mood stable and appropriate. Continued on home
duloxetine, trazodone, diazepam, and keppra.
Medications on Admission:
Medications according to pharmacy: ([**Location (un) 2274**] list not up to date)
- DIAZEPAM 5 MG TAB 3 tablets [**Hospital1 **] ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 26491**])
- CLONIDINE 0.2 MG TAB 2 tablets by mouth at bedtime
- IRON, FERROUS SULFATE, ORAL
- MULTIVITAMIN ORAL
- Acetaminophen (TYLENOL) 325 mg Oral Tablet
- Trazodone 100 mg Oral Tablet
- Duloxetine (CYMBALTA) 150 mg daily ([**Last Name (NamePattern1) 26492**])
- Keppra 500 mg qhs
- Prochlorperazine Maleate 10 mg Oral Tablet 1 tablet two times
daily as needed for nausea - confirmed
- Metformin (GLUCOPHAGE XR) 500 mg Oral Tablet Extended Release
24 hr (2 tabs)
- Oxycodone 30 mg Oral Tablet [**1-15**] po Q4-6 hours for breakthrough
pain, no more than 6 per day
- Oxycodone (OXYCONTIN) 80 mg Oral Tablet Extended Release 12 hr
1 po Q 8 hours
- Lasix 10 mg daily (per patient not taking)
Discharge Medications:
1. diazepam 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
2. clonidine 0.1 mg Tablet Sig: see below Tablet PO HS (at
bedtime): Take 0.3mg tonight on [**5-8**], then 0.2mg for the next
three days ([**Date range (1) 11757**]), then 0.1 for the next three days
(4/29-4/31), then STOP.
3. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Five (5)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Per Dr. [**Last Name (STitle) 26492**].
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) as needed for nausea.
10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
11. oxycodone 30 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do not take take more than 6 hours per
day. Do not drive while on this medication.
12. oxycodone 80 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every eight (8) hours: Do not
drive while taking this medication.
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Home oxygen
Home oxygen for sats >90%. Pt 85% on RA, 93% on 1L, and 96% on
2L. A handwritten script was given to the oxygen delivery
person.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hypoxemia, Diastolic heart failure
Secondary Diagnosis: Obesity, Osteoarthritis, Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Weight at discharge: 290.6 lbs
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for low oxygen levels. This is most likely a
result of lower than normal respiratory rates, which are likely
a result of being overweight, taking large doses of narcotics,
and possibly sleep apnea, as we discussed. However, a sleep
study would be required to confirm this, and you should discuss
consultation with a pulmonary (lung) doctor with your primary
care doctor.
In addition, you have a component of diastolic heart failure
where your heart is stiff and does not pump as effectively.
This results in fluid accumulation. You were given diuretics to
help remove some of this fluid.
The following changes were made to your medication list:
START lasix 40mg daily
START lisinopril 10mg daily
DECREASE clonidine: Take 0.3mg tonight on [**5-8**], then 0.2mg for
the next three days ([**Date range (1) 11757**]), then 0.1 for the next three
days (4/29-4/31), then STOP
Followup Instructions:
The following appointment was made for you:
Name: [**Last Name (LF) 26493**],[**First Name3 (LF) 26494**]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Friday [**2158-5-12**] 10:10am
You need to establish care with a Pulmonologist (lung doctor)
and see them within 2 weeks. Please discuss this with your
primary care physician, [**Name10 (NameIs) **] she will refer you to a physician.
ICD9 Codes: 4280, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5976
} | Medical Text: Admission Date: [**2141-3-21**] Discharge Date: [**2141-3-31**]
Date of Birth: [**2061-12-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Abdominal pain and generalized malaise
Major Surgical or Invasive Procedure:
CT guided abdominal drain placement [**2141-3-22**], [**2141-3-27**], and [**2141-3-28**]
History of Present Illness:
79 y/o male 3 weeks postop from open
aortobifem c/b graft thrombosis requiring emergent embolectomy.
Has been anticoagulated since that time. Now w/ 3-4d of
progressive weakness, 1 day of abdominal pain and
"discoloration"
of his abdomen. Son measured low blood pressures at home.
Of note patient with bacteremia with B.frag [**3-12**] 2of4 bottles.
Past Medical History:
PMHx: DM2, Aortic stenosis (mild per [**8-31**] echo), Hypertension,
Peripheral Artery Disease,
myelodysplasia/leukopenia/thrombocytopenia
PSHx: [**2141-3-2**] Open abdominal aortic aneurysm repair
with aortobifemoral bypass using a Dacron 18 x 9 bifurcated
graft. [**2141-3-9**] Bilateral femoral exploration and iliofemoral
embolectomy.
Social History:
Lives with wife, denies ETOH or drug use.
Family History:
N/C
Physical Exam:
Vital Signs: Temp: 98.8 RR: 28 Pulse: 75 BP: 91/55
Neuro/Psych: NAD.
Heart: Regular rate and rhythm.
Lungs: Clear, abnormal: Tachypnea.
Gastrointestinal: Abnormal: Distended, mildly tender diffusely,
no rebound or guarding, anasarca.
Extremities: Abnormal: Cool LE bilaterally, pale, 4s cap refill,
2+b/l pitting LE edema.
Brief Hospital Course:
[**2141-3-21**], the patient was admitted via ED to the CVICU for c/o
generalized malaise, and abdominal pain, CT abdomen showed
presence of massive right retroperitoneal abscess. Patient
started on broad spectrum antibiotics
(Zosyn/Vanco/Cipro/Falgyl). Patient was hypotensive, and anuric,
given fluids and started on Phynelephrine drip for BP support.
Started on Lasix IV BID, started diuresing. Patient was referred
to interventional radiology for retroperitoneal abcess drainage.
Patient made NPO overnight for procedure in the morning.
[**2141-3-22**], patient was lined for hemodynamic monitoring. General
surgery consulted-recommended IR drainage of RP abcess. Central
line was placed, started TPN, the patient was given FFP and
Vitamin K to reverse INR in preparation for IR procedure. The
patient underwent CT guided retroperitoneal abcess drainage and
drain placement, returned to the CVICU post procedure. Patient
was kept NPO. Started on Heparin drip. Continued on antibiotics,
IV Lasix, and on RISS for glycemic control.
[**2141-3-23**], noted to have right UE swelling, US was negative for
DVT. Patient remained in the CVICU. Remains on quadruple
antibiotics, Neo and heparin drips. Kept NPO, IV hydrated.
Continued antibiotics, IV Lasix, and on RISS for glycemic
control.
[**Date range (1) 76386**], VSS, off Neo drip. Remains on Heparin drip. Blood
cultures sent. Kept NPO on TPN. Patient was transfused 1 unit
PRBCs for low HCT. Transferred to [**Hospital Ward Name 121**] 5 VICU. Continued
antibiotics, IV Lasix, and on RISS for glycemic control.
Physical therapy consult placed.
[**2141-3-27**], VSS overnight. Repeat abdominal CT was done showing
Fluid collection anterior to the iliac bifurcation with
air-fluid level, slightly decreased from previous study.
Retroperitoneal fluid collection and primarily in the posterior
pararenal space now demonstrates no drain and appears larger
than previous study. An additional fluid collection tracking
laterally and anteriorly within the abdominal wall is markedly
increased and portions of it cannot be separated from colonic
wall. Both of these fluid collections would be amenable to
drainage. Patient was prepped and consented, under CT guidance a
10 French drainage catheter into right lower
abdominal abscess. The previous drainage catheter, which had
been dislodged with tip in right anterolateral abdominal wall,
was removed. Patient tolerated the procedure well, transferred
back to floor. Continued antibiotics, IV Lasix, and on RISS for
glycemic control
[**2141-3-28**], patient had an episode of BP drop below 90's, was given
Albumin w/ good BP response. Heparin drip was held for
anticipated CT w/ possible drain placement. Patient had another
abdominal CT, after which, patient was prpped and cosnented and
under CT guidance, had successful insertion of percutaneous
catheter into abscess in right anterior abdomen. Heparin resumed
post procedure and dosed with Coumadin. Continued antibiotics,
IV Lasix, and on RISS for glycemic control. Cultures from first
abcess drainage came back positive for VRE, started on
Linezolid. ID consulted- recommended to d/c Linezolid, switch to
Daptomycin and Zosyn, continued with Cipro and Flagyl.
[**Date range (1) 76387**], patient's vital signs stable. Started on clears then
advanced to regular diet which was well tolerated. Cipro and
Flagyl were discontinued per ID recommendations. Physical
therapy evaluated patient and recommended rehab placement, rehab
screening started. PICC line was placed in anticipation for
longterm IV antibiotic therapy. IJ central line, A-line and
foley were discontinued. Patient was transfused 2 units of PRBCs
for low HCT, w/ appropraite post transfusion HCT rise. Continued
IV lasix for diuresis, repleted electrolytes daily. 2
retroperitoneal drains remained in place and draining thick
creamy material. Heparin drip continued while being dosed with
Coumadin, on [**3-31**] INR was 2.2, Heparin drip was d/c'd. Physical
therapy continued to work with patient while awaiting rehab bed.
Home meds were resumed.
Discharged to rehab on Daptomycin and Zosyn, to FU w/ Infectious
Disease as planned to plan further antibiotic therapy, weekly
labs will be sent to them as well.
-Retroperitoneal drains remain in place as well, will be
re-evaluated by general surgery on FU who will plan removal of
drains. Patient will need abdominal CT prior to this follow-up
visit.
-Patient discharged on longterm [**Hospital **] rehab will continue to
monitor INR (goal 2-5-3.5) unitl dose and INR is stable, should
defer to PCP for further management.
-Patient will FU with Dr. [**Last Name (STitle) 1391**] as planned.
Details for all these follow ups were provided to patient and to
rehab upon discharge.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
3. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
4. Outpatient Lab Work
1. INR three times a week, until goal of 2.5-3.5 is attained
2. Weekly Chem 10, CBC with diff, Sed rate, CRP. Fax/call in
results to Infectious Disease ([**Hospital1 18**]): Fax: :([**Telephone/Fax (1) 1353**]
Attention: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**]
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Regular Insulin Sliding Scale Q6h
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units
120-159 mg/dL 2 Units
160-199 mg/dL 4 Units
200-239 mg/dL 6 Units
240-279 mg/dL 8 Units
280-319 mg/dL 10 Units
> 320 mg/dL Notify M.D.
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous every 6-8 hours as needed for line flush: and PRN.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
9. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Goal INR 2.5-3.5.
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Actoplus MET 15-850 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. Diclofenac Sodium 75 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Retroperitoneal abcesses related to ruptured appendix s/p
multiple CT assisted drain placements, ID to follow, on longterm
ABX
Ruptured appendix-on antibiotics, general surgery to follow
Anemia-myelodysplasia/leukopenia/thrombocytopenia- acute related
to infection, frequent phlebotomy, hemodilution and bone marrow
supression from medications
History of:
-DM2
-AS (mild per [**8-31**] echo)
-HTN
-PAD
-myelodysplasia/leukopenia/thrombocytopenia, HIT negative [**2-/2141**]
PSH: Aortobifem for AAA [**2141-3-2**], Graft thromboembolectomy
[**2141-3-9**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory as tolerated- requires assistance.
Discharge Instructions:
[**Hospital1 69**]
Discharge Instructions
- You were admitted for abdominal pain, CAT scan showed that you
had retro peritoneal abcesses that were most likely related to
ruptured appendix,
- Drains were placed in your abdomen to drain the abcesses,
these will stay until the drainage stops, the drains will be
removed by the General Surgery team or possibly in the
interventional radiology,
- You were treated with intravenous antibiotics, you will be on
these antibiotics for a long time, you will follow-up with the
infectious disease department, to determine when the antibiotics
will be stopped, and possibly switch to oral antibiotics,
ACTVITY:
- walk/out of bed as tolerated,
- you may shower, no tub baths.
Diet:
- continue your regular diet as tolerated
Medications:
- You were started on a blood thinner called Coumadin,
- You will need blood tests to determine the dose of Coumadin
until the level (INR is stable at goal)
- You will also be on longterm antibiotics for the infection,
the infectious disease doctors [**Name5 (PTitle) **] determine [**Name5 (PTitle) **] long you will
need the antibiotics.
Labs:
- You will need at least three times a weeks INR until your
Coumadin dose is stable with a therapeutic level INR.
- While you are on antibiotcs you will need weekly labs (CBC,
sed rate, Chem 10, CRP), results to be sent to the infectious
disease department at [**Hospital1 18**] c/o Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**].
Follow up:
1. Infectious Disease: Dr. [**Last Name (STitle) 4020**]
2. Vascular Surgery: Dr. [**Last Name (STitle) 1391**]
3. General Surgery: Dr. [**Last Name (STitle) **]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2141-5-31**] 3:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2141-5-31**]
3:30
ID: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**] Phone:([**Telephone/Fax (1) 4170**] Fax:([**Telephone/Fax (1) 10739**] Date/Time: [**2141-4-28**] 11:00 AM
Location: [**Last Name (NamePattern1) **]., Basement, [**Hospital Unit Name **],
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 3201**]
Date/Time:[**2141-4-21**] 1:30
Will need abdominal CT prior to this visit.
ICD9 Codes: 5849, 5119, 2859, 4241, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5977
} | Medical Text: Admission Date: [**2182-4-12**] Discharge Date: [**2182-4-23**]
Date of Birth: [**2100-2-23**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Dust & Pollen Filter Mask /
Hydralazine / Cyclophosphamide
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGD
Blood Transfusion
History of Present Illness:
82yo F with h/o renal artery stenosis, CKD stage III, pAF on
coumadin presents with BRBPR X 3 yesterday. Patient presented to
[**Hospital1 18**] about 1 month ago with increased creatinine to 3 (from
1.6). A workup including renal biopsy revealed pauci-immune
P-ANCA positive glomerulonephritis thought secondary to
hydralazine. She was started on prednisone and cyclophosphamide
at that point.
In addition, according to the patient and records from [**Hospital **] she was also recently admitted to [**Hospital3 **] after a
collapse one month ago. She was brought in and found to have AF
with RVR. Was started on dilt and metoprolol with reportedly
good control. Further workup there included an EGD and
colonoscopy which revealed gastric ulcers and polyps as well as
candidiasis. She received 2units pRBCs and her hct came up to
30. While there she was noted to be neutropenic. They thought
this was possibly medication related. Cyclophosphamide, bactrim,
and fluconazole were discontinued. She completed a course of
caspofungin and a TTE was negative for vegetations. Her WBC
count came up. She was discharged to [**Hospital3 **].
Today was feeling weak and tired and then had 3 episodes of
BRBPR so decided to come to Ed. Presented to ED in AF with RVR
to 160s. Received 10mg Iv Dilt with improvement in rate to high
90s/100. Received then 30mg PO dilt. Stable HRs since. Also
received 5mg IV metoprolol.
Initial VS: 97.8 137AF 111/78 16 99. No N/V/Abd pain. Just feels
tired. Rectal exam revealed guaiac positive dark stool. Received
IVF and 40mg IV protonix. Hct in ED is 27 consistent with
baseline (25-30) here at [**Hospital1 18**]. Were going to do NGL but decided
not to because didn't want her to go back into AF with RVR. GI
called in Ed and will see her on the floor.
.
On the floor, patient complained of being sick of being in the
hospital and dry mouth. Otherwise densies fevers, chills,
abdominal pain, diarrhea, constipation, nausea, and vomiting.
Has had some weight loss worked up in the past and possibly
related to depression (per the patient) after her friend died
recently. Complained of occasional flank pain at biopsy site and
a developing bed sore. Rest of ROS negative including no CP,
palps, sob, dysuria.
.
Past Medical History:
Past Medical History:
RAS, HTN
CKD III, baseline GFR~30 with Cr 1.6
paroxysmal AFIB on sotalol for 2 yrs and coumadin
Anemia of CKD
Nephrolithiasis (prior oxalate stone)
s/p appy, chole, and tubal ligation
Social History:
Lives alone, independent for ADLS, family lives in the area.
Denies ETOH, tobacco, and illicits
Family History:
HTN, colon CA
No DMII, no heritable kidney dz
Physical Exam:
Vitals: T: 96.2 BP:137/83 P:110 R:18 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Rectal: external hemorrhoids, good rectal tone, grossly bloody
stool, guaiac positive
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2182-4-12**] 07:25PM HCT-30.8*#
[**2182-4-12**] 07:25PM PT-20.4* PTT-26.0 INR(PT)-1.9*
[**2182-4-12**] 09:26AM GLUCOSE-81 UREA N-69* CREAT-2.2* SODIUM-143
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
[**2182-4-12**] 09:26AM CALCIUM-8.3* PHOSPHATE-4.4 MAGNESIUM-1.7
[**2182-4-12**] 09:26AM PT-25.1* PTT-27.0 INR(PT)-2.4*
[**2182-4-12**] 09:25AM HCT-24.0*
[**2182-4-12**] 05:30AM GLUCOSE-106* UREA N-73* CREAT-2.2*#
SODIUM-143 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-17
[**2182-4-12**] 05:30AM estGFR-Using this
[**2182-4-12**] 05:30AM cTropnT-0.01
[**2182-4-12**] 05:30AM WBC-7.2 RBC-3.08* HGB-8.9* HCT-27.3* MCV-89
MCH-28.8 MCHC-32.6 RDW-18.3*
[**2182-4-12**] 05:30AM NEUTS-80.7* LYMPHS-15.4* MONOS-3.5 EOS-0.1
BASOS-0.3
[**2182-4-12**] 05:30AM PLT COUNT-229
[**2182-4-12**] 05:30AM PT-22.9* PTT-25.3 INR(PT)-2.2*
[**2182-4-13**] 02:48AM BLOOD WBC-6.1 RBC-3.61* Hgb-10.6* Hct-31.0*
MCV-86 MCH-29.4 MCHC-34.2 RDW-18.4* Plt Ct-167
[**2182-4-14**] 07:53AM BLOOD WBC-7.1 RBC-3.64* Hgb-11.2* Hct-31.6*
MCV-87 MCH-30.7 MCHC-35.4* RDW-19.1* Plt Ct-146*
[**2182-4-15**] 06:20AM BLOOD WBC-7.4 RBC-3.66* Hgb-10.5* Hct-32.3*
MCV-88 MCH-28.7 MCHC-32.6 RDW-18.9* Plt Ct-131*
[**2182-4-16**] 06:25AM BLOOD WBC-8.4 RBC-3.88* Hgb-10.8* Hct-34.5*
MCV-89 MCH-27.9 MCHC-31.4 RDW-17.9* Plt Ct-145*
[**2182-4-12**] 07:25PM BLOOD PT-20.4* PTT-26.0 INR(PT)-1.9*
[**2182-4-13**] 02:48AM BLOOD PT-18.4* PTT-25.5 INR(PT)-1.7*
[**2182-4-14**] 07:53AM BLOOD PT-12.9 PTT-23.5 INR(PT)-1.1
[**2182-4-14**] 07:53AM BLOOD Glucose-97 UreaN-53* Creat-2.2* Na-142
K-3.7 Cl-102 HCO3-29 AnGap-15
[**2182-4-15**] 04:40PM BLOOD Glucose-165* UreaN-38* Creat-2.1* Na-142
K-4.2 Cl-106 HCO3-24 AnGap-16
[**2182-4-16**] 06:25AM BLOOD Glucose-159* UreaN-35* Creat-2.1* Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
[**2182-4-12**] 05:23PM BLOOD ANCA-POSITIVE*
Brief Hospital Course:
82yo F with h/o PUD and CKD with recent acute renal failure from
hydralazine induced pauci-immune glomerulonephritis admitted
with BRBPR and atrial fibrillation with RVR.
.
# GIB: Given significant orthostasis, hct down to 24 (baseline
30) and history of PUD, initially concerned about UGIB. NG
lavage was negative which was reassuring. She was given 2u pRBC
with stable blood counts and hemodynamics. She had an EGD on
[**4-13**] without e/o active bleeding. Per GI likely LGIB and will
need c-scope sometime during this admission. She was also given
2u FFP given coagulopathy and concern for GIB and need for
endoscopy. Bleeding ceased, however, colonoscopy deferred
secondary to difficult to control AFib with RVR. She should
follow-up as an outpatient for colonscopy.
.
# AF with RVR: She had been on sotolol for several years until
her recent admission to [**Hospital1 18**] when this was discontinued in the
setting of her worsening renal failure. She was noted to have
AF with RVR to 140s. Initially felt to be worsened by volume
depletion with GIB. However, despite blood products, she
remained tachycardic and thus nodal agents were resumed.
Anticoagulation was held in acute setting, with coagulopathy
reversed in the setting of GIB. She was uptitrated on her PO
regimen to Metoprolol 50mg TID and Diltiazem 30mg QID which kept
her HR in reasonable control until she underwent a bowel prep
for her colonoscopy. On the morning of the scheduled
colonoscopy, she developed AFib with RVR in the setting of
dehydration evidence by alkalosis and hypernatremia. She
received agressive IV hydration and multiple IV medications to
help control rate. Her heart rate initially responded and
stabilized in the 90-100's. However, the following evening, she
required another bowel prep and her heart rate escalated to the
150's. She received additional IV nodal agents and her PO
regimen was increased. An electrophysiology consult was obtained
and the recommendation was for rate control and uptitration with
her current medications. Rhythm control was deferred. She was
restarted on anti-coagulation on HD#5 with a heparin gtt. A TEE
showed no evidence of thrombus. A cardioversion was attempted
and was unsuccessful. The patient was loaded with amiodarone and
the Metoprolol was uptitrated to 100mg [**Hospital1 **] to achieve adequate
rate control. She was started on Diltiazem which was uptitrated
to 45mg PO QID. HR was in the 80s on discharge. Her coumadin
was re-started and heparin gtt was continued until the INR was
therapeutic. Her INR became supratherapeutic and Coumadin was
held on discharge. She should follow-up with Dr. [**Last Name (STitle) **] as an
outpatient. She should have INR checked in 2 days and coumadin
restarted. If her Amiodarone converts her to sinus rhythm or
drops her heart rate as she becomes therapeutic, she may need to
stop her Metoprolol.
.
# CHF: In the setting of Atrial Fibrillation with RVR, the
patient was noted to develop signs and symptoms concerning for
CHF, such as rales and O2 requirement. The patient was diuresed
adequately with Lasix and symptoms improved. The patient was
weaned off supplemental oxygen and was staturating 95% on RA.
Her creatinine bumped and Lasix was stopped. Her peak
creatinine was 2.8 on [**2182-4-21**] and came down to 2.5 on [**2182-4-23**].
Lasix can be considered as an outpatient if she develops signs
and symptoms of congestive heart failure.
.
# CKD: Renal function improving. Per renal, taper prednsione to
40 mg and then to 30mg. She remained on prednisone 3omg Daily
and her creatinine remained stable. Her steroid ppx including
PCP [**Name9 (PRE) **], PPI, calcium, vit D were continued. She was followed
by the renal consult service during her admission and Lasix was
held when Creatinine was elevated. She is on Atovaquone
Suspension 1500 mg PO/NG DAILY for prophylaxis.
.
There are no pending studies at the time of discharge.
Medications on Admission:
Nystatin S+S X 7 days ( day 3 today)
Docusate Sodium 100 mg PO BID
Ranitidine 150mg daily
Diltiazem SR 120mg po daily
Coumadin 2.5mg daily
Atovaquone 1500mg daily
Vit B12 500mcg daily
Folate 1mg daily
Prilosec 40mg [**Hospital1 **]
Toprol XL 50mg daily
Calcium/Vit D 600-400units twice daily
Prednisone 50 mg daily
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
2. Cyanocobalamin 500 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO Q8H
(every 8 hours).
8. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 2 days: on [**2182-4-25**], please change to 200mg PO BID for
1 week, then on [**2182-5-2**] change to 200mg daily.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
start on [**2182-4-25**] for 1 week, then change to 200mg PO daily.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia, anxiety.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
16. Outpatient Lab Work
Please check electrolytes (Na, K, Cl, HCO3) and renal function
(BUN, CREAT), and hematocrit in 1 week.
17. Outpatient Lab Work
Please check INR and Hematocrit in 2 days. Please restart
Coumadin at 2.5mg daily if INR less than 2.5. Recheck INR every
2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Bright Red Blood Per rectum
Anemia requiring blood transfusion
Atrial Fibrillation with RVR
pauci-immune glomerulonephritis with p-anca positive
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 were admitted to the hospital for bleeding from your rectum.
You received a blood transfusion for anemia. You blood count
improved and your bleeding stopped.
The gatroenterologists performed an upper endoscopy which was
normal. You were continued on a antacid. The plan was for you to
undergo a colonoscopy.
While undergoing the prep for the colonoscopy, you developed a
very fast heart rate from your atrial fibrillation. Your blood
pressure medications were increased to help control our heart
rate. The cardiologists attempted to cardiovert you out of
atrial fibrillation, but were unsuccessful. You were started on
Amiodarone and continued on metoprolol. You were started on
Diltiazem for heart rate control. You were given lasix for heart
failure but this was stopped prior to discharge.
When you came into the hospital, you were taking prednisone. The
nephrologists recommended that your prednisone be decreased to
30mg per day. You should continue to take Prednisone 30mg Daily.
CHANGES IN YOUR MEDICATION;
1. Amiodarone 200mg Three times per day for 1 week. On [**2182-4-25**],
change to 200mg 2 times per day for 1 week and then 200mg Daily.
2. Metoprolol 100mg PO BID
3. Prednisone 30mg Daily
4. STOP Prilosec 40mg Daily
5. START Protonix 40mg Twice Daily
6. CHANGE Diltiazem to 45mg PO QID
Followup Instructions:
You need to schedule a follow-up appointment with the [**Hospital **] clinic.
You can call them @ ([**Telephone/Fax (1) 2233**] to schedule an appointment
and outpatient colonoscopy.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Cardiology
Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 5768**]
When: [**Last Name (LF) 766**], [**4-29**] at 11:30am
We are working on a follow up appointment with Dr [**Last Name (STitle) **] in the
Nephrology department in the next week. You will be called with
this appointment. If you have not heard or have questions,
please call :([**Telephone/Fax (1) 10135**]
ICD9 Codes: 5789, 2851, 2760, 4280, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5978
} | Medical Text: Admission Date: [**2184-10-16**] Discharge Date: [**2184-10-18**]
Date of Birth: [**2131-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Etoh withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53year-old male with a history of Etoh abuse w/h/o seizures
w/withdrawal who presented w/acute etoh intoxication to the ED 1
day PTA. His initial Etoh level was 429 w/last drink day 1 day
PTA. He drink 2 bottles of vodka daily. He was observed
overnight in the ED and appeared to be stable until this AM when
he became hypertensive and tachycardic.
.
In the ED, he was afebrile, BP 162/103 HR 62 O2sat 97%RA. He
received Thiamine, folate and Diazepam 5 mg IV x 1(once at 9AM
and once at 10AM) per CIWA scale which was started this AM.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
-Alcohol abuse h/o withdrawal c/b seizures
-Hypertension
-Hepatitis C
-Seizure disorder
Social History:
Smokes a few cigarettes a day x many years. Heavy alcohol
history, about 1pint vodka a day now. History IVDU,
cocaine/crack use Multiple unprotected female partners.
Homeless, living at shelter. Mainly around [**Hospital1 756**] Circle. PCP
is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], [**Hospital 2025**] healthcare for the homeless. Lives
with sister in [**Name (NI) 5110**] when sober. Works in trucking when
sober. He was born in [**State 5111**], worked as a chef. He finished
High School
Family History:
Non-contributory
Physical Exam:
Vitals: T 99.4 : BP 170/110 : HR 80 : RR 17 : O2Sat: 97% RA
GEN: anxiouse appearing, well-nourished, in obviouse distress
HEENT: EOMI, PERRL, no epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, +tremor
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2184-10-16**] 10:00AM WBC-2.6* RBC-3.38* HGB-11.5* HCT-33.7*
MCV-100* MCH-34.1* MCHC-34.1 RDW-16.3*
[**2184-10-16**] 10:00AM NEUTS-56.8 LYMPHS-37.1 MONOS-4.4 EOS-0.9
BASOS-0.8
[**2184-10-16**] 10:00AM PLT COUNT-143*
[**2184-10-15**] 09:30PM ASA-NEG ETHANOL-429* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2184-10-16**] 10:00AM GLUCOSE-84 UREA N-8 CREAT-0.8 SODIUM-145
POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-28 ANION GAP-16
[**2184-10-16**] 10:00AM ALT(SGPT)-84* AST(SGOT)-220* LD(LDH)-505* ALK
PHOS-46 TOT BILI-0.5
[**2184-10-16**] 10:00AM ALBUMIN-4.2
.
Brief Hospital Course:
This is a 53 year-old male with a history of alcohol abuse who
presented with acute intoxication. He was monitored for 1 day in
the ICU prior to call out to the floor. Pt ultimately left AMA.
.
# Alcohol Withdrawal: Pt reported his last drink was 1 day PTA
[**2184-10-15**]; has h/o seizures associated w/withdrawal and stated
that his last seizure was 3 weeks prior to admission. During his
ICU course the pt was kept on a PO valium CIWA scale q1 hours.
In addition he received MVI/Thiamine/Folate, a social work
consult called, and was placed on aspiration precautions. A
dilantin level was checked and found to be sub-therapeutic. The
pt was restarted on dilantin. Upon call out to the floor, he
required 20 mg Valium in a period of 12 hours. He was noted to
have a DBP of 115 with some mild tremors and diaphoresis, as
well as difficulty ambulating. He was requesting to sign out
AMA, at which point security sitters monitored the patient until
it was deemed pt had capacity to leave. Several hours later, the
patient was still agitated, stating he wanted to leave b/c he
had obligations in the afternoon, and that he understood if he
left he could die or have seizures. A psychiatry consult was
requested, but the pt became extremely angry, was ambulating
with mild staggering gait but mostly steady, and did appear to
have capacity, so the patient was signed out AMA prior to
psychiatry being able to formally evaluate pt. Attempt was made
to call pts PCP, [**Name10 (NameIs) **] went into voicemail. Pt was asked to f/u
with his PCP the following day, was seen by SW, and given phone
numbers for detox centers. He stated he was going to go back to
drinking after discharge. He was noted discharged on dilantin as
this was stopped per prior d/c summary when PCP told the
[**Name9 (PRE) **] at the time that the pt has no h/o seizure disorder.
.
# HTN: Upon admission the patient was hypertensive in the
setting of EtOH withdrawl. The pt in on atenolol as an
outpatient. The patient was started on Metoprolol TID titrated
up to 37.5 TID at the time of transfer to the floor. The
patients home dose of HCTZ was held in the setting of
hypokalemia. He was restarted on his home BP meds at the time of
discharge. Pts DBP was 115 at time of discharge, pt warned of
symptoms of hypertensive urgency and risk of death with severe
hypertension/withdrawl. Pt still decided to leave AMA,
reiterated the risks of leaving back to me.
.
# HCV: The were no serologies in the [**Hospital1 18**] system.
.
# Pancytopenia: most likely due to alcohol abuse leading to vit
deficiency. to be w/u as outpatient
Medications on Admission:
Hydrochlorothiazide 25mg daily
Atenolol 50mg daily
Dilantin 300mg daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication
Discharge Condition:
leaving against medical advice, diastolic blood pressure 115,
ambulating with a little gait abnormality but steady on the
feet, mild tremors
Discharge Instructions:
You were admitted with alcohol intoxication. You were treated
with valium. You were not quite finished withdrawing and your
blood pressure was still very high. We discussed that you are at
risk for death or stroke if your blood pressure remains high.
You are also at risk for seizures if you are withdrawing. You
were having difficulty ambulating while you were here, but this
improved at the time of your discharge.
.
Please go to your doctor in the next day if able.
.
Go to the ER or call your doctor if you have any chest pain,
shortness of breath, seizures, dizziness, blurred vision, falls,
dehydration, vomiting, abdominal pain, fever, hallucinations, or
any other concerning symptoms.
Followup Instructions:
You need to stop drinking. You were seen by social work, but you
refused detox.
.
You can call any of the following for addictions counseling:
[**Last Name (un) 5112**] ([**Telephone/Fax (1) 5113**]) [**Street Address(2) 5114**], [**Hospital1 3494**]
* Outpt. Addictions Services ([**Telephone/Fax (1) 5115**]) [**Street Address(2) 5116**],
[**Hospital1 3494**]
* [**Hospital6 1597**] ([**Telephone/Fax (1) 5117**]) 330 [**Hospital3 **] St.,
[**Hospital1 8**]
.
Please see Dr.[**Name (NI) 5118**] in the next 1-2 days.
ICD9 Codes: 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5979
} | Medical Text: Admission Date: [**2126-10-21**] Discharge Date: [**2126-11-25**]
Date of Birth: [**2060-4-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p MVC with major chest injury
Major Surgical or Invasive Procedure:
[**2126-11-2**] tracheostomy, percutaneous endoscopic gastrostomy,
inferior vena caval filter placement
History of Present Illness:
66M with history of Afib on Coumadin, restrained driver v.
truck, no LOC, presented to [**Hospital3 1443**] Hospital with L
neck hematoma and R chest pain. CT at OSH demonstrated possible
splenic laceration.
Past Medical History:
PMH: paroxysmal atrial fibrillation, hepatitis C, GERD, HTN,
DMII
Social History:
Married. Works as a tailor. Alcohol about once per month. No
tobacco
use.
Family History:
Sister with CAD s/p CABG. Brother with CAD. Brother with
pancreatitis.
Physical Exam:
On admission:
99.3 80 155/71 30 97%RA
Gen: uncomfortable
Neuro: GCS 15, A&O x 3, CN2-12 intact
HEENT: PERRLA, EOMI, OP clear
Neck: L neck tense hematoma in supraclavicular (Zone 1) area
Chest: tender and crepitant to palpation over L anterior thorax.
Visible central flail chest.
CVS: RRR, nl S1S2
Pulm: CTA b/l, no stridor
Abd/Rectal: soft, ND, NT, guiaic negative
Spine: no tenderness
Ext: no c/c/e, no deformities, FROM
On [**2126-11-24**]:
98.7 72 178/74 27 100% CPAP+PS 0.4/430x27/5/5
Gen: alert, GCS 11
HEENT: PERRLA, EOMI
CVS: RRR, no m/r/g
Pulm: crackles at R base, otherwise CTA
Abd: soft, NT, ND, +BS
Ext: edema L>R
Pertinent Results:
On admission:
[**2126-10-21**] 10:45PM WBC-6.9 RBC-3.79* HGB-11.8* HCT-33.2* MCV-88
MCH-31.1 MCHC-35.5* RDW-14.1
[**2126-10-21**] 10:45PM NEUTS-76.9* LYMPHS-15.3* MONOS-5.7 EOS-1.9
BASOS-0.2
[**2126-10-21**] 10:45PM PLT COUNT-149*
[**2126-10-21**] 10:45PM PT-16.9* PTT-34.2 INR(PT)-1.5*
[**2126-10-21**] 01:04PM LACTATE-2.0
[**2126-10-21**] 01:04PM HGB-13.4* calcHCT-40
[**2126-10-21**] 12:58PM UREA N-32* CREAT-0.9
[**2126-10-21**] 12:58PM AMYLASE-47
[**2126-10-21**] 12:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-10-21**] 12:58PM FIBRINOGE-245
.
[**2126-10-21**] CTA head/neck:
1. Large left neck hematoma with active extravasation of IV
contrast within the hematoma. Part of this extravasation
appears to be arising from the left subclavian vein. The more
superior active extravasation is located adjacent to a deep
cervical artery branch of the right thyrocervical trunk.
2. There is compression and anterior displacement of the left
internal jugular vein by the large neck hematoma.
3. Comminuted sternal fracture with stranding of the anterior
mediastinal fat suggestive of mediastinal hemorrhage and likely
hemorrhage along the left lung apex. Recommend further
evaluation with a dedicated CTA of the chest.
4. Multiple nodular densities at the right lung apex, which may
represent prior granulomatous disease, but this can be better
evaluated by the dedicated chest CT.
.
[**2126-10-21**] CXR:
Limited study with probable right middle and right lower lobe
collapse. Left lower lobe collapse is also likely. Increased
pleural thickening along the right lung may reflect blood in the
pleural space with multiple right-sided rib fractures noted.
.
[**2126-10-21**] L subclavian arteriogram:
No arterial bleeding or pseudoaneurysm was noted on left
subclavian arteriogram.
.
[**2126-10-25**] sputum: Haemophilus influenzae (Beta lactamase
negative)
.
[**2126-10-28**] sputum: MRSA, Haemophilus influenzae (Beta lactamase
negative)
.
[**2126-10-28**] CXR:
Endotracheal tube has been placed terminating 3 cm above the
carina with the neck in a flexed position. New diffuse but
asymmetrically distributed airspace opacities have developed
affecting the right lung to a much greater degree than the left.
It is uncertain whether this represents asymmetric edema or
massive aspiration. Left lower lobe shows improved aeration,
but there is persistent collapse of the right lower lobe.
Moderate layering right pleural effusion is present as well as
multiple right-sided rib fractures. Likely small left pleural
effusion is also demonstrated.
.
[**2126-10-31**] CT chest:
1. No strong evidence of empyema, but there are small bilateral
pleural
effusions layer dependently, a portion of the right pleural
effusion is
loculated posteriorly.
2. Diffuse ground-glass opacity in both lungs, most likely
edema,
alternatively hemorrhage or pneumonia.
3. Multiple tharacic fractures, including the manubrium and
right second through ninth ribs, multiple in the fifth and sixth
ribs.
4. Coronary artery calcifications and atherosclerotic
calcification of the aorta.
.
[**2126-11-5**] Renal US:
No evidence of hydronephrosis, calculi, or renal masses.
.
[**2126-11-6**] CXR:
In comparison with study of [**11-5**], there appears to be
increasing
opacification involving much of the left hemithorax, consistent
with the
clinical impression of widespread pneumonia. Lower lung volumes
appear to
accentuate the areas of atelectasis on the right. Tracheostomy
tube and right central catheter remain in place.
.
[**2126-11-7**] echo:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) 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 stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. There is an anterior space
which most likely represents a fat pad.
.
[**2126-11-12**] RUE US:
No ultrasonographic evidence of DVT involving the right upper
extremity.
.
[**2126-11-14**] CXR:
Previously cleared right lung has returned to severe
consolidation,
accompanied by worsening of left lung consolidation which was
predominantly suprahilar. Most likely this is due to a somewhat
asymmetric pulmonary edema, given the simultaneous increase in
heart size and volume of small pleural effusions. Tracheostomy
tube in standard placement. No pneumothorax.
.
[**2126-11-14**] sputum: Enterobacter cloacae (pan sensitive)
[**2126-11-14**] BAL: Enterobacter cloacae
.
[**2126-11-15**] IR placement of tunneled catheter:
Successful placement of a 15.5 French 23 cm cuff-to-tip length
double-lumen hemodialysis catheter via the right internal
jugular vein. The tip of the catheter is located in the right
atrium. The catheter is ready for use.
.
[**2126-11-20**] CXR:
1. Status post insertion of double lumen central venous
catheter with no
evidence of complications.
2. Overall improvement of pleural effusion and parenchymal
consolidation.
.
On [**2126-11-24**]:
[**2126-11-24**] 01:44AM BLOOD WBC-10.1 RBC-3.02* Hgb-9.0* Hct-27.0*
MCV-90 MCH-29.8 MCHC-33.3 RDW-14.9 Plt Ct-204
[**2126-11-24**] 01:44AM BLOOD PT-17.5* PTT-29.1 INR(PT)-1.6*
[**2126-11-24**] 01:44AM BLOOD Glucose-145* UreaN-79* Creat-4.6* Na-136
K-4.3 Cl-99 HCO3-26 AnGap-15
[**2126-11-24**] 01:44AM BLOOD Calcium-7.4* Phos-3.2 Mg-2.1
[**2126-10-25**] 10:55AM BLOOD %HbA1c-5.9
Brief Hospital Course:
Patient underwent CTA of the head/neck for his L neck hematoma;
it demonstrated extravasation from the L subclavian vein and a
deep cervical arterial branch of the R thyrocervical trunk.
Patient underwent L subclavian arteriogram for possible
embolization; no bleeding was noted.
.
His other injuries included a small splenic hematoma, flail
chest (R 2nd-9th rib fractures), and a comminuted sternal
fracture. He was admitted to the floor for observation, with
serial hematocrits and serial exams, both of which were stable.
.
He had intermittent episodes of decreased O2 saturation. He
underwent bronchoscopy on [**10-25**] for persistent RLL collapse; he
was found to have a mild to moderate quantity of thick mucoid
sputum on the R side, which was aspirated. Levofloxacin was
started for CAP. Pulmonology recommended aggressive IS,
albuterol nebs, and stronger pain control; PAP was felt to be
unnecessary. On [**10-26**], he was triggered for "confusion" as
reported by the patient's family. As per the HO note, he was
"not remotely confused" and that he was "not hypoxic...acting as
expected with manageable O2 requirements in the setting of PNA &
multiple rib fractures." Vancomycin was added for broader CAP
coverage.
.
On [**10-27**], he was transferred to the ICU for acute respiratory
failure (RR 26-45 and O2 sats 85% on 6L). He was intubated.
Levofloxacin was switched to Zosyn. He was placed on a dilt gtt
for his A-fib. Diuresis was started. On [**10-28**], he underwent
bronch with BAL. Dilt was d/c'd and switched to metoprolol.
Methadone was started and fentanyl gtt was d/c'd. Tube feeds
were started. On [**10-30**], an insulin gtt was started for poor RISS
control. A chest tube was placed for his R pleural effusion.
Dilt gtt was restarted for rapid A-fib. On [**10-31**], he underwent
CT of the chest, which did not demonstrate empyema, and another
bronchoscopy. On [**11-1**], dilt gtt was switched to amiodarone gtt.
Lopressor was continued. Hydralazine was used prn for blood
pressure control. Insulin gtt was weaned off. On [**11-2**], patient
underwent tracheostomy, PEG, and IVC filter placement. On [**11-3**],
his CT was d/c'd. Tube feeds were started via the PEG.
.
On [**11-4**], his creatinine rose from 1.2 to 1.7. Lasix was held.
Vanc was also held for trough 32.8. He was oliguric. He was
bolused and started on IVF. On [**11-5**], his Cr rose to 2.8.
Nephrology was consulted. The etiology of his ATN was not
clear, but it was attributable to many factors, including CTA
contrast, vanc toxicity, relative kidney hypoperfusion in the
setting of infection, and uric acid nephropathy ([**12-28**] to
increased metabolism [**12-28**] infection). Conservative management
was recommended; he was transfused, his medications were renally
dosed, ASA was d/c'd, and his tube feeds were switched to Nutren
Renal. On [**11-6**], citalopram was d/c'd. He received Kayexelate,
Lasix, and Diuril for hyperkalemia, as recommended by Renal.
His K decreased, but his urine output was unresponsive to the
high dose diuretic administration. Aluminum hydroxide was
started for hyperphosphatemia. A CXR demonstrated worsening
PNA. On [**11-7**], his Cr was 5.2. CVVHD was started via a L groin
Quinton catheter. Amiodarone was switched to sotalol. A
transthoracic echo was normal. Tube feeds were restarted. On
[**11-8**], antibiotics were d/c'd to complete a 10 day course. He
was afebrile and his WBC was normal. His BP was labile,
intermittently requiring neo; sotalol was decreased accordingly.
Transplant Surgery was consulted on [**11-11**]; his dialysis
requirement was felt to be too temporary to require a tunneled
line.
.
On [**11-12**], CVVHD was stopped. Celexa was restarted. He
tolerated trach mask for a period of time. RUE edema was noted,
but an ultrasound was negative for DVT. Cardiology was
consulted. As per their recommendations, sotalol was d/c'd
secondary to renal clearance and long qT pauses on telemetry.
Metoprolol and heparin gtt were started. On [**11-14**], he was
febrile. His dialysis catheter was d/c'd. He underwent
bronchoscopy with BAL, which had 4+ GNR on Gram stain. Zosyn
and Cipro were started. One dose of vanc was given. On [**11-15**],
a tunneled catheter was placed in IR. On [**11-16**], he underwent
his first HD. Coumadin was also started. On [**11-17**], his BAL
culture grew pan-sensitive Enterobacter; Zosyn was d/c'd.
Mucomyst was added to aid with secretion clearance. On [**11-18**],
heparin gtt was d/c'd as INR was therapeutic. TF were advanced
to goal. For the remainder of his hospital course, HD was
continued every other day, as per Renal (last [**2126-11-24**]). Vanc
was administered at HD. He was transfused prn.
.
At discharge, he is afebrile with stable vital signs. He
tolerates trach mask intermittently, requiring pressure support
in between. His tube feeds are at goal. His urine output is
increasing. PT and OT are following him.
Medications on Admission:
metoprolol 50', metoclopramide 5 prn, Humalog SS, sotalol 160",
Lantus 50U qAM, Coumadin 2', Toprol XL 100 qAM/50 qHS,
lisinopril 10", omeprazole 40'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 500 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Albuterol 90 mcg/Actuation Aerosol [**Month/Day/Year **]: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: Four (4)
Puff Inhalation Q4H (every 4 hours) as needed.
5. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day/Year **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Zolpidem 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
7. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
8. Citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
11. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
13. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed.
14. Warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
15. Hydralazine 20 mg/mL Solution [**Last Name (STitle) **]: 0.5 ml Injection Q4-6H ()
as needed for prn sbp>180.
16. Outpatient Physical Therapy
Fixed NPH Dose
Breakfast 25 Units
Bedtime 5 Units
Regular Insulin Sliding Scale
Check fingersticks q6 hours
0-50 mg/dL [**11-27**] amp D50
51-120 mg/dL 0 Units
121-140 mg/dL 7 Units
141-160 mg/dL 11 Units
161-180 mg/dL 15 Units
181-200 mg/dL 19 Units
201-220 mg/dL 23 Units
221-240 mg/dL 27 Units
241-260 mg/dL 31 Units
261-280 mg/dL 35 Units
281-300 mg/dL 39 Units
> 300 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p MVC, L neck hematoma, comminuted sternal fracture, R 2-9th
rib fractures with flail chest, pneumonia, acute renal failure
Discharge Condition:
Afebrile with stable vital signs, tolerating trach mask with
intermittent pressure support as needed, tolerating tube feeds,
on hemodialysis with improving urine output.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2127-5-5**] 9:00
Provider: [**Name10 (NameIs) 2194**],[**Name11 (NameIs) 900**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6429**] Follow-up appointment
should be in 2 weeks
Provider: [**Name10 (NameIs) 4343**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 26330**] Follow-up appointment
should be in 2 weeks
Completed by:[**2126-11-24**]
ICD9 Codes: 486, 5849, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5980
} | Medical Text: Admission Date: [**2169-10-27**] Discharge Date: [**2169-11-1**]
Date of Birth: [**2119-7-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
COFFEE-GROUND VOMIT
Major Surgical or Invasive Procedure:
ENDOSCOPIC GASTRODUODENOSCOPY with biopsy
History of Present Illness:
50M with history of heavy ETOH use, Meniere's disease,
psychiatric history including panic disorder, depression &
anxiety, presented 2d ago with hematemesis, RUQ & R-sided chest
pain, and intoxication after binge drinking. Binge drinks on
vodka 1/5 L at a time, recurrent admissions for withdrawal
management and detox. 3 days ago he started having severe RUQ
pain, non-radiating, exacerbated by movement and eating, no
known alleviating factors. Started vomiting 2 days PTA; vomiting
progressively increasing frequency until admission. Vomiting
intermittently streaked w/black blood. ROS positive for mild,
productive cough x1 week & gradual weight loss x 2 years,
negative for F/C.
.
Substance abuse history includes 30 yrs heavy drinking, several
admissions for ETOH withdrawal, hx attending dual diagnosis
detox programs, 2 withdrawal seizures (one at home, one while
hospitalized). Past ICU admissions for DTs. Longest sober period
was 5 years ([**2155**]-[**2160**]). Cocaine and marijuana use in the past,
not currently using.
.
In the ED, initial VS were: 140 132/90 16 95%. Coffee ground
emesis witness in the ED but unknown volume. RUQ US negative for
cholecystitis. CXR showed RLL opacity, slightly more dense than
prior. Labs notable for leukocytosis WBC 13 (w/ 87.4% PMN no
bands), ETOH 202, plt 105, HCT 38 -> 33. Total 3L IVF received,
no blood products given. Received diazepam 10mg x2, Ativan 2mg
x2, morphine 4mg x1, PPI bolus/gtt, and zofran. Despite
benzodiazepines, he remained tachycardic and tremulous. 2 large
bore PIVs placed.
.
In the MICU over the past 2d he was retching frequently. No
further hematemesis, but he did receive benzos on CIWA for
tremor, anxiety & tachycardia. Reported similar vomiting
episodes have occured with Meniere's disease flares previously.
C/o persistent RUQ pain. He received IVF for low uop.
.
He has been followed in the MICU by GI who initially recommend
EGD but delaying until patient no longer retching and
withdrawing from ETOH. Suggested NGT placement (not done),
antiemetics (on compazine), PPi drip, and transfusion for Hct
<25. Hct stable >25 x3 today. When rectal exam showed guaiac
positive brown stool, GI concluded no indication for EGD. CT
chest showed R rib fracture (minimally displaced ninth and
nondisplaced eighth). Also increased RLL opacity on CXR read as
worsening atelectasis. Prior to MICU callout his benzos were
decreased to q4H and diet advanced to clears. On the floor pt
reports no appetite. Focused on R-sided chest pain where he says
he has multiple rib fractures he suspects he sustained during
his recent bender but cannot remember specifically. We note that
although he reported suicidality w/plan (heroin o/d) during
another recent admission, he denies suicidality at present.
Past Medical History:
Past Medical History:
- COPD
- Meniere's disease - diagnosed in [**2165**], has not followed up
with
outpatient care
- Hypothyroidism
- Hx of Borderline HTN
- History of frostbite to bilateral toes ("my toes turned
black")
Past psychiatric history:
-Diagnoses: Depression, anxiety, panic disorder
-Hospitalizations: [**Hospital1 **], [**Location (un) **] , [**Hospital3 **]. Numerous
detoxes ([**Location (un) 22870**], [**Location (un) 3244**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). Thinks last
inpatient psych was [**Hospital1 **] 4 11/[**2168**].
-SA/SIB: Denies
-Violence: Denies
-Therapist: [**Doctor First Name **] at [**Location 8391**] Behavioral Health until 2-3
months ago, when she fired him for coming to an appointment
intoxicated. She now no longer works there.
-Psychiatrist: Has been seeing someone at [**Location 8391**] BH
Social History:
He lives alone in an apartment in [**Location 8391**]. Divorced after
he crashed 2 cars while intoxicated. He has been homeless in the
past. Has been in jail for burglary and steeling whisky. He used
to smoke
1-1.5 ppd (started smoking at age 10), but now smokes a few
cig/day. He drinks daily ([**1-25**] vodka). He states the past 2 years
have been very hard, mostly because of death of his sister.
Family History:
Father - alcoholism
Mother - depression, anxiety, hospitalizations
Two sisters - depression, anxiety, psych hospitalizations, EtOH.
One sister died of cirrhosis, other is sober.
Physical Exam:
MICU ADMISSION EXAM
VS: HR 108, BP 140/80s, 94% on 2L NC
General: Alert, oriented, intermittently falls asleep during
interview, slightly movement triggers wretching, came up from ED
with emesis bin with approx 100 cc gastric contents with some
red blood
HEENT: Sclera anicteric, MMdry, no visible lice
Neck: supple, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased breath sounds right base, otherwise no
wheezes/rhonchi/rales
Abdomen: soft, tender in RUQ to moderate palpation with
voluntary guarding, no rebound,
Skin: 1 cm blanching macules on abdomen
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: CN2-12 intact, 5/5 strength, no sensory deficits
.
MICU->FLOOR TRANSFER EXAM
VS 97.5 120/77 85 18 97/RA
General: Alert, oriented, fatigued-appearing, not retching
HEENT: NCAT EOMI sclera anicteric, MM dry, no visible lice
Neck: supple, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: decreased breath sounds R base & halfway up, R-sided
chest wall tenderness to palpation, lidocaine patch in place,
prominent wheeze throughout all lung fields
Abdomen: soft, distended RUQ ttp +voluntary guarding, no
rebound,
Skin: 1 cm blanching macules on abdomen (c/w tinea versicolor)
Ext: WWP, 2+ pulses, no edema
Neuro: CN2-12 intact, 5/5 strength, no sensory deficits, +mild
UE tremor R>L
.
DISCHARGE PHYSICAL EXAM
VS 98.9 98.4 127/92 73 18 98/RA
General: Alert, oriented, lying comfortably in bed
HEENT: NCAT EOMI sclera anicteric MM dry no visible lice
Neck: supple no LAD
CV: RRR, normal S1/S2, no murmurs, rubs, gallops
Lungs: decreased breath sounds R base, R-sided chest wall mildly
tender to palpation, lidocaine patch in place, no wheeze
Abdomen: soft, distended RUQ mildly ttp no guarding, no rebound,
Skin: no rash
Ext: WWP, 2+ pulses, no edema
Neuro: CN2-12 intact, 5/5 strength, no sensory deficits, +mild
UE tremor R>L
Pertinent Results:
ADMISSION LABS
[**2169-10-27**] 05:52AM BLOOD WBC-13.5*# RBC-3.97* Hgb-13.0* Hct-38.8*
MCV-98 MCH-32.6* MCHC-33.4 RDW-16.1* Plt Ct-140*
[**2169-10-27**] 05:52AM BLOOD Neuts-87.4* Lymphs-7.4* Monos-4.0 Eos-0.9
Baso-0.3
[**2169-10-27**] 08:20AM BLOOD PT-12.3 PTT-22.4 INR(PT)-1.0
[**2169-10-27**] 05:52AM BLOOD Glucose-201* UreaN-25* Creat-0.8 Na-131*
K-5.5* Cl-84* HCO3-23 AnGap-30*
[**2169-10-27**] 05:52AM BLOOD ALT-40 AST-81* AlkPhos-50 TotBili-0.5
[**2169-10-27**] 05:52AM BLOOD Albumin-4.6 Calcium-8.4 Phos-4.2 Mg-2.0
[**2169-10-27**] 08:20AM BLOOD TSH-3.2
[**2169-10-27**] 08:20AM BLOOD Free T4-0.52*
[**2169-10-27**] 05:52AM BLOOD ASA-NEG Ethanol-202* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-10-27**] 01:07PM BLOOD Lactate-1.6
.
MICRO
.
[**10-27**] BLOOD CULTURES - PENDING
[**10-31**] R ANTECUBITAL FOSSA WOUND CULTURE (FROM SITE OF PIV) -
PENDING
.
PATHOLOGY
.
[**10-31**] GI BIOPSY - PENDING
.
IMAGING
.
RUQ US: No imaging signs of acute cholecystitis. No gallstones.
Normal CBD.
.
CXR: The RLL opacity with chronic pleuroparenchymal scaring and
calcifications has slightly increased over time. Chest CT might
be considered for further work-up. Otherwise, the lungs are
clear, the hila and cardiac shilhouette are normal and there is
no pneumothorax.
.
CT chest/abdomen [**10-28**]:
Increased right lower lobe opacity on chest radiograph likely
reflects superimposition of bibasilar atelectasis upon the
preexisting chronic changes in the basal right pleura.
2. Minimally displaced right ninth rib fracture and nondisplaced
eighth right rib fracture.
.
CT HEAD [**10-29**]
FINDINGS: No acute intracranial hemorrhage, edema, mass effect
or major
vascular territorial infarction is seen. [**Doctor Last Name **]-white matter
differentiation is preserved, with mild periventricular white
matter hypodensity compatible with chronic small vessel ischemic
disease. There is no shift of normally midline structures. The
ventricles and sulci are mildly prominent, compatible with
alcoholism, if diagnosed clinically. Mineralization is seen in
the bilateral basal ganglia. There is no fracture. Imaged
paranasal sinuses and mastoid air cells demonstrate minimal left
maxillary mucosal thickening.
IMPRESSION: No acute intracranial pathological process.
.
RUE DOPPLER ULTRASOUND [**10-31**]
FINDINGS:
The right and left subclavian vein are patent with normal color
flow and
symmetric waveforms with normal phasicity. The right internal
jugular vein, subclavian vein, axillary vein, brachial and
basilic veins demonstrate normal grayscale appearance,
compressibility, color flow, and waveforms. At the antecubital
fossa and just proximal to the antecubital fossa, there is
echogenic clot distending the right cephalic vein which is
noncompressible and has no color flow consistent with acute
thrombus. Downstream, the right cephalic vein is patent (more
proximally in the arm).
IMPRESSION:
1. Partial thrombosis of the right cephalic vein at and just
proximal to the antecubital fossa consistent with superficial
thrombophlebitis.
2. No right upper extremity DVT.
.
EGD [**10-31**]:
Ulcer in the gastroesophageal junction
Erythema and congestion in the antrum and stomach body
compatible with gastritis (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up biopsy results
Continue PPI daily.
Gastritis likely [**2-22**] EtOH.
Bleeding likely [**2-22**] clean-based esophageal erosion.
Brief Hospital Course:
50 y/o w/ heavy ETOH use and depression/anxiety and panic
disorder presented with coffee ground hematemesis and
tachycardia, RUQ pain, found to have now-resolved UGIB and and R
rib fractures.
.
#Alcohol Abuse/Withdrawal
ETOH 202 on admission. Noted pt's hx of multiple presentations
for detox. Current psychiatric/social issues likely barrier to
ETOH cessation. Initially scored on CIWA for tremor, anxiety,
nausea/vomiting, received valium initially q1H then spaced out.
No DTs, no seizure, no hallucinations. No benzodiazepines
received in last 4d prior to discharge. Patient reports that his
post-dc plan is to return home and try to stay sober again, has
an AA sponsor. Very high risk of recurrence esp given that this
plan as it has failed him repeatedly in the past. Followed by
social work.
.
#Upper GI Bleed
Presented w/coffee-ground emesis. Initial ddx included
gastritis/esophagitis, MW tear and/or PUD. Unknown amount of
blood loss; Hct trending down from 38.8 on admission to a nadir
of 25.8 one day later. Coffee-ground emesis also witnessed
directly in the ICU. EGD initially deferred until patient was no
longer actively withdrawing from alcohol; once he was stable, an
EGD was performed which showed only a clean ulcer near the G-E
junction, no active bleeding. Hct self-resolved and trended
upward, Hct 34.7 upon discharge. No blood transfusion. We note
here that we also suspected esophageal varices from presumed
underlying alcoholic cirrhosis given years of heavy ETOH, but
imaging showed no signs of cirrhosis and EGD revealed no
varices.
.
#Recurrent vomiting
Patient was actively retching in ED and MICU. This was thought
to be [**2-22**] known Meniere's disease and alcohol withdrawal.
Patient reported symptoms as similar to prior flares of his
Meniere's. Resolved after 2d, concurrent with cessation of
withdrawal symptoms but also received meclizine and PRN
compazine. We also investigated possible head injury given rib
fractures, but head CT showed no intracranial bleed nor signs of
head trauma.
.
#Traumatic R rib fractures
Patient reported R-chest pain and RUQ abdominal pain. No memory
of trauma while intoxicated, but imaging showed new 8th and 9th
R rib fractures. RUQ US and CT torso negative for other
pathology. Pain initially treated with oxycodone which was
weaned. Continued to receive tylenol PRN and daily lidocaine
patch. CT chest/head negative for other injuries.
.
#RLL opacity
Patient has chronic inflammation and scarring of his RLL [**2-22**] an
old stab wound. CT torso showed increasingly dense effusion
overlying this site, which could have represented pneumonia,
effusion, or atelectasis. He has history of smoking and COPD. No
leukocytosis or fever. Chest CT read as increasing bibasilar
atelectasis superimposed on the chronic RLL plaque. No oxygen
requirement. No sputum cultures sent. No antibiotics given.
Initial leukocytosis (likely inflammation [**2-22**] rib fractures)
self-resolved.
.
#Mild transaminitis
RUQ US shows only fatty liver, no cirrhosis, not suggestive of
cholecystitis or free RUQ fluid. Lipase wnl. CT abdomen showed
normal liver, GB, and pancreas. LFTs only very mildly elevated
in non-obstructive pattern. Chronic alcoholism and recent
"bender" likely inflammed chronically-challenged liver. LFTs
trended down towards wnl prior to discharge, and patient had no
further abdominal pain, only reproducible R chest wall pain at
rib fracture sites, as above.
.
#Thrombocytopenia
He presented w/thrombocytopenia new since 1 month ago, although
review of older labs shows prior episodes of thrombocytopenia
too. Considered whether it might be due to underlying liver
dysfunction, but INR was normal. No evidence of DIC/TTP or other
consumptive process. Hemolysis labs negative. No clear history
of HIT. Heparin was avoided. Platelets improved to wnl after
UGIB resolved.
.
#COPD
Chronic. We noted wheezing on exam despite Spiriva QD and
albuterol nebs Q6H. Temporarily given q8H iprotoprium and q4H
albuterol nebs until wheezing resolved, then restarted on home
tiotoprium QD. RR and O2 sat remained >95%/RA throughout
admission.
.
#Lice
Treated with lindane shampoo in ED and permethrin in the MICU.
Contact precautions maintained. No evidence of lice seen on the
floor.
.
#Chronic hypothyroidism
Patient takes synthroid at home, reportedly not fully complaint
with medication when he is intoxicated. Labs showed TSH wnl, fT4
low. He was restarted on synthroid home dose 75 mcg QD. Will
require outpatient follow-up for dose adjustment prn.
.
#Hx Depression/anxiety and panic disorder
Longstanding. Likely contributing to ETOH dependence. Patient
had been suicidal during recent admission but answered no to
questions of current suicidal ideation during this admission.
Denied depression and anxiety throughout this admission, and
indeed he was very calm and well-appearing. He was continued on
home citalopram. Did not re-start clonazepam at time of
discharge given tendency toward addiction.
.
# TRANSITIONAL ISSUES
I. Needs repeat chest CT in 3 months to monitor chronic changes
in basal R pleura.
II. Needs follow-up thyroid function testing in [**1-22**] months.
III. Review biopsy results at GI appointment, eval any need for
H pylori treatment.
Medications on Admission:
Of note, patient states he does not reliably take his
medications while drinking ETOH
1. citalopram 40 mg daily
2. clonazepam 1 mg [**Hospital1 **]
3. omeprazole 40 mg daily
4. ferrous sulfate 325 mg daily
5. Spiriva daily
6. ProAir HFA 90 mcg/Actuation q4-6H PRN
7. folic acid 1 mg daily
8. thiamine HCl 100 mg daily
9. multivitamin daily
10. levothyroxine 75 mcg daily
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: maximum 3 grams per day.
Disp:*100 Tablet(s)* Refills:*0*
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain for 2 weeks: apply to right chest near rib
fractures.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation once a day.
10. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
11. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
UPPER GASTROINTESTINAL BLEED
.
SECONDARY DIAGNOSES
GASTRIC ULCER
GASTRITIS
ALCOHOL DEPENDENCE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after vomiting blood.
You were in the intensive care unit. We watched your blood
counts, which normalized. We also did an endoscopy which showed
a healed ulcer in your stomach and generalized stomach
inflammation called gastritis. This, in combination with nausea
and vomiting from drinking alcohol, caused you to bleed.
Bleeding like this can be life-threatening. This is another
important reason to stop drinking alcohol.
.
We treated you for alcohol withdrawal symptoms. You saw a social
worker here to discuss your efforts to stop drinking. We support
your effort to quit drinking, and encourage you to get help from
your AA sponsor and physicians when you are struggling.
.
You had bad nausea and vomiting related to alcohol withdrawal
and Meniere's disease. This stopped several days before you went
home.
.
You were also treated for lice.
.
We also found that you had rib fractures, which were very
painful. We treated you with tylenol, oxycodone, and lidocaine
patch. Your pain was resolving before you left the hospital.
.
You developed a blood clot in a vein near your right elbow. This
was not a large clot and not very deep, so it should resolve by
itself.
.
We made the following changes to your medications:
1. STOPPED CLONAZEPAM
2. STARTED LIDOCAINE PATCH, APPLY 1 PATCH TO RIGHT CHEST ONCE
PER DAY FOR TWO WEEKS.
3. STARTED MECLIZINE, TAKE TWO 12.5 MG TABLETS (25 MG TOTAL
DOSE) THREE TIMES PER DAY FOR NAUSEA OR VOMITING ASSOCIATED WITH
YOUR MENIERE'S DISEASE.
4. STARTED TYLENOL, TAKE TWO 325 MG TABS EVERY 6 HOURS AS NEEDED
FOR RIB FRACTURE PAIN. MAXIMUM TYLENOL DOSE 3 MG PER DAY.
.
Please review the attached medication list with your primary
care doctor at your next appointment.
Followup Instructions:
Follow-up appointments:
.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital **] COMMUNITY HEALTH CENTER
Address: 409 [**Location (un) 61346**], [**Location **],[**Numeric Identifier 46146**]
Phone: [**Telephone/Fax (1) 6511**]
Appointment: MONDAY [**11-6**] AT 12:10PM
.
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2169-11-15**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
ICD9 Codes: 2875, 496, 2851, 2449, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5981
} | Medical Text: Admission Date: [**2120-12-24**] Discharge Date: [**2121-1-10**]
Date of Birth: [**2055-4-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
SOB/fever
Major Surgical or Invasive Procedure:
Doboff tube placed by interventional radiology
PICC Placement on Right arm
Left sided thoracentesis
History of Present Illness:
Pt is a 65 y.o male with h.o esophageal ca s/p surgical
intervention, chemo/radiation, MI, HTN, HL who presents with
SOB/fever/orthopnea. Pt is a transfer from OSH where CTA
performed showed a large R.sided consolidation with b/l effusion
R>L. D-dimer 1.63, WBC 8.9, given 300CC NS, 40mg IV lasix. BNP
326. CK 33, CKMB 2.8, Trop 0.03
.
In the ED at [**Hospital1 18**] initial vitals demonstrated T 99, HR 108, BP
125/85, RR 24 sat 95%. Due to BNP and CXR findings pt was given
vanco/levo/ctx for PNA.
.
Vitals prior to transfer to ICU. HR 100-110, BP 149/70, RR 24,
sat 91% on 5L
.
Pt reports 2 days of SOB, orthopnea, cough (acute on chronic,
non-productive), +subjective fever, +sick contacts URI at home,
-CP. Otherwise denies headache/lh/dizziness/blurred
vision/+palpit chronic, -abd pain/n/v/d/c/melena/brbpr,
dysuria/hematuria, joint pain/skin rash, +poor po intake.
Reports sometimes difficulty with swallowing, unsure if
chokes/coughs during eating.
.
Past Medical History:
esophageal ca s/p esophagectomy [**8-5**], radiation+chemo
weight loss
HTN
HL
MI [**2109**]
s/p CCY
Social History:
He is married. He has four children in their 20s. He lives in
[**Location 5110**] with his wife. [**Name (NI) **] is retired from the meat cutting
industry. He does not smoke cigarettes nor has he in the past.
He drinks alcohol rarely about a six-pack per summer.
Family History:
His mother is alive at age 88 with breathing difficulties and
memory loss and heart problems.
His father is alive at age [**Age over 90 **] and was just recently diagnosed
with gastric
cancer.
He has a sister who died at age 61 of pancreatic cancer and a
sister who is alive at age 54.
There is no other family history of breast, ovarian, uterine, or
colon cancer.
Physical Exam:
Vitals: T. 97.6, BP 131/81 HR 101, RR 11 sat 98%
GEN:cachetic, ashen, frail, cooperative, alert
HEENT: nc/at, PERRLA, EOMI, anicteric.
neck: +JVP to thyroid cartilage, supple no LAD
chest: b/l ae, poor effort, decreased breath sounds RML/RLL,
also LLL. No w/c
heart:s1s2 rrr 2/6 systolic flow murmur, no r/g
abd:cachetic, +bs, soft, NT, ND, well healed surgical scars.
ext: thin, no c/c/e 2+pulses, warm
Pertinent Results:
Admission labs:
[**2120-12-24**] 12:30AM
PT-13.7* PTT-30.7 INR(PT)-1.2*
PLT COUNT-245#
NEUTS-94.2* LYMPHS-2.7* MONOS-3.1 EOS-0 BASOS-0
WBC-9.9# RBC-4.60# HGB-14.3#
HCT-39.1*# MCV-85 MCH-31.0 MCHC-36.5*# RDW-14.2
proBNP-5268*
GLUCOSE-139* UREA N-16 CREAT-0.8
SODIUM-142 POTASSIUM-3.0* CHLORIDE-100 TOTAL CO2-26 ANION GAP-19
LACTATE-1.7
[**2120-12-24**] 01:06AM URINE
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2120-12-24**] 07:02AM
ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-1.8 IRON-19*
CK-MB-3 cTropnT-<0.01
ALT(SGPT)-40 AST(SGOT)-29 LD(LDH)-133
CK(CPK)-23* ALK PHOS-143* AMYLASE-55 TOT BILI-0.8
LACTATE-1.4
TYPE-ART PO2-112* PCO2-41 PH-7.50* TOTAL CO2-33* BASE XS-8
[**2120-12-24**] 04:51PM CK(CPK)-24*
.
ECHO [**12-24**]:
Compared with the findings of the prior study (images reviewed)
of [**2119-9-25**], anteroseptal hypokinesis with focal apical
akinesis is now present.
.
CT ABDOMEN W/O CONTRAST Study Date of [**2120-12-24**] 3:38 PM
IMPRESSION:
1. Bilateral pleural effusions that are increased compared to
[**2120-7-30**].
2. Compressive atelectasis of the right lower lobe with possible
superinfection.
3. ALthough limited by lack of contrast, esophageal-gastric
anastomosis
appears intact. Collapse of the distal esophagus and stomach,
which precludes evaluation for mass. Small amount of simple
fluid just distal to the anastomosis of uncertain clinical
significance.
4. No evidence of intra-abdominal fluid collection or abscess.
Interval loss of the subcutaneous fat plane in the left mid
abdomen.
.
[**2121-1-1**] CTA Chest:
IMPRESSION:
1. Negative examination for pulmonary embolism.
2. Moderate pleural effusions, left greater than right. The left
effusion is slightly smaller. The right pleural effusion is
unchanged with persistent loculation laterally.
3. Unchanged right lower lobe consolidation.
4. Limited evaluation of the gastroesophageal pull-through and
of the upper abdomen. Specifically, evaluation for upper
abdominal lymphadenopathy is suboptimal.
Thoracentesis:
[**2120-12-30**] 12:37PM PLEURAL WBC-50* RBC-[**Numeric Identifier **]* Polys-6* Lymphs-83*
Monos-10* Macro-1*
[**2120-12-30**] 12:37PM PLEURAL TotProt-2.7 Glucose-84 LD(LDH)-84
Albumin-1.7
Pleural fluid cytology: NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
The patient is a 65 year old man with a history of hypertension,
hyperlipidemia and esophageal ca s/p surgerical
intervention/chemo/radiation, admitted to the ICU with SOB,
fever, orthopnea.
.
#SOB/fever: CXR on admission with bibasilar opacities; left side
noted to be chronic. CT chest from OSH and CT torso from
admission reviewed with unchanged pleural effusion, new RLL and
RML infiltrates. Also, difficult to track esophagus but still a
question of fistula or obstruction. Additionally, BNP elevated
on admission and CHF was also considered (see below). Patient
was initially started on VANC/levo/flag then switched to
Levo/flagyl to cover for aspiration pneumonia.
.
A thoracentesis was performed to alleviate some of his SOB/O2
requirement and assess for a malignant effusion. Pleural fluid
was negative for malignancy, but recurrence was still highly
suspected with elevated CEA and continued weight loss. A trial
of prednisone was started for his SOB and appetite. He did well
and will continue a taper. He currently requires 3L O2.
.
Given tenuous status and discussion with Dr. [**Last Name (STitle) 3274**] about
likely cancer recurrence, patient decided to shift goals of care
to comfort oriented care. He was given morphine as needed for
SOB. Still prescribing meds for comfort. He decided to work
toward hospice.
.
#CAD- BNP elevated on admission. ECHO showed interval change
from previous with
moderately-to-severely depressed (ejection fraction 30 percent).
Cardiac enzymes were negative.
.
#Esophageal ca: Paitent reported extensive weight loss and
diminished appetite. Oncology was consulted; CEA noted to be
elevated at 90. Given concern for possible malignant
recurrance, pt was transferred to the oncology service once
stable.
.
# Nutrition: Speech and swallow felt he was too ill for inital
evaluation. He was made NPO for concern of aspiration risk.
Dobhoff tube was placed via IR due to anatomy of his espohagus.
Pt was started on tube feeds. Speech and swalloe re-evaluated
on floor and clear patient for full diet. The dobhoff tube was
pulled. Nutrition recomended calorie counts and ensure
suplements.
.
# Acute likely systolic CHF: Patient with new diagnosis of CHF
with pleural effusion and EF of 30%. He was diuresed until his
Cr elevated slightly, but his effusions remained. He was then
only diuresed for symtom management.
.
# Anemia: Iron studies consistent with ACD
.
# Goals of care: as noted above, Dr. [**Last Name (STitle) 3274**] discussed
likelyhood of recurrence of cancer given elevated CEA and
continued loss of appetite and weight. The patient decided to
be DNR/DNI and to move towards hospice. He will be discharged
to [**Last Name (un) 72158**] house.
.
Medications on Admission:
lexapro 20mg daily
lipitor 5mg daily
megestrol 625mg/5ml, 5ml po daily ?
metoprolol 50mg [**Hospital1 **]
asa 325mg
colace
omeprazole 20mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
3. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
for 3 days.
4. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
for 5 days: Start after last 20 mg dose.
5. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
for 5 days: Start after last 20 mg dose.
6. Morphine Concentrate 20 mg/mL Solution [**Hospital1 **]: 10-20 mg PO Q1hrs
as needed: for respiratory distress.
7. Lexapro 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]
Discharge Diagnosis:
Aspiration Pneumonia
weight loss
Esophogeal cancer
Discharge Condition:
Feeling well, on 3L O2, comfortable.
Discharge Instructions:
You were admitted to the hospital because of shortness of
breath. You initially went to the intensive care unit because
of your need for oxygen. You recieved IV antibiotics and had a
tube placed in your nose to recieve nutrition. You were stable
to leave the intensive care unit and go to the oncology floor.
You were seen by speech and swallow team who said you were safe
to eat and so the tube was pulled. While a tap of fluid around
your lung did not show malignancy, we continue to suspect that
you have a cancer recurrence. After discussion with Dr.
[**Last Name (STitle) 3274**] about signs that indicate cancer recurrence, it was
decided to shift goals of care to comfort oriented care. You
were given morphine as needed for SOB and other meds as needed
for comfort. You will be dischaged to hospice.
.
All of your medications have been changed. Please take as
prescribed.
.
Please call your doctor or your hospice care if you have
concerns.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 3274**] at ([**Telephone/Fax (1) 3280**] as needed for an
appointment.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2121-1-10**]
ICD9 Codes: 5070, 5119, 4280, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5982
} | Medical Text: Admission Date: [**2156-6-4**] Discharge Date: [**2156-6-8**]
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: This is an 86-year-old gentleman
with multiple medical problems who sustained a fall from a
standing position and found to have a subarachnoid hemorrhage
at an outside hospital.
The patient was transferred to [**Hospital1 188**] for further care. Unknown whether he had loss of
consciousness. The patient was oriented to self only at
baseline and was unable to offer further history.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Coronary artery disease; status post coronary artery
bypass graft.
3. Congestive heart failure.
4. Benign prostatic hypertrophy.
5. Chronic renal insufficiency with left hydronephrosis.
6. Hypertension.
7. History of hematuria.
8. Gout.
9. Dementia.
MEDICATIONS ON ADMISSION:
1. Lipitor 10 mg by mouth once per day.
2. Flomax 0.4 mg by mouth once per day.
3. Potassium chloride 10 mEq by mouth every day.
4. Allopurinol 100 mg every other day.
5. Colace 100 mg by mouth twice per day.
6. Multivitamin by mouth every day.
7. Vitamin C 500 mg by mouth once per day.
8. Aspirin 81 mg by mouth once per day.
9. Remeron 15 mg by mouth at hour of sleep.
10. Aricept 10 mg by mouth once per day.
11. Lasix 40 mg by mouth in the morning.
12. Lasix 80 mg by mouth at hour of sleep.
13. Synthroid 75 mcg every other day.
14. Synthroid 50 mcg every other day.
15. Trazodone 25 mg by mouth twice per day.
16. Zyprexa 7.5 mg by mouth every day.
17. Proscar 5 mg by mouth once per day.
18. Atenolol 25 mg by mouth once per day.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives a [**Doctor First Name 391**] Bay nursing
facility.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 96 degrees Fahrenheit, his blood pressure was
101/61, his heart rate was 66, his respiratory rate was 14,
and he was saturating 98% on 2 liters of nasal cannula. The
patient was alert and oriented to self only, which apparently
is his baseline. Head, eyes, ears, nose, and throat
examination revealed a right forehead laceration. The pupils
were equal, round, and reactive to light. The tympanic
membranes were clear bilaterally. The oropharynx was clear.
The neck was in cervical collar. The tongue was midline.
Pulmonary examination revealed the lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed the patient had a regular rate and rhythm. The
abdomen was protuberant but soft, nontender, and
nondistended. He had full range of motion of all
extremities. The extremities were nontender, and no
deformities. He was guaiac-negative with normal rectal tone.
The back was nontender.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 6.6, his hematocrit was 28.4, and his
platelets were 163. Sodium was 143, potassium was 4.5,
chloride was 106, bicarbonate was 29, blood urea nitrogen was
51, creatinine was 2, and blood glucose was 108. The
urinalysis was negative. The patient had a prothrombin time
of 13.7, his partial thromboplastin time was 35.4, and his
INR was 1.3. He had a troponin of 0.01.
PERTINENT RADIOLOGY/IMAGING: His electrocardiogram showed no
ST elevations. He had Q waves in II and III (which were
likely old), and poor R wave progression.
A computed tomography of the head showed a subarachnoid
hemorrhage in the right cistern with an intraparenchymal
hemorrhage.
A computed tomography of the abdomen and pelvis showed a
large right pleural effusion, a small left pleural effusion,
fluid around the liver, gallstones, bilateral renal cysts,
and mass at the prostate. No acute injuries were found.
A chest x-ray confirmed a right pleural effusion.
A computed tomography of the cervical spine showed slight
widening of the C4-C5 disc space. The computed tomography
was negative.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Trauma Surgical Intensive Care Unit for every 1-hour
neurologic checks and cardiovascular monitoring. The patient
was started on Dilantin for seizure prophylaxis.
A Neurosurgery consultation was obtained for management of
his intracranial hemorrhages. A magnetic resonance
imaging/magnetic resonance angiography was obtained which
showed no evidence of aneurysm but confirmed known head
computed tomography intracranial hemorrhages. The cervical
spine was cleared with a magnetic resonance imaging of the
cervical spine.
Throughout, the patient remained oriented to himself only
(which apparently is his baseline). The patient had no
neurological deficits during his hospital stay.
Hematuria was noted in the Foley later on hospital day one,
and a Urology consultation was obtained. Given a negative
CTU, there was low suspicion for trauma etiology. Discussion
with primary care physician confirmed that this was an
ongoing issue and that the patient already had a urologist
(Dr. [**Last Name (STitle) 43569**] who was aware. Hematocrit reached a nadir of 25,
for which the patient was transfused one unit. His
hematocrit stabilized at 31, and the patient was to be
discharged with a Foley catheter.
A Cardiology consultation was obtained for the unknown reason
for the patient's fall and observed an erratic heart rate,
alternating between tachycardia and bradycardia. Per
Cardiology, they thought that he likely developed
supraventricular bradycardia, and his beta blocker was held.
Atenolol was decreased from 25 mg once per day to 12.5 mg
once per day.
An echocardiogram was performed which showed severe mitral
regurgitation with a flail of the anterior leaflet of the
mitral valve. The patient had an ejection fraction of 35%
and severe hypokinesis of the inferior wall and apex.
Given his multiple medical problems, the patient was not
considered an operative candidate. The plan was for the
patient to be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for
further evaluation of possible dysrhythmias.
A large right pleural effusion was noted on initial Radiology
examinations. This improved somewhat on subsequent chest
x-rays five days later. A discussion with the patient's
primary care doctor confirmed that this was an ongoing issue
which she is following.
DISCHARGE DIAGNOSES:
1. Right subarachnoid hematoma in the sylvian fissure;
which is stable.
2. Subdural hematoma in the right midbrain; which is
stable.
3. Intraparenchymal hemorrhage; which is stable.
4. Closed head injury.
5. Scalp laceration.
6. Right pleural effusion.
7. Hematuria.
8. C4-C5 disc space widening.
9. Coronary artery disease.
10. Chronic renal insufficiency with left hydronephrosis.
11. Dementia.
12. Severe mitral regurgitation with partial flail of
anterior mitral leaflet with an ejection fraction of 35% and
severe hypokinesis of the inferior wall and apex.
MEDICATIONS ON DISCHARGE: (The patient was to resume all of
his regular medications except)
1. Atenolol 12.5 mg by mouth once per day (versus old dose
of 25 mg once per day).
2. Discontinue aspirin until [**2156-7-6**].
3. The patient was to be on Dilantin 150 mg by mouth three
times per day (last dose to be given on [**6-9**]).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up in Neurosurgery with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] in two weeks (telephone number [**Telephone/Fax (1) 1669**]). The
patient needs a head computed tomography prior to this visit.
2. The patient was to follow up in Cardiology with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] in two weeks. The patient to call
telephone number [**Telephone/Fax (1) 285**]. At this time, the patient is
to have a primary cardiology evaluation as well as evaluation
of the results from the [**Doctor Last Name **] of Hearts monitor.
3. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) 43570**] within one month.
4. The patient was instructed to follow up with his
urologist (Dr. [**Last Name (STitle) 43569**] within one month.
5. The patient was to have suture removal by a medical
doctor; either his primary care physician or the medical
doctors at his [**Name5 (PTitle) **] nursing facility on [**2156-6-11**].
CONDITION AT DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE DISPOSITION: To a [**Year (4 digits) **] nursing facility
([**Doctor First Name 391**] [**Hospital **] Nursing Home).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 37631**]
MEDQUIST36
D: [**2156-6-8**] 15:31
T: [**2156-6-10**] 09:56
JOB#: [**Job Number 43571**]
ICD9 Codes: 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5983
} | Medical Text: Admission Date: [**2162-5-2**] Discharge Date: [**2162-5-6**]
Date of Birth: [**2103-7-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
malignant central airway obstruction with necrotizing pneumonia
Major Surgical or Invasive Procedure:
[**5-5**] flexible bronchoscopy
[**2162-5-4**] Flexible and rigid bronchoscopy, endobronchial biopsy,
transbronchial needle aspiration of precarinal and subcarinal
lymph nodes, balloon dilation and metal covered stent placement.
[**2162-5-3**] Flexible bronchoscopy
History of Present Illness:
58F with COPD, anxiety and bipolar, transferred from [**Hospital 1562**]
Hospital with new diagnosis of large central lung mass causing
respiratory distress that required emergent intubation. She was
intially admitted to [**Hospital 1562**] Hospital 3 days ago with shortness
of breath, cough, malaise x2 weeks s/p failing a trial of Avalox
as an outpatient. CXR done in the OSH ER showed (by report
only) a very large left mid and lower lobe infiltrate with air
fluid level suggesting emypema. CT chest (report) showed
complex, large [**Location (un) 21851**] in mediastinum obliterating L main
PA, L main bronchus, and resulting in near complete
opacification of mid-to-lower left lung. She was started on
Zosyn and Levaquin for pneumonia, Solumedrol for COPD flare,
and sedation for extreme anxiety.
She then underwent bronchoscopy with FNA on [**4-30**], which showed
>75% narrowing of left mainstem bronchus at its most proximal
portion and then quickly leading into 100% obliteration
secondary to extrinsic compression. FNA was done, which showed
malignant cells, unclear whether nonsmall cell vs. small cell
vs. potential mix of pathology. L vocal cord was also noted to
be immobile,
suggesting involvement of the left recurrent laryngeal nerve.
On [**5-1**], she developed respiratory distress and became apneic,
and had to be emergently intubated during a code blue. She was
transfused 1U PRBC's and started on Fe for anemia. She was
stabilized and sedated, and transferred here for further care by
Interventional Pulmonology.
Per the chart, she has >60 pack year smoking history, quit
drinking 2 years ago, and has no known exposure history. FH
significant for mother who died of lung CA.
Past Medical History:
PMH:
1. h/o ETOH dependence, sober x2 yrs
2. COPD - no record of PFT's, no h/o treatments for COPD in past
3. Hypothyroidism
4. Chronic anxiety disorder
5. Bipolar disorder
6. Osteoarthritis
7. Avascular necrosis of right hip
8. Anemia
Past surgical history: none
Social History:
Social history: >60 pack year smoking, currently smoking, h/o
ETOH dependence, quit 2 yrs ago, currently not working -
previously worked doing farm labor. Lives alone in [**Hospital1 1562**]
Family History:
Mother died at 58 of lung CA, father died at 57
of sudden death. She was 2 healthy children.
Physical Exam:
VS: T 96.2 HR: 86-100 ST BP 138/80 Sats: 95% 4L NC
General: appears in no apparent distress
CV: RRR, normal S1,S2, no murmur/gallop or rub
Pulm: Coarse rhonchi bilaterally
Abd: soft, nondistended, normoactive bowel sounds
Ext: no c/c/e
Neuro: anxious, response appropiately, moves all extremities
Pertinent Results:
[**2162-5-6**] WBC-12.7* RBC-4.20 Hgb-11.1* Hct-34.8* Plt Ct-324
[**2162-5-5**] WBC-11.7* RBC-3.61* Hgb-9.7* Hct-30.6* Plt Ct-267
[**2162-5-2**] WBC-17.4* RBC-3.81* Hgb-10.1* Hct-32.7* Plt Ct-294
[**2162-5-6**] Glucose-122* UreaN-11 Creat-0.5 Na-147* K-3.6 Cl-104
HCO3-30
[**2162-5-5**] Glucose-134* UreaN-9 Creat-0.5 Na-146* K-3.7 Cl-106
HCO3-31
[**2162-5-2**] Glucose-134* UreaN-6 Creat-0.6 Na-145 K-4.5 Cl-110*
HCO3-26
[**2162-5-5**] Calcium-9.6 Phos-3.6 Mg-2.1
[**2162-5-2**] Type-ART Temp-36.2 Rates-16/3 Tidal V-350 PEEP-5
FiO2-40 pO2-149* pCO2-51* pH-7.33* calTCO2-28 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2162-5-4**] Type-ART Rates-/20 PEEP-5 FiO2-40 pO2-99 pCO2-46*
pH-7.44 calTCO2-32* Base XS-5 Intubat-INTUBATED
Date/Time: [**2162-5-3**] BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2162-5-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Pending):
ACID FAST SMEAR (Final [**2162-5-4**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
CT CHEST W/CONTRAST [**2162-5-3**]
IMPRESSION:
1. Central left upper lobe mas contiguous with a mediastinal
lymph node conglomeration, most consistent with advanced lung
cancer. There is direct contact and mild compression on the
aortic arch, encasement and obstruction of the left pulmonary
artery, and encasement of the left main stem bronchus with
partially obstructing mass distally.
2. Dominant central cavity in left lung is likely related to
necrotizing post- obstructive pneumonia, but cavity component of
neoplasm is also possible.
3. Multifocal bilateral pneumonia. Multiple left-sided cavities
are consistent with necrotizing pneumonia.
4. Diffuse right peribronchial thickening may be due to either
neoplastic infiltration or infection.
5. Small bilateral pleural effusions and pericardial effusion.
6. Cirrhosis and small amount of ascites.
CHEST (PORTABLE AP) [**2162-5-5**] 4:56 AM
In the interim, there is worsening of calcification in the left
hemithorax due to combined left pleural effusion and left
post-obstructive pneumonitis from a left hilar mass, which is
obscuring the left heart border and aortic shadow. There is also
worsened air space disease in the right lung that is attributed
either to pulmonary edema and/or pneumonia. A right subclavian
central line is noted with tip in the mid-to-proximal SVC. Both
diaphragms are partially visualized secondary to bibasilar
atelectasis. A stent is noted in the left main bronchus.
IMPRESSION:
1. Worsening of pneumonia and effusion in the left lung.
Worsening edema and/or pneumonia in the right lung.
Cytology Report PRE-COU Procedure Date of [**2162-5-3**]
REPORT APPROVED DATE: [**2162-5-5**]
DIAGNOSIS: Lymph node (precarinal), fine needle aspirate:
Blood and mixed inflammatory cells.
Note: Evidence of lymph node sampling is not identified.
[**2162-5-5**]
SPECIMEN RECEIVED: [**2162-5-3**] 08-[**Numeric Identifier **] MEDIASTINAL
DIAGNOSIS: Mediastinal mass, fine needle aspirate:
POSITIVE FOR MALIGNANT CELLS,
consistent with squamous cell carcinoma.
[**2162-5-5**]
SPECIMEN RECEIVED: [**2162-5-3**] 08-[**Numeric Identifier **] BRONCHIAL WASHINGS
CLINICAL DATA: BAL of left upper lobe.
PREVIOUS BIOPSIES:
[**2162-5-3**] 08-[**Numeric Identifier **] MEDIASTINAL
DIAGNOSIS: Bronchial washing, left upper lobe:
Necrotic debris and inflammatory cells.
Brief Hospital Course:
The patient was admitted [**2162-5-2**]. On HD 2, he had a flexible
bronchoscopy was at
the bedside in the intensive care unit through an endotracheal
tube. There was
near complete occlusion of the left main-stem bronchus with
extrinsic compression was noted. The bronchoscope could not be
advanced past this obstruction. Purulent sputum was seen
emanating from the left main-stem bronchus. On the right,
severe bronchomalacia was seen in the mainstem bronchus. A small
amount of purulent secretions seen in the right upper lobe,
bronchus intermedius, right middle and lower lobe segmental
bronchi, were all suctioned clean. Vancomycin and Zosyn were
started empirically for pneumonia. A BAL was sent. later on HD
2, she was taken to the OR for a rigid bronchoscopy. Please see
operative note for full details. A biopsy of the occlusive
airway lesion revealed a non small cell lung cancer. Her LMSB
was balloon dilated to 12 mm. A 14 x 40 mm covered metal stent
was placed. A CT scan was done which showed central left upper
lobe Mass contiguous with a mediastinal lymph node
conglomeration, most consistent with advanced lung cancer. There
is direct contact and mild compression on the aortic arch,
encasement and obstruction of the left pulmonary artery, and
encasement of the left main stem bronchus with partially
obstructing mass distally. Dominant central cavity in left lung
is likely related to necrotizing post- obstructive pneumonia,
but cavity component of neoplasm is also possible. Multifocal
bilateral pneumonia. Multiple left-sided cavities are consistent
with necrotizing pneumonia. Diffuse right peribronchial
thickening may be due to either neoplastic infiltration or
infection.
Small bilateral pleural effusions and pericardial effusion.
Cirrhosis and small amount of ascites. On HD 2, she was
extubated successfully. A flexible bronchoscopy was done at the
bedside- the stent was patent and secretions were aspirated.
Saline nebs and Mucomyst nebs were started and Mucinex was
started. On HD 3, she continued to be stable. A flexible
bronch was again performed at the bedside for therapeutic
aspiration of secretions. Overnight she had an episode of
mania. Psych was consulted (see note)recommended continue
Seroquel and Haldol prn for agitation. She was seen by radiation
oncology who recommended starting XRT . She received the first
of ten 300 cGy treatment today. She tolerated the treatment
well but was mildly paranoid. The patient was stable and to [**Location (un) 21541**] Hospital.
Medications on Admission:
Meds at home: Buspar 15'', Seroquel 300' + 100QHS, Synthroid
0.113'
Meds on transfer: Levaquin, Zosyn, Solumedrol 125, Midaz,
Propofol, Lovenox
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
7. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q6H
(every 6 hours) as needed for anxiety.
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
2.5/3ml Inhalation Q4H (every 4 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: 0.2 ml Inhalation
Q6H (every 6 hours).
13. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO BID (2 times a day).
14. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1)
Intravenous every eight (8) hours.
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous TID (3 times a day).
16. Haloperidol 0.5 mg Tablet Sig: 0.5-1 Tablet PO TID (3 times
a day) as needed for agitation.
17. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five
(5) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
Cape Code Hospital
Discharge Diagnosis:
Central airway obstruction s/p metal stent placement
COPD - no record of PFT's, no h/o treatments for COPD in past
Hypothyroidism
Chronic anxiety disorder
Bipolar disorder
Osteoarthritis
Avascular necrosis of right hip
Anemia
h/o ETOH dependence, sober x2 yrs
Discharge Condition:
Stable
Discharge Instructions:
Normal Saline nebs [**Hospital1 **]
Mucomyst nebs tid
Mucinex 1200 mg [**Hospital1 **]
continue zosyn 6 weeks started [**2162-4-29**]
TLC flushes
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 7631**] [**Telephone/Fax (1) 77787**]
Follow-up with Dr. [**Last Name (STitle) 61800**] [**Telephone/Fax (1) 61801**]
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4467**] [**Telephone/Fax (1) 77788**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2162-5-7**]
ICD9 Codes: 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5984
} | Medical Text: Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-16**]
Date of Birth: [**2065-6-30**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Speech problems
Major Surgical or Invasive Procedure:
[**2150-2-6**] Left ICA endarterectomy
[**2150-2-6**] Re-exploration of left carotid endarterectomy site,
arteriogram.
History of Present Illness:
[**Known firstname 794**] is an 84year-old right-handed woman with past medical
history significant for HTN, type II DM, hyperlipidemia who
presented episode of garbled speech and word finding
difficulties. Patient stated that she felt the symptoms last
night around 8pm but she could not report the event. She
described that her comprehension was intact but the words
wouldn't come out the way she inteted, and finally she described
as gibberish speech. The symptoms seemd improved later that
night and this morning she complained right that she was not
speaking the way she uses to. Per nurse description, she was
able to follow commands. When asked what day is today and other
simple questions she kept repeating "ahh, I can't even tell". He
reported that her pupils were equally reactive to light and her
left hand was weak to grip. BP was 155/75. patient was then
transfer to [**Hospital1 18**] and trigger as stroke code. Upon arrival she
was still complaining that her speech was not back to her
baseline.
Patient was admitted had a similar event in [**2149-10-21**]
characterized by garbled speech. Her examination was nonfocal
during hospitalization. Her workup included an MRI/MRA of the
brain, which was overall unrevealing, and telemetry. Workup for
toxic metabolic etiologies was unrevealing as well. She also had
a normal EEG study. The only abnormalities noted were elevated
LDL of 106.
ROS:
The patient denied headache, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, She had lightheadedness,
vertigo, yesterday during OT section. Denied focal weakness,
numbness, parasthesiae.
The pt denied recent fever or chills. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Denied arthralgias or myalgias.
Denied rash.
Past Medical History:
Essential hypertension
Hyperlipidemia
Peripheral neuropathy
Type II DM
Back pain
Admission to stroke service with possible diagnosis of TIA.
Left hip fracture after a fall with recent discharge on [**2150-1-28**]
Social History:
Independent in ADLs and IADLs. Widowed. Lives alone in senior
housing in [**Location (un) **]. Has a daughter and son, both of whom live
nearby and are involved in care. Denies ETOH, Tobacco, IVDU.
Family History:
M died in her 90s, but had a h/o of "heart disease". Sister had
bypass surgery but died several weeks ago from complications of
Alzheimer's
Physical Exam:
Per admitting resident
Physical Exam:
Vitals: T: afebrile P:83bpm R: 17 BP: 176/65mmHg
General: Awake, cooperative, NAD.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic: Patient's neuro exam was not consistent as she
fluctuates in some responses.
-Mental Status: awake, oriented x 3. Able to relate history with
some difficulty. Patient was not able to name [**Doctor Last Name 1841**] backward, but
she did forward. Language is fluent with intact repetition and
comprehension. Normal prosody. Pt. was able to name high
frequency objects but has significant difficulties with low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands, but she had clear signs of apraxia and somehow
perseverating in the tasks. She demonstrated left-right
confusion. patient was not able to write. At first she was not
able to calculate, but later she answered correctly.
CN
I: not tested
II,III: VFF to confrontation, pupils 3mm->2mm bilaterally, fundi
normal
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**3-25**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; no asterixis or myoclonus. Right
pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 4+ 5 4+ 5- 5- 5-
R 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L not tested hip fract 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 2 Flexor
R 2 2 2 2 2 Flexor
-Sensory: No obvious deficits to light touch, pinprick.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: not tested.
Exam On discharge:
T: 97.8 HR: 70 BP:127/64 RR: 16 Spo2: 97%
Gen: NAD, expressive aphasia
Cardiac: No carotid bruit
Lungs: CTA bilaterally
Abd: soft, NT, ND, no rebound, gaurding
Left neck incision cdi, no erythema or induration. Healing
ridge. Steri strips intact
Extremities: Minimal movement of right upper and lower
extremity. Able to move right toes on command at times.
Pulses: Fem [**Doctor Last Name **] DP PT
[**Name (NI) 2325**] palp palp palp palp
Right palp palp palp palp
Pertinent Results:
[**2150-2-4**] 12:14 am URINE Source: CVS.
**FINAL REPORT [**2150-2-5**]**
URINE CULTURE (Final [**2150-2-5**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
CT head [**2-3**]
IMPRESSION:
1. No evidence of intracranial hemorrhage or large [**Month/Year (2) 1106**]
territorial
infarct. If clinical suspicion is high for ischemic event, MRI
is more
sensitive if not contraindicated.
2. Stable appearance of small vessel ischemic disease and
age-related
involutional changes.
3. Patent intracranial vasculature without evidence of focal
stenosis,
occlusion, large aneurysm, or dissection. Moderate non-occlusive
atherosclerotic calcifications within the aortic arch, at the
origin of great
vessels, and at bilateral common carotid bifurcations, left
greater than
right. Distal internal carotid arteries measure 4mm bilaterally.
4. Prominent anterior spondylosis and widening of anterior
intervertebral
disc space at C6-7, probably degenerative in nature. If there is
clinical
suspicion for ligamentous injury or history of trauma, further
evaluation by
MRI may be of benefit.
The study and the report were reviewed by the staff radiologist.
CXR [**2-3**]
IMPRESSION: No acute cardiopulmonary process.
MRI/A [**2-3**]
IMPRESSION:
1. No evidence of an acute infarct, hemorrhage or mass.
2. Stable areas of white matter hyperintensity are a nonspecific
finding, but
likely represent the sequela of chronic microangiopathy given
the patient's
age. Dialted ventricles can relate to volume loss; however, to
correlate
clinically to exclude associated NPH.
3. Stable focus of susceptibility artifact in the right
cerebellar
hemisphere, likely represents the sequela of prior hemorrhage.
No new focus
of hemorrhage is identified.
4. No evidence of a hemodynamically significant stenosis,
occlusion or
aneurysm more than 3mm, within the limitations of the MRA
technique.
[**2150-2-11**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman s/p L CEA c/b stroke
REASON FOR THIS EXAMINATION:
evaluate for swallow
Final Report
INDICATION: Status post left CEA complicated by stroke, coughing
with solid
food intake, evaluate for swallow.
VIDEO OROPHARYNGEAL SWALLOW: The study was conducted in
collaboration with
speech pathology. Various consistencies of barium was
administered by mouth.
There is no significant retention in the valleculae or piriform
sinuses.
There is a small amount of penetration into the vestibule seen
with thin
consistency barium. There is no definite aspiration seen into
the airway.
IMPRESSION: Penetration with thin consistency barium.
Please refer to the complete report from speech pathology that
is available on
CareWeb.
The study and the report were reviewed by the staff radiologist.
[**2150-2-10**]
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 147**] VICU [**2150-2-10**] 3:17 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 28615**]
Reason: eval for hemorrhagic transformation/interval change
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with s/p large L stroke s/p L CEA
REASON FOR THIS EXAMINATION:
eval for hemorrhagic transformation/interval change
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Large left infarction, status post left carotid
endarterectomy.
COMPARISON: [**2150-2-7**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is a large evolving watershed infarction in the
left cerebral
hemisphere, involving both the anterior/middle cerebral arterial
watershed
territory and the middle/posterior cerebral arterial watershed
territory.
There is no change in associated edema or mass effect. There is
minimal tilt
of the septum pellucidum to the right, as before. There are
small faint foci
of hyperdensity in the infarcted left parietal cortex, (images
2:23, 2:20),
which could represent microhemorrhage or mineralization related
to
pseudolaminar necrosis. There is unchanged effacement of the
posterior left
lateral ventricle. There are unchanged scattered hypodensities
in the right
hemispheric white matter, without mass effect, likely related to
chronic small
vessel ischemic disease.
Internal carotid and vertebral arterial calcifications are again
noted. The
bones are unremarkable. The imaged paranasal sinuses and mastoid
air cells
are well aerated.
IMPRESSION:
Evolving large watershed infarction in the left cerebral
hemisphere with
unchanged mass effect. Scattered small foci of parietal cortical
hyperdensity, which could indicate microhemorrhage or
pseudolaminar necrosis
of the infarcted cortex. No large hemorrhagic transformation.
[**2150-2-10**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with postoperative stroke s/p L CEA
REASON FOR THIS EXAMINATION:
eval stroke progression
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: ENYa SAT [**2150-2-7**] 12:22 PM
Interval progression of hypodensity in the left
occipito-parietal region
extension superior to the left frontoparietal region in the
vertex, compatible
with interval increase of cerebral edema and evolution of the
known stroke. No
acute intracranial hemorrhage. No significant shift of midline
structures.
Final Report
HISTORY: 84-year-old woman, postoperative strokes, status post
left CEA.
Assess for stroke progression.
COMPARISON: CT cerebral perfusion analysis on [**2150-2-6**] at
4:18 p.m.
TECHNIQUE: Non-contrast MDCT images were acquired from the
brain.
FINDINGS: Compared to the study approximately 19 hours ago,
there is
increased extensive hypodensity spanning in the left
occipitoparietal region
extending superiorly to the frontoparietal region in the vertex.
There is no
acute intracranial hemorrhage. The prominent ventricles are
grossly
unchanged, allowing for mild mass effect from the increased
cerebral edema as
described before. There is no evidence of developing
hydrocephalus.
There is minimal shift of midline structures, but no evidence of
herniation.
Marked periventricular hypodensities are compatible with
moderate underlying
microvascular ischemic disease.
Mild scattered opacification of the ethmoid air cells is noted.
The remaining
visualized paranasal sinuses and mastoid air cells are clear.
There is no
acute fracture.
IMPRESSION: Interval increase of extensive hypodensity spanning
the left
occipitoparietal to the frontoparietal region, compatible with
evolving
watershed infarcts. No acute intracranial hemorrhage. No
significant shift
of midline structures or developing hydrocephalus.
The study and the report were reviewed by the staff radiologist.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2150-2-12**] 04:12AM 7.1 3.55* 9.8* 29.6* 83 27.6 33.1 17.2*
370
Source: Line-art
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2150-2-4**] 05:10AM 69.7 21.8 4.3 3.6 0.6
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2150-2-12**] 04:12AM 370
Source: Line-art
LAB USE ONLY
[**2150-2-12**] 04:12AM
Source: Line-art
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2150-2-13**] 05:39AM 0.6 3.6
Source: Line-cvl
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2150-2-11**] 02:57AM Using this1
Source: Line-right subclavian CVL
Using this patient's age, gender, and serum creatinine value of
0.5,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2150-2-4**] 05:10AM 20 21 223 971 70 0.6
NEW REFERENCE INTERVAL AS OF [**2149-11-24**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
OTHER ENZYMES & BILIRUBINS Lipase
[**2150-2-4**] 05:10AM 26
CPK ISOENZYMES CK-MB cTropnT
[**2150-2-4**] 05:10AM <0.011
[**2150-2-4**] 05:10AM NotDone2
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2150-2-13**] 05:39AM 8.4 2.8 1.9
Source: Line-cvl
DIABETES MONITORING %HbA1c eAG
[**2150-2-4**] 05:10AM 6.2*1 131*2
[**Doctor First Name **] RECOMMENDATIONS:; <7% GOAL OF THERAPY; >8% WARRANTS
THERAPEUTIC ACTION
ESTIMATED AVERAGE GLUCOSE, CALCULATED FROM A1C USING ADAG
EQUATION.
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2150-2-4**] 05:10AM 165 156*1 45 3.7 89
LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
PITUITARY TSH
[**2150-2-4**] 05:10AM 5.5*
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2150-2-4**] 05:10AM NEG NEG1 NEG NEG NEG NEG2
NEG
80 (THESE UNITS) = 0.08 (% BY WEIGHT)
POSITIVE TRICYCLIC RESULTS REPRESENT POTENTIALLY TOXIC
LEVELS;THERAPEUTIC TRICYCLIC LEVELS WILL TYPICALLY HAVE NEGATIVE
RESULTS
LAB USE ONLY EDTA Ho RedHold
[**2150-2-8**] 02:50AM HOLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat Comment
[**2150-2-7**] 05:59AM 7.44 GREEN TOP
[**2150-2-7**] 01:53AM 7.47* GREEN TOP
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2150-2-6**] 02:14PM 141* 1.9 138 3.8 107
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT
[**2150-2-6**] 02:14PM 9.2* 28
CALCIUM freeCa
[**2150-2-7**] 05:59AM 1.20
[**2150-2-7**] 01:53AM 1.06*
Brief Hospital Course:
Ms. [**Known lastname 28613**] was admitted to neurology service stroke for
evaluation of recurrent episodes of speech difficulties. She
underwent CT scan of head with CTA head/ neck which did not show
any acute infarct , however suggested stenosis at the left
internal carotid artery. This was in accordance with the carotid
ultrasound few days ago, which showed the stenosis at the level
of left ICA as well.
It was discussed with the [**Known lastname 1106**] surgery team. The recurrent
epsiodes of speech problems are consistent with TIAs originating
from the left ICA affecting the language area leading to the
clinical presentation. The risk of stroke was considerable and
hence after discussion with patient and family, she was
scheduled for carotid endarterectomy on [**2150-2-7**]. She underwent
the endarterectomy with no intraoperative complications.
Postoperatively she was noted to have right upper extremity
weakness and recurrent aphasia. A heparin drip was started and
she was taken emergently back to the operating room and an
angiogram was performed. This showed the endarterectomy site to
be widely patent. A cerebral arteriogram
was performed which did not show any major vessel cut off. At
this point, the decision was made to maintain the patient on
heparin perform a CT scan.
The neurology stroke team was consulted in the recovery room.
The CT showed left watershed infarcts. Supportive care and
heparinization were continued. Postoperatively she made a slow
recovery however has progressed well. She was seen by speech
and swallow and her diet was slowly advanced as she improved.
She still has limited use of her RUE but she regained her
speech. She has right sided neglect, but is able to overcome
this intermittently. She is slowly progressing with physical
therapy, occupational therapy and speech. The decision was made
to not initiate coumadin anticoagulation and instead the patient
was continued on aspirin and double dose Plavix. Patient
tolerating diet well with aspiration precautions. CYP2C19 test
for plavix resistance sent to outside lab.
On [**2150-2-16**] the patient was discharged to Rehab [**Hospital3 2558**].
She will follow-up with [**Hospital3 **] Surgery and Neurology on an
outpatient basis.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Cholecalciferol (Vitamin D3) 400 unit [**Unit Number **].5 Tablets DAILY
3. Cyanocobalamin 500 mcg Two (2) Tablet PO DAILY
4. Docusate Sodium 100 mg 1 Capsule PO BID
5. Acetaminophen 325 mg 2Tablet PO Q6H PRN for pain
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
7. XIBROM 0.09 % Drops Sig: ASDIR Ophthalmic ASDIR.
8. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Gabapentin 100 mg [**11-22**] Capsules PO HS (at bedtime).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. T.E.D. Sequnt Compress Device Misc Sig: ASDIR
Miscellaneous once a day.
14. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aphasia
Symptomatic Left Carotid Artery Stenosis
Postoperative CVA
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
.
Division of [**Location (un) **] and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call [**Location (un) 1106**] surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
We have increased your dose of simvastatin to 40mg day and have
added plavix to your medications.
Please take your medicines as advised. Please call if you have
any concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-2-24**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2150-3-12**] 2:30
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2150-3-19**]
9:00
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2150-3-24**] 3:00
Completed by:[**2150-2-16**]
ICD9 Codes: 2449, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5985
} | Medical Text: Admission Date: [**2194-11-10**] Discharge Date: [**2194-11-17**]
Date of Birth: [**2128-8-7**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Bactrim
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Bronchoscopy [**2194-11-11**]- with severe malacia distal to the stent.
History of Present Illness:
66 year old female with history of COPD on home O2, CAD, CHF
with diastolic dysfunction, tracheomalacia s/p Y stent last in
[**7-/2194**], recent RUL MRSA pneumonia; admit on [**11-10**] to
thoracics/IP service with multifocal pneumonia. She was
admitted to OSH in [**Month (only) 359**] for MRSA pneumonia and treated with
IV vancomycin with eventual transition to PO bactrim and
discharged to rehab. Discharged home from rehab on [**11-7**]. Doing
well at home until [**11-9**], when developed worsening cough,
shaking chills, and noted fever to 102. Called EMS; upon
arrival temp > 103. Brought to OSH and noted to have multifocal
pneumonia on CXR. Transferred to [**Hospital1 18**] for continued care.
.
Arrived at [**Hospital1 18**] last night. Admitted to IP. Vancomycin given.
Flex bronch performed this morning. Bronch showed stent in
place (but malacia distal to stent); thick brown secretions.
BAL of superior segment of LLL performed. 4 versed and 100
fentanyl given. Following the procedure, she required
increasing O2 (6L with transition to NRB). Noted to be wheezy.
Nebs and solumedrol given. Admitted to ICU due to increasing O2
requirements.
Patient reports a cough with production of white with sometimes
tan and sometimes blood streaked mucous. No current/recent CP
(does report intermittent chest tightness during rehab stay when
breathing more difficult and wheezing). No abdominal pain,
nausea. No dysuria. +diarrhea.
MICU course: The pt was initially admitted to the IP service two
days ago for MRSA multifocal pneumonia as most of her care is
here. Got bronched here, got bronchospasm vs sedation from the
bronch. With the wheezing she was placed on a non rebreather.
She improved to 4L, which is her baseline. She still has diffuse
multifocal pneumonia. She is currently on Vancomycin and wsa
tapered from IV steroids to PO prednisone. A PICC was placed
bedside for a 14 day course of abx. Pending results for bronch
results. She will remain on coumadin for mitral valve
replacement.
Past Medical History:
- Tracheomalacia s/p tracheal Y-stenting in [**5-31**] and [**8-1**]
- COPD - reported on 3L O2 in the past; most recently on 1 L NC.
Prior PFTs also showing restrictive defect ([**8-/2194**])
- CAD, s/p CABG, with LAD and LCx stenting
- CHF, diastolic dysfunction
- CRI (baseline Cr low-1s): erythropoietin deficiency
- AFib
- GERD
- Gout
- Obstructive sleep apnea - on home CPAP (reports setting of 10)
- HTN
- Hyperlipidemia
- Hypothyroidism
- Depression
- Obesity
- Discoid lupus (inactive)
- s/p MVR with St. Jude valve ([**2188**]), on coumadin
- s/p L parietal CVA ([**2186**]), no residual neurologic deficits
- h/o bladder CA
- h/o colonic polyps and diverticulosis
- s/p cholecystectomy, t&a, tubal ligation, C-section, vocal
cord
polyp excision
Social History:
15 yr hx tobacco, 1pk every 3d, quit [**2186**]
Occasional EtOH
Disability
Lives alone, just moved to new home without stairs
Divorced, one daughter
[**Name (NI) **] IVDU
Family History:
Cardiomyopathy
AFib
Valvular heart disease
Older sister - RA
[**Name (NI) **] sister - COPD ([**Name2 (NI) 1818**]), GERD
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 5 cm.
CARDIAC: RR, ,metallic S1, S2. ii/vi SEM at LLSB No r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Aeration was diminished
throughout, with some end expiratory wheezes at LLB, some
crackles at LLB CTAB. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Left/Right: Carotid 2+ Radial 2+
Pertinent Results:
[**2194-11-11**] CXR Multifocal bilateral pneumonia. No pneumothorax. No
pleural effusion.
.
ECG: NSR at 92, NANI. Does have S wave in I, Q in III and TWF
in III, but all are unchanged from prior dated [**2194-8-12**].
.
PFTs Date: [**2194-9-23**]
Actual Pred %Pred Actual %Pred
TLC 3.37 4.23 80
FRC 1.61 2.41 67
RV 1.60 1.65 97
VC 1.77 2.58 69
IC 1.76 1.82 97
ERV 0.01 0.76 1
RV/TLC 47 39 122
He Mix Time 2.25
FVC Actual: 1.55 % Predicted: 60
FEVI Actual: 1.26 % Predicted: 68
DLCO Actual: 10.24 % Predicted: 59
.
Echo [**2194-8-11**]: EF >55%. TR gradient 47-59. Bileaflet MVR with
normal motion and gradients. 1+ MR, 1+TR, mod PA HTN.
.
PA/LAT [**2195-11-11**]: 1. Multifocal bilateral pneumonia.
2. Status post CABG and aortic valve replacement.
.
PORTABLE CXR [**2194-11-12**]: In comparison with the study of [**11-11**],
there is continued diffuse bilateral airspace consolidation
representing multifocal bilateral pneumonia. No definite pleural
effusion. There is evidence of a prosthetic mitral valve and
previous CABG procedure. Broken second metallic suture is also
seen.
.
[**2194-11-12**] PICC placement: 1) Left-sided PICC with tip projecting
over the right atrium and will need to be withdrawn
approximately 2 cm. 2) Worsening bilateral air space opacities
likely representing worsening multifocal pneumonia. 3) No
pleural effusion. No pneumothorax.
.
[**2194-11-13**] Abdominal u/s: 1. Limited evaluation of the liver, but
no intrahepatic biliary ductal dilatation. 2. Common hepatic
duct is prominent, measuring up to 6 mm, which could be within
normal range for patient's age or could be related to prior
cholecystectomy; however, choledocholithiasis cannot be
excluded, and correlation with MRCP can be performed if
clinically indicated.
.
[**2194-11-14**] PA and lateral: Multifocal pulmonary consolidation
which has been present in the past, reappeared on [**11-11**],
improved on [**11-12**], and has remained stable subsequently.
Although this could be multifocal infection, in the past,
abnormalities like this have been due to pulmonary hemorrhage,
sometimes due to over anticoagulation. Mild chronic cardiomegaly
and pulmonary vascular engorgement suggesting at least
borderline cardiac decompensation are also noted.
Tracheobronchial stent in place. Status post MVR.
Brief Hospital Course:
66 yr old female with severe COPD, tracheomalacia, recurrent
MRSA pneumonia presenting with shortness of breath.
1)Respiratory distress. Patient initially presented for bronch.
She developed wheezing, dyspnea, and increased O2 requirement
following bronch. Treated with nebs and solumedrol. Likely
related to airway reactivity. Transitioned to prednisone and
needs to complete taper as outlined in medication list.
Treatment of pneumonia as below. Follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **]
recommended - his secretary will call rehab facility to set up
appointment.
2) Pneumonia. Pt presented with multifocal pneumonia, high
fevers. Living at home but 3 days PTA was in nursing
facility/rehab, so covered broadly. Later Bronchialveonar
lavage revealed MRSA and proteus sp which was pansensitive.
Initially on Vanco/Zosyn, then changed to Vanco and Ceftriaxone.
Needs 14 day total course
3) COPD. On home O2. Likely contributed to Resp distress. S/p
Bronch [**11-11**] by Interventional pulmonology. Nebulizers
uptitrated and steroid taper in place.
4) s/p MVR. On coumadin, goal 2.5-3.5. Recent echo with valve
in good position, 1+MR. ON coumadin, but sub-therapeutic so on
heparin gtt to bridge. Once therapeutic after one day will stop
heparin.
5) Anemia. Slightly below baseline, likely [**1-25**] anemia of
inflammation from acute illness. Continued on Iron
supplementation.
6) Congestive heart failure. Preserved EF, ?diastolic
dysfunction. MVR in place. Appears slightly hypervolemic
currently, but improved compared to baseline.. Continued home
bumex dosing. Not on BB likely b/c of COPD, but not on ACEI for
unclear reasons. This should be addressed with primary care.
7) Transaminitis. ALT 113 at OSH, AST 45. Mildly elevated ALTs
now and in past here. ?NAFLD. Outpatient follow up recommended.
8) Depression. Continued home venlafaxine, benzos, lexapro.
9) CRI. At baseline creatinine of 0.8 at time of discharge to
rehab.
10) Afib. Currently in sinus. Continued verapamil, coumadin.
Medications on Admission:
D51/2 NS with 20 mEq KCl at 50 ml/hr
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Acetaminophen 650 mg PO Q6H:PRN fever
Allopurinol 100 mg PO BID
Guaifenesin [**5-3**] mL PO Q6H:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezes
Influenza Virus Vaccine 0.5 mL IM ASDIR
Aspirin 81 mg PO DAILY
Levothyroxine Sodium 50 mcg PO DAILY
Atorvastatin 80 mg PO DAILY
MethylPREDNISolone Sodium Succ 40 mg IV Q8H
Benzonatate 200 mg PO TID
Bumetanide 1 mg PO BID
Montelukast Sodium 10 mg PO DAILY
CloniDINE 0.1 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Clonazepam 0.5 mg PO BID
Tiotropium Bromide 1 CAP IH DAILY
Colchicine 0.6 mg PO BID
Vancomycin 1000 mg IV Q 24H
Escitalopram Oxalate 20 mg PO DAILY
Verapamil SR 240 mg PO Q24H
Ferrous Sulfate 325 mg PO DAILY
Venlafaxine XR 150 mg PO DAILY
Zolpidem Tartrate 10 mg PO HS Order date: [**11-10**] @ 2222
.
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO every eight (8) hours.
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
15. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): as per insulin sliding scale
which is attached to DC form.
18. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
22. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
23. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime):
will need repeated INR check as on heparin drip and coumadin
until in therapeutic range 2.5-3.5.
24. 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.
25. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours): can check a vanc level
in two days and dose for range of 15-20
END [**11-28**] .
26. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours): total 14 days.
End [**11-28**].
27. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Four
(4) Tablet Sustained Release PO once a day.
28. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 4 days: end [**11-20**] to decrease dose per taper.
29. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 4 days: end 12/1 per taper.
30. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days: to end [**11-26**].
31. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
to maintain on 5 mg.
32. Heparin (Porcine) in NS 10 unit/mL Kit Sig: Eight Hundred
Fifty (850) units Intravenous once a day: ON HEPARIN DRIP. for
subtherapeutic INR. 850/HR. TITRATE PER PTT. PLEASE SEE ATTACHED
schedule.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Multifocal pneumonia with Staph Aureus and Proteus Mirabilis
COPD
Tracheomalacia
Discharge Condition:
stable on 2.5L oxygen on IV antibiotics Vancomycin and
Ceftriaxone by PICC line and heparin drip for subtherapeutic INR
and mechanical valve to rehabilitation facility
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted with a mutlifocal pneumonia and had
bronchoconstriction in the setting of a bronchoscopy. The
samples grew out staph aureus and proteus mirabilis. Two
organisms that are being treated with Vancomycin and Ceftriaxone
for 14 day course via your PICC line.
-Please continue to take your antibiotics Vancomycin and
Ceftriaxone for fourteen day total course.
-Please continue prednisone taper to 5 mg standing dose to be
discussed with your PCP
[**Name10 (NameIs) 21421**] continue heparin drip for subtherapeutic INR until INR
is between 2.5 and 3.5
-Please continue to hold Statin and allopurinol in the setting
of elevated liver tests until discussed with PCP. [**Name10 (NameIs) **] should be
reassessed and followed as an outpatient with potential MRCP if
no resolution.
-Your foley is still in but should be removed with voiding trial
at the rehab facility.
Followup Instructions:
You are going to acute rehabilitation.
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1692**] [**Last Name (NamePattern1) 42167**] [**Telephone/Fax (1) 54195**] for follow
up appt.
Please follow up with Interventional Pulmonary. You will need to
call Dr. [**First Name (STitle) **] [**Name (STitle) **] at ([**Telephone/Fax (1) 17398**] for an appointment in the
next 2 weeks.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5986
} | Medical Text: Admission Date: [**2182-10-15**] Discharge Date: [**2182-10-27**]
Date of Birth: [**2148-6-12**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
ascending aortic dissection
Major Surgical or Invasive Procedure:
sp repair of ascending aorta/hemi arch dissection [**2182-10-15**]
History of Present Illness:
34 M w/ hx of chest pain and back pain X 3 days. Hx of
hypertension, but poor compliance with medications.
ECG diffue ST elevations.
CT chest type A aortic dissection
Past Medical History:
Hypertension
Social History:
marijuana Qday
Family History:
? dissection
Physical Exam:
moderate distress
RRR, holosystolic murmur
CTAB
soft, NT, ND
Pertinent Results:
[**2182-10-15**] 09:57PM PT-19.7* PTT-150* INR(PT)-2.5
[**2182-10-15**] 09:57PM PT-19.7* PTT-150* INR(PT)-2.5
[**2182-10-15**] 11:22PM TYPE-ART PO2-467* PCO2-50* PH-7.37 TOTAL
CO2-30 BASE XS-2
[**2182-10-15**] 08:49PM PLT COUNT-163
[**2182-10-15**] 08:49PM WBC-9.3 RBC-4.40* HGB-12.6* HCT-35.6* MCV-81*
MCH-28.6 MCHC-35.4* RDW-13.0
[**2182-10-15**] 04:40PM GLUCOSE-103 UREA N-13 CREAT-1.3* SODIUM-140
POTASSIUM-3.1* CHLORIDE-97 TOTAL CO2-30* ANION GAP-16
[**2182-10-15**] 06:15PM D-DIMER-3340*
[**2182-10-15**] 04:40PM CK-MB-2 cTropnT-<0.01
[**2182-10-15**] 04:40PM WBC-8.5 RBC-4.99 HGB-14.4 HCT-40.6 MCV-82
MCH-28.9 MCHC-35.5* RDW-13.0
[**2182-10-15**] 04:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
Brief Hospital Course:
Hospital course was complicted by acute renal failure. Renal
recommended renal US and MRI which were boht WNL. Renal
function improved with time. Multiple anti hypertensive
medications added (please see medication list).
Pt was tolerating a regular diet and pain was well controlled on
PO pain medications upon DC. Pt was cleared by pphysical
therapy and was DC's to home with VNA on POD 11.
Medications on Admission:
lisinopril 40 PO QDay, Maxide 75/50, Norvasc 10 PO QDay
Discharge Medications:
1. 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:*2*
2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
6. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*30 Patch Weekly(s)* Refills:*2*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Captopril 25 mg Tablet Sig: Six (6) Tablet PO TID (3 times a
day).
Disp:*540 Tablet(s)* Refills:*2*
10. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*2*
11. Hydralazine HCl 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
sp repair of ascending aorta/hemi arch dissection [**2182-10-15**]
Discharge Condition:
stable
Discharge Instructions:
Please call physician if experiencing redness/drainage from the
wound, chest pain/shortnes of breath, persistent
nausea/vomiting.
Do not lift > 10 lbs for 6 weeks. Do not swim or bath for 6
weeks. [**Month (only) 116**] shower. Follow cardiac healthy diet. Follow up
with PCP regarding new medications (captopril, clonidine patch,
HCTZ, hydralazine, labetolol).
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1290**] in 4 weeks; call the office
for an appointment [**Telephone/Fax (1) 170**].
Follow up with PCP [**Last Name (NamePattern4) **] [**1-25**] weeks regarding new anti-hypertensive
medications (see above).
Completed by:[**2182-10-28**]
ICD9 Codes: 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5987
} | Medical Text: Admission Date: [**2132-10-18**] Discharge Date: [**2132-10-28**]
Service: MEDICINE
Allergies:
Keflex / Ambien
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83M with PVD s/p balloon angioplasty to both legs presents with
increasing shortness of breath, bilateral leg swelling x2 weeks,
and substernal chest pain this evening lasting at least 20
minutes. Chest pain occured while he was getting into bed; he
thought it was indigestion and took a tylenol for it, with
eventual resolution in He recently had a toe amputation 1 week
ago [**3-8**] arterial insufficiency and has been relatively less
mobile during this time. He developed some dyspnea with the CP
today and then presented to [**Hospital3 **]. There, CXR showed
pulm edema, also had an elevated BNP and TnI. D-dimer was also
elevated at 393. Lidocaine was started for VT and he was
transferred to [**Hospital1 18**].
.
In the [**Hospital1 18**] ED, afebrile, pulse 80s, BP 100s/60s, RR 28, Sat
80%RA, 100% NRB. Started heparin gtt, ASA, and given lasix 20mg
IV.
Past Medical History:
Hypertension
Peripheral Vascular Disease
Hip replacement in [**2130**]
L toe osteomyelitis leading to partial amputation one week ago
Social History:
Lives with wife; has two grown children. Prior smoker, quit many
years ago. No alcohol.
Family History:
Son w/ CAD at young age
Physical Exam:
VS:108/62, 82, 22, 96%RA
HEENT: MMM, No appreciable JVD
Heart: RRR, III/VI SEM at URSB
Lungs: Decreased breath sounds in the bases, mild crackles to
midlung, no wheezes, mild rhonchi in L midlung.
Abdomen: Soft, NT, ND, BS+, No HSM
Ext: Partially amputated L second toe w/ 2 sutures in place. No
LE edema. Pedal pulses dopplerable. Radial pulses 2+ and equal.
Neuro: A/OX3, CNII-XII grossly intact w/ slight facial droop to
R.
Pertinent Results:
[**2132-10-18**] echo
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 10-20mmHg.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (LVEF = 25 -30%). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is markedly dilated with
mild global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (area 1.2cm2). The mitral valve leaflets are
mildly thickened. The mitral valve leaflets are elongated. Mild
to moderate ([**2-6**]+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] 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.
[**2132-10-18**] LE doppler: No e/o DVT
[**2132-10-18**] CXR
EMI-UPRIGHT VIEWS OF THE CHEST AT 12:10 A.M.: There are moderate
bilateral
pleural effusions, with associated atelectasis. Pulmonary
vasculature appears
slightly engorged, and increased opacity at both lung bases
likely reflect
mild pulmonary edema. The heart is enlarged. There is no hilar
or
mediastinal enlargement. There is no pneumothorax. Soft tissue
and bony
structures are notable for convex leftward curvature of the
upper spine, but
are otherwise unremarkable.
IMPRESSION: Moderate bilateral pleural effusions, enlarged heart
and mild
pulmonary edema.
Brief Hospital Course:
83M with PVD, HTN, history of tobacco, presents with CHF and
NSTEMI; hihg-risk features in this patient include the presence
of chest pain at rest, positive biomarkers, CHF signs/symptoms,
and patient already on ASA.
.
# CAD/Ischemia: NSTEMI in pt with existing CAD-risk equivalent.
High risk feature of CHF. Pt. had indigestion on the day after
admission which responded to 2 sublingual nitroglycerin was not
associated w/ ECG changes and did not return. Pt. was initially
scheduled for catheterization, but was unable to lay flat for
procedure due to orthopnea. It was decided that pt. would be
high risk for cath and may require intubation from which he
would be a very difficult wean. It was determined that given his
history of severe PVD he likely has 3vd without a single
intervenable culprit lesion and that he would be a very poor
candidate for CABG given his debilitated state. He will f/u with
cardiologist as an outpt. for possible future catheterization
when he is more able to lay flat. His medical regimen was
optimized w/ ASA, plavix, BB, ACEI and he was diuresed several
liters after which his orthopnea significantly improved. CT
coronaries was considered but decided against because either
result (3vd vs. single lesion) would require a catheterization
for confirmation.
.
# PUMP: LVEF is 25% with moderate AS (1.2cm2), mild-to-moderate
MR, and severe TR. Pt. appeared severely volume overloaded on
presentation and could not be cathed secondary to orthopnea. He
was diuresed several liters with furosemide and acetazolamide
and his oxygen requirement and orthopnea decreased progressively
with diuresis.
.
#Hypercarbia: pt. was noted to have a compensated respiratory
acidosis in addition to his initial hypoxia. This was not
entirely explained by his pulmonary edema as CO2 is soluble in
water. His mental status improved with diuresis, and an ABG was
not rechecked after he improved but it is likely that his lungs
were stiff from edema fluid increasing the difficulty of
breathing and thus causing him to hypoventilate.
.
# Rhythm: afib, new diagnosis, was started on warfarin,
metoprolol for rate control. Pt. had no episodes of RVR.
.
#HTN: Pt. was initiated on several new antihypertensive
medications and for most of his admission his BP was normal to
low. He had several episodes of SBP in high 70's, usually in the
afternoons when sitting up in the chair during which he mentated
appropriately and produced significant UOP. He was also noted to
be orthostatic by PT. He had been taking midodrine at home but
we did not restart this as he has known PVD and now CAD w/ low
EF. We decreased his diuresis and encouraged PO intake as he
appeared dry on exam.
.
# elevated D-dimer: PE was not very high on the differential as
pt. was short of breath and hypoxic but clearly in florid heart
failure. Pt. was r/o for DVT/PE w/ LE dopplers
.
# Depression: continued home duloxetine 30mg daily and trazodone
50mg QHS.
.
# Macrocytic anemia: Pt. was on B12, thiamine, folate
supplementation. TSH normal. Vitamin B12 and folate studies were
pending on d/c.
.
# Code: full
.
Medications on Admission:
lisinopril 20mg daily
ASA 81mg daily
lasix 20mg daily
duloxetine 30mg daily
trazodone 50mg QHS
thiamine
folic acid
MVI
Vit C
Vit B12
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
10. Cyanocobalamin 250 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
19. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
21. Outpatient Lab Work
INR on [**2132-10-31**] , results to be sent to Dr. [**Last Name (STitle) **] rehab.
22. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**]
Discharge Diagnosis:
Ischemic Coronary Artery Disease s/p Non ST Elevation Myocardial
Infarction.
Acute Systolic Congestive Heart Failure
Atrial Fibrillation
Anemia
Peripheral Vascular disease s/p PCI x2
Osteomyelitis s/p amputation of left second toe
Hypertension
Discharge Condition:
stable.
Discharge Instructions:
You were admitted because you had a heart attack and because
your body was overloaded with fluid making it difficult for you
to breath. We increased your medicines in order to protect your
heart. We considered doing a cardiac catheterization to
evaluate your cardiac vessels more precisely but because you
looked very ill we decided to try and maximize medical therapy
first.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters
Followup Instructions:
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD/ Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone: [**Telephone/Fax (1) 62**]
Date/Time: Tuesday [**11-11**] at 3:20pm.
.
Vascular Surgery:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 80155**], MD [**Apartment Address(1) 67514**], [**Hospital1 **],
[**Numeric Identifier **]
Phone: ([**Telephone/Fax (1) 80156**]
[**10-30**] at 11:45pm.
.
Sleep study: Please discuss this with your primary care doctor,
Dr. [**Last Name (STitle) **].
.
Primary Care:
Please make an appt to see Dr. [**Last Name (STitle) **] in your home after you
return.
Please have your INR drawn on [**2132-10-31**] and results sent to
Physician on site at rehabilitation center.
.
You should have a podiatrist see you at the rehabilitation
center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2132-10-28**]
ICD9 Codes: 2762, 4280, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5988
} | Medical Text: Admission Date: [**2157-9-15**] Discharge Date: [**2157-9-17**]
Date of Birth: [**2096-5-22**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Heparin Agents / Bactrim
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief this is a 60 yo female with muliple complications from
uterine CA s/p XRT including radiation cystitis/colitis with
multiple enteric and vessicular fistulas requiring bowel
resections and chronic colostomy and nephrostomy who presents
with 2 days of bladder spasm, and fever to 101.5. Most recently
admitted in [**Month (only) **] with line infection (MRSA, VRE in urine),
treated for 2 weeks with dapto. During that admission she was
noted to have EF 20-30% with global hypokinesis.
Seen in office yesterday ([**9-13**])with low grade fever, bladder
spasm. Urine/blood cultures taken and based on previous cx,
vanco/levo started. B/l urine cx from nephrostomys now growing
>100,000 GNRs. Tonight she calls and says that she has a fever
to 101.8 and also that she had a twinge of chest pain. Referred
to ED for eval.
She was started on vanco and levo since yesterday.
In the ED, initial vital signs were T 101.8, HR 121, BP 123/66,
RR16, O2 96%RA. Urine cultures from [**2157-9-13**] came back growing
GNR's. Her blood pressure dropped to 83/60 and she received
500cc NS. She received a total of 1.5L NS and her SBP remained
in the mid 70's. She refused a central line, but was started on
levophed through her central line. She received zosyn 4.5mg IV x
1.
Past Medical History:
1. Endometrial/cervical cancer
2. S/p TAH in [**2153**] (due to uterine cancer)
3. Chylous ascites
4. Colectomy, cholecystectomy, and ileostomy ([**11-16**], likely
related to radiation bowel damage.) and chronically draining
fistula
5. Small bowel removal and ileostomy ([**6-17**]) c/b chronic skin
infection
6. S/p ventral hernia w/ repair
7. PE s/p IVC filter
8. Anxiety
9. Nephrostomy tube replacements, multiple
10. Hyperbilirubinemia and hyper alkaline phosphatemia thought
to be [**1-14**] TPN induced chronic cholestasis.
11. Anemia of chronic disease
12. VRE
13. Basal cell of face
Social History:
Lives with her husband and has 2 children. Denies current
alcohol use. Had been banking executive prior to development of
health issues. Smokes + [**12-14**] PPD for 19 years.
Family History:
Father 83 (deceased, CVA, MI); Mother (deceased, 92, CVA);
Brother (79, esophageal cancer); Sister (60s, colon cancer, lung
mass, afib)
Physical Exam:
Vitals - T99.4, HR94, BP 118/55, RR19, O2 98%
Gen - NAD, appears chronically ill, somnolent, but arousable
HEENT - PERRL, MMM, no elev JVP
Heart - RRR, no murmur appreicates
Lungs - clear to [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] - soft, mild diffuse discomfort, no rebound/guarding. small
amount of discharge from fistula.
Extrem - [**1-15**]+ pitting edema bilaterally
Neuro - CNII-XII intact, [**4-16**] UE and LE strength
Skin - multiple echymosis, no rashes
Pertinent Results:
[**2157-9-15**] 01:00AM GLUCOSE-94 UREA N-25* CREAT-0.7 SODIUM-138
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-26 ANION GAP-12
[**2157-9-15**] 01:00AM WBC-3.3* RBC-2.93* HGB-9.8* HCT-28.9* MCV-99*
MCH-33.4* MCHC-33.8 RDW-18.3*
[**2157-9-15**] 01:00AM NEUTS-66.6 LYMPHS-23.4 MONOS-8.4 EOS-1.1
BASOS-0.5
[**2157-9-15**] 01:16AM LACTATE-3.1*
[**2157-9-15**] 01:30AM URINE BLOOD-LG NITRITE-POS PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-12* PH-6.5
LEUK-NEG
[**2157-9-15**] 01:30AM URINE RBC-[**11-1**]* WBC-[**11-1**]* BACTERIA-MOD
YEAST-NONE EPI-0
[**2157-9-15**] 07:14AM PT-16.5* PTT-37.9* INR(PT)-1.5*
[**2157-9-15**] 07:14AM GLUCOSE-107* UREA N-23* CREAT-0.7 SODIUM-138
POTASSIUM-2.9* CHLORIDE-108 TOTAL CO2-25 ANION GAP-8
[**2157-9-15**] 07:14AM CALCIUM-7.3* PHOSPHATE-2.3* MAGNESIUM-1.5*
[**2157-9-15**] 07:14AM WBC-3.9* RBC-2.54* HGB-8.3* HCT-24.5* MCV-97
MCH-32.7* MCHC-33.9 RDW-18.4*
[**2157-9-15**] 07:30AM LACTATE-2.1*
[**2157-9-15**] 11:07AM CORTISOL-19.3
[**2157-9-15**] 11:07AM CORTISOL-24.3*
[**2157-9-15**] 03:41PM POTASSIUM-3.6
[**2157-9-15**] 04:04PM LACTATE-1.5
.
Micro:
Blood culture ([**2157-9-13**], [**2157-9-15**]): No growth to date.
Urine ([**2157-9-13**]): Klebsiella pneumoniae, coag positive staph
aureus
([**2157-9-15**]): Staph aureus
.
Imaging:
CXR ([**2157-9-15**]): The heart size is moderately enlarged but the
precise appreciation of its borders is difficult due to new
bilateral moderate pleural effusions accompanied by bibasilar
atelectasis. Perihilar haziness has increased in the meantime
interval suggesting either volume load or pulmonary edema or
combination of both. Central venous line inserted through the
left subclavian line terminates at the cavoatrial junction with
its tip looped and pointing upward, unchanged since [**2157-8-16**].
Brief Hospital Course:
Ms. [**Known lastname 3694**] was admitted with complaints of bladder spasms,
fevers and hypotension. There was high concern for sepsis
physiology and she was found to have an elevated lactate. The
patient was volume resucitated and recieved broad antibiotic
therapy with zosyn and daptomycin. Her bp improved and urine
cultures grew klebsiella and staph aureus. Her klebsiella was
pan sensitive, but because of her history of pan resistent
klebsiella we continued to treat with zosyn. Her staph aureus
was MRSA and was continued to be treated with daptomycin. She
will complete a 10 day course at home. She was discharged home
from the ICU.
Medications on Admission:
Mirtazapine 15 mg Tablet QHS
Ativan 0.5 mg Tablet 1-2 Tabs PO Q8hrs
Epoetin Alfa 4,000 unit/mL Solution Sig: 20000u qtuesday
Loperamide Two Capsule PO QID prn
Fludrocortisone 0.1 mg daily
Opium Tincture 10 mg/mL Tincture qid
Diphenoxylate-Atropine 2.5-0.025 mg q6h
Discharge Medications:
1. Piperacillin-Tazobactam-Dextrs 4.5 g/100 mL Piggyback Sig:
One (1) dose Intravenous Q8H (every 8 hours) for 7 days.
Disp:*21 doses* Refills:*0*
2. Daptomycin 500 mg Recon Soln Sig: Two [**Age over 90 1230**]y (250) mg
Intravenous Q24H (every 24 hours) for 7 days.
Disp:*1750 mg* Refills:*0*
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
5. Epoetin Alfa 4,000 unit/mL Solution Sig: 20,000 units
Injection once a week.
6. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Opium Tincture 10 mg/mL Tincture Sig: One (1) dose PO three
times a day.
8. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO every six (6) hours.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
MRSA/Klebsiella Urosepsis
Discharge Condition:
Stable; normotensive
Discharge Instructions:
You were admitted to the hospital because of a urinary tract
infection and low blood pressue. We are treating your infection
with 2 antibiotics. You will need to continue these medications
for another 7 days at home.
Your new medications:
1. Zosyn - an antibiotic to treat your urinary tract infection
2. Daptomycin - an antibiotic to treat your urinary tract
infection
Please continue all of your other medications as you were prior
to being hospitalized.
Please return to the hospital for fevers, chills, worsening
pain, difficulty breating.
1.
Followup Instructions:
-- Please make an appointment to see Dr [**Last Name (STitle) **] in the next
1-2 weeks.
ICD9 Codes: 5990, 4254, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5989
} | Medical Text: Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-4**]
Date of Birth: [**2080-10-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
[**2141-5-24**]:
- Extensive debridement of complicated wound, including
multiple abscesses.
- Component separation of the anterior abdominal wall with
fascial dissection and reconstruction.
- Repair of large incisional hernia with mesh.
- Lysis of adhesions
[**2141-5-29**] PICC line placement
History of Present Illness:
60 y/o male status post liver transplant. Subsequent to his
liver transplant, he developed a mycobacterial infection of the
skin. Despite aggressive
attempts at antibiotics and local debridement, he was not able
to clear his mycobacterial infection. After consultation with
multiple providers including hernia experts and infectious
disease, it was elected to take him back to
the operating room to completely clean out his anterior
abdominal wound, place a mesh, and close the wound.
Past Medical History:
PAST MEDICAL HISTORY:
- metabolic bone disease
- hepatitis C cirrhosis s/p OLT [**2-14**] c/b poor wound healing, as
below.
- interstitial lung disease - dx 2y ago, no pulmonary follow-up,
does not use home inhalers presently.
- GERD
- chronic pain - abdominal and B LE (neuropathy)
- chronic BLE edema
- psoriasis
- DM2 - dx over past year, on insulin.
- h/o B LE burns [**2-7**] trauma in fire.
.
- denies CVA, CAD, HTN, CKD, PE/DVT, malignancy.
.
PAST SURGICAL/PROCEDURAL HISTORY
[**2138**] RFA of liver lesion
[**2132**] lung biopsy
[**2131**] Extensive burns&#[**Numeric Identifier 25684**];skin graft surgeries
[**2140-2-28**] liver transplant with repair of chronic diaphragmatic
hernia.
[**2140-3-1**] Exploratory laparotomy, repair of ventral hernia with
mesh and liver biopsy.
Social History:
Currently smoking [**1-7**] ppd, denies etoh, ivdu. History of IVDA
and ETOH abuse. He has abstained from both since transplant.
Family History:
Mother, 85: No known illness
Father, dead 76: Liver cancer
Twin brother, dead 18: Murdered
Brother, 35: No known illness
Brother, 46: No known illness
Physical Exam:
VS: 98.6, 79, 123/65, 24, 98% 5L
General: Initially receiving ketamine drip and dilaudid IV for
pain management post op
Card: Nl S1S2, RRR
Lungs: Few crackles bilater bases
Abd: Soft, mild distention, initial dressing left on for 5 days
to protect initial incision. POst op the incision has remained
intact, without erythema or drainage. 1 JP drain with
serosanguinous fluid
Extr: No edema, venodynes in place
Pertinent Results:
On Admission: [**2141-5-25**]
WBC-23.0*# RBC-3.47* Hgb-10.9* Hct-33.2* MCV-96 MCH-31.4
MCHC-32.8 RDW-15.4 Plt Ct-127*#
PT-15.3* PTT-33.0 INR(PT)-1.3*
Glucose-197* UreaN-24* Creat-1.0 Na-135 K-5.5* Cl-106 HCO3-24
AnGap-11
ALT-71* AST-78* AlkPhos-127 TotBili-1.7*
Albumin-2.8* Calcium-7.6* Phos-2.7 Mg-1.8
At Discharge: [**2141-6-2**]
WBC-7.1 RBC-2.96* Hgb-9.2* Hct-28.6* MCV-97 MCH-30.9 MCHC-32.0
RDW-16.5* Plt Ct-123*
Glucose-146* UreaN-52* Creat-1.4* Na-130* K-5.9* Cl-101 HCO3-24
AnGap-11
ALT-50* AST-71* AlkPhos-293* TotBili-1.6*
Calcium-7.8* Phos-4.5 Mg-1.5*
tacroFK-5.8
Brief Hospital Course:
60 y/o male with complicated post liver transplant surgery
course. Since last year his course has been complicated by
recurrent hernias requiring debridements and
infection with Mycobacterium abscesses. (MYCOBACTERIUM
ABSCESSUS/MASSILIENSE/BOLLETII GROUP)
He was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] for
Extensive debridement of complicated wound, including multiple
abscesses, Component separation of the anterior abdominal wall
with fascial dissection and reconstruction, Repair of large
incisional hernia with mesh, Lysis of adhesions times 1 hour and
Repair of wound more than 30 cm. This was an ext4ensive surgery,
which the patient tolerated well.
Due to past hsitory of narcotic tolerance, the patient was
initially managed on a ketamine drip in addition to dilaudid and
his baseline methadone. Over the course of the hospitalization
the regimen now includes Home Oxycontin and methadone,
breakthrough oxycodone and IV Morphine for breakthrough also.
The initial dressing was taken down at 5 days per Dr [**Last Name (STitle) 15283**]
instructions, and the incision has remianed intact, with no
erythema or drainage noted. The small wound from the previous
attempt at debridement has been intact as well.
Per ID recommendations, who were following prior to this
surgery, initial antibiotics were amikacin, tigecycline and
vancomycin. After further consideration, the Vanco was stopped
and azithromycin was added. ID continued to follow during this
admission, and when the creatinine was noted to be increasing,
the amikacin was stopped and Linezolid was added.
The patient received 4 days of lasix in an attempt to diurese.
He remains about 5 Liters above his admission weight, no further
lasix has been attempted, creatinine has leveled at 1.4
(baseline around 1)
On POD 8 he had a large amount of ascitic appearing fluid drain
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Methadone 10 mg Tablet Sig: Eleven (11) Tablet PO DAILY
(Daily): Home dose.
4. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
5. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
Once daily PRN constipation as needed for distention.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
13. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): This is
patients home dose.
14. Tigecycline 50 mg Recon Soln Sig: Fifty (50) mg Intravenous
Q12H (every 12 hours).
15. Azithromycin 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q24H (every 24 hours).
16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
17. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous PRN (as needed) as needed for line flush.
18. Morphine Sulfate 1-4 mg IV Q4H:PRN breakthrough pain
19. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous Q12H (every 12 hours).
20. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours): needs tacrolimus levels q wk.
Disp:*180 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Complex abdominal wound with multiple abscesses, necrotizing
infection, and large hernia
Narcotic tolerance
Liver transplant [**2-/2140**]
Discharge Condition:
Stable/Fair
A+Ox3
Poor ambulatory state, needs extensive rehabilitation
Discharge Instructions:
please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, increased abdominal pain, increased
drainage from the JP bulb or area around the JP drain insertion.
There is a pouch covering the JP drain insertion site due to
some leaking.
Drain and record JP drain output twice daily and more often as
needed. Please call the transplant clinic if the drainage
increases rgeatly, develops a foul odor or becomes bloody in
appearance.
No heavy lifting
Continue labwork q Monday/Thursday with results faxed to
transplant clinic. CBC, Chem 10, AST, ALT, Alk Phos, T bili,
Trough Prograf
Continue antibiotics via PICC line
Wear abdominal binder at all times
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-6-8**] 10:40
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-6-12**] 8:00
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-6-15**] 8:00
ICD9 Codes: 5849, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5990
} | Medical Text: Admission Date: [**2121-11-21**] Discharge Date: [**2122-1-13**]
Date of Birth: [**2121-11-21**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 916**] [**Known lastname 467**] is a former 1.36
kilogram product of a 29-1/7 week gestation pregnancy born to
a 33 year old G-1, P-0 woman. Prenatal screens - Blood type
A positive, antibody negative, Rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
Strep status unknown. The pregnancy was uncomplicated until
preterm labor on the day of delivery leading to a spontaneous
vaginal delivery without anesthesia. There was no
intrapartum fever noted. Rupture of membranes occurred at
the time of delivery yielding clear fluid. There was
intrapartum antibacterial prophylaxis prior to delivery. The
infant emerged vigorous at delivery. He required drying,
bulb suction and free flow O2. Apgar's were 7 at one minute
and 8 at five minutes. He was transported to the Neonatal
Intensive Care Unit for management of prematurity.
PHYSICAL EXAMINATION: Weight 1.36 kilograms, length 40.5 cm,
both 50th percentile. Head circumference 26.5 cm
approximately 25th percentile. General - Nondysmorphic
preterm male in moderate respiratory distress. HEENT -
Palate intact, neck and mouth normal, significant occipital
caput without other cranial abnormality, moderate nasal
flaring, positive red reflex bilaterally. Chest - Mild to
moderate intercostal retractions, good breath sounds
bilaterally, few crackles. Cardiovascular - Well perfused,
regular rate and rhythm, femoral pulses normal, normal S1 and
S2, no murmur. Abdomen - Soft, non-distended, no
organomegaly, no masses, bowel sounds active. Anus - Patent.
GU - Normal male genitalia, testes palpable bilaterally.
Integumentary - Normal. Musculoskeletal - Normal spine,
limbs, hips and clavicles. Neurologic - Active, alert and
responsive to stimuli. Tone appropriate for gestational age
and symmetric, moving all extremities symmetrically, weak
suck, gag intact, symmetric grasp.
HOSPITAL COURSE:
1. Respiratory. [**Known lastname 916**] was initially placed on continuous
positive airway pressure. His respiratory distress
persisted and he was electively intubated and given a dose
of Surfactin. He was later extubated back to continuous
positive airway pressure on day of life one and then
weaned to room air. He continued on room air for the rest
of his Neonatal Intensive Care Unit admission. He did
require treatment for apnea of prematurity with caffeine.
The caffeine was continued through day of life number 25.
His last episode of spontaneous apnea occurred on [**2121-12-24**].
At the time of discharge, he is breathing comfortably 40-
50 times per minute.
2. Cardiovascular. [**Known lastname 916**] has maintained normal heart rates
and blood pressures. An intermittent soft murmur has been
noted through the last two weeks of admission.
3. Fluids, electrolytes and nutrition. [**Known lastname 916**] was initially
NPO and maintained on intravenous fluids. Enteral feeds
were started on day of life number two and gradually
advanced to full volume. His maximum caloric intake was
28 calories per ounce with additional protein powder. At
the time of discharge he is taking expressed breast milk
fortified to 26 calories with Similac powder and 2
calories as corn oil or Similac formula 24 calories with
an additional 2 calories of corn oil. Weight on the day
of discharge is 2.83 kilograms with a head circumference
of 34.5 cm and a length of 47 cm. Serum electrolytes were
checked in the first week of life and were within normal
limits.
4. Infectious disease. Due to the unknown group beta Strep
status of the mother and the preterm labor, [**Name (NI) 916**] was
evaluated for sepsis at the time of admission to the
Neonatal Intensive Care Unit. A white blood cell count
was 7,700 with a normal differential. A blood culture was
obtained prior to starting intravenous antibiotics. The
blood culture was no growth at 48 hours and the
antibiotics were discontinued. On day of life number six
with some episodes of hypothermia, he was again evaluated
for sepsis. A blood culture was obtained and vancomycin
and gentamicin were started. The blood culture was no
growth at 48 hours and the antibiotics were discontinued.
There have been no other infectious disease issues through
the remainder of the Intensive Care Unit admission.
5. Hematological. Hematocrit at birth was 48.9 percent.
[**Known lastname 916**] did not receive any transfusions of blood products.
The most recent hematocrit on [**2122-1-12**] is 26.5 with
reticulocyte count of 6.8.
6. Gastrointestinal. [**Known lastname 916**] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peaks
in the bilirubin occurred on day of life two to a total of
8.4/0.4 mg/dl direct. He received phototherapy for ten
days. Rebound bilirubin 48 hours after stopping the
phototherapy was a total of 4.8/0.2 mg/dl direct.
7. Neurology. [**Known lastname 916**] has maintained a normal neurological exam
during admission. He has had two normal head ultrasounds
on [**11-28**] and [**2122-12-18**].
8. Sensory.
Audiology - Hearing screening was performed with automated
auditory brain stem responses. [**Known lastname 916**] passed in both ears on
[**2122-1-12**].
Ophthalmology - [**Known lastname **] eyes were most recently examined for
retinopathy of prematurity on [**2122-1-5**]. At that time his
retina's were found to be mature. Recommended follow up with
pediatric ophthalmology at nine months.
9. Psychosocial. Of note, his father is confined to a
wheelchair secondary to hemiplegia from a fall off from a
ladder. The father is known MRSA colonized. Both parents
have been very involved in [**Known lastname **] care during admission.
[**Hospital1 **] social work has been involved with
the family. The contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**].
She can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents. The primary
pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital **] Pediatrics, [**Street Address(2) 56673**], [**PO Box 60079**], [**Location (un) **], [**Numeric Identifier 58561**], phone number
[**Telephone/Fax (1) 40204**] FAX ([**Telephone/Fax (1) 60080**].
CARE AND RECOMMENDATIONS:
1. Feeding - Breast milk fortified to 26 calories per ounce,
4 calories by Similac powder, 2 calories by corn oil or
Similac 26 with 2 calories corn oil.
2. Medications - Ferrous sulfate 0.3 ml PO once daily.
3. Car seat position screening was performed. [**Known lastname 916**] was
observed in his car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
4. State newborn screens were sent on [**11-24**] and [**2121-12-4**] with
all results within normal limits. A third screen was sent
on [**2122-1-2**] with no notification of abnormal results to
date.
5. Immunizations received - Hepatitis B vaccine was
administered on [**2121-12-22**]. Synagis was administered on
[**2122-1-5**].
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: First born at less than 32 weeks; second is born
between 32 and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; or
thirdly with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home care-givers.
1. Follow-up appointments recommended: Appointment with Dr.
[**Last Name (STitle) **], primary pediatrician, within three days of
discharge and pediatric ophthalmology at nine months of
age.
DISCHARGE DIAGNOSES:
1. Prematurity at 29-1/7 weeks' gestation.
2. Respiratory distress syndrome.
3. Suspicion for sepsis ruled out.
4. Apnea of prematurity.
5. Unconjugated hyperbilirubinemia.
6. Status post circumcision on [**2122-1-6**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2122-1-12**] 04:13:05
T: [**2122-1-12**] 06:48:59
Job#: [**Job Number 60081**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5991
} | Medical Text: Admission Date: [**2172-9-28**] Discharge Date: [**2172-10-28**]
Date of Birth: [**2131-10-1**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC: loss of consciousness.
Major Surgical or Invasive Procedure:
[**9-29**]: Left crani, clipping M1 aneurysm
[**10-1**]: External ventricular drain placement
[**10-2**]: emergent Lt hemicrani
[**10-5**], [**10-7**], [**10-8**]: cerebral angiograms
[**10-19**]: VP shunt placement
tracheostomy
PEG
History of Present Illness:
HPI: Ms. [**Known lastname **] is a 40 y/o female in previously good health who
did not present with predictive symptoms before falling in her
bathroom today. The fall was unwitnessed, and the family found
her unconscious. She was taken to an OSH where a head CT
revealed apparent subarachnoid hemorrhage with blood noted in
both sylvian fissures, interhemispheric fissure, and prepontine
cisterns. She was transferred to [**Hospital1 18**] ED for higher level of
care, and was given propofol, etomidate, succinyl choline, and
other sedatives. She was also noted to have possible
aspiration. At [**Hospital1 18**] ED, Ct angio showed 8 x 13mm focal region
of hemmorhage in high left frontal lobe, also diffuse SAH in
sylvian fissures and basilar cisterns (intraventricular bleed
noted as well in
occiptal horns b/l, 3rd and 4th ventricle). However, no discrete
aneursym was appreciated.
Past Medical History:
GI bleed
Social History:
Social Hx:
lives at home with family
Family History:
first degree relative died of brain hemorrhage per mother
Physical Exam:
***ON ADMISSION***
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-29**] bilaterally
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Comatose and intubated.
Orientation: none.
Recall: none.
Language: NO Speech
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
Other cranial nerves could not be fully assessed.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength could not be adequately assessed.
She localizes bilateral upper extremities and withdraws both
lower extremities
Sensation: could not be assessed.
Toes downgoing bilaterally
Eyes open to noxious stimuli
positive corneals, gag, and cough reflexes
***ON DISCHARGE***
Pertinent Results:
CT: Ct angio showed 8 x 13mm focal region of hemmorhage in high
left
frontal lobe, also diffuse SAH in sylvian fissures and basilar
cisterns (intraventricular bleed noted as well in occiptal horns
b/l, 3rd and 4th ventricle). However, no discrete aneursym was
appreciated.
[**2172-9-28**] 04:20PM UREA N-10 CREAT-0.7
[**2172-9-28**] 04:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2172-9-28**] 04:20PM WBC-36.5* RBC-4.30 HGB-12.7 HCT-37.8 MCV-88
MCH-29.5 MCHC-33.5 RDW-12.9
[**2172-9-28**] 04:20PM NEUTS-91.2* BANDS-0 LYMPHS-7.0* MONOS-1.6*
EOS-0.1 BASOS-0.1
[**2172-9-28**] 04:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2172-9-28**] 04:20PM PLT SMR-NORMAL PLT COUNT-304
[**2172-9-28**] 04:20PM PT-13.7* PTT-26.7 INR(PT)-1.2*
Brief Hospital Course:
This 40 yo F was admitted after being found down and was found
to have a SAH. Subsequent studies revealed that she had an M1
aneurysm which she had clipped via an open craniectomy on [**2172-9-29**]
with concurrent placement of an EVD. Her neurological exam
remained limited, as she did not respond to verbal or tactile
stimuli. Her ICP's remained elevated, and she was started on
hypertonic saline. Additionally she was placed in a pentobarb
coma. On [**10-2**], her serum sodium was elevated to 158 and ICP was
still elevated. Her pupils were felt to be somewhat unequal, so
she was taken for emergent decompressive craniectomy. On [**10-4**],
she experienced fever to 104 F, and at that time, dilantin was
switched to keppra, and she was pan-cultured. Sputum was shown
to grow MSSA, and she was started on Nafcillin and Zosyn. She
underwent trials of ventricular catheter clamping on [**10-6**] and
[**10-7**] but ICPs rose requiring unclamping. On [**10-8**] she underwent
angiogram which showed increasing size of aneurysm requiring
stent placement. Repeat angiogram [**10-9**] showed no spasm but new
small L MCA stroke. On [**10-12**] CSF showed high wbc and she was
started on antibiotics. She had trials of EVD clamping which she
did tolerate in terms of ICPs but CT showed evidence of
hydrocephalus and it was opened. She was readied for OR on [**10-19**]
for VP shunt placement but had episode of elevated ICP due to
EVD line obstruction, subsequent CT showed new bleed into L
frontal as well as R sdh. She was brought to angio which showed
clot in aneurysm. Her exam continued to be poor with extension
of upper extremities and withdrawal of lowers.Dr. [**First Name (STitle) **] had
ongoing discussions with family about grave prognosis. On [**10-23**]
with family present, it was decided to make the patient comfort
measures only. On [**10-26**] Palliative care consulted for assistance
with transfer to hospice.
Medications on Admission:
none
Discharge Medications:
1. Morphine Concentrate 5 mg/0.25 mL Solution Sig: One (1) PO
Q3H (every 3 hours).
2. Morphine Concentrate 5 mg/0.25 mL Solution Sig: [**1-29**] PO Q1H
(every hour) as needed.
3. Lorazepam 2 mg/mL Concentrate Sig: 0.5 - 1 PO Q1H PRN () as
needed for agitation.
4. Scopolamine Base 1.5 mg Patch 72 hr Sig: [**1-30**] Transdermal TID
(3 times a day) as needed.
5. Acetaminophen 650 mg Suppository Sig: One (1) Rectal Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
SAH secondary to aneurysm
Large Lt MCA Infarct
Discharge Condition:
poor neurological exam
Discharge Instructions:
please titrate medication to comfort
Followup Instructions:
none
Completed by:[**2172-10-28**]
ICD9 Codes: 5070, 2760, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5992
} | Medical Text: Admission Date: [**2148-12-24**] Discharge Date: [**2149-1-6**]
Date of Birth: [**2100-1-9**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old man
with a past medical history not completely clear, but include
apparent developmental delay, living at home with parents who
presents with a two to three week history of weakness, mental
status changes, decreased po intake, limited ambulation per
father who finally called EMS. The patient was found by EMS
lying on the couch, surrounded by feces and apparently
urinating into bottles. The home environment was reportedly
poor with a strong smell of urine and feces. Per father the
son was "normal" two to three weeks ago and alert and
oriented times three. He has no apparent history of head
trauma. He has no recent history of nausea, vomiting,
diarrhea, chest pain, or shortness of breath.
The patient was initially sent to [**Location (un) 745**] [**Hospital 18896**] Hospital and
then transferred to [**Hospital1 69**] for
further care. At [**Location (un) 745**] [**Hospital 18896**] Hospital his vital signs
were 110/66, 104, 18, 97% on room air, potassium 3.2, sodium
147, BUN 34, creatinine 1.6, white blood cell count 13.2, and
a negative urine and serum tox screen.
PAST MEDICAL HISTORY:
1. Developmental delay.
2. Rheumatoid arthritis.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: Aspirin.
SOCIAL HISTORY: The patient lives with his parents. He has
a 77 year-old mother who is wheel chair bound.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.5. Heart
rate 110. Blood pressure 119/65. Oxygen saturation 98% on
room air. General, disheveled, no acute distress, somewhat
conversant. HEENT poor hygiene, forehead excoriations, no
stiffness of the neck. Lungs clear to auscultation
bilaterally. No adventitious sounds. Cardiovascular
tachycardic. Regular rate and rhythm. Normal S1 and S2. No
murmurs. Abdomen soft, nondistended, slight diffuse
tenderness, no rebound or guarding. Extremities right hip
decubitus ulcer (stage one) no clubbing, cyanosis or edema.
Skin dry, multiple scattered excoriations. Neurological
alert and oriented to person only. Cranial nerves II through
XII intact.
LABORATORIES ON ADMISSION: White blood cell count 15.3,
hematocrit 39.6, platelets 547, sodium 154, potassium 3.8,
chloride 102, total CO2 22, BUN 38, creatinine 1.5, glucose
96, calcium 9.1, magnesium 3.7, phosphate 2.3. Urinalysis
yellow, hazy, positive nitrite, 6 to 10 red blood cells, 6 to
10 white blood cells, many bacteria. Chest x-ray negative
for pneumonia, limited secondary to rotation. Head CT
negative for bleeding or mass. Electrocardiogram sinus
tachycardia, normal axis, normal intervals, ST depressions in
V2 through V4.
HOSPITAL COURSE: 1. Neurological/psychiatric: The patient
was initially admitted to the Medical Intensive Care Unit for
presumed urosepsis. Initially the patient was very poorly
responsive to verbal and other types of stimulation. A
workup for his ulceration and mental status initially
included the head CT and a lumbar puncture, which did not
reveal abnormalities that would account for a change in
mental status. On [**2148-12-24**] the patient was noted to
have a sodium of 159. This value was corrected with D5 water
infusion, but the patient's apparent encephalopathy persisted
even after the sodium was corrected. After transfer to the
floor on [**2148-12-25**] the patient had additional studies
to workup his delirium, including two MRIs of the head
(limited by motion artifact), an electroencephalogram
(revealing evidence of metabolic encephalopathy, but no
epileptiform activity), and neurology and psychiatry
consultations. At the time of this dictation ([**2149-1-5**]) the
patient has continued delirium, however, with improvement in
his ability to interact and answer questions.
It is unclear what the patient's true baseline is. From the
father's history the patient is extremely functional and
attended [**University/College **]. However, it also appears that the
patient has had limited social interactions throughout his
whole life not developing a close relationship with his
father and per his father never having any friends of either
sex. The patient has also been noted by family members to
exhibit obsessive compulsive behavior, notably pertaining to
obsessions about cleanliness. The patient's current delirium
precludes further evaluation of any possible baseline
condition the patient might have at this time.
2. Infectious disease: As above, the patient had evidence
of a urinary tract infection on his admission urinalysis.
His urine culture did not grow any organism. Blood cultures
likewise did not grow any organisms. The patient completed a
seven day course of Ceftriaxone for this urinary tract
infection. At the time of this dictation, the patient has
had an increasing white blood cell count to a current value
of 19.2 on [**1-5**]. The differential diagnosis for this
is felt to include C-difficile colitis, pneumonia, and
noninfectious etiology. The patient was started on
Levofloxacin for possible pneumonia on this date and a stool
study for C-difficile toxin is pending.
3. Hematology: The patient has had anemia of unclear
etiology throughout this admission. His initial blood smear
demonstrated substantial variation in red cell size, as well
as ovalocytes, burr cells, tear drop cells, and bite cells.
He has received a total of three units of blood ([**12-26**],
[**12-28**] and [**1-2**]) to maintain his hematocrit over 25.
He was noted to have a folate deficiency and was placed on
folic acid since [**2148-12-30**]. A hemolysis workup (LDH,
haptoglobin and bilirubin) was negative and the patient has
passed guaiac negative stools. At the time of this dictation
a hematology consult is pending for further workup of the
patient's anemia.
4. Nutrition: The patient was noted to have approximately
two weeks of decreased to absent po intake prior to his
admission. In the early portion of this admission when the
patient was relatively unresponsive to outside stimuli, he
was fed via nasogastric tube and given fluids via
intravenous. The patient self discontinued his nasogastric
tube and was evaluated by the Swallowing Service and felt to
be capable of tolerating a diet of soft solids and thin
liquids. As his mental status improved the patient was
eating more and more. His diet was supplemented with
multivitamin, folate and thiamine.
5. Pulmonary: Prior to admission in the Emergency
Department attempts were made to place a right internal
jugular venous catheter. This was complicated by a tension
pneumothorax for which the patient received needle
decompression followed by placement of a chest tube. The
patient's pneumothorax resolved and the chest tube was
discontinued several days later. Thereafter the patient did
not have any problems with oxygenation or ventilation.
6. Electrolytes: As aforementioned the patient had
substantial hypernatremia in the initial portion of his
hospital stay. This was most likely secondary to dehydration
relating to the patient's lack of food and water intake prior
to admission. The patient's sodium was corrected via
administration of free water. His sodium value remained
improved once his po intake improved.
7. Rheum: The patient is noted to have a history of
juvenile rheumatoid arthritis. Per his father the patient's
baseline is being able to ambulate with the aid of canes.
However, prior to admission the patient did not ambulate for
four to six weeks, remaining on the couch. At the time of
this dictation the patient has remained in bed and has not
ambulated. He was noted to have a mildly elevated
erythrocyte sedimentation rate at 57. It is felt that
further evaluation of the patient's rheumatic disease is
appropriate as his mental status improves and his functional
status improves.
The above is a dictation of the [**Hospital 228**] hospital course
through [**2149-1-5**]. Please refer to the discharge
addendum for the remainder of the hospital course, as well as
discharge information.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 7561**]
MEDQUIST36
D: [**2148-1-6**] 05:23
T: [**2149-1-8**] 10:21
JOB#: [**Job Number 18897**]
ICD9 Codes: 5990, 2765, 2760, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5993
} | Medical Text: Admission Date: [**2113-5-29**] Discharge Date: [**2113-6-2**]
Date of Birth: [**2036-1-4**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Subcapsular liver hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 year old female two week ago started complaining of
abdominal pain, she went to her PCP work up found to have with
liver mass 10 cm in size, she was scheduled to see hepatology
service on [**2113-6-9**]. However, yesterday at 4pm had acute
onset
of RUQ pain, the pain was constant, radiating to the back, she
went to OSH found to have subcapsular hematoma. then the patient
was transferred to [**Hospital1 18**] for further management.
The patient denies trauma, no fever, chills, N/V, no chest pain,
no shortness of breath. no melena, no hematemesis, no jaundice,
the review of system was unremarkable
Past Medical History:
MI [**2100**]
CVA [**2108**] fully recovered
DT x 2 last one [**2111**] for which was admitted to the ICU
HTN,
High cholesterol
Osteoarthritis
Vit D deficiency
PSH:
Appendectomy
Angioplasty [**2108**] on Plavix no stent per patient son and daughter
[**Name (NI) 86228**] removal R eye
R CEA [**2108**] complicated by stroke
Social History:
Smoke: 2 PKT a day 56pkts year history
Drink: Glass of wine daily last drink 2-3 days ago
Lives with husband
Family History:
Noncontributory
Physical Exam:
VS: T 97.2 F P 74 BP 132/64 RR 20 Sat 98 % RA
Gen: NAD, A & O x3
C: RRR
R: CTAB
GI: BS +, Soft, slightly tender RUQ, NR, NG
Rectal exam: Spincter normotonic, no hemorrhoid, no fissure, no
fistula
Pertinent Results:
On Admission: [**2113-5-28**]
WBC-8.5 RBC-3.67* Hgb-11.4* Hct-34.1* MCV-93 MCH-31.0 MCHC-33.3
RDW-12.2 Plt Ct-379
PT-11.1 PTT-21.5* INR(PT)-0.9
Glucose-116* UreaN-22* Creat-0.9 Na-140 K-4.3 Cl-106 HCO3-24
AnGap-14
ALT-35 AST-35 LD(LDH)-169 AlkPhos-226* TotBili-0.7
Albumin-3.3* Calcium-8.7 Phos-4.2 Mg-2.1
HBsAg-NEGATIVE HBcAb-NEGATIVE HCV Ab-NEGATIVE
CEA-6.8* AFP-3.4 CA125-38*
At Discharge: [**2113-6-2**]
WBC-6.7 RBC-3.48* Hgb-10.9* Hct-32.6* MCV-94 MCH-31.3 MCHC-33.4
RDW-13.1 Plt Ct-284
Glucose-82 UreaN-11 Creat-0.5 Na-143 K-3.1* Cl-109* HCO3-26
AnGap-11
ALT-39 AST-37 AlkPhos-174* TotBili-1.5
Brief Hospital Course:
77 y/o female admitted with abdominal pain.
CT of abdomen on admission showed:
- Large heterogeneously enhancing mass encompassing almost the
entire right
lobe of the liver and extending into the main, right, and left
portal veins
with cavernous transformation. Perihepatic blood could represent
a component
of subcapsular vs free hemorrhage. There was no evidence of
active extravasation.
There was also some fluid in the pelvis consistent with a bleed.
For the first two days the Hct was monitored q 6 hours and there
was no evidence of further bleeding. Her vital signs remained
stable and she was afebrile. It was determined that there were
not surgical issues at this time.
An oncology consult was obtained based upon the CT findings.
Assessment and recommendations include: "large right lobe
hepatic mass. While this is likely
a primary hepatic cancer, it is also possible that this
represents a metastasis from somewhere else... A colon primary
seems unlikely based on her history and the fact that she has a
normal MCV." Dr [**Last Name (STitle) **] recommended waiting at least two weeks to
obtain a liver biopsy to allow the liver to heal following the
hemorrhage
She will be followed up in the oncology clinic for liver biopsy
and then discussion of further treatment based on the biopsy
results.
She was evaluated by physical therapy while in house and was
deemed to require a skilled nursing facility for monitoring,
(fall risk) and for around the clock care.
Medications on Admission:
Plavix 75 daily
Metoprolol unknown dose
Simvastatin 40 '
Lidoderm 5 % 700 mg/patch TP'
Alendronate 70mg '
Seroquel 25 "
Allergy: ASA
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
4. Thiamine 100 mg IV DAILY
5. FoLIC Acid 1 mg IV Q24H
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Liver mass with liver hematoma
ETOH abuse
Confusion
Discharge Condition:
Mental Status: Confused - sometimes.Level of Consciousness:
Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
1) regular diet
2) activity as tolerated
3) you may shower or bathe
4) [**Name8 (MD) **] MD or come to emergency department if you experience
dizziness, bright red or dark red blood per rectum, bloody
vomit, inability to tolerate liquids, diarrhea/vomiting.
Hold Plavix (angioplasty no stent [**2108**])
Followup Instructions:
Oncology: Dr [**Last Name (STitle) **] Phone ([**2108**], Date:Time [**6-14**],
2:30. [**Hospital Ward Name 23**] Building, [**Location (un) 24**].
Evaluate and plan for biopsy which should be 2 weeks out from
hospitalization
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2113-6-2**]
ICD9 Codes: 2851, 3051, 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5994
} | Medical Text: Admission Date: [**2197-3-31**] Discharge Date: [**2197-4-5**]
Date of Birth: [**2135-1-7**] Sex: M
Service: SURGERY
Allergies:
Demerol / Reglan / Ritalin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Left leg pain, swelling
Major Surgical or Invasive Procedure:
Procedure [**2197-3-31**]: s/p aborted LLE venous thrombectomy
1. Ultrasound-guided puncture of left posterior tibial
vein.
2. Ultrasound-guided puncture of left popliteal vein.
3. Ultrasound-guided puncture of left femoral vein of the
thigh.
4. Ultrasound-guided puncture of left common femoral vein.
History of Present Illness:
The patient is a 62-year-old male with a longstanding history of
left lower extremity deep venous thrombosis, with originally
identified thrombus
approximately 20 years ago complicated by pulmonary embolism and
treatment with IVC filter placement. The patient noted
increasing swelling at the left lower extremity approximately 3
weeks prior to original presentation and was seen at an outside
facility, where CT scan demonstrated significant thrombus along
the length of the left lower extremity with evidence of
calcification of the pre-existing thrombus along the length of
the leg, extending into the inferior vena cava up to the level
of the IVC filter.
Past Medical History:
1. Barrett esophagitis; Esophageal CA, status post
esophagogastrectomy in [**2188-11-16**] ([**Doctor Last Name **]) c/b
recurrent post op bleed for esophagitis. Nl sig [**6-19**], Nl
colonoscopy, SBFT [**3-19**].
2. DMII diagnosed in [**2178**].
3. Deep venous thrombosis; s/p provoked DVT and unprovoked
pulmonary embolism. Hypercoagulation work-up negative. IVC
filter placed perioperatively for esophagectomy.
4. Bipolar disorder. Depression
5. Sleep apnea (not on CPAP since surgery, followed by Dr. [**Last Name (STitle) **].
[**Doctor Last Name **]).
6. Gastroesophageal reflux disease.
7. Status post cholecystectomy.
8. Asthma (Last Sx in ??????02, moderate reduced FEV1, FVC, mild
restrictive disease).
9. Venous insufficiency.
10. Hypercholesterolemia.
11. History of perirectal abscess
12. GI bleeding [**1-18**] esophagitis
14. Dumping syndrome c/b hypoglycemia [**5-20**]
Past surgical history:
1) Esophagogastrectomy in [**11/2188**] for esophageal cancer.
Social History:
Tobacco: smokes 1 ppd,
Alcohol: denies any alcohol use
Lives with fiance
Family History:
Father died pancreatic Ca at 85, no history of
hypercoagulability or other malignancies
Physical Exam:
PHYSICAL EXAM
Vital Signs: Temp: 96.4 RR: 18 Pulse: 49 BP: 129/52
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit, abnormal: R IJ CVL.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No RLE edema, No
varicosities,
abnormal: LLE swollen, erythematous, diffusely tender.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. Popiteal: P. DP: P. PT: P.
LLE Femoral: P. Popiteal: P. DP: D. PT: D.
Pertinent Results:
[**2197-3-31**] 10:45PM BLOOD WBC-5.4 RBC-3.18* Hgb-9.5* Hct-27.3*
MCV-86 MCH-29.7 MCHC-34.7 RDW-15.1 Plt Ct-226
[**2197-4-1**] 04:58AM BLOOD WBC-5.9 RBC-3.28* Hgb-9.8* Hct-28.3*
MCV-86 MCH-29.7 MCHC-34.5 RDW-15.3 Plt Ct-214
[**2197-4-2**] 03:00AM BLOOD WBC-4.9 RBC-2.91* Hgb-8.5* Hct-25.3*
MCV-87 MCH-29.2 MCHC-33.7 RDW-15.2 Plt Ct-183
[**2197-4-2**] 10:24AM BLOOD Hgb-8.9* Hct-26.8*
[**2197-4-3**] 05:30AM BLOOD WBC-4.1 RBC-3.06* Hgb-9.0* Hct-26.1*
MCV-86 MCH-29.4 MCHC-34.4 RDW-15.3 Plt Ct-190
[**2197-4-4**] 05:19AM BLOOD WBC-4.7 RBC-3.09* Hgb-9.0* Hct-26.6*
MCV-86 MCH-29.2 MCHC-34.0 RDW-15.4 Plt Ct-196
[**2197-3-31**] 10:45PM BLOOD PT-30.9* PTT-150* INR(PT)-3.0*
[**2197-3-31**] 10:45PM BLOOD Plt Ct-226
[**2197-4-1**] 04:58AM BLOOD PT-29.2* PTT-150* INR(PT)-2.8*
[**2197-4-1**] 04:58AM BLOOD Plt Ct-214
[**2197-4-1**] 11:14AM BLOOD PTT-114.5*
[**2197-4-1**] 11:14AM BLOOD Plt Ct-230
[**2197-4-2**] 03:00AM BLOOD PT-21.5* PTT-58.9* INR(PT)-2.0*
[**2197-4-2**] 03:00AM BLOOD Plt Ct-183
[**2197-4-2**] 10:24AM BLOOD PT-21.2* PTT-57.4* INR(PT)-2.0*
[**2197-4-2**] 04:09PM BLOOD PTT-57.2*
[**2197-4-3**] 12:15AM BLOOD PTT-49.1*
[**2197-4-3**] 05:30AM BLOOD PT-24.3* PTT-65.1* INR(PT)-2.3*
[**2197-4-3**] 05:30AM BLOOD Plt Ct-190
[**2197-4-4**] 05:19AM BLOOD PTT-31.1
[**2197-4-4**] 05:19AM BLOOD Plt Ct-196
[**2197-3-31**] 10:45PM BLOOD Fibrino-525*
[**2197-3-31**] 10:45PM BLOOD Glucose-122* UreaN-10 Creat-0.9 Na-137
K-3.8 Cl-105 HCO3-23 AnGap-13
[**2197-4-1**] 04:58AM BLOOD Glucose-203* UreaN-11 Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-26 AnGap-12
[**2197-4-2**] 03:00AM BLOOD Glucose-155* UreaN-10 Creat-0.9 Na-139
K-4.0 Cl-106 HCO3-28 AnGap-9
[**2197-4-3**] 05:30AM BLOOD Glucose-130* UreaN-10 Creat-0.8 Na-140
K-4.1 Cl-106 HCO3-28 AnGap-10
[**2197-3-31**] 10:45PM BLOOD ALT-17 AST-19 CK(CPK)-36* AlkPhos-99
TotBili-0.2
[**2197-4-3**] 05:30AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
CT ABD & PELVIS WITH CONTRAST Study Date of [**2197-4-2**] 10:49 AM
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 147**] VICU [**2197-4-2**] 10:49 AM
CT ABD & PELVIS WITH CONTRAST Clip # [**Clip Number (Radiology) 93175**]
Reason: Ct venogram of the mid thicgh region tot he diaphragm to
[**Doctor First Name **]
Contrast: OPTIRAY Amt: 150
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with phlegmalasia and IVC filter
REASON FOR THIS EXAMINATION:
Ct venogram of the mid thicgh region tot he diaphragm to eval
clot burden
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: 62-year-old man with phlegmalasia and IVC filter.
Evaluate IVC filter to determine presence of clot burden.
COMPARISON: None.
TECHNIQUE: Contiguous axial images were obtained through the
abdomen and
pelvis with the administration of IV contrast. A CTV protocol
was used to
assess the abdominal veins and extremity veins upto the mid
thigh.
Multiplanar reformats were generated and reviewed.
FINDINGS: There is left lower lobe atelectasis, less likely
infectious
process. Otherwise, the lungs are clear. No pleural effusion.
Large hiatal
hernia is noted.
The liver shows no focal liver lesions. Minimal intrahepatic
biliary dilation is noted. The common bile duct measures 10 mm.
These are likely secondary to post-cholecystectomy state. The
patient is status post cholecystectomy. The spleen, pancreas,
and bilateral adrenal glands are unremarkable. Both kidneys
demonstrate mild perinephric stranding which is likely
nonspecific. Parapelvic cysts are noted in the left kidney.
Bilateral hypodensities, too small to characterize, are noted
within both kidneys which likely represent renal cysts.
Intra-abdominal loops of large and small bowel are unremarkable.
There is some free fluid within the pelvis which may represent
postoperative change, correlate clinically.
The infrarenal IVC filter appears well seated within the vena
cava with clot in the center which extends into bilateral common
iliac veins as well as into the left external iliac, left common
femoral, left superficial femoral veins.
There is a minimal amount of clot noted in the origin of the
left profunda
femoral vein with reconstitution beyond this point. The right
external iliac, common femoral, and superficial femoral veins
are patent.
There is no free air within the abdomen. The bladder and distal
ureters are unremarkable.
Visualized osseous structures are grossly unremarkable. There is
some
surrounding soft tissue subcutaneous stranding within the left
thigh.
IMPRESSION:
1. Large hiatal hernia.
2. Minimal intrahepatic biliary dilation and dilation of common
bile duct to 10 mm, likely post-cholecystectomy.
3. Parapelvic cysts on the left and bilateral hypodensities, too
small to
characterize, in bilateral kidneys.
4. Small amount of fluid in the pelvis may represent
post-surgical changes, correlate with surgical and clinical
history.
5. Infrarenal IVC with clot in the center extending into
bilateral common
iliacs and left external iliac, left common femoral, and left
superficial
femoral veins. There is some clot burden within the left
profunda femoral at its origin, but the left profunda femoral is
reconstituted thereafter. The right external iliac, right common
femoral, and right superficial femoral veins show no evidence of
clot.
6. There is some surrounding soft tissue subcutaneous stranding
within the
left thigh.
Brief Hospital Course:
Mr. [**Known lastname 15131**] was transferred to [**Hospital1 18**] from [**Hospital3 **] on [**2197-3-31**]
due to concern for phlegmasia and was taken to the OR the same
day for attempted thrombectomy. Venous access could not be
[**Last Name (LF) 93176**], [**First Name3 (LF) **] he was admitted to the floor for medical
management. Heparin drip was resumed and his leg was ACE wrapped
and elevated above his heart. A HIT panel was sent which
returned negative. Hematology was consulted
Medications on Admission:
Zegerid 40/1680
Coumadin 5mg po daily
Perphenazine 8mg po qHS
Trileptal 900mg qHS
Percocet PRN
Imodium PRN
Metamucil 1 pckt daily
Discharge Medications:
1. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
Disp:*30 Syringes* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 7 days.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Zegerid 40-1,680 mg Packet Sig: One (1) packet PO twice a
day: Per home regimen.
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. perphenazine 8 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. oxcarbazepine 600 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Regular Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units
120-159 mg/dL 2 Units
160-199 mg/dL 4 Units
200-239 mg/dL 6 Units
240-279 mg/dL 8 Units
280-319 mg/dL 10 Units
> 320 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Acute-on-chronic deep venous thrombosis of the left lower
extremity with associated phlegmasia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2197-4-21**] 9:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2197-4-21**] 10:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 15631**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2197-5-31**]
11:00
Provider: [**Name6 (MD) 93177**] [**Name11 (NameIs) **], MD(Hematologist) Phone: [**0-0-**] Date/Time: [**2197-4-7**] 9am at [**Hospital6 5016**]
Completed by:[**2197-4-5**]
ICD9 Codes: 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5995
} | Medical Text: Admission Date: [**2144-5-25**] Discharge Date: [**2144-6-4**]
Date of Birth: [**2087-12-10**] Sex: M
Service: MEDICINE
Allergies:
Tramadol / Hydrocodone Bitartrate/Apap
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 109738**] is a 56-year old male w/ NSCLC, dementia, residual
brain damage from drug OD in [**2118**], known brain tumour from lung
CA mets and CVA who presents to the ED with altered mental
status and lethargy.
.
Per pt's wife, he had been more lethargic than usual, refusing
to get out of bed, and experiencing urinary incontinence. She
states he had been in his USOH (ambulating with a cane, A&Ox3,
conversant appropriately) until the day prior to admission when
he experienced extreme fatigue and slept all day until noon,
when he normally gets up around 7am. Per his wife, pt had been
feeling more weak and had been wetting himself while trying to
get up to go to the bathroom and urinating on himself in bed
several times, more of a function of weakness and inability to
reach the bathroom in time rather than incontinence.
.
He has residual left-sided weakness and numbness at baseline but
per wife's report this has been worse lately. Also per wife's
report pt had been eating extensively although he is not
supposed to given G-tube. He has only been receiving water
flushes.
.
Of note, he was hospitalized on [**4-28**] for changes in
mental status, and was treated empirically for meningitis with
vancomycin, ceftriaxone, ampicillin and acyclovir. He was
discharged on a 14 day course of vancomycin and cetriaxone. LP
was not done at the time and BCx showed NGTD. In the [**Name (NI) **], pt
refused LP.
He presented to [**Hospital 1474**] Hospital with altered mental status on
day of admission.
In the ED, initial vs were: 98.9 93 19 139/57 SaO2 98% on 4L.
Patient was treated w/ CTX, ampicillin, flagyl, azithromycin and
zosyn.
.
He was dx w/ NSCLC (large-cell) in [**7-/2143**] and underwent left
upper lobectomy followed by chemo XRT. (Previous notes and D/C
summaries document this as Right upper lobectomy; however,
[**Year (4 digits) **] data is consistent with Left upper lobectomy). His
post-operative courrse was c/b PAC infection requiring removal
and vocal cord paralysis. Mr. [**Known lastname 109739**] neurologic problems
began in [**2-/2144**] w/ L-sided weakness and difficulty with
cognition. MRI at the time showed a large right frontal lobe
mass. He is s/p right frontal craniotomy on [**2144-3-1**] and
pathology was c/w metastatic lung ca. He subsequently underwent
whole-brain XRT from [**Date range (1) 109740**].
ROS: unable to obtain as pt obtunded
Past Medical History:
1. Non small cell lung CA s/p radiation, chemo. left upper
lobectomy lung lobectomy.
2. Vocal cord paralysis after post lung surgery
3. DM2
4. Dementia for last 2 yrs
5. Residual brain damage from drug overdose [**2118**]
6. Possible NPH seen on MRI [**2133**]?
7. RUE DVT 4/[**2143**].
8. S/P R subclavian portcath placement [**2143-7-3**] c/b infection
removed 1 week later. Now Arteriovenous fistula between the
peripheral R subclavian artery and vein
9. cardiac catheterization [**3-/2142**] x2
[**44**]. psych hospitalization x2 for depression several yrs ago
11. MVA
12. hospitalization [**3-/2143**] for "diabetic seizure"
13. s/p head injury [**2118**]
PSurgHx:
1. s/p Right frontal craniotomy [**2144-3-1**]
2. s/p PEG [**2144-3-4**]
3. s/p LUL resection
4. s/p tonsilectomy [**2092**]
Social History:
Lives with his wife [**Name (NI) **], active [**Name (NI) 1818**] trying to quit (was 2
ppd X25 years 10 years ago); no alcohol consumption
Family History:
DM, Heart Disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 101.7, HR 97 BP 152/58 SaO2 97% on 2L NC HT 5'9 Wt 175 lbs
GEN: somnolent, lethargic difficult to arouse, falling asleep
HEENT: Sclera anicteric, MMM, oropharynx clear PERRLA
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2
LUNGS: anteriorly CTAB/L, posterior exam lim by body habitus
ABD: +BS soft, NT ND, PEG in place, not erythematous (Guiac
negative brown stool in ED)
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: somnolent, difficult to arouse, was able to state his
name and say he was in a hospital. opens eyes to voice and
touch. audibly snoring and falling asleep in conversation.
responding very slowly to questions w/ one-word answers.
Pertinent Results:
[**5-25**]- CT HEAD: post-operative change status post right frontal
lesion resection is stable. white matter hypodensity may in part
reflect post-treatment change and is also stable from prior
studies. no hemorrhage or mass effect. no acute process.
.
[**5-25**]- CT TORSO: s/p LUL resection. there is extensive new LLL
consolidation most c/w PNA. underlying mass not excluded. small
adjacent effusion unchnaged from prior study. no PTX.
abd/pelvis: no acute pathology, including no free fluid or free
air and no evidence of abscess. g-tube in good position.
left sided pneumonia, nodular opacities on R that could be
additional foci of infection, new from [**Month (only) 958**]. hard to say if
there is underlying mass lesion. Likely pulmonary mets. Also
colonic wall thickening that could be infectious.
.
EKG: NSR rate 93, w/ RAD. rSr' in V1. nonspecific septal ST-T
changes
.
DISCHARGE LABS:
WBC Hgb Hct MCV Plt Ct
[**2144-6-4**] 00:00 12.7* 12.0* 36.2* 93 376
[**2144-6-3**] 00:30 12.6* 12.7* 38.9* 93 441*
.
Gluc UreaN Creat Na K Cl HCO3 AnGap
[**2144-6-4**] 00:00 209*1 26* 0.7 138 4.6 102 27 14
[**2144-6-3**] 00:30 142*1 23* 0.7 141 4.4 104 28 13
.
Ca Phos Mg
[**2144-6-4**] 00:00 8.9 3.3 1.7
[**2144-6-3**] 00:30 9.2 3.3 1.8
Brief Hospital Course:
Mr. [**Known lastname 109738**] is a 56 year-old gentleman with non-small cell lung
cancer with known metastatic disease to the brain, s/p
R-craniotomy and whole brain radiation, history of dementia and
stroke, who presented with altered mental status and increased
lethargy.
.
ICU COURSE:
.
1. ALTERED MENTAL STATUS- The differential for Mr. [**Known lastname 109738**] was
broad given his immunocompromised state and obtunded
presentation. The patient and his wife made it clear that they
did not want a lumbar puncture performed and understood the
serious risks of turning down the LP including delay in
diagnosis or even death. Therefore, the initial differential
included bacterial meningitis and HSV encephalitis especially
given pt's lethargy and somnolence. He was initially covered
with vancomycin, cefepime (due to pseudomonal coverage and good
CSF penetration), ampicillin (for listeria coverage) and
acyclovir. Also in the differential was worsening of pts
malignancy w/ known brain mets, seizure, or other infectious
etiology such as PNA. Hyperglycemia could also cause this pt's
AMS as FSBS was > 300 on arrival. Toxic-metabolic cause cannot
be excluded given waxing and [**Doctor Last Name 688**] mental status. Also, he had
colonic wall (ascending colon and cecum) thickening on CT which
could represent infectious colitis but is a nonspecific finding;
pt's wife did not endorse specific GI complaints but stool
studies were sent. Pt's outpatient Neuro-oncologist Dr. [**Last Name (STitle) 724**] was
asked to comment on pt's status and he felt the picture was more
consistent with encephalitis and agreed with broad antibiotic
coverage, but decided to hold off on MRI until later, as pt just
had MRI at the end of his radiation treatment which did not show
new progression of disease. Dr [**Last Name (STitle) 724**] agreed with bedside EEG to
rule out seizure and this was performed on [**5-26**].
.
2. [**Name (NI) **] Pt had evidence of left lower lobe consolidation
on chest CT that was likely pneumonia. This underlying infection
was most likely the cause of his altered mental status.
Initially, broad antibiotic coverage for hospital acquired
organisms and aspiration was initiated with vancomycin, cefepime
(as above), flagyl for anaerobes and levofloxacin for atypical
coverage. Sputum cultures were also sent as well as urine
legionella, which later returned negative. The infectious
disease service was then consulted and agreed with vancomycin,
cefepime and flagyl but suggested discontinuing levofloxacin,
acyclovir and ampicillin which was done on [**5-26**]. Since patient
had been on long-term steroids, PCP prophylaxis with bactrim was
also initiated. Pt's WBC count improved as did his mental status
and by the 2nd ICU day he had become more alert and arousable.
He was transferred to the general medical service on [**5-27**].
.
3. [**Name (NI) **] pts FSBS > 300 on this admission. Home lantus was
initially continued at half pt's normal dose as he had been NPO,
but then was increased to his normal dose when tube feeds began.
He was also covered with humalog sliding scale, as outpatient
metformin was held.
.
4. LEUKOCYTOSIS- could be due to infection, inflammation,
seizure or steroid use. However, steroids are of chronic
duration and leukocytosis is relatively acute. Therefore,
infectious etiology is of concern. U/A appeared unremarkable.
White count was trending down upon transfer from the ICU.
.
OMED COURSE:
.
# Altered Mental Status: Pt was initially on abx for
meningitis, which were subsequently stopped. EEG was negative.
Blood and urine cx were negative. LLL consolidatio nwas seen on
CT chest and pt was treated for a pneumonia with
Vanc/Cefepime/Flagyl. Pt was continued on Bactrim for PCP [**Name Initial (PRE) **].
His mental status eventually came back to baseline. Pt was also
continued on home Levitiracetam and Dexamethasone taper (2mg
daily currently). Per Dr.[**Name (NI) 6767**] rec, start Dexamethasone 1 mg
daily on [**6-8**], then start 0.5mg daily on [**6-22**], then start 0.5mg
every other day on [**7-6**], and then stop dexamethasone on [**7-20**].
.
# Pneumonia: Pt was treated with Vanc/Cefepime/Flagyl. Pt was
continued on Bactrim for PCP [**Name9 (PRE) **] since he is on steroids.
.
# Leukocytosis: Pt remained afebrile. Pt was treated for
pneumonia as above. This is likely [**2-4**] steroids.
.
# NSCLC with brain mets s/p craniotomy: Treatment plan will be
per primary oncology team. Pt has a follow-up appointment next
week. Pt likely needs reimaging of lungs after resolution of
pneumonia to evaluate for underlying cancer.
.
# DMII: Pt's home Metformin was held during hospital stay but
restarted upon discharge. Pt's Lantus was titrated down to 26
units at lunch. Pt's sugars were in reasonably good range
(200s) and thus his insluin can be further titrated. Pt was
also on insulin sliding scale and fingersticks QID.
.
# C diff colitis: Pt was found to be c diff positive. Was
treated with Flagyl PO, which needs to be continued for 4 more
days to complete a 10 day course. Pt's diarrhea is much
improved at time of discharge.
.
# Tobacco abuse: Pt's on Nicotine patch daily.
.
# Anxiety/Insomnia: Pt was conitnued on home Clonazepam,
Zolpidem.
.
# Pt was on tubefeeds through PEG tube, which he tolerated well.
Pt did have occasions when he stated that he wanted to eat,
knowing that it will make him at increased risk for aspiration
and complications from it. However, after counseling him about
it, pt would decide again that he wants to stay NPO and on
tubefeeds to reduce risk of aspiration. IF pt and HCP do decide
to let him eat, he should be on ground solids and nectar thick
liquids. Pt has an outpt S&S eval on [**2144-6-25**] to reassess the
situation at that time. Pt was on SC Heparin for DVT ppx. Pt
also on PPI. Pt was full code.
Medications on Admission:
1. Amantadine 100mg [**Hospital1 **] (0700 and 1200).
2. Ambien CR 12.5g QHS.
3. Clonazepam 1mg PO q8h.
4. Dexamethasone 2mg daily (weaning, changed on [**2144-5-25**] from 2
mg [**Hospital1 **]).
5. Lantus 40u SC at noon.
6. Keppra 500mg PO BID.
7. Nystatin swish TID.
8. Omeprazole 20mg PO Daily.
9. Oxycodone 30mh PO q4h PRN pain.
10. Spiriva 18 mcg 1 puff daily.
11. Metformin HCl 500mg PO BID.
12. MVI 1 cap daily.
13. Lactulose 10 gm/15 mL - 30 mL [**Hospital1 **] prn constipation
Discharge Medications:
1. Levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Amantadine 50 mg/5 mL Syrup Sig: One (1) PO BID (2 times a
day).
6. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. Lantus 100 unit/mL Solution Sig: Twenty Six (26) units
Subcutaneous at lunch.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) 1439**]
Discharge Diagnosis:
penumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because you had confusion and fatigue. You
were initially started on antibiotics for meningitis, but that
was stopped once it became clear that you did not have that.
You did however have a pneumonia which was treated with
appropriate antibiotics. Your confusion resolved and you did
very well. You were still weak however so were discharged to a
rehab facility where you can regain your strength. We do not
expect you to be there greater than 30 days. Your wife, your
health care proxy, will be allowed to make decisions for you.
Please make the following changes to your medications:
START Nicotine 21 mg/24 hr Patch daily
START Sulfamethoxazole-Trimethoprim 800-160 mg every
Monday-Wednesday-Friday
START Metronidazole 500 mg every 8 hours for 4 more days
CHANGE Lantus to 26 units Subcutaneous at lunch.
Followup Instructions:
Please keep your appointment with your oncologist:
Provider [**Name9 (PRE) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2144-6-11**]
10:30
Provider [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2144-6-11**]
10:30
Please also keep your speech & swallow assessment appointment:
Provider [**Name9 (PRE) 326**] UPPER GI (WEST) [**Name9 (PRE) 706**] Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2144-6-25**] 9:45
Completed by:[**2144-6-4**]
ICD9 Codes: 5070, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5996
} | Medical Text: Unit No: [**Numeric Identifier 56902**]
Admission Date: [**2175-12-2**]
Discharge Date: [**2175-12-16**]
Date of Birth: [**2101-9-15**]
Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 74-year-old gentleman
presented to the Cardiology service with history of
intermittent chest pressure and dyspnea on exertion for
approximately 4-5 weeks. He had an episode of chest pain on
the day of admission. He said it did not radiate, but it is
also not associated with any nausea, dizziness, vomiting,
palpitations, diaphoresis. He said it usually happens when
he is lying down while he is short of breath and is relieved
by walking around and it seems to happen frequently to him
and it lasts about 25 minutes. Recently he complains of
shortness of breath even with minimal walking in his house.
PAST MEDICAL HISTORY: Diabetes type 1.
Hypertension.
Hyperlipidemia.
SOCIAL HISTORY: He drinks approximately 1-2 drinks per day
and has a 30 pack year history of tobacco.
FAMILY HISTORY: Noncontributory.
He was admitted to the Cardiology service for workup for his
chest pain and was started on Heparin, aspirin, beta-blocker,
nitroglycerin. Placed on telemetry to determine whether or
not he would rule in or out for myocardial infarction.
Lisinopril was held because of his renal function.
At the time of admission, over the next 48 hours, he was
covered by the Cardiology service in preparation for cardiac
catheterization, which was determined when he had elevated
troponins and ruled in for non-ST-elevation myocardial
infarction. Creatinine preoperatively was 1.5. It is
unknown what the patient's baseline creatinine was, but the
patient was aware of chronic renal insufficiency and patient
received hydration prior to going to cardiac catheterization
and was covered by Cardiology service, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
Cardiac catheterization was performed on the [**8-3**],
which revealed severe three-vessel disease with plaquing in
the left main, heavily calcified LAD with subtotal occlusions
of first septal and diagonal 2. Diagonal 1 had a 70 percent
lesion. Circumflex was totally occluded in the A-V groove
with moderate plaquing in the OM-3. The right coronary
artery had proximal and ostial 80 percent lesions and was
totally occluded in the mid portion. Patient also had
moderate-to-severe LV diastolic heart failure. His LVEDP was
23 as well as moderate pulmonary artery hypertension and
mitral regurgitation. Patient was referred to Dr. [**Last Name (STitle) **].
PAST SURGICAL HISTORY: Also includes appendectomy at age 6.
ALLERGIES: He had no known drug allergies.
MEDICATIONS AT THE TIME HE WAS SEEN:
1. Glyburide 1.25 mg by mouth daily.
2. Lipitor 10 mg by mouth daily.
3. Hydrochlorothiazide 12.5 mg by mouth daily.
4. Multivitamin by mouth daily.
5. Lisinopril 10 mg by mouth daily.
6. Aspirin 325 mg by mouth daily.
PHYSICAL EXAMINATION: On exam, he is 6 feet tall, 109 kg or
240 pounds with a temperature of 96.6, blood pressure 118/62,
in sinus rhythm at 76, respiratory rate 20, and saturating 94
percent on room air. He was sitting upright in bed in no
distress. He is alert and oriented times three and
appropriate. He had no carotid bruits. He had diminished
breath sounds at the right base and fine rales at the left
base. His heart has regular rate and rhythm with S1, S2
tones and no murmurs, rubs, or gallops. His abdomen is soft,
round, nontender, and nondistended with positive bowel
sounds. Extremities were warm and well perfused with no
peripheral edema. No varicosities noted, but some
superficial spider veins. He had 2 plus bilateral radial
pulses, 1 plus bilateral dorsalis pedis pulses, 2 plus PT
pulse on the right, and a 1 plus PT pulse on the left.
PREOPERATIVE LABS: White count is 7.8, hematocrit 29.5,
platelet count 261,000. Sodium 139, K 4.3, chloride 105,
bicarb 25, BUN 31, creatinine 1.4 with a blood sugar of 137.
PT 12.9, PTT 28.7, INR 1.0. ALT 17, AST 17, alkaline
phosphatase 38, amylase 36, total bilirubin 0.6. Urinalysis
was negative.
Preoperative EKG showed sinus rhythm at 71 with PVCs, a left
atrial abnormality, and a question of both anteroseptal old
myocardial infarction and an old inferior wall myocardial
infarction.
Additional laboratory work done showed a calcium of 9.0,
magnesium 2.0, hemoglobin A1C at 5.8 percent.
Preoperative chest x-ray showed background COPD with probable
mild CHF and small effusions. Please refer to the x-ray
final report dated [**2175-12-2**].
Preoperative CTA of the chest showed no evidence of pulmonary
embolism as well as bilateral pleural effusions and increased
septal thickening consistent with interstitial edema from
mild LV congestive heart failure. It also noted calcified
coronaries and aortic atherosclerotic disease. Please refer
to the final report dated [**2175-12-2**].
On [**12-6**], the patient underwent coronary artery
bypass grafting times four by Dr. [**Last Name (STitle) **] with a LIMA to the
LAD, vein graft to the PDA, vein graft to the OM, vein graft
to the diagonal. He also underwent mitral valve repair with
a 30 mm [**Doctor Last Name 405**] annuloplasty band. He was transferred to
Cardiothoracic ICU in stable condition on a propofol drip at
10 mcg/kg/minute, Levophed drip at 0.03 mcg/kg/minute,
milrinone drip at 0.1 mcg/kg/minute, and an insulin drip at 2
units/hour.
On postoperative day one, he was on a lidocaine drip for
premature ventricular contractions. Remained on Levophed,
which was weaned during the day, milrinone drip at 0.25,
lidocaine drip at 1 mg, and insulin drip at 5 units/hour.
Postoperatively, his white count was 11.1, hematocrit 29.4,
platelet count 138,000. BUN 34, creatinine 1.6. He remained
sedated and intubated on ventilatory support.
On postoperative day two, the patient was extubated, remained
on milrinone drip, and Natrecor was started at 0.01 for his
heart failure. He remained on a lidocaine drip at 1.
Aspirin was started and he also began IV Lasix diuresis. He
received some Ativan for agitation. His creatinine rose
slightly to 1.8.
Preoperative echocardiogram estimation of his ejection
fraction was 15 percent. Patient was seen by Cardiology
everyday for assistance with his congestive heart failure
management. He was also seen by the clinical nutrition team.
Patient was started on carvedilol beta-blockade, transitioned
off his Natrecor. He was weaned off the Levophed and
milrinone and remained on the Natrecor drip at 0.01.
Diuresis continued. Creatinine decreased slightly to 1.6.
He was also seen by Electrophysiology service. At that
point, he was off all his drips. The patient was awake and
alert on exam, and was also seen by Physical Therapy for
initial evaluation, though he remained in the ICU.
On postoperative day four, he was hemodynamically stable on
no drips. Receiving IV Lasix and carvedilol. Creatinine
continued to improve to 1.4. White count dropped to 9.8.
Hematocrit was stable at 29. Foley was discontinued. A line
was also discontinued. He remained in Cardiothoracic ICU an
additional day pending resolution of his ATN and to monitor
him closely for ectopy. He was restarted on his lisinopril
and seen by Case Management in preparation for moving out to
the floor.
On the 15th, the patient was transferred out to [**Hospital Ward Name 121**] 2 to
begin work with Physical Therapy. He was seen again by the
EP fellow to evaluate him for workup for possible ICD in
approximately one month postoperatively, also pending whether
or not his ejection fraction improved. Patient was also
evaluated by the CHF service from Cardiology.
On postoperative day six, the patient did have one run of
nonsustained V-tach and continued on all of his oral
medications. His exam was unremarkable and incisions were
clean, dry, and intact. He had positive bowel sounds. Had 1
plus peripheral edema. Decision was made that the patient
would follow up with EP postoperatively in one month.
Patient was strongly encouraged to work with his incentive
spirometer and improve his pulmonary toilet as well as
increasing his by mouth intake in all preparation for his
probable discharge to home.
The following day the patient also had four beats of
nonsustained V-tach. He was completely asymptomatic and was
waiting clearance so that he can do his physical therapy.
His creatinine rose slightly from 1.3 to 1.4. He received
additional magnesium repletion. Patient was also seen by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] of Electrophysiology service and patient
went to the EP laboratory on the 18th for a study and
received an ICD implant.
On postoperative day nine, patient continued to be in sinus
rhythm, but had frequent atrial and ventricular ectopic beats
status post the ICD being placed. The new pacer site was
clean, dry, and intact. His heart rate was irregular. As
previously noted, he was saturating 96 percent on 2 liters
with a blood pressure of 112/52. His carvedilol was changed
to Toprol XL per recommendations of Electrophysiology service
with plans to hopefully discharge him if he remains stable
for the next 24 hours.
His EP device was also interrogated one day prior to
discharge. On the 20th, the day of discharge, patient was
hemodynamically stable in sinus rhythm at 60, blood pressure
123/61, respiratory rate of 18, and saturating 95 percent on
room air. He is alert and oriented. He had a nonfocal
neurologic examination. His lungs were clear bilaterally.
Incisions were clean, dry, and intact with trace peripheral
edema. He was discharged to home with VNA services on
[**2175-12-16**].
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting times four with mitral valve repair.
ICD placement.
Non-insulin dependent-diabetes mellitus.
Hypertension.
Hyperlipidemia.
DISCHARGE MEDICATIONS:
1. Lisinopril 5 mg by mouth daily.
2. Iron 150 mg by mouth daily.
3. Vitamin C 500 mg by mouth twice a day.
4. Lipitor 10 mg by mouth daily.
5. Amiodarone 400 mg by mouth once a day.
6. Glyburide 1.25 mg by mouth once a day.
7. Lasix 40 mg by mouth once a day times 10 days.
8. Metoprolol 50 mg by mouth daily.
9. Coumadin 5 mg by mouth once a day for two days, then
patient is to check with his physician after laboratory
draw prior to his next dose.
10. Keflex 500 mg by mouth four times a day for seven
days.
11. Potassium chloride 10 mEq by mouth twice a day for
10 days.
12. Percocet 5/325 one tablet by mouth as needed pain
every four hours.
FOLLOW-UP INSTRUCTIONS: The patient was instructed to
followup at the EP Device Clinic on the [**Hospital Ward Name 23**] [**Location (un) 436**]
[**Hospital Ward Name 516**] on [**12-26**] at 11:30 a.m. He is also
instructed to followup with Dr. [**Last Name (STitle) **], his surgeon for a
postoperative surgical visit in one month postoperatively and
he was also instructed to followup with Dr. [**Last Name (STitle) 56903**], phone
number [**Telephone/Fax (1) 56904**] in [**1-27**] weeks. Patient was instructed to
be in contact with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 56905**] for followup of Coumadin dosing with INR blood
draws by the VNA service. Again, the patient was discharged
home with VNA services on [**2175-12-16**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2176-1-29**] 10:51:01
T: [**2176-1-29**] 11:31:21
Job#: [**Job Number 56906**]
ICD9 Codes: 4240, 4111, 9971, 4271, 4280, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5997
} | Medical Text: Admission Date: [**2129-9-23**] Discharge Date: [**2129-10-3**]
Date of Birth: [**2052-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
left arm pain, nausea
Major Surgical or Invasive Procedure:
[**2129-9-28**] s/p Coronary artery bypass grafting x4:
Left internal mammary artery graft to left anterior
descending, reverse vein graft to the first marginal, second
marginal and third marginal branches of the circumflex
History of Present Illness:
77 year old male presented to outside hospital with left arm,
axilla, and flank pain, additionally diaphoresis and nausea. He
was transferred to [**Hospital1 18**] for cardiac evaluation
Past Medical History:
coronary artery disease
s/p PCI [**2119**] (2 stents to OM1)
gout
hypertension
hypercholesterolemia
osteoarthritis
skin cancer
Social History:
Occupation: retired from trucking business
Lives with: wife
[**Name (NI) 1139**]: denies
ETOH: denies
Family History:
brothers with CAD, s/p CABG
Physical Exam:
Pulse: 67 Resp: 16 O2 sat: 98% RA
B/P Right: 157/81 Left:
Height: Weight: 94.9kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2129-10-3**] 06:25AM BLOOD Hct-26.1*
[**2129-10-1**] 06:55AM BLOOD WBC-14.3* RBC-2.53* Hgb-8.6* Hct-25.0*
MCV-99* MCH-34.1* MCHC-34.5 RDW-13.3 Plt Ct-159
[**2129-9-24**] 04:40AM BLOOD WBC-10.7 RBC-3.74* Hgb-12.5* Hct-36.3*
MCV-97 MCH-33.4* MCHC-34.4 RDW-13.5 Plt Ct-187
[**2129-10-1**] 06:55AM BLOOD Plt Ct-159
[**2129-9-24**] 01:43AM BLOOD Plt Ct-189
[**2129-9-24**] 04:40AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0
[**2129-10-3**] 06:25AM BLOOD UreaN-23* Creat-1.0 K-4.8
[**2129-9-24**] 01:43AM BLOOD Glucose-197* UreaN-16 Creat-0.9 Na-136
K-4.3 Cl-103 HCO3-23 AnGap-14
[**2129-9-26**] 05:59AM BLOOD ALT-14 AST-15 LD(LDH)-155 AlkPhos-76
TotBili-0.7
[**2129-9-24**] 04:40AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2129-9-26**] 05:59AM BLOOD %HbA1c-7.7*
PA AND LATERAL CHEST ON [**2129-10-1**] AT 15:39
INDICATION: CABG.
COMPARISON: [**2129-9-30**].
FINDINGS: Basilar atelectasis is seen bilaterally with a right
effusion. The
latter appears a little more prominent than the prior study.
There is a
patchy opacity in the left lower lobe, which could be
atelectasis or
pneumonia. Clinical correlation is needed. No definite
pneumothorax is seen.
Cardiomegaly is stable and the pulmonary vascular markings are
within normal
limits.
IMPRESSION:
Slight increase in right pleural fluid. Somewhat improved
aeration of the
previously seen retrocardiac density, but pneumonia cannot be
ruled out.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SAT [**2129-10-1**] 9:17 PM
Cardiology Report ECG Study Date of [**2129-9-28**] 8:48:06 PM
Sinus rhythm. Prior inferior myocardial infarction. Incomplete
right
bundle-branch block. Since the previous tracing of [**2129-9-27**]
incomplete right
bundle-branch block pattern is now present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 192 110 382/438 47 -42 66
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 82989**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82990**]
(Complete) Done [**2129-9-28**] at 3:02:23 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: [**2052-5-8**]
Age (years): 77 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 427.89, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2129-9-28**] at 15:02 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: Suboptimal
Tape #: 2009AW4-: Machine: AW2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA
ejection velocity. All four pulmonary veins identified and enter
the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Top normal/borderline dilated LV cavity
size. Mild-moderate regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
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. Suboptimal image
quality. The patient appears to be in sinus rhythm. Frequent
ventricular premature beats. Results were personally reviewed
with the MD caring for the patient.
Conclusions
PRE BYPASS The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. The left ventricular cavity size is top
normal/borderline dilated. There is mild to moderate regional
left ventricular systolic dysfunction with severe inferior and
inferolateral hypokinesis/akinesis and mild global hypokinesis
of the remaining myocardial segments. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. 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 The patient is receiving epinephrine by infusion.
There is normal right ventricular systolic function. The left
ventricle displays continued severe inferior and inferolateral
wall hypokinesis/akinesis but all other segments now show
improved and near normal function. Left ventricular ejection
fraction is in the 45% range. Valvular function is unchanged and
the thoracic aorta appears intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2129-9-28**] 16:25
Brief Hospital Course:
Transferred from outside hospital for cardiac evaluation, he was
ruled out for myocardial infarction, troponin < 0.01, and
underwent cardiac catherization [**2129-9-23**] which revealed coronary
artery disease. He was referred for surgical evaluation. He
underwent preoperative work up and on [**2129-9-28**] was brought to the
operating room and underwent coronary artery bypass graft
surgery. See operative report for details. He received
vancomycin for perioperative antibiotics as he was in the
hospital preoperatively. He was transferred to the intensive
care unit for hemodynamic management. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact,
and was extubated without complications. On post operative day
one he was started on beta blockers and diuretics, and
transferred to the post operative floor for the remainder of his
care. Physical therapy worked with him on strength and
mobility. He had issues with back pain that was limiting
activity, his medications were adjusted with good response and
improved mobility. He was ready for discharge home with services
on post operative day five.
Medications on Admission:
Plavix 75 mg daily
Zocor 80 mg daily
Allopurinol 300 md daily
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. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p cabg
Hypertension
hyperlipidemia
osteoarthritis
skin cancer
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, 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, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 82991**] in 1 week [**Telephone/Fax (1) 65735**]
Dr. [**Last Name (STitle) **] in [**3-15**] weeks
Wound check appointment as instructed by [**Hospital Ward Name **] 6 nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2129-10-3**]
ICD9 Codes: 4111, 5859, 2720, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5998
} | Medical Text: Admission Date: [**2201-12-22**] Discharge Date: [**2202-1-9**]
Date of Birth: [**2135-12-21**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy [**2201-12-23**] by Drs. [**First Name (STitle) 908**] and [**Name5 (PTitle) 23099**]
History of Present Illness:
66 y/o male with HIV, HCV, cirrhosis c/b ascites with recurrent
varcieal bleeds s/p TIPS c/b encephalopathy, active
endocarditis, mycotic aneurysm and AS who presents from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] with possible GIB. Patient was seen in [**Hospital 702**] [**Hospital **]
clinic where he was told that his hematocrit was 21% and he was
instructed to present to the hospital for a transfusion. Upon
interview by his ID physician he reported that he had noticed
blood on his toilet paper for several days. He stated that his
stool had been normal color. He denied any melena or frank
hematochezia. He denied any associated pain though did report an
intermittent LLQ pain that is unrelated to when he notices blood
on the toilet paper. He further denied any dizziness, chest
pain, or shortness of breath. Of note patient had a recent
endoscopy approximately one month ago that did not show any
varices. At [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the patient's hematocrit was noted to
be 27%. The patient was started on octreotide and Protonix drips
and transferred to [**Hospital1 18**] for further evaluation. Vitals signs
prior to transfer were 96.9, 48, 127/52, 97%. Hematocrit at
transfer was noted to be 27 and INR was 1.2.
.
In the ED, initial VS were 97.8, 54, 122/96, 14, 100%. Patient
was noted to have guaiac positive brown stool, no external
hemorrhoids, and no internal hemorrhoids were visible on
anoscopy. His serum potassium was noted to be 6.0. An EKG from
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] revealed sinus rhythm at 56, NA and no STT changes.
EKG here revealed sinus bradycardia with peaked T-waves. He was
subsequently given an Amp of D50, 10 units of Regular insulin,
Calcium gluconate and Kayexalate. Repeat potassium was 5.1.
Vitals signs at transfer were 97.8, 50s, 138/55, 22, 98% on RA.
.
On arrival to the floor, the patient denied any active
complaints and reported the history as detaile above.
.
REVIEW OF SYSTEMS: Positive per HPI. Denies fever, chills, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
* Cirrhosis c/b ascites and variceal bleeding, no encephalopathy
-- cause not yet clearly established
-- h/o liver biopsy in [**2186**] showing lobular hepatitis, CMV
positive
-- EGD [**3-9**] OSH which revealed esophageal varices:
3 columns-2 grade III and 1 grade II esophageal varices with
stigmata of bleeding and were banded. Pt was also noted gastric
varices. Banded x2 at OSH.
-- EGD [**2201-11-25**] without evidence of varices but revealing
Barrett's Esophagus
* Hepatitis B, but HbSAb positive/HbCAb positive
* HIV (CD4 most recent CD4 290 in [**3-/2201**], VL <48 [**2200-3-10**]) on
HAART, on dapsone ppx
* HTN
* Hyperlipidemia
* Anemia
* GERD
* Hemorrhoids
* Aortic stenosis - aortic valve area 0.7
Social History:
Lives alone in [**Location (un) 20935**] MA and he had been working in carnival
business. Divorced with 2 grown sons that live nearby. Has VNA
1x per week. He states he used to smoke 1PPD x40 years and he
quit 15 years ago. States does not drink ETOH and only drank
rarely in the past. Denies IVDU.
Family History:
Unavailable as patient states he never knew his family well.
Physical Exam:
Admission Exam:
VS - 97.8, 50s, 138/55, 22, 98% on RA
Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. MMM, OP benign.
Neck: Supple, full ROM. No JVP distention. No cervical
lymphadenopathy. No carotid bruits noted.
CV: RRR with normal S1, S2. Systolic murmur [**3-5**] heard throughout
the precordium spots.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: No edema. Distal pulses intact radial 2+, DP 2+, PT 2+.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. No asterixis.
On Discharge:
VS: T 97.6 HR 67 BP 144/63 RR 16 02Sat 96% on RA
GEN: NAD, Comfortable, AOx3, cachectic
CV: RRR, nl s1 and s2, systolic murmur unchanged
PULM: CTA b/l, no respiratory distress
ABD: Soft, BS +, non-distended, minimally tender, incision c/d/i
with staple removed and steri-strips in place, JP stitch was
removed and JP site was c/d/i without erythema.
EXT: No c/c/e, no tremor or asterixis.
Pertinent Results:
Admission Labs:
[**2201-12-22**] 12:00AM WBC-5.5 RBC-2.87* HGB-7.9* HCT-25.1* MCV-88
MCH-27.5 MCHC-31.4 RDW-18.0*
[**2201-12-22**] 12:00AM PLT COUNT-198
[**2201-12-22**] 12:00AM GLUCOSE-89 UREA N-31* CREAT-1.4* SODIUM-139
POTASSIUM-6.0* CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
[**2201-12-22**] 12:00AM ALT(SGPT)-13 AST(SGOT)-17 ALK PHOS-106 TOT
BILI-0.5
[**2201-12-22**] 12:00AM LIPASE-46
[**2201-12-22**] 05:30AM ALBUMIN-3.5 CALCIUM-9.7 PHOSPHATE-3.9
MAGNESIUM-2.1 IRON-54
[**2201-12-22**] 05:30AM calTIBC-250* FERRITIN-45 TRF-192*
Oncologic Labs:
[**2201-12-23**] 06:21AM BLOOD CEA-3.1 AFP-1.4
Colonoscopy [**2201-12-23**]:
Findings:
Protruding Lesions A fungating non-bleeding mass of malignant
appearance was found in the distal sigmoid colon. The mass
caused a partial obstruction. The scope did NOT traversed the
lesion. With a injector needle the area was tattooed. Cold
forceps biopsies were performed for histology at the distal
sigmoid colon mass.
Other Due to the size of the mass, the rest of the colon was
NOT evaluated.
Impression: Mass in the distal sigmoid colon (biopsy)
Due to the size of the mass, the rest of the colon was NOT
evaluated.
Otherwise normal colonoscopy to sigmoid colon
Recommendations: 1. Follow up pathology results
2. Resume diet as tolerated
3. Will discuss with primary hepatolgist
4. Consult colorectal surgery
5. Consider CT abdomen and pelvis with contrast
6. Check a CEA level
Sigmoid Mass Pathology:
SPECIMEN SUBMITTED: G I BIOPSY (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
[**2201-12-23**] [**2201-12-23**] [**2201-12-25**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf
Previous biopsies: [**-9/5489**] GI BX (1 JAR)
DIAGNOSIS:
Colon, 20 cm, biopsy:
Colonic adenocarcinoma, low grade.
CT CHEST ABDOMEN PELVIS [**2201-12-23**]:
LUNGS: Mild apical scarring and centrilobular emphysema is seen.
There is no pneumothorax or pleural effusion. The heart size is
normal and there is no pericardial effusion. There are no
suspicious nodules or masses seen within the lungs. The
descending aorta is ectatic with a significant amount of soft
plaque. The major airways are patent to their subsegmental
levels.
ABDOMEN: The liver enhances homogeneously without evidence for
masses. There is no biliary ductal dilatation. A TIPS stent is
present and patent. Note is made of cholelithiasis, but no
cholecystitis. The spleen size is top normal but homogeneous.
The pancreas is normal. The kidneys enhance homogeneously
without evidence for hydronephrosis. A left renal cyst (3:66)
and right renal cyst (3:61) are noted. There is a 1-cm left
adrenal mass which is unchanged from prior study and
statistically represents an adenoma. The right adrenal gland is
normal. The stomach and small bowel are normal. The ascending
colon appears collapsed and limits complete evaluation.
PELVIS: The bladder, prostate, and seminal vesicles are normal.
Within the
sigmoid colon is an approximately 5-cm area of thickening
concerning for
malignancy and corresponding to lesion seen on colonoscopy.
There is no
pelvic or inguinal lymphadenopathy present. No free fluid is
seen. Again
noted is a small right side fat-containing inguinal hernia.
BONES: There are no suspicious lytic or blastic lesions
concerning for
metastatic disease. There are stable degenerative changes about
the lower
lumbar spine with disc space narrowing at L2-L3.
IMPRESSION:
1. Approximately 5-cm sigmoid mass concerning for malignancy.
There is no
evidence for metastatic disease and no lymphadenopathy.
2. Highly ectatic aorta with extensive atherosclerotic
calcification and
plaque formation.
3. Status post TIPS which is widely patent.
4. Cholelithiasis without cholecystitis.
5. Unchanged 1-cm left adrenal nodule, statistically
representing an adenoma.
6. Collapsed ascending colon which cannot be completely
evaluated on this
study. If clinically indicated, a CT colonoscopy can be
performed for better
evaluation.
TTE [**2201-12-24**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. 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%). Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The descending thoracic aorta is mildly dilated.
The abdominal aorta is mildly dilated. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is critical aortic valve stenosis (valve area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy and
cavity size with preserved global and regional biventricular
systolic function. Mildly dilated ascending aorta, descending
thoracic aorta, and abdominal aorta. Critical aortic stenosis by
transvalvular velocity and gradients, but visually the aortic
valve appears to be more pliable, and likely consistent with
moderate to severe aortic stenosis. Normal pulmonary artery
systolic pressure.
Compared with the prior study (images reviewed) of [**2200-3-11**],
the severity of aortic stenosis has increased by transvalvular
velocity and gradients from moderate to critical; however,
visually the valve appears to be similarly pliable.
[**2201-12-26**] KUB:
There is residual contrast in the colon with increase in fecal
material in the ascending and descending colon. There is no
evidence of bowel obstruction. Moderate degenerative changes are
in the lumbar spine. A TIPS stent is present.
[**2201-12-30**] Pathology:
DIAGNOSIS:
I. Sigmoid colon, segmental colectomy (A-S, U-AD):
1. Invasive adenocarcinoma; see synoptic report.
2. Sixteen lymph nodes with no carcinoma identified (0/16;
additional levels are examined on blocks N and U).
II. Anastomotic donuts (T):
Colonic fragments with no carcinoma seen.
[**2201-12-30**] TEE Intraoperatively: No spontaneous echo contrast is
seen in the left atrial appendage. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
At the end of the operation there were no changes.
[**2201-12-30**] CXR: Swan-Ganz catheter is in the main pulmonary
artery. There is no pneumothorax or pleural effusion. There is
mild cardiomegaly. Aside from atelectasis in the left lower
lobe, the lungs are grossly clear. Emphysema and scarring in the
right upper lobe are better seen in prior CT from [**12-23**].
There is pneumoperitoneum. There is a TIPS stent.
[**2202-1-4**] KUB: IMPRESSION: 1) Findings are consistent with a
postoperative small bowel ileus. If concern for mechanical small
bowel obstruction persists, a CT would provide better
characterization.
2) Intraperitoneal free air compatible with recent surgery.
[**2202-1-4**] CXR: FINDINGS: As compared to the previous radiograph,
the patient has received a nasogastric tube. The tube shows
normal course and the tip projects over the middle parts of the
stomach. Normal size of the cardiac silhouette. No pleural
effusions. No pneumothorax. The previously placed Swan-Ganz
catheter has been removed. The free intraperitoneal air,
previously visible in the right upper quadrant, has completely
resolved.
[**2202-1-5**] CT Abdomen: IMPRESSION:
1. Mildly dilated fluid-filled loops of ascending and descending
colon
suggestive of focal ileus. Patent distal colon without clear
transition point to suggest large bowel obstruction.
2. Minimally prominent loops of small bowel measuring up to 2.5
cm, however, no signs of clear obstruction. Findings may also be
secondary to
postoperative ileus.
3. Expected moderate pneumoperitoneum due to recent sigmoid
colectomy.
4. Normal appearance of the surgical anastomosis. No evidence of
extraluminal leak or stenosis.
5. No organized fluid collection in the abdomen or pelvis to
suggest abscess.
6. Standard position of TIPS shunt which appears grossly patent.
7. Stable bulky appearance of the bilateral adrenal glands, left
greater than right.
[**2202-1-6**] KUB: IMPRESSION: Non-obstructive bowel gas pattern. Air
seen throughout the non-dilated colon, extending to the rectum,
could reflect mild colonic ileus.
[**2202-1-4**] 07:24PM BLOOD WBC-5.0 RBC-3.42* Hgb-10.1* Hct-30.1*
MCV-88 MCH-29.7 MCHC-33.7 RDW-16.5* Plt Ct-191
[**2201-12-31**] 12:46AM BLOOD WBC-7.6 RBC-3.33* Hgb-9.5* Hct-29.4*
MCV-88 MCH-28.7 MCHC-32.5 RDW-16.8* Plt Ct-107*
[**2201-12-29**] 05:05AM BLOOD WBC-5.9 RBC-3.64* Hgb-10.5* Hct-31.8*
MCV-87 MCH-28.9 MCHC-33.1 RDW-16.8* Plt Ct-155
[**2201-12-30**] 05:38AM BLOOD Neuts-48.4* Lymphs-38.6 Monos-5.3
Eos-6.9* Baso-0.8
[**2201-12-22**] 12:00AM BLOOD Neuts-54.6 Lymphs-35.0 Monos-4.7 Eos-5.2*
Baso-0.6
[**2202-1-4**] 07:24PM BLOOD Plt Ct-191
[**2201-12-30**] 02:40PM BLOOD PT-12.3 PTT-30.6 INR(PT)-1.1
[**2201-12-29**] 09:33AM BLOOD PT-12.2 PTT-32.1 INR(PT)-1.1
[**2201-12-22**] 05:30AM BLOOD PT-11.7 PTT-32.5 INR(PT)-1.1
[**2202-1-7**] 05:14AM BLOOD Glucose-100 UreaN-9 Creat-1.0 Na-135
K-3.7 Cl-104 HCO3-25 AnGap-10
[**2202-1-6**] 05:38AM BLOOD Glucose-94 UreaN-11 Creat-1.0 Na-139
K-3.5 Cl-107 HCO3-24 AnGap-12
[**2202-1-3**] 04:58AM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-23 AnGap-14
[**2201-12-30**] 02:40PM BLOOD Glucose-102* UreaN-24* Creat-1.0 Na-140
K-4.4 Cl-112* HCO3-21* AnGap-11
[**2202-1-5**] 04:31AM BLOOD ALT-12 AST-24 AlkPhos-104
[**2201-12-22**] 05:30AM BLOOD ALT-12 AST-14 LD(LDH)-124 AlkPhos-99
TotBili-0.5
[**2201-12-22**] 12:00AM BLOOD ALT-13 AST-17 AlkPhos-106 TotBili-0.5
[**2201-12-22**] 12:00AM BLOOD Lipase-46
[**2202-1-7**] 05:14AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.1
[**2202-1-5**] 04:31AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.8
[**2202-1-1**] 04:48AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.8
[**2201-12-30**] 12:27PM BLOOD Glucose-103 Lactate-1.6 Na-139 K-4.0
Cl-113*
[**2201-12-30**] 10:09AM BLOOD Glucose-87 Lactate-2.1* Na-139 K-3.8
Cl-113*
[**2201-12-30**] 12:27PM BLOOD freeCa-1.09*
[**2201-12-30**] 10:09AM BLOOD freeCa-1.13
Brief Hospital Course:
Primary Reason for Hospitalization:
66 y/o male with HIV, HCV, cirrhosis c/b ascites with recurrent
varcieal bleeds s/p TIPS c/b encephalopathy, active
endocarditis, mycotic aneurysm and severe AS who presented from
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with BRBPR and anemia, and found to be hyperkalemic
with EKG changes.
Active issues:
# Colon adenocarcinoma: Pt presented due to BRBPR and anemia on
outpatient labs. It was decided to proceed with inpatient
colonoscopy since he continued to have BRBPR and there was
concern about monitoring his fluid status during prep for
colonoscopy given his comorbidities (particularly severe AS).
Unfortunately colonoscopy on [**12-23**] showed a sigmoid mass, and
pathology confirmed adenocarcinoma. He was evaluated by the
colorectal surgery service, who recommended resection. Due to
his severe aortic stenosis, he was also evaluated by the
cardiology service, who felt that he could proceed with surgery
with intraoperative TEE monitoring and did not require valve
replacement prior to surgery.
# Acute on chronic anemia: Pt presented with Hct 22, baseline
Hct ~28. Likely [**12-31**] colon cancer. He received 1 unit pRBCs and
his Hct appropriately increased. On discharge his Hct was 30.1.
#. Aortic Stenosis: [**Location (un) 109**] on TTE obtained [**12-24**] 0.7 cm2. He was
evaluated by cardiology service pre-operatively, who felt he
could proceed with surgery with intraoperative cardiac
monitoring. He is being evaluated for possible AVR as outpt.
#. Acute on CKD: Creat elevated to 1.4 on admission, thought
likely pre-renal. His creatinine returned to his baseline of
1.1 without intervention.
#. Hyperkalemia: Potassium was elevated on admission to 6.0 with
EKG changes concerning for peaked T waves. He received
insulin/glucose/calcium and kayexolate and his potassium
returned to [**Location 213**]. Thought likely [**12-31**] high potassium content
diet (pt frequently eats bananas, baked potatoes at home) and/or
acute on chronic renal failure. Felt unlikely to be related to
losartan therapy since he had been on it for 2 years. He was
counseled about avoiding high potassium foods.
#. S. anginosus Bacteremia: During previous hospitalization, pt
had blood cx [**11-17**] and [**11-28**] that grew Strep anginosus in
setting of GI bleed. He was initially treated with clindamycin
but then switched to IV ceftriaxone after speciation became
available. He was continued on his home IV ceftriaxone on
admission, and he remained afebrile with nl WBC. He completed
his course of ceftriaxone on [**12-26**] (was treated for 4 weeks to
empirically treat endocarditis although no vegetation was seen
on TTE during previous admission). Blood cultures were repeated
on [**2201-12-28**] and were negative.
Chronic issues:
#. Idiopathic Cirrhosis s/p TIPS: On admission pt's LFTs, T
bili, and INR were normal. He has h/o esophageal varices on no
varices were visualized on EGD of [**2201-11-25**] during previous
hospitalization. He was continued on his home rifaximin,
nadolol, sucralfate.
#. HIV: Stable. Last CD4 94 on [**2201-11-27**], viral load
undectectable. He was continued on his home darunavir,
ritonavir, lamivudine, and dapsone.
#. Gastric ulcers: Diagnosed on EGD during previous
hospitalization in [**11-9**]. He was continued on his home PPI and
sucralfate.
Transitional issues:
- He maintained DNR/DNI code status (reversed for procedures and
surgery).
The patient was transitioned to the care of the Colon and Rectal
Surgery service on [**2201-12-30**].
The patient presented to pre-op on [**2201-12-30**]. Pt was
evaluated by anaesthesia and taken to the operating room for
open sigmoid colectomy w/primary anastomosis. Please see the
operative note for details. Pt was monitored intraoperatively
with a TEE and no changes in hemodynamics were noted. Pt was
extubated, taken to the TSICU overnight for close cardiopumonary
monitoring with arterial line and swanz ganz catheter. Patient
recovered well without incident and was transferred to floor on
POD 1 after removal of Swanz and Arterial line.
Post-operatively:
Neuro: The patient was alert and oriented throughout his
recovery; pain was initially managed with a diluadid PCA and IV
tylenol; he was transitioned to intermittent dilaudid on POD 2.
He was transitioned to oral pain medications on POD 5 but was
put back on IV tylenol after having to place and NGT for
vomiting. He was again put on PO pain meds on POD 8 after diet
was advanced and pain was well controlled.
CV: The patient was closely monitored from a cardiovascular
standpoint with a goal SBP above 120mmHg. Patient recieved
fluid boluses PRN as well as albumin to keep pressures in an
acceptable range and his beta blocker was held postoperatively
until his pressures and HR improved. By POD 3 he had become
cardiovacularly stable - vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: He was initially kept NPO and he was advanced to sips
on POD 1 and clears on POD 2. Patient continued to have
problems with nausea and distension and his diet was backed down
to NPO and then re-advanced after having several small BM's
though no flatus. On POD 5 he vomited 300cc, put back to sips,
KUB showed air fluid levels,and
an NGT was placed putting out 500cc of bilious fluid. On POD 6
a CT scan that day failed to show leak or ascites and confirmed
an ileus. On POD 7 HIV meds were crushed and placed down NGT
without issue and clamping trials were started after he began to
pass flatus and had low residuals. On POD 8 NGT was d/c and he
has advanced to sips without issue and a KUB was obtained after
he stopped passing flatus and it showed colonic air - pt was
given a suppository and began passing large amounts of flatus
and had a BM which continued into POD 9 at which time he was
advanced to a regular diet which was well tolerated. A JP drain
was discontinued on POD 4 and a stitch was placed which was
removed before discharge. C. diff was sent on POD 6 for liquid
stools but were all negative. Foley was dicontinued at midnight
on POD 3 without incident. PICC line was dinscontinued before
discharge. Patient's intake and output were closely monitored
and electroyltes repleted as needed.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. Blood, urine, and stool
cultures were all negative.
HEME: The patient's blood counts were closely watched for signs
of bleeding post-operatively, of which there were none. No
post-operative transfusions were required and hematocrit was 30
at discharge and stable without signs of GI bleed.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Darunavir 800 mg PO daily
2. Ritonavir 100 mg PO daily
3. Dapsone 50 mg PO daily
4. Rifaximin 550 mg PO BID
5. Lamivudine 150 mg PO daily
6. Pravastatin 10 mg PO daily
7. Polyethylene glycol 3350 17 gram PO daily
8. Lorazepam 0.5 mg PO QHS PRN insomnia
9. Pantoprazole 40 mg PO Q12H
10. Sucralfate 1 gram PO QID
11. Losartan 50 mg PO daily
14. Nadolol 10 mg PO once a day
15. Acetaminophen 500 mg PO Q6H PRN pain
16. Ceftriaxone 2 gm IV daily
Discharge Medications:
1. dapsone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Colonic adenocarcinoma
Acute blood loss anemia
Aortic stenosis
HIV
Idiopathic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 13099**],
You were admitted to [**Hospital1 18**] because you were anemic. You had a
colonoscopy, which unfortunately showed a cancer in your colon.
You were evaluated by the colorectal surgery service, who
recommended surgical removal of the mass. You received 1 unit
of blood prior to surgery and your blood counts improved.
You were admitted to the hospital after an open Sigmoid
Colectomy with Primary Anastamosis for surgical management of
the mass obstructing your colon which was revealed to be colonic
adenocarcinoma. You have recovered from this procedure well and
you are now ready to return home. Samples from your colon were
taken and this tissue was sent to the pathology department for
analysis. As mentioned during you visit the results were that it
was cancerous and you will need to continue to follow up with
the Oncologists at [**Hospital1 18**].
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
We made no changes to your medications while you were in the
hospital but we did add medications for pain and a stool
softener. Please continue taking your medications as prescribed
by your outpatient providers.
Please monitor your bowel function closely. Some loose stool and
passing of small amounts of dark, old appearing blood are
explected however, if you notice that you are passing bright red
blood with bowel movments or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonges loose stool, or constipation.
You have a long vertical incision on your abdomen that was
closed with staples. These have been removed and covered with
Steri-strips which should remain in place for 10-14 days. This
incision can be left open to air or covered with a dry sterile
gauze dressing if the incision become irritated from clothing.
Please monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated.
You will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
It has been a pleasure taking care of you at [**Hospital1 18**] and we wish
you a speedy recovery.
Followup Instructions:
Provider: [**Name10 (NameIs) 3150**],[**Name11 (NameIs) **] MD Phone:[**Telephone/Fax (1) 11133**]
Date/Time:[**2202-1-15**] 3:30
Department: LIVER CENTER
When: FRIDAY [**2202-2-12**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5789, 7907, 2767, 5715, 4241, 4589, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5999
} | Medical Text: Admission Date: [**2201-5-20**] Discharge Date: [**2201-5-25**]
Date of Birth: [**2146-7-9**] Sex: M
Service: CT SURGERY
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
male with a known history of coronary artery disease, who was
transferred her from an outside hospital after a positive
stress test which was performed because of chest pain while
running. This showed a tight left anterior descending lesion
and moderate occlusion of the right coronary artery with a
normal ejection fraction. He was admitted for definitive
surgery.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Benign prostatic hypertrophy.
MEDICATIONS ON ADMISSION:
1. Atenolol.
2. Cardura.
3. Prinivil.
4. Zocor.
5. Aspirin.
HOSPITAL COURSE: The patient underwent a coronary artery
bypass graft times three on [**2201-5-20**]. Apart from a slightly
difficult intubation, his surgery was uneventful. He was
transferred to the CSRU intubated. He was extubated later
the same day. He was transferred out to the regular floor on
postoperative day one where he remained stable.
His chest tubes were left in because of a small air leak on
postoperative day one. His chest tube and pacing wires were
discontinued on postoperative day three. His Foley was also
discontinued but had to be reinserted, probably likely due to
his benign prostatic hypertrophy. On postoperative day five,
his Foley was discontinued and he did void after it came out.
He is being discharged home today in a stable condition.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. q.d. for one week.
3. Potassium Chloride 20 meq q.d. for one week.
4. Cardura 8 mg p.o. q.d.
5. Zocor 40 mg p.o. q.h.s.
6. Aspirin 325 mg p.o. q.d.
7. Colace 100 mg b.i.d.
8. Percocet one to two tablets q4-6hours p.r.n.
FO[**Last Name (STitle) **]P: With primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in two
weeks, and with Dr. [**Last Name (Prefixes) **] in four weeks.
CONDITION ON DISCHARGE: Stable.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2201-5-25**] 11:24
T: [**2201-5-25**] 20:36
JOB#: [**Job Number 42015**]
ICD9 Codes: 4111, 4019, 9971 |
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